Family History: An Opportunity to Disrupt Transmission of Behavioral Health Problems

The family history is conventionally used to identify risk for genetically loaded physical conditions, such as cardiovascular disease. Yet, too often, behavioral and mental health problems that frequently run in families^4,–6 are not given comparable attention. Beyond genetic vulnerabilities for mental health problems, parents and grandparents convey multigenerational risk through role modeling and dysfunctional parenting behaviors, including harsh discipline, stress, abuse, and indirect trauma associated with domestic violence.^7,–10 For example, a grandparent with alcoholism may have taught the parent to handle difficult emotions through binge drinking or through patterns of raging followed by contrition and excessive indulgence in addition to child and spousal abuse. The emotional consequences on children of such vulnerable parenting undermine the children’s mental and relational health. Accordingly, the adult child of a parent with alcoholism may “inherit” dysfunctional emotional regulation and parenting regardless of whether he or she has problems with alcohol. Similarly, adult children of parents with depression may likewise be impaired in teaching their children healthy emotional regulation even if they themselves do not have depression. When parental mental health problems co-occur with potent social stressors, including insufficient finances, housing and food insecurity, or joblessness, the consequences may result in adverse social experiences or child maltreatment that further exacerbate the intergenerational transmission of social, emotional, and behavioral problems throughout the life course.

Parents with behavioral health conditions are more likely to have grown up exposed to the same or related disorders manifested by their parents (our patients’ grandparents). Hence, a family history of at least 3 generations helps us to understand an important context for conscious or unconscious sources of parental concern and anxiety for themselves and their children. To the extent that a parent experiences a behavioral health problem, an extended family history offers a window of opportunity to help parents perceive their children’s experience with empathy, recognizing the similarities between their own childhood experiences and their children’s. This perspective may also help parents to perceive and reflect on the need, with or without help, to make changes in their parenting to break the chain of intergenerational transmission.

Although multifactorial influences perpetuate behavioral health problems in families, it is important to emphasize that children inherit only half their genes from each parent. These are not autosomal dominant traits, and history is not destiny. Many parents with mental health problems provide at least “good enough” nurturing care to make their children’s experience vastly different from their own upbringing. Often the other parent or other important adults in the children’s lives provide what the affected parent cannot.

The pediatric clinician should elicit a 3-generation family tree, asking specifically about the presence of depression, alcoholism, drug dependency, posttraumatic stress disorder, anxiety, and suicide. Depending on time and context, supportive acknowledgment can be made without extensive discussion. Going forward, the pediatrician should continue to bear the family history in mind because issues may arise during later ages, especially adolescence. Often because this history has been made explicit, further discussions become easier and more valued by the family over time. In addition, the family history allows the pediatrician to be aware that the parent may also later manifest symptoms that relate to the family constellation of illness. A pediatrician might say, “At a previous visit, we talked about relatives with mental health concerns. I found that helpful in understanding your family and its history.” The clinician can then inquire the following:

1. Because this problem runs in families, do the parents or their siblings have any similar problems? If yes, are they being treated, or do they need support to obtain treatment? If no, are they worried that they may develop some of these problems?

2. Do the parents perceive that their own childhood experiences due to the behavioral health problems of their parents currently affect their parenting? Are they, for example, overprotective, overly strict, not emotionally connected, or easily angered? Asking parents such questions provides them with a chance to reflect on the linkage of past and present behaviors.

3. Are parents concerned that their children might develop similar or related behavioral health problems, if not imminently then perhaps in adolescence?

The reflective discussions based on these questions opens many opportunities for supporting parents to recall their childhood experiences in the presence of a supportive and nonjudgmental clinician, potentially providing some long-overdue comforting. This increases the potential to break intergenerational dysfunctional parenting styles regardless of whether the parents have a diagnosable condition.

The pediatrician need not learn everything at any 1 visit because the story can unfold over time, unless there is an acute serious problem. Initially, an appropriate “referral” may be to a trusted selected member of their support network, as in, “It sounds like you have many memories and feelings. I would encourage you to continue to talk about them with your spouse, sister, or friends who you feel safe with. This could help you figure out what you want to do and not do as a parent.” A referral to a professional now or in the future could be discussed, but should not be done too hastily because it might awaken a parent’s guilt or shame.

Both science and clinical experience tell us that parents’ reflection and self-understanding can enhance their ability to be good parents. The clinician’s role is to recognize potential risks, support changing parenting behavior, and arrange referrals as needed. For colleagues concerned about the time involved, taking a family history at a visit in the first 6 months should only take 1 to 3 minutes. As we suggested, the discussion about the impact on parents can be discussed over time, especially when relevant issues arise. A relationship between pediatrician and parents allows questions to evolve, answers to unfold, and actions to be taken over time. Although research questions remain on the effectiveness of this approach, clinical experience suggests that helping parents recognize the potential influences on their parenting is worth pursuing to open the door to enhanced child well-being and break the cycles of generational transmission of behavioral health disorders.

We thank Robert Needlman, MD; Martin Stein, MD; Jane O’Neil, PhD; David Willis, MD; Tina Cheng, MD; Megan Bair-Merritt, MD; Edward Schor, MD; and Frank Oberklaid, MD, for their thoughtful and helpful comments.