ROLE OF MATERNAL CHILDHOOD TRAUMA ON PARENTING AMONG DEPRESSED MOTHERS OF PSYCHIATRICALLY ILL CHILDREN

Abstract

Background

Independently, maternal depression and maternal history of childhood abuse confer risk for impaired parenting. These associations may be compounded when depressed mothers with histories of childhood abuse are faced with the challenge of parenting offspring who themselves struggle with mental health problems. This study examined the relationships among maternal history of childhood abuse, maternal depression, and parenting style in the context of parenting a psychiatrically ill child, with an emphasis on examining maternal emotional abuse and neglect. We hypothesized that maternal childhood emotional abuse would be associated with maladaptive parenting strategies (lower levels of maternal acceptance and higher levels of psychological control), independent of maternal depression severity and other psychosocial risk factors.

Method

Ninety-five mother-child dyads (children ages 7–18) were recruited from child mental health centers where children were receiving treatment for at least one internalizing disorder. Participating mothers met DSM-IV criteria for major depressive disorder. Mothers reported on their own childhood abuse histories and children reported on their mothers’ parenting.

Results

Regression analyses demonstrated that maternal childhood emotional abuse was associated with child reports of lower maternal acceptance and greater psychological control, controlling for maternal depression severity, and other psychosocial risk factors.

Conclusions

When treating psychiatrically ill children, it is important for a child’s clinician to consider mothers’ childhood abuse histories in addition to their history of depression. These mothers appear to have additional barriers to effective parenting.

INTRODUCTION

Independently, maternal depression and maternal histories of childhood trauma are known to negatively impact parenting.^[1,2] Therefore, being a depressed mother with a history of childhood trauma may confer additive or even synergistic risk to parenting.^[3] Depressed mothers with histories of childhood trauma may be particularly disadvantaged when faced with the challenge of parenting psychiatrically ill children, who display greater negativity in parent–child interactions.^[4] It is currently unknown how different types of trauma histories, particularly emotional abuse and neglect, affect depressed mothers’ interactions with their psychiatrically ill children. This study examines the association between maternal childhood trauma experiences and maternal parenting style—specifically acceptance, behavioral, and psychological control—within the context of depressed mother/psychiatrically ill child dyads. In addition, we examine whether specific types of trauma histories predict mothers’ parenting style over and above maternal depression severity and other psychosocial risk factors (such as maternal education, income, or single parent status).

MATERNAL DEPRESSION, MATERNAL CHILDHOOD TRAUMA, AND PARENTING

MATERNAL DEPRESSION AND PARENTING

When depressed, mothers experience lower mood and diminished energy, which may alter the quality of her caregiving. Robust evidence demonstrates that maternal depression compromises parenting across a range of behaviors, with particular emphasis on affective components of parenting.^[5] Compared with both nondepressed psychiatric and nonpsychiatric controls, depressed mothers display differences in affection and behavioral control toward their children. For example, they engage in more angry, intrusive, hostile, and conflictual behavior^[6] and alternate between harsh discipline and permissive under-control.^[7]

MATERNAL CHILDHOOD TRAUMA AND PARENTING

Several studies demonstrate that maternal childhood trauma predicts poorer parenting,^[8–11] with an emphasis on the impact of mothers’ history of childhood physical or sexual abuse on her own use of physical abuse and aggression or even permissive parenting. The study of these specific types of parenting behaviors likely originated in an attempt to understand mechanisms involved in the “intergenerational cycle of abuse,” which uses attachment and learning models to explain how violence transmits across generations.^[10] Fewer studies have examined how mothers’ history of childhood emotional abuse or neglect relates to the dimensions of parental warmth and acceptance of her child.

Developmentally, parents tend to use less physical discipline as children enter mid-childhood and early adolescence.^[12] As the parent–child relationship changes, children begin to have more input into decisions and are able to understand and be shaped by nonphysical discipline or other behavioral control strategies.^[13] One salient, yet relatively unexplored parenting behavior is the use of psychological control. Parental psychological control has been defined as parental control attempts that intrude into a child’s psychological and emotional development by stifling his/her independent thinking and self-expression.^[13] Mothers with trauma history may utilize greater psychological control in an effort to prevent their children from asserting autonomy, because independent behaviors on the part of the child may elicit anxiety, protection^[14] or be misinterpreted by mothers who have experienced abuse.^[15]

Depressed mothers who were emotionally abused during childhood may be particularly disadvantaged when facing the challenge of parenting a psychiatrically ill child. First, these mothers may not have had an appropriate model for parenting with warmth and consistency, while encouraging autonomy. Further, an ill child’s irritability, emotional withdrawal, and externalizing behaviors will inevitably test mother’s ability to parent with equanimity. Mothers with histories of emotional abuse have more pronounced physiological indicators of emotional reactivity,^[16] which has also been demonstrated within a child focused stress task.^[17] In these parenting scenarios, a mother’s emotional or physiological reactivity may manifest in her exhibiting contradictory or confusing parenting behaviors, such as giving a child permission to be with friends, while attempting to make them feel guilty for doing so. Social learning models and attachment theory would suggest that exposure to childhood emotional abuse and neglect may lead some mothers to replay similar behaviors within their own parenting, even if to a lesser extent than would qualify as abuse.^{[18, 19]} Although the use of parental psychological control is not necessarily volitional (nor is it necessarily abusive), the resultant efforts to control the child may have deleterious effects.^[18]

MATERNAL CHILDHOOD TRAUMA IN THE CONTEXT OF DEPRESSION

Given that many depressed mothers have also experienced childhood trauma, it stands to reason that many children and adolescents are being raised by mothers with two potent parenting risk factors.^[16] Two studies have attempted to disentangle the differential impact that maternal depression and maternal cumulative trauma have on parenting. Both studies measured parent behaviors using mother’s report of her own parenting practices. One study found that maternal depression partially mediated the relationship between mothers’ own cumulative trauma history and lower parental satisfaction.^[2] Another study found that maternal cumulative trauma predicted abuse potential, punitiveness, psychological aggression, and physical discipline beyond other maternal psychiatric disorders.^[22] However, no study has tested whether mothers’ own childhood trauma history, with a focus on maternal emotional abuse and neglect, predicts child, and adolescent reports of parenting independent of maternal depression severity.

PARENTING A PSYCHIATRICALLY ILL CHILD

Compared to studies examining how maternal depression affects parenting, there has been little research testing how psychiatrically ill children affect the parenting they elicit and receive. As transactional models argue that both parents and children contribute to parenting,^[18] it is important to consider how psychiatrically ill children impact their families. Broadly, families with depressed children report higher levels of conflict and less cohesion across all family members,^[19] and families with children with attention-deficit hyperactivity disorder, conduct problems, and anxiety report more parenting stress.^{[24, 25]} However, only a few studies have actually examined what kind of parenting behaviors are elicited by psychiatrically ill children.^[4,26] In one such study, parents of depressed children ages 9–16, reported more parenting stress and found their child to be more difficult compared to parents of nondepressed children.^[26] In a rare study using observational measures of parents and their 8–17-year-old children, mothers of depressed children were observed to be less engaged and less active compared to mothers of nondepressed control children, while youth demonstrated more negativity and less positivity.^[4]

Depressed mothers who also have histories of childhood trauma, particularly emotional abuse and neglect, may be greatly challenged by parenting youth who are more negative as a result of their own depression, or emotionally dysregulated because of their own psychiatric illness. Psychiatrically ill children and adolescents may require—yet actually thwart—greater levels of acceptance and warmth from parental caregivers. Thus, depressed mothers with a history of childhood emotional abuse and neglect may be particularly challenged to provide warm and consistent parenting when faced with child negativity or emotional dysregulation.

In the current report, we examined the association between maternal childhood trauma and child perception of maternal acceptance and psychological control in mother-child dyads, both of whom suffer from psychiatric illness. We hypothesized that maternal reports of childhood emotional abuse and neglect would be associated with lower levels of child-reported maternal acceptance, and higher levels of child-reported maternal psychological control. In addition, we tested whether maternal histories of emotional abuse and neglect would be associated with child-reported parental acceptance and psychological control after controlling for well-known parenting risk factors, including maternal depression severity,^[5] low family income, and maternal education,^{[27, 28]} single parent status,^{[29, 30]} and minority race.^[31] Finally, exploratory analyses were conducted to evaluate relationships among child-reported parenting and less frequent types of maternal childhood abuse or neglect (including physical and sexual abuse/neglect).

METHOD

PARTICIPANTS AND PROCEDURES

The current investigation is part of a larger study testing the treatment effects of interpersonal psychotherapy^[32] versus brief supportive psychotherapy with clinically depressed mothers whose children were receiving mental health services. The results presented here use data collected from the baseline visit with 95 initial participant dyads. All procedures were approved by the Institutional Review Board at the University of Pittsburgh. After a complete description of the study to the subjects, written informed consent (mothers and 18-year-old children) or assent (children ≤ age 17) was obtained. The two primary recruitment sources were a child mental health clinic and a clinic that specializes in the treatment of suicidal adolescents, but participants were also referred from other child specialty mental health clinics and pediatricians’ offices. Mothers were deemed eligible if they had a current diagnosis of major depressive disorder according to DSM-IV criteria, received a score ≥ 15 on the Hamilton Rating Scale for Depression (HAM-D 25-item version)^[33] and were the custodial parent of a 7–18-year-old child receiving psychiatric treatment for an internalizing disorder. Exclusion criteria for mothers were: (1) not currently living with the child, (2) at serious risk for child abuse or neglect, (3) comorbid psychotic disorder, organic mental disorder, current substance or alcohol abuse, borderline or antisocial personality disorder, or bipolar disorder, (4) significant, unstable, medical illness, (5) not fluent in English, (6) cognitive impairments that would prevent completion of study questionnaires, or (7) currently in another form of individual psychotherapy. Child exclusion criteria included: (1) meeting DSM-IV criteria for mental retardation, autistic disorder, schizophrenia, or current substance or alcohol abuse, (2) cognitive impairments that would prevent completion of study questionnaires, or (3) chronic medical illness that might explain psychiatric symptoms.

Eligible dyads completed a baseline visit in which mothers reported on demographic information and their history of childhood abuse, and completed the structured clinical interview for DSM-IV (SCID).^[34] During this same visit, children reported on their perception of their mothers’ parenting, and completed the schedule for affective disorders and schizophrenia for school aged children (K-SADS-PL).^[35] Baseline (pretreatment) data obtained from the first 95 mother-child dyads enrolled in the study were utilized for analyses.

MEASURES

Maternal Depression

Maternal depression was assessed using the self-report quick inventory of depressive symptomatology-16.^[36,37] The scale yields scores of 0–27 with higher scores indicating greater depressive symptoms. The average score was 11.13 (SD = 4.12).

Maternal Childhood Trauma

Mothers completed the child trauma questionnaire-short form,^[38] which is a 28-item self-report inventory, using a 5-point Likert scale from “never true” to “very often true.” The 28 items create five subscales that were used to test the primary and secondary hypotheses. Previously established moderate to severe cut-points (≥10 for emotional abuse; ≥ eight for physical abuse, physical neglect, and sexual abuse; and ≥15 for emotional neglect) were used to describe the prevalence of abuse in this sample.^[39] An example of items from the emotional abuse scale is, “People in my family said hurtful or insulting things to me,” and for the emotion neglect scale is, “People in my family felt close to each other (reversed).”

Child Report of Parenting

Staff read all items to children who reported on their perception of their mother’s behavior on a 56-item version of the child report of parent behavior inventory (CRPBI). This report includes six dimensions: acceptance, child centeredness, control through guilt, instilling persistent anxiety, nonenforcement, and lax discipline. The original CRPBI was a 260-item version,^[40] with factor analysis yielding three scales, (1) acceptance versus rejection, (2) psychological autonomy versus psychological control, and (3) firm control versus lax control,^[41] with several other factor analyses producing similar factors. One study completed a factor analysis on the 56-item version, revealing similar dimensions.^[42] However, in the factor analysis, the dimensions of nonenforcement and lax discipline demonstrated questionable stability. Similarly, a study that conducted a factor analysis on the 108-item version of the CRPBI, revealed that nonenforcement and lax discipline were distinct factors, further suggesting these dimensions should not be combined.^[43] Examining our own data, lax discipline and nonenforcement were not correlated, r = .05, P = .63 and combining these dimensions resulted in poor reliability of an overall firm control scale, α = .54. However, independently the reliability for lax discipline and nonenforcement were still low, α = .60, α = .49, respectively. Therefore, these dimensions were dropped from further analyses. The other four dimensions were combined according to previous factor analyses, yielding two scales. Acceptance and child centeredness were correlated, r = .77, P < .01 yielding the acceptance dimension (α = .94). The dimensions controlling through guilt and instilling persistent anxiety were correlated, r = .69, P < .01, creating the psychological control dimension (α = .83). The average score for the acceptance was 58.58 (SD = 10.93) and for psychological control was 27.94 (SD = 6.35).

ANALYTIC APPROACH

We first explored descriptive data on maternal and child demographic and clinical characteristics, maternal reports of childhood abuse and neglect, and univariate associations among well-known parenting risk factors (maternal depression, education, income, partner status, and race) and maternal trauma histories. To test our primary study hypotheses, we first examined zero-order correlations and univariate regressions between maternal history of emotional abuse and neglect and child-reported perception of maternal acceptance and psychological control. Multiple linear regression analyses were used to test whether maternal emotional abuse and neglect were independently associated with parental psychological control and acceptance, controlling for maternal depression severity and other well-known parenting risk factors. Finally, exploratory analyses were run to evaluate correlations among the parenting dimensions with physical and sexual abuse/neglect. All analyses were conducted with SPSS 18.0.

RESULTS

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF THE STUDY SAMPLE

Maternal demographics including ethnicity, income, education level, marital status, and age are provided in Table 1. Of the maternal sample, all met for current diagnosis of MDD, with 3% reporting a current or past history of dysthymia. Of the mothers that also met criteria for a current, comorbid anxiety disorder (61% of the study sample), most commonly reported were specific phobia (18%, n = 17), panic disorder (17%, n = 16), PTSD (14%, n = 13) and social phobia (13%, n = 12). While none of the sample met criteria for a current alcohol abuse or dependence disorder, 17% met criteria for lifetime alcohol use disorder. As would be expected, mothers reported moderate to high levels of depressive symptoms at baseline assessment on the HAM-D-17 (Mean = 16.95, SD = 4.53, Range = 6–32).

TABLE 1.

Maternal demographics

Maternal Demographics	N (out of 95)	(%)
Ethnicity
African American	19	20
Asian	2	2
White	73	77
Multiracial	1	1
Education level
Partial High School	5	5
High School or GED	17	18
Some College/Tech/Associates	36	38
College	22	23
Graduate or Professional	15	16
Income
< $30,000	28	30
$30,000–75,000	40	40
>$75,000	27	30
Age (years)	44 (SD = 7.5)
Marital status
Never married	22	23
Married/living together as married	46	48
Separated/divorced	24	25
Widowed	3	3

Child demographic and clinical data are presented in Table 2. On average, children were 15 years old (range = 7–18) with an average child depressive inventory T-score of 54.03 (SD = 13.33). While a majority (82%) of the child sample met criteria for a current mood and/or anxiety disorder, a subset of the sample also met KSADS criteria for ADHD or another externalizing diagnosis (Table 2).

TABLE 2.

Child demographics and clinical characteristics

Child demographics	Mean or %
Age	15.05 (2.8) years
% Boys	44% (n = 42)
Child clinical characteristics	N (out of 95)	%
Major depressive disorder	38	40
Bipolar NOS/bipolar I/bipolar II	6	6
Generalized anxiety disorder	25	26
Simple phobia	19	20
Attention deficit disorder	42	44
Oppositional defiant disorder	17	18

MATERNAL REPORTS OF CHILDHOOD ABUSE AND NEGLECT

Of the maternal sample, 50% (n = 47) met criteria for self-reported childhood emotional abuse (Mean = 10.8, SD = 5.10), 31% (n = 29) for emotional neglect (Mean = 12.57, SD = 5.53), 33% (n = 32) for physical abuse (Mean = 7.65, SD = 3.79), 37% (n = 35) for physical neglect (Mean = 7.67, SD = 3.85), and 23% (n = 22) for sexual abuse (Mean = 7.88, SD = 6.02). Mothers reporting lower household income, lower education, and greater depression severity were more likely to report childhood histories that included various types of abuse and neglect (Table 3).

TABLE 3.

Correlations of maternal demographics, maternal depression, and maternal childhood trauma

	Mat Edu	Income	Minority race	Single parent	Dep severity	Emo abuse	Phy abuse	Sex abuse	Emo neglect	Phy neglect
Mat Edu	–	.54**	−26*	− .24*	− .27*	− .23*	− .22*	− .09	− .38**	− .31**
Income	–	–	−.33**	− .52**	− .32**	− .32**	− .28**	− .19	− .34**	− .37**
Min race	–	–	–	.28**	.20	.00	.12	.05	.04	.08
Single parent	–	–	–	–	.12	.13	.07	− .05	.08	.10
Dep severity	–	–	–	–	–	.50**	.36**	.50**	.44**	.38**
Emo abuse	–	–	–	–	–	–	.66**	.46**	.68**	.63**
Phy abuse	–	–	–	–	–	–	–	.48**	.55**	.66**
Sex abuse	–	–	–	–	–	–	–	–	.47**	.43**
Emo neglect	–	–	–	–	–	–	–	–	–	.63**
Phy neglect	–	–	–	–	–	–	–	–	–	–

Mat Edu, maternal education; Dep severity, maternal depression severity; Emo abuse, history of emotional abuse; Phy abuse, history of physical abuse; Sex abuse, sexual abuse; Emo neglect, emotional neglect; Phy neglect, physical neglect.

^*P < .05;

^**P < .01.

PRIMARY ANALYSES: MATERNAL HISTORY OF CHILDHOOD EMOTIONAL ABUSE/NEGLECT AND CHILD-REPORTED PARENTING

Maternal history of emotional abuse was negatively related to child reports of maternal acceptance (r = −.27, P = .01) and positively related to maternal psychological control (r = .30, P < .01). Thus, maternal emotional abuse accounted for between 7–9% of the variance in child-reported levels of parental acceptance and psychological control, respectively. Maternal history of emotional neglect was related to greater psychological control (r = .25, P = .01), but not to maternal acceptance (r = −.06, P = .54). Univariate regression analysis showed that mothers with childhood emotional abuse were significantly lower in acceptance (b = −.57, P = .01) and higher in psychological control (b = .37, P < .01). Mothers’ childhood emotional neglect was significantly associated with higher levels of psychological control (b = .29, P = .01). However, there was no association between maternal depression and child reported acceptance (b = −.12, P = .67) or psychological control (b = .20, P = .22). Results were consistent in multiple regression models controlling for maternal depression severity and parenting risk factors (Table 4), indicating that maternal childhood emotional abuse was independently related to both child report of lower acceptance and greater psychological control. Finally, a trend-level association between maternal history of emotional neglect and lower psychological control was obtained in models controlling for maternal depression severity and parenting risk factors (Table 4).

TABLE 4.

Linear regression models of covariates and maternal emotional abuse/neglect predicting acceptance and psychological control

	Child report of maternal acceptance b coefficient (95% CI)	Child report of maternal psychological control b coefficient (95% CI)
Maternal education	−.89 (−2.66 to .89)	−.76 (−1.80 to .29)	−.53 (−1.63 to .56)
Maternal income	−.66 (−1.96 to .64)	.61 (−.15 to 1.36)	.52 (−.25 to 1.29)
Minority race	−.71 (−6.32 to 4.90)	.28 (−3.03 to 3.58)	−.15 (−3.49 to 3.19)
Single parent status	.06 (−5.17 to 5.29)	−.28 (−3.36 to 2.81)	.01 (−3.14 to 3.15)
Depression severity	.19 (−.48 to .85)	−.02 (−.40 to .36)	.08 (−.29 to .46)
Maternal childhood emotional abuse	−.82* (−1.35 to −.28)	.42* (.11 to .73)	–
Maternal childhood emotional neglect	–	–	.28** (−.01 to .57)

^*P < .05;

^**P < .10.

MATERNAL HISTORY OF CHILDHOOD SEXUAL/PHYSICAL ABUSE AND CHILD-REPORTED PARENTING

Exploratory analyses indicated that maternal history of physical abuse was also related to higher levels of psychological control (r = .21, P = .04). Maternal histories of physical neglect and sexual abuse were not, however, related to any of the parenting variables.

DISCUSSION

This study examined the association between maternal childhood trauma and parenting style in the context of depressed mothers raising psychiatrically ill children. Notably, in the current clinical sample 50% of mothers endorsed at least moderate levels of childhood emotional abuse and 31% reported childhood emotional neglect. In addition, even within a clinically depressed group, there was a positive association between maternal depression severity and maternal histories of emotional abuse and neglect. The high rates of childhood abuse histories reported by these depressed mothers raise an important question as to whether maternal emotional abuse and neglect confer risk to parenting independent of depression severity, a known parenting risk factor.

Consistent with our primary hypotheses, maternal childhood emotional abuse was associated with a modest yet significant reduction in child-reported levels of parental acceptance, and greater use of psychological control. These results remained even after controlling for maternal depression severity and additional parenting risk factors—including maternal income, education, minority race, and single parent status.^[10] Taken together, these findings suggest that depressed mothers may respond to their children with behaviors similar to how they were raised.^[44] Moreover, we would speculate that the challenging behaviors observed in psychiatrically ill children may increase the risk that mothers revert to such learned, maladaptive parenting patterns.

Correlational analyses revealed that maternal history of emotional neglect and physical abuse were also related to child reports of maternal psychological control, but maternal history of sexual abuse was not associated with any of the parenting variables—a finding that is inconsistent with other studies demonstrating that maternal history of sexual abuse is associated with worse parenting outcomes.^[7,9] This inconsistent finding may be explained by different characteristics of study samples evaluated across extant reports. Unlike other studies examining the effects of maternal childhood sexual abuse on later parenting, the current study did not recruit participants based on childhood trauma history as evidenced by the low prevalence of sexual trauma in this sample (~23%). Parental acceptance and psychological control are not commonly examined in the maternal sexual trauma literature where mothers who have been sexually abused in childhood have been shown to demonstrate more permissive parenting behaviors.^[9,45] While it is possible that maternal history of sexual abuse would have been associated with lower behavioral control, we were unable to test this hypothesis because of the poor reliability of the CRPBI behavioral control scale.

Both the elevated levels, and significant parenting impact, of childhood histories of emotional abuse among depressed mothers represent important clinical findings. These results suggest that clinicians treating children may obtain valuable information about children’s exposure to maladaptive parenting by inquiring about the mother’s depression and history of childhood emotional abuse. Depressed mothers with histories of emotional abuse may be at particularly high risk to engage in relational parenting behaviors that not only damage the parent–child relationship, but also undermine children’s sense of personal autonomy and acceptance. Unfortunately, diminished levels of parental acceptance and elevated use of psychological control exacerbate problems in vulnerable children.^{[46, 47]} Thus, improving parenting in these domains may represent crucial treatment targets for depressed mothers and their psychiatrically ill children.

Limitations of the current study include the use of a cross-sectional design, reliance on child’s report of maternal parenting, absence of information on fathers, and heterogeneity of child diagnoses and potential variations of maternal and child treatment exposure. Despite the likelihood that lower acceptance and greater use of psychological control contribute to children’s ongoing psychiatric illness, without the use of longitudinal repeated measures models, we were unable to test such causal hypotheses. In future studies, it will be important to measure parenting at more than one time point, to examine whether perspectives on parenting shift with changes in maternal depression or child symptoms. Similarly, despite the likely transactional nature of maternal–child relationships, this study was unable to disentangle the unique contributions of child and maternal factors to the parenting behaviors measured. Child psychiatric symptoms may confound accurate reporting of parenting; therefore, future studies should use a multi-informant perspective to measure parenting. In addition, while fathers were present in some households, paternal factors represent an important but unobserved variable in the mother–child relationship. A final limitation was that the current study included children across a relatively wide range of age and psychiatric problems as well as potential variation in maternal and child treatment exposure. Further research will be needed to determine whether the observed relationships operate similarly across groups of children who vary by age and psychiatric disorder status. Additionally, cumulative maternal and child treatment exposure should be considered in subsequent studies.

CONCLUSIONS

This study advances our knowledge of the impact of maternal childhood emotional abuse on parenting in depressed women whose children have psychiatric disorders. In addition, this study points to the additive difficulties that depressed mothers with a history of childhood trauma may face when parenting psychiatrically ill children. Mothers with a history of emotional abuse may be at elevated risk to exhibit lower levels of child-focused acceptance and rely on parenting tactics that use psychological control. Depressed mothers with a history of trauma are more difficult to treat,^[21] and so it is likely that additional or novel approaches may be required to optimally address the needs of depressed mothers with early emotional abuse histories, especially when she is parenting a child with mental health challenges.