1. family and parenting
2. children

Comprehensive Reviews
Maternal Schizophrenia: Psychosocial
Treatment for Mothers and their Children
Robin E. Gearing 1, Dana Alonzo 1, Caitlin Marinelli 1
Abstract
Objective: Psychosocial treatments that address the unique needs of mothers with schizophrenia and their children are
sorely lacking. In striving to explore and understand treatment of maternal schizophrenia, this paper focuses on two objectives: 1) to identify and examine specialty psychosocial interventions for parents, notably mothers with schizophrenia
and their offspring; and, 2) to describe recommendations for the development of specialty psychosocial treatment for
this population. Methods: A systematic literature search of peer-reviewed articles was conducted in PsycINFO, MEDLINE, CINAHL, Social Work Abstracts, and Social Service Abstracts databases prior to January 1, 2010. The authors
reviewed each article for psychosocial interventions treating mothers diagnosed with schizophrenia and their children.
Forty-three (n=43) studies were identified. Results: Two areas of specialized psychosocial interventions designed to
treat maternal schizophrenia and their children were identified: 1) inpatient interventions programs, primarily Mother Baby Units (MBU); and, 2) outpatient interventions programs. Conclusions: Interventions targeting mothers with
schizophrenia spectrum illnesses and their children are lacking. Women with schizophrenia are at risk for not engaging
in treatment due to fears of barriers and losing their children. Although scarce, inpatient MBUs offer focused treatment,
but services are limited to the baby’s first year. Minimal outpatient psychosocial treatments are available to this population. Flexible treatment approaches that incorporate environmental supports, childcare resources, child welfare systems,
and family involvement are highly recommended.
Key Words: Maternal Schizophrenia, Mother, Offspring, Serious Mental Illness, Psychotic Disorder,
Psychosocial Treatment, Mother Baby Units, Intervention
Introduction
Schizophrenia is a chronic, serious mental illness (SMI)
that has devastating consequences for millions of individuals and families (1-4). Over the past three decades, women
diagnosed with schizophrenia spectrum disorders are increasingly having children (5-7), and the management and
treatment of schizophrenia remains a challenge to mothers and their children. Available psychosocial treatments
Columbia University, School of Social Work, New York, NY
1
Address for correspondence: Robin E. Gearing, PhD,
Columbia University, 1255 Amsterdam Avenue, New York, NY 10027
Phone: 212-851-2246; Fax: 212-851-2206;
E-mail: [email protected]
Submitted: June 16, 2010; Revised: October 17, 2010;
Accepted: January 7, 2011
specifically targeting the distinct needs of this vulnerable
population and their offspring remain largely nonexistent.
Further, the impact of accessing and engaging services may
be a discernable barrier to existing treatment for this underserved population, as mothers receiving treatment fear being judged as poor parents and may be exposed to the risk of
losing custody of their children (8, 9).
The research objectives of this review are: 1) to identify and examine the specialty psychosocial interventions
for parents, notably mothers, with schizophrenia and their
offspring; and, 2) to describe recommendations for the development of specialty psychosocial treatment for this population.
Background and Significance
The average age of onset of schizophrenia for females
ranges between 25 to 35 years (10, 11), which parallels
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Maternal Schizophrenia
the age range for childbirth (12). In the past, women with
schizophrenia were less likely to marry, be sexually active,
and, therefore, to have children (13, 14). Recent research,
however, indicates that women with schizophrenia have the
same fertility rates as women in the general population (6)
and are just as likely to have children (5, 15, 16). Research
also proposes that between 50 and 59% of women with a
serious mental illness (SMI) are mothers (8, 17), and that
54 to 80% of mothers with schizophrenia are raising at least
one of their own children (18, 19). According to Hearle and
colleagues’ (1999) study, almost 40% of women with a psychotic disorder had children who were under the age of 16
years (8). In Craig and Bromet’s (2004) study on parents with
psychosis, over 77% of the mothers’ youngest child at time of
first admission was under the age of 16 years (20).
In the past, women with schizophrenia were
less likely to marry, be sexually active, and,
therefore, to have children. Recent research,
however, indicates that women with schizophrenia have the same fertility rates as
women in the general population and are
just as likely to have children.
Women with a psychotic disorder are twice as likely as
men to actively parent their children (20) and are less likely
than fathers to have someone help them raise their children
(5). Women with serious mental illnesses lose custody of
their children more frequently than those without a psychiatric illness (5, 14, 15, 17, 21). Also, women with serious
mental illnesses are three times more likely to have involvement with the child welfare system or experience out-ofhome placement of a child (7). Additionally, 25 to 50% of
offspring with a mentally ill parent are placed in institutions
or foster care (20, 22). Joseph and colleagues (1999) found
that only 25% of mothers with a serious mental illness had
contact with their children in the past week, and only 20%
maintained full custody (17). Studies report that 50% of
mothers with schizophrenia will lose custody of at least one
child (18, 23).
Given this evidence, it is not surprising that one-third of
parents with a psychotic disorder are reluctant to seek childcare assistance for fear that their children might be taken
away from them (8). Indeed, research has found that pervasive in the minds of these women is the specter of being
judged unfit by child protective services and the court and
having their children removed from their care (9). Thus,
the real and perceived negative consequences of seeking and
receiving treatment may act as a barrier to engagement in
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treatment and may serve to further isolate these vulnerable
families.
High-risk (HR) studies is a field of research that investigates the offspring of women with schizophrenia; however,
these studies have been largely limited to examining the biological transmission and development of schizophrenia in
offspring of women with the disorder, rather than the availability and effectiveness of treatment for this population (2434).
A number of maternal factors exist that influence offspring functioning and highlight the unique needs of this
group that merit recognition when considering treatment
aimed at supporting mothers with schizophrenia. Mothers
with schizophrenia are more likely to experience greater
emotional, financial and social deprivation than mothers
without this condition (18, 35, 36). Low socioeconomic status (SES) of mothers has been found to be a stronger predictor of developmental problems and psychiatric disorders in
children than maternal diagnosis alone (37-40). In addition,
mothers with schizophrenia often have weak social support
networks and provide less stability for their children, which
have lasting impacts on cognitive, emotional, behavioral and
social development (14, 41, 42).
The psychotic symptoms of schizophrenia may affect
the mother-child relationship through a number of mechanisms including: involvement of the child in delusions,
hallucinations or passivity experiences; by rendering the
mother unavailable to her infant when her symptoms demand preferential treatment; behavioral disorganization;
abnormal expressions of emotion; and, blunted or perplexed
affect (35, 41, 43). Mothers with schizophrenia may be less
responsive, sensitive or energetic, and more remote, silent,
demanding, self-absorbed or intrusive with their child emotionally (36, 42, 44). Research suggests that this poor parentchild interaction results in offspring rating their mothers
with schizophrenia as less caring and overprotective (45).
Also, the child-rearing environment of mothers with schizophrenia has been found to be significantly poorer than with
mothers with other mental illnesses or controls (32, 46).
Although not all offspring of maternal schizophrenia
will experience negative outcomes (47), HR studies have
identified several areas of increased risk for functional impairment. In their seminal review of HR studies, Niemi and
colleagues (2003) concluded that the development of children at high risk for schizophrenia differs from that of control children; specifically in that HR children have poorer developmental outcomes (32). Offspring born to parents with
serious mental disorders repeatedly perform poorer than
control children in motor and sensorimotor areas of functioning during their first year of life (48), and significantly
poorer in language development in their first four years (49).
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Furthermore, Yoshida and colleagues (1999) found that infants of mothers with schizophrenia are more likely to have
impaired cognitive development (50). Notably, HR studies
indicate that children of mothers with schizophrenia have
more difficulty and are slower to become friendly or open
when compared with children of mothers who are not mentally ill (14, 42). Eack and colleagues (2009) noted that individuals at familial high risk for schizophrenia demonstrate
significant social cognition deficits in emotion recognition,
an early precursor to the development of positive symptoms
of this mental illness (51). These impairments may result in
mothers with schizophrenia experiencing greater difficulties
in raising their children than non-mentally ill mothers (14,
52). Conversely, a good parent-child relationship, stability
in the parental home, high-level involvement with a nonpatient parent, good social support network in young adolescence, and high IQ have been identified in research to be
protective factors for offspring of mothers with schizophrenia (24, 53, 54).
Despite the unique challenges associated with parenting
that exist for mothers with schizophrenia, a large sample of
child protection and mental health professions tend to believe that parents with mental illness can raise their children
safely as long as they have ongoing support (55). However,
inadequate services are a major problem area for this client
group (55). The HR literature investigating this population
does not address treatment specifically; literature that does
examine interventions designed to attend to the needs of
mothers with schizophrenia is sorely lacking; and this deficit of literature is reflective of the shortage of options available to this vulnerable population. Seeman’s 2008 review of
preventive services for women with schizophrenia describes
both the lack of services and the specific need for programs
to include mothers and their children (56). The remainder of
this article is an examination of the findings of this body of
literature.
Methods
Research studies were identified through a search of the
electronic databases PsycINFO, MEDLINE, CINAHL, Social Work Abstracts, and Social Service Abstracts prior to
January 1, 2010. Each database was independently searched
for peer-reviewed published articles matching the following
criteria: 1) child, children, adolescent, adult children, adult
offspring, offspring, and children of parents with a mental
illness (COPMI); 2) serious and persistent mental illness,
serious mental illness, chronic mental illness, Psychotic
Disorder, Schizophrenia, and Schizoaffective Disorder; 3)
evidence-based medicine, evidence-based practice, treatment, therapeutics, intervention, and therapy; and, 4) maternal, paternal, parent, paternal behavior, maternal behav-
ior, mother, and father. The search was limited to the English
language and human subjects. A total of 971 articles were
located across the five databases. The research team, composed of 2 PhD level and 2 Master level clinicians, reviewed
the articles for interventions treating families in which the
mother was suffering from a schizophrenia spectrum disorder. Non-intervention studies, individual case studies, and
articles targeting the treatment of pregnant mothers were
excluded, resulting in the inclusion of 43 research studies in
the review. The authors independently reviewed each article;
discrepancies were resolved through discussion and consensus.
Despite the unique challenges associated with
parenting that exist for mothers with
schizophrenia, a large sample of child
protection and mental health professions tend
to believe that parents with mental illness can
raise their children safely as long as they
have ongoing support.
Results
Overall, this search highlights the disturbing lack of
research that has been conducted on mothers with schizophrenia and their offspring, particularly as it pertains to interventions developed to treat this specific population. Two
main areas of interventions for mothers with schizophrenia
and their offspring were identified: 1) inpatient interventions programs, primarily in the form of Mother Baby Units
(MBU) that serve mothers and their newborns; and, 2) outpatient interventions programs, either through family treatment programs or home treatment, focusing on mothers and
their children. These studies were examined for their effectiveness at addressing maternal mental health outcomes (i.e.,
rates of rehospitalization, length of hospital stays, length of
psychotic episodes), parenting outcomes (i.e., ability to bond
with offspring; level of sensitivity and responsivity to baby’s
needs), and offspring outcomes (i.e., meeting developmental
milestones).
Inpatient Intervention Programs
Inpatient interventions centering on mothers with
schizophrenia and their offspring focused solely on Mother
Baby Units (MBU). No other inpatient interventions were
identified. Although 59 MBU studies were identified, only
34 investigations had samples that included mothers diagnosed with a schizophrenia spectrum disorder. Five of these
articles did not match review criteria and were excluded.
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Two of these were reviews (41, 57), two focused on diagnostic classifications (58, 59), and another on pathoplastic
factors (60).
The remaining 29 MBU studies employed a range of
methodologies, but no randomized controlled trials (RCT)
were identified. Five studies used a comparison group or
case controls to examine the characteristics and outcomes
of women admitted to MBUs (61-65) and four studies used
registry or archival data (44, 66-68). Thirteen articles employed naturalistic case study methodologies to examine the
characteristics and outcomes of women admitted to MBUs
(36, 69-75), of which three investigations also had a followup assessment (43, 76, 77). Seven descriptive studies focused
on unit characteristics, as well as maternal characteristics
(78-84).
Mother Baby Units (MBU), also referred to as Mother
Baby Psychiatric Units or Mother Baby Facilities, are specialized units established in adult or pediatric psychiatry
hospital departments specifically targeted to those mothers who experience a psychotic episode severe enough to
require hospital admission within the first year following
giving birth. A milieu intervention first employed in 1948
(80), MBUs currently exist mainly in Europe, specifically in
England, France, Belgium, Australia and New Zealand (71).
The rationale for these units is that women are more likely
to suffer from mental illness following childbirth than at any
other time in their lives (85), and that the risk of psychotic
illness is greatly increased in the first thirty days following
childbirth (85, 86). In addition, research has found that
mothers separated from their infants during hospitalization
for a psychiatric disorder experience a longer period of illness and greater difficulty bonding with their infants than
mothers jointly admitted with their infant to a specialized
unit (65). Admission criteria, length of stay, and treatment
philosophy vary across these units; however, all aim to provide specialized psychiatric care for women experiencing
postnatal psychiatric disorders, to provide a space for their
infants (up to one-year old) to promote the child’s development, and to assess the mother’s parenting skills (68, 70, 71,
73, 87).
Results from case control and comparison studies
of MBUs provide some, albeit limited, evidence for their
effectiveness (65). Specifically, these studies found that more
than half of mothers with schizophrenia and other psychotic disorders had good outcomes at discharge in terms of
developing adequate parenting behaviors (caretaking
abilities) and symptoms management (65). Furthermore,
most women with schizophrenia spectrum disorders
indicated that they were satisfied with the services they
received while on the MBU.
However, these studies also indicate that a diagnosis of
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schizophrenia was associated with the highest risk of poor
parenting and psychiatric illness-related outcomes (61, 65).
One study found that five out of seven mothers diagnosed
with schizophrenia relapsed within one month of childbirth (61). Women with schizophrenia or chronic delusional
disorders, personality disorders, or intellectual disability
remained hospitalized longer, improved less (44, 71), and
were more often separated from their babies at discharge
(73, 75) or discharged with supervision (44, 71) than women
admitted with other diagnoses. Furthermore, women with
schizophrenia were less likely to be living with their children
4–6 years post discharge from an MBU (77). These mothers
displayed more interaction deficits with their infants, specifically decreased responsivity and sensitivity, than mothers
with mood disorders (43, 74, 77). In addition, these women
shared other vulnerabilities, such as low social class and
poor social skills (65).
Among the mothers with schizophrenia, those with
positive social networks, higher socioeconomic status, and
non-mentally ill partners exhibited the most positive parenting outcomes (88). Conversely, women with behavioral
disturbances, low social class, a poor relationship with the
partner, or a partner who also had a psychiatric illness have
poorer outcomes (44). Mothers most likely to require further inpatient care were those assessed as having poor parenting skills or being more likely to self-harm or harm their
infants, and those separated from their infants at discharge
(65).
Similarly, findings from the seven descriptive studies
indicate that mothers with schizophrenia have impaired relationships with their offspring (83) and were hospitalized
sooner after the birth of their child than mothers without
schizophrenia (82). Also, the greatest demand for an MBU
was for young women suffering from psychosis post childbirth (82-84). Nevertheless, these studies conclude that a
psychotic mother with the proper supports in place can fulfill her infant’s developmental needs and is capable of maternal competence to some extent (78).
There was only one study that examined patient satisfaction with an MBU, but it was not exclusive to women
with schizophrenia. Neil et al. (2006) surveyed 41 women
discharged from an MBU over the course of one year, 66%
of whom had a psychotic disorder (89). The average length
of stay was 41 days. Overall, findings indicated that women
were highly satisfied with waiting time for admission, unit
environment, facilities and equipment, multidisciplinary
care, problem discussion, and partner involvement. However, half of the respondents were dissatisfied with their involvement in planning and decision making (89).
Overall, while Mother Baby Units demonstrate some
positive support and help for mothers suffering from schizo-
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phrenia, given that women with schizophrenia were less
likely to be living with their children 4–6 years post discharge from an MBU, this treatment modality clearly does
not provide sufficient support to mothers with schizophrenia to keep families intact. More long-term service options
are necessary to provide continued parental assistance to
these mothers.
Outpatient Interventions Programs
Outpatient interventions centering on parents with
schizophrenia and their offspring were very limited. Only
three outpatient interventions were identified that serve
parents with a serious mental illness, including a subsample
of parents with schizophrenia spectrum disorders and their
offspring.
The first outpatient intervention program focused on
family treatment for children and their parents with chronic
psychiatric illnesses, including fathers with schizophrenia.
According to Rosenheck and Nathan (1984), this was the
first program of its kind. The study found that adults were
afraid to have their children treated due to concerns of being misunderstood and harshly judged as parents; however,
these parents were willing to bring their children into the
VA setting where they were being treated themselves. The
intent of the program was that treatment for the children
would reduce stress and, thereby, positively influence the
chronically ill parents (90). Also, productive participation
in parenting would lessen stigma and enhance self-esteem.
The provision of direct treatment services for children appeared to be a useful addition to the broad-based treatment
approach, but specific details were provided. The treatment
led to a reduction in the level of overall psycho-physiological stress, an improvement in medication adherence in parents, and improved functioning of the family, and further
strengthened the relationship of the family with the hospital
treatment team (90). Overall, this program found that treating parents along with their offspring enhanced their own
family life and self-esteem and further facilitated their own
treatment (90).
The second outpatient program taught parenting skills
to mothers, monitored children’s development, and provided early intervention as required (91). This supplemental
specialty program for women offered treatment to a limited
number of mothers with schizophrenia and their preschool
offspring. The Mothers’ and Children’s Project provided
transportation and 2.5 hours of programming each week.
Mothers and children joined together in small groups that
focused on developmental education, directed play, language development, and role modeling (91). Following a
transitional break with snacks, children went to a therapeutic nursery, allowing mothers to continue in their own
group therapy. The program ended with a nutritious lunch.
Although engagement by mothers was a concern, with over
40% refusing admission to the program, preliminary results
from the program indicate success in improving parenting skills of participants and mother-child interactions, as
reported by staff, as well as enhanced treatment adherence
(91). Unfortunately, the program was limited by resources
and attempts by courts to use the program for custody evaluations.
There are few specialized psychosocial treatments that exist for mothers diagnosed with
schizophrenia spectrum disorders, to address
their unique parenting needs and provide
the support necessary to allow them to keep
their families intact.
The third outpatient intervention identified was a
home treatment designed for mothers living with schizophrenia and their dependent offspring. Khalifeh and colleagues (2009) explored the treatment preferences and needs
of mothers who were treated at home as an alternative to
hospital admission (9). As part of the introduction of crisis resolution teams (CRT) in the United States, the United
Kingdom, and Australia, patients in a mental health crisis
were offered intensive home treatment as a substitute for
admission whenever possible. Overall, mothers receiving
home treatment reported satisfaction with good quality care
and avoided unwanted hospital admission, but nevertheless struggled to provide adequate parenting (9). Mothers
described difficulties meeting children’s physical needs, feeling emotionally distant, being dependent on children during the crisis, and struggling to protect the children from
exposure to symptoms or distress (9). Results indicated that
mothers preferred the home treatment; however, during a
crisis their children preferred parental inpatient treatment as
it relieved worry. During a crisis, home treatment may meet
patient’s treatment needs, but children may be exposed to
risks, such as parental violence, poor communication, and
lack of access to professional support. Mothers recognized
the child’s need for support, but reported often being reluctant to seek professional help because of fear about custody
loss. Consequently, Khalifeh and colleagues (2009) recommended access to alternate support from sources other than
the agencies that implement child protection; that may limit
the impediment of the fear of losing custody to the mothers’
willingness to seek help. Nevertheless, the findings from this
study pertained to a population of mothers with a variety
of mental illnesses, and the results were not differentiated
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specifically for schizophrenia. Therefore, as these findings
deal with an umbrella of mental health issues, they must be
viewed cautiously when creating intervention programs tailored to maternal schizophrenia.
Discussion
There are few specialized psychosocial treatments that
exist for mothers diagnosed with schizophrenia spectrum
disorders, to address their unique parenting needs and provide the support necessary to allow them to keep their families intact. Excluding hospital admissions of index patients
during periods of crises, the only inpatient interventions
serving their needs are Mother Baby Units (MBU). However,
MBUs are not common in the United States and are limited
to mothers with children less than one year of age. It is unfortunate, but apparent, that forming a loving attachment
within a structured hospital setting such as an MBU does
not necessarily result in a mother with schizophrenia being
able to manage raising a child outside of hospital without
a substantial network of support (78). Unfortunately, such
psychosocial supports for mothers living with schizophrenia
become less available and more inaccessible as their children
get older.
Outpatient interventions jointly treating parents with
schizophrenia and their offspring were found to be very
limited. One study that examined an outpatient family treatment service found that parents were often worried about
involving their children in treatment out of fear that they
would be misunderstood and harshly judged as parents (90).
Families who engaged in the program found the provision of
direct treatment services to be a useful addition, with reduction of overall stress, improved medication adherence, better
family functioning, and a stronger relationship between the
hospital and the family (90). Home treatment as an alternative to inpatient admission during a crisis appeared to meet
the mothers’ own needs better, but offspring were found to
remain at increased risk (9).
Identifying the existing psychosocial treatment interventions for mothers with schizophrenia and their offspring
has yielded few peer-reviewed articles. MBUs provide some
programming to assist this population, but do not provide
service for older children or adolescents. Outpatient psychosocial services were even more limited, with only three
interventions identified in the literature. Clearly identified in
this review is a pronounced lack of treatment options available to this underserved and vulnerable population.
Research has clearly found that for the past three decades women with schizophrenia spectrum disorders are
increasingly having children (5-7). Despite the need to clinically engage and treat these mothers and their children, there
remains a paucity of psychosocial treatments for this vulner-
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able population. While treatment and clinical research have
advanced in similar populations, such as maternal depression (92, 93), parents diagnosed with a psychotic condition
remain underserved. Further exacerbating this issue are the
fears and concerns that parents managing these conditions
consider before engaging in treatment. Specifically, parents
reaching out for treatment may lose custody of their children (8, 18, 23), and perceived barriers and limited services
may further exacerbate feelings of isolation and stress for
mothers managing a schizophrenia spectrum disorder (9,
55).
This review is limited by the search parameters, including the exclusion of non-English language articles. Also,
the focus on peer-reviewed journals excludes any treatments or interventions that are unpublished manuscripts, or
published in conference abstracts, dissertations, and book
chapters. A majority of the study samples are comprised of
heterogeneous groups of SMI clients, thereby limiting findings. As this review focused on mothers with schizophrenia,
interventions that provide general mental health treatment
without identifying participant diagnosis may have been excluded. In addition, we excluded studies depicting treatment
programs for other at-risk non-identified populations, nonintervention studies, individual case studies, and articles targeting the treatment of pregnant mothers in general.
Recommendations
Mothers with schizophrenia and their offspring have
distinctive needs. Current research indicates that these
mothers demonstrated improved parenting skills from participation in clinical treatment with their child, including
enhanced early parent-child bonding (65), and improved
ability to fulfill their children’s developmental needs (78).
Also, parents with schizophrenia were found to have reduced
levels of stress, enhanced self-esteem, improved medication
adherence, and stronger relationships with healthcare professionals through their involvement in appropriate interventions (90).
Despite the scarcity of research, the literature offers
several recommendations for working with this unique and
underserved population. A number of areas of intertwined
clinical recommendations emerge from the literature. One
area focuses on the provision of practical parenting, skills
training, and the ongoing availability of services. In particular, the onset and length of treatment are essential to consider for interventions to be effective with mothers with schizophrenia and their children. Early interventions, such as
MBUs that provide puerperal aftercare service that supports
the ongoing bonding of mother and child, are strongly recommended in the literature (68, 77). In order to improve the
relationship between mother and child, Wan and colleagues
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(2007) recommended that treatment focus on improving
maternal sensitivity and involvement by teaching practical techniques to enhance maternal responsiveness, infant
stimulation and mutual enjoyment (77). In addition, longer
term treatment approaches beyond the first year are necessary in order to have an ongoing impact on mothers with
schizophrenia and their offspring. Interestingly, research
has found that mental health and child welfare professionals
believe individuals with a mental illness can safely parent
with ongoing support (55).
Treatment for mothers with schizophrenia may have
improved outcomes in terms of parenting related skills
and symptom management if they incorporate partners,
support networks and environmental supports. Research
recommends that treatment should include the patient’s
larger support network; specifically, the women’s partner
and/or coparent can positively contribute to improved
maternal mental health and family outcomes (44). Also,
incorporating family supports into treatment approaches may help in reducing parental distress and risks to the
children, particularly for more socially isolated
parents (9).
Another recommendation centers on the need to
include practical and flexible components to treatment.
It is recommended that treatments adopt more flexible
approaches to the provision of care for—and support
of—children of mothers with schizophrenia, such as easy
access to nursery day care, financial support, and home
child care (9, 55). In addition, Lagan (2009) argued that
enhanced coordination within the healthcare system is
required in an approach that is collaborative between
disciplines (94). For example, Waldo and colleagues
(1987) recommended the importance of specific programs
for this population that augment services provided by a
psychiatrist and/or mental health clinic (91).
Lastly, treatments that assist in positively bridging
mothers with available services may improve access and
ongoing engagement. Park and colleagues (2006)
recommended the development of appropriate coordination
to meet the needs of women with mental health problems
who are at risk of losing their children (7). For example,
mothers may need support negotiating with the child welfare system. In addition, more in-depth training for child
welfare workers may help sensitize frontline professionals
to the unique fears and needs of mothers with schizophrenia, enabling these underserved women to feel less judged
and more able to access services during times of need.
Oluwatayo and Friedman (2005) advocated for national
minimum standards in allocating these services, so that the
approach to assisting this population is no longer in “no
man’s land” (95).
Beyond clinical recommendations, the most consistent reference in the literature is the call for more research
in treating mothers with schizophrenia and their children.
Existing research is also limited by the lack of longitudinal
investigations that can follow the needs of mothers and their
children over time, and a lack of rigorous RCT research of
existing treatments.
Mothers with schizophrenia have unique needs. Further development of specialty programs and evidence-based
interventions that work with this population are of great importance. Research has found that these women and their
children benefit from participation in clinical treatment;
lack of treatment options and fear of accessing the system
are among the areas that we need to tackle to improve care
for this marginalized high-risk population.
References
1. Dyck DG, Hendryx MS, Short RA, Voss WD, McFarlane WR. Service use
among patients with schizophrenia in psychoeducational multiple-family
group treatment. Psychiatr Serv 2002;53(6):749-754.
2. Foldemo A, Gullberg M, Ek AC, Bogren L. Quality of life and burden in parents of outpatients with schizophrenia. Soc Psychiatry Psychiatr Epidemiol
2005;40(2):133-138.
3. Buchanan RW, Carpenter WT. Schizophrenia. In: Saddock BJ, Saddock VA,
editors. Comprehensive textbook of psychiatry. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 1096-1110.
4. Wu EQ, Birnbaum HG, Shi L, Ball DE, Kessler RC, Moulis M, et al. The economic burden of schizophrenia in the United States in 2002. J Clinical Psychiatry 2005;66(9):1122-1129.
5. Miller LJ, Finnerty M. Sexuality, pregnancy, and childrearing among women
with schizophrenia-spectrum disorders. Pyschiatr Serv 1996;47:502-506.
6. Nimgaonkar VL, Ward SE, Agarde H, Weston N, Ganguli R. Fertility in
schizophrenia: results from a contemporary US cohort. Acta Psychiatr Scand
1997;95(5):364-369.
7. Park JM, Solomon P, Mandell D. Involvement in the child welfare system
among mothers with serious mental illness. Psychiatr Serv 2006;57:493-497.
8. Hearle J, Plant K, Jenner L, Barkla J, McGrath J. A survey of contact with offspring and assistance with child care among parents with psychotic disorders.
Psychiatr Serv 1999;50:1354-1356.
9. Khalifeh H, Murgatroyd B, Freeman M, Johnson S, Killapsy H. Home treatment as an alternative to hospital admission for mothers in a mental health
crisis: a qualitative study. Psychiatr Serv 2009;60(5):634-639.
10. Hafner H, Maurer K, Loffler W, Fatkenheuer B, an der Heiden W, RiecherRossler A, et al. The epidemiology of early schizophrenia. Influence of age
and gender on onset and early course. Br J Psychiatry-Supplementum
1994;(23):29-38.
11. Hafner H, an der Heiden W. Epidemiology of schizophrenia. Can J Psychiatry
1997;42(2):139-151.
12. Martin J, Hamilton B, Sutton P, Ventura J, Menacker F, Munson M. Births:
final data for 2003. In: Services USDoHaH, editor. National Vital Statistics
Reports: National Center for Health Statistics; 2005. p. 1-25.
13. Propping P, Hilger T, Haverkamp F. Is there an increase of reproductive rates
in schizophrenics? European Arch Psychiatr Nervenkr 1983;232:439-450.
14. Miller LJ. Sexuality, reproduction, and family planning in women with
schizophrenia. Schizophr Bull 1997;23(4):623-635.
15. Nicholson J, Sweeney EM, Geller JL. Mothers with mental illness. I. The competing demands of parenting and living with mental illness. Psychiatr Serv
1998;49:635-642.
Clinical Schizophrenia & Related Psychoses April 2012
Gearing Online.indd 7
• 33
3/22/12 11:04 AM
Maternal Schizophrenia
16. Oyserman D, Mowbray CT, Zemencuk JK. Resources and supports for mothers with severe mental illness. Health Soc Work 1994;19(2):132-142.
17. Joseph JG, Joshi SV, Lewin AB, Abrams M. Characteristics and perceived
needs of mothers with serious mental illness. Psychiatr Serv 1999;50:13571359.
18. Chernomas WM, Clarke DE, Chisholm FA. Perspectives of women living
with schizophrenia. Psychiatr Serv 2000;51:1517-1521.
19. Ritsher JE, Coursey RD, Farrell EW. A survey on issues in the lives of women
with severe mental illness. Psychiatr Serv 1997;48:1273-1282.
20. Craig T, Bromet EJ. Parents with psychosis. Ann Clin Psychiatry
2004;16(1):35-39.
21. Coverdale J, Aruffo J, Grunebaum H. Developing family planning services
for female chronic mentally ill outpatients. Psychiatr Serv 1992;43:475-478.
22. Wang AR, Goldschmidt VV. Interviews with psychiatric inpatients about
professional intervention with regard to their children. Acta Psychiatr Scand
1996;93(1):57-61.
23. Bagedahl-Strindlund M, Rosencrantz-Larsson L, Wilkner-Svanfeldt P. Children of mentally ill mothers: social situation and psychometric testing of
mental development. Scand J Soc Med 1989;17:171-179.
24. Erlenmeyer-Kimling L, Cornblatt B. The New York High-Risk Project: a follow-up report. Schizophr Bull 1987;13(3):451-461.
25. Erlenmeyer-Kimling L, Cornblatt BA, Rock D, Roberts S, Bell M, West A. The
New York High-Risk Project: anhedonia, attentional deviance, and psychopathology. Schizophr Bull 1993;19(1):141-153.
26. Erlenmeyer-Kimling l, Squires-Wheeler E, Adamo UH, Bassett AS, Cornblatt BA, Kestenbaum CJ, et al. The New York High-Risk Project. Psychoses
and cluster A personality disorders in offspring of schizophrenic parents at 23
years of follow-up. Arch Gen Psychiatry 1995;52(10):857-865.
27. Jorgensen A, Teasdale TW, Parnas J, Schulsinger F, Schulsinger H, Mednick
SA. The Copenhagen High-Risk Project. The diagnosis of maternal schizophrenia and its relation to offspring diagnosis. Br J Psychiatry 1987;151:753757.
38. Costello EJ, Angold A, Burns BJ, Erkanli A, Stangl DK, Tweed DL. The Great
Smoky Mountains Study of Youth: functional impairment and serious emotional disturbance. Arch Gen Psychiatry 1996;53(12):1137-1143.
39. Kessler RC, Foster CL, Saunders WB, Stang PE. Social consequences of psychiatric disorders, I: educational attainment. Am J Psychiatry 1995;152:10261032.
40. Robins LN, Regier DA. Psychiatric disorders in America: the epidemiologic
catchment area study. New York: Free Press; 1991.
41. Bosanac P, Buist A, Burrows G. Motherhood and schizophrenic illnesses: a
review of the literature. Aust N Z J Psychiatry 2003;37:24-30.
42. Walker E, Emory E. Infants at risk for psychopathology: offspring of schizophrenic parents. Child Dev 1983;54:1269-1285.
43. Snellen M, Mack K, Trauer T. Schizophrenia, mental state, and mother-infant
interaction: examining the relationship. Aust N Z J Psychiatry 1999;33(6):902911.
44. Salmon M, Abel K, Cordingly L, Friedman T, Appleby L. Clinical and parenting skills outcomes following joint mother-baby psychiatric admission. Aust
N Z J Psychiatry 2003;37(5):556-562.
45. Helgeland MI, Torgersen S. Maternal representations of patients with
schizophrenia as measured by the parental bonding scale. Scand J Psycholol
1997;38:39-43.
46. Goodman SH. Emory University project on children of disturbed parents.
Schizophr Bull 1987;13(3):411-423.
47. Niemi L, Suvisaari J, Haukka J, Lonnqvist J. Childhood growth and future
development of psychotic disorder among Helsinki high-risk children.
Schizophr Bull 2005;76(1):105-112.
48. Marcus J, Auerbach J, Wilkinson L, Burack CM. Infants at risk for schizophrenia. The Jerusalem Infant Development Study. Arch Gen Psychiatry
1981;38:703-713.
49. Henriksson KM, McNeil TF. Health and development in the first 4 years of life
in offspring of women with schizophrenia and affective psychoses: Well-Baby
Clinic information. Schizophr Res 2004;70(1):39-48.
28. Ingraham LJ, Kugelmass S, Frenkel E, Nathan M, Mirsky AF. Twenty-five-year
followup of the Israeli High-Risk Study: current and lifetime psychopathology. Schizophr Bull 1995;21(2):183-192.
50. Yoshida K, Marks MN, Craggs M, Smith B, Kumar R. Sensorimotor and cognitive development of infants of mothers with schizophrenia. Br J Psychiatry
1999;175:380-387.
29. Mirsky AF, Kugelmass S, Ingraham LJ, Frenkel E, Nathan M. Overview and
summary: twenty-five-year follow-up of high-risk children. Schizophr Bull
1995;21:227-239.
51. Eack S, Mermon D, Montrose D, Miewald J, Gur RE, Gur RC, et al. Social
cognition deficits among individuals at familial high risk for schizophrenia.
Schizophr Bull 2010;36(6):1081-1088
30. Niemi L, Suvisaari J, Haukka J, Lonnqvist J. Childhood predictors of future
psychiatric morbidity in offspring of mothers with psychotic disorder: results
from the Helsinki High-Risk Study. Br J Psychiatry 2005;186:108-114.
52. Corrigan PW, Green MF. Schizophrenic patients’ sensitivity to social cues: the
role of abstraction. Am J Psychiatry 1993;150:589-594.
31. Niemi L, Suvisaari J, Haukka J, Lonnqvist J. Do maternal psychotic symptoms
predict offspring’s psychotic disoder? Findings from the Helsinki High-Risk
Study. Psychiatry Res 2004;125(2):105-115.
32. Niemi L, Suvisaari J, Tuulio-Henriksson A, Lonnqvist J. Childhood developmental abnormalities in schizophrenia: evidence from high-risk studies.
Schizophr Res 2003;60(1-2):239-258.
33. Owens DG, Johnstone EC. Precursors and prodromata of schizophrenia:
findings from the Edinburgh High Risk Study and their literature context.
Psychol Med 2006;36(11):1501-1514.
34. Talovic SA, Mednick SA, Schulsinger F, Falloon IR. Schizophrenia in
high-risk subjects: prognostic maternal characteristics. J Abnorm Psychol
1980;89(3):501-504.
35. Brunette MF, Dean W. Community mental health care for women with severe
mental illness who are parents. Community Ment Health J 2002;38(2):153165.
36. Wan MW, Salmon MP, Riordan DM, Appleby L, Webb ER, Abel KM. What
predicts poor mother-infant interaction in schizophrenia? Psychol Med
2007;37:537-546.
37. Johnson J, Cohen P, Dohrenwend BP, Link BG, Brook JS. A longitudinal investigation of social causation and social selection processes involved in the
association between socioeconomic status and psychiatric disorders. J Abnorm Psychol 1999;108(3):490-499.
33A •
Gearing Online.indd 8
53. Dellisch H. Children of schizophrenic mothers. Acta Paedopsychiatr
1989;52(4):266-270.
54. Dunn B. Growing up with a psychotic mother: a retrospective study. Am J
Orthopsychiatry 1993;63(2):177-189.
55. Darlington Y, Feeney J. Clients’ and professionals’ experience of traversing
mental health and child protective systems: implications for practice. Families
and Societies: The Journal of Contemporary Social Services 2009;90(4):382389.
56. Seeman MV. Prevention inherent in services for women with schizophrenia.
Can J Psychiatry 2008;53(5):332-341.
57. Joy CB, Saylam M. Mother and baby units for schizophrenia (review). The
Cochrane Collaboration 2007;1:1-13.
58. Brockington IF, Margison FR, Schofield E, Knight RJ. The clinical picture of
the depressed form of puerperal psychosis. J Affect Disord 1988;15(1):29-37.
59. Klompenhouwer JL, van Hulst AM. Classification of postpartum psychosis: a
study of 250 mother and baby admissions in The Netherlands. Acta Psychiatr
Scand 1991;84(3):255-261.
60. Davies A, McIvor RJ, Kumar RC. Impact of childbirth on a series of schizophrenic mothers: a comment on the possible influence of oestrogen on
schizophrenia. Schizophr Res 1995;16(1):25-31.
61. Bosanac P, Buist A, Milgrom J, Burrows G. General issues in research in motherhood and schizophrenic illnesses: a pilot study. Stress and Health: Journal
Clinical Schizophrenia & Related Psychoses April 2012
3/22/12 11:04 AM
Robin E. Gearing et al.
of the International Society for the Investigation of Stress 2004;20(1):43-44.
ness and their newborns. Zero to Three 2009;29(5):40-44.
62. Brockington IF, Meakin CJ, Brown GW, Goldberg D, Margison F. Stress and
puerperal psychosis. Br J Psychiatry 1991;157:331-334.
79. Bardon D. A mother and baby unit in a psychiatric hospital. Nurs Mirror
1977;145(23):30-33.
63. Fowler DB, Brandon RE. A psychiatric mother and baby unit. Lancet
1965;288(1):160.
80. Cazas O, Glangeaud-Freudenthal NM. The history of Mother-Baby Units
(MBUs) in France and Belgium and of the French version of the Marce checklist. Arch Womens Ment Health 2004;7(1):53-58.
64. Howard L, Shah N, Salmon M, Appleby L. Predictors of social services supervision of babies of mothers with mental illness after admission to a psychiatric
mother and baby unit. Soc Psychiatry Psychiatr Epidemiol 2003;38(8):450455.
65. Howard LM, Thornicroft G, Salmon M, Appleby L. Predictors of parenting
outcome in women with psychotic disorders discharged from mother and
baby units. Acta Psychiatr Scand 2004;110(5):347-355.
66. Abel KM, Webb RT, Salmon MP, Wan MW, Appleby L. Prevalence and predictors of parenting outcomes in a cohort of mothers with schizophrenia admitted for joint mother and baby psychiatric care in England. J Clin Psychiatry
2005;66:781-789.
67. Mowry BJ, Lennon DP. Puerperal psychosis: associated clinical features in a
psychiatric hospital mother-baby unit. Aust N Z J Psychiatry 1998;32(2):287290.
68. Salmon MP, Abel K, Webb R, Warburton AL, Appleby L. A national audit of
joint mother and baby admissions to UK psychiatric hospitals: an overview of
findings. Arch Womens Ment Health 2004;7(1):65-70
69. Bardon D, Glaser YI, Prothero D, Weston DH. Mother and baby unit: psychiatric survey of 115 cases. BMJ 1968;2(5607):755-758.
70. Buist AE, Dennerstein L, Burrows GD. Review of a mother-baby unit in a
psychiatric hospital. Aust N Z J Psychiatry 1990;24(1):103-108.
71. Glangeaud-Freudenthal NM. Mother-Baby psychiatric units (MBUs): National data collection in France and in Belgium (1999-2000). Arch Womens
Ment Health 2004;7(1):59-64.
72. Kumar R, Marks M, Platz C, Yoshida K. Clinical survey of a psychiatric
mother and baby unit: characteristics of 100 consecutive admissions. J Affect
Disord 1995;33(1):11-22.
73. Poinso F, Gay MP, Glangeaud-Freudenthal NM, Rufo M. Care in a motherbaby psychiatric unit: analysis of separation at discharge. Arch Womens Ment
Health 2002;5(2):49-58.
74. Riordan D, Appleby L, Faragher B. Mother-infant interaction in postpartum women with schizophrenia and affective disorders. Psychol Med
1999;29(4):991-995.
75. Seneviratne G, Conroy S, Marks M. Parenting assessment in a psychiatric
mother and baby unit. British Journal of Social Work 2003;33(4):535-555.
76. Bell AJ, Land NM, Milne S, Hassanyeh F. Long-term outcome of post-partum
psychiatric illness requiring admission. J Affective Disord 1994;31(1):67-70.
77. Wan MW, Warburton AL, Appleby L, Abel KM. Mother and baby unit admissions: feasibility study examining child outcomes 4-6 years on. Aust N Z J
Psychiatry 2007;41(2):150-156.
78. Almeida A, Merminod G, Schechter D. Mothers with severe psychaitric ill-
81. Kissane D, Ball JR. Postnatal depression and psychosis--a mother and baby
unit in a general hospital. Aust N Z J Obstet Gynaecol 1988;28(3):208-212.
82. Maizel S, Kandel Katzenelson S, Fainstein V. The Jerusalem psychiatric mother-baby unit. Arch Womens Ment Health 2005;8(3):200-202.
83. Milgrom J, Burrows GD, Snellen M, Stamboulakis W, Burrows K. Psychiatric
illness in women: a review of the function of a specialist mother-baby unit.
Aust N Z J Psychiatry 1998;32(5):680-686.
84. Sharp PT, Dennerstein L, Hrasky M, Lynch C, Burrows GD. A mother and
baby unit in a psychiatric hospital. Aust N Z J Obstet Gynaecol 1986;26(1):4448.
85. Kendell RE, Chalmers JC, Platz CL. Epidemiology of puerperal psychoses. Br
J Psychiatry 1987;150:662-673.
86. Terp IM, Mortensen PB. Post-partum psychoses. Clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry 1998;172:521-526.
87. Buist A, Minto B, Szego K, Samhuel M, Shawyer L, O’Connor L. Mother-baby
psychiatric units in Australia—the Victorian experience. Arch Womens Ment
Health 2004;7(1):81-87.
88. Webb R, Abel K, Pickles A, Appleby L. Mortality in the offspring of people
with psychotic disorders: a critical review and meta-analysis. Am J Psychiatry
2005;162:1045-1056.
89. Neil S, Sanderson H, Wieck A. A satisfaction survey of women admitted to a
Psychiatric Mother and Baby Unit in the northwest of England. Arch Womens
Ment Health 2006;9(2):109-112.
90. Rosenheck R, Nathan P. Treatment for children of volatile psychotic adults in
the adult psychiatric setting. Am J Psychiatry 1984;141(12):1555-1559.
91. Waldo MC, Roath M, Levine W, Freedman R. A model program to teach
parenting skills to schizophrenic mothers. Hosp Community Psychiatry
1987;38(10):1110-1112.
92. Feinberg E, Smith MV, Morales MJ, Claussen AH, Smith DC, Perou R. Improving women’s health during internatal periods: developing an evidencedbased approach to addressing maternal depression in pediatric settings. J
Womens Health (Larchmt) 2006;15(6):692-703.
93. Riley AW, Valdez CR, Barrueco S, Mills C, Beardslee W, Sandler I, et al. Development of a family-based program to reduce risk and promote resilience
among families affected by maternal depression: theoretical basis and program description. Clin Child Fam Psychol Rev 2008;11(1-2):12-29.
94. Lagan M, Knights K, Barton J, Boyce P. Advocacy for mothers with psychiatric
illness: a clinical perspective. Int J Ment Health Nurs 2009;18:53-61.
95. Oluwatayo O, Friedman T. A survey of specialist perinatal mental health services in England. Psychiatric Bulletin 2005;29(5):177-179.
Clinical Schizophrenia & Related Psychoses April 2012
Gearing Online.indd 9
• 33B
3/22/12 11:05 AM