Children living with a mentally ill parent: the role of public health nurses.
Abstract: Public Health Nurses work with children under 18 years in schools and the community. Increasingly children are living with a parent suffering from a mental illness. Consequently Public Health Nurses are encountering more mental illness as part of their practice. The research reported in this article aimed to identify the Public Health Nurse's role with regard to children in these circumstances. A qualitative research design was used with eight Public Health Nurses working in rural and urban settings. Participants engaged in a focus group from which data were gathered and analysed thematically using axial coding. To evaluate the identified themes six of the participants went on to take part in a further focus group. The three key themes identified were Advocacy, Assessment, and Relational Knowing and Clinical Practice. It emerged that the role of Public Health Nurses working with such families involved advocating for the child, using a range of assessment skills to gather relevant information and make referrals, with all informed by expert knowledge and clinical experience. Findings indicate the need for more acknowledgement of the frequency with which Public Health Nurses are encountering problems associated with mental illness; and hence the need for provision of appropriate education and support that will enable them to effectively advocate for children's safety and well- being.

Key Words: Public health nurses, parental mental illness, advocacy, assessment, focus group.
Article Type: Report
Subject: Child care (Research)
Nurses (Research)
Nurses (Aims and objectives)
Author: Mahoney, Laurie
Pub Date: 08/01/2010
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: August, 2010 Source Volume: 26 Source Issue: 2
Topic: Event Code: 310 Science & research; 220 Strategy & planning
Product: Product Code: 9105260 Family Planning & Child Care; 8043100 Nurses NAICS Code: 92312 Administration of Public Health Programs; 621399 Offices of All Other Miscellaneous Health Practitioners
Accession Number: 291701796
Full Text: Public Health Nurses in New Zealand work with children under the age of 18 years and their families in schools and the community. Often they are the first health providers for many children in schools particularly in high deprivation areas. Their role is to promote health and well-being and advocate for children and families (Clendon & McBride, 2001). It is through this role Public Health Nurses come into contact with children who live with a mentally unwell parent.

With the shift from institutional to community care for adults with a mental illness since the 1990s internationally (Cowling, 1999) there has been an increase in the number of children living with a parent who suffers from mental illness. Research over the last three decades identifies children living with a mentally unwell parent are at higher risk of developing psychopathology (Beardslee, Gladstone, Wright, & Cooper, 2003; Beardslee, Keller, Podorefsky, Staley, Lavori, & Shera, 1996; Nicholson & Clayfield, 2004; Smith, 2004), and are at greater risk of abuse or neglect (Beardslee et al., 2003; Foss, Chantal, & Hendrickson, 2004; Nicholson & Clayfield). This article reports research undertaken to identify the Public Health Nurse's role with children who live with a mentally unwell parent.

Literature Review

The incidence of mental illness in society is increasing and the World Health Organisation has identified depression as the leading cause of disability globally (Bayer & Sanson, 2003). There is unequivocal evidence linking parental mental illness with poor psychosocial outcomes for children (Beardslee et al., 1996, Cowling, 1999; Rutter & Quinton, 1984). Children living with a parent with a mental illness have been labelled as invisible or hidden (Cowling; Lancaster, 1999), and research in general ignores the children's perspective (Garley, Gallop, Johnston, & Pipitone, 1997; Mordoch & Hall, 2002). Unless children present with a behavioural or learning problem at school, or parents request support with their children, children's needs and voices are likely to go unrecognised (Ahern, 2003; Mordoch & Hall). Children referred to in this article are of primary school age, between 5 to 12 years.

The specific nature of the parent's mental illness has implications for how it impacts on children's health outcomes. This research is heavily weighted toward the impact of maternal depression on children. The effects of parental depression on children include delays in language development, social and emotional dysfunction, behaviour problems and depression (Ahern, 2003; Beck, 1999; Lancaster, 1999; Smith, 2004; Stevens, 2006). Children of depressed parents are two to five times more likely to develop behavioural problems than other children (Beck; Fergusson & Lynsky, 1993, Smith), are more likely to have accidents at home and to suffer from neglect (Beardslee et al., 2003; Beardslee et al., 1996; Nicholson & Clayfield, 2004). The parenting patterns of depressed mothers are likely to be inconsistent, lax or ineffective, especially with regard to discipline. They are more likely to yield to their child's demands rather than use consistent parenting strategies (Beck).

Conversely, disordered thinking and psychoticsymptoms in parents with schizophrenia lead to lowered parental affect and inappropriate responses to their child who may not understand inappropriate parental responses, such as laughter or staring blankly, when their child is distressed. Blurred parent-child boundaries, impaired or inappropriate communication, and possible developmental delay may occur for the child (Lancaster, 1999). A parent with schizophrenia may also involve their child in their distorted or paranoiac thinking, which may frighten children. Some children of parents with schizophrenia learn to parent themselves and their siblings (parentification), and may take on the role of caring for the parent (Lancaster). Children of parents with alcohol and/or drug dependence are more likely to present with behaviour difficulties, attention deficit and conduct disorders, truancy, delinquency and social and school inadequacy, and may develop problems such as depression and anxiety (Ahern, 2003; Lynskey, Fergusson, & Horwood, 1994).

Prior to 1980, research focused on genetic factors contributing to the vulnerability of children of mentally unwell parents. Since then the emphasis has been on environmental factors. Rutter and Quinton's (1984) seminal work that identified family variables included severe marital discord, low socio-economic status, overcrowding or large family size, paternal criminality, maternal mental disorder and social agency involvement. This is further supported by recent studies linking parental mental disorders and children's psychopathology with parental marital disharmony (Ahern, 2003; Devlin & O'Brien, 1999; Fraser, James, Anderson, Lloyd, & Judd, 2006; Rutter & Quinton; Stevens, 2006), parenting problems, and chronic and severe depression in parents (Beardslee et al., 2003; Fergusson & Lynskey, 1993; Lancaster, 1999; Rutter & Quinton; Smith, 2004; Thomas & Kalucy, 2003). Children with just one of these environmental factors alone are at no greater risk of developing a psychopathology than are other children. However, where two or more variables are present the likelihood of developing a mental illness increases fourfold (Ahern; Stevens).

The Public Health Nurses' Role

Public Health Nurses are New Zealand registered nurses working with schools, children and families in the community. Children are referred to Public Health Nurses when there is a concern for a child's health and, increasingly, if there are concerns about a child's behaviour. Support offered to parents varies from client to client, but includes listening to them, giving realistic information on parenting skills, and assessing the need for an intervention to assist their child. The assessment directly relates to parent identified issues, and is child focused (Kristjanson & Chalmers, 1991). Relevant interventions include referrals to specialist paediatric and child and family mental health services for assessment of psychopathology, and to other child-focused services. However, there is a dearth of literature specifically on the Public Health Nurses' role in mental health. In an international literature review on Public Health Nurses for the World Health Organisation, Edgecombe (2001) stated, "... public health nurses have for many years discussed their role in respect to the care of individuals in mental disabilities, but few studies have been undertaken to examine this aspect of their role in any detail" (p. 6).

With the rise in emotional and behavioural problems in children, secondary mental health services internationally are at breaking point, leaving primary health services to pick up more mental health issues, with their role extending to caring for parents and children with a mild-moderate mental illness. Nurses in primary health have a significant and growing role in primary mental health. Primary mental health includes early identification and referral to secondary mental health services to make a positive difference in child health outcomes (Honeyman, 2007).

Public Health Nurses' practice includes home visiting, placing them in a critical role to assess the risk factors already mentioned for children and families (Appleton, 1994; Baggaley & Keen, 1999; Kristjanson & Chalmers, 1991; Long, McCarney, Smyth, Magorrian, & Dillon, 2001; Murray, Baker, & Lewin, 2000). Home visiting provides the opportunity for nurses to identify and provide support for parents, and work therapeutically to enhance the parent-child relationship and develop positive parenting skills (Cohen & Reutter, 2007; Long et al.; Smith Battle, Diekemper, & Leander, 2004).

This research arose from my enquiry into identifying the Public Health Nurses' role in primary mental health, and in particular the effect of parental mental illness on the Public Health Nurses caseloads. The research question asked was, "What is the Public Health Nurse's role with children who live with a parent with a mental illness?" The research aimed to: (a) identify trends in the Public Health Nurses' work where parental mental illness had an impact on their caseload, (b) determine how Public Health Nurses identified when a parent was mentally unwell, and if so what their role was, and (c) articulate Public Health Nurse practice in the primary mental health setting.

Design and Method

Qualitative research design using focus groups as the method of data collection was identified as the most appropriate to answer the research question. According to Kitzinger (1995) and Krueger (1994), focus groups are an effective method to generate data, and are useful for discovering how people think and talk about specific issues (Ivanoff & Hultberg, 2006).

Participants.

The number of participants in focus groups is determined by the aim of the research, with the optimum number being six to twelve (Krueger, 1994). Therefore, to capture the participants' depth of knowledge, at least six to eight participants were necessary. Nurses practising for more than one year were included in this research, to gain an understanding of the participant's knowledge and experience. Public Health Nurses working in other areas of population health were excluded. For instance, those working in the area of hard to reach immunisation, because their role is targeted to immunisation rather then general child health issues. Nurses in supervisory or management roles were also excluded to avoid any power relationships influencing the participants' contributions (Krueger). The time required to travel to the focus group meetings was restricted to between 1 to 2 hours. This enabled equal representation from both urban and rural practice at the focus group meetings.

Once ethical approval was gained, recruitment of participants commenced. To protect initial anonymity the primary care manager agreed to be the conduit between the researcher and the participants. The manager sent invitations to all potential participants. Ten potential participants made contact with the researcher, and eight agreed to participate. Two focus group meetings were held with the first meeting being face-to-face with all eight participants attending. The second focus group meeting was held by means of teleconference. Six of the original participants took part in this.

Data collection.

Krueger (1998b) stated data collection and analysis should occur simultaneously, claiming analysis of data occurs on a continuum (Figure 1), starting at the collection of raw data and finishing at recommendations. As described above most participants took part in two focus groups. The aim of the second meeting was to verify the data and the thematic analysis arising from the first focus group meeting (a strategy suggested by Krueger (1994)).

[FIGURE 1 OMITTED]

Krueger (1994) suggested that a set of up to twelve open-ended questions was ideal to elicit the participants' ideas and opinions. Questions were sequenced to allow maximum insight, using them to lead participants into the topic and providing an opportunity for them to share opinions, and to listen to the opinions of other participants (Krueger). This purposive facilitation of the focus group discussion, suggested by Jamieson and Mosel Williams (2003), Krueger (1998a), and Waldegrave (2003), optimised participants' opinions being elicited. The discussion flowed freely with participants sharing their opinions and experiences. While they generally agreed with each other, divergent opinions and experiences were also evident.

Raw data took a number of forms. First, an electronic reflexive journal was kept by the researcher. This journal allowed for a continual critical reflection on the process, on my own knowledge, beliefs and values and how these influenced this research (Koch & Harrington, 1998). Second, notes were taken during both meetings. Third, the first focus group was audio-taped and transcribed verbatim. The second focus group was not recorded due to equipment failure, although extensive notes were taken at the time, and were used as data.

Data analysis.

A systematic approach was used to interpret the data (Krueger, 1998b). A process of repeated reading and listening to the transcripts simultaneously allowed immersion in the data (Fereday & Muir-Cochrane, 2006; Jamieson & Mosel Williams, 2003). Several copies of the transcript were made electronically allowing for axial coding (Krueger). During axial coding the data were fractured and reassembled to identify the themes (Krueger). An original copy of the transcript was kept, while a second copy was formatted into two longitudinal halves, to enable one to two words coding on a line-byline basis. By the end of this stage, emerging themes could be identified. On a third electronic copy of the transcript, quotations representing the themes were identified and colour coded. Finally, the colour coded quotations were cut and pasted together allowing for comparison and contrasting of the data. Following the axial coding, findings were sent to all participants with a covering letter inviting them to consider whether the main themes had been captured, and whether these represented the focus group conversation.

Rigour.

Data verification was used to establish rigour for the study, and occurred when, "... another researcher ... arrive[d] at similar conclusions using available documents and raw data" (Krueger, 1994, p. 129). This process was achieved by establishing a trail of evidence, and undertaking a rigorous process for analysis of the data (Koch, 1994). The first step in verifying data occurred at the end of both focus groups when the participants were offered a final opportunity to make a statement confirming their perspective (Tuckett, 2005). The second step, arose from in-depth reflective notes which were compared with the transcripts while analysing the data (Tuckett). Finally, participants were asked to verify the accuracy of transcripts, thematic analysis, and selected data excerpts. These were sent to the individual participants for verification of the themes arising from the first focus group and accuracy of the intent of the quotations. This was a process suggested by Krueger (1998b), and was the purpose of the second focus group. Verification was achieved by individuals, and by participants collectively at the second focus group.

Findings

Three key themes emerged from the focus group data. These were Advocacy, Assessment, and Relational Knowing and Clinical Practice. In addition, a position was developed outlining the role of Public Health Nurses when working with a family where a parent has a mental illness. Public Health Nurses' contact with children is generally in schools through an education or observational role, or when causal or purposive contact is made when the Public Health Nurse is in the school environment--for instance, school-based immunisation. Public Health Nurses do not usually work directly with children in a therapeutic manner. This position was affirmed by the participants, with a slight change to the wording to make it clear that Public Health Nurses, while their focus was on the child or children, worked with the families, rather than individually with a parent or a child or children.

Advocacy.

In the context of this study, advocacy means advocating or pleading for the rights of children living with a parent with a mental illness for better health outcomes. It occurs at an individual and a policy and political level. The Public Health Nurse's role in advocacy aims to enhance the resilience of a child, and involves assessing the child's needs, and referring on to appropriate child health agencies. Advocacy encompasses ensuring the school is aware of the wider family situation affecting a child (with parental consent and within the limits of privacy), and ensuring the appropriate support is in place for a child or children at school. Advocacy was seen as a key role for Public Health Nurses, with different participants saying it was a "big part of the job", and stressing that Public Health Nurses "maintain the paramouncy of children". At the same time one participant reminded everyone, "it is important that mental illness does not become an excuse for poor parenting"

Assessment.

Public Health Nurses are required to make accurate and appropriate assessments of the family in a holistic way. According to the participants this role is extending into primary mental health. The identification of potential risks for children hinges on Public Health Nurses' ability to make accurate assessments of children and families, a skill requiring considerable clinical experience. Public Health Nurses often delve under the surface to identify issues within a family that may be impacting on the child. This involves nurses assessing the mental health issues of individual family members, and making referrals to appropriate agencies. One participant referred to this as "looking behind the obvious", while another identified the area of parental mental health as the "swampy lowlands".

Relational Knowing and Clinical Practice.

Many of the participants articulated expert public health nursing practice, although they were also aware of the limitations in their practice and their professional boundaries. Equally important was reflecting on their own perceptions and assumptions about mental illness as indicated by one participant who said, it was "important to be aware of their own perceptions of mental illness". One participant explained coming to understand mental illness with this experience on the cusp of expert practice after Ave years as a Public Health Nurse. Another participant reminded others that without a recognised national certificate in public health nursing practice, all Public Health Nurses come to the position with different knowledge and experience, so working with a parent with a mental illness "has a comfort level that comes from experience".

Discussion

There is strong evidence that children living in a family where a parent has a mental illness are vulnerable (Foster, O'Brien, & McAllister, 2004/05; Handley, Farrell, Josephs, Hanke, & Hazelton, 2001). Public Health Nurses supporting children who live with a parent with a mental illness advocate for the child, and undertake assessment activities. They make sense of the information they are confronted with by using their experience and expert knowledge gained from years of working in the area of public health nursing. Advocacy for children living with a mentally unwell parent may be enhanced through respectful working partnerships with the parents, schools and other appropriate agencies (Handley et al., 2001). This includes ensuring the health issues are addressed with community-based adult mental health services to raise awareness of the needs for the whole family. Devlin and O'Brien (1999), however, suggested agencies working with these families often work in isolation, and called for better case co-ordination and interagency communication.

The role of advocate should extend to fostering resilience in children where there is a parent with mental illness. Fraser and Pakenham (2009) referred to resilience as, "... the ability to respond adaptively in the face of adversity and can be conceptualised as the process by which the harmful or detrimental effects of risk factors are mediated or removed by the influence of protective factors (pp. 573-574)". Public Health Nurses can encourage schools to include education related to developing resilience in children, and improve their mental health literacy by providing information on mental health issues, such as stigma (Cohen & Reutter, 2007; Fraser & Pakenham). Foster et al. (2004/05) stress the importance of working from a strengths basis, and focusing on protective factors in the development of resilience. Nevertheless, the evidence regarding resilience interventions in children with a parent with mental illness is not conclusive. For example, Fraser and Pakenham's study found while some improvement in mental health literacy (knowing about mental illness, and understanding a parent's mental illness), depression and life satisfaction occurred following resilience interventions, these were not statistically significant.

Registered nurses in New Zealand are required to be competent in undertaking assessments in accordance with the Nursing Council of New Zealand's Registered Nurse competencies, under the domains of management of nursing care and interpersonal relationships (Nursing Council of New Zealand, 2007). Participants articulated a high level of assessment skills, using various models such as the HEADSS (Home, Education & Employment, Activities, Drugs, Sexuality, and Suicide/Depression) assessment, which target various aspects of a young person's life (Goldenring & Cohen, 1988), and Family Systems Assessment (Wright & Leahy, 2000). When assessing from a holistic perspective, Public Health Nurses identified the needs of every individual family member, and the family as a whole; which means they work with both individuals and families (Anderson, 2006; Clendon & McBride, 2001; Gallaher, 1999). Hartrick and Lindsey (1995) explained this as recognising the polyphonic voices of the family; listening to the individual voices, stories and experiences of each family member.

The literature establishes that home visiting places nurses in a critical role of assessing the risk and protective factors (Appleton, 1994; Baggaley & Keen, 1999; Honeyman, 2007). Yet, this risks venturing into the "swampy lowlands" described by one participant, a term coined by Schon (1983) when he referred to as knowledge derived from clinical "situations [that] are confusing messes" (p.42). According to Schon knowledge gained through practice is interpretive, practical and contextual, and contrasts the 'high hard ground' of science and theoretical thinking. The "swampy lowlands" is evident when Public Health Nurses delve under the surface to identify issues within a family. Gallaher (1999) referred to this as the 'darker side' of Public Health Nurses' practice. Public Health Nurses delving beneath the surface to peel back the layers is described by Gallaher as, "... a dynamic process which was continuous and based upon the understanding that situations are often more complex than they appear"(p. 21). Interpreting what is found requires experience and expert knowledge.

Smith Battle and Diekemper (2001) maintained clinical and relational knowing comes from practice experience that cannot come from the use of protocols, guidelines and taxonomies. They referred to Benner (1984) to describe how expert Public Health Nurses practice encompasses a "... holistic and finely tuned grasp of clinical situations" (p.401), requiring skilful judgement and practical reasoning. Therefore, a critical relationship between clinical reasoning and clinical experience is undeniable according to Benner. In a study on skill development of Public Health Nurses, relational skills improved with experience, with more-experienced nurses, ". addressing the personhood of the parent" (p.9), rather than attaching blame for the chaotic nature of the family circumstances (Smith Battle et al., 2004).

Given that Public Health Nurses are working with families where a parent may have a mental illness, they require education support to assess and refer to the appropriate services in order to advocate and improve the outcomes for children. It also requires improved communication between primary health and the secondary mental health services, to improve referral pathways. These recommendations were included in a submission to optimise primary mental health care (New Zealand Nurses Organisation, 2010).

The research reported here is a small qualitative study with eight Public Health Nurses, and therefore the use of the findings in other settings should be done with caution. Having said that, the study provides useful insight into an aspect of Public Health Nurses' practice requiring further exploration and discussion. Therefore, further research is recommended with Public Health Nurses working with families who have a parent who has a mental illness. Research is also needed regarding the role of rural Public Health Nurses, as these nurses have specific needs associated with their rural context. They work with a lack of resources to support families where a parent has a mental illness.

Conclusion

Children who live with a parent with a mental illness are at greater risk of developing a psychopathology and of being abused and neglected. With the rise in emotional and behavioural problems in children, Public Health Nurses are detecting more mental health issues, with their role extending to caring for parents and children with a mild-moderate mental illness. This places these and other nurses in primary health in a situation characterised by a significant and growing role in primary mental health. This role in primary mental health includes the early identification and referral to secondary mental health services.

This research examined Public Health Nurses' roles with children who live with a mentally unwell parent. Their practice and role with children, who live with a mentally unwell parent, is primarily advocacy and assessment drawing on expert knowledge and clinical experience.

Children who live with a mentally unwell parent are vulnerable, living in at-risk situations. It has become part of the Public Health Nurse's role to identify the risk associated with parental mental illness for a child or children, and to respond to this risk through effective assessment, advocacy, and referral to secondary mental health services.

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Laurie Mahoney, RN, MN, Public Health Nurse, Southern District Health Board, Dunedin & Senior Lecturer, School of Nursing, Otago Polytechnic, Dunedin
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