BY Ruwan Laknath Jayakody
Although there have been many cases of shared delusions in children whose parents have schizophrenia, presentations where genuine concern predominates, fueled by the negative experiences of a mother with schizophrenia, are rarely described, which means which makes this an area that deserves further study in order to provide better support for both these parents and children.
This observation citing “Shared Psychotic Disorder in Children of Parents with Untreated Schizophrenia: A Case Series” by HB Nachane was made by PKDHJLDS Rajaratne and DMA Dahanayake (both attached to Lady Ridgeway Hospital for Children with the latter also attached at the University of Colombo Faculty of Medicine) in a brief report on “My Daughter Is Not Well: The Fears of a Mother Suffering from Severe Psychiatric Illness” which was published in the Sri Lanka Journal of Psychiatry 12 (2) in December 2021.
Schizophrenia (a chronic and severe mental disorder and illness involving psychosis, characterized by distortions of thinking, perception, emotions, language, self-esteem and behavior, with hallucinations [hearing voices or seeing things that are not there] and illusions [fixed and false beliefs] experienced), as noted in âChildren of a Parent with Mental Illness: Perspectives on Needsâ by D. Maybery, L. Ling, E. Szakacs and A. Reupert, is a major mental illness with a significant impact on both individuals and their families, where although children of parents with schizophrenia feel emotionally detached from affected parents, fear the uncertainty of the disease and long for normalcy, their needs are often overlooked by professionals who take care of parents. In addition, according to âSchizophrenia: The impact of parental disease on childrenâ by V. Somers, there is limited evidence regarding the impact of schizophrenia on the family, especially children in South Asian countries such as Sri Lanka.
There is a significant hereditary component to schizophrenia, with 80% childhood schizophrenia, according to “Childhood onset schizophrenia: What do we really know?” by J. Bartlett, presenting a positive family history. However, according to âPsychotic Disorders in Children and Adolescents: An Introduction to Contemporary Assessment and Managementâ by JR Stevens, JB Prince, LM Prager, and TA Stern, psychotic symptoms in children of parents with schizophrenia do not. do not necessarily portend impending schizophrenia. When a child with a parent with schizophrenia develops psychotic symptoms, it is necessary, as Stevens et al. and Nachane, to exclude organic causes, substance-induced psychosis, depression, shared delusions, Munchausen syndrome by proxy (now known as factitious disorder imposed on another, which is a mental illness and a psychological behavioral disorder marked by attention seeking behavior on the part of a caregiver, often the primary caregiver, through those he cares for, seeking medical help for exaggerated or invented symptoms in a child, including physical or mental illness, even if the caregiver is not really sick) and untreated delusions or obsessions in the parent. It may be difficult to distinguish true hallucinations and delusions from imaginative play, and a child may have limited understanding and skills to express internal experiences while in addition, children with underdeveloped language skills may imitate speech and a disorganized thinking characteristic of schizophrenia (by Bartlett).
Rajaratne and Dahanayake presented a case report that describes a mother undergoing treatment for schizophrenia who feared her daughter would develop a psychotic illness. This presentation was unusual because of the underlying factors contributing to her concerns and illustrates the impact of the lived experience of mental illness on a mother’s worries.
A 12-year-old girl was brought by her mother to the child psychiatry clinic, requesting an urgent psychiatric evaluation. She reported that the child was smiling to herself and had socially withdrawn for several weeks.
Upon detailed evaluation, no features of a major psychiatric disorder were found. The child was bored because she was confined to her home for several months, due to the Covid-19 pandemic situation; however, she continued to function at a satisfactory level, completing schoolwork and engaging in hobbies.
She was the youngest of three siblings. Her father was a professional and her mother a retired teacher. The mother and her family had a major influence in the lives of the children. There was a strong family history of schizophrenia, with the mother and maternal uncles being treated for the disease. The mother said her 16-year-old eldest daughter was undergoing treatment for schizophrenia and developed symptoms in her early teens. The mother was prescribed the first atypical antipsychotic drug. The mother and sister (the latter who was on an antidepressant of the class of selective serotonin reuptake inhibitors) were in compliance with treatment and in remission.
Despite assurances that the daughter did not show symptoms of mental illness, the mother continued to bring the daughter to the clinic on several occasions, reporting that she was having seizures and demanding additional assessments and the initiation of treatment. drug treatment. The mother was extremely worried that the same fate as hers could befall her daughter, unless urgent care was provided. She was reassuring, however, but extremely vigilant, and brought the child back to the slightest difference in behavior, such as, for example, being afraid immediately after seeing a scary movie.
The child was admitted for observation, where it appeared that she had been harassed at home by the mother and sister who called her “psychotic”. She had received several doses of an atypical antipsychotic, both covertly and erratically, by her mother. It turned out that she was under severe psychological stress and grieved over the loss of a normal family life. No features of psychotic illness were observed during the ward stay.
She has denied the chilling memories of her mother during her past relapses. She was primarily cared for by her maternal grandmother, who she remembers as being strict and emotionally distant. She felt closer to her mother than to her father and understood her mother’s illness. She took on domestic responsibilities because of it. She was sometimes embarrassed by her mother’s behavior and refrained from bringing friends home. Considering recent events, she resented her mother and sister and felt abandoned by her family.
The psychiatric ward caring for the sister revealed that she was diagnosed with depression, while the mother was concerned about a psychotic illness.
A meeting was held with the participation of the multidisciplinary team and the child protection authorities.
A second opinion was sought, which confirmed the lack of evidence of a psychotic illness in the child.
Concerns about the child’s safety were discussed and she was returned to her family under strict surveillance, with plans for follow-up.
The possibility that the presentation was due to a prodrome (an early symptom indicating the onset of illness or disease) of psychotic illness was considered.
She did not show any features suggesting psychiatric illness during her father’s regular follow-up visits. Regular follow-up sessions were offered and psychological support was provided to the family to manage their distress.
Rajaratne and Dahanayake explained that this case illustrates a unique presentation of a child whose parent has schizophrenia, highlighting the myriad of biological, psychological and social factors leading to these children being brought to mental health services.
This mother feared her daughter would end up with a chronic mental illness similar to hers, inadvertently doing more harm than good to the child. Her concerns stemmed from the love for her child, which her daughter recognized. The mother was the dominant parent in the family and the influence of her own family was crucial in compounding the mother’s sense of responsibility and anxiety about a possible psychotic illness in her daughter. The strong genetic predisposition and the reference to the eldest daughter as having schizophrenia compounded the mother’s concerns. She found it difficult to come to terms with her eldest daughter’s diagnosis of depression, claiming that a diagnosis of schizophrenia had already been made and despite psychoeducation on subsequent visits, she continued to be uncertain about the eldestâs diagnosis. .
The assessment confirmed that the mother’s worries were not the result of delusional beliefs and that she had no motive or advantage to suggest Munchausen by proxy.
If you think that you or someone you know might be affected by this content or might need help, the following institutions may be able to help:
The National Institute of Mental Health: 1926
Sri Lanka Sumithrayo: 0112 682 535
Shanthi Maargam: 0717 639 898
Police Office for Children and Women: 011 2444444
Courage Compassion Commitment Foundation (CCC): 1333