children ofimpaired parcntsjchildren of thementally ill;mental illness;parenting;service provision

18: 67-80.

Childrc» C?j'parcnts with a menta} illness have been identified as vulnerable to

cxpcricncin8 a variety C!I psychosocial c:JIcets arisina Jrom the impact C!Iparental mental illness. Many children do not however, experience cl~Olcultics as

a result ~rlhcir parent's mental illness and arc able to thrive despite what may

be an adverse situation. Until recently there has been a lack ifadequate service

provision in Australiafor these children and theirfamilies. Recent Bovernment

initiatives have led to arcata awareness and recognition if the needseifc.hi/drcn

whose parents have a mental illness. and key principles and actions have been

developed to assist health services to adequatelj! carefor them. The aim rif this

paper is to overview the risk and protective factors that may impact on the

psychosocial health of children '!FparenlS with a mental illness. and provide

some strategies that nurses in a range eif health settings mpyuse/ to assist,families where parents have a mcntal illness. ! I - '

I r \Rcccil'cJ 5 Auamt 200-1 AcceplcJ 15 September 200-1 ~"'_____ /, \ I

C/

KIM FOSTER

Senior LecturerSchool of Nursing

James Cook UniversityTownsville, Australia

LOUISE O'BRIEN

Associate ProfessorSchool of Nursing Family and

Community Health and WesternSydney Area Health Service

Cumberland HospitalParramatta. Australia

MARGARET McALLISTERAssociate ProfessorSchool of NursingGriffith UniversityBrisbane, Australia

Copyright of Full Text rests with the originalcopyright owner and, except as permitted under the~opyri~t Act 1968, copying this copyright materialIS prohibited without the permission of the owner orits exclusive licensee or agent or by way ofa licencefrom Copyright Agency Limited. For informationabout such licences contact Copyright AgencyLimited on (02) 93947600 (ph) or(02) 93947601(fax)

Volume 18, Issue 1-2, December 2004-January 2005 CJV 67

C:J( Kim Foster, Louise O'Brien and Margaret McAllister

INTRODUCTION

My mum had depression. During my Grade

2 year it was had, 'cause I didn't really know

what was going on ... The best thing for mewas learning that I wasn't the only kid that

this happened to ... so I guess what I'velearned from this is that not e,'crything can

go the way we want it to. (Alice, 2004: 1)

Since the 19205 there has been extensive

empirical research and review literature on

the varying effects of parental mental illness onchildren. Until more recent times however,

there has been limited recognition of their

needs in terms of service provision. In Australia

the National Inquiry into the Human Rights of

People with Mental Illness in 1993 highlightedthe harmful impact that parental mental illnessmay have on the child and other members of

the family. The Inquiry outlined the serious dis­

advantages these children may face, and recog­nized the lack of effective prevention andintervention strategies in place to support thefamily's functioning (Burdekin, GUilfoyle &

Hall, 1993).More recently, the Children of Parents

Affected by a Mental Illness Seoping Project

(Australian Infant Child Adolescent and FamilyMental Health Association, AICAFMHA, 2001)was conducted under the Mental Health Promo­

tion & Prevention National Action Plan (1999)

in order to ascertain the current responses inAustralia to the issues facing both children and

their families. In a more positive light, the find­ings revealed an emerging awareness of the

needs of this group, and a growing movement toeffectively respond to their needs. Further tothis, in 2002 the Children of Parents with a

Mental Illness (COPMI) National Initiative wasconducted, where Widespread consumer, carer,

service provider and expert consultation result­ed in the recent release of the Principles andActions for Services and People Working with

Children of Parents with a Mental Illness docu­

ment (AICAFMHA, 2004). After many )'ears of

apparcnt invisibility, research-based evidence as

well as information from parents, children,

adult children and health professionals working

directly with families affected by parental men­tal illness, has served to bring about well­

deserved recognition of, and attention to, this

large group of potentially vulnerable Australianchildren.

The purpose of this paper is to review thecontext within which parental mental illnessmay arise and the interaction between major

risk and protective factors that affect psychoso­

cial outcomes for children of parents with a

mental illness, so as to provide an understand­

ing for nurses of the key issues. The most effec­

tive current strategies to address the needs of

this group of children are outlined so that nurs­es' knowledge and awareness of the needs ofthese children and their families is enhanced,and effective interventions to meet their needs

may he incorporated into mll"singpractice.

Context of parental mental illnessIt is commonly acknowledged that between onein four to five, or twenty to twenty five percent

of Australians, experience some form of mentalillness in their lifetime (McDermott & Carter,

1995; SANE Australia, 1998; Commonwealth

Department of Health & Aged Care & Aus­tralian Institute of Health & Welfare, 1999). The

terms mental illness and mental health problemcover a broad spectrum of diagnostic nomen­

c1ature including anxiety, personality, cognitive,mood, and psychotic disorders. In terms ofserious mental illness, around three percent of

the population will develop a major psychotic

disorder such as Schizophrenia or Bipolar Affec­tive Disorder (SANE Australia, 1998). Approxi­

mutely equal number-s of mcn and women

experience the illness of schizophrenia (Bennett& Posscy, 2001), although women arc morelikely than men to experience effective disor­ders such as depression (Harvey, Meadows &

Singh, 2001).

It has been reported that women with men-

68 C:J( Volume 18, Issue 1-2, December 2004-January 2005

Addressing the needs of children of parents with a mental illness C:;v

tal illness arc more often parents than maleswith mental illness, being up to twice as likelyto report having children as men, and alsobeing more likely than men to have custody oftheir children (Caton et ai, 1999; Hearle,

1999). This may account for the significantamount of research that has focused exclusivelyon the mother with regard to the impact of

parental mental illness on the child (eg.Gruncbaum , Cohler, Kauffman & Gallant,1978; Cannon et al , 1994; Klimes-Dougan &

Bolger, 1998). Other key studies, although

including both genders in their sampling, havealso found that parent participants were moreoften women with mental illness than men(Rutter, 1966; Grunebaum & Cohler, 1983;

Jablensky et al, 1999).The general incidence of children whose

parents have a mental illness has been difficultto identify (AiCAFMHA, 2001). As Cowling

(1999) recognized, in Australia data on the inci­

dence of adult psychiatric clients who are par­ents is not regularly collected. Estimates musttherefore be made from epidemiological orcensus data. Cowling (1999) calculated thatroughly 27,000 Australian children may beaffected by their mothers' mental illness. Vari­

ous Australian surveys have found betweentwenty nine to thirty five percent of clients ofmental health services are women with one ormore dependent children (Cowling, 1999;

Hearle et ai, 1999; Farrell et ai, 1999). Thenumber of children affected by their father's

mental illness is not known, although as Devlin& O'Brien (1999) point out, there are poten­

tially very large numbers of children from com­bined parental illness who may be at risk. Oneestimate suggests that up to SO in every 100

clients with a mental illness are mothers orfathers with a mental illness who are living withdependent children (Gopfert, Webster & See­

man, 1996). Clearly, there are signillcant num­bers of young children who are living withparents who suffer mental illness. The followingdiscussion explores the risk and protective fac-

tors that may variously impact on these childrenand result in a range of outcomes.

DIALECTICS OF RISK,VULNERABILITY AND PROTECTION

For the child, the impact of parental mentalillness may range from short-term traumati­

sation , through to domination of the child'searly life experience.

(Clausen & Huffine, 1979: 183)

There has been a large volume of literature andresearch into factors that may either increasethe risk of negative psychosocial outcomes forchildren of parents with mental illness, or pro­tect against the risks. The term 'risk' can bedefined as individual or environmental factorsthat increase a child's vulnerability to experi­encing negative developmental outcomes(Beardslee et al , 1983; Kostelny & Garbarino,

1994). Protective factors on the other hand, arcseen as those that positively mediate the effects

of risk, decreasing the likelihood of negative

outcome. Researchers have conceptualized thenotions of risk and protection in terms ofparental mental illness in a variety of ways. Shih(1995) for instance, put forward the view thatrisk and protection could be consideredthrough the metaphor of the coin, protectivefactors constituting the reverse side of risk. It isimportant to note however that both thesegroups of factors may exert influences that arcindependent of each other (Garmezy, 1987;Rutter, 1988).

An analysis of the interrelationship betweenthe two groups of factors considered as beingpotentially risk and/ or protective reveals theycan be viewed as being in a dialectical relation­ship, where they arc inter-related. From this

perspective the factors that may be either risk

or protective of the child from the effects ofparental mental illness include as follows; indi­vidual factors, family factors, parental function­ing and parenting, and social and environmentalfactors. As may be seen in the following discus-

Volume 18, Issue 1-2, December 2004-January 2005 CJIf 69

CJV Kim Foster, Louise O'Brien and Margaret McAllistcr

sian, each factor can be either protective or risk

in a dynamic dialectic depending on context,interaction with other factors, and relative

:;trcngth and influence.

Risk factorsIt has been well recognised that children of par·cuts with a mental illness have a greater individ­ual risk of dcyeloping a mental disorder than

children of mentally well parents (Landau ct aI,1972; Beardslee, Bemporad, Keller & Klei-man,

1983; Rutter & Quinton, 1984). In terms of

genetic predisposition for instance, the child has

a 10-16% chance of developing schizophreniaor another psychotic disorder (SamerofT, Bnro­cas & Seifer, 1984; Worland, Weeks & Janes,

1987; Gottesman, 1991).lfhoth parents have apsychosis, the risk rises to around 40%

(Gruncbaum & Coh1er, 1983). Beardslee et al(1983), in a review of the literature, also reporthigh rates of impairment in children of p<lrcntswith an affective disorder.

Other individual risk factors linked to thedevelopment of adver-se psychosocial outcomesfor COPMI include a younger age at time orparental illness, male gender, 'difficult' tem­

perament, low self-esteem, 100\'er level of intel­ligence, birth defects, medical illness, and

learning disabilities (Rutter, 1988; LaRoche,

1989; Brooks, 1994). The age between 6months to 4 yl'ars has been found to be most

vulnerable period for stressful events, and in

general, the younger the <1ge the greater theimpact of parental mental illness (Anthony,

J969; Rutter, 1988). In terms of gender andstress, hoys have heen found in general to be

more vulnerable to developing adverse n::spons­

cs than girls (Rutter, 1988). Self-esteem hasalso been a key component in determining risk(Marsh, 1996). Children with low self-esteem

have been found to lise counter-productive

coping behavior-s such as denying, bullying orgiving up which arc used to escapc from chal­

lenging situations rather than <1dapting to them(Brooks, 1994).

Review literature and research on family riskfactors has also noted an association between a

gre<1ter risk for the child, and marital conlliet,

high levels of chronic family stress, difficulty

with communication, discordant family environ­ment, and overall reduction in effective family

functioning (LaRoche, 1989; Kadow, GrayDeering & Racusin, 1994; InofT-Germain et al,1997). Parenting plays a significant role in termsof risk. A secure attachment between motherand child may be impaired by the mother's men­

tal illness. In a relatively sm<111 comparison study

with fort)' {he first-time mothers and their chil­

dren, divided into three groups where two ofthe groups were mothers with schizophrenia or

depression, and with one a control group,D' Angelo (1986) sought to identify whether theusc of the standard 'Strange Situation' attach­

ment procedure, rated b), observers, would

result in differences in attachment responsesbetween the groups. Results from the standard'Strange Situation" procedure were compared

with the abbreviated version of the procedure.Children of mothers with depression and schiz­

ophrcnia in this study were found to experience

higher levels of anxious attachment with thestandard procedure; however the abbreviated

version found signific<1ntly more r<1tings ofsecure attachment for the children of motherswith schizophrenia or depression. These findings

therefore indicated a possible over-identification

of secure attachment with these mothers, andusc of the abbreviated ver-sion of this procedure

required further investigation (D' Angelo,1986). Other' research however, has found that

separation of mother/caregiver and childthrough hospitalization has heen associated with

impaired attachment (Rutter, 1972j Hall,1996). Repeated separations and loss of the

c<lrcgiver relationship and secure attachmenthave been found to have harmful consequences,contributing to the child's potential difficulty in

de\'eloping healthy relationships "vith others

(Rutter, 1972).The parent's most recent overall level of func-

70 C:JtI Volume J8, Issue 1~2, December 2004-Jal1uar), 2005

Addressing the needs of children of' parents with a mental illness C;pr

tinning has also been associated with the risk of

children's behavioral problems (InofT-Germain

ct ai, 1997). Parental hostility, irr-itability and/ or

aggression toward the child can be more impor­tant in terms of risk than the disorder itself

(Rutter & Quinton, 1984). In a critical review of

research evidence for a relationship between

child maltreatment/abuse and parental mental

disorder, Tomison (1996) found that although ithas been recognised there is a relationship

between the two, there was inadequate research

data to clearly define the causative link (Tomi­son, 1996). There are however, numerous docu­

mentations or negative and sometimes abusive

parenting practices including violence and homi­cide, by persons who have a mental illness ­particularly those that have chronic and/or psy­

chotic disorder (Anthony, 1986; Buist, 1998;Devlin & O'Brien, 1999). Further, the impair­

ment of the parent through illness/ substance

abuse may lead to a role reversal where the childassumes adult functioning, 'parentification ' ­

which may also be considered a form of mal­

treatment. Neglect of the child can also beevident when parents arc unwell and/ or experi­

ence a lack of motivation as a result of their ill­ness, resulting in insufficient supervision,inability to plan activities and lack of emotionalavailability and interaction, which may increasethe risk of danger for the child (Devlin &

O'Brien, I999; Thomas & Kalucy, 2003).It is important to note that not all parents

with a mental illness arc ineffective, inconsis­tent or abusive in their parenting. As stated, nocausal connection has been found between

harmful or uniform parenting practices and

parental mental illness (Silverman, 1989; Jacob­

sen & Miller, 1998). Many mentally ill parents

arc competent and caring parents with warm

relationships with their children, although thisis variable (Inoff-Gennain et a], 1997; Nichol­son ct al , t 998). Indeed, it is recognized there

may even be a reciprocal effect where problems

experienced by the child can negatively impa<;:ton the parent's mental health, and that parent-

ing itself Illay not have a positive impact 011 the

course of the parent's illness (Rutter & Quin­

ton , 1984; Nicholson ct al, 1998; Caton c t al,

1999).

Process by which parental mentalillness affects childrenA number of empirical studies have found that

in respect to the development of psychosocialimpairment and/or mental disorders in chil­

dren of the mentally ill, the main risk has beenfrom psychosocial disturbance in the family

and/ or an unsettled living situation, rather thanfrom parental mental illness itself. The chronic

symptoms of mental illness may still however,have an influence (El-Gucbaly & Offord, 1980;Rutter & Quinton, 1984; Cantwell & Baker,1984; Kraemer Tcbcs et ai, 2001; Ahern,

2003). As Hindle (1998) recognised, a linearmodel of causation oversimplifies the complexi­

ty of the situation. The mental health problems

of one person do not as such, cause disturbancein the children. It has further been argued that

it is difficult to separate the direct effects ofparental mental illness, including suicidal

tendencies and homicidal delusion, from theindirect effects of marital disharmony, separa­tion due to hospitalisation, unemployment,impaired parenting, disrupted parent-child

bond, and social disadvantage, as they may besynergistic (Anthony, 1986; Dunn, 1993; Cowl­

ing et ai, 1995; Hall, 1996).In 1984 Rutter and Quinton conducted a

pivotal study, which laid the groundwork forIllany subsequent investigations, to identify the

process by which a parent's mental illness mightlead to disorder in the child. They conducted

one of the relatively few prospective studies on

COPMI, which over four years followed a rep­

resentative sample of 137 patients who hadchildren under the age of fifteen, and had been

newly referred for psychiatric services. The

children were followed through yearly teacherquestionnaires, and yearly, standardised inter­

views were conducted both simultaneously and

Volume 18, Issue 1-2, December 200+--january 2005 C:JI{ 71

C:;v Kim Foster, Louise O'Brien and Margaret McAllister

separately with the patients/parents and theirspouses. The results were compared with thoseof a control group in the general populationwho had ten- year-old children.

Major findings by Rutter and Quinton(1984) included an increased rate of emotionaland behavioral disturbances and significantlygreater risk of developing a mental illness dur­ing childhood for these children, and a highlevel of marital discord between parents. Just assignificantly Rutter and Quinton also found thatapproximately one third of the children did notsuffer any form of disturbance, and that themajor risk for COPMI was not from theparental mental illness, but from associated ps)'·chosocial disturbances such as marital discordand disturbed family relationships.

Outcomes for the child whoexperiences parental mental illnessChildren and adolescents may develop a num­bcr of disorders and/or psychosocial problemsas a result of their parent's mental illness. 25­50% of children will experience some disorderor problem during their childhood and/oradolescence (Worland, Weeks & [anes, 1987).Research has however; consistently revealed lit­tle correlation between the type of parentalmental illness and the type of disorder the childmay develop (Cantwell & Baker, 1984; Rutter &

Quinton, 1984). Significant large-scale follow­up and/or prospective studies I by Rutter andQuinton (1984), Parnas ct al. (1993) and Hig­gins et al. (1997), have added to understandingof the effects of parental mental illness on chil­dren. Findings included that children of theseparcnts may develop a variety of psychiatricdiagnoses, and that these tend to be the rnoreserious and persistent mental disorders. Theyinclude schizophrenia (particularly paranoid),schizo-aJTcctivc disorders, schizophrcniformpsychosis, schizotypal, paranoid and schizoidpersonality disorders, major depression, sub­stance abuse and dependence, post-traumatic

stress disorder, phobias, non-psychotic rnooddisorder and atypical psychosis.

The child's psychosocial functioning Ina)' alsohe adversely affected by parental mental illness.Children of parents with mental illness haveheen found to have higher rates of academicproblems, peer interaction problems, andschool discipline problems than children ofnun-mentally ill parents (Billings & Moos,1983). Children's capacity to form interperson­al relationships has also been linked withparental mental illness (Grunehaum & Cohler,1983). Children of mentally ill parents haveadditionally been found to have an increasedsuicide rate, related to the genetic and psy­chosocial stresses of their parent's illness, feel­ings of fear, a sense of isolation, and oftensignificant responsibility and burden throughfor example, parentification (Anthony, 1986;Drake, Racusin & Murphy, 1990; Rossow &

Lauritzen, 2001).

Protection against problemsarising from parental mental illnessThe literature discussed so far has revealed adominant thread where problematic and nega­tive effects for the child have been consideredto result from the biopsychosocial effects ofparental mental illness. Indeed, it is only throughunexpected research discoveries in the 1960sand 1970s of children who were functioningwell that there came an awareness that not allchildren were negatively affected by their par­ent's illness, and would not necessarily go on todevelop future psychosocial problems (Feldman,Stiffman & jung, 1987; Silverman, 1989). Vari­ous ter-ms were developed to describe this groupof children who became of increasing interest toresearchers. These include the 'invulnerable'(Anthony & Koupcrnik, 1974; Carmczy, 1974),or 'supcrkids' (Kauffman et ai, .1979).The termsdescribed children who were considered to be

outstanding and functioned even more success­fully than those who had parents without mentalillness (Gruncbaum & Cohler, 1983). The con-

72 C:JII Volume 18, Issue 1-2, December 2004-janua,-y 2005

Addressing the needs of children of parcnls with a mental illness CJlf

ccpt ofexceptional' children, whilst intriguing,

has subsequently been viewed as misleading in

that the ability of the child to avoid risk associat­

ed with parental mental illness was found to

Fluctuate. A developmental progression could

occur; where vulnerabilities and/or further

strengths cmt:rged in the child according to

changes in life circumstances (Rutter, 1985;

Feldman et aI, 1987; Luthar et ai, 2000a). Subse­quellt to these discoveries, the concept of'invul­

ncrabilitv' has developed to the mor-e relativeone of 'resilience' (Rutter, 1985; Luthar et al,2000a). Further to this, resilience itself has heenproposed to exist in varying degrees within a

spectrum of successful outcome (Osborn,

1990).

Becoming resilientAlthough it has not been prominent until morerecently, the concept of resilience has been

present in the literature for more than thirty

years. As illuminated in the previous section,

the literature discussing the effects of parentalmental illness on the child played a significantrole in the emergence of childhood resilience as

a theoretical topic of discourse (Luthar et ai,2000a). Garmezy (1983) for instance, foundthere were children who seemed to thrive even

in the face of severe stress. This finding illus­trates an important facet of resilience research

in that it has been concerned not only with theabsence of dysfunction, but also with exploringthe dimension of wef lness itself (Luthar et al ,

2000b). This rellected in an important change

in research focus where parental mental illness

was recognised as by no means indicative offuture difficulties for the child.

There have been a number of operational

definitions of resilience over time. Resilience

has been described as an ability to rebound

frorn adversity and overcome difficult circum­stances in one's life (Marsh et ai, 1996).Resilience has also been viewed in terms of two

major concepts, those of competence and vul­nerability. Children who were vulnerable due

to risk yet achieved 'competence' have been

deemed resilient (Osborn, 1990). More recent­

Iy resilience has been viewed as a complex cul­

tural construct that involved the dynamic

interaction between individual or family main­

tenancc 01" positive adaptation despite experi­cncc(s) of considerable adversity (Luthar ct al ,

2000a; Marmion & Joyce, 2001; Dcvcson ,

2003). This definition notably includes the con­

cept of the family as a group, rather than justthe individual, as having the ability to demon­stratc resilience.

Protective factors and resilienceProtective factors are seen as influences that are

able to modify, alter or improve an individual'sresponse to an external risk that may have oth­

erwise predisposed them to a negative out­come. Protective factors arc not however;

always pleasant or positive characteristics or

experiences and can include a personal quality

such as gender, or an experience such as pre­ventative interventions (Rutter, 1985). In terms

of parental mental illness, protective factors arcthe specific resources the child may have or

experience that can support them in developingand maintaining resilience (Brooks, 1994).

A number of protective factors have beenspecifically considered to mediate the morenegative effects of environmental stress includ­

ing that of parental mental illness (Rutter &

Quinton, 1984; Thompson & Calkins, 1996).These can be separated into internal factorswithin the child and external resources

accessed by the child that support the develop­ment and maintenance of the construct of

resilience. Internal factors that have been found

by empirical research to provide protection

against adversity and strengthen resilience

include higher intelligence, a belief in their owneffectiveness (internal locus of control), ability

to be autonomous, being optimistic, having alow risk or 'easy' temperament, using effectivecommunication and problem-solving, having a

sense of humour, involvement in social activi-

Volume 18, Issue 1-2, December 2004-January 2005 C:;v 73

C:J( Kim Foster, Louise O'Brien and Margaret McAllister

tics and commitment to relationships with oth­

ers, haYing a special interest or hobby, havinghigh self-esteem and positive self-concept, sub­

stantial self-understanding, and the ability to

manage emotional regulation (Rutter & Quin­ton, 1984; Luthar & Zigler, 1991; Werner,

1995; Fonagy et ai, 1994; Seligman, 1996;Thompson & Calkin" 1996; McGrath, 2001).

External protective factors include those

within the family and in the community that

may enhance the child's resilience such as a pos­

itive relationship with a caregiver, positive sib­

ling relationships and support, reading and

interest in literature, use of music, and supportand positive feedback from other adults (Kauff­man et al , 1979; Silverman, 1989; Werner,

1995; Inoff-Germain et al, 1997). The opportu­nity to establish a close bond with a competentand emotionally stable person, particularly a

schoolteacher, has been considered an impor­tant protective factor for many resilient chil­ch-en. The development of positive emotional

bonds with other adults throughout develop­ment has been found to provide the child with

caring role models who reinforced the child'scompetencies and affirmed their intrinsic worth

(Kauffman ct ai, 1979; Anthony, 1987).Werner (1995), in a major longitudinal study

on resilience in children, followed 698 children

in Kauai over three decades from the prenatal

period through to hirth and ages one, two, ten,

eighteen and thirty two. In monitoring the chil­dren's biological and psychosocial risk factors,protective factors and stressful life events, Wern­er and her associates found that thir-ty percent of

the children were considered high risk due to

factors such as parental mental illness and povcr­ty. Her findings however, reinforced previouslycited literature in that parental mental illness

and other risks did not necessarily determinefuture problems; as one third of these children

who ',,"'CIT considered to be high risk went on to

develop into competcnt and confident adults.

They were able to overcome their difficulties in

adulthood by participation with external sup-

portive influences such as supportive friends,

marital partners, church involvement, and edu­

cational programs such as community collegesand voluntary military service. Rutter (1993)supports that these turning points in a person's

life can enable them to change to a more positivecourse, due to the benefits and resilience the

experiences may bring.

ADDRESSING THE NEEDS OFCHILDREN OF PARENTS WITHA MENTAL ILLNESS: PRIORITIESSERVICE PROVISIONThe previous overview of the needs of children

of parents with a mental illness has revealed anumber of key areas for health services to

address. This group of children is relatively easi­ly identified and due to the benefits of protec­tive factors and enhancement of resilience is

therefore likely to respond well to preventionand early intervention strategies (AICAFMHA,2001). The challenges for service provisioninclude the need to str-engthen and supportchildren and their families so that protective

factors are facilitated and contribute to bothchildren's and their parent's mental health, and

the need to identify and reduce risk factors in

the parehts with a mental illness, along withthose in the family and wider community,

so that children's well-being is enhanced

(AICAFMHA, 2004). Effective strategies maybe grouped according to three levels of inter­vention: policy and service level changes, sup­port for the family, and SUppOl·t for the child(AICAFMHA, 2001).

The guiding principles for ser-vice provision

in the recently launched 'Principles and Actionsfor Services and People Working with Childrenof Parents with a Mental Illness' arc:• Recognition or children's rights to, for

instance, the support, protection and care

that is needed for their well-being

• That parents and families have rights, respon~

sihilities, roles and diver-se hackgrounds and

needs.

74 C::Jl{ Volume 18, Issue 1-2, December 2004-January 2005

._------------------------------------

Addres~ing the needs or children of parents with a mental illness C:J'{

• That people with a mental illness have bothrights and responsibilities as stated in the

Australian Ministers' Mental Health State­

ment or Rights and responsibilities (1995),

and the United Nations Principles 011 theProtection of People with a Mental Illness

( 1992)

• Promotion of mental health, prevention ofdisorder and early intervention play J vital

role with those who demonstrate signs or

symptoms of' mental health problemsCollaboration and empowerment of children

and their families is the responsibility of

mallY sectors and human services

• Quality and effectiveness arc important goals

for research, service provision, workforce

development and education for families where

a parent has a mental illness.(AICAFMHA,2004).

Specific strategies that have been recommended

as helpful for both children and their families

include:• Family-focused assessment and management

of inpatient and community mental health

clients: ic: identification of dependent chil­dren, their needs and risk levels throughimproved intake and assessment procedures,

and data-gathering• Education of parent and child(ren) on the

mental illness, including heredity risks, med­ications, the course of illness, and stigma

• Development of resilience/ coping skillsthrough social skills training, problem-solv­ing skills training and decreasing parent! flea­

tion or the child

Increased community & school-based educa­

tion and promotion of tolerance for mental

illness

• Validation and support of the parenting role,

ego peer-support groups, home-based train­ing, development of parenting skills, andfamily friendly mental health services

Provision of specialised services. such asmother-bahy inpatient and day services, sup-

ported accommodation, and dedicated

COPMI programs/services

• Provision of parent support groups, and

child/peer support groups: sec the following

website for examples of specific COPMf

groups and services available in Australia:

http://,,,\vw.copmi.net.au/ common/sen'iccs.hrrnl

• Planned care, provision of respite services,assistance with housing, health and vocation­

al training for parents and families.(AICAFHMA,2001)

Other strategies for health services recom­mended by recent research are to include the

whole family in care and management (Fudge et

al, 2004), perform early assessment or both thechild and the parent's and child's relationship

(Ahern, 2003), and undertake assessment and

support of the child-care and domestic capaci­

ties or the parent (Thomas & Kalucy, 2003).

Implications for nursesNurses from a variety of practice areas may

cngage in providing care for children and fami­

lies where a parent has a mental illness. Thoseworking in areas such as child and adolescentmental health services, paediatric settings, adultmental health services, and women's health/

perinatal services are particularly likely to workwith p;}rcnts with mental illness and / or their

children.

Attention to, and awareness of childrenwhose parents have a mental illness is a funcla­

mental strategy for all nurses. The current focus

on a supportive and empowering approach tochildren and rami lies, the benefits or early

assessment and intervention, and provision of

practical and timely interventions highlights theimportant role nur-ses can play in many areas of

health care. Garley ct al (1997) suggest that thepotential effect parental mental illness may have

on the child means it is particularly importantnurses broaden their practice to incorporate

primary prevention strategies into their work.

Volume 18, Issue 1-2, December 2004-january 2005 C:Jl[ 75

CJIf Kim Foster, Louise O'Brien and Margaret McAllister

This may include for instance the regular provi­

sian of both support groups and psychocduca­

tional groups for children of parents with amental illness. The promotion of mental health

in families may be seen as an essential role fornurses in child and youth, adult mental health,

and women's health services. Devlin & O'Brien

(1999) highlight that nurses are also uniquely

positioned to assess the needs of the children

and their families so that potential and actual

problems may be identified and interventions

put in place to limit their impact.Blair (2004), a psychiatric mental health

nurse and adult child of a parent with mentalillness, recommends that those working with

children of parents with mental illness attend tospecific areas when identifying a child of a par­ent with mental illness. These include referral

to support agencies, COPMI support groups,counselors, literature and videos on issues pcr~

tinent to children of parents with mental ill­ness. As Blair identifies, facilitating the child's

contact with support enhances universality ­

knowing that they are not alone and others alsoshare the same issues and/ or difficulties. This is

a benefit all health professionals can offer to the

child, regardless of their expertise or healthsetting. Dunn (1993) suggests that in all strate­

gies used to support families with a mentally ill

parent, health professionals need to be awareof the potential lo),alty conflicts that ma)' beengendered by the interventions, and the guilt

that may be felt by the children. As man)' chil­dren of mentally ill parents are also in a care­

giving role with their parent, the likelihood ofparentification means there is a need for nursesto VI/ark directly with the parents to strengthen

their caregiving and parenting capacity. One ofthe most useful strategies that nurses can lise is

to encourage the family to enlist the support ofother adults such as friends who may provide

emotional and practical support, particularly to

the children. Thomas and Kalucy (2003) further

suggest that practical support for parents in theform of assistance with daily living and domes-

tic chores such as cooking and washing has heen

reported by parents to he of significant help in

resuming their parenting role and relieving theburden on carers after an episode of illness.

Approaching the child and their family froma strengths perspective, which involves building

on an individual's/family's strengths rather

than focusing on deficits and vulnerabilities(AICAFMHA, 2004), is a further supportive

strategy suggested by Blair (2004). This ap­

proach may diminish the stigma of mental ill­ness that can impact on both the child and their

family, and its use implies an understanding that

children are by no means inevitably negativelyaffected by parental mental illness.

Specific interventions nurses can provide,

especially for mothers with mental illness,include support to parents through assistancewith practical issues such as breastfceding and

mother-craft skills, and strategies to enhanceparenting skills such as helping parents 'read'and respond appropriately to their child's signalsfor care and attention (Svcd Williams, 2004).

These interventions arc important in facilitatinga warm parent-child bond and attachment,which has previously been identified as an

important protective/f-isk factor.From a workforce development and training

perspective it has been recommended thatinclusion of information on the needs of

COPMI and their families in undergraduate,postgraduatc and in-ser-vice training and educa­tion for nurses would support improved out­comes (AICAFMHA, 2004).

In conclusion, children of parents with a

mental illness may be vulnerable to experienc­ing higher rates of psychosocial disorder thanthe general population. It is important to notethat with recognition of their needs, a focus on

supporting the [aruily as a whole, attention to

primary prevention and early intervention, andthe widespread provision of appropriate inter­

ventions and support, these children will not

necessarily suffer adver-se outcomcs as a resultof their parent's mental illness. A dialectical

76 CJIf Volume 18, Issue 1-2, December 2004-janual'y 2005

Addressing the needs of children of parents with a mental illness CJ\f

relationship between risk and protective factors

suggests that the greater the focus on enhancing

protective factors, the greater the chance of

developing resilience in the child and their fam­

ily. Nurses and other health professionals arc in

a key position to respond in a timely and cffcc­tivc way to the needs of children and families

where a parent has a mental illness.

Endnote1 As diagnostic criteria/nomenclature for

many mental disorders has changed over

time however, there is some difficulty incomparison of diagnoses in older studies, eg1970s, to more recent ones from the 1990s

& 2000s. Nevertheless, these are large­scale, pivotal international studies which

span up to three decades.

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Reviewers of Advances in ContemporaryChild and Family Health Care manuscripts

T he authors and publisher of Contemporary Nurse gratefully acknowledge the detailed, patient and

constructive advice provided by the following editors and peer reviewers of manuscript sub­missions, and their revisions, which arc published in this issue. While we have endeavoured to make

this list exhaustive, we apologise in advance to "11)' reviewer who may have been unintentionally

omitted.

Gail Anderson Gay Edgecombe Rose Mcfildowncy Chantal Fraser Ski

Una Kunlahi Badr Karen FlowersMargaret McMillan Carol Smith

Tony Barnett Donna GilliesAnne McMurray Janine Smith

Candice Bodkin Carol GrbicbJudy Mannix Olle Sotlcrhamn

Fiona BogossiallBrenda Happel]

Michael Morrissey Sandra Speedy

Isla Bowen Sue Nag)' Colleen Stainton

Vickcy Brown Debra Jackson Blake Peck Winsome St John

Catherine Cameron Linda Johnston Charmaine Power

Rose Chapman Garth Kendall Nicholas Procter Kim Usher

Judith CondonTom Laws Brxlil Rasmussen

Lesley CuthhertsonSing Lee jennifer Rowe Denise Wilson

Philip Darhyshire [udy Lumby Inger Sanden Sarah \Vise

80 C:J>f Volume 18, Issue 1-2, December 2004-Januar), 2005