AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022

Executive Summary

Forward/Contents/Etc
Executive Summary (includes brief recommendations)
Report in Full
Issues & Recommendations
Appendices 1-3
Appendices 4-5

1. Executive Summary

This scoping study was commissioned and endorsed by the Mental Health and Special Programs Branch of the Department of Health and Aged Care, and carried out by the Australian Infant, Child, Adolescent and Family Mental Health Association (AICAFMHA). Funding for the project came from the federal Department of Health and Aged Care. The project brief was as follows:

To undertake a project that will identify current major state and territory evidence-based initiatives in relation to how each jurisdiction is addressing the needs of children of parents with a mental illness, and future plans for work in this area. It is expected that the project will result in a report that outlines major activities, identifies gaps and makes recommendations regarding future work and action in this area. Activities will include:

• gathering information from, and consultation with, state and territory mental health branches on key projects and services for children of parents with a mental illness in their jurisdiction and any future plans they have for work in this area; and
• analysis and reporting of project findings, including the evidence base of current activities, their availability and sustainability, and recommendations for future action.

The Department of Health and Aged Care contracted AICAFMHA to carry out this scoping study, employing a part-time project officer in September 1999 with a view to submitting a draft of the report to the PPWP in February 2000. Consultation with the PPWP and the federal Department of Health and Aged Care regarding the recommendations was completed in July 2000 and the report was completed by August 2000.

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Project Design

Information was gathered via a number of strategies:

1. consultation with the project reference group, which included representatives from all states, and further individual consultations with other state and territory contacts that developed through networking of the project;

2. consultation with professional and consumer groups when opportunities arose; and

3. wide distribution of a questionnaire seeking information as required by the project brief.

Project Background

The Mental Health Promotion and Prevention National Action Plan: Under the Second National Mental Health Care Plan, 1998–2003 (1999) was established in January 1999, and identified several areas requiring attention with regard to children with parents affected by mental illness. These included researching effective community-based interventions, evaluating the effectiveness and sustainability of prevention initiatives, and developing positive outcomes for these children, including improved support, mental health and parenting, and better knowledge and understanding of parental illness.

A number of recent Australian reports and policy papers were located by the project. These indicated the lack of statistical information on the number of children who have a parent with a mental illness in Australia. Australian studies have found that, during survey periods, between 29% and 35% of adult mental health service clients are female parents of dependent children under the age of 18 (Cowling, 1999; Hearle et al, 1999; and Farrell et al, 1999). Seventy per cent of these children are living with their mother. The reported prevalence of emotional and behavioural difficulties among children with a parent affected by a mental illness varies, but is reported to be much higher than for the general population (Farrell et al, 1999). These children are also over represented in out of home care services (Cuff & Pietsch, 1997a).

Having a mental illness can make it difficult at times for parents to provide for their children’s needs, which include love, physical and emotional nourishment, security, protection, stimulation, an appropriate learning environment and socialisation (Pope, 1998; Kowalenko et al, 1999). However, families containing a parent affected by mental illness can be supported to effectively parent their children. In addition, interventions that target the risk factors experienced by these children, and develop their ability to cope with adversity, can decrease the risk of these children developing poor mental health.

This report summarises the recommendations made by these previous Australian reports, which fall under three main themes:

1. interventions need to support children, for example, services to provide continuity of care, peer support, education on mental illness, and improved resilience and coping skills;

2. interventions need to support the parent, for example, planned care and respite services, those that provide validation and support of the parenting role, family-focused mental health services, and practical in-home help; and

3. policy/service-level changes should be aimed at better identifying and meeting the needs of these children and their families.

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Selected Project Findings

The project was successful in gathering a great deal of relevant information and identifying issues that require attention. As it was limited to a scoping study and the time frames were short, it did not encompass a full literature review or wide consultation (apart from that described above) and so does not map services in detail.

However, the findings clearly illustrate that there is an emerging awareness across Australia regarding the existence of this group of children and the developmental risks they may be experiencing, and a move towards identifying and meeting these needs. Policy frameworks to support mental health services in recognising the needs of both the parents and their children and responding effectively are either in place or under development in most states.

As would be expected, some states, for example, Victoria and New South Wales, are further developed in their responses to these children and families than others, but initial collaborative or research work to identify and address these needs could be identified in all states. Fifty programs were classified as specifically addressing the needs where their responses indicated that children of parents affected by mental illness were the particular targets of the intervention, either directly or indirectly. Indirect strategies included activities such as interagency networks to facilitate effective responses, or working with adult mental health services to identify those clients who have children and what, if any, their support needs might be. Direct strategies were classified as any that worked directly with the child or the parent, including support groups, respite care tailored to their needs, and so on.

Of these 50 programs, 44 responded in time to be included in the analysis. Programs were all targeting those strategies and responses currently understood as most helpful for these children and their parents. This included addressing the needs of the child and/or the needs of the parent, and initiating change at a policy or service level.

Considering the issues identified by the study will help the states and territories continue to move forward in addressing the needs of these children and families. A flexible network of support should be available in our community, which clearly requires a high degree of interagency collaboration. These children and their families are highly individual and have different types and degrees of need at different times, so the type of support required will vary and must be flexible and responsive. These children, and indeed their parents, may present to a wide range of non-mental health agencies, who should be aware of this, know how to respond appropriately and know the resources that are available.

There are a number of challenges to such interagency collaboration that require consideration. Agencies are not always aware that the adult who has a mental illness is also a parent, and they are often concerned about the adult mental health client’s right to confidentiality. The parents themselves may fear that they will lose their children if they indicate they need help. Agencies should also be clearer about their responsibilities, roles and practices.

A number of states have already begun addressing the initial identification of these ‘hidden’ children by asking adult mental health clients on intake whether they are parents. Other positive changes that are underway in some services include developing strategies in adult mental health services that are holistic and family oriented, and reorienting services to prevention of mental illness and promotion of mental health. This will be assisted if adult mental health workers are educated about identifying the needs of children, and of parents with regard to their parenting role, and initiating appropriate referral and liaison with other agencies. Many workers indicated that the amount of time this takes, as well as current record keeping and funding arrangements, are a barrier to working in this manner.

Of the 44 programs located, 21 were able to provide support directly to the child, while the remainder were involved in more indirect strategies. A few were able to provide services that have been identified by parents who have a mental illness as a high priority. These include services such as support and skill development groups for the children, similar groups for the parents, in-home support (for example, immediately after hospitalisation), planned and emergency respite care with consistent caregivers, and supported accommodation. While these types of services are resource intensive, both consumers of adult mental health services and workers from a range of agencies clearly indicated that such services were greatly needed.

While one program had begun to identify the needs of children of migrants experiencing significant mental health problems, the needs of Indigenous communities, and children living in rural and remote areas (as opposed to regional country centres) are yet to be specifically addressed.

Finally, responses indicated that workers acknowledged the importance of using research evidence as a foundation for their practice, and were interested in accessing this type of information. However, workers were hampered by time and resource constraints in identifying and analysing the research, and by the fact that the evidence regarding effective interventions for these children and their parents is scarce. In addition, respondents to the questionnaire did not always have a clear idea about what was meant by the National Health and Medical Research Council’s evidence-based standards. Nevertheless, a high level of commitment to program evaluation indicated that, with expert assistance, there may be opportunities for program providers to participate in further developing the research evidence base by upgrading their program evaluations to contribute this type of research information.

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Recommendations

Some recommendations can be made on the basis of information gathered so far by this scoping project. The following recommendations were developed with the assistance of the reference group for the project, and further refined after consultation with the PPWP and the federal Department of Health and Aged Care. Recommendations are grouped under three headings: mental health services, intersectoral collaboration and research and education.

Recommendation 1.1: An expert multidisciplinary group should be convened to develop and disseminate guidelines for child and adult mental health services on appropriate responses to children with parents affected by mental illness and the parents themselves. The Commonwealth should then publish these standards and encourage their adoption by mental health services.

There is room for improvement among mental health agencies in identifying and responding to the needs of children and parents in families where a parent has a mental illness. An expert multidisciplinary reference group of key professional disciplines in mental health service delivery could be convened to develop these guidelines. An organisation that has a multidisciplinary focus across sectors, such as AICAFMHA, could be contracted to coordinate this consultation and disseminate the guidelines once they are developed.

Endorsement of the guidelines by the National Mental Health Working Group would facilitate their use as part of routine clinical practice for all mental health professionals. These clinical practice guidelines will develop the knowledge base of practitioners and incorporate good practice principles for working with this population, including:

• identifying these children, and all family members (this requirement should be considered in the context of the conclusions and recommendations in the document Toward a national approach to information sharing in mental health crisis situations [2000]);
• assessing for and determining the appropriate response to the needs of these children, including offering or facilitating access to a broad range of support and intervention options in both the mental health and other service sectors, such as family support, peer-support programs, education and so on;
• determining parents’ needs and assisting parents in accessing resources to support them in their parenting role, such as peer support, and respite and in-home support;
• clearly identifying and allocating case-management responsibilities for families containing a parent affected by mental illness, particularly where a number of agencies are involved;
• supporting generic agencies in providing service responses tailored to the special needs of these families (possible strategies are described under recommendations on intersectoral collaboration below); and
• ensuring that the rights and confidentiality of all family members are addressed and protected.

To ensure rapid uptake of protocols and clinical guidelines, an active dissemination and communication strategy must be implemented. This should be a multilevel strategy and include booklets on the guidelines, dissemination via electronic media and presentations at conferences. Appropriate networks could be contracted to develop and implement these dissemination strategies, for example, AICAFMHA, the Mental Health Council, and the Annual Mental Health Services Conference of Australia and New Zealand (THEMHS).

The scoping study indicates that there are currently few programs across Australia that directly address the needs of children with parents affected by mental illness, and indirectly support the children by assisting their parents in their parenting role. A focus on developing such programs would be complementary to the implementation of the guidelines and strategies developed under Recommendation 1.1, and meet a current need in the community.

Recommendation 2: Intersectoral collaboration

The scoping study highlighted the fact that children with parents affected by mental illness have different needs and issues, and may never present to a mental health agency. They may instead come into contact with other agencies, where opportunities to respond appropriately to their needs — either within that agency or through referral to more specific services — may not be recognised, and the children continue to be ‘hidden’. The following recommendations address this issue.

Recommendation 2.1: Mental health services should take a leadership role in developing protocols, linkages and coordination across all sectors involved with children. This collaboration would aim to help other agencies identify and respond appropriately to children who would benefit from support as a result of a parent’s mental illness.

Children may present with issues related to their family circumstances to general health services, general practitioners, and welfare, family court and education sectors. Collaboration across these sectors by mental health services would be facilitated by the development of the guidelines suggested in Recommendation 1.1 and through the endorsement of the PPWP. Commitment to and implementation of this collaborative approach should be facilitated and required at all levels of management and service delivery (federal, state, organisational and individual) and be directed to all levels of intervention (child, parent and family, and organisational service and policy).

Both federal and state and territory mental health agencies are in a position to raise awareness and educate the agencies that are likely to come into contact with the children and their parents regarding identification and appropriate responses. Dissemination of information on their needs to mental health agencies, and agencies with which mental health agencies will be developing linkages, will assist in uncovering these ‘hidden’ children and families. Dissemination strategies could include presentations at conferences, state-based consultations and education activities, professional and continuing education courses, and web-based strategies. Appropriate networks could be contracted to develop and implement these dissemination strategies.

Recommendation 2.3: State and territory mental health agencies should investigate strategies for educating and supporting all agencies or organisations who are likely to come into contact with parents who have a mental illness and their children about the special needs of these clients.

These activities should involve establishing collaborative strategies to assist agencies to meet these families’ needs. Strategies could include presentations at conferences and meetings of peak bodies, and targeted mail-outs of information.

 

Recommendation 2.4: Barriers to appropriate and collaborative service delivery for children with parents affected by mental illness should be clearly identified, along with practical strategies for overcoming these.

A number of barriers to collaboration between mental health services and other sectors have already been identified by this report, and more may exist (O’Donovan, 1994; Cuff & Pietsch, 1997a; Einfeld & McLaughlin, 1998; McEnroe, 1998; Cowling, 1999; Farrell et al, 1999; and Kalucy & Thomas, 1998). Any development of guidelines or strategies arising from Recommendation 1.1 should address these barriers. Strategies for identifying the barriers and possible solutions could include a face-to-face consultation with key sectors at a state and federal level on this issue, or further indirect consultations utilising the scoping study methodology. In addition, professional development within mental health services could focus on skills needed to achieve successful interagency collaboration and solve problems.

Recommendation 3.1: The nature of mental health practice should be examined by a multidisciplinary reference group of key mental health professionals with a view to reorienting it to support the clinical practice guidelines identified by Recommendation 1.1.

Current practice within most adult mental health services are characterised by an individualistic and ‘medical’ model. This approach does not help practitioners provide a holistic family-friendly approach that better supports the children, spouses, other family members and parents with mental illnesses themselves. A reorientation of the services should also ensure that data collection identifies children of adult clients (including direct carers) of adult mental health services, and acknowledges service activities related to providing support to, and involving the children and their parents in, mental health promotion and prevention activities.

A number of Australian reports by federal and state funding bodies regarding support for children with parents affected by mental illness already exist and include recommendations that, given their recent nature, are likely to be relevant. These recommendations should be collated and examined to clarify why they have not been implemented.

 

Time constraints incumbent on mental health workers make it difficult for them to access and analyse current research evidence related to the needs of children with parents affected by mental illness and their families. If they do have time to carry out this work, it may represent a duplication of effort as few reviews appear to be published. An organisation such as the Department of Health and Aged Care could contract AICAFMHA to develop such a resource, and make it available nationally.

Most of the programs to support children with parents affected by mental illness indicated that they were engaged in evaluation activities, but that these activities are not research based and will not contribute to the evidence base for this area of practice. States and territories could consider strategies such as collaboration with universities or government health research units to maximise opportunities to further develop the sparse research evidence available on successful interventions for these children and their families.

Experience in Victoria has indicated that the strategy of promoting and sharing knowledge of ‘good practice’ programs has assisted in further development of programs and strategies for children with parents affected by mental illness in that state and around Australia. First, the information regarding programs and practices gathered by this scoping study should be disseminated. It is recommended that this type of information be shared across Australia through as many avenues as possible, for example, in conference presentations and by placing information on the AICAFMHA website. A mechanism for continued peer review and updating of these programs on the AICAFMHA website would greatly facilitate networking and development of support.

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Last Modified: 11-12-2002 16:36:25