Multiple layers and contexts

Models of knowledge translation, dissemination, and implementation in health services research routinely depict multiple layers of complexity in the diffusion of new ideas and the uptake of new interventions (Mendel et al., 2008; Proctor et al., 2011). Providers and consumers are nested within care organizations, which are, in turn, influenced by professional networks and communities of practice, organizational networks, insurers, purchasers, interest groups, and regulatory agencies, all within the context of the overarching legal/political environment. In a similar systems model of factors affecting the implementation of evidence-based practices, “outer context” factors include the sociopolitical context (e.g., legislation, policies), funding, client advocacy, and interorganizational networks (Aarons et al., 2011).

Different opportunities and strategies to promote the exchange of ideas and make change happen may emerge in diverse policy and practice contexts (Chaskin, 2008). Key actors in knowledge utilization include state-sector players (e.g., policymakers, administrators, program managers, and practitioners), members of the scientific community (e.g., researchers, research funders), and actors in civil society (i.e., practitioners, advocates, service users, policy entrepreneurs, the media, and citizens). These individuals participate in the process of developing, exchanging, and implementing new ideas, which is couched in the policy and sociopolitical context, and the characteristics of which include receptivity, the recognition of social problems, organizational readiness, and data availability (Chaskin, 2008).

The influence of these “outer context” factors has been documented in studies of interventions for families living with parental mental illness (Hinden et al., 2006). Funding sources, for example, play a significant role in shaping services by setting priorities, identifying target populations, and specifying anticipated outcomes. Programs funded by a state child-welfare agency may target children at risk of abuse as a priority population, and look for decreases in reports of abuse or out-of-home placements as outcomes. The larger community and the availability of resources (e.g., transportation or housing) provide a context for program success or failure. Likewise, the field may be influenced in the other direction, from the “inside out,” when individual advocates (e.g., providers, consumers) become champions for change, or set their own desired goals and outcomes within an intervention context (Hinden et al., 2006). It is fair to speculate that effective change is most likely to occur when “outer” and “inner” contextual factors are aligned, and key actors are working collaboratively on a shared vision, mission, and agenda.

The importance of timing and time

Timing is important in creating opportunities for change, with streams of activity occurring over time (Kingdon, 1984). Advocates for policy change play a critical role in linking three separate activity streams, with obvious parallels in the practice arena: (1) a problem stream, in which a problem comes to the attention of policymakers; (2) a policy stream, where policy solutions are created and evaluated; and (3) a political stream, where problems and solutions are linked and reach the policy agenda. Policy change and practice reforms may occur as the consequence of a lawsuit (Leslie et al., 2014) or an unfortunate family tragedy reported in the media; these are examples of the problem stream. Alternatively, federal government reports or critical reviews, probably inspired by events at the interface of politics and social problems, can inspire innovation and change, and preserve the vision of change over time (Fudge and Robinson, 2009; Leslie et al., 2014).

Australia

Australia has been a leader in the promotion of policy and the development of resources for families where parents have mental illness. These efforts have largely been the result of many years of consistent and dedicated work by champions – key organizations and individuals – and have been guided by a number of significant reports. Families’ needs were first highlighted in a national inquiry (Burdekin et al., 1993). The subsequent National Action Plan (2000) provided a public health policy framework for promoting mental health and intervening early in mental health problems, with an action statement specifically directed at supporting children of parents with mental health disorders. As a consequence, the Australian Infant, Child, Adolescent and Family Mental Health Association (AICAFMHA) was established (2000), which founded the national Children of Parents with a Mental Illness (COPMI) Initiative (2002), funded by the Australian Government. COPMI aims to increase awareness and promote the uptake of family-oriented practices, with more recent funding directed at the promotion and development of resources for the workforce and materials (e.g., booklets, care plans) for children and families. COPMI is responsive to community needs and actively works with national government authorities and professional organizations.

States across Australia vary in terms of family-focused policy and practice. Most significantly, the Victorian Mental Health Act (2014) states that “children, young persons and other dependants of persons receiving mental health services should have their needs, well-being and safety recognized and protected” and should be “involved in decisions about assessment, treatment and recovery.” In Victoria, the FaPMI (Families Affected by Mental Illness) strategy includes coordinators across eleven regions, who are responsible for encouraging family-focused practice through training and networking.

A number of factors have promoted these changes. Cross-agency collaborations, a critical element for delivering family-oriented services, are sustained by cross-agency governance and formal signatory documents which are aligned to national, jurisdictional, and regional policies (Owen, 2010). Other strategies involve articulating a clear organizational mission or vision statement, including consumers in workforce training, and identifying champions who are able to promote and embed family-focused practices into their respective organizations (Owen, 2010; Reupert and Maybery, 2008).

Nonetheless, considerable barriers to change and sustainability remain, including government and agency silos, and a related lack of sharing of resources and information (Owens, 2010; Maybery and Reupert, 2006). Securing consistent funding is another challenge. While the national COPMI initiative has received funding in 3-year periods, as of 2014, COPMI received 1 year of funding, with its future being uncertain. In Australia, changing political agendas that tend to be crisis- rather than prevention-focused are a significant challenge.

National guidelines are needed for intake protocols to record the parenting status of clients. Undergraduate and postgraduate training programs for health and allied health groups should be encouraged to incorporate principles and approaches for working with families. New ways of thinking and funding are required to support the development, dissemination, and evaluation of interventions for different family types, including indigenous and refugee families. While the national COPMI initiative has successfully promoted the implementation of interventions from other countries, more is needed on adapting and disseminating such interventions across international boundaries.

Canada: the examples of British Columbia and Manitoba

In British Columbia, policy development is directed by the Healthy Minds, Healthy People (Ministry of Health Services, 2010) document, a 10-year mental health plan that specifically mentions the needs of children and families with parents with mental health or substance use problems. A family mental health task force led by the Ministry of Health Services and the Ministry of Children and Family Development created a framework document, Families at the Centre, outlining strategies for agencies to fulfill the expectations of the mental health plan. The tragic deaths of three children murdered by their father, who suffered from undiagnosed mental illness and substance misuse, further shaped policy and practice. The consequent initiative, Safe Relationships, Safe Children, is an action plan guiding pilot projects leading towards province-wide adoption. With this high-level direction, agencies delivering adult mental health, child welfare, and women’s domestic services aim to work collaboratively, identify mental illness and substance misuse in parents, and, together, consider the needs of children. Through these government-mandated initiatives, what was largely a voluntary workforce change strategy is on the cusp of becoming required practice.

In 2007, the Healthy Child Manitoba Act (HCMA) was passed to guide the development of the Manitoba Child Health Strategy. The strategy focuses on prevention and intervention to ensure that all children achieve the best possible outcomes. Underlying the development of the HCMA were the problems of the large number of children in foster care, low rates of high-school graduation, high crime rates, and the recognition of social, cultural, and economic restraints. The HCMA recognizes that no one government department can address children’s holistic needs, and legislates that government departments collaborate.

The Manitoba Child Health Strategy utilizes best-practice evidence with the goal of strengthening community development, supporting children and their families, and responding to recommendations from a cross-sectorial committee of education, health, policymakers, and other partners. Child-focused public policy based on financial and community supports further promotes positive outcomes for children. While children of parents with mental illness may be identified in family programs such as Towards Flourishing, in general, children of parents with mental illness are not specifically targeted in any formal policy.

The document Rising to the Challenge: A Strategic Plan for the Mental Health and Well-Being for Manitobans (2011) reflects the perspective that family members can foster support for recovery and well-being, though, again, children who live with a parent with a mental illness are not specifically discussed. In summary, while Manitoba has made considerable and commendable efforts in broad policy development for the best possible outcomes for Manitoba children, the needs of children of parents with mental illness are not directly addressed in policies or services.

Norway

Inspired by international research and their own practice experiences, health personnel and organizations began developing projects for the children of ill parents from the beginning of the 1990s. In 1997, a government report advised adult psychiatric service providers to focus on the children of their adult patients through the establishment of routines for identifying children’s needs, and collaborations across child psychiatry, child-protection, and community healthcare services (Sosial- og helsedepartementet, 1997). A Ministry of Social and Health Services report highlighted the importance of addressing children’s needs for information and support when a parent has a severe somatic illness or is dying (Sosial- og helsedepartementet, 1999).

Between 1998 and 2004, the Adults for Children organization led a national education program focusing on children of parents with mental illness. During this period many new projects were initiated including children’s groups, adult groups, psychoeducation for families, the designation of child-responsible personnel, refined practice procedures, and a targeted website. Nonetheless, an evaluation of psychiatric services for adults found a gap between the children’s needs and the support received (Aamodt and Aamodt, 2005). Projects were initiated by enthusiasts or champions, but not implemented systematically on a national basis. Individual clients were generally the focus rather than the family, and service providers rarely cooperated. Similar evaluations appeared from the substance-abuse field (Statens institutt for rusmiddelforskning, 2006) and the Norwegian Cancer Society (Ryel, 2005).

As part of an Action Plan Against Poverty (2006–7), the Norwegian parliament initiated a new national movement against inequality in health for children of mentally ill and substance-abusing parents, with children of parents with severe somatic illness included later. Early identification was a main focus (Arbeids- og sosialdepartementet, 2006). This movement was underpinned by significant documents which emphasized the need for (1) an enhancement of workforce competence, (2) the development of routines for identifying children and providing follow-up support, and (3) the piloting of new models. The Ministry of Health and Care Services, and the Ministry of Children and Equality implemented the initiative and provided funding for several projects.

Through the Model Municipality Project 2007–14, twenty-six municipalities developed different models for early intervention and systematic follow-up procedures for children of parents with a mental illness or substance-abuse disorder (Barne-, ungdoms, og familiedepartementet, 2010). Similarly, the specialist health services piloted preventive family teams following families at risk carefully from pregnancy until the child reaches school age. (Høgskolen i Buskerud, 2011).

Important changes in law were introduced in 2010, mandating that personnel in psychiatric, substance-abuse, and physical health fields consider children’s needs for information and follow-up when parents are ill. Health authorities are also obliged to appoint child-responsible personnel to teach and supervise their colleagues (Helse- og omsorgsdepartementet, 2009). The specialist healthcare services received funding to develop procedures and for the employment of coordinators for this work. A national network to promote competence regarding these issues, Children’s Best Interest, was established to foster the communication of new knowledge and methodology, facilitate research and professional development, and advise central health authorities. A network of child-responsible personnel and a research network were then established (BarnsBeste, 2014), as was a network focusing on young children.

In sum, during the last twenty-five years there have been many developments in Norway related to children of ill parents. The legal requirement to provide support and information to children of parents with illnesses, including mental illness, has been a milestone. The collaboration of researchers, organizations, consumers, and clinicians has been an important enabler in these developments, working along with national authorities who have prioritized and governed these processes. The priority now is to evaluate whether and how these initiatives have impact.