EDITORIAL
Parental Psychiatric Symptoms and Children’s
Outcomes: Toward Understanding and Responding to
Intergenerational Risk in Child Psychiatry
Matthew G. Biel, MD, MSc
amily history of psychiatric illness is a core feature
F of any competent clinical history taken in a child
and adolescent psychiatry clinical setting, and this
history is often limited to reviewing caregivers’ reports of
diagnosed or suspected mental disorders in biological parents
and relatives across several generations. Less commonly
included is a detailed inquiry into parents’ and caregivers’
current mental health, including psychiatric symptoms at the
time that their child is presenting for evaluation. Recent ev-
idence is a strong reminder that parental mental illness is an
important adversity that critically affects lifelong mental well-
being in offspring, and that maternal depression in particular
is an established factor influencing offspring mental health.1-3
In this issue of the Journal, Wesseldijk et al. present their
article “Do Parental Psychiatric Symptoms Predict Outcome
in Children With Psychiatric Disorders? A Naturalistic
Clinical Study,” an effort to examine relationships between
parental psychiatric symptoms and clinical outcomes in child
psychiatric patients.4 The study moves beyond a focus on
maternal depression as a risk factor for offspring psychopa-
thology to include a range of active psychiatric symptom-
atology in both mothers and fathers at the time that children
are presenting for clinical evaluation, and again at follow-up
over a year and a half later.
In the present study, 742 mothers, 400 fathers, and their
811 children were assessed for internalizing and externalizing
psychiatric symptoms via parent report at their first evalua-
tion appointment in 3 child and adolescent psychiatric clinics
in the Netherlands, and then reassessed at follow-up an
average of 1.7 years later. The study’s naturalistic design
allowed for treatment of children and parents at clinicians’
and families’ discretion between the two time points. Girls in
the study were an average age of 11.9 years, and boys averaged
10.9 at baseline. The authors investigated whether children’s
symptoms at follow-up were predicted by parental symptoms
at baseline, parental symptoms at follow-up, and children’s
symptoms at baseline. Children whose mother or father
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scored above a subclinical threshold for psychiatric symptoms
at baseline had higher symptom scores at baseline and at
follow-up. Children’s follow-up scores were most strongly
predicted by their own scores at baseline, and parental psy-
chiatric scores at follow-up also predicted children’s out-
comes; importantly, the magnitude of association was similar
for mothers and fathers. Offspring scores at follow-up were
not well predicted by parental scores at baseline. Higher
symptom scores at follow-up in children of parents with
elevated psychiatric symptoms were explained mainly by
higher children’s symptom scores at baseline. The relative
improvement in symptoms in children with parents with
elevated psychiatric symptoms was similar to the improve-
ment experienced by children without elevated scores, as
measured by effect size. However, as children with parents
with psychopathology were more symptomatic at baseline,
their outcomes at follow-up showed higher rates of persistent
symptoms. This difference appears to be explained by more
severe symptoms at baseline in children with affected parents,
as well as by the association between children’s symptoms and
parents’ symptoms measured at follow-up.
There are several important limitations to this compel-
ling study. As acknowledged by the authors, reliance upon
parental report for both child and parent symptomatology is
problematic, particularly given the hypothesis of a relation-
ship between child and parent mental health and the likely
influence of parents’ own symptoms upon their reports of
their children’s symptoms. Replication of these findings
augmented with clinician- and child-reported signs and
symptoms would significantly strengthen the authors’ con-
clusions. In addition, the naturalistic design of the study
resulted in two important gaps in information: how did
treatment for parents or children influence outcomes? And
did the high rates of drop-out from the study (half of the study
sample was lost to follow-up) skew the findings? Although
those families who persisted in the study did not differ
significantly at baseline from those who dropped out, we do
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 9 / September 2018

not know whether a change in clinical status of children,
parents, or both may have influenced rates of study
completion. Of additional importance is the relative homo-
geneity of the study population—this was a population of
parents with relatively high levels of education and employ-
ment, and high rates of biological parents raising children
together. In addition, participants had to speak fluent Dutch
to be included in the study. The generalizability of these
findings to economically, ethnoculturally, and linguistically
diverse populations needs to be established in other studies.
The heritability of mental disorders is well established, and
results from a complex interplay of genetic and environmental
factors leading to a combination of transgenerational equifin-
ality and multifinality in offspring.5,6 This study contributes to
the evidence base detailing the complex contributions of
parental psychopathology to child mental health outcomes.
Previous efforts to examine active parental psychiatric symp-
toms as predictors of outcomes in children presenting for clin-
ical care have tended to focus on measuring parental symptoms
at baseline rather than at follow-up, and have particularly
focused on mothers’ influence on offspring outcomes.7 The
finding of Wesseldijk et al. that children with psychiatrically
symptomatic mothers or fathers are themselves more symp-
tomatic at baseline, and remain more symptomatic at follow-up
in a naturalistically designed study, is an important contribution
to our efforts to conceptualize intergenerational risk. As the
authors acknowledge, this study does not elucidate direction of
effect: we know from previous work that changes in parent
symptoms affect child mental health, and that changes in child
symptoms may affect parent mental health.8,9
What is confirmed by this study is a concept that may
seem intuitive to many clinicians and is long established in
classic literature in our field: that the interplay between
child and parent symptoms is likely to be ongoing, bidi-
rectional, and sensitive to environmental stressors, such as
poverty or trauma, that are critical to clinical outcomes for
REFERENCES
1. Weissman MM, Wickramaratne P, Gameroff MJ, et al. Offspring of depressed parents:
30 years later. Am J Psychiatry. 2016;173:1024-1032.
2. Goodman SH, Rouse MH, Connell AM, et al. Maternal depression and child psycho-
pathology: a meta-analytic review. Clin Child Fam Psychol Rev. 2011;14:1-27.
3. Beardslee WR, Gladstone TR, O’Connor EE. Transmission and prevention of mood
disorders among children of affectively ill parents: a review. J Am Acad Child Adolesc
Psychiatry. 2011;50:1098-1109.
4. Wesseldijk LW, Dieleman GC, van Steensel FJA, et al. Do parental psychiatric symp-
toms predict outcome in children with psychiatric disorders? A naturalistic clinical study.
J Am Acad Child Adolesc Psychiatry. 2018;57:669-677.e6.
5. van Santvoort F, Hosman CMH, Janssens JMAM, et al. The impact of various parental
mental disorders on children’s diagnoses: a systematic review. Clin Child Fam Psychol
Rev. 2015;18:281-299.
6. Gratten J, Wray NR, Keller MC, Visscher PM. Large scale genomics unveils the genetic
architecture of psychiatric disorders. Nat Neurosci. 2014;17:782-790.
7. Kennard BD, Hughes JL, Stewart SM, et al. Maternal depressive symptoms in pediatric
major depressive disorder: relationship to acute treatment outcome. J Am Acad Child
Adolesc Psychiatry. 2008;47:694-699.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 9 / September 2018
EDITORIAL
both generations.10 If we (think) we know this already, why
do we so rarely design clinical evaluation and intervention
strategies that take this hypothesis into account? Why are
child psychiatry clinical programs so rarely focused on
assessment and treatment for both children and caregivers?
Although the evidence base supporting family-directed
psychotherapy treatments continues to grow, our field
similarly needs to develop clinical strategies that take on
multigenerational psychiatric risk and psychopathology.
Risk accumulates in a significant number of families who
present to child psychiatry clinics: exposure to chronic
adversity, plus parental psychopathology (often with spousal
resemblance), plus child psychopathology, resulting in
reciprocal effects across generations that likely sustain
elevated symptomatology in children and parents (and
grandparents and other caregivers). For these families,
clinical programs should develop the capacity to assess and
treat multiple family members, and research efforts need to
evaluate the effectiveness of these approaches. Several
notable examples of this strategy have emerged, and present
the possibility that “family psychiatry” may be a promising
pathway toward improved outcomes for some of child and
adolescent psychiatry’s most high-risk patients.11
Accepted July 12, 2018.
Dr. Biel is with Georgetown University Medical Center/MedStar Georgetown
University Hospital, Washington, DC.
Disclosure: Dr. Biel has received grant or research support from the DC
Department of Health, the DC Healthy Communities Collaborative, the Mar-
riott Foundation, the Bainum Family Foundation, the Prince Charitable Trusts,
and the Chan Zuckerberg Initiative.
Correspondence to Matthew Biel, MD, MSc, MedStar Georgetown University
Hospital, 2115 Wisconsin Avenue NW, Suite 200, Washington, DC 20007;
e-mail: mgb101@gunet.georgetown.edu
0890-8567/$36.00/ª2018 American Academy of Child and Adolescent
Psychiatry
https://doi.org/10.1016/j.jaac.2018.06.010
8. Wickramaratne P, Gameroff MJ, Pilowsky DJ, et al. Children of depressed mothers 1
year after remission of maternal depression: findings from the STAR*D-Child Study. Am
J Psychiatry. 2011;168:593-602.
9. Settipani CA, O’Neil KA, Podell JL, et al. Youth anxiety and parent factors over time:
directionality of change among youth treated for anxiety. J Clin Child Adolesc Psychol.
2012;42:9-21.
10. Rutter M, Quinton D. Parental psychiatric disorder: effects on children. Psychol Med.
1984;14:853-880.
11. Hudziak J, Ivanonva MY. The Vermont family based approach: family based health
promotion, illness prevention, and intervention. Child Adolesc Psychiatr Clin N Am.
2016;25:167-178.
All statements expressed in this column are those of the authors and do not
reflect the opinions of the Journal of the American Academy of Child and
Adolescent Psychiatry. See the Instructions for Authors for information about
the preparation and submission of Editorials.
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