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Clinical Child Psychology and
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Parenting Related to Child and Parental Psychopathology: A Descriptive Review

of the Literature
Turid Suzanne Berg-Nielsen, Arne Vikan and Alv A. Dahl
Clinical Child Psychology and Psychiatry 2002; 7; 529
DOI: 10.1177/1359104502007004006
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06 Berg-Nielsen (to/d) 11/13/02 1:13 PM Page 529
Parenting Related to Child and Parental

Psychopathology: A Descriptive Review of the
Literature
TURID SUZANNE BERG-NIELSEN & ARNE VIKAN

Norwegian University of Science and Technology, Norway
ALV A. DAHL
University of Oslo, Norway
A B S T R AC T
Two areas of recent research on parenting are examined: (i) Parenting problems
in families with parental psychopathology, and (ii) parenting problems when
children have psychiatric disorders. Review of literature showed that parental, as
well as child, psychopathology represents major stressors for a family and substan-
tially impacts parenting abilities. Two main dimensions of dysfunctional parenting
occur in families with child or parental psychopathology: (i) Parental negativity,
and (ii) various forms of ineffective discipline practices. For parents, the level of
parental social functioning and responsiveness may be more crucial for parenting
skills than psychiatric symptoms per se. For children, the impact of dysfunctional
parenting seems to be non-specific for child outcome, related to both internalizing
and externalizing disorders. However, evidence does point to links among parental
negative, affectionless control and depression/anxiety in children, whereas incon-
sistent, disruptive parenting with insufficient monitoring is more characteristic of
parents with conduct-disordered children.
K E Y WO R D S
child, child-rearing, parenting, psychiatry, psychopathology
I N T H I S R E V I E W two areas of recent research on parenting are investigated, studies

focusing on how adult psychopathology may affect parenting capabilities, and studies
linking parenting and psychosocial problems in children. These two seemingly different
topics are actually related. Psychopathology is often manifest within generations. The
troubled child may very well have parents that are not only worried or distressed, but
sometimes deviant or even personality disordered, hence diminishing their ability to
maintain optimal parenting of their child. Although parents of disordered children most
often do not have any mental problems, and most children of parents with psychiatric
problems usually grow up well adjusted, parenting problems are common in families with
Clinical Child Psychology and Psychiatry 13591045 (200210)7:4 Copyright 2002

SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 7(4): 529552; 027565
529

CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)
either child or parental psychopathology. Serious parenting problems may be due to

deviant children, or parents own psychological problems, or both. In any case, parents
or childrens psychiatric problems are considerable family stressors that affect the
parentchild relationship.
Some evaluation of parenting skills or rough estimate of parenting capabilities is
necessary for treatment planning and will always be a primary clinical task. Often we
find ourselves trying to handle difficult or deviant parents, in addition to treating
troubled children. Up-to-date knowledge of recent research on parenting associated with
child and adult disorders may facilitate clinicians judgement.
When links between parenting and child psychopathology are found, causality is often
too hastily asserted, implying that dysfunctional parenting leads to child psycho-
pathology. Behaviour genetic researchers argue that the established relationship
between impaired parenting and child psychopathology may just as well be due to child
characteristics shaping parenting behaviour as the other way around. Earlier socializa-
tion research focused mainly on parent effects on children, emphasizing parental influ-
ence on child behaviour. Current behavioural genetic research has stressed the
importance of child effects, and has demonstrated how genetically transmitted charac-
teristics of children actively shaped their surroundings, including parental behaviour
(Ge, Conger et al., 1996; OConnor, Deater-Deckard, Fulker, Rutter, & Plomin, 1998).
The predominant viewpoint among most parenting researchers today is an interaction-
ist one, which assumes that each member in any ongoing relationship is a significant
feature of the others environment to which each must adapt. Maccoby (2000) has argued
that from an interactionist perspective, the idea that in a long-standing relationship, the
child would be influencing the parent, but the parent would not be influencing the child,
is absurd.
At present, it is still a challenge to find research designs that can sort out the direction
of influence: who is most dominant in shaping the others behaviour over time parent
or child? The search for causality may seem futile to some; nevertheless, it has clinical
implications. Although the parentchild interaction usually is the focus of psychosocial
treatment within child and adolescent psychiatry, many clinicians still disagree about the
main target of therapeutic intervention: child/adolescent or parents/family?
T U R I D S U Z A N N E B E R G - N I E L S E N worked as a Clinical Specialist (PhD) for 17 years in

psychiatric hospitals and outpatient clinics before entering into full-time research on parent-
ing and child psychopathology 6 years ago. She is currently Associate Professor in Clinical
Child Psychology at the University of Trondheim and has written five scientific articles on her
recent parenting research.
C O N TA C T :
Department of Psychology, Norwegian University of Science and Technology,
Trondheim, Norway.
A R N E V I K A N has extensive research experience within developmental psychology and child

psychiatric epidemiology. He is Professor of Developmental Psychology and currently leader
of the Clinical Child Psychology outpatient clinic at the Department of Psychology,
University of Trondheim.
A LV A . DA H L is Professor of Psychiatry at the University of Oslo and Head of the Treat-

ment Unit for Anxiety Disorders at Gaustad Hospital. He has a wide range of research experi-
ence and has published widely on personality disorders, anxiety disorders and differential
diagnoses of psychotic disorders.
530

BERG-NIELSEN ET AL.: PARENTING AND PSYCHOPATHOLOGY
Two areas of parenting research are not covered in this review:

1. The extensive earlier socialization research on parenting and child outcome. This
research has documented broad evidence on the importance of parenting variables,
such as warmth and control, for the healthy development of normal children.
2. Studies on adult retrospective reporting of perceived parenting in their own childhood
(Arrindell et al., 1986; Parker, 1990; Perris, Arrindell, & Eisemann, 1994) are also
omitted from this review. Some methodological problems exist concerning retrospec-
tive studies and bias of recall. The extent to which adults accounts of parenting in
their childhood are valid reflections of actual parental behaviour has been a matter of
dispute (Gerlsma, 1994). These accounts may be idiosyncratic reflections of perceived
parenting tainted by their personality and/or psychopathology. Adults reports of past
parenting may have interesting parallels with issues highlighted in this review, yet are
excluded as this research is somewhat less pertinent to child psychiatric clinicians.
It is important to bear in mind that numerous studies exist on parent characteristics
such as parent psychopathology in relation to child outcome, but without regard to
parenting variables. These studies are referred to only to outline a problem, or to point
to the lack of research on parenting variables when adult and child psychopathology are
associated.
The many research studies described in this review originate from the most common
theories within child clinical psychology and psychiatry (e.g. behavioural, cognitive,
psychoanalytical, familial). In this review, the theoretical orientation of the authors is
that of developmental psychopathology, which resembles the interactionist perspective
of current socialization research. According to this understanding, both healthy and
pathological development results from a continuous interplay of interactions between an
active organism and an active environment. Developmental psychopathology is the
study of the prediction of the development of maladaptive behaviours and processes
(Lewis, 1990). Ollendick and Vasey (1999) have stated that developmental psycho-
pathology does not endorse or prescribe a particular theoretical orientation or expla-
nation for the understanding of child disorders, nor does it supplant particular theories;
rather, it represents a kind of theoretical pluralism. Developmental psychopathology
intends to sharpen awareness about connections among phenomena that may otherwise
appear unrelated or disconnected. It is therefore important to identify those specific
factors that promote or inhibit early deviations of healthy development, of which parent-
ing is one.
The concept of parenting

The concept of parenting, as used in this article, consists of parental everyday behaviour
towards offspring including parents cognition, emotions and attributions toward their
child, as well as parenting attitudes and values. Thus, parenting is a broader concept than
child-rearing. The concept of parenting is limited to the relationship between parent and
child, whereas grandparents as well as teachers may take part in child-rearing. When the
term dysfunctional parenting is used, it is based on Kendziora and OLearys (1993) defi-
nition: Dysfunctional parenting is anything the parent does, or fails to do that may
adversely affect the child.
Behavioural genetic researchers have sorted out those aspects of environmental influ-
ence that are more significant in shaping childrens development, namely non-shared
environmental factors that are specific to an individual child in the family, for example,
sibling position and peer relations. Research findings have demonstrated that the effects
of non-shared environment appear to be much greater than those of shared environment,
531

that are common to all members of a family, for example, mothers depression, or moving
to a better neighbourhood (Plomin, 1994; Plomin, Chipuer, & Neiderhiser, 1994). Rutter,
Silberg, OConnor, and Simonoff (1999) have argued that the effects of shared environ-
mental factors have been underestimated, and increase when measurement error is
taken into account. Parenting behaviour has usually been regarded as shared within a
family, but shared parenting may be specific in its effects as it impinges quite differently
on siblings dependent on the individual childs temperament, gender, age, etc. Moreover,
Dunn and McGuire (1994) found that children often perceived that they were treated
differently by their parents. Yet, how valid that perception was, and to what extent
parenting might be non-shared, remains an open question.
Determinants of parenting
Research findings have clearly indicated that parenting has multiple determinants,
including circumstantial factors such as everyday stress, lack of social support, and
adverse economic conditions, in addition to genetic factors (Kendler, Sham, & MacLean,
1997). Webster-Stratton and Hammond (1999) also found that marital discord had a
significant impact on parenting. In some studies, external factors influenced parenting by
increasing parental negativity and irritability (Conger, Ge, Elder, Lorenz, & Simons,
1994; Crnic & Greenberg, 1990). But the relationship between a high stress level and
dysfunctional parenting is probably not linear, as Abidin (1992) found that very low
levels of parental stress were also associated with dysfunctional parenting.
Patterson, Cohn, and Kao (1989) suggested that stress factors amplify adjustment
problems and therefore may particularly affect the parenting of those who already
exhibit weak personal resources. Growing evidence has indicated that contextual stres-
sors on parent behaviour may be mediated by the psychological resources of the parents
(Dix, 1991; McKenry, 1991). Researchers have argued that inner determinants of
parenting, such as parents personality and motivation, have not received sufficient
attention (Belsky, 1984; Webster-Stratton, 1990). Several studies have shown that
although moderate stress influenced parenting practices, it hardly affected children
adversely if parenting capabilities remained competent (Gribble et al., 1993; Klinnert,
Mrazek, & Mrazek, 1994; Patterson, Reid, & Dishion, 1992; Quinton & Rutter, 1985).
Dimensions of parenting in socialization research

Earlier socialization research suggested two global domains of parenting, parental
warmth and parental control (Baumrind, 1971; Maccoby & Martin, 1983). Parental
warmth consists of an attitude characterized by nurture, support and reassurance
towards offspring. It also implies being emotionally sensitive and available to childrens
needs. The parenting construct of control is positively defined, encompassing discipline
behaviour, such as teaching children to act in accordance with rules, setting limits in a
consistent, unemotional way, enhancing compliance, having age-appropriate expec-
tations, and monitoring activities and whereabouts. According to Baumrinds (1991)
parent typology, parents who are both warm and practice sufficient control are called
authoritative. Parents with good control, but low scores on warmth are authoritarian.
Permissive parents are low on control, yet warm and caring, whereas parents that are
low on both parenting factors are called neglecting. The importance of parental warmth
and control have repeatedly been confirmed in later socialization research (Hethering-
ton & Clingempeel, 1992; Lamborn, Mounts, Steinberg, & Dornbusch 1991; OConnor,
Hetherington, Reiss, & Plomin, 1995; Reiss et al., 1995; Steinberg, Emen, & Mounts,
1989). Adolescents who perceived their parents to be authoritative were better adjusted
than adolescents with authoritarian, permissive or neglecting parents. They did better in
532

school, had better relations with peers, and showed less experimentation with alcohol
and drugs (Lamborn et al., 1991; Steinberg, Lamborn, Dornbusch, & Darling, 1992).
Parenting characteristics of parents with psychiatric disorders

In this section we do not focus on associations between parents and childrens mental
problems, but how parents mental state affects their parenting. Within adult psychiatry
one tends to regard adult patients partly as victims of childhood psychosocial adversity.
To a far lesser extent have the adult psychiatric patients own parenting skills been a
clinical focus, and even less have they been a target of research. Jacobsen, Miller, and
Kirkwood (1997) found that very few adult psychiatric facilities routinely collected data
on whether their patients have small children, in spite of the established fact that the
children of psychiatric patients are a high-risk group for the development of psychosocial
problems. This omission is primarily a result of mental services tending to be either child-
or adult-specific. Because of the complexity of the problem and our limited knowledge
of parenting issues and mental illness, clinicians are presented with great challenges
when working with families with parental psychiatric disorder.
Most studies linking parental psychopathology with parenting have investigated the
impact of mothers psychopathology on parental behaviour. We know little about the
impact of psychopathology on fathers parenting, even though substantial associations
between paternal psychiatric symptoms and child maladjustment have been found
(Phares & Compas, 1992).
Depressed parents and their parenting

Beardslee, Versage, and Gladstone (1998) found that by the age of 20 someone with an
affectively ill parent had a 40% chance of experiencing an episode of major depression.
It is not known how much this increase was accounted for by aspects of parenting,
although it is widely accepted that depression has a substantial impact on parents ability
to guide and nurture their children.
In their review on depressed mothers, Lyons-Ruth, Wolfe, and Lyubchik (2000)
described what they called the Janus-faced nature of depression, in which angry, intru-
sive or coercive behaviour toward others coexisted with withdrawn, listless behaviour.
In several studies, depressed mothers have shown more negative mood, were more
critical, rejecting, and expressed more negative affect towards their children (Goodman,
Adamson, Riniti, & Cole, 1994; Gordon et al., 1989; Murray, Kempton, Wooglar, &
Hooper, 1993; Radke-Yarrow, Nottelman, Belmont, & Welsh, 1993; Whitbeck, Hoyt,
Simons, & Conger, 1992). Depressed mothers have also shown diminished sensitivity to
their childrens needs and an impaired disciplinary functioning (Rutter, 1990), with more
power assertion and inconsistency (Conger et al., 1992). Their negative moods may also
lead them to inappropriately use infants as a source of comfort. Dix (1991) found that
depressed, avoiding and negative mothers were characterized by a high self-focus and
low child focus. This self-focus was possibly present in the depressed mothers in Kochan-
skas study (1990). She found that depressed mothers parenting was more related to how
much they liked their children, whereas parenting of normal mothers to a larger extent
was predicted by their child-rearing ideology.
Within the last decade, several researchers have pointed to the possibility that parent-
ing difficulties might not be a function of depression at all, but rather stem from the
impairments in the parents social functioning. These impairments might initially have
placed them at risk for depression. Mufson, Aidala, and Warner (1994) demonstrated in
their study that maternal depressive symptoms per se did not create the biggest problems
533

in offspring, but rather the mothers level of social ability, regardless of severity of
depressive symptoms. The fact that parenting continued to be impaired in non-depressed
women with an earlier history of depression (Stein, Gath, Bucher, Bond, & Cooper,
1991) underlines the fact that there may not be a direct association between impaired
parenting and depression. When examining childrens level of intellectual and social
competence, it was the mothers parenting practices, not their depressive symptoms, that
were crucial. It was the degree to which mothers were responsive and able to encourage
their childrens active problem-solving and feelings of mastery and control, not maternal
diagnosis of depression, that accounted for differences in childrens display of helpless-
ness (Chorpita & Barlow, 1998; Nolen-Hoeksema, Wolfson, Mumme, & Guskin, 1995).
This helplessness is often a prerequisite for the development of child depression. Not all
researchers have found that depression is linked with poorer parentchild interaction,
so it is a great overgeneralization to indicate that all women who feel depressed will
function poorly as parents, or that impaired parenting is caused by parental depression
(Frankel & Harmon, 1996). Dysfunctional parenting is evidently more related to inade-
quate social functioning than to depressive symptoms.
Parents with schizophrenia and their parenting

The diathesisstress model, which has been a framework for risk research on schizo-
phrenia, assumes that constitutional vulnerability interacts with environmental stressors
in the production of psychopathology (Walker, Downey, & Bergman, 1989). In adoption
studies of children whose biological parents were schizophrenic, the genetic propensity
for developing schizophrenia was mostly manifest in the presence of a disturbed family
environment of the adoptive parents (Rutter, 1997; Tienari et al., 1994). This research
supports the model assumption that children of schizophrenic parents that grow up with
more environmental stressors, for example dysfunctional parenting, are at a heightened
risk for developing problem behaviour. Longitudinal studies of children at high risk for
schizophrenia, the UCLA High Risk Study (Goldstein, 1985) the Israeli High-Risk Study
(Goldstein, 1988), and Finnish adoption study (Tienari et al., 1994) found that families
in which the adopted children developed schizophrenia had poorer parenting skills than
those families with at-risk children growing up with schizophrenic parents, who had,
nevertheless, competent parenting skills. All at-risk children in the Israeli study who
developed schizophrenic disorders had a combination of early neuropsychological
anomalies and poorer parenting (Marcus, Nagler, Auerbach, Mirsky, & Aubrey, 1987).
As for the effects schizophrenia may have on parenting skills, it is generally acknow-
ledged that schizophrenic disorders have a dramatic impact on the ability to maintain
close and reciprocal relations. The rates of custody loss for schizophrenic mothers are
consequently high (Miller & Finnert, 1996). But empirical evidence on parenting and
schizophrenia is still rather scarce (Caton, Cournos, Felix, & Wyatt, 1998; Mowbray,
Oyserman, Zemencuk, & Ross, 1995), and the specificity of the parenting variables is
rather low in studies with schizophrenic parents. Jones, Rodgers, Murray, and Marmot
(1994) found that the mothers of children who later developed schizophrenia had been
rated by health visitors as less skilled in their management and understanding of the
children when the children were four years old. Sacker, Done, Crow, and Golding (1995)
suggested that the chaotic lifestyle of schizophrenic women was likely to be associated
with poor mothering skills. Riordan, Appleby, and Faragher (1999) compared the
parenting of schizophrenic mothers with that of mothers with affective disorders. They
found that mothers with schizophrenia were more remote, insensitive, intrusive and self-
absorbed. As is the case with depressed mothers, it may be that schizophrenic parents
ability to relate socially to their children is more important for child outcome than the
534

severity of their symptoms. If a child is part of a parents delusional system, parenting

capability is most likely at stake. But the fear of custody loss hinders schizophrenic
mothers from seeking help with parenting problems when needed, so they often
minimize their illness and its impact on their children (Sand, 1995).
Some might argue that it is not the parenting behaviour of schizophrenic parents that
affects children the most, but the children growing up stigmatized by a mentally ill
parent. However, Downey and Walker (1992) demonstrated that children of parents with
schizophrenia showed very low levels of internalizing and externalizing problems when
they had not been exposed to dysfunctional parenting, in contrast to those who were.
Yoshida, Marks, Craggs, Smith, and Kumar (1999) found that the parenting environ-
ment provided by mothers with schizophrenia before and after birth contributed to the
cognitive impairment observed in their infants. Most recent studies seem to confirm the
diathesisstress model. However, further longitudinal studies are needed to disentangle
those genetic factors that place the infant at risk from the impact of the environment that
mothers with schizophrenia provide for their children.
Parents with personality disorders and their parental practices

In contrast to numerous studies of parental practices among depressed mothers, a
remarkable paucity of research exists on parenting capabilities of parents with person-
ality disorders. Studies linking parental psychiatric symptoms with parenting have so far
focused on Axis I disorders and have not included personality disorders. This is
somewhat surprising considering Rutter and Quintons prospective study from 1984 of
children of psychiatric patients. They found that the psychiatric risk to children of all
patients was highest if the parent had a personality disorder characterized by hostility.
In a more recent pilot study, children of borderline mothers were found to be a high-risk
group for developing several kinds of psychosocial problems (Weiss et al., 1996). One of
the criteria for antisocial personality disorder in the earlier DSM-III was neglect of
parenting obligations. Teenage mothers who had an antisocial history were significantly
more unresponsive towards their infants (Cassidy, Zoccolillo, & Hughes, 1996).
Research has suggested that symptoms of depression or anxiety per se have not influ-
enced mothers parenting capabilities as much as their social ability has. Accordingly,
personality disorders should seriously interfere with adequate parenting, as personality
disorders are regarded as disturbances of interpersonal relating, most often manifest in
close relationships.
The clinical impression is that children of parents with personality disorders are more
frequent among child psychiatric patients than children of parents with Axis I disorders.
One reason for this might be the fact that the social network mobilizes and helps families
in which one parent has been defined as ill and in need of hospitalization. Whereas a
personality-disordered parent characterized by hostility will neither evoke nor accept
help offered by their social network. Adults with borderline, antisocial or paranoid
personality disorders often distance themselves from family and friends, leaving the child
at the mercy of the parent without alternative, stable, adult attachment figures. However,
we have not found any study that has investigated comprehensive personality traits or
personality disorders among parents of children/adolescents referred to child psychiatric
clinics.
In a study on the effect of parenting skills on asthma in high-risk asthma infants, it was
found that even non-pathological deviance in parents personality profile was related to
problematic parenting (Mrazek, Mrazek, & Klinnert, 1995. Kochanska, Clark, and
Goldman (1997) found in their study that personality traits such as negative emotional-
ity and disagreeableness interfered with adaptive parenting and thus affected child
535

outcome. These studies point to the necessity of further research on personality traits as
determinants of parenting behaviour.
Parents with anxiety disorders and parental practice

Of the various anxiety problems parents may have, Silverman, Cerny, Nelles, and Burke
(1988) showed that agoraphobic/avoidant parental behaviour in particular put children
at risk for maladjustment, possibly due to the model effect of parental caution and fear-
fulness. There is little available recent information on parenting characteristics of
parents with anxiety disorders even though high-risk studies have indicated a substan-
tial prevalence of anxiety disorders in the offspring of anxious parents, which was not
merely due to genetic inheritance (Beidel & Turner, 1997). Hirshfeld, Biederman, Brody,
Faraone, and Rosenbaum (1997) demonstrated that maternal anxiety disorders, coupled
with a high score of negative criticism towards offspring (measured with the Five-
Minute-Speech-Sample of Expressed Emotion), correlated significantly with a high
number of child disorders. Contrary to what might be expected, anxiety-disordered
mothers in one study monitored their children less than other mothers with or without
psychiatric disorders (Chilcoat, Breslau, & Anthony, 1996).
Parenting by mothers with eating disorders

Franzen and Gerlinghoff (1997) found that many of the mothers with eating disorders
treated in their clinic, struggled with feelings of inadequacy and serious parenting diffi-
culties. Eating-disordered mothers were more preoccupied than other mothers with
their childrens nutrition and weight. In one study, they were more intrusive and showed
more negative emotions towards their infants during mealtimes than other mothers
without eating disorders (Stein, Woolley, Cooper, & Fairburn, 1994). Later, Stein,
Woolley, and McPherson (1999) found that eating-disordered mothers inattention to
their childrens cues during mealtime, caused more conflict, and that 20% of the
variance in the weight of their infants was accounted for by mealtime conflict. White-
house and Harris (1998) demonstrated how nursery school childrens food refusal was
significantly correlated with the management style of mealtimes by caregivers with
eating disorders. However, implications of causality are not quite justified. One has to
consider that the fussiness of a child may also have influenced the caregiver. Further
investigations are demanded.
Nevertheless, Evans and le Grange (1995) found in their sample that at least half the
children of eating-disordered mothers suffered from emotional problems. Timini, Hodes,
and Robinson (1995) showed in their preliminary study of 26 anorectic and bulimic
mothers, that there was a 1729% risk of the child developing a psychiatric illness.
Parenting by substance-abusing parents

Although substance abuse is hardly a psychiatric disorder, researchers and clinicians
have become increasingly aware of the high prevalence of mental disorders among
substance-abusing individuals (Brown, Ridgely, Pepper, Levine, & Ryglewicz, 1989;
Regier et al., 1990). Substance abuse is also known to have an impact on parenting skills
(Kuperman, Schlosser, Lidral, & Reich, 1999; for a review, see Mayes, 1995). Parenting
problems have been observed with children of various ages and with women who use
different drugs. OConnor, Sigman, and Kasari (1993) found that even maternal social
drinking was related to poorer parenting at 1 year of age.
In what specific ways substance abuse affects the quality of parenting is not yet known.
Psychosocial risk factors associated with drug-use, for example, chaotic lifestyles, diffi-
cult or abusive relationships with partners, will most likely influence parenting.
536

Substance-abusing women who were exposed to a high number of environmental risk

factors had poorer parenting attitudes than those substance-abusing mothers exposed to
a low number of risks (Kettinger, Nair, & Schuler, 2000). Studies have suggested that the
risk factor accompanying substance abuse that affected parenting the most, was parental
mental disorder (Bernstein & Hans, 1994). Hans, Bernstein, and Henson (1999) found
that the association between maternal drug use and dysfunctional parenting was
mediated by maternal psychopathology. The relationship between psychological
symptoms associated with drug use and dysfunctional parenting was stronger than the
relationship between dysfunctional parenting and substance abuse. In particular,
maternal symptoms of antisocial and related personality disorders affected parenting.
Moreover, competent parenting mediated the effects on children of most other risk
factors associated with drug-abusing parents (Dawe, Harnett, Staiger, & Dadds, 2000).
Also psychopathology associated with fathers alcohol problems seems to play a more
important role in predicting parental attitudes than alcoholism per se (Das Eiden &
Leonard, 2000).
Parenting associated with psychosocial problems in offspring

When both parents and children have psychiatric problems within one family, the trans-
mission of psychopathology from one generation to another is not necessarily disorder
specific. The same psychosocial risk factors in childhood may be antecedents to several
psychiatric disorders in adults. The specific behavioural consequences of various risk
factors may be hard to identify, partly because it has become clear that risk factors are
highly intercorrelated, for example, parental psychiatric status, maltreatment and low
socio-economic status (Walker, Downey, & Bergman, 1989). The focus of the second
part of this article is to review aspects of parenting that are linked to various mental
problems in children.
Most types of childhood psychopathology have moderate to large genetic components.
Heritability estimates have ranged from 54 to 82% for attention deficit/hyperactivity
disorders in children, 21 to 74% for behaviour disorders, and 11 to 72% for internaliz-
ing disorders (Wamboldt & Wamboldt, 2000). Higher figures have usually come from
studies using parent report measures and the lower ones from observational studies.
Whereas parenting measures accounted for 2050% of the variance in child outcome
(Conger & Elder, 1994; Reiss et al., 1995).
In a study on the childrens point of view, those who had psychiatric problems gener-
ally perceived their parents to be much less supportive than did healthy children
(Kashani, Canfield, Borduin, Soltys, & Reid, 1994).
Children with anxiety symptoms and parenting characteristics

Compared with other parental disorders, there seems to be some degree of specificity of
transmission of anxiety disorders within families (Merikangas, Avenevoli, Dierker, &
Grillon, 1999). Although there may be early temperamental vulnerability factors
manifest in children before they develop anxiety disorders, environmental and familial
factors in the aetiology of early anxiety symptoms have been documented (Warner,
Mufson, & Weissman, 1995). Individual-specific environmental factors seemed to
account for approximately twice as much variance in liability to phobias as do genetic
factors (Kendler, Neale, Kessler, Heath, & Eaves, 1992); yet our ability to discriminate
between the different types of parental transmission for the liability to phobia is limited
within twin and adoption studies.
In studies that have not measured genetic influence, mothers of anxious children have
537

been found to show high levels of aversive control, and attempted to elicit compliance
with criticism and punishment (Dumas, La Freniere, & Serketich, 1995). Anxiety in
children has been correlated with parental negative control, rejection and inconsistency
(Rapee, 1997). Warner, Mufson, and Weissman (1995) found significant associations
between childhood panic spectrum disorder and a chaotic family environment. Parents
of anxiety-disordered children have been rated as less autonomy granting by observers,
and children rated their parents as less accepting (Siqueland, Kendall, & Steinberg,
1996). Maternal negativism was significantly associated with behavioural inhibition in
children (Hirshfeld et al., 1997), and Biederman et al. (1993) demonstrated that behav-
ioural inhibition was an antecedent to the development of anxiety disorders in children.
In Chorpita and Barlows (1998) review on the development of anxiety, the emerg-
ence of a new theoretical understanding of anxiety was discussed. The role of uncon-
trollability and unpredictability was stressed in the development of anxiety. According
to this notion, children that have early experiences with diminished control and influ-
ence on events in their surroundings, develop a psychological diathesis that may eventu-
ally give rise to increased anxiety. Parenting characterized by aversive control, criticism
and inconsistency may possibly foster childrens sense of reduced ability to influence
events.
Anxious parents have also been found to support their childrens avoidant behaviour
(Barrett, Rapee, Dadds, & Ryan, 1996), and their own anxious attitudes contributed to
anxiety levels in children (Gruner, Muris, & Merckelbach, 1999; Muris & Merckelbach,
1998).
Conduct-disordered children and parenting variables
Established associations Conduct problems are generally the most common reason for
referral of children to mental health services. The relationship between parenting and
conduct-disordered children has been a target for extensive research. Genetic studies have
pointed to the influence of non-shared environment for the development of the disorder
(Gottesman & Goldsmith, 1995). In a study on non-shared parenting, parental negativity
specific to each child was strongly associated with adolescent antisocial behaviour and
depressive symptoms (Reiss et al., 1995). This finding was in accordance with studies on
parenting and childhood conduct disorder (Farrington, 1995; Patterson, 1986; Sampson &
Laub, 1994; White, Moffitt, Earls, Robins, & Silva, 1990). Parental inconsistency and
disruptive discipline practices have especially been associated with conduct disorders
(Patterson, DeBaryshe, & Ramsey, 1989), as well as overreactivity in the form of harsh,
controlling and negative discipline (OLeary, Slep, & Reid, 1999). Lack of parental moni-
toring is also a strong predictor for early onset drug use and delinquency (Chilcoat et al.,
1996). However, links between parental inconsistency, monitoring, and low involvement
on the one hand and child conduct problems on the other hand depended on the age of
the children in Frick, Christian, and Woottons study (1999). This again stresses the import-
ance of considering child characteristics in relation to parenting variables.
In addition to impaired discipline practices, parental warmth or rather lack of such,
plays a part in parenting conduct-disordered children. In one study, early maternal rejec-
tion was the most consistent predictor of preschool externalizing problems (Shaw et al.,
1998). Rey and Plapp (1990) found that adolescents with conduct disorders and
oppositional defiant disorders perceived their parents to be less caring and more over-
protective (affectionless control) than did normal adolescents. Ge, Best, Conger, and
Simons (1996) showed how parental negativity could be a risk factor for both conduct
disorders and depression in adolescents, whereas shared positive affect between child
538

and caregiver promoted child compliance and internalization of parental prohibitions in

Kochanska and Aksans study (1995).
Webster-Stratton and Hammond (1999) found that poor skills in resolving marital
conflict, in addition to parental criticism and low responsiveness, were characteristic of
parents with conduct-disordered children. Erel, Margolin, and John (1998) showed that
such poor skills had a direct spillover effect on children, who behaved in a similar way
towards siblings.
Heredity and vulnerability to psychosocial adversity Children with early-onset conduct

disorder, especially those who are characterized by a callous interpersonal style, often
develop delinquent behaviour and antisocial personality disorder as adults (Christian,
Frick, Hill, Tyler, & Frazer, 1997; Moffitt, 1993). Wootton, Frick, Shelton, and Silver-
thorn (1997) found that distinct causal factors possibly existed for the development of
this disorder. Children with early-onset conduct disorder appeared to be particularly
susceptible to parental discord (Fergusson, Horwood, & Lynskey, 1991). In a Swedish
longitudinal study, Bohman (1996) showed that a genetic liability to antisocial behaviour
probably rendered the individual vulnerable to adverse environmental influences in
general. So parenting that is good enough for a robust child may not necessarily be so
for a child who is genetically susceptible to disruptive or antisocial behaviour. Results
both from prospective and genetic studies have suggested that there are cumulative
effects of genetic susceptibility and adverse environmental factors in the aetiology of
conduct disorders (Cadoret, Yates, Troughton, Woodworth, & Stewart, 1995; Wasser-
man, Miller, Pinner, & Jaramillo, 1996). Temperamental traits such as activity level and
irritability tend to be inherited. Moffitt (1993) suggested in his review that children
whose hyperactivity and angry outbursts might be curbed by firm discipline often had
parents who were inconsistent disciplinarians; the parents tended to be like their
children, irritable and impatient.
Studies have shown a high rate of antisocial personality disorder and substance abuse
among parents of children with severe conduct problems (Frick, Lahey, Hartdagen, &
Hynd, 1989; Frick et al., 1992). This association was not attributed to racial or socio-
economic differences. Furthermore, a link has been found between children who have
been clinic referred because of conduct problems and somatization disorders in their
mothers (Frick, Kupler, Silverthorn, & Cotter, 1995). Of course, somatization disorders
do not necessarily imply impaired parenting. However, Lilienfeld (1992) has suggested
that somatization disorders and antisocial behaviour are related syndromes, and soma-
tization in women might be a gender-specific manifestation of antisocial behaviour.
Child effects Ineffective parental disciplinary style might reflect parents reactions to the
aggressive and defiant child as much as the reverse (Ge, Conger, et al., 1996; Lytton,
1990). However, OConnor et al. (1998) found in their adoption study that parent effects
on childhood behavioural problems still contributed to some degree to child misconduct,
in addition to the child effects on parenting.
Depressed children and parenting characteristics

Extensive efforts have been made to investigate the potential role of parenting in the
aetiology of depression (Downey & Coyne, 1990; Mufson, Aidala, & Warner, 1994;
Radke-Yarrow, Nottelmann, Martinez, Fox, & Belmont, 1992; Radke-Yarrow et al.,
1993; Rutter, 1990). But far more studies have been conducted on parentchild relations
when an adult has a depressive disorder than when the child/adolescent is depressed.
Fathers role towards the depressed child has seldom been studied, with a few
539

exceptions (Cole & McPherson, 1993; Sanford, Szamari, & Spinner, 1995; Shiner &
Marmorstein, 1998) that have stressed the importance of the fatheradolescent relation-
ship for the development of adolescent depression. McFarlane, Belissimo, and Norman
(1995) found in their study of cross-gender effects of parenting styles on adolescent
depression, mother care affected sons well-being and father care affected daughters
well-being. Still the persistent lack of studies on fathers role in the aetiology of depres-
sion has resulted in a continued emphasis on mothers as transmitters of depressive
psychopathology (Zahn-Waxler, 1995).
Several researchers have found that parents of depressed adolescents were less warm
and supportive, less communicative, and more critical than were the parents of other
adolescents (Kaslow, Deering, & Racusin, 1994; Rey, 1995). Lack of maternal warmth,
emotional attachment and poor communication increased the risk of suicidal adolescent
behaviour (Adams, Overholser, & Lehnert, 1994; De Man, Labrche-Gauthier, &
Leduc, 1993). Gjerde, Block, and Block (1991) showed that mothers authoritarian
parental style (high score on control, lower score on warmth and support, but still within
the context of a positive relationship) toward 5-year-old daughters could predict
dysthymia when the daughters reached 18 years. Recent research confirms earlier
findings and represents sufficient evidence to suggest the link between child/adolescent
depression and inadequate parenting practices. Yet again, the interplay between genetic
vulnerability in the child and psychosocial adversity is far from clear.
Some researchers have tried to decipher the interaction of negative life events and
parentings impact on adolescents. Ge, Lorenz, Conger, Elder, and Simons (1994) found
that stressful life events placed adolescents at risk for developing depression only when
the stressful life events resulted in disruptive and inconsistent parenting practices.
Maternal warmth and support protected adolescent daughters against depression by
attenuating the correlation between stressful life events and depressive symptoms.
Discussion
In this review research has been highlighted that links child and adult psychopathology
with parenting factors. It seems beyond dispute that child as well as parental psychiatric
disorders represent major stressors for a family and substantially impact parenting
abilities. The level of parental social functioning and responsiveness may be more crucial
for parenting skills, than psychiatric symptoms per se.
The impact of dysfunctional parenting seems to be less specific for child outcome than
might be expected, associated with externalizing as well as internalizing problems in
children. For anxious and depressed children, however, it may seem like parental
negative, affectionless over-control is more characteristic, whereas inconsistent, disrup-
tive discipline with insufficient monitoring is more characteristic of parents of children
with conduct disorders.
The review showed that two main dimensions of dysfunctional parenting occur in
families with child or parental psychopathology: (i) Parental negativity, and (ii) various
forms of ineffective discipline practices.
Parental negativity
Parents negative behaviour towards their children is not merely synonymous with lack
of parental warmth, but implies an element of hostility, for example, rejecting, nagging,
criticizing, accusing, scapegoating, belittling, ridiculing. The various forms of negativity,
evident in parentchild communication or parental attitude, vary from study to study.
Most studies on parental negativity do not differentiate between the various aspects of
540

negativity. However, it seems that the level of parental negativity is more crucial for child
outcome, than how the negativity is expressed. Mothers with depression, anxiety or
eating disorders, as well parents with certain personality disorders, have a parental style
often characterized by some aspect of negativity. Children with anxiety, conduct or
depressive disorders all have parents that they themselves or researchers perceive to be
negative in some way towards their children. What the essence of parental negativity is
may only be speculated upon.
Some researchers have raised the possibility that parental negative dispositional attri-
butions of offspring behaviour might be part of most parental negativity (e.g. Dix, 1993).
Such attributions are characterized by ascribing non-existing adverse dispositions or
intentions to a specific child or magnifying already existing negative child behaviour or
traits. Consequently, the perceived adversity of child behaviour may legitimate parental
overreactions or negativity. The phenomenon is often termed scapegoating in the
parenting literature; one child in the family becoming a target of parental negativity
while siblings usually are spared. To what extent negative attributions are components
of the negativity and hostility that may occur in parenting associated with child psycho-
pathology remains to be studied. Negative attributions have proven to be characteristic
of parents with conduct-disordered children. Baden and Howe (1992) found that they
had lowered expectations for their own parenting effectiveness, and ascribed intention-
ality to their child for misbehaviour. Parents often ascribed a childs adverse behaviour
to dispositional attributes rather than to their own parenting practices, which again kept
parents from trying seriously to change the childs behaviour. A parental negative attri-
butional bias has proven to be especially characteristic of abusive parents (Bugental,
Blue, & Cruzcosa, 1989; Dix, 1991).
Negative attributions are surely not restricted to distressed, dysfunctional or disturbed
parents. Negative emotions in normal parents appeared to be linked with such attribu-
tions in Brody, Stoneman, and Burkes study (1988). At least two studies have shown
how marital conflict correlated positively with the frequency of maternal disapproval
statements towards sons but not towards daughters (Jouriles, Pfiffner, & OLeary, 1988;
OLeary, Slep, & Reid, 1999). The escalating coercive interchanges between a custodial
mother and her son following divorce that Hetherington and Clingempeel (1992) found,
may possibly be due to this kind of negative maternal bias.
Ineffective discipline
Discipline problems are present in many families with either child or parental psycho-
pathology. Harsh, disruptive and inconsistent discipline practices are characteristic of
families with conduct-disordered children. They are also characteristic of parents with
certain personality disorders and possibly also of substance-abusing parents. Inconsis-
tent parenting is characterized by partial, recurrent and unpredictable breakdowns in the
parental control factor. Cerezo and DOcon (1995) have shown that parents of conduct-
disordered and anxious children were more inconsistent than other parents. Inconsis-
tency is also characteristic of abusive families. To our knowledge, no studies exist on the
relationship between parental personality disorders and inconsistent parenting. Parental
inconsistency is a parenting variable that is especially difficult to measure in self-report
inventories or to detect in time-limited observation studies, as it requires repeated
measures.
It is not unexpected that a childs uncertainty and inability to predict the reactions of
its immediate social environment due to inconsistent parenting should have an impact
on child development. Some children may develop feelings of not being able to influence
events in their surroundings, a helplessness that may dispose them for anxiety. Others
541

become disruptive like their parents and often manipulative. The latter is possibly a
coping mechanism, a means by which the children try to control their unstable surround-
ings.
Insufficient monitoring is an aspect of parental control that has repeatedly been
connected with conduct-disordered children. Among parents with psychopathology lack
of monitoring has been found in parents with anxiety disorders and antisocial personal-
ity disorders.
Future research
To better understand the interplay of parent and child effects shaping each others behav-
iour, future research needs to integrate childrens individual differences with parenting
variables. Such integration necessitates two types of research.
Direction of effects
Research designs that make it possible to differentiate between parentings effect on
children and childrens effect on parenting are necessary. The question of direction of
effects seems to have been addressed successfully in only one adoption study by
OConnor et al. (1998) with conduct-disordered boys. In their study, child-effects on
parenting were substantial, yet parent-effects on childhood behavioural problems still
contributed to child misconduct.
Specificity of parenting variables

Studies are necessary that can show how the same specific parental variables may
impinge differentially on children, dependent on the childrens characteristics. One study
has shown how the lack of parental monitoring, harsh parenting or parental over-
involvement induced either depressive or aggressive symptoms in a child, dependent on
the childs activity level and fearfulness (Colder, Lochman, & Wells, 1997).
The level of specificity concerning parenting factors varies to a large degree in studies
linking psychopathology and parenting and therefore limits some studies clinical
relevance. This lack of specificity concerns the parenting variables as well as whether
these variables are restricted to the relationship with the index child or are generally
applicable for all children in the family.
Specific parenting factors that may represent a risk or a protection are especially
important to investigate in families where child outcome is unexpected, for example,
well-adjusted children of mentally ill parents, or children with psychiatric disorders and
high-functioning, empathic parents (Table 1).
However, during the past decades parents of children with psychiatric disturbances
have unjustly been regarded as less relevant subjects for research. This is due to the
already mentioned fear of inducing unnecessary guilt in parents. From a research point
of view this is unfortunate, as we still need to know more about how aspects of parental
negativity and ineffective discipline operate together with child variables, external
circumstantial factors, and genetic susceptibility. Studies suggest that above-normal child
IQ and good parenting variables may be fundamental adaptational systems that protect
child development in the context of severe adversity (Masten et al., 1999). By also
studying parenting characteristics of psychiatrically disturbed parents whose children do
not have any psychosocial problems, one can increase our present knowledge of protec-
tive parenting factors that may enhance child resilience. Knowledge from this research
may facilitate clinicians in early detection and more precise pinpointing of parental
behaviour that may conserve or ameliorate childrens mental problems.
542

06 Berg-Nielsen (to/d)
11/13/02
Table 1. Overview of research linking parenting and psychopathology and suggestions for future research
Adult psychopathology
1:13 PM

Child psychopathology Present Absent
Present Dysfunctional parenting linked with parental In these families, child effects on parental
psychopathology represents a major stress behaviour are often evident and parent effects
Page 543
factor, especially for the genetically susceptible less discernable. More studies on direction
child, and may aggravate child outcome. of effects are necessary, as well as subtle aspects of
543
child-specific parental behaviour.
Absent Regardless of parental symptoms, good Numerous studies from socialization research
parenting can buffer a childs susceptibility document that authoritative parenting is
to a disorder. More research is needed on related to well-adjusted children. Level of
parenting factors that may prompt child specificity of parenting variables need to be
resilience. enhanced in future studies.
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Clinical Child Psychology and

Parenting Related to Child and Parental Psychopathology: A Descriptive Review

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Parenting Related to Child and Parental

TURID SUZANNE BERG-NIELSEN & ARNE VIKAN

I N T H I S R E V I E W two areas of recent research on parenting are investigated, studies

Clinical Child Psychology and Psychiatry 13591045 (200210)7:4 Copyright 2002

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

either child or parental psychopathology. Serious parenting problems may be due to

T U R I D S U Z A N N E B E R G - N I E L S E N worked as a Clinical Specialist (PhD) for 17 years in

A R N E V I K A N has extensive research experience within developmental psychology and child

A LV A . DA H L is Professor of Psychiatry at the University of Oslo and Head of the Treat-

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BERG-NIELSEN ET AL.: PARENTING AND PSYCHOPATHOLOGY

Two areas of parenting research are not covered in this review:

The concept of parenting

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

Dimensions of parenting in socialization research

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BERG-NIELSEN ET AL.: PARENTING AND PSYCHOPATHOLOGY

Parenting characteristics of parents with psychiatric disorders

Depressed parents and their parenting

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

Parents with schizophrenia and their parenting

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BERG-NIELSEN ET AL.: PARENTING AND PSYCHOPATHOLOGY

severity of their symptoms. If a child is part of a parents delusional system, parenting

Parents with personality disorders and their parental practices

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

Parents with anxiety disorders and parental practice

Parenting by mothers with eating disorders

Parenting by substance-abusing parents

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BERG-NIELSEN ET AL.: PARENTING AND PSYCHOPATHOLOGY

Substance-abusing women who were exposed to a high number of environmental risk

Parenting associated with psychosocial problems in offspring

Children with anxiety symptoms and parenting characteristics

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

Conduct-disordered children and parenting variables

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BERG-NIELSEN ET AL.: PARENTING AND PSYCHOPATHOLOGY

and caregiver promoted child compliance and internalization of parental prohibitions in

Heredity and vulnerability to psychosocial adversity Children with early-onset conduct

Depressed children and parenting characteristics

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

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BERG-NIELSEN ET AL.: PARENTING AND PSYCHOPATHOLOGY

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

Specificity of parenting variables

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child-specific parental behaviour.

CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 7(4)

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