1. Introduction

Parenting is a challenging, lifelong task that requires flexibility to adapt to shifting circumstances and demands, to societal expectations, and to the needs of individual children as they grow and change. Flexibility, however, is not a hallmark of schizophrenia, nor, for that matter of any serious illness. The rate of motherhood in schizophrenia varies widely, not only by age and illness severity, but also by culture and custom; approximately 50% of women with this disorder become mothers, a rate very similar to that of women in the general population ^[1]. But in contrast to the general population, any mothers with this diagnosis are unmarried or unstably unpartnered, making motherhood, an already difficult lifelong task, substantially more difficult ^[2]. A meta-analysis from the U.K. of 1404 participants with schizophrenia (mean age = 39.9), found that only 15.6% of their sample was married ^[3].

The likelihood of marriage is dependent, of course, on cultural, religious, and economic factors. In India, for instance, marriage rates in the context of schizophrenia are known to be relatively high. This may be because marriages are typically arranged by families and, thus, do not require initiative (usually lacking in schizophrenia) on the part of the bride or groom. It is also possible under some circumstances to keep a diagnosis of schizophrenia hidden from the prospective spouse and family. One factor to which the relatively high rate of marriage in India of this population has been attributed has been the traditional belief that mental illness can be cured by marriage ^[4]. In Western countries, mothers with schizophrenia are mainly single, abandoned not only by the fathers of their children but also, too frequently, by their family of origin ^[5]. In many instances, it is the women, because of delusional paranoia, who have fled an intimate relationship or the family home. These women are unemployed and live in poverty, periodically homeless ^[6], often friendless. The rate of gainful employment among this diagnostic population is low, in Europe, reportedly ranging between 8% and 35% ^[7]. In Denmark, where this has been studied, individuals with schizophrenia earn only 14% of the wages earned by their age peers ^[8]. Most schizophrenia patients are on disability benefits and live in inadequate housing. Symptoms such as lack of initiative, low self-confidence, cognitive deficits, unpredictable moods, poor hygiene, and sometimes eccentric behavior make employment very nearly impossible. It can make child rearing impossible as well. In many cases, child protection services are involved, children may be taken to foster care, some are looked after, wholly or partially, by relatives, usually grandmothers; some are adopted and forever separated from their birth mothers.

2. Challenges of Motherhood for Women with Schizophrenia

2.1. The Burden of Antipsychotic Medication

Most women with schizophrenia are likely, at some point in the trajectory of their illness, to be offered antipsychotic treatment and, for two thirds of those who accept it and adhere to it, the most evident of their psychotic symptoms (delusions and hallucinations) become well-controlled ^[9]. The other third, and those not in treatment, struggle with often-debilitating psychotic symptoms, which cause anguish, negatively affect behaviour, and prevent access to quality of life. The symptoms of schizophrenia, beyond delusions and hallucinations, are not well-treated with current medications. Many women with schizophrenia report apathy, anhedonia, social alienation as well as cognitive deficiencies (problems with attention, memory, analytic skills) ^[10], in addition to depression, and anxiety ^[11]. Adjunctive drugs are often used, increasing the variety and burden of somatic, cognitive, and emotional adverse effects. In the context of the vigilance needed in mothering, many of the drugs used to treat schizophrenia exert strong sedative properties that over-sedate mothers and interfere with their ability to respond appropriately to their offspring ^[12][13].

2.2. Societal Stigma against Motherhood in Schizophrenia

Constant severe symptoms can be incompatible with Winnicott’s concept of “good enough” infant and child care ^[14] which refers to the ongoing provision of unconditional care and commitment to a child. It requires the ability to set consistent behavioural limits and to facilitate a child’s development to adulthood and beyond. This becomes very difficult in the context of economic insufficiency and meager social support, which is why worry is aroused when women with schizophrenia become mothers. There is often justifiable concern for the safety and well-being of the children because severely ill mothers have difficulties meeting their own considerable challenges and, thus, being unable to concentrate on those of others. The concern is also for the mothers themselves because the responsibilities and stresses of motherhood may sufficiently aggravate the mothers’ mental health to lead to relapse and rehospitalization and, sometimes, suicide attempts ^[15][16].

2.3. Effects of Pregnancy and the Post-Partum Period

During the pregnancy itself, and especially in the postpartum period, the severity of psychotic symptoms may increase ^[17]. Women with this diagnosis suffer high rates of obstetric difficulties ^[18]. There is fear that the children born to mothers with schizophrenia will inherit a genetic susceptibility to the same disorder, and will be made even more vulnerable by difficult gestations, obstetric complications, adverse effects of mother’s drugs during fetal life and lactation, under par parenting, poverty, stigma, poor schooling, poor housing and the potential effects of mother’s social isolation ^[19].

2.4. Contraception

It is now possible to defer conception until one feels ready and prepared for motherhood. There are a wide variety of contraceptives and “morning after” choices that no longer rely solely on the co-operation of male partners ^[20][21]. Women with schizophrenia may be safer taking non-hormonal contraceptives because of potential interactions with antipsychotics ^[22]. On the other hand, the estrogen in contraceptive pills may help dampen down psychotic symptoms ^[23].

2.5. Abortion and Adoption

Approximately half of the pregnancies in women with schizophrenia are unplanned and 25% of those unplanned pregnancies are terminated because the mother recognizes her inability to care for a child ^[24] These high rates are attributable to a relative lack of knowledge about contraception and also to pregnancy very often resulting from sexual coercion and rape in this population ^[25][26][27]. Induced abortion can be psychologically traumatic. Bearing a child and giving the child away for adoption is even more difficult for many women with schizophrenia.

Childcare agencies are increasingly advocating kinship care in preference to foster care when they determine that children require placement ^[28]. This allows for safe and affectionate care and for an uninterrupted relationship with their mother. These personal decisions are difficult to make for women with disabilities such as schizophrenia ^[29]; decisional capacity is sometimes deficient in this population and personal choices can, in such cases, be overruled by surrogate decision makers.

2.6. Mothering with Schizophrenia

Although definitions of good mothering vary, it is generally agreed that optimal fulfillment of parental tasks demands time and vigilance and substantive parental well-being. Well-being and, therefore, vigilance may be missing in mothers suffering from schizophrenia, vigilance being also muted by the effects of antipsychotic medication. The presence of thought disorder makes communication with children unclear while apathy and seclusion make the task of socializing children very difficult. Consistent limit setting may vary with mood and the provision of a safe environment for children may be threatened by fears/delusions/hallucinations and by perceived stigmatization and by insecure finances. Individuals with schizophrenia are reported to have trouble putting themselves into the shoes of another person and discerning affective cues –an especially important ability when caring for pre-verbal children. Mothers with severe mental illness are also at known to be at risk for substance use disorders, as are male partners. Substance abuse poses significant problems for parenting and may be accompanied by domestic abuse, which further undermines parenting ability.

Important to note is that the children of approximately 20% of parents with psychosis are said to require high intensity care from both a behavioural and a psychological standpoint ^[30]. This means that highly challenged, usually single, mothers with schizophrenia bring up children whom most mothers would, from the start, find extremely difficult to rear.

Despite their many challenges, many women with schizophrenia prove to be effective mothers ^[31]. They are able to garner support, make the necessary provisions should they suffer relapse and hospitalization, and be conscientious about the care of their children while also seeing to their own health needs. Nevertheless, they encounter many problems ^[32][33].

2.6.1 Impact on Children

Children who are questioned report feeling anxious and depressed about their mother’s well-being ^[34]. They report that the manifestations of their mother’s mental disorder stands in the way of making friends, it produces financial disadvantages, it leads to discrimination in peer relationships. They report feeling responsibility for their mother’s health and they report a lack of safety. Life is described as tense. They feel conflicted about spending time away from their family home. They do not, however, mention neglect, maltreatment, or violence directed at them. They do not believe that their educational development had been slowed or that their physical health had been negatively affected by their mothers illness. Gladstone et al. ^[35] described interviewed children monitoring their parents’ behaviours, and adjusting their own behaviours according to the parent’s mood. One of the worries expressed by older children was whether they, too, would develop a mental illness.

Some of these children are, however, remarkably resilient. Herbert et al. ^[36][37] stress the development of resilience through the experience of successfully meeting adversities in early life. It has been interestingly suggested that such children, brought up in demanding environments, subsequently do well in difficult life circumstances and less well in safe, nurturing environments to which their developmental skills are not adapted ^[38].

2.6.2 Impact on Mothers

Nicholson ^[39] and Dolman ^[40] have synthesized the qualitative research literature on the experiences of motherhood in women with severe mental illness. Fear of custody loss stands out as a prime concern ^[41] and means that mothers with schizophrenia try their best to mask their symptoms from others. As part of this strategy, they may try to discontinue their treatment in an effort to show Children’s Aid agencies that they are well enough too not need them. Some feel shame at not being ideal mothers. Clear communication with their children is a concern for many, as is the ability to provide food, clothing, appropriate housing, transportation and medical attention. Also of concern is how best to appropriately discipline the children, how to help them with school work, how to arrange time for oneself. Most mothers are quick to say that children bring joy, make life worth living, that children motivate them to look after their health and that their experience of illness makes them a better parent. Nevertheless, approximately one fifth of the mothers who responded to an Australian survey were assessed as suffering from severe functional impairments ^[42]. Objective observations showed relatively few mutually satisfying interactions between mothers with schizophrenia and their children ^[43].

2.6.3 Child Custody

The first year of a child’s life is the most vulnerable period for a woman with schizophrenia in terms of custody loss. Her symptoms may not have recovered from postpartum exacerbation, and, at the same time, this is the time period during which the child is totally dependent on the mother. Child-protection agencies know that there is a significant relationship between parental perinatal mental health problems and the risk of child maltreatment ^[44][45].

Under the influence of delusional thinking, mothers with psychosis may physically hurt their child ^[46] or, as a result of negative symptoms or of the adverse effects of antipsychotics on cognition, mothers may neglect to feed or provide much needed child care. When this occurs, child-protective services (CPS) step in and temporarily (sometimes permanently) remove the child to a foster home.

Involvement with CPS can be counterproductive; in the case of parental serious mental illness, detrimental effects on both children and parents have been shown ^[47]. Custody loss can be prevented not only by attending to a mother’s mental health but also by addressing the contributions to poor parenting by factors such as lack of education, non-existent social support, domestic violence, substance abuse, and poverty ^[48].

3. How to Support Women with Schizophrenia in Motherhood

One avenue of effective intervention mothers is to improve the economic circumstances of this population ^[49]. Increases in household income can improve child and maternal health and raise the quality of parenting. Linking mothers to sources of aid such as loans, foodbanks, budgeting advice, skill development, therapeutic support, enabling them to meet practical needs (for furniture, food, clothing, rent), introducing employment opportunities, and ensuring welfare rights all lead to positive impacts. Trained and responsible peer support is very helpful to women as it is often easier to talk to someone who has had similar experiences than to a professional care provider ^[50]. Radley et al. ^[51] offer a scoping review of 34 interventions designed to support parents: parent buddy systems, parent discussion groups, formal education about parenting, parenting camps, nurse visitors, respite arrangements, family therapy, and online education courses. A comprehensive service needs to include diagnostic and treatment components, emergency, inpatient, and outpatient services, outreach to parents and children, linkages with schools, camps, extended families, child protection and legal services, obstetric and pediatric facilities. Among the required resources, there need to be case management outreach teams, neuropsychological assessors, parenting capacity assessors, therapeutic group leaders, child, adult, and family therapists, and pharmacotherapists. Interventions should include symptom management, parenting classes, addiction treatments, family planning education, therapeutic nurseries, support and information groups, occupational and vocational help, homemaking help, and respite opportunities.

4. Conclusions

Being a good parent is a task that is made exceedingly difficult when the parent is also dealing with a serious psychiatric illness. The challenges are inherent in the disorder—schizophrenia—but are aggravated by the associated stigma, poverty, social isolation, and adverse life circumstances the mothers experience. There are difficult decisions to be made for mothers with schizophrenia, which are hampered by a lack of resources. Not only resources, but also thought and guidance are needed to make these decisions effectively. Assistance is theoretically available in many potential forms, but is not always accessible, and is not guaranteed to prove effective for all persons with schizophrenia who are also parents. Care providers are recommended to partner with mothers with schizophrenia, appreciate their strengths as well as their frailties, offer a wide array of family services and social supports, monitor closely, and be generous with positive feedback.

This entry is adapted from the peer-reviewed paper 10.3390/healthcare11212882