After examining the assigned readings, complete Adult DSM 5 Self-rated Level 1 Cross-cutting Measure (link found in the Week 9 Books and Resources). Submit a discussion post that addresses the following questions: What did you learn about yourself after completing the assessment?Describe your understanding of the Cross-cutting symptom measures, noting at least two main advantages of this type of assessment. Cite at least three specific challenges presented by comorbidities and how you, as an MFT, will be able to address these challenges. Include references to the assigned readings. Length: 350-400 words



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Child and Adolescent Mental Health Volume 17, No. 3, 2012, pp. 153–160
doi: 10.1111/j.1475-3588.2011.00622.x
Engaging with, and understanding children whose
parents have a dual diagnosis
Andrea Reupert,1 Melinda Goodyear2,3 & Darryl Maybery2
Monash University, Faculty of Education, PO Box 6, Clayton, Victoria 3800, Australia. e-mail: andrea.reupert@
Department of Rural and Indigenous Health, School of Rural Health, Monash University, Moe, VIC, Australia
The Bouverie Centre, La Trobe University, Brunswick, VIC, Australia
Background: The perspective of children whose parents have a mental health and a substance use disorder
(dual diagnosis) are rarely considered in either research or clinical practice. This study sought to (i) identify the
issues when engaging children whose parents have a dual diagnosis into research, and (ii) present their needs
and preferred supports. Method: Semi-structured, qualitative interviews were conducted with 12 children
whose parent had a dual diagnosis. Analyses involved thematic analysis, inter-rater reliability and respondent
validation. Results: Building trust with parents was crucial to gain access to children. Children described the
importance of family, the secrecy around their parentÕs substance abuse, and various maladaptive coping
strategies. Children requested more positive times in their families and specific support for their parentÕs
substance abuse. Conclusion: The primacy of family in the childÕs life is highlighted. The need to acknowledge
and work with the individual needs of children and parents, as well as family dynamics, is indicated.
Key Practitioner Message:
• Children living with a parent with a dual diagnosis are prevalent though largely neglected in research and
• Engaging with parents in a meaningful manner is necessary before approaching children to participate in
research about sensitive topics
• Children require support in developing adaptive coping strategies and their parent needs specific support
to address his/her substance abuse
• Practitioners need to encourage parents to acknowledge the impact of their substance use on children
• Practitioners should promote positive events and interactions within the family when a parent has a dual
Keywords: Family functioning; mental health; parent–child interaction; parent–child relationships; parental
alcohol use
It is difficult to obtain the prevalence of children
whose parent has a dual diagnosis (co-morbidity of
mental disorders and substance use disorders)
though related statistics would suggest that it is high.
The Office of Applied Studies (2009) found 11.9% of
US children live with at least one parent who was
dependent on or abused alcohol or an illicit drug
during the previous year. Maybery and colleagues
(2009) found that 21-23% of children have a parent
with a mental illness. Conners et al. (2003) showed
that depression (40%), psychological trauma (11.5%)
and bipolar disorder (6.7%) were the most common
mental health issues reported by women seeking
treatment in 50 residential substance abuse treatment programs for pregnant and parenting women.
Collectively, such data indicate that young people who
have a parent with a dual diagnosis are a highly
prevalent group within the community.
Several quantitative studies have examined the
impact of a parentÕs dual diagnosis on children
(see Chassin, Rogosch, & Barrera, 1991; Dierker,
Merikangas, & Szatmari, 1999; Hans, Bernstein, &
Henson, 1999; Luthar et al., 1998; Stanger et al., 2002).
For example, Luthar and Sexton (2007) investigated the
impact on children of substance abuse and affective/
anxiety disorders across four groups of mothers (diagnoses of substance use only, affective/anxiety disorder
only, dual diagnosis, and neither). They found that a
psychiatric diagnosis was one and a half times as high
among children in the maternal affective/anxiety only
group as well as in the dual diagnosis group compared
to the neither group. However, children whose mother
had a substance use disorder only did not differ significantly from the control (neither diagnosis) group.
Further analyses of the same data set showed mothersÕ
stress and negative parenting behaviour (hostility,
rejection, neglect, and lack of warmth) were more likely to
be implicated in childrenÕs adverse outcomes than
 2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
Andrea Reupert et al.
maternal substance abuse and psychiatric disorder.
Such data highlight the importance of a contextual
approach when examining the issues for such families.
We have not been able to locate any studies that
consider the perspectives of young people living with a
parent with a dual diagnosis and that provide them with
a voice about their needs and issues. The lack of
research mirrors also the lack of service provision.
Psychiatric and other mental health staff generally work
in a client centred manner, often without considering
clientsÕ parenting responsibilities or the needs of
dependent children (Maybery & Reupert, 2006). While
there are several specifically designed programs for
those with a dual diagnosis (Barreira et al., 2000; Drake
et al., 2001; Tiet & Mausbach, 2007; Timko, Dizon, &
Moos, 2005), these typically focus on the client alone,
with little or no acknowledgement of dependent children. Programs that do acknowledge a clientÕs family
tend to focus on adult family members and not children
(Barrowclough et al., 2001; Mueser & Fox, 2002).
Qualitative research with children living in similar
contexts provides an indication of some of the issues for
these children. Several interview-based studies with
children whose parents have a mental illness have
highlighted disruptions in the parent-child relationship, due to the parent being hospitalised and/or the
child being involved in the parentÕs delusions (Maybery
et al., 2005; Mordoch & Hall, 2008). Studies have found
that some young people have several misconceptions
about their parentÕs mental illness, for example, blaming themselves for their parentsÕ illness, or worry about
ÔcatchingÕ the illness themselves (Cooklin, 2006; Fudge
& Mason, 2004; Mordoch, 2010; Stallard et al., 2004).
Another related group of research has investigated the
perspectives of children whose parents abuse either
alcohol and/or drugs. One of the main themes is the secrecy and denial around the parentÕs drug use, with the
resulting message being Ônot to talk about itÕ within the
family nor to Ôtell othersÕ outside of the family (Barnard &
Barlow, 2003). As a result, many children are intensely
loyal to their parents but at the same time shamed by, and
actively dislike, their parentÕs drug taking behaviour
(Backett-Milburn et al., 2008; Barnard, 2005; Barnard &
Barlow, 2003; Fraser, McIntyre, & Manby, 2009; Moe,
Johnson, & Wade, 2007; Orford, Krishnan, & Velleman,
2003; Templeton et al., 2009). A breakdown in family
relationships and conflict, at times escalating into violence and abuse, are other features seen in families where
a parent abuses alcohol/drugs (Kroll, 2004).
There are overlaps with both groups of children
including the caring responsibilities these young people
assume, for themselves, their parents and/or siblings
(Kroll, 2004; Maybery et al., 2005; Moe et al., 2007), in a
process that Aldridge and Becker (2003) described as
ÔparentificationÕ. The stigma associated with family
members who have mental illness or substance abuse
problems (Bancroft & Wilson, 2007; Reupert & Maybery, 2007) is another shared characteristic, as too are
the disruptions to family relationships (Barnard &
Barlow, 2003; Kroll, 2004; Mordoch & Hall, 2008).
Different ways of coping or reacting to their parentÕs
mental health or substance abuse have also been documented, including anger, worry, depression or acting
out (Barnard & Barlow, 2003; Mordoch & Hall, 2008).
Finally, being hyper-vigilant and always on guard are
Child Adolesc Ment Health 2012; 17(3): 153–60
features some have identified in both groups of children
(Repetti, Taylor, & Seeman, 2002).
In order to develop appropriate interventions and
supports, it is important to know how the experiences of
children who have a parent with a dual diagnosis might
differ from other young people. We have not been able to
identify a study in which the voices of children living
with a parent with a dual diagnosis have been shown.
Service decisions, however, will be better informed and
more likely to be utilised if the views of young people are
heard and their views genuinely considered. As the
difficulties in accessing a sample of children living with
parents who are substance abusers has been highlighted (Barnard & Barlow, 2003; Kroll, 2004), another
aim of this project was to document the methodological
considerations when engaging childrenÕs participation
in research. The aim therefore of this study is to document the process of engaging with young people who
have a parent with a dual diagnosis, and present their
experiences and preferred supports.
The research was informed by childrenÕs rights, as
highlighted by the United Nations Convention of the
Rights of the Child (United Nations, 1989, p. 4): Ô… the
child has the right to express his or her opinion freely
and to have that opinion taken into account in any
matter or procedure affecting themÕ. Accordingly, it was
important to not only engage with children but to
actively listen to what they had to say about their
individual circumstances. While it was acknowledged
that childrenÕs lives are constrained and influenced by
the adults in their lives, children were regarded as
having the ability to shape their social worlds and
as capable of saying whether or not they wanted to be
involved in the research (Prout, 2002).
Theoretically, the research is interpretive, and
presents the lived experiences and meanings of children regarding their families, as interpreted by the
researchers involved in the project. Reflecting this
interpretive framework, in-depth, one-to-one, semistructured interviews with children were employed to
collect the data, followed by respondent validation
(Kitto, Chesters, & Grbich, 2008), to allow for the
negotiation of meaning between child and researcher.
The young people interviewed in this project were
recruited through Northern Kids Care: On Track Community Programs, in Northern New South Wales,
Australia, an organisation that specifically delivers
services to families where a parent has a dual diagnosis.
Families included those who had:
1. Dependent children currently living at least 20% of
the time with parent/s;
2. A parent with a diagnosed dual diagnosis
(co-occurring mental health and substance abuse
3. The parent had or was in the process of developing
a Mental Health Plan (meaning that parents
acknowledged mental health and alcohol/drug
abuse issues); and
 2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health.
4. Children knew that their parent had mental health
and alcohol/drug abuse issues.
Ethics was obtained by university committee to
interview children aged between 8 and 18. To be eligible
in the current study, first parents and then their children had to provide consent. Consequently, where the
parent was very unwell and/or hospitalised, the children were not eligible for involvement.
This study was part of a broader study that investigated the needs of parents with a dual diagnosis
(in preparation). In the first instance, parents were
informed about the two components of the project at a
monthly parent support meeting run by the service. We
found that whilst many parents were happy to participate themselves, we initially received very few consent
forms from parents for their children to be involved.
Hence the interviewer (MG) started with the parent
interviews. It was found that once parents had been
through the interview process themselves, developed a
relationship with the interviewer and felt comfortable
about the process (including the opportunity to review
transcripts and make changes), they were more comfortable about giving permission for their children to be
involved. We need to be clear, however, that parents
were not reminded during the interviews, or coerced in
any way, about involving their children in the study.
Thus, building rapport and engagement with parents is
crucial; it should also be stressed that the engagement
with parents was not tokenistic but involved regular
and meaningful discussions about the research process and getting to know the interviewer in a relaxed,
though professional, manner. This building of trust
was far more involved than merely explaining the
research process and providing information sheets,
and meant that parents experienced firsthand the
collaborative nature of the interviews.
Nonetheless, there were still a sizable minority of
parents who did not want their children to be involved.
The 12 parents interviewed had in total 24 dependent
children. Among this group, 4 parents did not provide
consent to interview their 10 children, resulting in 14
children eligible for participation in the current study.
Some parents were not keen for their children to discuss what they considered to be Ôfamily problemsÕ to
ÔoutsidersÕ. Other parents believed that the process
would be too distressing for their children. On occasion,
some parents and their children were not able to attend
pre-arranged appointments because of what else was
happening in their lives (for example, eviction or subsequent periods of hospitalisation). Moreover, two
children did not want to be interviewed, even though
their parents had provided consent. Finally, finding
appropriate interview times could be problematic as all
young people were seen out of school time or on school
holidays, for privacy reasons.
Children whose parents have a dual diagnosis
asked questions about their parent and family life. We
ascertained childrenÕs prior knowledge and readiness to
participate from their parent and the case worker.
The interviewer discussed the project individually
with children, provided sample questions and answered
childrenÕs questions. We were also clear about the
possibility of children becoming upset or uncomfortable
when discussing family issues. To ensure that potential
participants felt in control of the process, they were
told, ÔYou donÕt have to be involved in this interview if
you donÕt want to be, no one will be angry with you if
you decide you donÕt want to do itÕ (as recommended by
Abramovitch et al., 1995). Children were clearly
informed that involvement in the study had no impact
on services. Issues of confidentiality were openly discussed at the recruitment phase and children were told
that unless he or she was at risk or of harming someone
else, no one, including their parents, would have access
to what they said. No disclosures arose in the interviews
that required notification.
In this study, young people were repeatedly told that
they were the ÔexpertsÕ in their lives, and that the
interviewer hoped to learn from them (as per Singh,
2007). To build on the child-interviewer rapport already developed during recruitment, the interviewer
found something to connect herself to each child and
gave information about herself and so in this way was
first a social person and, second, a professional with
a distinctive and genuine purpose (Docket & Perry,
2007). Given the potentially distressing subject matter, the interviewer was sensitive to the verbal and
non verbal cues of the young people, knew when to
probe and when to back off, to offer further assistance
and assurances and/or other professional support. At
the conclusion of each interview the young person
was debriefed and asked whether they had any concerns or wanted any additional support. Support
personnel were available if needed, but were not requested.
The interviews were semi-structured with questions
around ÔWhat it is like to live in families such as yours?Õ
Interviews varied in length and content depending on
the age of the child and what they were most interested
to discuss. Initial questions were open ended about
their family; however, if the child did not raise issues
directly related to their parentÕs dual diagnosis, the
interviewer openly asked: ÔSome families have additional issues when a parent has a mental illness and
abuses drugs or alcohol. What has been your experience?Õ We believed that this prompt provided permission for children to talk about these issues but was
vague enough so that children did not feel coerced into
discussing family matters if they did not want to.
Informed consent
Whilst others have discussed the importance of children
fully appreciating what research participation entails
(Alderson, 1995; Cree, Kay, & Tisdall, 2002; Lind,
Anderson, & Oberle, 2003; Masson, 2000), in this study
informed consent meant that eligible children already
knew that their parent/s abused alcohol/drugs and had
a mental health issue, and understood they would be
ChildrenÕs demographics
The individual demographics for each of the children
interviewed are outlined in Table 1. There were several
sibling groups involved in the study, and parents had a
range of mental health issues and substance abuse
disorders. Diagnoses for parents and children were
obtained from the parent and confirmed by the case
 2011 The Authors. Child and Adolescent Mental Health  2011 Association for Child and Adolescent Mental Health.
Andrea Reupert et al.
Child Adolesc Ment Health 2012; 17(3): 153–60
Table 1. Demographics of children interviewed
Child Gender Age
Child’s mental
Parent’s mental
illness diagnosis
eating disorder,
Australian PTSD and anxiety
anxiety, self-harm
None identified
None identified
None identified
Diagnosed with
anxiety disorder
None identified
None identified
Mother: bipolar
None identified
None identified
Mother: bipolar
Australian and depression
None identified
None identified
Australian depression
Australian depression
None identified
substance use
Mother: painkillers;
past narcotic abuse
Step father: bipolar Step father: marijuana
Australian and ADHD
and alcohol
Aboriginal Father: bipolar
Father: marijuana
and ADHD
and alcohol
Australian schizophrenia
Father: alcohol
and marijuana
Mother: anxiety,
Australian depression, OCD,
Mother: marijuana,
past heroin use
Mother: bipolar,
Australian PTSD, anxiety and
panic attacks
manager. Ten of the children lived with their parent full
time, while two siblings lived with their parent 50% of
the time.
Data analysis
Data were analysed according to Interpretative Phenomenological Analysis (IPA: Smith, 1996; Smith &
Osburn, 2004). IPA is an approach that seeks to identify
participantsÕ lived experiences and the meanings that
participants hold for those experiences (Smith &
Osborn, 2004). One of the authors attached labels to
lines or paragraphs of data, and then described the data
at a concrete level (Anfara, Brown, & Mangione, 2002).
Focused coding followed, which moved the coding
process to a conceptual level, from which categories
were created and named (Constas, 1992). At this point,
the identified categories and original transcripts were
shown to each child, in another interview (respondent
validation: Kitto et al., 2008). Children were invited t …
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