The Continuum of Need: Parental mental illness is everyone’s responsibility

  • Author: Dr Adrian Falkov Senior Staff Specialist, Westmead Hospital Director, Redbank House Child Adolescent & Family MH Service
  • Series editors: Andrea Reupert and Darryl Maybery (Monash University) on behalf of the Australian COPMI national initiative.

Quick facts

  • Parental mental health is everyone’s responsibility.
  • Families with mentally ill parents and dependent children will be found across most, if not all, services.
  • The ‘Continuum of Need’ provides a basis for thinking about need along a theoretical continuum, based on the diversity of individuals’ needs within families.
  • Workforce training must help staff adopt a broader family perspective, which combines child safety with parental needs; prevention with acute crisis management and vulnerability with resilience in care and recovery plans.

Research summary

The Continuum Approach

The ‘Continuum of Need’ (CoN) provides a basis for thinking about levels of need along a theoretical continuum, based on the diversity of individuals’ needs within families. At one end, many parents cope exceptionally well, showing warmth, sensitivity and understanding of children’s developmental needs, despite the presence of significant mental health problems. Children show few, if any, adverse effects.

Moving along the continuum, other parents experience greater difficulty in managing the tasks and responsibilities of parenting, despite appropriate treatment and support.6 Their children are at greater risk of experiencing a range of mental health and social problems.7

Children in families with multiple, complex problems will be at greatest risk of harm. This severe end of the CoN also encompasses the small subgroup of children who are killed by parents with severe/complex mental health and associated problems.8

‘Need’ is a dynamic, ever changing factor within the daily ‘lived experience’ of individuals and their families, with substantial variation (in type and magnitude) over time. Some of this variability can also be attributed to resilience. This means that:

  • many parents and their children do well despite adversity
  • mental illness does not automatically imply an inability to parent well and
  • when children have a caring role – this may or may not be harmful.

The Continuum of Need (CoN) Model5

This conceptual CoN model helps staff see the relevance of family-focused approaches regardless of where they work. It does this by emphasising the presence of parents with mental health problems and their children in both adult and child services and by helping staff describe individual/family needs by locating them on the continuum.

Five broad categories of children can be classified within the CoN. Within each of these categories, subgroups of dependent children can be located on the CoN according to service contact status.

1. Children not known to services

This category includes children:

  • who are well (not known to, nor in need of services), born with a particular combination of biogenetic strengths. The ill parent may be coping well, experiencing few environmental stressors and receiving good social support. Identifying these families provides prevention opportunities (psychoeducation) and school-based support, should circumstances change.
  • who are not known to services, but who should be. For example, some infants; children in culturally and linguistically diverse (CALD) groups. The hidden needs of these families present special challenges for improved service access for ethnically, culturally and linguistically diverse families.
2. Resilient children in need of some support

This category includes children:

  • who look after an ill parent. Young carers tend to be resilient and appear well. As a result, their underlying needs are often unrecognised.
  • whose parents are known to adult mental health and primary care services, who do not need specialist referral, and who would benefit from provision of information about parental mental illness and knowing who to call for assistance.
  • attending school where significant opportunities for early identification and support initiatives arise.
3. Children who are vulnerable and in need of services (‘children in need’)

This category includes children:

  • whose parents are known to adult mental health and children’s services.
  • whose parents are being treated in primary care settings.
  • of refugee and minority community parents experiencing mental illness.

Children may not be at immediate risk but they are vulnerable, especially if parental symptoms are chronic and parenting stresses exist. These children constitute a large proportion of children known to mental health services and organizations from the non-government sector. Such children are more likely to show emotional or behavioural difficulties, educational under-achievement, attachment problems and social impairments5 than children in the previous two groups. Provision of timely and targeted support can act as an early intervention measure, enabling the family to avoid a crisis.

4. Children who are vulnerable and in need of services and protection

This category includes children:

  • whose parents struggle to meet their needs, including safety, despite their best efforts and the provision of additional supports. These parents are more likely to have comorbid psychiatric disorders, including substance misuse and/ or personality disorder.5 Child protection procedures will need to be followed and alternative care arrangements considered.
  • who are ‘looked after’ (in out of home care).
  • in families where enduring, comorbid parental illness occurs in conjunction with multiple psychosocial adversities, poor social support and poverty.
5. Children at risk of imminent harm

This category contains the small but significant subgroup of families in which children experience severe maltreatment and are at immediate risk of significant harm. At its most extreme fatalities can occur, although this is rare.8

Working better together

By demonstrating the diversity of individual need within families the CoN approach highlights that no single service will be sufficient. Collaboration and cooperation between adult and child services staff is essential. Effective partnerships are based on consistency of service responses with clear service thresholds and eligibility criteria.

The essential first step to working better together is to identify the location of children, parents and families along the continuum. Workforce training should be provided which helps staff to adopt a broader family perspective, and combines child safety with parental needs; prevention with acute crisis management, and vulnerability with resilience in care and recovery plans.

  1. Maybery JD, Reupert AE, Patrick K, Goodyear M. Prevalence of parental mental illness in Australian families. The Psychiatrist 2009; 33: 22–26.
  2. McLaughlin KA, Gadermann AM, Hwang I. Parent psychopathology and offspring mental disorders: results from the WHO World Mental Health Surveys. British Journal of Psychiatry 2012; 200(4): 290–299.
  3. Hosman C, van Doesum K & van Santvoort F. Prevention of emotional problems and psychiatric risks in children of parents with a mental illness in the Netherlands: I. The scientific basis to a comprehensive approach. Australian e-Journal for the Advancement of Mental Health 2009; 8(3): 2250–2263.
  4. Beardslee W, Gladstone TR & O’Connor EE. Transmission and prevention of mood disorders among children of affectively ill parents: a review. Journal of the American Academy of Child and Adolescent Psychiatry 2011; 50(11): 1098-1109.
  5. Falkov A. The Family Model Handbook: An integrated approach to supporting mentally ill parents & their children. East Sussex: Pavilion; 2012.
  6. Bifulco A, Moran PM, Ball C. Childhood adversity, parental vulnerability and disorder: examining intergenerational transmission of risk. Journal of Child Psychology and Psychiatry 2002; 43(8): 1075–1086.
  7. Dean K, Stevens H, Mortensen PB. Full spectrum of psychiatric outcomes among offspring with parental history of mental disorder. Archives of General Psychiatry 2010; 67(8): 822–829.
  8. Falkov A. Department of Health Study of working together ‘Part 8’ Reports: Fatal child abuse and parental psychiatric disorder. Department of Health ACPC Series Report No. 1; 1996.

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