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research-article2014

QHRXXX10.1177/1049732314528068Gladstone et al.Qualitative Health ResearchGladstone et al.

Article

Analysis of a Support Group for Children of Parents with Mental Illnesses: Managing Stressful Situations

Qualitative Health Research 1­–12 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314528068 qhr.sagepub.com

Brenda M. Gladstone1, Patricia McKeever1, Mary Seeman1, and Katherine M. Boydell1

Abstract We report an ethnographic analysis of a psycho-education and peer-support program for school-aged children of parents with mental illnesses. We conducted a critical discourse analysis of the program manual and observed group interactions to understand whether children shared program goals predetermined by adults, and how, or if, the intervention was responsive to their needs. Children were expected to learn mental illness information because “knowledge is power,” and to express difficult feelings about being a child of a mentally ill parent that was risky. Participants used humor to manage group expectations, revealing how they made sense of their parents’ problems, as well as their own. Suggestions are made for determining good mental health literacy based on children’s preferences for explaining circumstances in ways they find relevant, and for supporting children’s competencies to manage relationships that are important to them. Keywords children, discourse analysis, dramaturgical analysis, ethnography, group interaction, humor, resilience, risk, symbolic interactionism

We studied a peer support group for children of parents with mental illnesses in Canada. Our analysis was undertaken in the context of newly emerging policy, practice, and research on this subject, and early evidence about the effectiveness of interventions for children and families (Reupert et al., 2012; Siegenthaler, Munder, & Egger, 2012). It is estimated that 12.1 % of all Canadian children under age 12 live with a mentally ill parent. This represents 570,000 children, many of whom are exposed to one or more serious parental psychiatric disorders such as anxiety, major depression, and bipolar disorder (Bassani, Padoin, Philipp, & Veldhuizen, 2009). Prevalence is likely comparable to higher international figures, which includes individuals ≤ age 18 (Maybery, Ling, Szakacs, & Reupert, 2005). Much has been written about children’s risk for developing mental illness. Compared to peers, these children might have greater cognitive, emotional, and behavioral difficulties, potentially leading to diagnosable psychiatric disorders (Beardslee, Versage, & Gladstone, 1998; Göpfert, Webster, & Seeman, 1996, 2004). However, hereditary effects of illness might be less detrimental for children than the social, psychological, and economic consequences of living with an illness (Hall, 2004; Rutter, 1989). Children describe unpredictability and other

difficulties managing daily life, underscoring the need to prevent negative short- and long-term outcomes, and to determine which interventions, if any, are helpful to children (Gladstone, Boydell, Seeman, & McKeever, 2011).

Psycho-Education and Peer-Support Groups for Children The Children’s Group is a pseudonym we use to refer to an 8-week, psycho-educational and peer-support program for school-aged children. Referrals were made to the program by children’s mental health organizations, protection agencies, and family members. Comparable programs combine peer support and shared personal experiences with structured informational content on mental illness to increase children’s resilience and prevent future mental illnesses (e.g., Orel, Groves, & Shannon, 2003; Pitman & Matthey, 2004).

1

University of Toronto, Toronto, Ontario, Canada

Corresponding Author: Brenda M. Gladstone, SickKids, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8. Email: [email protected]

2 Although programs have been described in detail (e.g., van Doesum & Hosman, 2009), evidence about their benefit is just emerging (Reupert et al., 2012). Evidence is most often elicited by gathering information from clinicians and parents, and effectiveness is measured by demonstrating children’s ability to meet program goals that have been determined by adults (Orel et al., 2003; Pitman & Matthey, 2004; Riebschleger, Tableman, Rudder, Onaga, & Whalen, 2009). Children tend to be asked supplementary questions concerning their likes/dislikes, which they answer in positive but truncated and vague ways, making it difficult to fully determine how they respond to program goals. We examined children’s behaviors in and responses to the Children’s Group to understand whether they shared the goals of the program, and how, or if, their needs were met. Therefore, we did not focus our study on targeted outcome measures as the primary—and often assumed to be the only—route to really understanding what is effective. Rather, we analyzed the Children’s Group as an interactive setting and conceptualized it as more than a straight­ forward, information-sharing, and emotional support session, using a qualitative approach described as critical dramaturgy (Paolucci & Richardson, 2006a, 2006b).

Examining the Children’s Group as an Interactive Setting Our study was based on Goffman’s (1959) dramaturgical analyses of the reciprocal influence individuals have on one another in face-to-face encounters, influenced by George Herbert Mead’s (1934) sociological formulation of symbolic interactionism and expanded upon by Herbert Blumer (1969). According to symbolic interactionist theory, people ascribe meaning to behavior and things as a central element of life, shaping individuals’ interpretations of themselves, events, environments, and others; those interpretations influence how people respond to situations, regardless of the objective reality of the situation itself (Charmaz, as cited in McLeod & Lively, 2007). Taking a symbolic interactionist perspective is particularly apt for considering how individuals alter their responses to subtle, sometimes unrecognized social comparisons or through confrontation and conflict (McLeod & Lively). This perspective accords with recognizing that children, despite vulnerabilities, are full participants in social life. Their behaviors are competent, rational, purposeful, and “practical achievements” of social interaction, albeit contained, shaped, and bounded by the contexts in which they live (Hutchby & Moran-Ellis, 1998, p. 14). Blumer (1969) elaborated important elements of symbolic interaction, which led us to conceptualize the support group as a type of performance in which meaning arose out of participant interactions such that the

Qualitative Health Research  performance was handled in and modified through a joint interpretive process in which individuals sought to influence one another. Uncertainty, contingency, and transformation are part of dynamic interaction, which is consistent with Goffman’s (1959) notion of social life as dramatic performance. Goffman emphasized the dramaturgical aspects of face-to-face encounters as “the reciprocal influence of individuals upon one another’s actions when in one another’s immediate physical presence” (p. 15). His analyses of interaction demonstrate how social environments are settings of mutual monitoring (Clarke, 2005) because individual beliefs and interpretations are influenced through social intercourse as participants attempt to manage how they and others respond to the situation. For example, participants in the Children’s Group practiced the art of impression management, taking “expressive responsibility to prevent the many minor but inadvertent acts that happen to be well designed to convey impressions that are inappropriate” (Goffman, p. 208). For the performance to succeed, the participants learned to act as performers with loyalty (that is, developing a mutual moral obligation), discipline (sharing accountability), and circumspection (readying themselves for unseen events). From a critical perspective, we focused on the microenactment of power as participants managed, manipulated, and controlled information to ensure a smooth performance and prevent embarrassing disruptions (Goffman, 1959). We were also interested in the behavioral expectations of the setting, itself framed by broader arenas of interaction in which shared institutionalized meanings governed (often idealized) presentations of self (Paolucci & Richardson, 2006a, 2006b). As an object of analysis, discourse is one way of thinking about how issues are framed and function to organize children’s experience and guide their behaviors. By discourse we mean two things: a group of ideas or patterned way of thinking that is identifiable in written and verbal communications and located in wider social structures (Lupton, as cited in Cheek, 2004, p. 1142); and its effects, evident in the ways discourses are part of the construction of social identities and social relations, and systems of knowledge and belief (Fairclough, 1992). Goffman (1959) described how issues are framed by directing our attention to a particular part of reality (Paolucci & Richardson, 2006a), making critical discourse analysis (CDA) compatible with his body of work. In CDA it is assumed that language is highly symbolic, shaping the way phenomena are viewed; that is, language is not just descriptive: it does things. Our intention was to analyze how metaphors, rhetorical strategies, phrases, and images were used in the Children’s Group program manual to shape the portrayal of information about mental health and illness in the context of being a child of a

Gladstone et al. mentally ill parent (Petersen, 2001). We wanted to understand how ideas were imported to evoke a larger meaning in the text (Hollander & Gordon, 2006), because the manual content itself was shaped by discourses external to the text (Taylor & Ussher, 2001). Therefore, prior to implementing the CDA, we reviewed contemporary ways of thinking about mental health/illness and children, as described in publicly available government documents at the time of the study.

Study Design Study criteria aligned with the Children’s Group admission requirements. Seven children, 7 to 13 years of age, enrolled in the study group. Children of parents with a temporary illness (i.e., drug-induced psychosis) or with a mental illness and developmental disability were excluded. Upon receipt of ethics approval from affiliated hospital- and university-based research institutions, the Children’s Group intake coordinator informed individuals who referred children to the program about the study. Those who agreed to hear more about it were contacted directly by the first author to arrange a convenient meeting time and location, most often the home where the child currently lived. The recruitment and consenting process was completed 1 week prior to the first session of the Children’s Group to allow participants sufficient time to consider study procedures, potential harms and benefits, and to ask further questions without interfering with the programmed activities of the first session. The first author explained the study further, addressed questions, and obtained written consent from the parents or legal guardians and assent from the children. Children preferred to complete this process in the presence of their parent or legal guardian. Although there were no refusals with respect to participation, children were reassured that they could leave the study at any time, for any reason; however, they would have to join a concurrent Children’s Group session in a different location if they wanted to continue the program, and data collected to that point would be analyzed. This might have been less convenient for the child and the family; however, it was not ethical to exclude children from the program because of the study. The Children’s Group facilitators also provided consent to participate in the study. The three-stage, iterative study process included: (a) a critical discourse analysis of the program manual; (b) participant observation and informal interviewing during group interactions; and (c) a separate group interview with the children during the final session, after the completion of formal program activities. The Children’s Group facilitators were not present for this last discussion. Children were asked direct, evaluative questions about what they

3 liked and did not like about being part of the Group, what they found helpful, and what they would have liked to change to improve the program for other children. The first author conducted all data-generation activities. The children’s drawings, used in the group to “show and tell” their experiences, became another source of indirect responses to the program but were not analyzed as visual data on their own (Guillemin, 2004). The full range of routines and group activities was documented by comprehensively sampling different time intervals and events over the course of the 8-week program. A confidential question box created for the study allowed children to ask questions anonymously and provide feedback about the group. The children were told that no one would observe them when they occupied the quiet space (a time-limited space to opt out of program activities). Following Miles and Huberman (1994), we developed a specific data-management strategy in alignment with the study purposes. The first two steps, data reduction and display, involved transcribing and translating raw data— handwritten field notes, photographs, drawings, and so forth—into a digital format that could be managed electronically. We also constructed descriptive summaries for each of the sessions, which were helpful to check emerging analysis when dealing with enormous amounts of data. To aid the analysis of social interaction, we developed a system for transcribing field notes into a dialogic format. The observational data—the handwritten, recorded observations of the group in situ and later transcribed into a digital format—were further transformed to explicitly reflect what participants said to each other and what they did together. This final transcription resembled a theatrical script, allowing us to follow how participants responded to one another verbally and what they did with each other during nonverbal activities. This dramatic reworking of the data also included text that functioned like stage directions in a play, indicating scenery, props, and other background information necessary to perform the action required in that scene. These transcripts were similar to those generated out of focus groups and shared the same potential to highlight the dramatic interaction between participants, enabling us to move beyond simplistic analysis (Kitzinger, 1994). An illustrative example of a dialogical script is included in the results section of this article. A separate set of reflexive notes documenting personal observer responses and analytic memos allowed a coupling of observations with preliminary analysis in an iterative process from the outset. Photographic field notes documented visual data (drawings, props, and settings; not human subjects) and were incorporated into the iterative analytic process. We followed a classic set of coding strategies for thematic analysis (Braun & Clarke, 2006). The CDA considered (a) the context that produced the program manual; (b) the manual details; and (c) how the

4 information in the manual content was received by participants during sessions of the Children’s Group (Fairclough, 1992). We asked questions about how, why, and when the manual was produced and how the authority to speak on mental health and illness and being a child of a mentally ill parent was established in the manual (Crowe, 2005).

Results The Script: The Children’s Group Program Manual In this article we focus on an analysis of participant responses to the information and support activities of the Children’s Group. Accordingly, our CDA is limited to a brief overview of program beliefs about mental health and illness and what it means to be a child of a mentally ill parent. We suggest that the manual content became a kind of script outlining what was expected of the performance to follow, which was integral to our analysis of children’s responses to the program. The manual described mental illness as an illness “like any other,” as a brain disorder represented by “the broken brain.” It posited that abnormal parental behaviors are symptoms of illness, that the illness is a chronic condition that requires trained medical experts for care, and that “children are not responsible for parents’ wellbeing.” Hereditary risk was described as only slightly greater for children of parents with mental illnesses; real risk was from prolonged exposure to the stress of living with unpredictable and frightening parental behaviors. The manual suggested that children are “naturally skilled and knowledgeable,” but adopt problematic coping behaviors that can lead to stress, and physical and “even mental illnesses.” To remain “mentally healthy,” at-risk children must learn to stop thinking negatively; express their feelings, especially fears related to illness behaviors; ask for help; and understand they did not cause the illness nor can they control or cure it. They can “learn to cope with it.” The manual stated that children must learn to “feel and be safe,” to become competent managers of their own thoughts, feelings, and behaviors so that they can develop into persons who have control, choice, and responsibility, but only over “how their own [and not their parents’] story will go.” Children were represented in the manual as “innately resilient,” like other children, but also as having coping skills that “require fine tuning, to learn to act appropriately.” Like other children, they are also dependent on adults for support, but might require more support because of possible learning disabilities, social-skill deficits, and the social isolation and invisibility assumed to be central to their experience. Consequently, “their needs for support may [also] be hidden from view.” Child–parent

Qualitative Health Research  relationships might be unsafe because of the dysfunctional thinking, uncontrolled emotion, and unmanaged behaviors associated with mental illnesses, whereas relationships with other adults might be more trustworthy. The manual pointed to significant adults in the children’s life, such as the group facilitators—who had legal responsibilities for protecting children—but also those biomedical and scientific experts whose knowledge informed and authorized the manual content. Children who acquire appropriate knowledge are protected because “knowledge is power”; however, information about genetic risk was played down to shape hopeful futures in which children’s subjectivities are constructed as positive.

The Performance: Children’s Responses to the Program We use illustrative examples from the observational data to show how program beliefs were implicated in performances of the Children’s Group and how children responded to expectations outlined in the manual. We use dramaturgical language to describe two broad but interrelated analytic categories. The first describes how participants performed mental health and illness talk. The second category refers to how they performed as children of mentally ill parents. Seven children attended the group we observed; there were two sets of siblings. All children lived with the ill parent. One parent was hospitalized at the time of the study. Parental diagnoses included bipolar disorder, schizophrenia, obsessive-compulsive disorder, depression, and anxiety. There was an experienced facilitator and another in training; one ethnographer observed the group.

Performing Mental Health and Illness Talk Emphasis was put on learning the right language in the Children’s Group. There was a correct way to talk about mental illness and an obligation to use acceptable language. The children learned to identify with each other by repeating the phrase, “We are all here because we have a parent with a mental illness.” The phrase worked dramaturgically to convey specific meanings. It framed a rationale for the group and controlled expectations about how they should think about each other, and in a way that incorporated certain values. In conjunction with other, more explicit teachings about correct mental health information, children were given explicit language to explain and talk about their experiences and to articulate their needs and feelings. By verbally acknowledging mental illness as the reason for attending the Children’s Group, the children were initiated into a collective understanding about their individual circumstances and asked to develop a mutually agreeable way to interpret and give meaning to their experiences.

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Gladstone et al. The children resisted medical and illness language. As talk turned to specific diagnoses, Colin1 asked, “Why can’t they call it manic happiness?” Colin was observed smiling to himself in response to his own joke. It seemed to us that he knew the correct medical terminology. To play with these words he had to have a fairly sophisticated understanding of bipolar disorder as a psychiatric category referencing mania and depression. By making fun of the grim emphasis of this medical label, Colin was able to question how behaviors are understood and categorized through language. In other instances, children talked about “it” as a “problem” and ignored constant admonishments to use “mental illness” to describe their experiences. This happened most often when children’s talk emphasized behaviors that marked their parents, and possibly themselves, as different. For example, in one exercise Colin and Eliot liked Mark’s imaginary book title, Why is My Parent Different? The word “different” seemed to convey an aspect of the language that was otherwise missing from the proscribed group language, that circumstances that signify difference itself could be a problem for the parent and for the child. The struggle to define the problem is indicative of how challenging it was to discern whether the talk about illness—children’s ability to recognize and be knowledgeable about it—concerned its effect on the parent or the child. Such confusion was worrying in light of the program belief that psycho-education is a significant protective factor for children. Children who misinterpret their parent’s behaviors as something other than a symptom of illness are likely to feel guilty and responsible for their parent’s difficulties. These feelings make it difficult to shift self-perceptions so that children believe they have some control over their own future. The children were not asked if they felt guilty or to blame for their parent’s or family’s circumstances, and no participant expressed these feelings overtly. However, consider the separate cases of Michele and Mark. Michele’s family members wanted her to understand that her parent behaved badly toward her because of “delusional thinking,” and that Michele was not to blame. Yet Michele seemed angry, and her responses focused on her own feelings rather than the medical explanations about the causes of her parent’s behaviors. She expressed this explicitly with words and in her drawing of her parent’s “well” and “unwell” behaviors. Michele insisted that her parent was “threatening,” and rejected medical explanations of “suspicion” and “paranoia.” Michele remained convinced that her parent was responsible for behaviors that affected her. Biomedical talk about causes did not alleviate Michele’s negative feelings. Conversely, Mark, who was referred to the group as respite from his caring responsibilities at home, was very enthusiastic

about learning biomedical educational material. He talked explicitly about protecting his parent from blame by teaching his other parent and siblings about the illness. Mark hoped they would understand that it was the illness and not his ill parent that was responsible for many of their problems. Children expressed irritation and disappointment when talk about the causes of mental illness was confusing. At the end of a drawn-out sequence trying to guess how people “get it,” the children were told, “There are a lot of reasons,” and with finality, “It happens in the brain.” Ambiguous teachings symbolized by the “broken brain” were met with frustration and resignation, typified by one participant who said, “It’s all in their heads.” This double entendre hinted at the uncertainty in performing mental illness talk, and whether the behaviors children witnessed were best explained as originating in their parents’ heads (the broken brain metaphor) or as being just in their heads—as the exasperated tone of this comment suggested. Rationalizing bad behaviors by talking about the causes and consequences of mental illness as a “lack of control over thoughts, emotions, and behaviors” did not seem particularly helpful. Conversely, talk was observed to be least disruptive when children were asked to describe everyday life when a parent was not well, and to draw and act out their own impressions of troubled or unusual behaviors. At these moments, the children were less likely to tease the facilitators, joke with each other, and interrupt planned activities. Children’s stories depicted problematic behaviors that were relevant because even if it was just in their parent’s head, they remained consequential, and the children tended to share a mutual if unspoken agreement about how they understood the problem.

Performing as Children of a Mentally Ill Parent As talk shifted from illness to health, program teachings focused on the children’s abilities to cope better rather than on parents’ symptoms of illness. Children learned about risk (“What are my chances of getting it?”) based on assumptions about the nature of their fears (“I can’t control it; I didn’t cause it”), which required knowledge about feeling and being safe (“But I can cope with it.”). Although risk was on the children’s minds, this appeared to be difficult for them to express overtly. Instead, children asked anonymously, through the question box. They also distanced themselves from explicit talk about risk, using jokes and sarcasm. In the following sequence, participants responded to the group facilitator, Martha, discussing the difficulty of talk about, and the stressful emotions associated with, being a child of a mentally ill parent:

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Qualitative Health Research  Martha (M): Does anyone know why we are here tonight? Eliot (E): To bake a chocolate cake? [Snickering around the table.] M: [Somewhat impatiently] Okay, okay. Only one person speaks at a time . . . you know, like school, but not school. [pause] So if you look up here on this piece of paper, the agenda, you can see the kinds of things we’ll be doing. Augusto (A): But when do we eat? M: What number is it on the agenda? A: [In a small voice.] Eight? M: Then that’s when we’ll eat! [Eliot pulls another chair up close and puts his feet on it, settling in comfortably, while Augusto slides down into his seat, slipping three quarters of his face down into his jacket, as if responding to things getting serious now.] M: [Continuing.] You are all here tonight because someone in your family has a mental illness. A: [Loudly.] What? [General agreement with this statement around the table, indicated by murmured assent.] M: [Ignoring Augusto.] Okay, so let’s all say this together: [bringing her hands together like a symphony conductor.] “I am here because someone in my family has a mental illness.” All participants: [In unison, with loud voices; no one refuses or sits out.] “We are here because someone in our family has a mental illness.”

The final phrase was repeated at different points throughout the program; here, it was intended to help the children see themselves in a new way—as family members. The session began with Eliot resisting Martha’s overture, explaining why they were attending the Children’s Group. Perhaps he resisted because he did not want to say what he felt about becoming a member of this group, or what it might mean to talk about a topic that was risky. Eliot might have sensed the rhetorical nature of the question, refusing to produce what was expected of him. His response, a sarcastic, incongruous, and funny image about “bak[ing] a chocolate cake,” elicited laughter from the other children. He challenged Martha without giving away too much about what he really thought or felt at that point. This tactic helped Eliot avoid a direct answer to her question. It demonstrated to everyone present that he was not going to be compliant, and that he might have his own suspicions about what was expected of the group—which was probably not anything as innocuous as his image of baking a cake suggested. The joke seemed to garner him social capital with the other children, who “snickered” in response. Although it is not clear whether they read the situation in the same way he did, their suppressed laughter, with its edge of irony, suggests they were willing to go along with Eliot. With some ambivalence, Martha invoked familiar school rules about turn taking and drew attention to the agenda to manage the disruption. This statement reinforced to the group the expectations about how things should unfold. Martha reasserted her authority and the children

obliged, allowing the sequence to come to an end in a recitation aimed at fostering group solidarity. The phrase— “We are here because someone in our family has a mental illness”—underscored what was expected of a group of loyal, disciplined participants, and by implication, of those who now had an (unspoken) moral obligation to one another because they were in similar situations. It was important that participants recognize their commonalities as children of mentally ill parents to perform well in the group. Because the children were assumed to be reluctant to attend the group, the facilitators perceived their responsibilities to be managing the children’s negative reactions. A significant management strategy involved a group drawing activity that highlighted the importance of understanding that as children of mentally ill parents, “We are all in the same boat.” As the children named things they had in common, Martha added their statements to the picture of a boat that Colin had drawn on an easel at the front of the room. These words and the image itself worked together in a powerful way because of the dramatic claim made on individuals to see themselves as belonging, and “not alone,” in addition to being family members of someone with a mental illness. The image dramatized a more implicit idea about a shared identity whereby (loyal) group members would see that because they faced similar challenges, they could depend on one another and learn to work together to successfully manage their problems. This idea was reinforced during games played by participants, games in which no one was a winner, reminding the children that they played for the same team. Although no one mentioned it at the time, a review of the photographic field notes showed that Colin had added a graffiti-like detail to this image, in effect relabeling the boat the “Titanic.” Colin and the other children would have recognized the Titanic as a familiar cultural symbol because the ill-fated ship was the subject of a popular American film at the time of the study. It seemed to us that Colin used this image ironically to publicly (although nonverbally) and perhaps politically express difficult emotions about a situation he might have considered hopeless. Although he might have accepted that as children of mentally ill parents they were now “in the same boat,” they were not much better off if that boat was sinking.

Discussion Humor: The Art of Managing Dramaturgically Stressful Situations Critical dramaturgy allowed us to see how participants managed expectations of being children of mentally ill parents and of talking about mental health and illness that was risky. Like other children living within stressful circumstances, the participants used humor to reduce

Gladstone et al. tensions, build rapport, and cope with complex emotions in a group context (Brewer & Sparkes, 2011). Although undertheorized in Goffman’s work (Paolucci & Richardson, 2006b), humor is comparable to his notion of a “disguise,” which allows for the introduction and management of difficult ideas and emotions by revealing more than they hide: Given the dangers of expression, a disguise may function not so much as a way of concealing something, but as a way of revealing what may be tolerated in an encounter. We fence our encounters in with gates; the very means by which we hold off part of reality can be the means by which we can bear introducing it. (Goffman, 1959, p. 136).

Humor is useful in face-to-face encounters that are expected to be orderly: “As a metaphorical, symbolic, paradoxical construction [humor] is capable of conveying powerful messages. In this sense, humor in interaction means more than what it says” (Fine, 1984, p. 97, emphasis in original); for example, carrying “weighty messages about what is expected from oneself and others” (Hollander & Gordon, 2006, p. 194); calling for an immediate response from others, although its meaning can be denied without the speaker “losing face” (Fine); or communicating inappropriate or taboo ideas in dramaturgically stressful situations where performers have to keep up appearances inconsistent with what they might be feeling (Freund, McGuire, & Podhurst, 2003). The implicit meaning is comprehensible because humor is rooted and comprehended in a particular context; it has power in group contexts because it is embedded, interactive, and referential (Fine & De Soucey, 2005). Participants in the Children’s Group used humorous cultural references that were part of what they knew about mental illness and what it means to be a child of a mentally ill parent, without knowing one another prior to the program. Children used humor to identify with each other, make claims on one another, and challenge ideas and beliefs without saying anything too explicit. This became a basis for developing a kind of “joking culture” that helped to smooth group interaction, share affiliation, and secure the compliance of group members (Fine & De Soucey, 2005).

Managing Expectations About Being “All in the Same Boat” Children used irony and simple jokes to “hold off part of reality” while simultaneously challenging beliefs about being “in the same boat” (Goffman, 1959). This strategy aided our understanding about the children’s responses to the group and what was most (in)tolerable for them in this encounter. Eliot avoided revealing what he really thought

7 about attending the group, and this allowed others to implicitly question the motivation for the group. The children had to understand what was (not) being said about why they were there, at least enough to appreciate the incongruity of Eliot’s remark (Sen, 2012), and why “baking a chocolate cake” was funny in these circumstances. The joke interrupted the facilitators’ script to introduce ideas that could not be said more seriously. Unlike “baking a chocolate cake,” attending the group and talking about the real reason they were there might not have been innocuous, easy, or desirable. Eliot’s manipulation might have signaled his reservations about the group, and perhaps also his seeking confirmation of what the other participants were thinking and feeling. He accomplished this without exposing his feelings about being in the Children’s Group or about having a parent with a mental illness. Eliot’s joke allowed him to subtly and safely indicate his understanding of the real and emotionally charged reason they were there. Had Eliot been directly challenged by the facilitators, or poorly received by the other children, he could have retreated from these implications under the cover that he was only joking. Eliot’s response created conditions for the group to function together. When the others laughed along with him, they appeared to acknowledge a mutual understanding of what they had in common—in the things not said. This tacit acknowledgment suggested the acceptance of a moral obligation to one other, to keep one another’s secrets by expressing things discretely and not staging their own individual show (Goffman, 1959). Another instance of using humor and irony to manage risk within the group was Colin’s addition of “the Titanic” to the boat drawing as a way of questioning the hopelessness of their situation. Although the lifeboat he added might have signaled a desire to escape (from the Children’s Group specifically or the situation more broadly), it also conveyed potential feelings of futility about the future. To our knowledge, these added details went unnoticed at the time, which made us think of Colin’s reinscription as a type of graffiti, a form of communication about something serious that was also subversive and ironic (Rahn, 2002). Graffiti marks territory and signifies group affiliation, and this interpretation helped us think about what Colin’s actions and words allowed him to express. He claimed this territory of being “all in the same boat” for his own, adding his critique to those things that Martha had directed the group to include and identify with each other. His subversive actions were humorous and enabled Colin to talk about an emotionally difficult idea without risking a more serious, explicit conversation. Although it allowed him a degree of power over Martha’s definitions of their situation, he did not have to challenge her openly. And

8 because none of the players knew each other very well at this stage of the performance, his statement had to speak for itself without confronting anyone or demanding a response from the others. This incident gained significance because Colin came to identify with the group by the end of the program, acknowledging that his mother had a mental illness. Colin did not seem convinced so much by educational material, or by the medical language he was coached repeatedly to use, but by his growing sense of belonging to the group. Peer support might have been more beneficial than actual educational content because mutual understanding based on shared experience has been described as less judgmental and more socially inclusive (Hayman, 2009). A shared understanding might have helped Colin identify with mental illness as a reasonable explanation for some difficulties. Toward the end of the program Colin commented, “I didn’t know there were so many kids like us . . . like me.” His response hinted at a possible tension between identity claims we make for ourselves and those that are made for us. Choosing to belong, to be “in the same boat” in the way Colin seemed to do over the course of the program, is not the same as having an identity ascribed by others (Gladstone, Boydell, & McKeever, 2006). Making a choice implies a process of exploration and decision making that contrasts with discriminatory and marginalizing practices in which labels are likely to engender a sense of powerlessness (Bottrell, 2009; Wexler, Difluvio, & Burke, 2009). Interactional processes and the discourses that underpin them challenge our conception of how identities might be reframed or reimagined by participation in support groups (Francis, 1997), and in whose interest that redefinition is enacted. Wexler and colleagues (2009) argued that group affiliation can provide young people with a stabilizing resource, a shared platform from which to reconceptualize personal difficulties as politicized struggles, making a case for personal/collective meaning making as part of resilience research in public health. But group affiliation by way of the Children’s Group was time limited, with an agenda to change individuals’ perceptions of themselves as responsible only for managing their own future. Participants were discouraged from turning to peers for support outside the group, which culminated in a volatile disagreement with the facilitators about why, as Augusto demanded, “friends don’t count.” Others have raised the issue of peer support and whether fostering ingroup relationships occurs at the expense of helping children develop and maintain naturally occurring, external social networks (Maybery et al., 2005). The children talked about significant friendships outside the Children’s Group, but did not know how to discuss problems related to mental illness. Most felt guilty about keeping their

Qualitative Health Research  group involvement a secret, and expressed a desire to tell particular friends about their experiences. This seemed a lost opportunity to talk about stigma and discrimination and to support the children in talking with peers outside the group. Our observations ended on the last night of the program, and we cannot know how, or if, being “in the same boat” had a longer-term impact on children’s lives. There was no formal provision to help children keep in touch. Children told us that they were excited to return to their everyday lives, to watch favorite television shows again, to do their homework without scheduling conflicts, and to talk to friends. They might have wanted to limit contact with each other, too, for reasons we could only speculate about, although all participants said that what they would miss most about the Children’s Group was seeing one another. Resilience-building interventions similar to the group we studied focus on shifting how individuals see themselves, often by constructing new identities, literally replacing old “self-stories” with new ones (e.g., Ungar, 2004). However, there is a danger of support groups replicating social inequalities and exacerbating existing power differentials if discourses define these situations without reference to power and in ways that result in inequities (Holden & Schrock, 2007). This is more likely when education and support activities like those of the Children’s Group conceptualize the responsibility for change only at the individual level. Fjone, Ytterhus, and Almvik (2009) have argued that children’s private problems should be a matter of public concern; for example, by changing environments so that schools and other social services become more accepting and tolerant of what is considered normal. Others have argued for a shift in social responsibility over how we understand and expect children to manage difficult circumstances. Bottrell (2009) argued “that interventions for resilience building need to recognize the embeddedness of resilience in social inequities, social processes and the differentiated societal and ideological expectations of young people” (p. 321). Disadvantaged young people who resist particular labels might be enacting a form of resilience that is actually protective but hasn’t been interpreted as such in theorization about resilience (Bottrell). When most of the children told us at the end of the Children’s Group sessions that they still thought they could help their ill parent, despite being instructed to believe otherwise (and however much they prevaricated by stressing that they knew the rules about only being able to “cope with it, but not control it”), we considered whether their responses could be reframed as a form of resistance to normative expectations about appropriate parent–child relationships. There is a tension in the literature between children’s desire to remain deeply connected to their parent and their desire to develop a separate

Gladstone et al. sense of self (Mordoch & Hall, 2008), to help at home and express their own needs for support (Griffiths, Norris, Stallard, & Matthews, 2012). Similarly, parents with mental illness describe reciprocal caring relationships that involve moral dilemmas and complex emotions because of the normative expectations associated with appropriate parent–child relationships (Tjoflat & Ramvi, 2013; Van Parys & Rober, 2012). We suggest that changes in current practice and policy could support Mark’s growing independence and competence and his desire to take some responsibility for caring for his family, rather than being pathologized (and labeled “parentified”) for worrying about his parent.

Implications for Research, Policy, and Practice Canada’s new mental health framework is similar to other jurisdictions that stipulate the inclusion of individuals with lived experience of mental illness and their families in planning, organizing, and evaluating how health services and support are developed and delivered (Mental Health Commission of Canada, 2012). However, although family likely refers to parents, we argue for broadening the narrow but powerful way we frame children’s roles to consider their lived experiences and specific educational and support needs when a parent has a mental illness. Children contribute to the health and well-being of others, and should be recognized for their efforts and supported in ways they find meaningful, not the least because this will influence their own well-being (e.g., Van Parys & Rober, 2012). To develop a mental health system that emphasizes family centered care requires ongoing critical examination of the ways dominant ideas lead to discriminatory attitudes and the inequitable distribution of power (McNeil, 2013). Careful consideration must be given to the benefits and limitations of dedicated peer-support groups and those that integrate psycho-education and support services for children and their parents (Cowling & Garrett, 2012; Foster, O'Brien, & Korhonen, 2012; Pihkala, Sandlund, & Cederstrom, 2011). A significant caveat is to ensure that newly emerging policies, practices, and research in this field do not disenfranchise children further by reproducing situations in which they are not listened to or recognized for their contributions to the family. Support groups can help children learn how to better manage relationships that are important to them, and children would benefit from learning how to talk about their experiences with those whom they value outside dedicated forums like the Children’s Group. Reframing children’s goals this way does not discount their need for practical and emotional support, especially if we acknowledge that helping children cope better on their terms will

9 involve removing structural and discursive barriers that are difficult to change. Actual changes in systems of knowledge, beliefs about mental health/illness, and how we think about ways of being a child (and ways of being an adult) require a shift in thinking, as well as changes in children’s material circumstances. The results of our study lead us to suggest, “All knowledge is [not necessarily] power.” Information should be evaluated to determine how talk about current mental illness educational content is helpful to children (Reupert & Maybery, 2009). This discourse obscures troublesome contradictions in current understandings about the real nature and consequences of mental illness and the tensions between competing and often polarized explanatory claims about mental illness as purely a biomedical or social problem. Based on the results of our study, we question what appropriate educational content is for children of mentally ill parents, including whether content can or should be standardized, and how decisions should be made and who should make them about what constitutes optimal mental health education. We also question the most appropriate context for communicating information. In contrast to Pihkala and colleagues’ (2011) evaluation of a family focused (and parent-led) model of psycho-­ education, the participants in our study demonstrated an understanding of their parents’ problems and of their own, which they managed in their interactions with peers and the adult facilitators. Whether this approach was more beneficial requires further evaluation. Mark did talk about sharing his new knowledge with family members, and although other participants did not talk about this, most wanted some guidance on how they might talk to their peers outside the group. Children did not seem relieved or freed from excessive worry or responsibility by being better educated from a biomedical perspective (Pihkala et al.); however, the children did respond when invited to talk about their own experiences and what might be helpful and why. Participants’ motivations to learn more might have been in conflict with beliefs about what is best for children. One way to address this would be to take different kinds of knowledge into account (Boydell, Gladstone, & Crawford Stasiulis, 2002); for example, by considering how children’s understandings differ from those of adults who want to help but often end up qualifying children’s knowledge as deficient and in need of change (Alasuutari & Jarvi, 2012). Although children might be reluctant to ask explicitly for information, the participants in our study were adept at asking questions, critiquing information, and questioning the relevance of educational material in strategic ways that were emotionally safe. These strategies might not have been necessary had the children been asked

10

Qualitative Health Research 

more directly about their circumstances, what they wanted or needed to learn about the illness, and what was happening more generally to them and their family. How children understand their situations could inform decisions about what constitutes good mental health literacy. How they construct and use alternative concepts is useful for thinking about developing and implementing education activities and support practices (Alasuutari & Jarvi, 2012; O'Reilly, Taylor, & Vostanis, 2009). Finally, we recognize that our study is part of an ongoing process of constructing knowledge about children of parents with mental illness. Our epistemological approaches contribute to how we understand mental health/illness and characterize children and childhood according to particular discursive formulations. Discourse analysis can lead to “a self-referential circular process in which a text is produced by analyzing a text and the process goes on” (Crowe, 2005, p. 62). One way to mitigate this risk is to test our analysis as a new set of assumptions, to consider how, or if, it is meaningful and consequential in other interactive settings. This would include other psycho-education and support groups with goals comparable to those of the Children’s Group (e.g., Riebschleger et al., 2009). Readers might also judge whether study results are transferable to other contexts where children have a parent with a chronic illness and/or disability that requires education and support, and a parent or family that might also be considered different. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support was received from the Canada Graduate Scholarship Program of the Social Sciences and Humanities Research Council of Canada, and a Graduate Award from the Ontario Centre of Excellence for Child and Youth Mental Health (Grant number 6A-262). The views expressed do not necessarily reflect those of supporters or funders.

Note 1.

All names used are pseudonyms.

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Author Biographies Brenda M. Gladstone, PhD, is an assistant professor at the Dalla Lana School of Public Health, University of Toronto, and SickKids Foundation/Canadian Institutes of Health Research New Investigator, SickKids, Toronto, Ontario, Canada. Patricia McKeever, RN, PhD, is a professor at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, and senior scientist, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada. Mary Seeman, MDCM, FRCPC, DSc, is a professor emerita in the Department of Psychiatry, University of Toronto, in Toronto, Ontario, Canada. Katherine M. Boydell, MHSc, PhD, is a professor in the Departments of Psychiatry and Dalla Lana School of Public Health, University of Toronto, and senior scientist, SickKids, in Toronto, Ontario, Canada.