Editorial: Parents with Mental and/or Substance Use Disorders and Their Children, vol III

Joanne Nicholson^1*Jean Lillian Paul²Geneviève Piché³Anja Wittkowski⁴

• ¹Brandeis University, Waltham, United States
• ²Medical University Innsbruck, Innsbruck, Austria
• ³Université du Québec en Outaouais, Saint-Jerome, Quebec, Canada
• ⁴University of Manchester, Manchester, England, United Kingdom

This is the third Frontiers Research Topic volume focusing on parents with mental and/or substance use disorders and their children. Once again, international researchers actively contributed, with 33 articles written by 179 authors from 13 countries, including Austria, Australia, Canada, the Czech Republic, Germany, Ireland and Northern Ireland, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Earlier volumes (1,2) focused on the experiences of families living with parental mental illness, emphasizing the need for rigorous research designs, innovative methods, and the development and testing of interventions for adults, children, and their families. These prior volumes reflected a gradual shift in the work, from exploring experiences and documenting prevalence, to developing solutions for supporting family members in optimizing outcomes. In announcing Volume III, we acknowledged the need for widespread knowledge translation and dissemination efforts, with an eye towards improving both policy and practice. Our goal was to engage international colleagues in highlighting the nuanced needs of diverse target populations, treatment settings, and service contexts; elevating policy issues impacting these families; and further developing and testing interventions to build the evidence base. The submitted articles illustrate updates in our knowledge regarding the prevalence and characteristics of adults and children living with parental mental illness. The experiences and needs of mothers and families in the perinatal period are elaborated on and addressed in conceptualizing intervention opportunities, targets and outcomes. Innovative measures and methods are highlighted, along with the development, adaptation, implementation, and testing of family-focused interventions. Workforce efforts and challenges in sustaining interventions are described.Nine papers in this Research Topic special issue focus on the characteristics of children or adults when there is parental mental illness in the family. These papers include one systematic review (3), seven original research articles (4-10), and one perspectives piece (11). Study designs are all cross-sectional and include six quantitative studies (4,5,7,9,10,12), one using mixed methodologies (6) and one qualitative study (8). Articles reflect work in Germany, Canada, United Kingdom, Belgium, and Australia. Four are from the large COMPARE trial (6, 7, 9, 10), the protocol of which was published in the second volume of this Research Topic (13).Following their studies, these authors suggest target areas for new interventions to support family mental health. They argue for the involvement of physical activity in family-focused interventions, both for parents and children, with the knowledge that physical and mental health are interconnected (5). For parents, they propose including a specific focus on parental stress (9), and emotional regulation (4, 7) to enhance parenting skills. For children, in addition to physical activity, they suggest that interventions cover facial emotional recognition, which could be impaired in children of parents with a mental illness (10), and helping children build their social networks, recognizing the active role children have in navigating the social and formal relationships around them (8). Overall, the need for longitudinal studies and a consideration of the developmental stage of the child during the parent's acute phase of mental illness is highlighted. Finally, following the sustained growth of research and practice in family mental health studies, one paper calls for a reflection on the "frame" of risk and vulnerability and its potential impacts on families and services (11).A number of papers in this volume bring attention to the experiences and needs of mothers (and fathers) during the perinatal period, particularly related to their mental health and the parenting of infants (12,(14)(15)(16)(17)(18)(19)(20). The papers are largely exploratory, engaging women and professionals who highlight the importance of positive connections (i.e., with therapist, baby and motherhood), elaborate important mechanisms for change (e.g., sensitivity and engagement in the therapeutic relationship), and set priorities for future interventions (15,16). Wozniak et al. focus on changes in maternal self-construal following admission to Mother and Baby units in England, assessing how mothers view themselves in relation to self and others (18). Most mothers report positive and more adaptive changes to self-esteem and self-perception. Mothers referred to a Mother Baby unit in Australia provide evidence of significant rates of lifetime trauma exposure, with 24% meeting criteria for complex PTSD (12), suggesting the importance of attending to the ways in which trauma histories are likely to impact mothers' relationships with infants. Isobel (12) suggests the potential benefits of a shift in perinatal mental health treatment to include a focus on navigating the transition to parenting and considering the impact of trauma in transgenerational attachment. Millard et al. (17) reviewed the current literature on compassion focused therapy (CFT) offered to women who are mothers in the perinatal period. The authors underscore the limited evidencebase and the need for future research. Eleven perinatal mental health peer support programs were identified in a systematic review of the literature (14) (20)(21)(22)(23)(24). These contributions come from diverse international contexts, including Germany (21,23), Austria (20), Australia (24), and an international collaboration with the leading author based in Canada (22). Two of these papers again are part of the large COMPARE project (21,23), which continues to make substantial contributions to the field. Among these studies, Fahrer et al. present a new method for measuring interactive behaviors between parents and children when a parent has a mental illness, offering valuable insights into family dynamics that can inform intervention development (21). Stracke et al. contribute by validating and shortening a stigma questionnaire specifically designed for children of parents with a mental illness, making it more accessible and efficient for both research and clinical settings (23). Meanwhile, Schöch et al. critically review existing screening tools for paternal perinatal mental illness, identifying gaps and proposing refinements to enhance their accuracy and relevance (20). Notably, they highlight that the widely used Edinburgh Postnatal Depression Scale (EPDS) may fail to capture atypical depressive symptoms in men, such as irritability, aggression, or substance misuse (20).The scoping review by Piché, Davidson et al. highlights significant gaps in qualitative research on parental mental illness, particularly the need to capture diverse family experiences-such as those of children, fathers, and other family members. The authors emphasize the need for holistic research approaches to better understand how parental mental illness impacts family systems. The authors also advocate for greater family involvement in setting research priorities to enhance the quality and relevance of future work (22). Lastly, Reupert et al. apply the Social Return on Investment (SROI) approach to evaluate a program for children and young people who have families living with mental illness, highlighting the broader social value of such interventions (24). Together, these contributions exemplify how rigorous methodological innovation can expand our capacity to measure, understand, report and respond to the complex challenges faced by families experiencing parental mental illness. Understanding the challenges that health and social care professionals face in their efforts to support the mental health and wellbeing of parents and their children is critical to the successful implementation of interventions and family-focused approaches. The views and experiences of professionals in different service and research contexts and in different countries are explored in several papers. Zegwaard et al. (31) describe the implementation of innovative interagency, family-focused case consultation teams, which boosted practitioner confidence in supporting families with complex challenges, six months post-implementation. Their study underscores the need for sufficient time, resources, and expert support to enhance interagency collaboration and address complex family needs. In a study of the predictors of family-focused practice, professionals working with adult mental health patients in Quebec, Canada, completed the Family Focused Mental Health Practice Questionnaire (32). Apart from working full-time, the strongest predictors for the adoption of higher family-focused practice levels among these professionals are, similar to the findings of Zegwaard et al. (31), having a perceived higher level of skills, knowledge, and confidence towards FFP and having a supportive workplace environment. Oakes et al. (33) investigated the views and experiences of health and social care professionals recruited from six National Health Service (NHS) and Local Authority settings in England to gain a better understanding of their experiences supporting parents with serious mental illness (e.g., schizophrenia and bipolar disorder) and their children. Professionals indicate that available services remain inaccessible and unacceptable to these parents. They further describe experiencing a conflict in their attempts to balance the needs of parents with those of their children. These authors highlight the need for specialist family-focused services, with collaboration across health and social care settings. The professionals in their study report the need for greater service knowledge and more training in parenting with mental illness, which supports Piché, Villatte et al.'s findings (32). As part of the implementation of the ParentingWell Practice Approach, adapted from Let's Talk about Children, practitioners working with adults with mental illness were invited to participate in the ParentingWell Learning Collaborative, including in-person orientation and learning sessions, and virtual follow-up coaching sessions (34). Participants report that coaching sessions allowed practitioners to share concrete approaches to supporting parents, and to reflect more deeply on the needs of these parents alongside their own personal experiences and need for selfcare in this field of work. Linderborg et al. (35) explored the utility of the Family Model in Swedish child/adolescent and adult mental health services with clinicians and managers in a qualitative study using naturalistic enquiry. Their analyses on a meta understanding level indicate that the Family Model was perceived as a useful tool for families, with its potential to influence prevention and to bridge the gap between child and adult mental health services. The Family Model seemed to empower families with its focus on strengths, which in turn motivated clinicians to use it more. The authors recommend the gradual implementation of this model following training and ongoing guidance in its use, comparable to Piché, Villatte et al.'s findings (32). Sufficient time and resource allocations alongside family "champions" in organizations are also recommended. Given the well-documented barriers (e.g., organizational policy, interagency collaboration, professional and parental factors) to keeping the whole family in mind or to implementing a family-focused practice, Stolper, van Doesum et al. (26) offer the main elements for such an approach to succeed, based on their work with professionals and parents. Once more, the need for integrated, multidisciplinary and multiagency work, offered by a specialist team, is stressed.The contributions in this volume highlight significant advancements in understanding and addressing the needs of families when a parent has a mental illness. However, they also point to critical gaps in research, intervention development, and systemic integration that require further attention. In this discussion, we outline key directions for future efforts across intervention development, research priorities, workforce considerations, and broader systemic and policy implications.Rethinking Mental Health Systems: Supporting Families Across the Lifespan One overarching theme emerging from this volume is the need to rethink mental health care systems to accommodate the needs of diverse families better at different life stages. The articles highlight the necessity of a continuum of services, ranging from early prevention efforts in the perinatal period to long-term support for families with older children. The development of new interventions must be informed by a nuanced understanding of the characteristics and needs of parents, children, and families, emphasizing the following aspects.• An integrated family approach: Future interventions should move beyond individualfocused treatments to incorporate family dynamics, considering how mental illness impacts relationships within the household and/or the wider family. This approach includes a greater emphasis on the roles of fathers, non-birthing parents, and other caregivers beyond the traditional focus on mothers, acknowledging the diverse ways in which families function and provide support. We should also consider the family and social impact on these broader caregivers in providing unpaid social support. • Sustainability and adaptability: Programs should be designed for long-term implementation, considering workforce training, resource allocation, and cross-sector collaboration to maintain impact over time.Advancing research: Methodological considerations and emerging priorities Future research must build on existing knowledge while addressing current methodological limitations. Several key research directions emerge.• Mixed methods approach: Integrating qualitative and quantitative methods can provide a richer understanding of family experiences, intervention processes and, ultimately, Intervention effectiveness. This volume illustrates the growing momentum in research and practice aimed at supporting families in which parents have a mental illness. As the field continues to evolve, a commitment to interdisciplinary collaboration, participatory research, and evidence-informed practice is essential. By addressing gaps in intervention development, research methodology, workforce training, and systemic integration, we can move towards a more comprehensive and sustainable approach to family mental health care and wellbeing. The challenge now is to translate these insights into action-ensuring that families receive the support they need, not only in crisis but throughout the course of their lives. We would like to express our heartfelt appreciation to Dr. Tytti Solantaus and Dr. William Beardslee, whose pioneering work has significantly shaped the field of family mental health. Their dedication to understanding and supporting families affected by parental mental illness has not only advanced scientific knowledge, but also transformed clinical practice and policy worldwide. Dr. Solantaus's contributions have emphasized the strengths and resilience of families, inspiring innovative, preventive approaches that acknowledge the experiences of both parents and children. Dr. Beardslee's groundbreaking work on resilience and family-focused interventions laid the foundation for evidence-based programs that continue to guide researchers and practitioners in their efforts to improve outcomes for families. Their wisdom, compassion, and commitment have shaped a field that is deeply attuned to the needs of families. We are honored to build upon the foundation they have laid.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.