Children of Mothers Admitted to Psychiatric Hospital: Care Arrangements and Mothers’ Perceptions

Original Article : Children of Mothers in Psychiatric Hospital

Children of Mothers Admitted

to Psychiatric Hospital: Care

Arrangements and Mothers’

Perceptions

Judi Cunningham, Femi Oyebode & Panos Vostanis

This paper describes the care arrangements made for children when their

mothers are admitted to psychiatric hospital. It also describes at admission,

and at 3 months follow-up, the views and opinions of mothers and carers

with regard to the admission, its impact on the family, and the service

received. It was found that children are predominantly cared for within

their family when their mother is admitted to hospital, and that mothers

and carers are concerned about the impact of the admission and its

associated problems.

Keywords: Care arrangements; mental health problems; carers ; psychiatric admission

Introduction

It is widely accepted that the children of psychiatrically ill

parents are at greater risk of developing psychiatric, social

and educational problems themselves (e.g., Rutter &

Quinton, 1984). There are many pathways through which

mental illness may impact upon children, including

indirectly through marital discord, social adversity and

multiple changes in care-takers (Oates, 1997).

Very little is known about the care arrangements for

children when women are taken into hospital, despite the

Department of Health highlighting the ‘significance and

effect of parental mental health problems on children’

(Department of Health, 1997). Hatfield, Webster and

Mohamad (1997) report that just over half of all psy-

chiatric admission episodes involve women (Department

of Health, 1995) but information on parental status does

not seem to be routinely recorded (Stormont et al., 1997).

Once psychiatric patients are recognised as parents and

part of a family unit, it is important that the impact of

their situation is considered.

Research specifically looking at the care arrangements for

children of hospitalised parents with mental health

problems has only just begun. A study by Stormont and

her colleagues (1997) documents that 9 out of 12 inter-

viewed parents taken into psychiatric hospital had chil-

dren temporarily looked after by family members, with

the rest being taken into care. Hawes and Cottrell (1999)

showed that, in their sample, 12 out of 53 children had to

move house as a result of their mother’s psychiatric

admission.

As admission to hospital is a regular occurrence for some

who have mental health problems, it has been suggested

that the patient who is also a parent should always be

asked about the effects of their illness on the children, with

the best interests of the child a priority (Oates, 1997).

Work has recently begun in this area, with Stormont et al.

(1997) showing that hospitalised parents do not readily

accept that their children have problems. However, 14 of

the 19 parents interviewed did express concern about the

impact of their illness on their children. A recent study

by Tamarit and Yin-Har Lau (1999) has also emphasised

that the children of psychiatrically ill mothers do not

receive the attention they need.

This study intended to replicate and extend the important

work begun by these researchers. Our aims were threefold.

First, to describe the care arrangements for children when

a mother is admitted to psychiatric hospital. Second, to

investigate the views and opinions of mothers and carers

regarding the admission itself, its emotional and economic

impact on all concerned, both at the time of admission,

and 3 months afterwards. Third, to record the evaluation

Judi Cunningham

School of Psychology,

University of

Birmingham,

Edgbaston, Birmingham

B15 2TT

Femi Oyebode

Trust Headquarters,

South Birmingham

Mental Health (NHS)

Trust, Vincent Drive,

Edgbaston, Birmingham

B15 2TZ

Panos Vostanis

Greenwood Institute of

Child Health, Westcotes

House, Westcotes

Drive, Leicester

LE3 0QU

Child Psychology & Psychiatry Review Volume 5, No. 3, 2000114


of both mothers and carers with regard to the service they

had received.

Method

The study was of longitudinal design. Recruitment was

from the Queen Elizabeth Psychiatric Hospital in South

Birmingham. During a 12-month period, mothers were

identified with children aged between 2 and 12 years.

Mothers were visited as soon as possible after their

admission to hospital, and asked whether they would

participate in the study. Recruitment was on a consecutive

basis, with some exceptions. Some mothers were missed

by the recruitment because they had stayed in hospital

overnight, or just for a weekend. Other women were

judged by the ward staff to be too distressed to take part

in the study. Mothers were given the Brief Symptom

Inventory (Derogatis, 1993), and interviewed with a semi-

structured interview specifically designed for the purpose.

Permission was asked from the mother to contact the

carer for her children. The carer was contacted and visited,

where possible, whilst the mother was still in hospital. The

carer participated in a semi-structured interview similar in

content to that conducted with the mothers, and com-

pleted the Child Behavior Checklist (Achenbach, 1991)

for each childwithin the age-range specified.Demographic

data were also collected.

Approximately 3 months after the mother was discharged

from hospital, both the mother and carer were contacted

and visited at home. Both the mother and the carer were

interviewed again; the mother completed the Brief Symp-

tom Inventory, and both mother and carer completed the

Child Behavior Checklist for each child within the age

range.

Subjects

Inclusion criteria

Mothers with children aged between 2 and 12 years

admitted to the Queen Elizabeth Psychiatric Hospital.

Mothers must have had their children resident with them

before the time of admission.

Mothers

Forty-two women fitting inclusion criteria were

approached and asked to participate in the study. Of

these, 13 women (31%) refused participation. Twenty-

nine women completed the initial part of the study.

Mothers had a mean age of 34 years (range: 20–49 years)

and had, on average, three children (range: 1–5). Women

were predominantly white (69%) and unemployed (83%),

although many of the women had young children at home.

Seventeen mothers (59%) were living with a partner at the

time of the admission. Mothers were seen, on average, 11

days after their admission to hospital (range: 0–28 days).

Seventeen of the 29 mothers (59%) completed the follow-

up. Mothers were predominantly diagnosed with a de-

pressive disorder (34%). Five women (17%) were diag-

nosed with bipolar disorders, five with schizophrenia and

other psychotic disorders, one with an alcohol related

disorder, one with an anxiety disorder, and seven (24%)

were unclassified.

Children

The cohort of 29 mothers had, between them, 76 offspring

of all ages. Only children between the ages of 2 and 12

years were included in the study, and these children

numbered 48: 24 female and 24 male. The mean age of the

children was 6 years. Children had a maximum of four

siblings. There were three children with no siblings in the

study, and two children who had adult siblings.

Carers

Of the 29 mothers involved in the study, six (29%) asked

for the carer of their children not to be contacted and six

carers could not be located. The remaining 17 carers were

asked to participate. Of these, 3 (18%) refused par-

ticipation, 14 (82%) completed the first part of the study,

and 11 (69%–one carer had died during the study)

completed the follow-up.

Measures

Mother

The Brief Symptom Inventory (Derogatis, 1993) is a 53-

item self-report questionnaire, designed to reflect current

psychological symptom patterns of psychiatric and medi-

cal patients. Each item is rated on a 5-point Likert scale

of distress from ‘not at all ’ (0) to ‘extremely’ (4).

Standardised T scores above 63 on any index indicates

‘caseness ’. The questionnaire yields nine primary symp-

tom dimensions, and three global indices. The Global

Symptom Inventory, an overall score, was used for this

study. The measure is sensitive to change and can be used

to measure patient progress. The measure is both reliable

and valid (Derogatis, 1993).

The initial qualitative interview and checklist was designed

to investigate the mother’s feelings towards her children

and her partner (if applicable) with regard to her ad-

mission to hospital. The interview also asked about the

care arrangements currently made for the children. Pre-

vious admission and demographic data were collected by

interviewing the mother, and through investigation of

hospital records.

The follow-up interview had a similar structure to the

initial interview, but emphasis was placed on the mother’s

opinion of the help and support she had received, and how

this could have been improved.

Children

The Child Behavior Checklist (CBCL) (Achenbach, 1991)

is a well-used instrument that comprises 113 behaviour

problem items that respondents score as 0 for ‘not true of

Child Psychology & Psychiatry Review Volume 5, No. 3, 2000 115


the child’, 1 for ‘somewhat or sometimes true of the

child’, and 2 for ‘very true or often true of the child’.

Scores are transferred to a behavioural profile designed to

score on syndromes derived from factor analysis. Narrow

band-like syndromes are grouped under ‘ internalising’,

‘externalising’ and ‘other ’ problems. The measure yields

a total T score, which was used for this study. Reliability

for this instrument is good (Edelbrock & Achenbach,

1980). The clinical threshold for this measure is a

standardised T score of between 60 and 63.

Results

Child-care arrangements

Figure 1 shows the diversity of care the children received.

Thirty-two children were placed with their father, or their

mother’s partner, whom they considered to be their father

figure. Eight children were placed with their grandparents,

fourwith other relatives including aunts and older siblings,

two were looked after by family friends, and two were

placed in care.

Three families had two main carers for the children, and in

these cases the primary carer was the father, and the

second carer the grandmother. Two of these families were

Asian families. The two children placed in care were from

the same family, and were later transferred to another

relative. The children who stayed with friends were from

different families and had no immediate family in the area

to look after them. An analysis of variance was conducted

on carer type and CBCL score at admission and at follow

up and was found to be non-significant (F [3,19]¯ .512

p" .05; F [2,15]¯ .861 p" .05).

Sibling separation

Mothers often had more than one child, and it was

detailed whether the children were placed with a carer as

a sibling group, or were separated from each other. In the

original analysis, five children were judged to be separated

from their sibling group as the mother and new-born were

admitted to the Mother and Baby Unit of the Queen

Elizabeth Psychiatric Hospital, whilst the other child or

children were placed with an alternative carer for the

Father

Grandparent

Relative

Friend

Care

Figure 1. Placement of individual children whose mothers are admitted topsychiatric hospital (n = 48)

4%4%

8%

17%67%

Care arrangements

period of the admission. Of the remaining families, 15

sibling groups stayed together as a unit. Of these, 13 were

cared for by the father figure, i.e., the mother’s partner.

One sibling group staying together was cared for by the

maternal aunt, the other by the paternal grandmother. In

retrospect, those children who were separated from their

new-born sibling when their mother and new-born were

admitted to the mother and baby unit were unlikely to

have formed significant attachments by this point. If these

groups are included in the analysis (two groups would

have been made lone children by the split and were

discounted), the number of sibling groups staying together

as a unit rises to 82%. An analysis of variance on whether

children were separated from their siblings and CBCL

score was conducted, and was also found not to be

significant (F [1,13]¯ .819 p" .05).

Mothers’ admission data and distress scores

The average length of mothers’ admission during the

course of this study was 51 days (SD 52.36, range 1–213

days). Mothers had, on average, three known admissions,

ranging from one admission through to as many as nine.

The actual number is probably much higher, taking into

consideration admissions to other hospitals and other

Trusts.

Mothers who completed the Brief Symptom Inventory

scored, on average, 53.44 (SD 10.38, range 28–70). At

discharge, the mean was slightly higher at 56 (SD 9.77,

range 39–73) and at follow-up the mean was lowest at

52.76 (SD 11.05, range 36–76). These means are not

significantly different from the norms published for the

appropriate populations for psychological symptom

distress.

There was no significant difference between the distress

scores for the mothers at each point in time (F¯ 2.48

[2,18] p" .05).

Description of child scores

The mean for the Child Behavior Checklist score for this

sample of children was 46.4 (SD 9.83) on admission and

47.6 (SD 7.65) at follow-up. The mean for the Child



Behavior Checklist as scored by the mothers was 52 (SD

10.77). The means for the non-referred population are 50

(SD 9.8) for boys and 50.1 (SD 9.9) for girls. This sample

does not differ significantly from the non-referred popu-

lation. Children did not score differently between ad-

mission and follow-up (t¯ .27, df¯ 13, p" .05) and

scores from the carers and the mothers also do not differ

significantly (t¯ 1.44, df¯ 36, p" .05). Mothers and

carers seem to have the same perceptions of the child’s

problem behaviours.

Factors associated with severity of children’s problems

It was hypothesised that factors such as mother’s distress,

admission length, and number of admissions may ad-

versely affect the children of mothers who are admitted to

hospital.However, children’s scores on theChild Behavior

Checklist were shown not to be associated with either the

length of the mother’s admission, nor the number of

admissions she had had in their lifetime. It seems that

children are not experiencing problems as measured by the

Child Behavior Checklist, and it could be suggested that

children being cared for by their immediate family have

attachment relationships that buffer the stress associated

with a mother’s hospital admission.

Description of children who experienced problems

Only one child was scored above the clinical threshold (T

¯ 63) by the carer on the Child Behavior Checklist whilst

the mother was in hospital. This child had reported

problems at school, with work stress and problems with

bullying, but the mother’s severity score was relatively

low (T¯ 48). At follow-up, this child’s score on the Child

Behavior Checklist had lowered to T¯ 57 from the carer

and T¯ 48 from the mother. The child’s school problems

had also significantly improved according to the parents.

One child scored T¯ 60 on the Child Behavior Checklist

whilst the mother was in hospital : a ‘borderline’ score.

During the interview, the carer of this child had also

reported problems, for example that the child was jealous

of younger siblings who were with the mother in hospital.

Unfortunately, no follow-up data are available for

this child.

At follow-up, two children from the same family were

scored by the mother well above the clinical threshold on

the Child Behavior Checklist (T¯ 76 and T¯ 75). The

mother reported in her interview that the children were

experiencing behavioural problems. The mother’s scores

were again relatively low on the Brief Symptom Inventory.

One child at follow-up was scored on the borderline (T¯60) by the carer.

It is interesting to note that in cases where children were

scored above the clinical threshold, there had been a

significant domestic problem between the mother and her

partner, and it was suggested by one mother that the

children were affected by the compound stressors of

marital disharmony and hospital admission. This sugges-

tion is supported by the literature, which cites family

disruption and marital disharmony as two major risk

factors in the development of problems in children (Rutter

& Quinton, 1984).

Views and opinions of mothers

On admission, all mothers were asked a series of questions.

One of these questions was ‘do your children know where

you are? ’ Twenty-four mothers (83%) said their children

did know where they were, and three (10%) specified that

their children knew they were in hospital, but were

unaware of the reason. One mother said that some of her

children (the older children) knew that she was in hospital,

but that her younger child did not. Only one mother said

that her children did not know where she was. When asked

whether or not the mothers were worried about their

children, 17 (59%) expressed that they were. Eleven

(38%) said they were not worried about their children,

and only one mother stated that she did not feel anything

at all about her children.

Seventeen of the mothers were given a forced choice

question on how they felt about their children. The options

were that they were worried about them, that they missed

them, that they loved them, or a combination. Fourteen

(82%) of these mothers expressed that they loved their

children. Only three mothers did not take this option. The

remaining 12 mothers were given an open-ended question:

‘how do you feel about your children?’ One mother stated

that she ‘wanted her children back’, one mother expressed

sadness, and four mothers said that they felt that their

children were OK and being well looked after. Of all the

mothers, 21 (72%) expressed that they missed their

children, with somewhat melancholy overtones, such as, ‘ I

really feel that they are better off without me’.

During the follow-up interview, mothers were asked

whether they had been readmitted in the intervening

period. Eleven mothers (65%) had been readmitted and

six had not. At the time of the follow-up interview all the

mothers except one now had full-time care of their

children. When asked what problems they had en-

countered since their discharge from hospital, six women

(35%) stated that they had had no problems. Of the

others, mothers experienced problems with money, and

with medication – forgetting to take it and experiencing

unpleasant side effects. Four women had experienced

behavioural problems with their children. Some women

reported general problems: ‘It’s such a huge effort to do

anything’.

On the question of mental health support, only three

mothers (18%) said they had received no support since

leaving hospital. Five women stated that their Community

Psychiatric Nurse was their main source of support since

being discharged, three mentioned social service support,

three were attending clinics or receiving outreach support,

and two received support from their families. One mother

said that her main sources of support were her consultant



and her chaplain. When asked about the sources of

support with looking after the children, six mothers said

that their families had been extremely helpful ; four

mothers said they had received help from social workers

and health visitors ; two said they received help from

schools and nurseries, five said that they had received no

support, and two mothers stated they had not needed

any help.

Mothers were also asked about their concerns, both for

their health and for their children. On the question of

health, only one mother stated that she had no concerns.

The longevity of mental illness was a recurrent theme for

many of the mothers, with comments such as: ‘ It seems to

be taking a long time to get back to normal ’. Some

mothers were concerned that their illness was affecting the

children, not only because of their admission, but also

because of the effects of seeing their mother when she was

ill. Mothers were also concerned that they were inadequate

as parents, blaming themselves for their family’s concerns:

‘ I feel as if I’m bringing devastation on my family ’.

When asked about improving the service they had had,

mothers were generally positive about their experiences ;

in fact, six mothers (35%) said they would not change or

improve upon the service they received. Generally, treat-

ment and care within the hospital was reported favour-

ably, with problems only arising with evaluation of the

transition from hospital to home. Mothers talked of

needing help with ‘everyday things ’. A strong theme was

a feeling of isolation when returning home, needing

someone to talk to or a day centre to maintain links with

those they had met whilst in hospital : ‘ I’d like somewhere

to mix with others like me’.

Mothers also expressed that they were worried about their

children visiting them in hospital, concerned that the ward

was not a suitable environment for children. A solution

was suggested in the form of a family room staffed by

nurses, where children could visit their parents without

having to enter the ward area. Other suggestions were that

there should be a checklist on admission to record whether

or not the client has children, and what provisions are

being made for them.

Views and opinions of carers

Carers were interviewed during the mother’s admission to

hospital, and also 3 months after the mother’s discharge.

Carers expressed a number of concerns, which ranged in

type from emotional to financial burden. Over half the

carers said that the admission had affected them econ-

omically.

The majority of carers admitted that the mother’s ad-

mission had affected them emotionally. Only one carer felt

that the mother’s admission to hospital was a relief, and

two carers said that the admission wasn’t long enough to

cause them or the children any real upset. However, it

seems those most affected are carers who are emotionally

involved with both the children and the mother, such as

parents and partners, and where the condition is chronic.

Even those who had said the admission had not affected

them emotionally expressed some concern at the follow-

up interviews. One carer stated: ‘ I didn’t think it had

(affected me) at the time, but I felt low afterwards,

drained…I couldn’t do any more’.

Eight carers also said that the admission had affected them

socially, and that they didn’t go out as much as they used

to: ‘ I don’t go out – I like to be in for the children…people

don’t come round anymore’. Seven (64%) of the carers

said they thought that the mother’s admission was

affecting the children emotionally, although only one

carer reported any school problems. Younger children

seem to be the most affected according to the carers, with

heavy emphasis on the effect the illness was having on

attachment: ‘ It’s bad, he doesn’t go to her when she calls,

and then she gets upset ’. ‘He’s not as secure – I think he

misses her ’. Even those carers who said that they thought

the children weren’t emotionally affected had reservations.

One carer said: ‘They’ve adjusted to it. They were (upset)

at the beginning, it was very traumatic. Now that’s gone

and they’re hardened to it…maybe too hard’.

During the follow-up interviews, carers were asked how

they would improve the service they and the mother had

received. Their answers reflect the pattern of answers

given by the mothers, often giving the impression that

carers feel that they are alone with the responsibilities of

looking after both mother and children. Carers also said

that they understood that help was available, but didn’t

know where or how to access it. They called for an

increase in the availability of all types of information,

including financial and emotional support and the location

of support groups.

Discussion

Our sample for this study was relatively small, especially

in the follow-up stage, and for this reason we must be

cautious in drawing firm conclusions. The voluntary

nature of the study meant that those families particularly

at risk may have been those who refused participation.

Selection criteria may have also biased results, as selection

was made on the basis of discretion by the ward staff. In a

study of this nature, it is important not to compound

existing problems, and so those who were deemed too ill to

be interviewed were either excluded from the sample, or

interviewed when their symptoms had abated. Thus, the

sample was skewed in favour of those mothers whose

symptoms were mainly of moderate degree. Drop-out

rates were also quite high: only 17 of the original 29

mothers completed the follow-up. It is the case that, in

a sample of this nature, families tend to be highly mobile,

and some had moved by the follow-up stage. Some

mothers wanted to distance themselves from their illness

once discharged, and refused any further participation.

Although much of our reported data are anecdotal, we



found it important to report the feelings of those con-

cerned. Many participants we interviewed stated that not

being listened to was one of their main grievances, and this

highlights further the need for this type of research.

Having acknowledged the methodological limitations,

however, some important themes emerged from our

research. The children in our sample were cared for very

much within the bounds of immediate family when their

mothers were admitted to hospital, and this echoes the

findings in previous research (Rice, Ekdahl, & Miller,

1971; Hawes & Cottrell, 1999). It seems that the families

of mothers admitted to psychiatric hospital are very

proficient in providing child-care arrangements. We must

bear in mind, however, that this sample came only from

hospital admissions, and a different picture may emerge

when examining the children of mothers cared for in the

community. Admission to hospital may be facilitated,

especially in a voluntary admission episode, where a

mother has a carer available to look after her children.

Also, as has already been suggested, those mothers who

did not agree to be interviewed may be those less secure

with their child-care arrangements, who may not have a

partner or family members to take care of their children.

Further studies should endeavour to report on this

‘missing’ population.

Despite the areas highlighted for concern, we feel that this

research has yielded positive results with regard to the

placement of children in a secure environment whilst their

mother is in hospital. The large proportion of children

staying with close relatives has implications for their

attachment status, with the traumatic effects of the

mother’s illness and its associated psychosocial problems

possibly being buffered by a secure attachment to an

alternative care-giver. Work is currently underway to

investigate the attachment status of these children.

Although children were cared for mostly within the family,

it remains clear from those we interviewed that mothers,

even at the peak of their own mental illness, are concerned

about their children’s welfare. Both mothers and carers

expressed anxiety about the effect illness and admission

may have on the children, and although complimentary

about the service provided by the hospital during the

admission, areas of concern arise with regard to the

transition from hospital to home, and the availability of

support information.

Although our sample was small, our investigation mirrors

other research in this area in that it highlights the need for

a formal set of guidelines to be implemented, making

practitioners and agencies aware of the larger sphere of

responsibility when a mother is admitted to hospital (e.g.,

Tamarit & Yin-Har Lau, 1999). Child and adult mental

health services are currently fragmented in many areas,

and this research shows that there is a need for joint

training within these services, with liaison between them a

priority. A multi-agency approach is called for to include

mothers, carers and children in achieving a care plan for

the family as an integrated unit, the whole of which is

affected by an admission to hospital.

Acknowledgements

The authors would like to thank the mothers and families

who participated in the study for their invaluable contri-

butions. We also would like to thank the staff of the Queen

Elizabeth Psychiatric Hospital, the Research and De-

velopment Unit, and particularly Mandy Dixon and

Emma Robertson for their help and support, as well as

peer reviewers for their comments on an earlier draft of

this paper. Lastly, we gratefully acknowledge the South

Birmingham Mental Health (NHS) Trust for providing

the funding for this research.

References

Achenbach, T. M. (1991). Manual for the Child Behavior

Checklist. Centre for Children, Youth and Families, University

of Vermont.

Department of Health Statistics Division (1995). Mental health in

England. London: Department of Health.

Department of Health (1997). Briefing paper for managers (23

January 1997). London: Department of Health.

Derogatis, L. R. (1993). Brief symptom inventory: Administration,

scoring and procedures manual. National Computers Systems

Inc.

Edelbrock, C., & Achenbach, T. M. (1980). A typology of child

behavior profile patterns: Distribution and correlates for

disturbed children aged 6–16. Journal of Abnormal Child

Psychology, 8, 441–470.

Hatfield, B., Webster, J., & Mohamad, H. (1997) Psychiatric

emergencies : Assessing parents of dependent children.

Psychiatric Bulletin, 21, 19–22.

Hawes, V., & Cottrell, D. (1999). Disruption of children’s lives by

maternal psychiatric admission. Psychiatric Bulletin, 23,

153–156.

Oates, M. (1997). Patients as parents : The risk to children. British

Journal of Psychiatry, 170 (suppl.32), 22–27.

Rice, E.P., Ekdahl, M.C., & Miller, L. (1971). Children of

mentally ill parents : Problems in child care. New York:

Behavioral Publications.

Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder :

Effects on children. Psychological Medicine, 14, 853–880.

Stormont, F., Craig, T., Atakan, Z., Loader, P., & Williams, C.

(1997). Concerns about the children of psychiatric in-patients :

What the parents say. Psychiatric Bulletin, 21, 495–497.

Tamarit, L.M., & Yin-Har Lau, A. (1999). Children’s needs when

their mothers are admitted to psychiatric units. Psychiatric

Bulletin, 23, 214–217.


Documents

Children of Mothers Admitted to Psychiatric Hospital: Care Arrangements and Mothers’ Perceptions