Hidden Heroes - Children Of Parents With Severe Mental Illness In School Practice


The consequences of hospitalisation of a parent with severe mental illness (SMI) may negatively affect a child's school performance in a wide range of areas. We have conducted a research study identifying the prevalence of parenthood among hospitalised patients with SMI and put it into context with the impact of this phenomenon on school achievement. Our study aimed to identify the number of students who may be at risk of school failure and to create recommendations for school psychologists based on previously published studies. We have analysed medical records of patients hospitalised in one specific hospital for SMI between 2017-2020. Following this, we reviewed studies focusing on the school functioning in students with parents with mental illness. Results show that a third of hospitalised SMI patients (n=730) are parents with 1376 offspring. Of these, 43.2% are under 18 years of age, most of whom attend primary school. Based on the findings of school functioning-focused studies, we can conclude that many children are at risk of psychological difficulties and adaptation problems that may significantly affect school performance due to problems connected with parents' SMI. The aim of this article is to raise awareness and understanding about this specific group of students to provide readers (e.g. school psychologists) with practical recommendations based on the current state of professional knowledge.

Keywords: Prevalence, school achievement, a mentally ill parent, school intervention, COPMI


Severe mental illness (SMI), defined in our study similarly to other authors (e.g., Woods et al., 2008; Yamanda et al., 2000), is based on ICD-10 diagnostic categories and includes schizophrenia disorders, recurrent depressive disorder, and bipolar affective disorder. SMIs share three characteristics - they are long-lasting, disrupt an individual's everyday functioning, and require long-term treatment.

This article aims to present preliminary results of the prevalence research study conducted in the Czech Republic and provide information on the proportion of parents among hospitalised patients with SMI. Furthermore, summarise current published research on school performance in children of parents with SMI, and offer practical recommendations for school psychologists on identifying and supporting these children.

Children of parents with SMI in school practice

Children of parents being treated for depression, schizophrenia, or bipolar disorder are at increased risk of developing mental health problems (see, e.g. Biederman et al., 2001), not only because of their hereditary burden (e.g. Rasic et al., 2014) but also due to several stressful psychosocial factors (Hosman et al., 2009). A parent's mental disorder itself may not necessarily have as significant impact on the mental health of the offspring as the social difficulties accompanying the illness (poverty, unemployment, stigmatisation of mental illness, single parenting, parental stress, foster care placement) (Connell & Goodman, 2002). Children of parents with mental illness (COPMI) may experience parentification, increased levels of stress, and increased risk for developing depression (Aldridge & Becker, 2003). Compared to their peers, COPMI have significantly reduced self-concept, experience significantly increased guilt and social hardship levels, and have poorer school performance (Abosh & Collins, 1996).

School can be one of the critical support structures for children of parents with SMI. For this reason, it should be the school's duty to be able to correctly identify these children and offer them appropriate support when needed. At the same time, the school can serve as a safe environment in which children who live with a parent with SMI have a respite from family demands, interact with friends, and receive essential social support during stressful times (Thomas et al., 2003).

Several research studies have addressed the topic of young carers (YC). A young carer, according to the UK Children and Families Act (2014), is "a person under 18 who provides or intends to provide care for another person (of any age, except where that care is provided for payment, under a contract or as voluntary work)". Recent research from Switzerland (Leu et al., 2020) and France (Justin et al., 2021) show that school professionals have little awareness of the family situation of these children. For example, in a study by Justin et al. (2021), 29 out of 33 professionals stated they had never heard of YC. Golsäter et al. (2017) found that even school nurses are often unfamiliar with the parental situation.

Difficulties in identifying children of parents with SMI could be since many children do not talk much about their family situation at school. They often fear being teased, intimidated, or bullied by classmates (Moore & McArthur, 2007) or placed in foster care (Marote et al.,2012).

The reasons for their behaviour are summarised by the Carers Trust and The Children's Society (2017):

Children themselves often may not even realise their lives may be different compared to others; they do not want to attract attention; it is a difficult topic to share with peers; some may wish to keep their school identity separate from their home identity; some may feel the school is not interested in their family or they do not have the opportunity to share their story; have irrational fears (parents will be terminated of parental rights); see no reason to share their story (nothing positive will come of it) (Carers Trust and The Children's Society, 2017).

Research focusing on the relationship between parental illness and school performance has shown that parental depression (Shen et al., 2016) and parental schizophrenia (Ranning et al., 2018) are associated with poorer school performance. Children of parents with SMI have been shown to score lower in school performance (Lin et al., 2016). They are less likely to complete primary education than a reference group of children from the average population (Ranning et al., 2018). Augustine and Crosnoe (2010) examined the association between child school performance and the education of depressed mothers. According to their findings, maternal depression predicts poor school performance only in mothers with lower education. The most recently published study by Ayano et al. (2022) conducted on a robust Australian longitudinal data sample shows that offspring of mothers with anxiety symptomatology are 3.6 times more likely to have below-average school performance and twice as likely to not enter tertiary education than offspring of mothers without anxiety symptomatology.

In their recent call to action, Kavanaugh and Stamatopoulos (2021) point out that young carers (which includes caregivers of the somatically and mentally ill) are still a neglected population and do not receive enough attention. Between 13% of all young carers (YC) of primary school age and 27% of secondary school age miss school or experience educational difficulties (Dearden & Becker, 2004). The children of parents with SMI are an even more specific group who, are also at risk of school failure. There are no studies on this topic in the Czech Republic, and to our best knowledge, children of parents with SMI receive little or no professional attention and support. Therefore, we conducted a prevalence study to highlight the importance of the topic and its scope.

A prevalence study in the Czech Republic - preliminary results

Since there are no available statistics on the number of children of parents with SMI and there is no evidence to launch and target appropriate support for this group in the Czech Republic, we have conducted research in a collaborating psychiatric hospital to find out how many SMI patients are also parents.


Published preliminary results consist of data from one hospital, where data was collected between 03/2022 and 05/2022 with the approval of the Masaryk University ethics committee and the hospital's consent. We performed a quantitative analysis of the medical records from the electronic medical system. Data was collected by a hospital employee who collected and anonymised the data from the medical records. Due to working with anonymised data, the consent of each patient was not needed. The data were further analysed using SPSS 27 software.


The sample (n=2189) consisted of patients hospitalised between 2017 and 2020. The main diagnosis was assigned by a qualified psychiatrist based on ICD-10 criteria and fit into one of the following categories: schizophrenia, schizotypal and delusional disorders (F2x), periodic depressive disorder (F33) and bipolar affective disorder (F31). The age of patients at the time of hospitalisation ranged from 18-60 years, as this age range most often coincides with the period of parenthood of children aged 0-18 years.


We collected the age and number of children of patients hospitalised with selected diagnoses. The sample was further divided by the age of the patients' children following the Czech school system into 0-2 years, 3-5 years, 6-15 years, 16-18 years and adults.


Parenting among patients hospitalised for SMI

Between 2017-2020, a total of 2189 SMI patients were hospitalised in the facility, of which 41.5% were diagnosed with schizophrenia (n=909), 40.4% with other psychoses except schizophrenia (n=884), 10.4% with periodic depressive disorder (n=234) and 7.4% with the bipolar affective disorder (n=162).

The parental prevalence rate in patients hospitalised for SMI is 33.3% (730 out of 2189 patients). Of these, 64.9% were male, and 35.1% were female.

Table 1 shows the prevalence of parenthood based on diagnoses. The most significant proportion of parenthood among hospitalised patients was found in patients with recurrent depressive disorder (53,4%). The prevalence of parenthood among patients with bipolar disorder was 47.5%, parenthood among patients with other psychoses was 38.5%, and the lowest prevalence of parenthood was found among patients with schizophrenia (20.7%).

Table 1 - Prevalence of parenthood by diagnosis
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Children of SMI parents

The total number of offspring in the sample was 1376, and the age of 1345 offspring was recorded in medical records. The mean number of offspring per patient-parent was 1.9 (SD=0.84), median 2, modus 2, and the number of offspring varied from 1 to 6. The stratification of offspring of parents with SMI by age can be seen in Table 2. In our sample were 43,2% (n=581) of children under the age of 18 years, and 30,6% (n=411) were in the school-age group (6-18 years).

Table 2 - Age of offspring of parents with SMI (n=1345)
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According to preliminary results of a prevalence study, one-third of patients hospitalised for SMI are at the same time parents. Approximately two-thirds are the father's hospitalisation, and one-third are the mother's hospitalisation. The prevalence of parenthood is highest among patients with depression (53.4%) and lowest among patients hospitalised for schizophrenia (20.7%).

The total number of minor children in the sample was 581 (43.2%); one-third of the children of hospitalised SMI patients were of school age, with 320 attending primary school and 91 attending secondary school.

Possibilities for support from schools

There is still no systematic support for children with SMI in schools in the Czech Republic. International research shows that, for example, 1 in 12 children have a family member with serious health or mental health problem (Howard, 2010), and of a sample of 6178 young carers, 2213 were caring for a parent with a mental disorder (Dearden & Becker, 2004). For this reason, we decided to undertake a literature search and summarise the available recommendations for school psychologists, as they play a significant role in YC work (Beaver, 2011). We divide the following chapter into three sections: “Identification”, “Diagnosis and assessment of the specific needs of the child and family”, and “Providing support and intervention”.


"Schools are vital to identifying young people and carers who may not already be in contact with local authorities" (Department of Health & Social Care, 2022). According to research by Bjorgvinsdottir and Halldorsdottir (2014), many young carers would like to share their family problems but feel unable to. In research by Ali et al. (2013), 77% of young people with a parent with mental illness did not know where to seek support. The lack of information increases the importance of school professionals who are knowledgeable about the topic, can identify pupils with parents with mental illness and offer support if needed. In this case, the school can be an important protective factor (Gough & Gulliford, 2020).

Asking all students (or their parents) whether they have a mental disorder is not ethical, often not helpful or time-efficient. It is, however, possible to be sensitive to warning signs that may help identify psychological difficulties or other excessive burdens that may be present in the offspring of parents with mental illness. An overview of these areas is offered, for example, by materials from Carers Trust and The Children's Society (2017), see Table 3.

Table 3 - Signs that a child might be a young carer (Carers Trust and The Children’s Society, 2017)
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School psychologists should encourage teachers to be sensitive and knowledgeable about these issues. If a teacher identifies difficulties, he should inform the student's tutor. In collaboration with the school psychologists, the next step is to work with the pupil to develop an individual support plan, the aim of which is to reflect with the child on his/her role, needs and specifics and to develop a plan to meet them. Some children may not need or want any support, others may find it helpful to take time off homework, and others may need individual therapy.

Diagnosis and assessment of specific needs and difficulties of the child and his/her family

Ingul et al. (2019) categorised risk factors for school avoidance into factors on the part of the child, the school setting and the family situation. The presence of a member with a mental disorder can negatively affect physical health, emotional well-being, and socialisation in COPMI (Robison et al., 2020). Therefore, it is essential to know which areas school professionals can help with and how to map them well.

School psychologists should focus on the following areas when talking to COPMI:

  • Mapping of the school and career preparation area - school performance and progress, attendance, follow-up school and career training, employability, factors and aspects making schooling and attendance difficult, peer awareness of the family member with SMI, peer support
  • Psychological functioning - problematic and disruptive behaviour, emotional experience, social functioning
  • Family member with special needs - child's relationship with the family member with special needs, child's level of knowledge about the family member's difficulties, the practical impact of the family member's difficulties on the child's daily life or school performance
  • Potential caregiving role - positive and negative impacts of the caregiving role, activities that are challenging or dreaded for the child, the extent of care, specific caregiving and assistance tasks
  • Leisure and self-fulfilment - favourite and enjoyable activities, time and opportunity to pursue them, opportunities to spend time with friends and other family members
  • Subjectively perceived level of social support - how much does the child feel that other people listen/talk to/share with them, how involved does the child feel in decisions about themselves and their life, and which people know about the child's current involvement in their care?
  • Options for support - which professionals are working/have worked with the child, who can the child turn to for advice and help, is it possible to contact/exchange information with/engage with the person, what would the child likes and need.

Another valuable tool for school psychologists to rely on in diagnosing and determining the child's specific needs is Aldridge and Becker's (2003) model. This two-axis model (X-axis - the child's caring role; Y-axis - the nature of the parent's mental disorder) helps to understand the gradation and variety of experiences that COPMIs may undergo, making it easier for professionals to identify and prioritise needs and the nature and level of support required. For more comprehensive information about this dynamic model, see Aldridge & Becker (2003).

Therapy, counselling and support

Providing support to offspring has a significant impact in several areas. It positively influences the outcomes of the intervention for the family member with mental illness, it has a positive impact on the parent-child relationship, it positively influences the quality of family life, and it has a protective effect on the functioning of the child itself. Systematic educational intervention increase understanding, reduces stress, and retains social functioning (Jönsson et al., 2011).

Young people with a parent with a mental illness have three basic needs - support, sufficient and relevant information and social contact. However, this support is often lacking in COPMI (e.g., Grant et al., 2008; Reupert et al., 2012). These needs can be met through individual support, group work and a range of other auxiliary sources of support.

Individual support

When a child begins to develop psychological difficulties in which the help and care of the family are no longer enough, it is advisable to offer professional help. A competent professional can provide help to the child and the entire family system in the following domains: orientation in the current life situation; an unbiased view "from a different perspective"; open-minded listening; information about the family member's disability; contacts to other professionals and support organisations; information and advice on how to cope with difficulties; connecting the needs of all family members (Havelka & Bartošová, 2019). The roles that the school psychologist can play in this process are summarised in Table 4.

Table 4 - The role of the school professional - inspired by Carers Trust and The Children’s Society (2017)
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Literature that can assist school psychologists in this area:

  • Willcock, C. (2006). Supporting Young Carers: A Programme to Develop Emotional Literacy. Routledge.
  • Aldridge, J., & Becker, S. (2003). Children caring for parents with mental illness: Perspectives of young carers, parents and professionals (1st ed.). Bristol University Press.
  • Cowling, V. (Ed.). (2004). Children of parents with mental illness 2: Personal and clinical perspectives (Vol. 2). Aust Council for Ed Research.
  • Cooklin, A., & Barnes, G. G. (Eds.). (2020). Building children’s resilience in the face of parental mental illness: Conversations with children, parents and professionals. Routledge.

Group interventions

Several programmes are directly targeted to support COPMI. These interventions typically focus on psychoeducation about the parent's mental disorder, emotional and peer support, and the development of adaptive coping strategies (Orel et al., 2003; Riebschleger et al., 2009). In addition to face-to-face interventions, there are also online group programmes (e.g. Woolderink et al., 2010). Many clinicians and researchers have consistently indicated that group intervention programs can help in screening and preventing mental health and adjustment difficulties (e.g. Tudor & Lerner, 2015). Outcome studies document a decrease in emotional difficulties and depressive symptoms (e.g., Morson et al., 2009), an increase in self-esteem, problem-focused coping strategies and connections within the family (e.g. Goodyear et al., 2009), and a significant increase in knowledge about the mental disorder (e.g. Richter, 2006). School psychologists can refer their clients to such a group or start their own support group. Fundamental information about running a group can be found in Carers Trust and The Children's Society (2017). Some studies also report that the specific protocol and the manual were followed (e.g. Goodyear et al., 2009; Gladstone et al., 2014). Alternatively, basic inspiration can be found in manuals for groups with similar focus but different populations (e.g. Havelka, 2020).

Auxiliary sources of support

In addition, other kinds of support that can be used in everyday life are often inexpensive and can be applied without much involvement of professionals. These interventions can reinforce the impact of the school psychologist's direct work and be preventive and supportive on a stand-alone basis.

Non-profit organisations

NGOs form platforms for disseminating awareness, researching and improving practice, gathering professionals, providing education and staff training, and accumulating and providing relevant client services and contacts. Several of these organisations are affiliated with the international association of carers, Euro Carers (https://www.eurocarers.org/). School psychologists can refer clients to these organisations or consult them for inspiration, advice or appropriate materials.

Books and movies

Reading can reflect on the stressful situation, release the accumulated tension, bring catharsis, insight, and awareness of the experienced problem, restore the joy of life, and strengthen psychological resilience. The book is also a valuable educational tool – for children, parents and psychologists (e.g., Vališová, 2010). School psychologists can provide children/parents with a list of appropriate literature, use books in sessions, organise a specialised reading club, and use/create/translate handouts and brochures for children/parents/teachers. Inspiration can be found in the study by Tussing and Valentine (2001).

Working with film is characterised by similar attributes to working with books. The advantage of film over a book may, under certain circumstances, be the lower demands it places on the recipient's time and activity. Therefore, psychologists may not only use it similarly to a book but may find it easier to screen it as part of more comprehensive education about COPMI issues.

Specialised websites

The internet is an essential source of information and communication for children and young people. Several professional organisations are therefore creating websites with verified content specifically for COPMI (such as Carers Trust (https://www.carers.org.uk/), Carer gateway (https://www.carergateway.gov.au/), The carers centre (https://www.banescarerscentre.org.uk/).) . The aim of the websites is to provide a safe and supportive environment for gaining information, sharing experiences and relaxing. Visitors can find discussion forums, professional help references, information handouts and brochures, links to pages with similar topics to professionals, and popular articles and books. There are also quite large COPMI communities on social media. Inspiring, interesting, and research-validated outputs in this area are, for example, the studies by Drost et al. (2011).


Preliminary results of our prevalence study show that 33.3% of patients hospitalised for SMI are also parents. These results are consistent with similar studies, for example, a cross-sectional study in psychiatric services in Sweden, where the rate of parenthood was 36% (Östman & Eidevall, 2005), or a prevalence of parenthood of 28.7% in a study of first-hospitalised patients with psychosis (Craig & Bromet, 2004).

A sample of 730 hospitalised patients had 1376 children, with one-third of the COPMIs being of school age. This shows that school professionals are certainly seeing children of parents hospitalised for SMI. Therefore, the school setting can serve as an important, often first, safety net for children who need support during stressful times, as mentioned by Beaver (2011) or the Care Act 2014 (Department of Health & Social Care, 2022). However, it is essential that school psychologists and school staff are aware of the issue and can provide appropriate support and understanding to children who may often be experiencing challenging situations. We have therefore summarised recommendations from the international literature on how to identify COPMI, map their needs and offer appropriate interventions.

Study Limitations

The preliminary results of our study are limited by the amount of available information on COPMI in medical records. Some detailed data are not present in medical records or are challenging to obtain. As these are preliminary results from only one healthcare facility, a larger sample could provide more valid information. The results show only basic statistical information; in-depth analyses of COPMI psychosocial variables could better outline the difficulties that children in schools may face and give more specific information for school psychologists. It would be helpful to link the results from the mental hospital with studies directly in schools and to ask specifically about children's experiences of parental SMI.


The results of our prevalence study confirm that COPMI are not a marginal group and are undoubtedly present in school practice. Our paper also serves as a reminder of this overlooked population. Finally, it provides recommendations for supportive interventions for school psychologists.


The study was supported by the Specific Research - support of student projects grant of Masaryk University within the project Children of parents with severe mental disorder: mapping prevalence and current clinical practice MUNI/A/1375/2021 (ID=63612).


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30 December 2022

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Havelková, A., Havelka, D., & Bartošová, K. (2022). Hidden Heroes - Children Of Parents With Severe Mental Illness In School Practice. In A. Güneyli, & F. Silman (Eds.), ICEEPSY 2022: Education and Educational Psychology, vol 3. European Proceedings of International Conference on Education and Educational Psychology (pp. 184-196). European Publisher. https://doi.org/10.15405/epiceepsy.22123.16