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A parent’s struggle to manage their emotions may have significant impact on small children. Helping a child understand in the here and now about what is going on for the parent, without blaming that parent or the child, may be useful for the child. It may also lead the child to seek different models of managing emotions and selfconcepts. Reading books with children, or bibliotherapy, could be useful for parents who experience stressrelated “meltdowns” or perhaps live with mental health conditions such as borderline personality disorder, and for those working with small children in educational, child care or child protection settings. This brief uses Meltdown Moments, a picture-story book written by an experienced mental health clinician and illustrated by a professional artist with lived experience of emotional turmoil, as an example of what may help in conversations about what is going on in the family. Introduction E of the more common mental health conditions such as postnatal depression and anxiety on small children are often documented and discussed. Less well-known but recently summarized1,2 are the effects of turbulent parental emotions. Tumultuous parental emotions vary from occasional “meltdowns” to a diagnosable mental health condition such as borderline personality disorder (BPD). Problems for infants living with mothers with BPD are identifiable within the first few months of life3 and onwards. Attachment problems are sometimes evident at 12 months,4 behavioral problems in childhood5 and intergenerational transmission noted by the time some offspring reach young adulthood.6 BPD can cause great disruption to the lives of the parent with the diagnosis, his or her children, and his or her family. When children live with emotional turbulence caused by significant parental mental health problems there may be other indirect effects. These include exposure to the general stigma around mental illness and negative societal attitudes about these difficulties.7 Borderline personality disorder (BPD) is perhaps even less well understood within the general community than conditions such as depression and anxiety8, and may also be more stigmatized. Thus, children living in families with parents with BPD may have few opportunities to understand why their parents may have rapid mood changes, outbursts of anger, and impulsive behavior. However, there is a paucity of work to guide interventions that may help parents with these challenges and alter potentially troublesome outcomes for the children. Bibliotherapy may provide one avenue for change. Key Points: Bibliotherapy, Mental Health Literacy and Children Bibliotherapy provides a narrative or story that children can relate to, thereby normalizing the problems. “I am not alone in the world – this happens to other people”. It may help children of parents with mental illness by improving the child’s understanding of difficulties in their lives.9 Bibliotherapy can also provide information to improve the child’s and parent’s mental health literacy. Mental health literacy relates to people’s knowledge, beliefs and understanding of mental health prob1 Sved Williams and Jonsson-Harrison: Using Picture-Story Books to Help Families Published by eScholarship@UMMS, 2018 lems. Jorm et al. (1997) outline the components of health literacy as the ability to recognize mental health disorders, knowing risk factors and causes, and knowing how to provide self-treatment and how to seek professional care.10 Improving mental health literacy is proposed to promote recognition, management, prevention and appropriate help-seeking for mental health concerns. A recent summary by Riebschleger, Grove, Costello, & Cavanaugh (2018) documents children’s problems stemming from low mental health literacy.11 They also describe the benefits of ensuring open discussion of parents’ mental illnesses. Potential benefits include better mental health understanding in general and the possibility that children will become more engaged in activities focused on actively learning skills to manage emotions. Activities that increase and improve family communication about mental health are strongly recommended in the Think Family Whole Family program, which actively promotes communicating about parents’ illnesses.12 Using Picture-Story Books Picture-story books, particularly when relatively realistic, can perhaps provide such psycho-education for small children. Reading together may lead to open discussions on the topics portrayed.13 Understanding mental health and mental illness may be particularly relevant for parents with mental health conditions such as borderline personality disorder (BPD) and their families, as the thoughts and behaviors of a person living with BPD may be hard to understand. In addition, the person living with BPD may have difficulty understanding the thoughts and behaviors of others, including their children. Reading children’s cues is an important component of parenting. When a parent living with BPD is upset, their ability to understand what is going on in their child’s mind or what is prompting their child’s behavior may be compromised. Thus, finding a pathway for parents to discuss mental health and mental illness with their children may be particularly relevant for all family members and may contribute to more positive relationships. One example of using a picture story book to help families discuss managing emotions and parental mental illness is Meltdown Moments14 (MM). MM is written by a perinatal psychiatrist and illustrated by an artist with lived experience of emotional turmoil. The book illustrates a story about a Mum who experiences intense outbursts (meltdowns) and the experiences of the other family members, Dad, and siblings Nate and Jane. The book demonstrates how children may cope with their parents’ behaviors – Nate by withdrawing and hiding away, and Jane by responding with a series of emotional outbursts herself. It also shows how Mum and family can get help for Mum’s mental health condition. The book shows the reality that family members love each other but, at times, don’t know what to do: “No-one knows now what to do. Not Mum, Not Dad. Not Nate, Do you?” Eventually, Dad suggests that Mum needs helps and although she initially rejects this idea, the family goes to their local doctor who is kindly and knowledgeable. Mum is referred to a mental health professional for help and Mum improves in the way that many people will improve – slowly, and initially inconsistently, and yet with a forward trajectory: “Sometimes she’s better. Sometimes no way. Tomorrow will be better than it is today”. The book concludes with six pages of psychoeducational material for parents that provide information aimed at helping family members understand mental health, mental illness and coping.

Using Picture-Story Books to Help Families Understand Turbulent Parental Emotions in Families with Small Children