Emotional and behavioral problems in children of parents with severe mental illness in Wuhan, China: the roles of child maltreatment and exposure to parental victimization

Guided by a developmental-ecological and trauma-informed framework, children of parents with severe mental illness (SMI) may develop emotional and behavioral problems (EBPs) through inherited vulnerability, disrupted caregiving, socioeconomic adversity, stigma, and trauma-related exposures. However, the roles of direct trauma (child maltreatment, operationalized here as emotional and physical abuse) and indirect trauma (exposure to parental victimization) remain poorly understood. This study investigated the prevalence of child maltreatment and exposure to parental victimization and their associations with EBPs among Chinese children of parents with SMI.

Trained staff conducted interviews during home visits with 369 children aged 8–17 years (mean age: 12.6 years; 52.8% boys) living with a parent with SMI, along with the child’s primary caregiver or guardian. Child maltreatment and parental victimization were assessed via standardized questions, with child maltreatment referring specifically to emotional and physical abuse, and EBPs were measured using the Strengths and Difficulties Questionnaire. Logistic regression and classification tree analysis (CTA) were used to examine associations and interaction pathways, respectively.

Among the participants, 15.7% of children reported at least one type of child maltreatment (emotional: 14.9%; physical: 7.3%), and 19.8% witnessed at least one type of parental victimization (emotional: 16.3%; physical: 13.6%). Child maltreatment and parental victimization, as well as their subtypes, were independently associated with EBPs (adjusted ORs: 2.05–4.72, P ≤ 0.025). CTA revealed interaction patterns between parental physical victimization and physical abuse of the child, and between parental emotional victimization and emotional abuse of the child, in relation to EBPs.

Within the broader ecological risks faced by families affected by SMI, direct and indirect trauma were prevalent and were significantly associated with EBPs in children. These findings suggest that trauma-related exposures may represent salient proximal pathways linking parental SMI to child mental health difficulties and support trauma-informed assessment and care. This work was supported by Academician Song Weihong Workstation in Yunnan Province (202305AF150180) and the Wuhan Natural Science Foundation Exploration Plan Municipal Medical Institutions Clinical Research Key Project (2025020701020282).

The authors would like to thank all the persons with disability, workers of China Disabled People’s Federation, and research staff involved in this study. Department of Psychiatry, Wuhan Mental Health Center, Wuhan, Hubei province, China Wen-Cai Chen, Yan-Min Xu & Bao-Liang Zhong Department of Psychological Consultation and Psychotherapy, Wuhan Hospital for Psycho-therapy, Wuhan, Hubei province, China Department of Public Health, Jining Medical University, Jining, Shandong province, China Department of Psychiatry, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan province, China Correspondence to Ling-Fei Liu, Jin Lu or Bao-Liang Zhong. The authors declare no competing interests.

The study was conducted in accordance with the Declaration of Helsinki and relevant local regulations in China. The research protocol was approved by the Medical Ethics Committee of Wuhan Mental Health Center (Approval No.: KY2024.0623.08; June 23, 2024). Written informed consent was obtained from the parents or legal guardians of all participating children, and age-appropriate consent was obtained from the children prior to participation.