C H A P T E R 8 THE IMPACT OF PARENTAL MENTAL ILLNESS ON SUPERVISED VISITATION Introduction
Supervised visitation programs receive case referrals involving parents with mental illnesses. Sometimes themental health status of the parent is known at the time of the referral; it may in fact be a factor in theremoval of children from a parent. In other cases, however, no mention of the illness may be made to staffprior to the parent arriving for intake or for scheduled visits. There are many types of mental illness withdiscrete symptoms which affect an individual’s mood, communication skills, interactions with others, andbehavior. The impact of parental mental illness on children can be significant and can impact their social,emotional and and/or behavioral growth. Visit monitors observing visits between a parent with mentalillness and his or her child may experience unique challenges.
In addition to the mental illness itself, psychotropic medications used to treat the symptoms of mentalillnesses may impair parenting by blunting a parent’s affect or sedating him or her enough to interfere withthe ability to interact during visits. Overview
Information in this chapter provides the visit monitor with an overview of the major forms of mental illness,common impacts of parental mental illness on children, risk identification, and strategies for facilitatingvisits. Additionally, material is presented on the major categories of psychotropic medications and commonadverse reactions to them.
Attention is also given to the mental health impact of domestic violence experiences on victims, which mayimpact their interactions in the supervised visitation setting. Objectives Upon completion of this chapter, a visit monitor will be able to:
1. Define major terms associated with mental health issues;
2. Recognize major categories of mental illness and their respective symptoms and treatment;
3. Recognize the five major types of psychotropic medication used to treat mental illness;
4. Identify risks that may be present during visits;
5. Identify strategies to facilitate a visit between a parent with mental illness and a child;
6. Recognize the impact of parental mental illness at different developmental stages of a child’s
7. Recognize the mental health sequelae of domestic violence that may be observed during super-
Some studies have reported that as many as 70% of parents with mental illness have lost custody oftheir children.
Research indicates that children who have a parent with a mental illness are at a significantly greater riskfor multiple psychosocial problems.
Bipolar disorders are the most common type of psychotic disorders women suffer during the perinatalperiod.
About 1% of the population in the U.S. are diagnosed with schizophrenia; 1-2% with bipolar disor-ders.
Major depression is diagnosed among 10-25% of women in their lifetime and among 5-12% of men. Mental Health Terminology
The following terms are used in the mental health field to refer to certain medications used to treat mentalillness and to describe categories of mental illness and their symptoms. The list is not all-inclusive but maybe used to better inform visit monitors of terms used by mental health staff. It may also be useful as areference for visit monitors to use when working with children whose parents have a mental illness or withthe parents themselves. Antidepressants are medications that help to reduce the symptoms of depression, which include feelings of sadness, anger, and/or lack of caring. These medications can help in restoring appetite, sleep, and overall mood. They also help redirect a person’s thoughts, behaviors and low-energy levels; once the medication takes effect, the person is no longer feeling depressed. Antipsychotics are medications that help individuals who have been diagnosed with schizophrenia, bipolar disorder, and certain other mental illnesses. These medications help individuals who are experiencing prob- lems in their thinking. They can also help calm feelings and actions. Anxiety is a problem that occurs when an individual worries to the point that the worrying prevents him or her from carrying out activities of daily living. Anxiety can cause sleep disorders, stomachaches, headaches, confusion, memory problems, pains in other parts of the body, and shortness of breath. Bipolar disorder (Manic-depressive illness) is a mental illness in which a person has pronounced periods of
being very “up,” and periods of being very “down.” When “up,” the individual feels very excited, high andenergetic; when “down,” he or she may feel very depressed, with little or no energy. These periods affect howthe individual is thinking and acting. Sometimes an individual with a bipolar disorder can become psy-chotic. Chemical imbalance refers to the condition in which the brain lacks the correct balance of chemicals to work properly. When this imbalance occurs, mental illness may result. Electroconvulsive Therapy (ECT) is a type of therapy used when other treatments for mental illness do not work. The therapy involves the use of electric “shocks” administered by a physician to a person’s brain. For a short period after receiving ECT, the individual may be confused and may have some temporary memory loss. Depression is a mental illness in which the individual has problems with feelings or mood. A person may feel extremely sad, angry, discouraged, or hopeless. These feelings may affect how the person is thinking and acting. Some depressed individuals may try to harm themselves. Lithium is a medication used to treat bipolar disorders. It helps by maintaining the correct balance of lithium in the blood, and produces more balanced feelings. Obsessive-Compulsive Disorders are a type of mental illness in which the individual has problems stopping unwanted thoughts, feelings, or actions. An individual may do things over and over again (like washing the hands or locking doors), but not be able to stop either the thoughts or the actions. Panic Disorders are a type of mental health condition in which individuals have intense anxiety, sudden attacks of fear, dramatic body changes (chest pains, shortness of breath, dizziness), or an overwhelming sense that something horrible is going to happen. Paranoia is a symptom in which an individual has a unwarranted fear that someone is going to harm him/ her, or that someone is controlling him/her. Phobias occur when an individual has a fear of certain places, things, or events, and avoids these because the fear is so strong. Psychosis occurs when an individual is unable to distinguish between what is real and what is not. Post Traumatic Stress Disorder is a psychiatric condition in which an individual has experienced an event that is traumatic (e.g., war, hurricane, accident), and then cannot remember details or cannot forget the event. PTSD affects thinking, feeling and actions. Individuals with this diagnosis may have sleep distur- bances, anxiety, and fear. Some domestic violence victims and victims of child maltreatment suffer symp- toms of PTSD. Schizophrenia is a mental illness in which the individual has difficulty in his/her thinking processes. The person may have delusions (e.g., thinking the FBI is chasing him) or may have hallucinations (e.g., hearing voices telling her to do certain things). This condition also impacts how individuals pay attention to per- sonal hygiene and how they interact with others. Defining Mental Illness
Mental illness is a broad term used to describe psychiatric conditions that impair a person’s cognitiveabilities, emotional reactions, behaviors, and abilities to perform activities of daily living. Mental illnessesdiffer in their characteristics, symptoms, prevalence, outcome, and duration. They can occur in people of allages, races, or income levels. Most mental illnesses occur in an episodic fashion. This means that a personmay have periods of dysfunction due to the mental illness, followed by periods of relatively normal func-tioning with no symptoms. Most mental illnesses respond to medications, psychosocial interventions, andfamily and community supports.
The Diagnostic & Statistical Manual IV is the official manual used to classify mental illnesses. The DSM-IV distinguishes between two major categories of mental disorders:
1. AXIS I disorders, encompassing the major mental health disorders such as depression, bipolar disor-
ders, schizophrenias, and anxiety disorders; and,
2. AXIS II disorders, encompassing “personality disorders,” thought to be life-long patterns of maladap-
tive behavior which result in significant impairment in a person’s social, vocational, interpersonal func-tioning and/or subjective distress.
Table 8.1 presents major categories of mental illness with a short list of symptoms commonly associatedwith each. It also includes the typical age of onset, and common treatment interventions. This list is notexhaustive and does not present all of the sub-types of each disorder. Instead, it gives an overview of themajor mental illness categories. If program directors have questions about more specifics of any of thesemental illness, they should contact their local community mental health center. Table 8.1 Categories of Major Mental Illness & Their Symptoms Symptoms Treatment Table 8.1 (cont’d) Categories of Major Mental Illness & Their Symptoms Symptoms Treatment
weight changes, feelings ofworthlessness, doom
Difficulty concentrating,thoughts of death or suicide,low energy
Common sometimes inwomen following childbirth
Decreased ability to care for selfor others
Problems with social skills,moods, emotional states
Personality traits: inflexible,maladaptive or inappropriate
Difficult in carrying out dailyactivities
Impact of Mental Illness on Parenting
There are no comprehensive studies documenting the percentage of parents with mental illness; however,several studies suggest that adults with mental illness are as likely to become parents as adults withoutmental illness. Findings from research studies do suggest that children with mentally ill parents are atsignificant risk for a number of psychosocial problems, depending upon the severity of their parent’s mentalillness, their age, family supports, and other interventions available to the family.
Table 8.2 looks at the impact of having a mentally ill parent on children at different developmental stages. Table 8.2 Impact of Mentally Ill Parent on Children Child may Parent may
Be unaware of infant’s crying; infant may
Become focus of delusions in severe cases;
Be distracted in caring for the child. Child may Parent may Child may Parent may Childhood (6-12 yrs
Exhibit all the behaviors listed in earlier
Be unable to assist with child’s academic or
Table 8.2 (cont’d) Impact of Mentally Ill Parent on Children Child may Parent may Childhood (6-12 yrs
Be emotionally unstable so that child does
Be unaware of issues of child who is entering
Child may Parent may
Previous characteristics listed above plus:
Not like change; be inflexible in meeting
Allow adolescent to take over care of younger
Psychotropic medications are used to control the symptoms of mental illness. These medications do not“cure” mental illness; they only provide relief from some of the major symptoms. While psychotropicmedications have improved since their first use in the 1960’s, it is still a trial and error process for patientsto learn what dosage works best and what type of drug provides the most relief. Compliance with medica-tions is complicated in some instances because of their side effects, their expense, and the patient’s lack ofunderstanding that the drugs often have to be taken for some period of time before symptoms are reduced.
There are five classes of psychotropic medications which visitation monitors should become familiar with:antipsychotic medications, anti-depressants, mood-stabilizing drugs, anti-anxiety medications, and psycho-stimulants. Visit monitors may encounter parents who are taking these medications to control the symp-toms of their particular condition. If the parent is complying with the prescribed use of the medication, thevisit monitor may observe certain side effects of these drugs which can impact the parent’s ability to interactwith his or her children during visits. Sometimes it is not the medication that causes the parent difficultybut the mental illness itself (or even a combination of both the symptoms of the mental illness and themedication). It is not the role of the visit monitor in most situations to assess the parent’s compliance withtheir medication. Rather, it is the monitor’s role to be informed about the types of psychotropic medica-tions and their role in controlling symptoms, as well as to be able to recognize common side effects whichmay impact visits. For example, some patients may experience jerking or tics from their medications; othersmay become so sedated that they are unable to attend to a child during a visit. Anti-psychotic medications are used to reduce the symptoms of psychotic disorders, such as delusional thinking, agitation, disturbances in affect, and cognitive disorders. These medications affect individuals differently, due to differences in body chemistry, metabolism, and compliance with the recommended dosage.
Common trade names of anti-psychotic medications are Thorazine, Haldol, Mellaril, Navare, Stelazine,Clozzril, and Risperdal. Adverse reactions to anti-psychotic medications can range from relatively minor toquite severe. These reactions include dry mouth, sedation, blurred vision, muscle spasms, constipation,drowsiness, and gastro-intestinal problems. Anti-depressant medications are specific types of prescription drugs used to treat major depressive episodes, dysthymia, and adjustment disorders.
Anti-depressant medications fall into one of three types: monoamine oxidase (MAO) inhibitors, tricyclicantidepressants, and serotomin receptola inhibitors (SSRI).
Examples of MAOs are Parnate, Nardil, Marplan and Aurorix. Examples of tricyclic are Elavil, Tofranil,Vivactil, and Adapin.
Trade names of SSRIs are Prozac, Paxil, Zoloft, Zyban, and Celexa.
Side effects or adverse effects include constipation, dizziness, insomnia, anxiety, lower sex drive, and seda-tion. Tricyclic antidepressants may take between two and six weeks to achieve full therapeutic affects. Mood-Stabilizing medications are medications used to treat individuals diagnosed with bipolar disorders. Examples of mood-stabilizing medications include Lithium, Depakene, and Tegretol. (Note: the later two drugs are also used as anti-convulsion medications.) Side effects of these drugs include confusion, fatigue, muscle weakness, and gastro-intestinal problems. Anti-anxiety medications are used to treat the symptoms of anxiety disorders such as panic disorders, phobias, obsessive-compulsive disorders, PTSD, and stress disorders.
Three types of anti-anxiety medications typically prescribed are benzodiazepenes, beta-blockers, andbuspirone.
Examples of benzodiazepines include Xanax, Librium, Valium, Ativan, and Dalmane. Beta-blockers include
Tenormin, Lopressor, and Inderal. Side effects of anti-anxiety medications may include sedation, dizziness,confusion, and headache. Psycho-stimulants are a class of drugs used to treat attention deficit hyperactivity disorder in children and adolescents. Trade names include Adderall, Dexadrin, and Retalin. Side effects of psycho-stimulants may include anxiety, insomnia, loss of appetite, and cardiac arrythmia. Case Examples & Discussion Questions Read the case examples below and then answer the questions about the case.Case One: Daphne is visiting her nine-month-old son, who is currently in an out-of-home placementdue to Daphne’s recent hospitalization for a major depressive episode. Daphne is separated from herhusband (her son’s father). Daphne was discharged from the hospital and was prescribed anti-depres-sant medication. She is very slow to respond to intake questions and seems to have problems stayingawake – her head droops and her eyes close. She tries to interact with her son, but she doesn’t seemaware that he needs to be changed or that he might be hungry. Case Two: Wanda brings her three children to a scheduled visit with their father. There is a history ofdomestic violence in the family and the court has ordered supervised visitation. The children appearunwashed and wear dirty clothing. Wanda is very tearful and upset, confiding to staff that she hasbeen unable to sleep, is anxious, can’t concentrate, and is unable to tend to her children’s needs. Case Three: Fred is the father of two children, ages six and eight. He has a long history of depression,and six months ago attempted suicide by shooting himself in the head. The attempt left him disabledand in a wheelchair. He drools and is incontinent but his mother (the children’s grandmother) hasrequested the court grant supervised visitation. Fred and the children’s mother are divorced. Thechildren have not seen their father for many months, and have not been told the details of their father’scondition.
1. How might each parent’s behavior or symptoms impact visits?
2. How might a visit monitor facilitate visits in each of these cases?
Identifying Risks During Visits
The purpose of identifying risks regarding a parent’s mental illness is twofold. First, it is to determinewhether mental health status may impair a parent’s ability to interact effectively with his or her childduring a scheduled visit. Second, it is to determine whether the child is endangered or upset over theparent’s behavior, emotional response or impaired thinking. Many parents may be fully able to interact inan appropriate manner during scheduled visits even if they have significant mental health issues, recenthospitalizations or problems with medication compliance. Some parents with mental illnesses, however,may experience severe disorders in their thinking or behavior, or may have problems with their medicationsuch that their participation in a supervised visitation setting might present a risk to others. Being aware ofpotential risks can assist in the determination of whether the visit should take place as scheduled, if the visitshould be rescheduled or if special considerations should be made to accommodate the needs of the parent.
While determining risks presented by a parent experiencing the symptoms of mental illness, a visitationprogram director might want to explore a variety of issues with both the parent and children prior tofacilitating a visit. Additional information on this topic is included in the Administrative Supplement.
Table 8.3 is a guide which visit monitors might use in on-going determinations of a parent’s mental healthstatus at intake and at visits. This guide may provide a framework to note observations in a consistentmanner. Most experienced human services staff, whether or not in mental health settings, routinely look atthese categories in their interactions with clients. The program director should consider these factors whendetermining whether visits can be facilitated. Table 8.3 Assessing Parents at Intake & Visits Appearance Check if present Behavior Table 8.3 (cont’d) Assessing Parents at Intake Visits Check if present Feeling or Mood Fearful
Tearful Perception Seems to have auditory hallucinations Thinking Orientation
Seems confused about date or time of day
Has delusions (fixed, false thoughts about something –
such as the CIA is following her or him).
Expresses belief that he/she is controlled by external forces (aliens, CIA)
Case Example & Discussion Questions Read the case example below and then answer the questions about the case.
Bob Wood, a visit monitor, is assigned to facilitate the visit between Mr. Callaway and his three children,ages six, eight and nine. Mr. Callaway, is divorced from the children’s mother and has a long mentalhealth history involving multiple hospitalizations. The first three visits have gone well, but on thefourth visit, Mr. Callaway arrives looking very disheveled. His clothes are dirty, his hair is uncombed,he has not shaved, and, although it is 95 degrees outside, he is wearing an overcoat. He tells Bob Woodin a very agitated voice that the CIA has told him he must take his children out of the country or the AlQaeda will kill them. He seems very confused about where he is and who Bob Wood is.
1. What, if any, risks are present in allowing Mr. Callaway to visit his children?
2. What categories in the checklist above might a visit monitor use in determining risks?
There are several strategies or techniques a visit monitor might employ to help facilitate a visit between aparent with mental illness and his or her child. If these do not work, however, the visit monitor should workwith the program director, mental health professional, or others to assess whether supervised visits areappropriate at this time for the child and parent.
Review background information and areas of concern prior to observing a visit. Do this each time a visitis scheduled. A parent’s assessment may vary depending on the episodic nature of the illness, compli-ance with medication, other treatment interventions, etc.
Use the checklist in Table 8.3 to help organize observations. Note the items checked and determine ifthey are severe enough to warrant either canceling the visit, rescheduling it, or some other option. Thesedecisions should be made by the program director.
Try to reduce any excess noise or other stimulation (TVs, radios, loud toys) in the room where the visitwill take place.
If the program’s resources allow it, assign one visit monitor to each family with a history of mentalillness instead of using group visits. Try to place that family in a room apart from others.
Use “I” statements – not “you” when requesting that the parent do something.
Do not challenge delusional thinking – for example, if the parent says the FBI is chasing him, don’t
challenge the statement or contradict it. At the point at which the parent expresses delusional thoughts,those thoughts are fixed and real – a visit monitor cannot persuade the parent to think otherwise.
Likewise, do not deny hallucinations – either visual or auditory. If the parent asks if you hear what heor she hears, you can say you don’t (if you don’t) but don’t say that the parent is “just hearing somethingthat isn’t there.”
Acknowledge the feeling the parent is having regarding either delusions or hallucinations – “I know itmust be difficult to think or worry that the FBI is following you.”
Ask the parent if he or she needs to take a break during the visit. If so, have him or her go to a quiet area,and see if time away allows the parent an opportunity to recover adequately or control emotions wellenough for the visit to continue.
If the parent is planning to visit for a long period of time (e.g., several hours), the program director orvisit monitor might want to ask the parent to help identify behaviors which may indicate a relapse –such as wearing unusual clothes, not sleeping, having disturbed thinking. Some parents might be ableto do this, and might also agree that visits will be rescheduled if the behavior occurs.
Have the child express any feelings of shame, guilt, or embarrassment prior to a visit or afterwards.
Inform the child about the adverse impact of a parent’s medication if the parent appears sedated orunable to communicate effectively.
Arrange with the child a signal to use if the parent’s behavior or emotions become too overwhelming. Have the child take a break or terminate the visit.
Inform on-site security if the parent’s mental health status is so unstable or unpredictable that thesafety of the parent, child, staff or anyone else on site is at risk. In Florida, law enforcement officers cantake custody of mentally ill individuals who present risk to themselves or others and can transport themto a mental health facility for examination under the provisions of the Baker Act. Mental Illness and Domestic Violence
The vast majority of batterers do not have mental illnesses. Many victims of domestic violence, however,may exhibit behaviors which can be mistaken for mental illnesses. Adult victims of domestic violence com-monly experience depression and symptoms of post-traumatic stress disorder, including sleep disorders,anxiety, hyper-vigilance, stress, and fear. A victim exhibiting these symptoms who brings her children to avisit should not be considered “mentally ill” because she appears upset while her partner appears calm. Perpetrators will often use the victim’s anxiety and depression to try and “prove” that the victim is unfit toparent or that she is so ill that she must have exaggerated allegations of abuse. Be aware of this dynamic. The victim’s depression and stress reactions are most often situational and will abate when she feels that sheand her children are safe.
1. Define what is meant by mental illness.
2. Discuss the major categories of mental illness.
3. Describe the impact of parental mental illness on children.
4. List some of the names of commonly prescribed psychotropic medications and their side effects.
5. Discuss strategies to employ when facilitating a visit between a parent with mental illness and his/
6. Identify potential risks that may affect a visit between a parent with mental health symptoms and
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