The task is to have parents acknowledge that they are also responsible for managing their child's problems. Kazdin and colleagues 8,15 have written of the barriers to change. In addition to work and family responsibilities, time will need to be allocated for appointments with the mental health professional. Parents will need to persuade the child to attend appointments, do homework suggested by the therapist, and take medication. They will also have to face the financial impact of their child's problem, including expenses for traveling to and from appointments and child care for their other children.8,15Which factors may make it difficult for parents?
Parents' own agendas will have to be acknowledged, if not addressed, before changes can be made in the child's behavior. The parents' background and their own upbringing may shape their self-worth, well-being, and ability to take on the work involved with a child who has a problem. This, in itself, may contribute to the child's behavior problem with a negative impact on discipline, limit setting, and having the child be the focus of attention.16,17
Although parents with mental illness may be good parents, many find the task of parenting very difficult. A parent who is not on medication may be depressed and have no energy; consequently, the children may be neglected (eg, not stimulated, protected, or monitored), which would result in behavior problems. Parents with mental illness are more likely to be living on their own or with a partner who also has a mental illness. They may well be the victims of violence and abuse, and their children may also be at risk.
Parents may be reluctant to admit that they have a mental disorder because of the stigma associated with it and the fear of losing their children.18 In the United States, 50% of parents with a serious mental illness have had their children taken away.19 When children whose mothers had a postpartum illness were followed up to age 5 years, they were found to have cognitive delay and social interaction problems; this particularly affected boys.20 This was compounded if the child also had a difficult temperament. The combination of a child with a difficult temperament and a parent with depression can lead to a hostile interactive parenting style; in this setting, behavior problems were more likely to develop in toddlers.21 Kumar22 found that mothers who had had a difficult labor and depression were more likely to say that they had not bonded with their infant--often feeling very angry and sometimes murderous towards the child, which continued into the preschool years.
A child who has a difficult temperament with poor emotional regulation, who is hyperactive, and/or who has extreme temper tantrums is difficult to parent. The child needs parents who are able to contain and soothe dysregulated children.23
The parent-child relationship is important because it allows the child to develop a sense of self-worth and problem-solving skills as well as the skills to cope with emotions. Parents are taught to encourage their child to "mentalize"--use language to make sense of surroundings, and communicate thoughts and feelings using words rather than anger or violence.17 Parents are trained to understand their child's abilities and encourage the development of new skills appropriate to both his physical and emotional levels.23,24 If the parent finds it difficult to handle a dysregulated child, then a harsh coercive cycle of relating can ensue.25
Parents who do not have the support of friends or family may find parenting more difficult, as may parents who are poor or have to work long hours with low pay and who may only be able to afford lower standards of child care. As already mentioned, parental ill health (mental, but also physical) may contribute to poor parenting.
Being disorganized will make parenting more difficult, especially if the child is also disorganized. Parents who had high scores on adult ADHD rating scales were less able to use a parenting program for children with ADHD.26 Mothers who had had a poor experience as children used parenting groups less well.27