Offspring of parents with schizophrenia (PwSZ) face several challenges. In addition to having greater vulnerability to develop schizophrenia and other psychiatric conditions, they experience higher levels of emotional difficulties, more observed psychopathology, impaired global functioning and prodromal symptoms, when compared to people born to apparently healthy parents [1, 2]. They are often identified as passive, quiet, socially isolated, or as having poor affective control; they also have lower self-esteem, higher levels of defensiveness about their self-concept, higher levels of maladjustment, and less personality integration [3, 4]. Children of PwSZ have been found to perform worse than their peers academically, experience deficits in cognitive development, have higher emotional distress, and demonstrate lower social competence and functioning [1, 5, 6]. Further, these children frequently face stigma related to parental mental illness, resulting in social withdrawal [7,8,9].

The Problem is Multifactorial

Several factors contribute to the disadvantages experienced by the children of PwSZ. Schizophrenia, as an illness, has potential to interfere with parental role performance. This has been observed across diverse cultures [10, 11]. Specifically, mothers with schizophrenia have been found to be more remote, intrusive and self-absorbed, which, in turn, influences various longitudinal child outcomes [12]. Having a person with schizophrenia is known to lead to difficulties in the family, which include neglect of others, deterioration in social and family relationships, marital breakdowns, financial constraints often resulting in poverty in a proportion of households, withdrawal of support from friends and other relatives and, increased negative emotions among many [13]. These get compounded with challenges such as poverty and unemployment, lack of affordable housing, lack of access to health care, community violence, lack of social support, substance abuse and medical-comorbidities. Thus, PwSZ face enormous difficulties in bringing up their children [14, 15]. Additionally, these challenges act as independent chronic stressors, which potentially interact with biological vulnerabilities of children of PwSZ, such as lower grey matter volume, higher neurological soft signs and higher obstetric complications [16, 17] and predispose them to develop several mental illnesses including psychosis. Finally, it is well-established that children born to PwSZ are genetically predisposed to develop schizophrenia [16].

Felt Needs of Children of PwSZ

Qualitative studies to understand the need of these children found that professional support was rarely available, with counselling centres and after-school programs being the most cited sources of support [18, 19]. A proportion of children was not keen to know about mental illnesses, because of the apprehension that it would make them feel worse and a few of them described that some interventions like family therapy were ineffective. They generally felt it would be helpful if they could have someone to accompany them through difficult situations. Another study focusing on the felt needs of children of PwSZ identified that these children had needs in areas such as assuming extra roles, where parents were too unwell or required hospitalization during illness episodes [20]. These children further elaborated that support from siblings, and from friends (especially at school) were highly helpful.

Interventions for Children of PwSZ

While the problems which the children of PwSZ face are plentiful, tools to identify the problems and interventions to mitigate them are sparse. Among the well-studied screening tools, the ones to identify clinical high-risk state for psychosis, such as the “at-risk mental state” or “ultra-high risk” state, have been well established to identify individuals who would potentially experience clinical state of psychosis [21]. Criteria such as the ultrahigh risk (UHR) or Basic Symptoms (BS) criteria can be used through certain clinical instruments [22, 23]. However, tools to screen psychosocial, emotional and cognitive difficulties in children of PwSZ have been underexplored. Further, while child protection or welfare services are available under various names in many countries, especially in the high-income ones, services designed to address the unique challenges of this high-risk population are far fewer.

Interventions designed for children of PwSZ target different domains. These include interventions addressing the mother–child relationship [24], programmes to prevent children at high risk for psychosis from developing psychosis [25, 26], programmes to improve mental health outcomes of children with parental severe mental illness [27, 28], and interventions to prevent child loss to custodial services [29]. These interventions involve children or parents as individuals, the parent–child dyad, or groups of individuals at high risk to develop psychosis. They focus on preventing psychotic relapses among the parents [26] ensuring family health, building coping and resilience, and preparing for crisis or alleviating adverse environmental circumstances [27]. However, significant gaps remain in this domain. Feasibility of these interventions across different settings, their efficacy and cost-effectiveness, are not yet firmly established. Only a few interventions have been specifically designed and tested for the psychosocial well-being children of a parent with schizophrenia [30].

A three-stage interview-based child-oriented family nursing intervention has been developed for families with both inpatients and outpatients with schizophrenia or bipolar disorder [31]. They describe three stages of their intervention: the construction stage, the problem-oriented stage, and the hope bridge stage. During the construction stage, the interviewers form close relationships with clients, offer a comfortable environment, and introduce certain topics. In the problem-oriented stage, the interviewers try to identify the potential problems by showing empathy and encouraging clients to self-disclose. The interviewers then offer possible coping strategies such as role modeling and support like offering summarize the material covered during the interviews, express appreciation, and offer a plan for the future. However, the feasibility and efficacy of the intervention are yet to be established. A recent scoping review [30] found studies evaluating the role of family therapy for children of PwSZ and reported that the children who underwent family therapy showed better outcomes in family functioning, psychological status, and self-rated health than those who received no intervention. The review also noted that group psychological counselling improved participants’ resilience.

The Role of Culture

The cultural and social contexts in which a child grows have an inseparable connection with parenting styles and family structures [32]. Further, these contexts differ across countries and continents. For instance, the Latin American and southern European regions have a horizontal collectivistic culture, which emphasizes interdependence and yet stresses on equality, making the culture more egalitarian [33]. In the Asian region, vertical collectivistic system is prevalent which emphasizes interdependence but also promotes hierarchy, with some members of the group or family having a higher status than the others [33, 34]. In North America, Australia & New Zealand and parts of Europe, the prevalent individualistic culture gives more importance to independence and the needs of the individual than the needs of the group [33, 34].

In more collectivistic cultures, often, multiple family members, apart from parents, play significant role in child rearing, than in other cultures. In the context of children of PwSZ, this may offer certain advantages in situations where a PwSZ is not able to perform his/her parenting role optimally, or when the home environment becomes disturbed because of the consequences of the illness. Further, as child welfare services are sparsely available, often parenting is taken over by other family members and even neighbours. In more individualistic societies, the role of child welfare services or children’s aid becomes paramount when PwSZ is not able to perform the parenting roles optimally or when children face abuse or neglect. For example, in USA, among parents in contact with child protection services, those with a serious mental illness were at a higher risk to lose the custody of their children compared to parents without mental illness [35]. Instances of parents losing custody of their children due to mental illness among the parents is extremely uncommon in countries with collectivistic cultures. Clearly, sociocultural factors play a major role in mediating the influence of parental mental illness on the growth and development of their children. There is a notable gap in the knowledge about the challenges faced by children of PwSZ in different regions and cultures, their felt needs, factors that could vitiate or protect the mental health of such children and interventions which are culturally relevant.

Future Directions

There has been considerable work towards the welfare of children of PwSZ in terms of early identification and screening for high-risk psychosis states, etc., in several high-income countries. However, much remains to be done for the overall psychosocial wellbeing of this population even in these countries. Research on these aspects from low and middle-income countries is sparse. Observations from high-income countries cannot be extrapolated to low- and middle-income countries. There is need to systematically explore perceived needs of these children, screening for psychosocial difficulties and develop culturally appropriate and accessible interventions. The fact that millions of children of PwSZ are continuing to experience significant psychosocial adversity in several domains of their lives, including a higher risk of developing mental illnesses, should warrant urgent measures to mitigate these challenges.