Parents suffering from depression, their experience engaging with school professionals

INTRODUCTION

In this study the term ‘engagement’ refers to the quality of the relationship between the school and home.^1,2 Successful outcomes for children depend on the relationship between the child and parent or carer as well as the nature of interactions between the families and schools.³ The success of interventions with children and adolescents who have socio-emotional and behavioral difficulties is enhanced when school professionals collaborate with parents through consultation, psychoeducation, and support for vulnerable families.^1,4-9

Children of parents suffering from depression are at greater risk of developing internalising behaviours such as anxiety and depression and externalising behaviours such as conduct problems, than are children whose parents do not have depressive symptoms.^10-15 While the correlation between mental health problems in parents and their offspring has been studied extensively, less is known about the perspectives of parents suffering from depression.

The study aimed to understand the lived experiences of parents with depression regarding their interactions with school professionals, exploring communication patterns, disclosure of diagnosis, valued professional attributes and school factors that promote or hinder family-school engagement.

MATERIALS AND METHODS

Approval for the study was granted on behalf of the Faculty Research Ethics Committee of the Faculty of Health Sciences of the University of Malta. A qualitative study method was used for its suitability to acquire understanding of experiences¹⁶ which could otherwise remain hidden.¹⁷ Braun & Clarke’s reflexive thematic analysis (RTA) was chosen because of the methodological rigour that its six phases of analysis provide.¹⁸ The vulnerability of participants made conscientious reflectivity, a central feature of RTA, more crucial.

The researcher discussed themes with her supervisors during ongoing regular supervision. Clark and Braun describe themes as capturing multiple facets of a central organizing concept. They explain that subthemes are only used if they add strength to a story, analyzing in greater depth one aspect of a theme.¹⁸ This analysis was conducted at the level of themes, without other layers, but multi-faceted manifestations were selected. These added meaning and depth to the theme but lacked sufficient data to constitute distinct sub-themes.

Purposive sampling was used to ensure participants provided relevant and ample data.¹⁹ The researcher selected Community Mental Health Clinics for geographical representativeness. Nurses in Charge were ideally positioned to present the information letters to interested patients, being familiar with medical histories without being their primary clinicians, thus reducing patients’ perceived obligation to participate. These clinics were chosen over private practitioners for the above reasons. Target sample size was ten to twenty¹⁰ preferring the lower range due to time constraints. Recruitment occurred from October 2021 to March 2022.

Inclusion criteria

Participants were required to have children aged 5-16 to reflect current experiences, a stable diagnosis of Major Depressive Disorder, and at least six-monthly mental health appointments. This choice was made on the six-month criteria of stability mentioned in other studies.^20-22 Nurses in Charge at Community Mental Health Clinics informed eligible patients about the study and handed them information letters, while maintaining voluntary participation. Interested participants then communicated directly with the researcher to provide informed consent or withdraw. Both fathers and mothers could participate.

Exclusion criteria

The recruitment method excluded parents not engaged in mental health services. Ethical considerations regarding their potential vulnerability outweighed the benefits of broader study scope. Parents whose children attended the researcher’s workplace schools, plus friends, neighbours, and colleagues were also excluded to prevent observation bias and dual role conflicts.

Figure 1 shows the recruitment process and decisions at each stage. The researcher used face-to-face contact with nurses in charge at the first five community mental health clinics, then emails/calls for subsequent recruitment. Despite these efforts, the initial five clinics yielded the same number of participants as all remaining Malta clinics combined at stage two. In the last stage, two participants were recruited through two medical professionals, one working in the private sector, matching the recruitment of two participants in each of the previous stages.

Figure 1

Data gathering

Data were gathered through individual semi-structured interviews. While open-ended questions could expose vulnerable participants to risk, they potentially empowered parents with depression to share experiences that needed to be heard.^16,23-25 Safety was increased using an interview guide based on research guidelines for composing interview questions.²⁶ A distress protocol²⁴ was formulated, allowing participants to skip questions and ensuring access to psychological support from Richmond Foundation if needed following the interview.

Analysis

Table 1 presents the phases of analysis guided by Braun and Clark’s six phases of RTA.^16,18

RESULTS

Although fathers could participate, all participants were women. Demographic data was not collected to protect participant identity on a small island. Some participants disclosed additional difficulties including physical health conditions and lack of family support. Professional contact ranged from solely mental health professionals to multiple specialists.

Following analysis, the researcher regarded four themes as encompassing the most significant findings: ‘Children’s needs prompt engagement,’ ‘Ease of access to school professionals matters,’ ‘The value of being understood,’ and ‘Understanding silence and distancing’. Table 2 presents the themes and their manifestations.

Children’s needs prompt engagement

One aspect that this study focused on was the nature of communication between parents and school professionals. Their children were a priority for participants. Participant 1 explained: “The children were always my priority [...]if, for example, they needed to do their homework, and I couldn’t deal with it, somehow I had to find the strength to do it.” Hence, parents approached school professionals to address concerns about their children's socio-emotional or academic well-being. Participant 2 approached a school professional when she suspected her daughter was making potentially troublesome decisions. Participant 3 came forward when special exam arrangements for her child were not implemented.

The study explored valued qualities in school professionals. Participants appreciated collaborative approaches to addressing concerns. Participant 4 explained, “I prefer that we sit around a table with the teacher and Head and see what the problem is.” Participant 3 confirmed “We move on and work together as a team.”

Parents appreciated school professionals who voiced concerns about their children. Participant 2 said, “The school had drawn my attention on Parents’ Day […] I was really pleased.”. Participant 3 highlighted the importance of honesty from professionals: “I would like the teacher [...] to be open with me […]. I will be the same with them.”

The value of being understood

An understanding attitude was another key quality parents valued. Participant 1 describes the impact this had on her: “Mental health, it’s like you have a stretched elastic band, if you pull it way too much, it explodes, and that’s what I was feeling, like I’m stretched way too much […] so the fact that they understood me, they helped this elastic band to loosen.”. Participant 5 confirmed the value of “kindness and understanding because a depressed person can get offended, or cry. You might say a word, “You always bring your son late!” That’s going to [be devastating].”

Understanding and sensitivity helps avoid a one size fits all approach to rules. Participant 4 explained that if for a parent without mental health difficulties it is normal to see their son or daughter enter school crying, “for other parents this is an experience that becomes a trauma with time.”

Another important quality identified was professionals investing time to engage with parents. Participant 3 shared “Many people see me and they judge […] but you need to spend time with a person [...]; the true person you are comes out.” Participant 2 confirmed the importance of investing time to build trust: “You need to lead him to the point when he tells you, ‘Yes now is the moment for me to seek help’.”

Understanding silence and distancing

The study explored whether parents disclosed their depression to school professionals. Findings suggest parents disclosed their mental health difficulty only when it impacted their children at school. Participant 2 explained “No, and not because I did not want to show, because I believe I would have. With the help I received, I started to control it.” Participant 1 recalled divulging her mental health problem when school professionals contacted her at the end of the scholastic year to return her child's schoolbooks. This was impossible as she was experiencing a difficult phase. Her openness resulted in understanding and support.

Findings confirmed the effects of blaming and judging on parents' disclosure of mental health problems. Participant 4, having experienced blame from a school professional, relates: “She did not see the situation as a whole, she just labelled [...] I felt like a small dot [...] I thought it was a good thing to speak up, but nowadays I shall not open up anymore.” When asked what advice she would give parents approaching schools about their children's needs, she advised, “if you need to speak up, you have to approach them, for the good of the children, but you need to be more careful.”

The study revealed that fear of being blamed and judged prevented parents from disclosing their mental health problems, even without previous negative experiences. This is illustrated by Participant 5: “I didn’t speak to anyone at the school for a while. [...] Me thinking that they’re feeling I’m not a good mother.”

Participant 1 related “I think the greatest deterrent against opening up with schools is always fear [...] that in some way, they are going to take their children away [...] what if they send someone over [...] will they see that the children have all they need emotionally or will they say, “because her room is in a mess or the floor needs to be swept.”

Ease of access matters

Participants appreciated easy access to school professionals, with different preferences. Participant 6, for example, praised online communication. “These services have become so efficient and [...] God forbid they will be stopped [...]because, we are well served.” Other participants, like Participant 4, preferred face-to-face communication: “Face-to-face [...]Understanding, how one is speaking, how the other person is reacting to me.”. Another preference was using Maltese rather than English in meetings, as expressed by Participant 2.

The study revealed other potential barriers to engagement. Participant 1 explained: “In a certain school, I often had a problem to get through by phone, so it was a bit of a deterrent, a person might then think twice, she would start saying, ‘Shall I say this or shall I let it pass once they’re not answering?” Confusion about which service provider to contact also left matters unresolved. Participant 3 expressed how she had not communicated about an issue concerning her child “because I was telling myself, “Shall I discuss with the psychiatrist or with the school?”. A key finding was the value of an assigned professional in schools for parent communication.

This study provided insights into the lived experiences of parents with depression who engage with schools and seek partnership with school professionals. While positive experiences encouraged collaborative relationships, negative experiences sometimes led to distrust and disengagement. Therefore, allocating appropriate resources and time to engage with these parents is crucial.

DISCUSSION

Research on engagement with parents with mental health problems focuses mostly on home visiting^27-28 and parenting programmes^29-30 rather than day to day interactions of parents with school professionals. Moreover, most studies focus on the impact of parental mental health problems on child outcomes.^11-12,31-33The subject is approached from a risk perspective, leaving parents' experiences with school professionals understudied. Interview data provided valuable insights into this experience. Findings reflect mothers' opinions since no fathers participated, though their participation would have provided interesting insights into engagement facilitators and barriers.

While aspects of engagement mentioned by participants would be valued by all parents, participants with mental health problems mentioned them specifically and spontaneously. School professionals may benefit from keeping these findings in mind when engaging with parents with mental health challenges.

Findings around "Children's needs prompt engagement" suggest that focusing on the child's needs is the best approach when communicating with parents with depression. This confirms findings from a home visiting study where families were more likely to remain in programmes when the focus was on child development and parent-child interaction rather than the parent or family. A family/parent case management approach was negatively associated with visit completion and retention.

This study’s insights into collaboration between parents and school professionals confirm earlier findings. Previous studies on parent engagement^34-35 including parents with post-natal depression receiving psychological therapy³⁶, support the value of cooperation between parents and professionals.

Participants' perspectives about feedback from school professionals reaffirm findings from a study on psychological therapy for mothers with post-natal depression, where many mothers would have appreciated parenting feedback as they were sometimes uncertain whether they were "doing a good job.”³⁶

This study’s findings about the value parents attach to understanding corroborates findings in a previous study on women's experiences accessing perinatal and infant mental health services.³⁷ Furthermore, results about understanding and sensitivity leading to a more flexible approach to rules supports another study underlining the need for schools to adapt to parents’ particular needs.³⁵ As this can be time consuming, it is important to allocate differing and sometimes increased time and resources to vulnerable parents, as affirmed in an earlier study.³⁸

This finding links to the two-generation approach that responds to both parents' and children's needs.³⁹ It proposes that prevention and early intervention with depressed parents be carried out in settings engaging both children and parents, such as childcare centers and school-based programmes. This could help vulnerable parents who have difficulty transitioning between services like health care, mental health, and community-based programmes. The potential of two-generational programmes ⁴⁰merits discussion among mental health professionals working with students and parents.

Some of the participants in this study alluded to the idea of being seen as a bad mother, resonating with findings from research on mothers at a mental health service⁴¹ where mothers experienced feeling they were a bad mother. Consequently, they were cautious about whether and how much to be open with staff.

The other fear leading to silence - having their children taken from them - echoes findings in earlier studies on mothers with mental health problems in mental health services and educational settings.^41-43 This knowledge has serious implications, as families who might benefit from professional support may not reach out.

The 2020 legislation on mandatory reporting of suspicions of child abuse in Malta has put an onus on professionals working with children and adults⁴⁴. The fear that parents with depression have of losing custody of their children could be heightened by premature flagging of suspicions to child protection services. Hence, school professionals, child protection services and mental health agencies need to discuss mandatory reporting, as confirmed in another study.⁴³

This study's findings on communication preferences (online versus face-to-face and mother tongue use) could be significant. The importance of addressing language barriers to improve parent engagement has been confirmed in several studies.^35,45-47 Potential communication barriers could be avoided if professionals invest time early in the engagement process to discuss parents' communication preferences, with other studies confirming the importance of addressing barriers early in the relationship.^48-49Furthermore, having an assigned professional could help facilitate communication between parents and school professionals, and between school professionals and external agencies working with the family. Other studies affirm the importance of parents knowing that someone at school was committed to their needs.³⁴

STRENGTHS AND LIMITATIONS

As far as the researcher is aware, this was the first study to focus on the daily interactions between parents suffering from depression and school professionals. The study offered parents an opportunity to share their experiences of engagement, with the resultant body of knowledge generated by parents as experts of their own experience. Since all parents were suffering from depression, the study contributed to understanding this particular group. At the same time, the group was heterogeneous, participants hailed from different socio-economic backgrounds with varied family structures and different experiences with school professionals. This provided a broader understanding of the research topic while semi-structured interviews facilitated in depth exploration of the research question.

Another strength of this study was the methodological rigour of data analysis, guided by RTA. This, together with the researcher’s reflexivity and discussion of findings with supervisors and mentors throughout the study, contributed to the results being as close as possible to the experiences related by participants.

The study has several limitations, including the novice researcher's inexperience with reflexive thematic analysis. All themes were discussed with the researcher’s supervisors during ongoing regular supervision and discussions helped validate interpretations and findings. Nevertheless, more experience applying the six stages of analysis could have enhanced reliability of findings.

The number of participants fell below the optimum minimum sample size recommended by Braun & Clarke.¹⁶ Additional participants would have helped to consolidate the results or provide new findings. Several reasons could have led to the small sample size, including Community Mental Health Clinics being under pressure due to a surge in mental health problems during the Covid Pandemic. Mental health professionals also mentioned that the six month criterion` restricted the number of potential participants. In future studies, this might need to be discussed with mental health professionals. The length of the information letter might also have been a deterrent. Following European Commission recommendations on informed consent for vulnerable adults⁵⁰ the researcher departed from the traditional format. This resulted in lengthy forms. Finally, the low sample size could also confirm the stigma that still exists around mental health problems.

A further limitation is that the voice of parents who are silent about their mental health problem is absent. Future research could address this gap, perhaps through quantitative methods such as questionnaires. As for the participants who did come forward, it is possible that they withheld some information knowing that the study could be made public. Social desirability might also have impacted the data provided.

RECOMMENDATIONS

Recommendations point towards increased professional knowledge on engagement with parents who have mental health problems, decisions at school and policy level and interagency collaboration.

Education for school professionals could be enhanced by addressing the relational aspect of engagement with parents, particularly those with mental health problems. This would lead to adopting practices to promote better engagement. These include addressing barriers early in the parent-school relationship and, when multiple professionals are involved, clearly explaining different roles and services to parents, supported by written information and contact details.

Judging from the insights that research participants such as Participant 6 contributed, professional education for mental health literacy could be enriched by input from parents who suffer from depression. This was recommended in a report from a World Health Organization (WHO) European Ministerial Conference⁵¹and encouraged in a later study.²²

The presence of a key professional in schools to support parents with mental health problems could prove valuable. This requires discussions at a school and policy level to identify and provide trained professionals. Discussion on the two-generation approach is also highly encouraged between mental health professionals supporting children and those supporting parents, both within and outside schools.

Finally, there appears to be a significant need for discussion on parents’ fear of losing custody of their children. School professionals, especially those in psychosocial roles, Child Protection Services and mental health agencies supporting families could discuss ways of mitigating this fear. Such interventions would need to be in line with the Mandatory Reporting Guidelines for Professionals.⁴⁴Moreover, clear communication to parents about school policies regarding safeguarding of children is also pivotal to addressing this barrier.

All families can benefit from support from professionals. However, the needs of families with parental mental health problems are particular and merit specific decisions and interventions.

SUMMARY

What is already known:

1. Trusting, collaborative relationships among teachers, parents and the community are the key principle in schools that succeed in engaging families.
2. Parents with depression fear being seen as a bad mother and losing custody of their children; this can keep them from seeking treatment or accepting help.
3. Parents with depression appreciate receiving feedback from mental health professionals about their parenting to ascertain whether they are doing a good job.

What are the potential new findings:

1. Parents suffering from depression wish to work in partnership with schools for the good of their children. They value having a professional in school who is committed to the needs of the family. This is especially true when their health and home circumstances are more complex.
2. Parents could divulge their mental health problem, albeit cautiously, for the good of their children.
3. An understanding disposition from school professionals helps mitigate anxiety in parents suffering from depression.
4. Parents have different preferences with regards to the medium for communicating with school professionals. Respecting this could facilitate engagement.

ACKNOWLEDGEMENTS

The research work disclosed in this publication is partially funded by the Endeavour Scholarship Scheme (Malta). Project part-financed by the European Social Fund - Operational Programme II – European Structural and Investment Funds 2014-2020 “Investing in human capital to create more opportunities and promote the well-being of society."

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