Editor’s Note: Dr. Eli Cahan (he/him) is the editor emeritus of the Section on Pediatric Trainees (SOPT) feature in Pediatrics, and an investigative journalist who covers child welfare. He is also a resident at The Boston Combined Residency Program. - Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
A couple weeks ago, Layla (name changed to protect confidentiality) was admitted. Her weight and height had been plummeting, dropping from the 25th to the 3rd percentile. And Layla’s mother, our nursing colleagues shared after yet another frustrating session trying to teach how to mix formula, just “didn’t seem to get it.”
Ms. Cameron (name changed to protect confidentiality) had been a challenge for our team. She’d swapped formulas around, continually agreeing to using one formula only to mix another from home when no one was watching. She routinely declined—always politely—the morning and afternoon medications we hoped would help push things in the right direction. A few times, she took Layla off the unit unannounced, for hours at a time.
As things go, it didn’t take long for concerns to be raised regarding the possibility that Ms. Cameron was experiencing a mental illness that was impacting the safe care she could provide her child.
Parents with a history of mental illness—regardless of their state of recovery—face both immense stigma and barriers when it comes to aspects of family life. Studies have found not only that people with mental illness face higher risks of household poverty at any time point, but that drops in income are strongly associated with the onset of mental illness. Levels of stable housing, food security, and employment also drop markedly following the onset of mental illness.
In an article being early released this week in Pediatrics, Alicia Nevriana, PhD, and colleagues at the Karolinska Institute and the University in Manchester evaluated the relationship between mental illness and another pivotal aspect of family life: whether individuals with mental illness are allowed to be parents at all (10.1542/peds.2023-061531). In a retrospective analysis using over a decade of Swedish registry data, the authors looked at the association of parental mental illness with removal of children from the home—and placement into out-of-home care (OHC).
The authors found that:
- Overall, children were over 4 times more likely to be placed in OHC if their parents had a history of mental illness.
- The youngest children faced an even higher risk: those younger than 1 year of age had a 6-times greater risk of OHC placement if their parents had a history of mental illness. Moreover, the risk was higher still in those facing other social risk factors, such as lower academic achievement, unemployment, low income, or use of any form of social welfare.
- Parents with intellectual disability or autism spectrum disorder also faced a roughly 5-fold increased risk of child removal than those without such conditions.
- Mothers with mental illness also faced a markedly higher rate of child removal than fathers with mental illness.
The authors attribute such marked elevations in risk of child separation to several factors:
- Higher levels of scrutiny in such families: “closer monitoring of families with serious parental mental illness might in part be responsible for their higher rates of offspring OHC,” the authors write.
- The system’s prioritization of “safeguarding” rather than family preservation.
- Resource gaps within the system—such that parenting support is more difficult to maintain than is separation. “Lack of resources and training for the painstaking, specialist work required to support ill parents to achieve their parenting goals,” Nevriana and colleagues write, “may mean social care systems become less likely solutions compared to measures such as OHC.”
- Regarding the noted differences in maternal versus paternal mental illness, “differences in parenting expectations between women and men” disproportionately burden women with primary caregiving responsibilities, particularly in early childhood.
In a commentary accompanying this article, Dr. Gabriel Otterman from Uppsala University and Dr. Suzanne Haney from the University of Nebraska described the findings as “sobering” (10.1542/peds.2023-063611). Early detection and screening are essential for the kinds of “timely and holistic interagency interventions” necessary to promote family preservation, they write. General pediatricians are a critical element of the kind of safety net needed to do this successfully, the commentary authors add.
In Layla’s case, ultimately—after much back and forth—our interdisciplinary team succeeded in working to support Ms. Cameron, avoiding the need for child protective services involvement. But this was just one case; certainly, in other versions of reality, a filing might have been made—in which case, it would have been incumbent upon us to gather the supports that could preserve the family.
I would encourage clinicians interested in the systemic factors leading to family separation—and intrigued by the potential role they can play to support family preservation—to read the article in full in the forthcoming issue of Pediatrics.