Current policy context
The Government’s strategy for improving children’s mental health, Future in Mind (2015), recommends that “professionals who work with children and young people are trained in child development and mental health, and understand what can be done to provide help and support for those who need it”. It also argues for an increase in parenting support provision to “build resilience and improve [children’s] behaviour”; however, it makes no mention of the links between parental relationship quality and children’s mental health, a factor which – as this briefing sets out – has a considerable bearing on child mental health.
In 2015, the authors of an analysis of CAMHS policy in England asserted that “Policies [in Future in Mind] prescribe self-care strategies and parenting support to help parents manage their children’s behavioural and emotional problems. This reproduces the idea, already embedded in earlier policy frameworks, that family life is reducible to a set of skills parents can be trained in, rather than thinking about whole families with histories and contexts, needing insight and support. This functions to entrench an individualising model of mental health, and enables a further retreat of the state from providing good-quality care to children and families” (Callaghan et al., 2016).
Support for this more socio-ecological approach has been voiced by the authors of an analysis of data from the Millennium Cohort Study, in which they state that policy which focuses on either the quality of adult couple relationships or mother-child relationships “to the exclusion of the other, is likely to be less effective in improving children’s well-being” (Kiernan & Garriga, 2015).
Generally, however, UK policy tends to stress the importance of supporting maternal mental health without acknowledging that the mental health of a mother is influenced, positively or negatively, by her context. For the majority of mothers (given the high rates of re-partnering among lone parents) this context comprises their relationship with their partner (e.g. the quality of the intimate partner relationship is significantly associated with postnatal mental health in both women and men (Wynter, Rowe and Fisher 2014) (Beck, 2001) (Carter, 2010)), as well as wider influences such as their circumstances, their support network, the neighbourhood in which they live, and wider societal factors.
A more ecological/systemic focus on children’s mental health challenges the current pre-occupation with the provision of more services. Tackling the underlying causes of childhood mental illness will inevitably become more centre stage, and the role of family functioning and parental relationships should be at the heart of a preventative strategy.
The impact of parental relationship quality on children’s mental health
In ChildLine’s 2016 annual report, ‘family relationships’ – defined as ‘conflict/arguments with family members, parents’ divorce/separation’ – is the only issue which appears in the topmost three concerns reported by each age-group of children surveyed (i.e. children under 11; young people aged 12-15; young people aged 16-18) (ChildLine, 2016).
This data from ChildLine echoes results from a recent survey of over 4,500 children across eleven child and adolescent mental health services (CAMHS), in which ‘Family Relationships Problems’ were reported by CAMHS clinicians as being the biggest presenting problem (Wolpert and Martin, 2015).
While the term ‘family relationships’ might encompass a number of different relationship dynamics, the relationship between a child’s parents is likely to account for a significant proportion of those having a troubling impact on children.
Indeed, research analysing Millennium Cohort Survey data shows there to be a clear link between parents’ relationship quality and children’s behavioural problems, even when other potentially confounding factors are taken into account (Kiernan & Garriga, 2015).
Of course, having difficulties and arguments is an ordinary and natural feature of couple relationships; where these are managed by couples and worked out, they can model how strong disagreements can be managed without resulting in the loss of love and affection (Cummings et al, 1991). Moreover, positive adult relationships can be a protective factor when there is a high-level of conflict in the mother-child relationship (Kiernan & Garriga, 2015).
Additionally, a considerable body of research (which has been comprehensively reviewed by the Early Intervention Foundation, in their report What works to enhance inter-parental relationships and improve child outcomes (Harold et al., 2016)) now clearly shows that conflict between partners which is frequent, intense and poorly resolved is very harmful to children’s mental and physical health.
In response to this kind of conflict, babies may become agitated, and children younger than five may respond by crying, acting out, freezing or withdrawing from, or intervening in, the conflict. Older children may show a range of distress including anxiety, depression, aggression, hostility, anti-social behaviour, and perform worse academically than their ability level (Harold et al, 2007).
Conflict does not just have to be violent or outwardly expressed; conflict that is characterised by deliberate coldness and withdrawal between partners can affect children, creating long-term emotional and behavioural problems (Cummings and Davies, 1994; Amato, 2001).
Furthermore, conflict in which children feel blamed, responsible, or that the conflict is at risk of turning on them is the most damaging of all (Grych, 2003). These negative impacts include girls blaming themselves for the difficulties between their parents, while boys tend rather to externalise their feelings leading at times to behavioural problems (Grych, 2003).
Mechanisms through which inter-parental conflict affects children
Parents embroiled in a hostile and distressed relationship are typically more hostile and aggressive toward their children and less sensitive to their children’s needs. This is often referred to as the ‘spillover’ effect by researchers (e.g. Erel & Burman, 1995).
Researchers have also demonstrated that children’s attachment processes – i.e. those which underpin their emotional security – are disrupted by destructive inter-parental conflict (Davies & Cummings, 1994).
In addition, it has been suggested (e.g. Harold and Conger, 1997) that the attributions children assign to conflict occurring in the marital relationship orient their expectations and representations of conflict in relationships, which in turn affects their long-term psychological adaptation.
The quality of the parental relationship in the context of child and adolescent mental health services
Between 2014 and 2012, Tavistock Relationships ran a number of training courses for senior CAMHS managers around the links between the quality of the parental relationship and children’s mental health. Feedback, based on 141 CAMHS practitioners, to these courses highlights an ongoing skills gap in this area, and a significant desire for further training:
- 77% of CAMHS practitioners attending the course felt better able to recognise relationship issues as a result of the training
- 79% of CAMHS practitioners attending the course felt better able to respond to relationship issues as a result of the training
- 95% of attendees indicated that they would be interested in further training with Tavistock Relationships.1
There is a lack of clarity currently about the extent, and kind, of work being undertaken in CAMHS which focuses directly on the inter-parental relationship. What seems more certain, however, is that CAMHS practitioners generally do not feel either qualified or mandated to work with the issues between couples. Indeed, feedback from CAMHS practitioners indicates that many services, and the commissioners of them, feel that dedicating resources to interventions focusing on the parental couple relationship would take away resources from direct work with children.
Whilst family therapy is an intervention offered in many CAMHS, there is an increasing focus on the provision of parenting support. However, it is arguable how much of this attends to the relationship between parents and their capacity to co-parent despite a now quite considerable evidence base showing that parenting interventions need to look particularly at the co-parenting relationship and not simply the vertical axis between parent and child (Harold et al., 2016).
Parents as Partners – the programme which garnered the highest rating out of all programmes assessed by the Early Intervention Foundation’s review (Harold et al., 2016) – is a programme which adopts just such an approach. Facilitated by one male and one female practitioner, this groupwork psychoeducational programme focuses on improving both parenting capacity and relationship quality, and how this plays out in the co-parenting. Evidence from this programme has replicated similar improvements to children’s SDQ scores (Tavistock Relationships, 2016) to those achieved by the U.S. version of the programme upon which it is modelled.
Recommendations for policy and practice
In light of the research outlined in this briefing which correlates relationship quality, parental psychopathology, parenting capacity and children’s mental health, we believe that there should be a rebalancing in favour of provision which includes a strong focus on relationships between parents (whether together as a couple or parenting separately).
This should involve mental health practitioners who are working with children recognising the role parental relationship distress may be playing in the presenting difficulties. Services which alleviate children of the burden placed on them by living in the context of adult conflict need to be developed in partnership with CAMHS and school-based services.
While we acknowledge there are significant workforce implications stemming from this, we believe that such an approach is necessary and warranted if we are to seriously address the levels of child mental health problems in the UK, with figures showing that one out of every ten children has a diagnosable mental disorder (Murphy and Fonagy, 2012).
We recommend therefore that:
- NHS England should write to all CAMH service commissioners and managers alerting them to the evidence contained in the Early Intervention Foundation’s review on inter-parental relationships and child outcomes;
- parenting work undertaken in CAMHS should, in light of the findings of this review, incorporate a relationship focus and, as part of this, the Parents as Partners programme should be made available in all CAMHS;
- research should be commissioned to test the effectiveness of couple therapy in the relief of symptomatology in children, given the research findings in the Early Intervention Foundation’s review regarding the impact of inter-parental conflict on children;
- all CAMHS, managers and practitioners should be required to attend training on understanding the impact of inter-parental conflict, and the quality of the parental relationship generally, on children’s mental health;
- the Government should set out a workforce development plan to ensure that schools and teachers become an ‘access point to identify inter-parental conflict in the home’, as recommended by the Early Intervention Foundation (Doubell, 2016).
Amato, P. R. (2001). Children of divorce in the 1990’s: An update of the Amato and Keith (1991) Meta-Analysis. Journal of Family Psychology, 15, 355–370
Beck, C. T. (2001) Predictors of Postpartum Depression: An Update, Nursing Research, 50(5), 275-285
Callaghan, J. E. M., Fellin, L. C., Warner-Gale, F. (2016) A critical analysis of Child and Adolescent Mental Health Services policy in England. Clinical Child Psychology and Psychiatry, April 6
Carter, W., Grigoriadis, S., Ross, L.E. (2010) Relationship distress and depression in postpartum women: literature review and introduction of a conjoint interpersonal psychotherapy intervention. Arch Women’s Ment Health, 13(3), 279-84
Childline (2016) It turned out someone did care. ChildLine Annual Review 2015-16
Cowan, P. A., Cowan, C. P., Ablow, J., Johnson, V., & Measelle, J. (Eds.). (2005). The Family Context of Parenting in Children’s Adaptation to School. Mahwah, NJ: Lawrence Erlbaum Associates
Cowan, P. A., Cowan, C. P., Pruett, M., Pruett, K., and Wong, J.J. (2009). Promoting fathers’ engagement with children: Preventive interventions for low-income families. Journal of Marriage and Family, 71(3), 663-679
Cummings, E. M., & Davies, P. T. (1994). Children and marital conflict: The impact of family dispute and resolution. Guilford series on social and emotional development. NewYork, NY, US: Guilford Press
Department of Health (2015) Future in Mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing
Doubell, L., Stock, L., Acquah, D., McBride. (2016) Inter-parental relationship support services available in the UK. Rapid review of evidence. Early Intervention Foundation
Erel, O., Burman, B. (1995) Interrelatedness of marital relations and parent-child relations: a meta-analytic review. Psychological Bulletin, 118, 1, 108-32
Grych, J. H., Harold, G. T., & Miles, C. J. (2003). A prospective investigation of appraisals as mediators of the link between inter-parental conflict and child adjustment. Child Development, 74, 1176–1193
Harold, G. T., Conger, R. D. (1997) Marital conflict and adolescent distress: the role of adolescent awareness. Child Development, 68, 333-350
Harold, G. T., Aitken, J. J. and Shelton, K. H. (2007), Inter-parental conflict and children’s academic attainment: a longitudinal analysis. Journal of Child Psychology and Psychiatry, 48
Harold, G. H., Acquah, D., Sellers, R., Chowdry, H. (2016) What works to enhance inter-parental relationships and improve outcomes for children. Early Intervention Foundation, London
Kiernan & Garriga, 2015, Parenting (mothering) and supporting couple relationships – findings from the Millennium Cohort Study)
Murphy, M., Fonagy, P. (2012) Mental health problems in children and young people. In Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays
Tavistock Relationships (2016) Parents as Partners – a summary of findings http://www. tavistockrelationships.ac.uk/index.php/policy-research/policy-briefings/910-parents-as-partners-a-summary-of-findings-2016
Wolpert, M. and Martin, P. (2015) THRIVE and PbR: Emerging thinking on a new organisational and payment system for CAMHS. New Savoy Partnership Conference, London, 11th February 2015
Wynter, K., Rowe, H. and Fisher, J. (2014). Interactions between perceptions of relationship quality and postnatal depressive symptoms in Australian, primiparous women and their partners. Australian Journal of Primary Health, 20(2), p.174