Fathers with mental illness: implications for clinicians and health services

In Australia, a significant proportion of fathers living with their natural, adopted, step or foster children experience mental illness. Because fathers influence children’s wellbeing through their parenting as well as through genetic factors, the impact of mental illness on fathering is an important consideration for clinical services.

Men in Australia typically become first-time fathers in their early 30s,1 and the proportion of men who are living with children peaks at 40% between the ages of 35 and 45 years.2 Examining the mental health of men over the period when they are parenting children through their formative years is therefore likely to identify those children whose development may be at risk.

When men aged 25–54 years were interviewed for the 2007 National Survey of Mental Health and Wellbeing,3 one in five was assessed as having a mental illness in the previous 12 months. Specifically, 13% had anxiety disorders and 7% had affective or substance use disorders. Among men reporting very high levels of psychological distress, 75% had a mental illness. Of these, 70% reported suicidal ideation or plans. The National Survey did not assess low-prevalence conditions such as psychosis; however, a survey of psychotic disorders in urban areas reported a rate of 5.6 per 1000 for men aged 18–64 years.4 Clearly, there are significant numbers of men experiencing mental illness who will have the care of, or contact with, children. However, the impact of fathers’ mental illness on children will vary according to a range of factors, including the severity and nature of the condition, the level of contact or parental responsibility, the level of other support, and factors relating to the child, such as their temperament and health status.

Population studies examining early childhood deaths have reported an increased mortality risk of 1.61 (95% CI, 1.30–1.99) for neonates and 2.65 (95% CI, 1.17–5.51) for toddlers born to fathers with schizophrenia, after controlling for mothers’ mental health status.5,6 Long-term studies tracking cause-specific deaths in the offspring of paternal psychiatric inpatients have found that younger children aged 1–4 years have a 10-fold higher risk (95% CI, 4.91–19.57) of death by homicide, and young adults aged 16–25 years are more than twice as likely to commit suicide (95% CI, 1.52–3.71), compared with children of fathers without psychiatric disorders.7 Children of alcohol-misusing fathers have also been reported to have higher rates of premature death, and a father’s substance misuse has been associated with mental health problems, learning difficulties, behaviour problems and physical illnesses in his children.8,9

Developmental impairment has also been reported in the children of fathers with milder forms of mental illness. When children whose fathers had reported symptoms of depression 8 weeks after birth were assessed at 3.5 years, they were found to have more than twice the population rate of emotional and behavioural problems (95% CI, 1.42–3.08), after controlling for maternal postnatal depression.10 Compared with children of symptom-free fathers, these children also recorded higher levels of psychiatric disorder 7 years later (95% CI, 1.07–2.77), after adjusting for maternal depression and paternal education level.11

Although the impact of a father’s psychopathology may be lower than that of a mother in some cases9 — and although the outcomes for children are significantly worse when both parents have a mental illness12 — the consequences of paternal mental illness are clearly substantial. The early identification of new fathers with serious psychiatric disorders is indicated to protect their infants from harm. However, for the majority of families where fathers are experiencing a mental illness, understanding the mechanisms linking fathers’ disorders with children’s outcomes will be important for targeting interventions to ensure children’s wellbeing.

Reviews examining paternal psychiatric disorders and children’s psychosocial development have identified several causal pathways to explain children’s outcomes, including the genetic burden passed from father to child, environmental effects such as reduced income and poor housing, family factors such as increased marital conflict, and impaired parenting.13,14 While the limitations of the available research make elaborating pathway steps difficult, there is sufficient evidence to suggest that clinicians need to focus on fathers’ relationships with their children. In a study of genetically related and unrelated pairs, fathers’ hostile parenting fully mediated the association between antisocial behaviour of fathers and children.14 Fathers’ parenting behaviour was also implicated in a longitudinal study that measured maladaptive parenting and child and parent psycho-pathology at several time points in a representative community sample (n = 593).15 In this study, fathers with psychiatric disorders (25% of fathers) spent less time with the child, showed less affection, communicated poorly and provided less supervision than fathers without psychiatric disorders. These fathers also had markedly more loud arguments with the mother and provided less assistance to the mother than unaffected fathers. When maladaptive parental behaviour was statistically controlled, the magnitudes of the associations between parental and offspring psychiatric symptoms were substantially reduced.15 As there is evidence that at least some parenting programs targeting fathers can produce improved parenting behaviours,16 addressing the fathering behaviour of men with mental illness may improve children’s outcomes.

Children’s healthy development is clearly vulnerable to their fathers’ impaired parenting in the presence of mental illness. However, many fathers with psychiatric disorders recover, and fathers with chronic psychopathology can manage, with support, to successfully parent their children.17 In recognising the seriousness of mental illness among fathers and the risk to family functioning, we should not discount the importance of relationships with children to fathers’ sense of identity and self-competence.17,18 A man’s children can represent a key goal in his recovery from a psychiatric disorder, or they can function as a motivator for him to better manage his illness19 (Box 1).

In primary clinical settings, men aged 25–54 years who are known to have a mental illness should be routinely asked about their fathering, as their children will be at increased risk of developmental disorders and, in serious cases, increased mortality. This includes occasions when the men present with physical symptoms. The questions for clinicians in Box 2 are intended to identify the father’s perception of his caring role and the effect of the mental illness on his relationship with his children. As it is common for fathers to present at health services without their children, the questions provide a prompt in the absence of the direct stimulus of children.

Qualitative studies of mentally ill fathers’ experiences suggest that when discussing parenting issues with these fathers, clinicians should be aware that some may fear that their illness will be inherited by their children, while others may gain strength from their children’s support.17,18,19 Clinician referrals to mental health services provide an opportunity to emphasise the importance of fathering as part of the patient’s health care goals. While there are few dedicated services for fathers, existing mental health services are available to address a father’s psychological needs and to enable him to improve his relationship with his children. Referrals to these services can indicate in the referral letter that improved fathering is a primary goal.

There is increasing recognition that, to improve children’s outcomes, health services should review their procedures and staff competencies to include fathers more effectively.20 However, more research into the effectiveness of father-inclusive practices is needed. In the case of fathers with a mental illness, studies examining the effectiveness of parenting programs and support in improving fathers’ parenting and children’s outcomes should be a priority. Clinical training should provide clinicians with the skills to talk to presenting fathers about their fathering role and the goals they have for their children, in order to enhance their motivation to better manage their mental health issues.

Fathers experiencing mental illness form a significant proportion of the population. A father’s mental illness can adversely affect his children’s development and, in cases of serious illness, can pose a risk to life. While there are several pathways linking paternal psychopathology to children’s poor outcomes, fathering behaviour is an important, potentially modifiable factor. Clinicians can assist fathers with mental illness and their families by proactively enquiring about children and by exploring fathering-focused psychological support.