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
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