Abstract
Objective
Parents with serious mental illness may be vulnerable to financial insecurity, making successful parenting especially difficult. We explored relationships among parenting, serious mental illness and economic status in a nationally representative sample.
Methods
The sample included all working-age participants from the 2009 and 2010 National Survey on Drug Use and Health (n = 77,326). Two well-established scales of mental health distinguished participants with none, mild, moderate, and serious mental illness. We compared economic status by parenthood status and mental illness severity.
Results
Rates of employment were low for parents with serious mental illness (38% full-time and 17% part-time among mothers; 60% full-time and 9% part-time among fathers) compared to parents with no mental illness (50% full-time and 19% part-time among mothers; 85% full-time and 5% part-time among fathers). Mothers and fathers with serious mental illness were twice as likely to fall below the US Census poverty threshold than their peers without mental illness.
Conclusion and Implications for Practice
Parents with serious mental illness are less likely to be employed than those without mental illnesses and are highly likely to be living in poverty. Reducing poverty by helping parents with serious mental illness achieve better jobs and education is likely to translate into family stability and better outcomes.
INTRODUCTION
Parents living with disabilities are severely economically disadvantaged compared to parents without. In 2009, over half of parents living with disabilities received Supplemental Security Income (SSI), and substantial numbers received Social Security Disability Insurance (SSDI), Supplemental Nutrition Assistance Program (SNAP, food stamps), and Temporary Assistance for Needy Families (TANF), benefits that are often inadequate in meeting their needs (Kaye, 2012; National Council on Disability, 2012). For parents living with serious mental illnesses, financial security may be especially difficult to achieve or sustain. National and international surveys of community samples report unemployment rates of 39 to 68 percent for people with serious mental illness (Mechanic, Bilder, & McAlpine, 2002). Yet no national data have been published to describe the prevalence of parenthood among people with serious mental illness, nor to quantify disparities in economic wellbeing in a decade.
Analyses of National Comorbidity Survey (NCS) data provided the best data to date on the prevalence of parenthood and characteristics of parents with mental illnesses in the U.S. (Nicholson, Biebel, Katz-Leavy, & Williams, 2004). NCS respondents were considered parents if they reported having natural-born children, regardless of age or where they lived. Using data from 1990–1992, of individuals meeting criteria for any psychiatric disorder in their lifetime, two-thirds of the women were mothers and half of the men were fathers. Of individuals meeting criteria for severe and persistent mental illness (Kessler et al., 1996), parenthood was even more common: two-thirds of the women were mothers and three-fourths of the men were fathers. Other data on the prevalence of mental illness among parents are usually limited to smaller studies, most often of hospitalized or community based mental health clinic samples (Nicholson, Biebel, Hinden, Henry, & Stier, 2001), or among parents with milder forms of mental illness, such as among parents receiving TANF (Rosman, McCarthy, & Woolverton, 2001). The needs of parents with disabilities and their families cannot be met without understanding the characteristics and life circumstances of parents with serious mental illnesses (National Council on Disability, 2012).
OBJECTIVE
Our objective was to explore the relationships among parenting, serious mental illness and economic status to inform psychiatric disability policy and rehabilitation program planning, and guide further research. We acknowledge the challenges inherent in secondary analyses of large data sets (Drake & McHugo, 2003), but such resources may provide the only available window into the prevalence, experiences and needs of parents living with serious mental illnesses and psychiatric disabilities apart from small scale studies of clinical samples (Banks & Pandiani, 2003; Valenstein, 2013). The National Survey on Drug Use and Health includes survey items regarding demographic and background characteristics (age, race/ethnicity, education, marital status, substance use and general health); parenting (number of children under the age of 18 residing in the same household); mental illness (none, mild, moderate, serious); and economic status, including employment (full- or part-time, unemployed, other) and other variables reflecting financial well being (government assistance, insurance status, poverty level, and individual and family income).
Using data from the NSDUH, we addressed the following research questions: (1) In this nationally representative sample, what is the current prevalence of parenting (defined as having children under the age of 18 living in the household) among working age adults (ages 18 to 64 years) living with mental illnesses? What is the prevalence of mental illnesses among parents? (2) How do the demographic and background characteristics of mothers and fathers living with serious mental illnesses compare with those of their counterparts with no mental illnesses, and with those of individuals living with serious mental illnesses who are not parents? and (3) How does the economic status of mothers and fathers with serious mental illnesses compare with those of well mothers and fathers, and non-parents living with serious mental illnesses?
METHODS
Data source and study population
The NSDUH is a survey of the civilian, non-institutionalized U.S. population aged 12 or older based on an independent, multistage area probability sample conducted annually by the Substance Abuse and Mental Health Services Administration since 1990 (See: http://www.icpsr.umich.edu/icpsrweb/SAMHDA/browse). The NSDUH covers households, college dormitories, homeless in shelters, civilians on military bases, migratory workers’ camps, and halfway houses. It excludes active-duty military, long-term hospital residents, nursing homes, prison populations, and homeless not in shelters. Thus, the NSDUH should cover the majority of people eligible for employment. The weighted response rates for 2009 and 2010 were as follows: 68,700 people completed interviews of 85,429 people selected in 2009 (weighted response rate = 75.68%) and 68,487 people completed interviews of 85,668 people selected in 2010 (weighted response rate = 74.66%) (Substance Abuse and Mental Health Services Administration, 2011). The majority of potential respondents who refuse to be interviewed in 2009 and 2010 provided one of the following explanations: “nothing in it for me” or “no time” (Butler et al., 2011; Cirella et al., 2010). For further details, see the NSDUH 2009 and 2010 Methodological Resource Books: http://www.samhsa.gov/data/Methodological_Reports.aspx. The ------- Institutional Review Board deemed this analysis of non-identifiable, publicly available data exempt from review.
Measures
Demographic and background characteristics
The following variables were available for use in the analyses: gender (female or male), age (18 to 25, 26 to 34, 35 to 49, and 50 to 64 years), race/ethnicity (White, Black, Hispanic, Other), education (less than high school, high school graduate, some college, college graduate), and marital status (ever been married). The NSDUH provides measures of substance abuse or dependence based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Marijuana, hallucinogens, inhalants, tranquilizers, cocaine, heroin, pain relievers, stimulants, and sedatives were all considered. Participants were categorized as having no substance use disorder, alcohol abuse only, alcohol dependence only, drug abuse only, drug dependence only, or abuse or dependence on both alcohol and drugs. In addition, a rating of general health was captured by asking respondents: “Would you say your health in general is excellent, very good, good, fair, or poor?” Due to the low frequency of responses indicating poor health, “fair” and “poor” categories were collapsed.
Mental illness
This paper reports statistics by mental health status based on two assessments of past year mental illness available in the NSDUH. Conducting clinical assessments for all NSDUH participants was not possible. Instead, all participants responded to two short self-assessments, the K6 assessment of non-specific psychological distress (Furukawa, 2003; Kessler, 2003), and a shortened, eight-item version of the WHODAS assessment of functional impairment (Rehm, 1999; Novak, 2010). In 2008, The Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a clinical validation study to determine the concordance between self-assessment ratings and clinically-validated classification of NSDUH respondents as meeting or not meeting criteria for serious mental illness (SMI). The methods and analysis used for the calibration study are documented elsewhere (Colpe, 2010; Aldworth, 2010).
Parenting
As part of the household composition information collected by the NSDUH, the survey asks respondents to report the number of the respondent’s own children younger than 18 years of age who resided in the household in the past year (zero, one, two, or at least three). In most analyses, we dichotomized this variable (parenting versus non-parenting) based on reports of zero versus one or more children living in the home. Biological, stepchildren, and foster children were included, but were not distinguishable due to question phrasing. The working definition of parenting using data available in the NSDUH obtained at one point in time does not reflect circumstances in which offspring are over the age of 18 (i.e., considered to be adults themselves) or living outside the home (e.g., living with another parent or grandparent, released for adoption, living in foster or residential care), or those born after the survey but during the lifetime of the respondent. Consequently the working definition of current parenting and the available data provide a conservative estimate of the overall prevalence of parenthood (i.e., ever giving birth to or fathering a child, or parenting step- or adopted children).
Economic status
To determine the respondent’s employment status, the NSDUH asked whether the respondent worked in the week prior to the interview and, among those who worked, whether they usually worked 35 or more hours per week. Following the practice used by the U.S. Bureau of Labor Statistics, “full-time” refers to respondents who usually worked 35 or more hours per week, and “part-time” refers to other working respondents. “Unemployed” respondents did not have a job, were looking for a job, or were laid off. “Other” respondents were not in the labor force (e.g., housekeeper or student). Respondents were asked about their government assistance program participation (SSI, food stamps, public assistance, welfare/job placement/child care). They were asked to report their personal health insurance status over the past year (any—yes/no) and insurance source, if applicable (private insurance, Medicare, Medicaid/CHIP, military [CHAMPUS, TRICARE, CHAMPVA, the VA, or military health care], or other). Additional variables included categorization regarding household poverty level (using the U.S. Census poverty threshold), respondent’s total income, and family income. NSDUH categorizes participants’ poverty status by dividing the respondent’s reported total family income by the Census Bureau’s poverty threshold for the corresponding family size and composition. If the resulting value is less than 100 percent, then every individual in the family is considered to be living in poverty. The NSDUH collected information on each respondent’s total income in increments of $10,000, as well as family total income.
Analysis
STATA SE version 12 was used to conduct all analyses (StataCorp, 2011). Descriptive analyses were conducted to compute parenting rates by mental health status and mental illness rates by parenting status. Demographic and background characteristics, and economic status are reported by parenting status among respondents with serious mental illness (i.e., mother with serious mental illness, father with serious mental illness) and by mental health status among parents (parent with serious mental illness, parent with no mental illness). All counts are crude counts reflecting the number of study participants in each category. All proportions and other estimates were computed using sample weights to reflect the target population of the study, working age adults in the US. In addition, variance estimates account for the complex stratified sampling design in the NSDUH using standard approaches (i.e., Taylor series approximations as implemented by Stata SE 12). F-tests were used to test the significance of associations, accounting for the complex sampling design by reducing the degrees of freedom in the denominator to reflect the number of strata and primary sampling units, using p < .05 significance criteria. Multivariate logistic regression was used to identify factors associated with several measures of economic status stratified by parenthood status, including: employment status (full- or part-time versus none), poverty status (in the past year), family received government assistance program participation (any in the past year), and family received any SSI payments (in the past year). Given the low reported prevalence of substance abuse or dependence, we dichotomized substance use status (any substance use disorder/none).
RESULTS
Rates of mothering among women were similar across mental illness categories ranging from 42% among women with no mental illness to 38% among women with serious mental illness; rates of fathering among men decreased linearly with increasing mental illness severity, ranging from 35% among men with no mental illness to 23% among men with serious mental illness. (See Table 1.) No significant difference in number of children under 18 in the household was found between parents living with mental illnesses and those with no mental illnesses (44% versus 42% lived with one child, 34% versus 37% lived with two children, and 23% versus 21% lived with three or more children among women who were mothers with and without serious mental illness respectively [p = .44]; 44% versus 42% lived with one child, 35% versus 34% lived with two children, and 21% versus 21% lived with three or more children among men who were fathers with and without serious mental illness respectively [p = .69]). Among women who were mothers in the sample, 7% reported having serious mental illness. Among men who were fathers, 3% have serious mental illness. (See Table 2.)
Table 1.
Nationally representative prevalence of parenthood by mental illness severity among working-age adults in the U.S.
| Mental illness severity | N | Adjusted % who are parents
|
|
|---|---|---|---|
| Females N=38,829 |
Males N=34,248 |
||
| None | 28,531 | 41.5 | 34.7 |
| Mild | 4,349 | 41.4 | 29.3 |
| Moderate | 1,599 | 36.9 | 25.0 |
| Serious | 1,598 | 38.2 | 22.9 |
Notes: Data from the 2009–2010 National Survey on Drug Use and Health; includes all respondents 18–64 years of age; parenthood status based on number of the respondent’s own children (biological, stepchildren, and foster) younger than 18 years of age who resided in the household in the past year (one or more). Sample sizes are unweighted numbers; proportions are weighted to be nationally representative.
Table 2.
Nationally representative prevalence of mental illness among working-age adults in the U.S. who are parents
| Mental illness severity | Mothers | Fathers | ||
|---|---|---|---|---|
|
| ||||
| N | Adjusted % | N | Adjusted % | |
| None | 11,087 | 75.0 | 7,342 | 85.5 |
| Mild | 2,227 | 13.3 | 862 | 9.0 |
| Moderate | 941 | 4.8 | 276 | 2.9 |
| Serious | 1,293 | 7.0 | 285 | 2.6 |
Notes: Data from the 2009–2010 National Survey on Drug Use and Health; includes all respondents 18–64 years of age; parenthood status based on number of the respondent’s own children (biological, stepchildren, and foster) younger than 18 years of age who resided in the household in the past year (one or more). Sample sizes are unweighted numbers; proportions are weighted to be nationally representative.
Compared to mothers with no mental illness, mothers with serious mental illness were significantly more likely to be under age 35, White, less well educated, never been married, have a substance use disorder, and be in fair/poor health. (See Table 3.) Patterns in comparisons of fathers with serious mental illness to those with no mental illness were similar, though fathers did not differ significantly in age, race/ethnicity or marital status between groups. Fathers with serious mental illness were more likely than fathers with no mental illness to lack a college education, have a substance use disorder, and be in fair or poor health. In comparisons of parents with serious mental illness to non-parents with serious mental illness, parents were older, more likely to have ever been married; less likely to have a substance use disorder; and in better health.
Table 3.
Nationally representative demographic characteristics among working-age adults in the U.S. by mental illness severity and parenthood status
| Mothers with serious mental illness | Mothers with no mental illness | Fathers with serious mental illness | Fathers with no mental illness | Parents with serious mental illness | Non- parents with serious mental illness | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||||||
| N | Adjusted % | Adjusted % | F | p | N | Adjusted % | Adjusted % | F | p | N | Adjusted % | Adjusted % | F | p | |
| Age | 23.82 | <.001 | 2.74 | .074 | 142.76 | <.001 | |||||||||
| 18–25 | 4,235 | 14.7 | 9.6 | 1,523 | 5.8 | 4.5 | 3,013 | 12.7 | 29.3 | ||||||
| 26–34 | 3,274 | 38.0 | 28.6 | 2,013 | 27.3 | 24.0 | 807 | 35.6 | 14.2 | ||||||
| 35–49 | 4,559 | 43.6 | 54.1 | 3,693 | 61.3 | 57.6 | 1,017 | 47.7 | 25.1 | ||||||
| 50–64 | 312 | 3.7 | 7.7 | 398 | 5.6 | 13.9 | 331 | 4.1 | 31.4 | ||||||
| Race/ethnicity | 9.13 | <.001 | 1.99 | .125 | 2.71 | .050 | |||||||||
| White | 7,016 | 69.7 | 58.3 | 4,865 | 67.6 | 64.1 | 3,531 | 69.2 | 74.9 | ||||||
| Black | 1,809 | 11.6 | 14.0 | 762 | 6.5 | 9.5 | 470 | 10.4 | 9.0 | ||||||
| Hispanic | 2,530 | 14.9 | 19.5 | 1,414 | 14.8 | 19.8 | 684 | 14.9 | 10.7 | ||||||
| Other | 1,025 | 3.9 | 8.2 | 586 | 11.1 | 6.6 | 483 | 5.5 | 5.5 | ||||||
| Education | 15.20 | <.001 | 2.92 | .038 | 45.6 | .86 | |||||||||
| Less than high school | 2,208 | 15.3 | 13.3 | 1,406 | 20.1 | 14.7 | 908 | 16.4 | 15.1 | ||||||
| High school graduate | 4,013 | 33.4 | 27.0 | 2,506 | 31.2 | 28.8 | 1,758 | 32.9 | 33.0 | ||||||
| Some college | 3,422 | 32.0 | 26.5 | 1,757 | 26.9 | 22.8 | 1,709 | 30.8 | 30.9 | ||||||
| College graduate | 2,737 | 19.3 | 33.2 | 1,958 | 21.8 | 33.8 | 793 | 19.9 | 21.0 | ||||||
| Ever been married | |||||||||||||||
| Yes | 8,608 | 76.0 | 83.0 | 15.70 | <.001 | 6,276 | 86.6 | 90.0 | 2.12 | .151 | 2,030 | 78.5 | 53.1 | 102.16 | <.001 |
| Substance use disorder | 62.00 | <.001 | 22.72 | <.001 | 4.86 | .001 | |||||||||
| None | 11,694 | 83.2 | 97.1 | 6,809 | 72.5 | 91.6 | 3,485 | 80.8 | 73.0 | ||||||
| Abuse alcohol only | 258 | 4.3 | 1.5 | 357 | 7.4 | 4.1 | 343 | 5.0 | 4.9 | ||||||
| Alcohol dependent only | 194 | 6.6 | 0.9 | 242 | 9.1 | 2.8 | 525 | 7.2 | 11.2 | ||||||
| Abuse drugs only | 25 | 0.5 | 0.1 | 38 | 1.9 | 0.4 | 72 | 0.8 | 1.2 | ||||||
| Drug dependent only | 126 | 4.0 | 0.3 | 100 | 5.7 | 0.8 | 316 | 4.3 | 5.7 | ||||||
| Abuse or dependent alcohol & drugs | 49 | 1.4 | 0.1 | 50 | 3.5 | 0.3 | 277 | 1.9 | 4.1 | ||||||
| General health | 73.29 | <.001 | 21.12 | <.001 | 5.49 | .002 | |||||||||
| Excellent | 3,448 | 12.3 | 30.6 | 1,995 | 12.3 | 27.9 | 741 | 12.3 | 11.2 | ||||||
| Very good | 4,660 | 34.1 | 37.9 | 3,054 | 30.1 | 40.1 | 1,759 | 33.2 | 28.5 | ||||||
| Good | 3,280 | 32.6 | 24.8 | 2,046 | 33.0 | 25.2 | 1,612 | 32.7 | 29.5 | ||||||
| Fair/poor | 991 | 21.0 | 6.7 | 332 | 24.5 | 6.8 | 1,056 | 21.8 | 30.8 | ||||||
Notes: Data from the 2009–2010 National Survey on Drug Use and Health; includes all respondents 18–64 years of age; parenthood status based on number of the respondent’s own children (biological, stepchildren, and foster) younger than 18 years of age who resided in the household in the past year (one or more). Sample sizes are unweighted numbers; proportions are weighted to be nationally representative.
includes men and women
The rates of employment were low for parents with serious mental illness (38% full-time and 17% part-time among mothers; 60% full-time and 9% part-time among fathers) compared to parents with no mental illness (50% full-time and 19% part-time among mothers; 85% full-time and 5% part-time among fathers). (See Table 4.) Other measures of economic status revealed disparities between mothers and fathers with serious mental illness and their peers without mental illness. Mothers and fathers with serious mental illness were twice as likely to fall below the US Census poverty threshold than their peers without mental illness (30% versus 17% for mothers with and without serious mental illness; 17% versus 9% for fathers with and without serious mental illness), adjusting for family size and number of children in the household. (See Table 4.) Other measures of economic status, including respondent’s income and family total income, family government assistance program participation, and insurance status, demonstrated that mothers and fathers with serious mental illness were supporting their children with tightly constrained means compared to their peers without mental illness. Compared with non-parents, those with serious mental illness who were parents were more likely to be employed, though living below the poverty level; were more likely to receive federal benefits (food stamps, public assistance, welfare/job placement/child care, any); and were more likely to be reporting higher incomes than non-parents.
Table 4.
Nationally representative economic status outcomes among the working-age adults in the U.S. by mental illness severity and parenthood status
| Mothers with serious mental illness | Mothers with no mental illness | Fathers with serious mental illness | Fathers with no mental illness | Parents with serious mental illness* | Non-parents with serious mental illness* | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||||||
| N | Adjusted % | Adjusted % | F | p | N | Adjusted % | Adjusted % | F | p | N | Adjusted % | Adjusted % | F | p | |
| Employment rate | 20.51 | <.001 | 41.89 | <.001 | 4.06 | .009 | |||||||||
| Employed full-time | 5,450 | 37.9 | 50.4 | 6,109 | 60.3 | 85.4 | 1,776 | 43.1 | 35.7 | ||||||
| Employed part-time | 2,391 | 16.7 | 19.4 | 483 | 9.0 | 4.8 | 1,149 | 14.9 | 17.1 | ||||||
| Unemployed | 933 | 9.3 | 5.3 | 622 | 7.1 | 5.9 | 660 | 8.8 | 11.3 | ||||||
| Other** | 3,606 | 36.1 | 25.0 | 413 | 23.6 | 3.9 | 1,583 | 33.2 | 36.0 | ||||||
| Family government assistance program participation in past year | |||||||||||||||
| Received SSI payments | 825 | 12.1 | 5.9 | 32.45 | <.001 | 343 | 11.0 | 4.2 | 11.07 | .002 | 566 | 11.8 | 13.8 | 1.15 | .287 |
| Received food stamps | 3,586 | 34.4 | 17.5 | 82.62 | <.001 | 1,351 | 32.7 | 11.0 | 61.88 | <.001 | 1,318 | 34.0 | 19.2 | 46.35 | <.001 |
| Received public assistance | 1,009 | 11.9 | 4.4 | 48.76 | <.001 | 312 | 10.5 | 2.4 | 27.84 | <.001 | 341 | 11.6 | 3.2 | 57.47 | <.001 |
| Received welfare/job placement/child care | 1,214 | 11.0 | 5.2 | 33.20 | <.001 | 363 | 6.8 | 2.7 | 19.82 | <.001 | 437 | 10.0 | 4.7 | 28.18 | <.001 |
| Received any | 4,186 | 39.1 | 21.9 | 76.22 | <.001 | 1,650 | 37.3 | 14.9 | 51.65 | <.001 | 1,666 | 38.7 | 27.3 | 23.97 | <.001 |
| Insurance status in past year | |||||||||||||||
| Private | 6,566 | 48.9 | 66.7 | 55.73 | <.001 | 5,109 | 54.9 | 74.1 | 25.92 | <.001 | 2,485 | 50.3 | 51.7 | .31 | .579 |
| Medicare | 144 | 5.9 | 0.9 | 104.90 | <.001 | 84 | 8.6 | 1.1 | 36.74 | <.001 | 286 | 6.5 | 12.4 | 18.84 | <.001 |
| Medicaid/Chip | 3,087 | 28.7 | 14.3 | 68.66 | <.001 | 645 | 19.5 | 5.7 | 50.02 | <.001 | 1,086 | 26.6 | 16.3 | 30.48 | <.001 |
| CHAMPUS | 368 | 2.9 | 2.4 | .86 | 0.357 | 195 | 7.8 | 2.4 | 14.64 | <.001 | 202 | 4.1 | 5.4 | 1.75 | .190 |
| Other | 301 | 10.0 | 9.5 | .04 | 0.848 | 147 | 8.9 | 9.5 | .01 | .925 | 163 | 9.8 | 10.7 | .18 | .672 |
| Any insurance | 10,049 | 82.7 | 83.6 | .44 | 0.509 | 5,979 | 81.9 | 82.8 | .10 | .750 | 3,885 | 82.5 | 78.4 | 7.14 | .010 |
| Poverty level (%US Census poverty threshold) | 40.00 | <.001 | 11.79 | <.001 | 9.03 | <.001 | |||||||||
| <100% | 3,116 | 29.5 | 17.1 | 1,063 | 17.1 | 9.3 | 1,348 | 26.7 | 22.0 | ||||||
| 100–199% | 3,367 | 28.4 | 22.3 | 1,912 | 30.7 | 21.4 | 1,356 | 28.9 | 23.9 | ||||||
| >=200% | 5,896 | 42.1 | 60.7 | 4,652 | 52.2 | 69.3 | 2,349 | 44.4 | 54.1 | ||||||
| Respondent’s total income | 6.96 | <.001 | 7.80 | <.001 | 3.24 | .006 | |||||||||
| Less than $10,000*** | 5,099 | 38.2 | 33.3 | 767 | 19.8 | 6.2 | 2,595 | 34.0 | 40.7 | ||||||
| $10,000 – $19,999 | 2,634 | 24.4 | 17.9 | 1,178 | 15.2 | 11.2 | 1,230 | 22.3 | 23.7 | ||||||
| $20,000 – $29,999 | 1,685 | 13.4 | 13.6 | 1,142 | 10.7 | 13.6 | 546 | 12.8 | 11.8 | ||||||
| $30,000 – $39,999 | 1,034 | 10.1 | 10.2 | 1,070 | 11.6 | 13.5 | 299 | 10.4 | 7.0 | ||||||
| $40,000 – $49,999 | 670 | 6.7 | 7.7 | 872 | 13.3 | 11.7 | 193 | 8.2 | 4.6 | ||||||
| $50,000 – $74,999 | 772 | 5.4 | 9.9 | 1,238 | 16.0 | 18.4 | 190 | 7.8 | 7.3 | ||||||
| $75,000 or more | 486 | 1.9 | 7.3 | 1,360 | 13.5 | 25.5 | 115 | 4.5 | 4.9 | ||||||
| Family total income | 32.32 | <.001 | 10.04 | <.001 | 2.24 | .090 | |||||||||
| Less than $20,000 | 3,071 | 29.1 | 16.3 | 987 | 17.0 | 8.0 | 1,806 | 26.3 | 32.0 | ||||||
| $20,000 – $49,999 | 4,329 | 36.1 | 29.6 | 2,523 | 38.8 | 28.5 | 1,777 | 36.7 | 34.5 | ||||||
| $50,000 – $74,999 | 1,981 | 16.1 | 17.4 | 1,463 | 17.5 | 18.6 | 695 | 16.4 | 13.8 | ||||||
| $75,000 or more | 2,999 | 18.7 | 36.7 | 2,654 | 26.7 | 44.9 | 889 | 20.6 | 19.7 | ||||||
Notes: Data from the 2009–2010 National Survey on Drug Use and Health; includes all respondents 18–64 years of age; parenthood status based on number of the respondent’s own children (biological, stepchildren, and foster) younger than 18 years of age who resided in the household in the past year (one or more). Sample sizes are unweighted numbers; proportions are weighted to be nationally representative.
includes men and women;
e.g., housekeeper, childcare, or student;
Including loss
Table 5 provides estimates from logistic regression analyses that predicted employment status (full- or part-time versus none), poverty status (in the past year), family received government assistance program participation (any in the past year), and family received any SSI payments (in the past year). Here we highlight some of the most relevant trends. The likelihood of employment generally decreased by increasing mental illness severity among parents and non-parents, while the likelihood of poverty status (in the past year), family received government assistance program participation (any in the past year), and family received any SSI payments (in the past year) increased by increasing mental illness severity. Education status was the strongest predictor of employment, regardless of parenthood status. Among parents, having more than three children reduced the likelihood of employment, increased the likelihood of being below the federal poverty threshold in the past year, increased the likelihood of being in a family that received assistance from any governmental program in the past year, and increased the likelihood of being in a family that received assistance from SSI in the past year compared to one or two children. Mothers were three-quarters more likely than fathers to be jobless, nearly twice as likely to be living in poverty, 43% more likely to be receiving family support via one or more governmental assistance programs, and 33% more likely to be in a family that received SSI payments after adjusting for potential confounders.
Table 5.
Predicting economic status among the working age U.S. population, by parenthood status (N = 73,002)
| Economic status measure | Regression model | Parenthood status | Mental illness severity
|
||||
|---|---|---|---|---|---|---|---|
| None | Mild | Moderate | Serious | ||||
| Full- or part-time employment versus unemployed or other | 1 | Parents | OR | --- | 0.82 | 0.85 | 0.55 |
| CI | --- | .71–.93 | .70–1.03 | .45–.67 | |||
| % | 74 | 71 | 72 | 63 | |||
|
| |||||||
| 2 | Non-parents | OR | --- | 0.81 | 0.61 | 0.49 | |
| CI | --- | .74–.89 | .52–.72 | .44–.55 | |||
| % | 73 | 69 | 63 | 59 | |||
|
| |||||||
| In poverty versus ≥100% of the federal poverty threshold* | 3 | Parents | OR | --- | 1.29 | 1.46 | 1.89 |
| CI | --- | 1.09–1.52 | 1.18–1.81 | 1.57–2.27 | |||
| % | 19 | 22 | 24 | 28 | |||
|
| |||||||
| 4 | Non-parents | OR | --- | 1.18 | 1.45 | 1.66 | |
| CI | --- | 1.08–1.30 | 1.20–1.76 | 1.42–1.93 | |||
| % | 16 | 18 | 21 | 23 | |||
|
| |||||||
| Family received any government assistance versus no assistance* | 5 | Parents | OR | --- | 1.45 | 1.63 | 1.99 |
| CI | --- | 1.23–1.70 | 1.30–2.04 | 1.63–2.44 | |||
| % | 32 | 38 | 41 | 44 | |||
|
| |||||||
| 6 | Non-parents | OR | --- | 1.38 | 1.66 | 1.97 | |
| CI | --- | 1.24–1.54 | 1.37–2.02 | 1.71–2.26 | |||
| % | 14 | 17 | 20 | 22 | |||
|
| |||||||
| Family received any SSI payments versus no SSI* | 7 | Parents | OR | --- | 1.38 | 1.29 | 1.83 |
| CI | --- | 1.06–1.79 | .90–1.83 | 1.37–2.46 | |||
| % | 6 | 7 | 7 | 9 | |||
|
| |||||||
| 8 | Non-parents | OR | --- | 1.39 | 1.93 | 1.93 | |
| CI | --- | 1.17–1.65 | 1.50–2.50 | 1.59–2.34 | |||
| % | 5 | 7 | 10 | 10 | |||
Notes: Data from the 2009–2010 National Survey on Drug Use and Health; includes all respondents 18–64 years of age; parenthood status based on number of the respondent’s own children (biological, stepchildren, and foster) younger than 18 years of age who resided in the household in the past year (one or more); parenthood status categories include men and women; Sample size is an unweighted number; Estimates are weighted to be nationally representative; % = adjusted predicted probability (i.e., marginal effect);
in past year; all estimates adjust for age, race, education status, sex, marital status, general health, and substance use disorder. Estimates among parents also adjust for number of children.
DISCUSSION
This was not a hypothesis-testing study, but we expected that parents living with serious mental illnesses would be disadvantaged in terms of economic status compared to parents without mental illness (due to illness burden) and compared to non-parents with serious mental illness (due to childcare responsibilities). The NSDUH data revealed that, as expected, parents living with serious mental illnesses are less likely to be employed, more likely to fall below the poverty line, and more likely to depend on governmental assistance programs than those without mental illnesses. Even though they are more likely to be employed than non-parent peers, they are also more likely to live below the poverty line. Multivariable logistic regression models show that parents who are female, in fair or poor general health, and who have three or more children in the same household are particularly vulnerable to joblessness.
Parenting is common among working age adults living with mental illnesses. Over one-third of women living with moderate to serious mental illnesses are actively mothering children under the age of 18. The prevalence of parenting for women is similar across groups. Approximately one-fourth of men falling in the moderate and serious mental illness categories are actively fathering. The numbers of children under 18 years old living in households with mothers or fathers with serious mental illnesses do not differ from those living with well parents. The prevalence of mothers and fathers with mental illnesses who are actively parenting in this study is somewhat less than the 48% of families in households with their own children under the age of 18 as reported in the 2000 U.S. Census (U.S. Bureau of the Census, 2004). The prevalence of mothers and fathers living with serious mental illnesses is similar to the prevalence of serious mental illness by gender in the general population (Substance Abuse and Mental Health Services Administration, 2008).
Parents with serious mental illnesses in in this sample fare more poorly than parents with no mental illnesses; they tend to be less well educated, and are more likely to live with substance use disorders and be in fair or poor health. Mothers with serious mental illnesses are more likely to be vulnerable to disparities associated with minority group membership, and more likely to be living with limitations in emotional and financial resources and status conveyed by never having been married. Yet, among people with serious mental illnesses, parents are more likely to have ever been married and appear healthier than their non-parent peers. They are less likely to report substance use. Many mothers with serious mental illness report that motherhood motivates drug cessation, socialization, and medication management (Mowbray, Oyserman, Bybee, MacFarlane, & Rueda-Riedle, 2001). Fathers may share these motivations, but research regarding the role of fatherhood in the recovery of men with serious mental illness is scarce (Nicholson, Nason, Calabresi, & Yando, 1999; Reupert & Maybery, 2009; Styron, Pruett, McMahon, & Davidson, 2002).
Because these data are cross-sectional, it is not possible to explore changes over time or causal links. Parents living with serious mental illnesses seem to be faring better than those who are not parents, but these data do not permit conclusions regarding whether individuals who are doing better are more likely to become parents or whether parenting in some way supports functioning and community linkages that contribute to recovery.
Parents living with mental illnesses are less likely to be employed than those without mental illnesses and more dependent on government assistance and public insurance. Even though they are more likely to be employed than non-parents, they are more likely to be living in poverty. Adjusted prediction models further supported these findings. Poverty and mental illness have a lengthy history of association (Draine, Salzer, Culhane, & Hadley, 2002). Poverty among those living with mental illnesses may only be overcome through the creation of “reasonable career trajectories with appropriate training at key intervals to permit advancement” (Manderscheid, 2013). This is especially important to parents with serious mental illnesses, for whom the goal of economic security for their children may require immense feats of upward social mobility.
Vocational rehabilitation models have been developed to address the needs of low-income parents (Meara, 2006), people with disabilities (including psychiatric disabilities) (Burkhauser & Daly, 2011), and people receiving mental health and/or substance abuse services in community mental health centers (Drake, Bond, & Becker, 2012). Some services designed for parents in the general population may not meet the needs of parents with serious mental illness. For example, even if TANF is available, stringent work requirements of 30 to 40 hours per week with limited supportive services do not promote treatment of mental illness (Danziger, Frank, & Meara, 2009; Jayakody, Danziger, & Pollack, 2000). Some states make exceptions for individuals with mental health on TANF (relaxing work requirements for example), while others do not (Rosman, et al., 2001). Whether or not existing vocational services and policies adequately meet the needs of parents with serious mental illness remains an open empirical question.
Again, it is important to remember that the working definition used in these analyses is the report of biological children under the age of 18 living in the household, a more conservative definition from that used in the only previous analysis of the prevalence of parenthood among mothers and fathers with mental illnesses in the National Co-Morbidity Survey (Nicholson, et al., 2002). The NSDUH point-in-time data do not allow us to investigate the lifetime prevalence of ever having mental illness or ever having parented biological, step- or adopted children; having offspring over the age of 18 or living outside the home; or the prospect of children not yet born. However, given the high prevalence of custody loss reported in previous research, the prevalence of parenthood among women and men living with mental illnesses during their lifetimes is likely to be much higher than the simple prevalence of parenting (i.e., living with children under the age of 18) at one point in time for working aged adults. Our findings are likely to be conservative estimates. Given the dearth of national data on the issues and experiences of parents living with mental illnesses, these data provide the best information to date on parenting, mental illness and economic status for these adults.
Several limitations to this study warrant consideration. First, as described above, these data are all cross-sectional, precluding causal interpretation. Second, the study sample did not include people in institutional settings (prisons, hospitals, treatment centers), where individuals with the greatest illness burden and related disability are likely to reside, although institutionalized individuals are not generally participating in the labor force and not residing with their children. Third, short-form diagnostic surveys commonly used in epidemiological surveys are limited in their ability to distinguish between individuals with moderate affective illness and individuals with serious mental illness, as indicated by large discrepancies in prevalence estimates across epidemiological studies with varying diagnostic methodologies. Although steps were taken to validate these self-reported measures of illness (Aldworth, et al., 2010; Colpe, et al., 2010), self-report bias may have under estimated the prevalence of serious mental illness.
CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
Parents with serious mental illness are less economically stable than parents without and even more likely to fall below the poverty line than non-parents with serious mental illness. Parents with greater economic stability may be more likely to avoid custody loss because parents who come to the attention of the child welfare system are evaluated on their ability to provide sufficiently for their children—a roof over their heads and food on the table (Barrow & Lawinski, 2009; Park, Solomon, & Mandell, 2006). Thus, parents with serious mental illness may particularly benefit from employment and education supports. By promoting better jobs and enhanced education, such services are likely to translate into family stability and positive outcomes for adults and children. Untangling the relationships between financial status, serious mental illness, and parenting capability is a critical literature gap and opportunity for future research.
Supplementary Material
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