Background
Improvement of mental health care has enabled people suffering from mental disorders to better invest their parenthood, due to less recourse to isolation in specialised institutes and to a better tolerance profile of psychotropic drugs [
1]. For example, 20–60% of those who receive mental health care in Australia and the United States are parents [
1‐
4]. In addition, 10–20% of women are thought to develop a psychiatric disorder during pregnancy or in the first post-partum year, more than 1% of whom develop severe disorders (schizophrenia spectrum disorders, bipolar affective disorders and/or severe depression) [
5].
A large body of research has investigated the potential impact of these parental disorders on child development [
6]. A literature review published in 2017 found a potential impact on psychomotor, language and behavioural development in children. An impact on the parent–child relationship, with an effect on attachment was also identified [
7]. Parents who suffer from mental illnesses must reconcile parenthood with the management of their disorder, which can make them unavailable from time to time, resulting in parental discontinuity, both physically and psychologically [
7,
8]. Mothers with schizophrenia may have unsettling or poor interactions with their children [
9,
10]. In addition, maternal antenatal depression is associated with an increased risk of disorganised attachment in children at 12 months of age [
11]. These attachment disorders in turn have repercussions on the child's development and interpersonal relationships, which may persist into adulthood [
7‐
12]. Studies also identify an association between these disorders and physical comorbidity (chronic pain, cardiovascular diseases and inflammatory pathologies) [
11,
13].
Early identification of these attachment difficulties is essential for early intervention and parenting support in order to prevent an impact on the child [
7,
14,
15]. Early childhood practitioners provide first-line care and play a key role in identifying children at risk through regular mandatory appointments during the first two years of life, a crucial period for attachment formation [
8]. Furthermore, parents with mental illnesses seek out the parenting support role that these practitioners can provide [
16,
17].
There are few studies on the experience of healthcare professionals concerning the parenting of patients with psychiatric disorders. Among psychiatrists who care for adults, the main results reveal fear of a breakdown in the therapeutic relationship with the patient if parenting is addressed, a feeling of incompetence, and difficulty coordinating with child and adolescent psychiatric services [
16,
18,
19]. However, to the best of our knowledge, there are no studies that focus on the experiences of early childhood practitioners on this subject.
Consequently, we decided to focus on the experiences of these private practitioners in the care of children whose parents suffer from psychiatric disorders. We conducted an exploratory qualitative study, using semi-structured interviews. The main objective of this research was to record the experience of professionals in these follow-ups, in order to identify their difficulties and needs. The aim of this work is to highlight areas that require improvement and strengthen the coordination of the multidisciplinary network in private practice.
Materials and methods
The study focused on French general practitioners and paediatricians working in private practice with children in their care whose parents suffer from psychiatric disorders. The interviewer and data interpreters are psychiatrist specialised in child and adolescent psychiatry. Their interests in this topic came from their clinical experience especially in perinatal psychiatric care, where interdisciplinary exchange is essential. We were aware of the importance of partnership work and support difficulties encountered by practitioners in these situations. The aim was to explore the experiences of professionals and to propose ways of improving the coordination of care.
The participants were informed about the research and the opportunity to participate through a mail shared with the associations of private paediatricians and of general practitioners in the area, with the permission of the heads of these associations. They were then directly contacted by the investigator via e-mail or telephone to offer to participate in the study. The condition for inclusion in the study was that they had experience in care for children whose parents had a psychiatric disorder. Recruitment ran from February to July 2021 with the inclusion of eleven professionals aged 31 to 75 years. The main socio-professional characteristics of the doctors interviewed in Toulouse and its region are summarised in Table
1. Although we tried to reach as many men as women, more female practitioners were included which may be partly due to the increasing proportion of women working in the medical field in France [
20]. Some practitioners declined to participate due to lack of availability or lack of patients in their practice who matched the topic of the study. Participants were not related in any way to the investigators. Some were able to put us in touch with other colleagues who might be interested in our study, thus creating a network of interest around the issue at hand.
Table 1
Demographic and professional characteristics of healthcare professionals
P1 | Paediatrician | Female | 53 | 25 |
P2 | Paediatrician | Female | 56 | 25 |
P3 | General Practitioner | Male | 63 | 15 |
P4 | General Practitioner | Female | 63 | 37 |
P5 | General Practitioner | Female | 58 | 15 |
P6 | Paediatrician | Male | 61 | 31 |
P7 | General Practitioner | Female | 33 | 4.5 |
P8 | Paediatrician | Female | 46 | 6 |
P9 | General Practitioner | Female | 31 | 2 |
P10 | Paediatrician | Female | 32 | 4 |
P11 | General Practitioner | Male | 71 | 44 |
Data were collected by means of semi-structured interviews of approximately 30 to 75 min, according to an interview grid presented in Table
2. The interviews were conducted in French with secondary translation into English after analysis of the results.
Career path | What is your profession and how long have you been in private practice? |
Clinical experience | In your practice, have you ever had to follow children with parents who suffer from psychiatric disorders? What was it like? Can you think of a specific situation? What made you aware? |
Feelings about the care of these families: | Did you find it complicated? If so, how? How did you handle the parent’s reactions in these situations? |
Needs related to support | What are your needs in these situations? |
Impact on development | Have you ever had particular concerns about a child's development because of the parent’s illness? |
Parent–child relationship if not previously mentioned by the practitioner | Have you ever had specific concerns about the bond between a child and parent due to the parent’s illness? |
These individual interviews were conducted by the principal investigator (PI) at the practitioner's office or home. The interviewees' anonymous comments were recorded with their consent and then transcribed. The data were analysed by Phenomenological Interpretative Analysis (IPA) [
21]. The interviews were coded using NVivo 12 Plus software [
22]. The themes and meta-themes were validated by two senior child psychiatrists (LF and LR) who supervised the research, allowing triangulation of the coding. Data saturation was reached at interview 9, as no additional themes emerged and the narratives were similar in the final interviews.
This study meets the COREQ criteria for validation of a qualitative study [
23]. The data were processed according to the CNIL reference methodology MR-004 [
24]. In compliance with the General Data Protection Regulation, the research was registered in the Toulouse University Hospital internal register under the reference RnIPH 2021–26.
Discussion
This study is the first to examine the experiences of private practitioners involved in the care of children whose parents suffer from psychiatric disorders. The IPA qualitative research method is a rigorous and validated method of analysing the experience of individuals through data collected in individual interviews, which provides a better understanding of the subjects' experiences.
The physicians who were interviewed emphasised that addressing parental psychiatric disorders presents a risk to the therapeutic relationship. This notion of risk to the relationship when certain subjects are addressed has been noted in other studies. One study in which adult psychiatrists were interviewed, found that some had difficulty discussing their patients' parenting for fear of damaging the therapeutic relationship [
18]. With regards to this, questioning whether so-called “anxiety-depressive” disorders fall within the field of psychiatry may be underpinned by the difficulty doctors have recognising less severe illnesses with which they themselves can identify or which they may observe in relatives, as psychiatric disorders. However, a study in Quebec of general practitioners who have more training in psychiatry, did not identify these difficulties [
25]. Therefore, our study highlights the value of mental health training for primary care physicians, which is consistent with previous work [
26]. Although it was not mentioned by the interviewees, using systematic questionnaires to investigate parents' mental health could also help practitioners to overcome barriers in addressing this topic.
Difficulties getting a parental psychiatric history or on-going psychiatric pathology result in late discovery of pre-existing psychiatric illnesses. However, early detection is of major importance for the prognosis of the child. Several researchers have studied the impact of preventive interventions in families with at least one parent with a mental illness [
25‐
28]. A recent meta-analysis showed that early intervention reduced the risk of psychiatric disorders in these children by 47%, mainly through cognitive behavioural therapy or psycho-education [
29]. The indirect approach to parenting difficulties by identification, used by some doctors is interesting, reminiscent of the psychotherapeutic technique of self-disclosure, which makes the doctor more accessible and normalises the patient's experience, thereby promoting the relationship [
29,
30]. In parallel, the notion of a “vulnerable child syndrome" which combines risk endophenotypes and subclinical symptoms is emerging, making it possible to identify among siblings, the children most at risk for psychiatric disorders, which is the target population for these interventions [
31]. These data, which contrast with the current lack of care for these high-risk children, support the development of child and adult psychiatric services to provide adequate, simultaneous and integrated follow-up of parental and child psychiatric illness from a global health perspective [
31].
Practitioners are torn between not wanting to stigmatise parents and their concerns for children. Underlying this ambivalence is the fear of making mistakes and harming families. In fact, children who have parents with psychiatric disorders are at greater risk of developmental delays and psychiatric disorders compared to the general population [
5,
31‐
36]. Moreover, the stigma of mental disorders remains strong in our societies [
37‐
40]. These preconceptions and prejudices also apply to doctors [
41], regardless of their specialities [
42]. The literature is nuanced on this issue. Some researchers stress that it is not so much the psychiatric diagnosis for parents that causes a risk of negative consequences for the child, but rather the severity and chronicity. Others insist on the fact that depressed or schizophrenic parents can be excellent caregivers [
43]. This uncertainty and the resulting fears are accompanied by counter-transference towards these parents, with two pitfalls: over-investment in the relationship by the physician or, on the contrary, unconscious rejection. In addition, the fear of care placement has an impact on the doctor/parent relationship, and is a source of anxiety for physicians. Yet these decisions are often necessary in the lives of these children as a form of protection or parental support. It is estimated that approximately 60–80% of parents with a severe psychiatric disorder have lost custody of at least one of their children [
44]. The challenge concerning care placement is to measure the therapeutic benefit for the child, while considering the negative impact on the parent. Once again, the importance of training becomes obvious. It enables practitioners to change their approach by considering care placement as a preventive or therapeutic tool. Access to supervision or analyses of practice would be useful for practitioners in all specialities, to identify the effects of transference and counter-transference in the encounter with these parents and to avoid the pitfalls of a possible defensive distancing of parents' mental illnesses. Recent developments in practitioner attitudes have seen the emergence of programmes based on the strengths that a parent with mental illness, even a severe one, can bring to their child. For example, the psychoeducational intervention “Let’s Talk About Children” offered parents with mental illness the opportunity to address their need to feel like an effective parent, using self-regulatory processes of self-efficacy and personal agency. Indeed, becoming a parent can also be an opportunity for parents with mental illness to change their perspective on their mental illness by shifting their personal identity in the cycle of their lives, with parenthood providing feelings of pride, motivation, hope and purpose.
Physicians emphasise the support of institutions that allow them to jointly refer the parent–child dyad, and those with which they can coordinate their care through telephone links. Nevertheless, doctors describe difficulties accessing care, which stem from the insufficient resources allocated to child psychiatry. Other health professionals worldwide describe the same barriers in referring their adult patients. This observation, made in France at the national level, led to the Assises de la Santé Mentale et de la Psychiatrie (Mental Health and Psychiatric Conference) in September 2021, with the announcement of government commitments to remedy this situation.
On the other hand, physicians regret the lack of communication with specialists, despite the clear benefit of these connections which provide them with a better understanding of situations and help them to adapt their approach to each one, as has already been observed in other studies [
23,
39]. Projects are implemented to improve such communication, such as the “CMP 2020 project” in which, through the allocation of financial resources, the CMPs of the various child psychiatry sectors of department 31 set up meeting times for partners (private doctors, maternal and child protection and child welfare agencies) to jointly reflect on and co-construct a partnership based on complex situations. To address their isolation, some practitioners suggest the creation of a multidisciplinary network of health professionals aimed at extending support for these follow-ups by providing advice and management guidance. Multidisciplinary and integrated mental health care that targets youth, leads to an improvement in their psychological status through a wide range of available interventions, and also has a demonstrated medico-economic impact [
45‐
49].
This desire to work in partnership is part of a will to improve professional practices, but also the well-being of practitioners who, as we have seen, are confronted with stressful follow-ups, sources of identification, and sometimes of psychological suffering.
This research has several limitations. The participants were recruited from only one French department. A selection bias can also be mentioned due to the voluntary nature of the recruitment. The physicians who participated in the study probably had a particular interest in the subject. Finally, as this study was conducted within the French health care system, these results are not directly generalisable to early childhood care systems abroad.
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