This is a republished version of an article previously published in MJA Open
An Australian epidemiological study found that 21%–23% of children have at least one parent who has a mental illness,1 with varying levels of risk exposure, depending on several child, parent, family and community variables.2 In recent years, there have been a number of programs that aim to promote the positive determinants of children’s wellbeing and reduce the risk factors associated with living with parental mental illness. As these children are at higher risk of developing mental illnesses, suicide ideation and attempts, and functional impairment than their peers,2 it is essential that appropriate early intervention programs are developed. Scoping projects conducted in 19993 and 20084 found that peer-support programs were the main form of intervention offered in Australia. However, Fraser and colleagues5 found that the evaluation methodology employed by most programs, including such peer-support programs, was weak and thus their effectiveness was uncertain.
Our review aimed to identify the range of interventions that clinicians might employ, or refer to, when working with such children. Building on previous reviews,3-5 this article presents available interventions for children, highlighting evidence data when available. Given the different needs of very young children and older children, we focused on programs that target children aged 5–18 years (although some programs also include younger or older children).
Grey (unpublished) and black (published, peer-reviewed) literature was sourced from three fields. First, we examined a review of evaluated programs by Fraser and colleagues,5 as well as Australia-wide scoping projects conducted in 19993 and 2008.4 Second, searches were conducted using PsycINFO and MEDLINE in June 2011, using key terms (list available from the authors on request) with no date limits, for papers published in English, Dutch or German. Finally, on the basis of these approaches, we identified various programs and circulated this list among our professional networks (carer and consumer groups, researchers and clinicians) to identify other programs and program types that we might have missed.
We included only those programs with a specific focus on children whose parents have a mental illness (excluding parental substance abuse). This meant that parenting programs for parents with a mental illness were excluded. Conversely, family programs were included if children were included in the intervention. Interventions targeting children with existing mental health problems were excluded. As the focus of our review was on identifying available programs, no restrictions were placed on study quality.
Information extracted included program description, length, target group and available evidence base.
Programs from Australia, Europe and North America were found and collated into (i) family interventions, (ii) peer-support programs, (iii) online interventions, and (iv) bibliotherapy.
We identified seven family-intervention programs (Box 1).6-13 Of these, six programs target families where a parent has depression and/or anxiety.7,8,10-13 The most prominent, Family Talk, targets families where a parent is diagnosed with a major depressive disorder or bipolar disorder, with children aged between 8 and 15 years who have never been treated for an affective disorder.10,11 Family Talk employs a cognitive psychoeducational approach of between six and 10 sessions, some of which are directed to parents, some to the children and some to the whole family. Another program, Family Options,9 employs a care-coordination model tailored for individual families where a parent has a serious mental illness; however, at this point, child outcomes are not available.
Overall, family programs focus on minimising family dysfunction and maximising children’s support networks and competencies. Family programs can range from two to 20 sessions, and more research is required to determine whether intensity equates to effectiveness. While current evaluation data are mostly rigorous (employing a randomised controlled trial design), programs need to be developed and evaluated for families where a parent has disorders other than, or in addition to, depression. As shown in Box 1, programs indicate positive results in terms of children’s symptoms.
We identified 12 peer-support programs, offered as school holiday programs, after-school programs, or camps (see Box 2).14-27 Peer-support programs target children aged 7–18 years, and aim to increase children’s knowledge about mental illness, develop peer relationships and enhance children’s adaptive coping skills. Programs commonly adopt a group, strengths-based, preventive approach. One program is facilitated by a peer leader who is also the child of a parent with a mental illness, thereby providing opportunities for the development of leadership skills.22,23
Potential risks associated with peer-support programs include exposing children to unsettling information about mental illness and limiting peer-support networks to those in the program.22 In one program, prosocial behaviour (measured by parents’ scores on the Strengths and Difficulties Questionnaire) decreased as children began to ask more questions about mental illness.16 Five of the 12 programs have been, or are currently, offered in Australia. Although a number of peer-support programs have been evaluated, many have not used valid outcome measures and have not employed waitlist or control groups. Longitudinal data are often not available, so long-term outcomes remain unclear. Overall, it would be appear that the evidence base for peer-support programs is emerging.
We identified two online interventions targeting older children and young adults (12–25-year-olds) (Box 3).28-30 Websites provide easy access at all times of the day and the option of remaining anonymous when studying information and/or sharing experiences. Potentially, young people might misunderstand a message in the absence of non-verbal cues, and websites do not necessarily provide the opportunity for immediate clarification. Additionally, staff must be trained in computing skills. Future evaluation needs to focus specifically on child outcomes. We did not find any online interventions that were designed for Australian young people.
Bibliotherapy presents children with literature involving characters who are in similar positions to themselves. This enables children to normalise their situation, gain insight into the problem-solving techniques of those characters, and apply this learning to their own lives. Tussing and Valentine31 advocate employing bibliotherapy with children whose parents have a mental illness, in conjunction with discussions about the material with a trained professional. In Australia, the Children of Parents with a Mental Illness national initiative identifies various books, DVDs and consumer stories (many of which are Australian) that might be employed in this approach (http://www.copmi.net.au/jsp/resources/resource_index.jsp). Bibliotherapy might consolidate other forms of psychoeducation, and could be useful for rural/remote populations and those on waiting lists. However, it requires a certain level of literacy and has the potential to be misinterpreted. There is no evidence for the efficacy of bibliotherapy in children affected by parental mental illness, although Marrs32 found that it was useful for adults, in conjunction with other forms of treatment.
The common component across programs is the provision of psychosocial education about mental illness to families and children. This suggests that it is important to provide age-appropriate information about mental illness to children whose parents have a mental illness, although further research is required to test this assumption. More evaluation is required to specifically examine the comparative efficacy of different approaches, to determine what interventions work, for whom, and how. With the exception of peer-support programs, most interventions are located in either Europe or North America. These interventions typically focus on children living with parental depression and/or anxiety. Although some programs have been evaluated in randomised controlled trials, further evaluation is required. Program evaluation needs to incorporate validated outcome measures and rigorous evaluation designs, compatible with the community settings in which many programs are delivered, and sensitive to the heterogeneous nature of the target group — children whose parents have depression and/or anxiety, as well as other disorders.
1 Family-intervention programs for children whose parents have a mental illness*
2 Peer-support programs for children whose parents have a mental illness
3 Online interventions for children and young adults whose parents have a mental illness
Provenance: Not commissioned; externally peer reviewed.
Received 11 September 2011, accepted 19 March 2012
- Andrea E Reupert1
- Rose Cuff2
- Louisa Drost3
- Kim Foster4
- Karin T M van Doesum5
- Floor van Santvoort5
- 1 Krongold Centre, Faculty of Education, Monash University, Melbourne, VIC.
- 2 Families where a Parent has a Mental Illness, The Bouverie Centre, La Trobe University, Melbourne, VIC.
- 3 Indigo Community Mental Health Centre, GGZ Drenthe, Assen, Netherlands.
- 4 Sydney Nursing School, University of Sydney, Sydney, NSW.
- 5 Radboud University Nijmegen, Nijmegen, Netherlands.
No relevant disclosures.
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Abstract
Objective: To identify and describe intervention programs to improve outcomes for children whose parents have a mental illness.
Data sources: Grey and black literature was sourced from (i) three previous reviews/scoping studies, (ii) PsycINFO and MEDLINE searches of English, German and Dutch papers, and (iii) in consultation with researchers, clinicians, consumers and carers in the field.
Study selection: Only programs specifically targeting children whose parent/s have a mental illness. No restrictions were placed on study quality.
Data extraction: Program description, target group and evidence base.
Data synthesis: Programs from Australia, Europe and North America were found and collated into (i) family interventions, (ii) peer-support programs, (iii) online interventions and (iv) bibliotherapy. Some programs had been evaluated, with promising results. Others had minimal or no evaluation.
Conclusions: The core component across programs is the provision of psychosocial education to children about mental illness. More rigorous research is required to establish the conditions through which children’s outcomes are enhanced.