GEMS edition 4
- Author: Dr Stefan Gruenert
- Series editors: Andrea Reupert and Darryl Maybery (Monash University) on behalf of the Australian COPMI national initiative.
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- There is lack of research on children whose parents have a Dual Diagnosis (DD).
- It is estimated that 23% of Australian children live in households where at least one parent has had a mental illness, 13% are exposed to a regular binge drinker, 2.3% live with a daily cannabis user, and 0.8% live with a monthly amphetamine user.
- Parents with a DD may experience other problems such as domestic violence, relationship breakdown, social isolation, poverty, and housing instability.
- Compared to other children in the community, children whose parents have a DD are at higher risk of abuse and neglect, being placed in care, and developing their own mental health, behavioural and substance use problems.
- Parents with a DD face multiple barriers in accessing services such as exclusion, fear of child removal, and lack of childcare and family-focused programs.
- Services are rarely offered directly to children, while existing family focused services in the adult treatment sectors are geographically patchy.
- Comprehensive, flexible and integrated treatment and support services are required for both parents and children in multi-problem families. Available evidence suggests that interventions should focus on parent-child relationships, worker engagement, and parent support that is tailored, goal focused and strengths-based.
Dual Diagnosis (DD) commonly refers to the co-existence of a psychiatric and a substance use disorder in an individual.1 DD is not uncommon, with up to 80% of people accessing drug treatment services also having a mental health disorder and around 30% of people accessing mental health services thought to have a substance use problem.2 Among Australian children it is estimated that:
- 23% live in households where one parent has had a mental illness3
- 13% (under 13 years) are regularly exposed to a binge drinker
- 2.3% live with a daily cannabis user
- 0.8% live with a monthly amphetamine user.4
In Victoria’s child protection system, it is estimated that 33% of substantiated cases of neglect or abuse involve drug misuse, 31% alcohol misuse, and 19% mental health problems.5 As a consequence of child protection involvement, children from multi-problem families are at higher risk of entering care earlier and staying in care longer.6 However, the experience and impact of a DD varies considerably depending upon the severity and chronicity of the mental illness and the amount and regularity of alcohol or drug use.
Parenting with a DD and the impact on children
Those with a DD may also experience other issues including poorer coping strategies, domestic violence, higher rates of offending and imprisonment, isolation, poverty, and housing instability.7 Together, these issues can impact on a parent’s capacity to respond to their children’s physical and emotional needs, reducing availability for adequate supervision and parenting sensitivity - factors important for the development of secure attachment.8 In addition to any in-utero exposure to substances,9 having a parent with a DD appears to have a cumulative effect on children, increasing the risk of birth complications, developmental delays, school failure, acting out, depression, suicide and a child’s own substance use problem.7, 10
Evidence of how best to reduce the impact of parental DD on children remains unclear. Common but untested strategies include:
- Reducing DD itself through community prevention and better co-ordinated treatment11
- Mainstream family support programs
- Targeted approaches aimed at reducing drug or alcohol, and mental health problems among parents
Interventions designed for children whose parents have a DD aim to decrease the multiple risk factors associated with their families while enhancing the protective factors necessary to strengthen children’s resilience and coping skills.10 Promising interventions are intensive, holistic, home-based and family focused, running concurrently with parental treatment. Such programs, with small case loads and appropriate funding, have recorded shortterm reductions in drug use and the risk of child maltreatment, and improvements in maternal psychopathology, problem solving and communication.12, 13
Unfortunately, outcome studies for generic family home-visiting or parenting programs typically exclude DD, while those that have targeted substance misusing families have found no or minimal improvements in parenting, and no or minimal reduction in the risk to their children.8 Evidence does suggest that adult focused parenting or treatment-only approaches have their greatest impact on children under about 8 years of age.8
Barriers to service access
Unfortunately, along with the complexity of the DD and its effects, parents with a DD are less likely to access treatment due to:
- Problems often being chronic and prone to relapse
- Lack of childcare or family focused programs
- Fear of stigma and the removal of children
- Parental secrecy around drug use, especially illicit drug use9
While a few services across Australia do offer support to parents with either a mental health or a drug or alcohol problem, they are rarely well integrated with each other and tend to be geographically patchy.4 Few offer support directly to children whose parent has a DD.14 To be effective in reducing the impact of parental DD on children, treatment services need to be systematically funded and integrated to offer family-focused treatments that are flexible (accommodating periods of wellness and relapse) and focused on both the adult’s parenting and treatment needs, and the safety and developmental needs of their children.15
There is a clear gap in the evidence and practice regarding children whose parents have a DD.10 None of the interventions described in the literature report rigorous outcome studies. Consequently, conclusions drawn here are based on a simple integration of the separate literatures on either substance dependency or mental illness and should be viewed as hypotheses at this stage.
- Rassool, G.H. Substance misuse and mental health: an overview. Nursing Standard. 2002; 16(50): 47-53.
- Teesson, M., Burns, L., & National Drug and Alcohol Research Centre. National Comorbidity Project. Canberra: Commonwealth Department of Health and Aged Care; 2001.
- Maybery, D.J., Reupert, A.E., Patrick, K., Goodyear, M. & Crase, L. Estimating the prevalence of Australian families and children where there is a parental mental illness. Psychiatric Bulletin. 2009; 33: 22-26.
- Dawe, S., Frye, S., Best, D., Lynch, M., Atkinson, J., Evans, C., & Harnett, P.H. Drug use in the family: Impacts and implications for children. Australian National Council on Drugs; 2007.
- Department of Human Services. An integrated strategy for child protection and placement services. Melbourne: Community Care Division; 2002.
- Semidei, J., Radel, L. F. & Nolan, C. Substance abuse and child welfare: Clear linkages and promising responses, Child Welfare. 2001; 80(2):109-28.
- Heggarty M. Supporting Children Affected by Parental Dual Diagnosis, Auseinetter. 2005: 25(3): 21-26.
- Dawe, S. Harnett, P, & Fry, S. Improving outcomes for children living in families with parental substance misuse. Child Abuse Prevention Issue. 2008; 29: Australian Institute of Family Studies.
- Gruenert, S., Ratnam, S., Tsantefski, M. The Nobody’s Clients project: Identifying and addressing the needs of children with substance dependent parents. Odyssey Institute of Studies; 2004.
- Finkelstein et al. Building resilience in children of mothers who have co-occurring disorders and histories of violence: Intervention model and implementation issues. Journal of Behavioral Health Services & Research. 2005; 32(2): 141-154.
- Minkoff, K. Developing standards of care for individuals with co-occurring psychiatric and substance use disorders. Psychiatric Services. 2001; 52(5): 597-599.
- Catalano, R. F., Gainey, R. R., Fleming, C. B., Haggerty, K. P., & Johnson, N. O. An experimental intervention with families of substance abusers: One-year follow-up of the focus on families project. Addiction. 1999; 94: 241–254.
- Dawe, S., & Harnett, P. H. Improving family functioning in methadone maintained families: Results from a randomised controlled trial. Journal of Substance Abuse Treatment. 2007; 32: 381–390.
- Dawe, S., Harnett, P.H. Improving family functioning in methadone maintained families: Clinical opportunities and challenges. Drug and Alcohol Dependence, 2000; 60: 1-13.
- Cowling, V.R., McGorry, P. D. & Hay, D.A. Children of parents with psychotic disorders. Medical Journal of Australia. 1995; 163: 119-120.