Working with families in which a parent has depression: A resilience perspective

Abstract

The association between parental depression and child maladjustment is well documented in the literature. Less is known about the strengths and potential protective mechanisms that help promote resilience for this population. This literature review on resilience in these families was conducted to help inform policy and practice for these families. Five protective factors (goodness of fit, self-esteem and self-efficacy, social support, family functioning, and opportunities for change) and four practice principles (discovery of resources and abilities, explanation of risk and protective factors, development of both collaborative family relationships, and social support) emerged from this review. Implications for policy and practice in light of these principles are provided.

Depression and its negative consequences continue to be serious public health problems. Depression affects about 121 million people worldwide and is among the primary causes of disability. Severe depressive symptoms increase the likelihood of impaired judgment, use of alcohol and illicit drugs, and suicide, and pose considerable financial, marital, and interpersonal challenges (Hans, 2006; Lovejoy, Graczyk, O’Hare, & Neuman, 2000). Compared with children of undiagnosed parents, children whose parents have depression are two to three times more likely to experience neglect or abuse, interpersonal conflicts, and school failure; develop adjustment problems and psychiatric illnesses; and to use mental health services (Hammen, 2003; Lovejoy et al., 2000). The relationship between exposure to parental depression and subsequent adjustment problems however, is complex because children and families differ in levels of resilience and other contextual factors. Prevention researchers have found that risk and protective factors identified in empirical studies are promising targets for preventing problems among at-risk children (Hawkins, Catalano, & Miller, 1992). While substantial literature addresses these families, the focus is primarily on risk not protective factors (e.g. Lovejoy et al, 2000). In line with the prevention literature that focuses on reducing risk and enhancing protective factors (Hawkins et al., 1992), we believe that a review focusing on protective factors for these children is needed to ensure that practice and future research are informed not only by what challenges these families experience, but also by the resources that can help promote their resilience (Amodeo & Collins, 2007). Therefore this literature review focused on protective factors and was guided by a resilience framework to generate greater understanding of protective factors and tentative practice implications to help promote resilience among these families.

Theoretical framework

When families face stress of parental depression, family adjustment is complex, influenced by multiple systems that can restrain their potential and/or promote their positive adjustment (Walsh, 2003) To better understand these multiple influences shaping child and family outcomes, a multisystem framework embracing risk and protective sources is necessary. The resilience perspective provides such a multisystem framework, suggesting that when paternal depression and related stress (risk factor) threaten adaptation and development, internal and external resources, characteristics, and abilities (protective factor) from various systems help mitigate the risk effects and help promote positive outcomes (Luthar et al., 2006; Rutter, 2000). Children and families who maintain favorable or positive outcomes, despite being exposed to significant risks, are considered resilient. Positive outcomes have been assessed in terms of developmentally related achievements, levels of stress-related symptoms, and the absence of stress-related illness (Amodeo & Collins, 2007). For instance, resilience among school-age children is often assessed in terms of good academic performance and the absence of depression and other mental illness (Garber & Little, 1999; Tiet et al., 2001; Werner, 2005).

Risk factor

A parental history of depression, either singly, or most often in combination with other risk factors, such as marital difficulties and inept parenting, is an key risk factor for their children’s internalizing and externalizing problems and poor school adjustment (Lovejoy et al., 2000; Rutter, 2000). Parental depression not only impacts early parent-child attachment but also leads to disruption in effective parenting and management. Symptoms of depression such as lack of interest and general sadness often result in mothers being socially withdrawn and indifferent to their children’s needs. They are less likely to express positive emotions or recognize their children’s strengths, and more likely to show impatience, hostility, and criticism when interacting with their children. When faced with child resistance, some mothers respond by enforcing obedience unilaterally or withdrawing rather than interacting and negotiating. Hence, children of these families tend to have low levels of self-esteem and are socialized to solve conflict through coercion or withdrawal (Fear et al., 2009; Hans, 2006; Lovejoy et al., 2000). In addition to the negative mother-child relationships and inept parenting practice, these families are also at increased risk of experiencing marital discord, interpersonal conflicts, poor social support, poverty, and discrimination (Hans, 2006). These preexisting risks and co-occurring stressors associated with depression increase families’ stress and decrease their capacity to respond to their children’s needs. Findings regarding the factors that contribute most to depression and poor childhood adjustment in these families, however, are mixed (Hans, 2006). Nevertheless, there is some consensus about the cumulative effect of multiple risk factors related to parental depression, rather than a single risk factor, contributions to negative outcomes among children (Hans, 2006; Rutter, 2000). Interventions that target multiple risk factors and promote related protective factors are more likely to decrease poor outcomes in the lives of these children.

Protective factor

The central focus of the resilience research concerning the positive adjustment for children at significant risks has been protective factors (Luthar et al., 2006). Garmezy (1993) categorized these protective influences into three categories: individual capabilities, family characteristics, and external support. Protective factors are contextual indicating that most effective protections vary by developmental stage of family members, desired outcomes, culture, as well as the degree and type of risks (Rutter, 2000). Resilience research on disadvantaged children and families (Rutter, 2000) has suggested that protective factors promote resilience by: 1) reducing the risk impact; 2) reducing the likelihood of negative chain reactions; 3) promoting and maintaining self-esteem and self-efficacy; and 4) opening up opportunities. Because most literature about families and parental depression addresses risk factors, many of which cannot readily be changed, this review focused on protective processes that can enhance services to help support these families.

Methods

This literature review was informed by the first author’s practice and research experience about parental depression and resulting effects on their children. Multiple databases (Psychin, Social Work Abstract, and the Science and Social Citation) were searched for articles and abstracts available in English between 2000 and 2010. The following search terms were used individually in and various combinations: depression, depressive, parental depression, mood disorders, protective, protection, resilience, resilient, family, children, offspring, and adolescent. The reference sections of some articles were further examined for additional relevant articles. Articles reporting survey and qualitative research, as well as controlled clinical trials addressing depression in families were reviewed. We excluded articles focusing only on children’s negative adjustment outcomes and those without information related to their protective factors.

Goodness-of-Fit

Temperament

The impact of stressful events upon a child’s adaptation depends upon differences in physical reactions to stress, meaning attached to their experiences, and stress-coping strategies used in addition to availability of resources (Pargas et al., 2010). Easygoing children and those who respond adaptively to stress are more likely to experience positive adjustment (Werner, 2005). By contrast, children with intense temperaments who respond to stress by acting out often experience stressful relationships with their parents and receive fewer nurturing parental responses (Rutter, 2000). However, given appropriate family support, children with intense temperaments do not present with any more problems than do more temperamentally adaptive children (Craig & Dunn, 2007). Conversely, chronic depression, financial hardship, and uncontrollable life events among socioeconomically disadvantaged families could place further stress on parents, affecting their capacity to respond to their children’s needs. These findings show that the interplay of environmental demands, available resources, and individual characteristics, rather than static circumstances, determine resilience.

Coping style

Individual thoughts and actions directed toward mitigation of the negative influences of stress also impacts adaptive outcomes (Langrock et al., 2002; Rutter, 2000). Researchers have examined a spectrum of coping styles ranging from a focus on problem solving to avoidance, concluding that an active problem-solving approach is most often associated with positive adjustment outcomes (Garber & Little, 1999). Others, however, suggest that coping strategies that work for one type of stressor may not work equally well for other kinds of adversity (Amodeo & Cellins, 2007). For example, some children use secondary control coping, defined as regulation of attention and thoughts, when faced with uncontrollable stressors; this may help them adjust to stressful environments without experiencing further strain. A study of 101 children living with a parent with depression from northern New England (98% Caucasian) suggested secondary control coping operated as a mediating factor that reduced the negative effect of disrupted parenting on child outcomes, helping them to avoid depression and aggressive behavior (Langrock et al., 2002). In contrast, rumination and intrusive thoughts were associated with high levels of emotional and behavioral problems among these children. Research with a more ethnically diverse sample supported an association between secondary control coping and children’s mental health (see Fear et al., 2009). A possible explanation for this dynamic is that adaptive children, instead of holding unrealistic expectations and trying to change unchangeable circumstances, found ways to avoid the circumstances, find meaning in their experiences, or focus on that which they could manage in other aspects of their lives. More empirical studies are needed to better understand effective coping factors among these resilient children.

Self-Esteem and Self-Efficacy

A person’s ongoing experiences profoundly affect the development of self-esteem and self-efficacy, both of which strongly influence well-being and resilience among children at risk. A positive primary attachment and personal accomplishments centered on a person’s interests greatly impact the development of high self-esteem and self-efficacy (Rutter, 2000).

Attachment

The quality of parent-child attachment provides children with initial impressions about their importance to other people and shapes their self-esteem (Craig & Dunn, 2007). When in an unfamiliar environment, securely attached children are calm rather than anxious and display curiosity about their surroundings (Hammen, 2003). Evidence also indicates that, in families with parental depression, children who perceive themselves to be the favorite child at home, report good family relationships and feel accepted by at least one parent; they also are not likely to be involved in illegal behaviors or develop severe mental illness (Garber & Little, 1999). Having healthy bonds with other adults who have a positive influence and who are supportive was also associated with greater self-esteem, confidence, and self-efficacy; less substance use and delinquent behavior; and better mental and physical health under stress (Pargas et al., 2010; Werner, 2005).

Personal accomplishments

Engaging in meaningful activities that help promote a sense of self-efficacy also promotes overall well-being (Werner, 2005). Reading, art, music, sports, school work, and other culturally valued activities and achievements that bring pleasure and comfort can protect individuals from developing severe emotional and behavioral problems (Garber & Little, 1999; Tiet et al., 2001). When children are engaged in school or other age-appropriate activities, they are less likely to ruminate about negative experiences or become vulnerable to high risk situations. Furthermore, when children take part in activities in which they interact as members of cooperative teams, they develop a sense of high self-value and the ability to master tasks (Werner, 2005). These activities can also provide opportunities to form nurturing relationships with others, discover personal strengths, and learn new coping skills.

Social Support

Extended families

For families with parental depression who face multiple risks such as financial stress and interpersonal conflicts and seem unable to foster their children’s well-being, formal and informal social resources can help promote their resilience (Gabber, 2005; Hammen, 2003; Werner, 2005). The effect of social support on young children reared in various adverse environments has been well documented (Chen, in press; Colarossi & Eccles 2003; Jones, 2005; Masten, 2001). Research suggests parents who perceive support from relatives and friends report little emotional distress and few financial challenges and household burdens (Hammen, 2003; Jones, 2005). Others have argued, however, that the effect of extended/kinship family support does not necessarily foster positive development for other at-risk children (Jones, 2005; Lyons et al., 2005). In some cases, family support while helpful cannot offset the parent’s difficulty engaging and relating to help enhance the child’s development (Lyons et al., 2005).

Non-parental adults

Support from adults outside the family has been recognized as an influential protective factor for high-risk children (Colarossi & Eccles 2003; Werner, 2005). Findings concerning support from nonparental adults are similar to those relating to socially supportive protective factors from various settings that promote children’s self-esteem and self-efficacy. Fundamentally, such support helps children to meet basic developmental needs for connection, belonging, safety, and self-confidence. Nevertheless, the influence of nonparental support could vary by ethnic group, parents’ circumstances, and the developmental outcomes under consideration (Casey-Cannon, Pasch, & Tschann, 2006). For instance, staying in school and pursuing higher education are more challenging for children in disrupted and impoverished families, in part, because they lack suitable places to study, information regarding college enrollment examinations, and funds for education. The protective factors to promote academic attainment, hence, should involve features that mitigate these risk influences. Teachers and coaches who have educationally relevant information and resources can play a key role in helping these children attain higher education (Chen, in press).

Prosocial peers

Peers constitute another important source of support for young people (Pargas et al., 2010). Resilient children often report higher levels of peer support than do those who are less well adjusted (Garber & Little, 1999; Polkki, Ervast, & Hupponen, 2004; Werner, 2005). Intervention research has suggested that prosocial peers and resilient young adult role models offer hope and inspiration that enable children to develop abilities and use resources to overcome challenges (e.g., Orel et al., 2003). The increases in peer influence during adolescence vary with individual and family circumstances. Generally, girls report more peer support than do boys, but girls are also more vulnerable than boys to interpersonal conflicts (Colarossi & Eccles, 2003; Gore & Aseltine, 1995). Moreover, given age-limited resources and abilities, evidence suggests that prosocial peer support may be most effective with personal and school-related distress and in preventing delinquency among children at risk; it may not be sufficient to protect children from the consequences of family distress.

Family Functioning

Communication

Risks associated with parental depression often accumulate over time, influencing a family’s capacity to succeed in rearing children (Hammen, 2003, Hans, 2006). Protective factors that can interrupt the accumulation of negative reactions are crucial to resilience. Good family communication has long been recognized as a key factor preventing negative consequences of family conflicts, misunderstandings, and stigma resulting from ineffective communication regarding mental illness (McCubbin, Thompson, & McCubbin, 1996; Walsh, 2003). Accordingly, Beardslee and colleagues (1997, 2007) proposed a cognition-communication focused intervention. Families in which a parent had depression were randomly assigned to either a clinician-based or a lecture-based intervention. Both groups received information about mental illness, with families in the clinician-based intervention receiving additional training and support from clinicians who helped to address each family’s specific concerns. Members of the clinician-based group displayed more significant improvement in family communication, positive attitudes among family members, parents’ coping skills, and related issues. Moreover, Beardslee et al. (2007) suggested that a change in parents’ knowledge and attitudes about depression was the key predictor, regardless of intervention format, for a decrease in internalizing symptoms among children. Although this connection requires further clarification, Beardslee’s rigorous research designs give plausibility to the findings. Perhaps when parents know more about depression and its possible influence on their children’s development, they become more vigilant about the quality of their parent-child interaction which, in turn, improves their communication and interaction as well as their child’s adjustment.

Parental monitoring

Perception of self-efficacy in conducting the parental role, particularly consistent parental monitoring, are strongly associated with children’s resilience even though parenting is one of the most challenging tasks for individuals with mental illness (Brennan, Brocque, & Hammen, 2003; Garber, 2005; Knoche, Givens, Sheridan, 2007; Tiet et al., 2001). Parents’ consistent efforts to know what their children are doing outside of the home, including knowledge of their peers and activities, helps prevent children from pursuing unfavorable developmental trajectories, fosters age-appropriate competence (Tiet et al., 2001), and exerts a broad protective effect on academic and behavioral outcomes (Chen, in press). This factor is consistent with Rutter’s (2000) notion that a protective process can mitigate a negative chain reaction that original risks initiate. Even when parents are less vigilant due to their own challenges, if youths are aware of their parents’ monitoring, they tend to anticipate the consequences of their behaviors, avoid transgressing parental norms, and concentrate on activities of which their parents approve (Chen, in press).

Flexibility

Well-adjusted families tend to be flexible in their ability to adjust their family roles, adopt effective problem-solving strategies, and seek support to address challenges (McCubbin et al., 1996). Because families differ in resources, relationship dynamics, and expectations of family members during crises, it is not unusual that, in families with limited resources, children may undertake domestic duties and adolescents may help support the family financially (Polkki et al., 2004). As long as they do not overwhelm the youths and needed support is available, these additional roles and duties could help to enhance children’s character and competence (Rutter, 2000). Children can learn coping strategies, life management skills, and a sense of self-efficacy. Some resilient children who display behavioral competence, however, may still experience emotional distress. Polkki, Ervast, and Hupponen (2004) describe some resilient children as “lonely and helpless with their rainbow of emotion” (p. 160) to illustrate the complexity and diversity of the circumstances resulting from parental mental illnesses.

Opportunities for Changes

Cumulative and ongoing stressors often increase rates of psychopathology among children with a parent who has depression. Developing symptoms tend to persist and worsen over time (Rutter, 2000). Evidence from longitudinal research, however, has shown that having a stable, consistent support provider or leaving a stressful environment can serve as a turning point to alter an individual’s outcome (Werner, 2005). For example, military service has been found to be protective for some individuals from high-risk environments (Werner, 2005), likely through providing additional learning opportunities and preventing early, escape-oriented marriages that could lead to further stress (Rutter, 2000). This can be particularly important to socioeconomically disadvantaged young people who leave school early.

Implications for Practice

Despite increased attention to this area of research, greater exploration of the protective factors that help these children thrive is needed, especially research that informs practice and how best to enhance their protective factors, which then helps empower these families. Too often when these families encounter helping professionals, the focus is solely on problems (Saleebey, 2006). Families present feeling overwhelmed by stress and unable to recognize any abilities or resources that they can use to address their challenges. Initial evidence reviewed in this article suggests that family, community, and individual resources and strengths could help promote resilience among these families through the above mentioned five factors. Based on this review, we suggest the following four practice principles for working with these families.

Practice Principles

Discovery of resources and abilities (assessment)

Practitioners first need to be aware that under their deficit and problem-saturated stories, families often have resources and strengths (Saleebey, 2006). The literature reviewed in this paper can help increase practitioners’ sensitivity in discovering and clarifying hidden messages of hope (see Table 1). Principles and skills that help uncover these hidden messages have been well documented in the strengths-focused practice literature (see Lee, 2003; Saleebey, 2006). An empowerment oriented, collaborative client-practitioner relationship is key to a culturally relevant understanding of clients’ perceptions of their challenges. This collaborative relationship serves as a fundamental base for practitioners and clients exploring when their chronic problems have not dominated their lives. Interview skills such as asking “exception questions” can encourage families to re-evaluate their challenges (see Lee, 2003) and identify hidden resources and abilities among these families.

Table 1.

Protective Factors That Promote Resilience

Domain	Processes
Goodness-of-Fit	Temperament. Young children with easygoing temperaments have fewer internalizing and externalizing problems. Temperament, however, does not determine adjustment; open, responsive caregivers and contexts that respond to their needs promote good adjustment.
	Coping style. Generally, the use of active problem-solving approaches is associated with positive adjustment outcomes. In some highly stressful and uncontrolled circumstances, children who regulate their attention and thinking show fewer symptoms of depression and aggressive behavior.
Self-Esteem and Self-Efficacy	Attachment. A positive attachment relationship that provides a young child with a sense of security and belonging involves communicating that the child is important to others. Secure children show less anxiety and display curiosity about their new environments.
	Personal accomplishments. Prosocial activities consistent with children’s own interests and social norms decrease likelihood of children having criminal records and a diagnosis of depression in adulthood.
Social Support	Extended family. Parental support systems may indirectly impact their child’s overall well-being by reducing the parent’s emotional distress, financial challenges, and household burdens.
	Non-parental adults. Support from non-parental adults can promote resilience in children through a variety of approaches depending upon the specific developmental stage and intended goal.
	Prosocial peers. This support reduces at-risk children’s behavioral problems and distress related to personal and school problems.
Family Functioning	Communication. Positive family communication encourages expression of affection and support; it can lead to early identification of problems, and reduction in misunderstanding of mental illness and family crises. Positive family communication could help reduce internalization of symptoms and unhealthy guilty feelings.
	Parental monitoring. Supportive family relationships and consistent parental monitoring are key protective factors that promote academic and behavioral resilience in children and adolescents.
	Flexibility. Flexibility allows family members to assume roles and responsibilities to meet the environmental demands. With appropriate support, this could provide a potential growth experience for children and help minimize emotional distress.
Opportunities for Change	Events, decisions, and encouragement (e.g., military enlistment, post- secondary education, new relationships) that enable individuals to avoid sources of risk, develop a career, or build positive attachments to supportive persons help high-risk children become responsible adults.

Moreover, when several existing or potential protective factors are identified, we suggest that practitioners first address those factors that are (1) easily malleable, (2) durable, (3) effective across multiple dimensions of adjustment outcomes, and (4) powerful enough to initiate protective processes (Chen, in press; Luthar et al, 2006). Because risk-focused research has found that some risks, particularly biological factors or individuals’ natural characteristics, cannot be easily changed, a focus on malleable protective factors that are more responsive to intervention has emerged. For example, one’s temperament cannot be readily changed. In contrast, factors such as parenting training have been found to be malleable through interventions that can sustain family functioning sufficiently to promote their child’s resilience. Hence, when parents express their frustrations regarding a child’s temperament-related behaviors, practitioners can help parents to understand the child’s temperament and learn how to respond appropriately.

Explanation of risk and protective factors (education)

This second practice principle is based on strong evidence suggesting that understanding the ways that parental depression might be associated with children’s adjustment outcomes could help avert the development or intensification of stress-related problems (Beardslee et al., 1997, 2007). Hence, with the information in Table 1, practitioners can help parents understand that their children’s paths to certain problems are influenced by multiple factors, and that the problems might be minimized through positive family interactions, effective coping, and the use of resources. It is important to explain there are no absolute good or bad individual traits, family structures, or problem solving strategies. Instead, looking for malleable factors to promote the goodness of fit between individual family members’ traits and their family environment is the key to promoting resilience.

Development of collaborative relationships in family

Evidence supporting this third practice principle suggests that even under highly stressful conditions family is a key resilience- promoting resource (Walsh, 2003). Thus, preventive interventions should focus on the enhancement of family processes that foster resilience, such as appropriate communication about their challenges, expression of concern, provision of support to each other, and adaptation of family roles to life’s demands. Furthermore, effective parenting is important in preventing behavioral and academic problems among children, suggesting training and resources to support parents in their child rearing role is essential in maintaining family functioning (Chen, in press).

Development social support

This fourth practice principle recognizes that support is needed outside the family. Resilience does not arise from a particular individual trait or ability; rather, the capacity for developing resilience is heavily influenced by environmental support and the extent of the risk (Masten, 2001; Walsh, 2003). Helping families build and maintain supportive relationships with others in their communities facilitates the fundamental human need for connection which is often compromised by stigma related to mental illness. Training in interpersonal interactions and how to secure outside services can help families develop their social capital which, in turn, provides further opportunities for learning and support.

Conclusion

Obviously these four practice principles are inter-related and woven into work with families, not in a linear step wise process, but using ongoing assessment and review that informs next steps. Another core assumption is of the importance of cultural relevance when working with any family. Honoring and understanding the complexity in families, each with its unique risk and protective factors, challenges practitioners when working with families and mental illness. Ongoing research is needed to better understand the needs of this diverse group of families as they strive to strengthen their lives when living with parental depression.