286 Chapter 34
history, one can ask about disciplinary consistency, and observe the num-
ber and tone of critical comments made by parents about their children,
and about their partner. These have been shown to be a reliable risk factor.
In discordant households, there is good evidence that children and
adolescents learn that aversive behaviours are an effective way of get-
ting parental attention, so that parents inadvertently encourage tantrums
and other undesirable behaviours, such as whining and disobedience. In
young children, this effect may be relatively situational, with children
behaving negatively when exposed to discord at home, but relating more
normally to people outside the family. With time, however, the negative
behavioural style becomes more set; the child appears to have internalised
the parents’ mode of interaction, repeating the same pattern in other
relationships. Put another way, the children are being brought up to
respond in a way that may help get their need for attention met at home,
but that is maladaptive in the outside world. On a more positive note,
scores of controlled trials have shown that parents can be taught better
disciplinary methods and improved ways to relate to their children, which
is accompanied by a reduction in discord and criticism. Such parenting pro-
grammes lead to marked reductions in disobedience and other antisocial
behaviours, and an increase in social relationship skills.
Parental mental health problems
When parents have mental health problems, such as marked depression,
drug misuse or a psychotic illness, their children are at increased risk
of developing emotional and behavioural problems themselves, with a
particularly marked increase in disruptive behavioural disorders. Some-
times, a parent and child will both have psychiatric problems because of
shared genes, shared environment, or direct modelling. This may apply, for
example, to some families where parents and children have anxiety or
depressive disorders. More often, however, the adverse effects of parental
mental health problems are mediated by the children’s exposure to poor
parenting, including parental hostility and marital discord. These factors
increase the risk of emotional and behavioural problems in children
in general. Parents with a personality disorder (whether antisocial or
otherwise) are even more likely than parents with affective or psychotic
disorders to have children who develop disruptive behavioural disorders.
This link primarily reflects the greater tendency of parents with personality
disorders to be inconsistent and hostile to their children. Child characteris-
tics may also be relevant since, other things being equal, temperamentally
difficult children are more likely to evoke parental hostility than tempera-
mentally easy children.
Other adversities
Other adversities seen fairly frequently in clinical practice include mal-
treatment (see Chapter 27), victimisation (see Chapter 35), poverty, and
the effects of war and subsequent migration.