June 2012

R E S E A R C H TO P RAC T I C E B R I E F
A Service of the
Childrens Bureau

Supporting Children of Parents

with Co-occurring Mental Illness
and Substance Abuse
When the police arrived at the home after receiving a report of domestic violence, they
found 6 year old Peter alone in the family room watching television in his pajamas. No
adults were present in the house, and open alcohol containers were strewn about the
kitchen. Peter was taken back to the station, where he was interviewed by a child
welfare worker. Peter informed the worker that he was not enrolled in kindergarten, and
spent most of his time on the couch watching cartoons. Peters file showed that he had
been in the care of three different family members over the years as his mother bounced
in and out of residential treatment for her substance abuse, depression, and multiple
suicide attempts. No formal supportive services had ever been offered to Peter.

For nearly a decade, the Substance Abuse and Mental Health Services
Administration (SAMHSA) has been advocating for integrated treatment of
co-occurring mental health and substance abuse disorders, with the understanding
that those who struggle with both addiction and mental illness face complex life
stressors and unique barriers to treatment (1). Up to 50% of substance abusers
are suffering from PTSD, and some reports show that up to 90% have a depressive
or anxiety disorder of some form (2, 3). Integrating the treatment for these two
types of disorders is recognition that the whole of a person is more than the sum
of his or her parts. Its not enough to merely treat the substance abuse, and then
send the individual for counseling (or vice versa). Instead, treatment should be
holistic, and respond to the whole persons needs. What is commonly left out of
the equation, however, is that according to the National Prevalence Data, over
two-thirds of women with co-occurring disorders are mothers (4). While integrated
treatment may respond holistically to the clinical diagnoses of the client, it rarely
attends to the needs of the client as a mother, the needs of the family system or
more specifically, to the needs of the children.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

R E S E A R C H TO P R A C T I C E B R I E F

Risk Factors for Children

Exposure to Violence and Trauma

Individuals with co-occurring disorders are more likely

It is well-documented in the literature that children

to have been exposed to violence than are individuals

growing up in homes headed by a parent with

with either a mental health or substance abuse

co-occurring mental health and substance abuse

disorder. In fact, in a large nationwide sample, most

disorders are at an increased risk for a multitude of

co-occurring mothers reported having experienced

psychosocial complications. These children are

violence in their lifetime (4). This abuse is commonly

commonly exposed to ongoing stressors that can

in the form of domestic violence. In a similar study,

have a cumulative impact on their behavior and

67% of interviewed children who had a mother with a

development (5). In fact, in a three-year longitudinal

co-occurring disorder reported domestic violence in

study, researchers found that the risk of child behavior

the home, compared to 22% of children living in a

problems increased with the number of areas in

home with no mental illness or substance abuse (8).

which the mother reported difficulties (6, 7).

It is common for these children to witness violence

Unfortunately, in families with parental co-occurring

and illegal activity in the home, and post-traumatic

disorders, multiple difficulties are commonplace.

stress disorder (PTSD) is typical for both the children,

as well as their mothers (9, 10). This trifecta of
parental mental illness, substance abuse, and
domestic violence brings with it a two to five times
greater risk for: homelessness, use of food banks, lack
of needed medical care, unreliable or unsafe child
care, and placement in foster care of the children in
the home (11).

Poverty
Over three-quarters of interviewed mothers diagnosed
with a co-occurring disorder were living below
the poverty line (12). Childhood poverty has been
found to be a powerful risk factor for a wide range
of poor outcomes in children from low birth-weight,
delayed development, and cognitive deficits to poor
earning power and major depressive disorder in
adulthood (13).

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

R E S E A R C H TO P R A C T I C E B R I E F

Neglect
Neglect is a serious concern for children of parents
with co-occurring disorders. Parental drug-seeking
behaviors may result in inadequate or inappropriate
care of the child. Children may be left alone for long
periods of time in front of the television or with
inconsistent supervision as parents seek their next

Housing and Custodial Instability

high (3, 10). The child may be inconsistently fed

and/or bathed, and placed at high risk for accidents

An unstable living environment is common for children

due to the lack of parental supervision. In addition,

living in households affected by parental co-occurring

some of the medications parents may take to combat

disorders. Less than 40% of interviewed mothers

their mental health diagnosis or substance abuse can

remained the primary caregiver of their children through-

make them lethargic, causing a lack of motivation to

out the first ten years of the childs life (15). In a

perform household tasks. Some parents choose to

nationwide study, 38% of children who had a parent with

stop taking sedating medication, or may refuse it from

a co-occurring disorder reported experiencing residential

the start, in an attempt to better care for their children.

instability, as defined by 2 or more residences in the

Unfortunately, in many cases, this often backfires

past 3 months (5). While reasons for moving vary,

when the parent becomes more symptomatic and less

research has shown that low-income families move

able to be present with their parenting responsibilities

frequently, generally resulting from unplanned or

(10, 14).

involuntary circumstances (16). For families with parental

co-occurring disorders, these circumstances range from
eviction and foreclosure to parental incarceration and
institutionalization (12, 17). While these moves sometimes
occur with the family unit, this special population of
children tends to bounce around between caregivers,
sometimes formally in the foster care system while a
parent is incapacitated, sometimes informally with friends
and extended family. Frequent moves tend to have
negative impacts on child and family welfare, such as
increased school absenteeism and a higher incidence of
neighborhood problems (16). In addition, already fragile
parent-child attachments are disrupted when the parent is
incarcerated, institutionalized, or chooses to seek
inpatient substance abuse or mental health treatment.
The distress and anxiety that these children experience
during periods of separation from their parents have
been linked to a childs failure to thrive, depression,
delinquency, and academic problems (18).

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

R E S E A R C H TO P R A C T I C E B R I E F

Effects on Children

were found to be 1.5 times higher among children who

had parents with co-occurring disorders, compared

Much research has been conducted on the singular

effects of maternal depression, anxiety, or substance
abuse on children. In contrast, considerably less
research has been directed to the effects of parental
co-occurring disorders on children. There are some
things we do know, however, about the heightened
risks these children face.

to children who had parents with no diagnosis or

substance abuse only (20). A much larger study
compared the outcomes of children of parents with
substance abuse issues, mental health issues, or
co-occurring disorders. The rates of substance abuse
and internalizing disorders were highest among the
children, ages 8-17, whose parents had a co-occurring
disorder (2). In addition to feelings of grief, loss,

Mental Health/Substance Abuse Disorders

sadness, anger, and depression, many children also

reported feelings of anxiety and concern about

While healthy debate persists as to the extent of nature

possibly developing a diagnosis themselves one

versus nurture in the onset of mental illness and

day (19).

substance abuse disorders, there is consensus that

children living in households with a parent with a

Developmental Delays

co-occurring disorder are at-risk on both fronts. They

may be born with a genetic predisposition for
substance abuse disorders and mental health issues,
as well as experience daily exposure to an environment
that may breed such disorders. One study found that
25-50% of children with a mentally ill parent will also
experience some psychological disorder during

These children are at great risk for developmental

delays due to potential in-utero substance exposure,
poor parent-child attachment, limited opportunities for
appropriate child development activities, exposure to
traumatic events, multiple transitions and caregivers,
and possible neglect (4, 9, 12, 18, 19).

childhood, adolescence, or adulthood (19). In a small

sample of qualitative interviews, psychiatric diagnoses

Stigma and Isolation

Isolation from peers, adults, and possible supports is
common with these children, as they generally feel
pressure to keep their parents illness hidden (19, 20).
If they do choose to share their situation, they are
commonly met with stigma and judgment reinforcing
their hesitance to reach out (20). This isolation can
lead to a lack of informal and formal supports in the
home, and the child feeling as if they need to care for
the parent independently.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

R E S E A R C H TO P R A C T I C E B R I E F

Parentification
Due to the parents incapacity at times, many children
in these homes are expected to perform household
tasks that are not age-appropriate, such as caring for a
younger sibling, making meals, doing laundry, and
buying groceries. This phenomenon, known as
parentification, further isolates the child keeping
him/her busy after school and unable to relate to the
care-free attitudes of peers (11, 17).

Prenatal/Postpartum Support
Offer Universal Screening

A Continuum of Services

Pregnant mothers should be screened for illicit and

prescribed substance use, as well as alcohol use, at

Clearly these children could benefit from intervention

each prenatal appointment. If a mother is found to

services of their own. Despite that fact that research has

have either a substance abuse disorder or mental

highlighted the specific risk factors for these children as

illness, she should then be screened for co-occurring

well as documented long-lasting effects of having a

disorders. Clinicians should have supportive

parent with a co-occurring disorder, there are minimal

community referrals on hand to help mothers

specialized services in place that take formal responsi-

manage their symptoms during pregnancy, including

bility for primarily addressing the childs needs. Children

referrals to integrated co-occurring treatment, case

generally only receive treatment once identified with

management, and public health nurses.

problem behaviors, and this treatment tends to be

time-limited and specific to the targeted behavior only,

Supportive services to children affected by parental

rarely taking into account the bigger picture. Knowing

co-occurring disorders can begin in-utero. Chronic

that they are at high-risk for a host of complications, an

stress during pregnancy can result in atypical fetal

intervention at a single point in time is not sufficient to

development and decreased immune support,

address the needs of these families. These children are

increasing the childs susceptibility to postnatal

living their lives in this environment, and may need

illnesses (21). The fetus of a woman with co-occurring

various supports throughout their childhood. To support

disorders may also be exposed to illegal substances,

children who have parents with co-occurring disorders,

as well as prescribed psychotropic medications used

the field needs a new tactic. An array of comprehensive

to alleviate maternal depression and anxiety. Working

family-centered prevention and intervention services that

with a mother to reduce substance use during

spans the prenatal stage through young adulthood is

pregnancy combined with closely assessing and

essential to adequately address the unique and

monitoring any prescription medications she may be

complicated needs specific to children of parents with

on is critical to minimizing fetal abnormalities,

co-occurring disorders.

reducing pre-term labor, and increasing infant birth

weight, all of which can lead to physically, mentally,
and emotionally healthier infants (22).

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

R E S E A R C H TO P R A C T I C E B R I E F

Provide Close Maternal Postpartum Monitoring

Substance exposed newborns often have an impaired

In-home supportive services, such as visits from public

ability to self-regulate. They tend to be fussier babies

health nurses or high-risk home visitors, are especially

who may be difficult to soothe and have trouble feeding

helpful during the postpartum period.

(24, 25). Simultaneously, a mother with a co-occurring

disorder may have reduced capacity to read and respond

Special attention needs to be paid to mothers with

to her childs cues, especially if she is actively using

co-occurring disorders in the postpartum period.

substances (12, 25). This combination can create

Hormonal changes that accompany pregnancy,

challenges for the initial mother-infant bonding leading

delivery, and lactation may heighten the symptoms of

to poor parent-child attachment (24). In a small study,

a womans mental illness, and may even bring on

over four-fifths of infants with mothers with co-occurring

new psychiatric symptoms related to postpartum

disorders were insecurely attached (26). Poor attach-

depression (23). This, combined with the added stress

ment has been associated with a wide range of poor

of parenting a newborn that may be especially fussy

outcomes later in life, and linked to child maltreatment

or challenging due to prenatal substance exposure,

and neglect (24). On the contrary, a secure mother-child

increases the risk that a mother will relapse or

attachment can act as a strong protective factor helping

continue her substance use (22).

to buffer a child from the multitude of risk factors and

stressors described above (27, 28).

Infancy/Toddlerhood (0-4 years of age)

Strengthen Mother-Child Attachment
Evidence-based infant mental health services and
home visitation programs work to increase the
parent-child attachment in the home.

Evidence-Based Programs:
Early Head Start
http://www.ehsnrc.org/
Nurse Family Partnership
http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=88
Circle of Security
http://www.cebc4cw.org/program/circle-of-security/
Child Parent Psychotherapy
http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=194
Partners with Families and Children: Spokane
http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=163
Promoting First Relationships
http://www.pfrprogram.org/index.html
Healthy Families America
http://www.healthyfamiliesamerica.org/about_us/
index.shtml

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

R E S E A R C H TO P R A C T I C E B R I E F

Find Family-friendly Residential Treatment Facilities

If inpatient services are needed, find a program that
can accommodate mom and child (ren).
Mothering is often seen as a normalizing experience
that connects women with others, and provides an
individual with a specific role and purpose, as well as a
source of hope for the future (4). Children are often the
motivation parents need to seek out treatment. At the
same time, parenting responsibilities are commonly
listed as a top reason for women refusing inpatient
treatment for co-occurring disorders (4). Even if a
woman recognizes that she needs residential services,
she frequently decides against it out of fear of losing
custody of her children (4). Research has shown that
facilities that provide residential care for mothers and
their children have an easier time engaging and
retaining women (29). Inpatient stays with mother and
child (ren) also provide a unique venue for assessing

Young School Age (5-11)

Educate about Parents Conditions

parenting skills and the parent-child attachment,

Help parents talk to their children about their

and providing intensive parenting interventions,

co-occurring disorders, and educate the child about

developmentally appropriate stimulation for the child,

and family therapy (30).

mental illness and substance abuse. Also, work with

the parent to better understand the effects of her
co-occurring disorders on her children (6).

The attitude that recovery must come first and that

By the time children affected by parental co-occurring

women need their own space to recover and cannot

disorders are in the early school age stage, they are

concentrate on their recovery with children present

aware that something is different in their family. This is

reflects a lack of understanding of access issues, and of

the fact that true recovery for a mother usually works
only when it includes her children. Norma Finkelstein

a great time to begin educating children on their

parents co-occurring disorders. Children are still very

(6)

egocentric at this age, and commonly feel they are

responsible for the problems in their family (31).
Knowledge is power, and children who understand that
they are not to blame for the potential dysfunction in
their families may not only release any guilt they feel,
but also have a normalizing context for the potentially
erratic and confusing behaviors of their parents.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse
R E S E A R C H TO P R A C T I C E B R I E F

Develop Support System for Child

The Blue Polar Bear
This book for children 5-7 years aims to assist workers,

Help child create a network of formal and informal

supports.

clinicians, and parents to introduce the issues of

parental mental illness and substance misuse,

Children who grow up in homes with parental

explore concerns and encourage positive coping and

co-occurring disorders appear to have limited resources

help-seeking behaviors.

to develop the skills and relationships that help buffer

http://www.community.nsw.gov.au/docswr/_assets/

against the risk factors they face (32). One of the most

main/documents/dualdiagnosis_polar_bear.pdf

important protective factors a child can have is a

positive and stable relationship with a caring and

The Flying Dream

Written for children 8-12 years of age, this book can
also be used with parents to help them understand

positive adult (5). Interventions at this age should

assist the child in identifying a personal support group
that may consist of a combination of compassionate

their childrens needs, and identify what they can do

differently to assist their children.
http://www.community.nsw.gov.au/docswr/_assets/
main/documents/dualdiagnosis_flying_dream.pdf

adults, such as aunts, uncles, older siblings, coaches,

teachers, mentors, neighbors, therapists, social
workers, or religious leaders (10, 20). This support
group will also assist in easing the isolation and stigma
the child may feel. The opportunity to talk to someone
about personal feelings has been cited by these
children as a simple, yet effective, way to feel more
confident and supported (20).

Evidence-Based Programs:
Big Brother/Big Sister
http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=227
Across Ages
http://nrepp.samhsa.gov/ViewIntervention.
aspx?id=138

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

R E S E A R C H TO P R A C T I C E B R I E F

Offer Support Groups

Coordinate with co-workers who are working with this
population to offer skills-building and support groups
for children of parents with co-occurring disorders.
For children who are struggling with isolation and
difficulties relating to peers, a simple support group
can be incredibly normalizing. Its also a wonderful
place to help these children develop a set of skills they
may be lacking, such as self-soothing, interpersonal
communication, relaxation techniques, and assertiveness training (6). Since substance abuse and mental

Encourage Family Togetherness

illness can break down family communication, the

Assist family in identifying and engaging in

group leader can help the child verbalize feelings, and

recreational activities together.

model appropriate expression of emotions (6).

In a qualitative interview of children living in homes
It may also be beneficial to involve the parents in

with parental co-occurring disorders, the children

some group sessions. This structured environment can

overwhelmingly reported that they cherished the times

provide a safe place for families to talk about the

their families were able to have fun together, and

hard to talk about issues, such as how the parents

wished they had more opportunities to participate in

substance use and mental illness affects the child (6).

normalizing family-fun activities (20). Encouraging

families to get outside together on a regular basis can

Develop Safety Plan

greatly reduce stress and infuse a sense of normalcy

Help parent and child work together to develop a safety

and silliness into an often serious and stressful

plan for the child in case of emergency.

family life.

The unfortunate reality of parental co-occurring

Provide or Refer to Family Therapy

disorders is that emergency situations can and do arise

Interventions focused on strengthening the family can

that can put the child at-risk. Parental suicidal ideation

be particularly helpful at this stage.

or suicide attempt, active domestic violence, drug

relapse or overdose, and acute psychiatric crises are
ongoing realities for these children. Creating a safety
plan that can be put into action in any of these
situations helps protect the child and the parent (6). It
can be as simple as having emergency phone numbers
posted on a wall or entered into a cell phone, and as

Evidence-Based Programs:
Parent Child Interaction Therapy (PCIT):
http://pcit.phhp.ufl.edu/
Strengthening Families Program
http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=44

complex as written plans detailing steps the child

should take in each situation the family can brainstorm.
This safety plan should be revised often, and always
take into account the developmental stage and ability
of the child.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

10

R E S E A R C H TO P R A C T I C E B R I E F

Adolescence (12-18)
Many of the supports and interventions that are
appropriate for young school-aged children are also

Trauma-informed Support for

Mothers

appropriate for adolescents if they can be modified for

an adolescents maturity level.
If you dont meet your own needs, how can you meet

Evidence-Based Programs:

the needs of another person? Tanji Donald

(17)

Reconnecting Youth: A Peer Group Approach to

Building Life Skills (RY)
http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=96
Coping with Stress

Its unrealistic to think you can holistically support a

child without concurrently addressing the needs of the

http://www.kpchr.org/research/public/acwd/

parent. A functional family system and optimal child

acwd.html

functioning require that all members needs are met.

For women with co-occurring disorders, the role of
trauma in parenting has to be addressed to adequately
support the children in the home. One agency reported
that over 60% of the women in their co-occurring
treatment program had been physically or sexually
abused (3). Mothers experiencing mental illness and
addiction describe many of the challenges they
experience in parenting as directly related to their
trauma history (17). Specifically, women may: pay
limited attention to the children due to a need to
seek out safety (from trauma), have limited physical/
emotional availability, struggle with trust issues, have
a diminished capacity to empathize with the child,
experience decreased intimacy with the child, lack
positive parenting role models, and lack confidence in
their ability to parent effectively (17). In addition to
integrated treatment for their mental illness and
addiction, mothers with co-occurring disorders can
benefit from a multitude of ancillary trauma-informed
interventions that will provide trickle down effects to
the children.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

11

R E S E A R C H TO P R A C T I C E B R I E F

Nurture Mothers
Utilize a strengths-based approach to help a mother
develop psychosocial skills, such as self-esteem,
self-mastery, and optimism.
Mothers with better psychosocial resources reported
higher interaction scores on an assessment of
parent-child attachment (27). Unfortunately, mothers
receiving treatment for co-occurring disorders often
describe feelings of inadequacy, low self-esteem, and
doubt in their parenting ability (3).
Many of these women were never nurtured themselves,
and have no conceptual framework for what a

need assistance learning age-appropriate expectations

nurturing relationship might look like. Nurturing the

and reactions as well as positive disciplining skills

mother is critical to helping her feel supported, while

(24). Video-taping of the mother-child interaction can

simultaneously learning how to nurture her children

be especially helpful for mothers who can then review

(17). Developing a strengths-based connection with

and process the tape with a supportive practitioner

the mother that models a positive and nurturing

(15). The most effective parent training seems to be

relationship can provide her with an opportunity to feel

offered in the community where skills can be modeled,

nurtured herself and recognize the invaluable role she

coached, and practiced in the setting where they will

plays in her childs life (3). Once a woman has the

be used (33).

chance to address her own psychosocial needs, she

is more able to take an active and positive role in
learning effective parenting skills (17).

Evidence-Based Programs:
Nurturing Parenting Program

Offer Parenting Interventions

Offer trauma-informed parenting interventions and
programs that provide tangible skills to participants.

http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=171
Nurturing Program for Families in Substance Abuse
Treatment and Recovery

Parenting interventions for this population should

assist parents in understanding the impact of their
substance use and mental illness on their family, and
provide them with tools they can use to speak with
their children about their disorders (17, 20). Many

http://nurturingparenting.com/ecommerce/
category/1:3:5/
Triple P- Positive Parenting Program
http://www.nrepp.samhsa.gov/ViewIntervention.
aspx?id=1

times, parents with co-occurring disorders are so

distracted by their own issues, they are unaware of
their childrens developmental milestones, and may

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

12

R E S E A R C H TO P R A C T I C E B R I E F

Assist with Basic Needs

accessing needed resources.

Supportive Interventions for

All Stages

For many parents affected by co-occurring disorders

Work with parents to develop standby or temporary

and living below the poverty line, providing adequate

guardianship for their children should the parent

food and shelter for their family may be a more

need to be institutionalized, attend residential

pressing concern than receiving treatment for

treatment, or become incarcerated (10).

Assess familys basic needs, and assist them in

addiction and mental illness (12). These families need

help meeting their basic needs, such as food, housing,

Assist parents in setting up a medical home for

and clothing, as well as transportation, employment,

children, and ensure children are visiting the

healthcare, education, child care, and legal services

doctor regularly for well-checks, in addition to

(34). Providing housing assistance and needed

as-needed care.

clothing and furniture has been shown to effectively

reduce the risk of substitute care placement, as well
as repeated child maltreatment (35). Learning about
community resources for basic needs such as Family
Resource Centers, food banks, and subsidized housing
lists can be invaluable to these families.

Build resiliency in the parent and the child by:

Helping the parent develop consistent and predictable
routines;
Linking both parent and child to a healthy relationship
with a caring and competent adult;
Acknowledging the strengths of both the parents and

Link to Peer Support

the children (6).

Connect mother to a trained peer worker.

Regularly conduct bio-psycho-social assessments

Peer mentors are effective in establishing relationships
with women, providing support and encouragement,

and evaluations on all children in the home, and

refer to needed services (18).

and modeling an appropriate supportive relationship

(3). Peer support upon discharge from a program
can also assist mothers in linking to services and
developing family-friendly activities (6).

Offer long-term (greater than one year) services to

families affected by co-occurring disorders. They
have been shown to have more lasting impact than
short-term intensive services (33).

Provide a multi-disciplinary integrated team to

support the family including a peer worker, masters
level clinician, case manager, and early childhood
mental health specialist (36).

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

13

R E S E A R C H TO P R A C T I C E B R I E F

Supportive Agency Practices

Parents entering treatment for their own problems
present providers with an unusual opportunity to
disrupt intergenerational patterns of substance abuse,
mental health problems, and violence through the
delivery of prevention and treatment services to
children along with parents (5)

Very few agencies and organizations specifically

target children of parents with co-occurring disorders.
Instead, these children are accessing services at a
multitude of locations. Even if an agency predominately serves adults with co-occurring disorders, a
number of policies and practices can be adopted to
provide comprehensive support to clients and their

By adopting a continuum of care for children affected

children. Agencies can:

by parental co-occurring disorders, no single agency

needs to be responsible for the full array of services.

Offer childcare services during a parents outpatient

treatment (10, 37);

Integrate a parenting assessment into the intake

Instead, system-wide collaboration can occur to ensure

that interventions are available and accessible at each
stage of development for children like Peter. Operating

procedure to determine if additional resources such as

in a vacuum is no longer sufficient. Supporting these

parenting interventions and family therapy may be

children requires an understanding of the complexity

warranted (9);

of their strengths and needs, as well as a firm

Create policies for child visitation or co-habitation at

residential treatment facilities whenever possible;

Develop an emergency form that clients can complete

commitment to partner with local agencies and

resources to fill in the gaps. The needs of the family
affected by parental co-occurring disorders transcend

with their case workers that describes the children in the

neatly defined departments, disciplines, and

home, chosen emergency caregivers, and special needs of

organizational scopes. They demand the development

the children should the parents become

of new partnerships, informal support networks, and

incapacitated for any reason (to download a sample form

a commitment to connecting systems that are not

created by Mental Health America of Hawaii, visit

typically aligned.

http://aia.berkeley.edu/media/pdf/crisis_plan.doc)

Account and plan for the clients role as a parent when

conducting treatment and discharge planning (9, 38).

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

14

R E S E A R C H TO P R A C T I C E B R I E F

References

6. Finkelstein, N., Rechberger, E., Russell, L., et al.

(2005). Building resilience in children of mothers

1. Substance Abuse and Mental Health Services

Administration. (2002). Report to congress on the
prevention and treatment of co-occurring substance
abuse disorders and mental disorders. Washington,
DC: Government Printing Office.
2. Luthar, S. & Sexton, C. (2007). Maternal drug abuse
versus maternal depression: Vulnerability and
resilience among school-age and adolescent
offspring. Development and Psychopathology, 19,
205-225. doi:10.1017/S0954579407070113
3. National Abandoned Infants Assistance Resource
Center. (2010). Parenting with substance abuse and
mental illness: Findings from a focus group.
Berkeley, CA.
4. Nicholson, J., Finkelstein, N., Williams, V., et al.
(2006). A comparison of mothers with co-occurring
disorders and histories of violence living with or
separated from minor children. The Journal of
Behavioral Health Services and Research, 33:2,
225-243. doi:10.1007/s11414-006-9015-5
5. VanDeMark, N., Russell, L., OKeefe, M., et al. (2005).
Children of mothers with histories of substance
abuse, mental illness, and trauma. Journal of
Community Psychology, 33, 445-459.
doi:10.1002/jcop.20062

who have co-occurring disorders and histories of

violence. The Journal of Behavioral Health Services
and Research, 32:2, 141-154. doi:
10.1007/BF02287263
7. Whitaker, R. C., Orzol, S. M., & Kahn, R. S. (2006).
Maternal mental health, substance use, and domestic
violence in the year after delivery and subsequent
behavior problems in children at age 3 years.
Archives of General Psychiatry, 63:5, 551-560.
8. Center for Mental Health Services Research (2006).
Families with overlapping needs. Boston, MA:
Hinden, B., Gershenson, B., Williams, V., &
Nicholson, J.
9. National Center for Children in Poverty (2000).
Promoting resilience: Helping young children and
parents affected by substance abuse, domestic
violence, and depression in the context of welfare
reform. New York City, NY: Knitzer, J.
10. New South Wales Department of Community
Services (2009). Dual diagnosis: A resource for case
workers. Ashfield, New South Wales.
11. National Center for Children in Poverty (2004).
Depression, substance abuse, and domestic violence:
Little is known about co-occurrence and combined
effects on low-income families. New York City, NY:
Lawrence, S., Chau, M., & Lennon, M.C.
12. National GAINS Center (2002). Attachment and
reunification: Building parental skills. Delmar, NY:
Karfgin, A.
13. Nikulina, V., Spatz Widom, C., & Czaja, S. (2010).
The role of childhood neglect and childhood poverty
in predicting mental health, academic achievement
and crime in adulthood. Journal of Community
Psychology, 48, 309-321. doi: 10.1007/s10464-0109385-y
14. New South Wales Department of Community
Services (2009). Dual diagnosis: A resource for
foster carers. Ashfield, New South Wales.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

15

R E S E A R C H TO P R A C T I C E B R I E F

15. Hans, S., Bernstein, V., & Henson, L. (1999).

The role of psychopathology in the parenting of
drug-dependent women. Development and
Psychopathology, 11, 957-977.
16. Center for Housing Policy (2011). Should I stay or
should I go: exploring the effects of housing
instability and mobility on children. Washington, DC:
Cohen, R., & Wardrip, K.
17. Jablonski, B. & Jahn Moses, D. (2002,). Nurturing
families affected by substance abuse, mental illness
and trauma: A parenting curriculum for women and
children. Rockville, MD: Substance Abuse and Mental
Health Services Administration.
18. National Center on Substance Abuse and Child
Welfare. Helping child welfare workers support
families with substance use, mental, and
co-occurring disorders. Retrieved from:
http://www.ncsacw.samhsa.gov/training/toolkit/
19. New South Wales Department of Community
Services (2009). Mind the gap: Children whose
parents have a dual diagnosis. Ashfield, New South
Wales.
20. Reupert, A. & Goodyear, M. (2011). Engaging with,
and understanding children whose parents have a
dual diagnosis. Child and Adolescent Mental Health.
Malden, MA.
21. Barker, E., Jaffee, S., Uher, R., & Maughan, B. (2011).
The contribution of prenatal and postnatal maternal
anxiety and depression to child maladjustment.
Depression and Anxiety, 28:8, 696-702. doi:
10.1002/da/20856
22. National Abandoned Infants Assistance Resource
Center (2006). Effects of prenatal substance
exposure on infant and early childhood outcomes.
Berkeley, CA.
23. Grella, C. (1997). Services for perinatal women with
substance abuse and mental health disorders: The
unmet need. Journal of Psychoactive Drugs, 29:1,
67-78. doi: 10.1080/02791072.1997.10400171
24. Future of Children (2009). Preventing child abuse

25. Pajulo, M., Pyykkonen, N., Kalland, M., et al. (2011).

Substance abusing mothers in residential
treatment with their babies: Postnatal psychiatric
symptomology and its association with mother-child
relationship and later need for child protection
actions. Journal of Psychiatry, 65:1, 65-73.
26. National Abandoned Infants Assistance Resource
Center (2011). Effects of parents mental health
issues on children: A Literature review. Berkeley, CA:
Branom, C.
27. Bernstein, V. J., Jeremy, R. J., & Marcus, J. (1986).
Mother-infant interaction in multiproblem families:
Finding those at risk. Journal of the American
Academy of Child Psychiatry, 25, 631-640.
28. Center on the Social and Emotional Foundations for
Early Learning. Infant mental health and early care
and education providers. Nashville, TN.
29. Claus, R. E., Orwin, R. G., Kissin, W., Krupski, A.,
Campbell, K., & Stark, K. (2007). Does
gender-specific substance abuse treatment for
women promote continuity of care? Journal of
Substance Abuse Treatment, 32, 27-39.

and neglect with parent training: Evidence and

opportunities. Princeton, NJ: Barth, R.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu

Supporting Children of Parents with Co-occurring Mental Illness and Substance Abuse

16

R E S E A R C H TO P R A C T I C E B R I E F

30. Hinden, B., Biebel, K., Nicholson, J., et al. (2006). A

survey of programs for parents with mental illness and
their families: Identifying common elements to build the
evidence base. Journal of Behavioral Health Services &
Research, 21-38.
31. Woodside, M. (1988), Research on children of alcoholics:
past and future. British Journal of Addiction, 83, 785792.
doi: 10.1111/j.1360-0443.1988.tb00513.x
32. Conners, N., Bradley, R., Whiteside, L., et al. (2004).
Children of mothers with serious substance abuse
problems: An accumulation of risks. The American
Journal of Drug and Alcohol Abuse, 30:1, 85-100.
33. Brunette, M. & Dean, W. (2002). Community mental
health care for women with severe mental illness who are
parents. Community Mental Health Journal, 38:2, 153-165.
doi: 10.1023/A:1014599222218
34. Substance Abuse and Mental Health Services
Administration. Promoting Recovery: Women with
children and youth. Washington, DC. Retrieved from
http://www.samhsa.gov/co-occurring/about/women_with_
children_and_youth.aspx

The National Abandoned Infants Assistance Resource

Centers mission is to enhance the quality of social

35. Choi, S. & Ryan, J. (2007). Co-occurring problems for

substance abusing mothers in child welfare: Matching
services to improve family reunification. Children and

and health services delivered to children who

are abandoned or at risk of abandonment due to the
presence of drugs and/or HIV in the family by

Youth Services Review, 29:11, 1395-1410. doi:

10.1016/j.childyouth.2007.05.013
36. Morrow, C., Mansoor, E., Hanson, K., et al. (2010). The

providing training, information, support, and resources

starting early starting smart integrated service model:

to service providers who assist these children and

Improving access to behavioral health services in the

their families. The Resource Center is located at the

pediatric health care setting for at-risk families with

University of California at Berkeley, and is a service

young children. Journal of Child and Family Studies, 19:1,

of the Children's Bureau.

42-56. doi: 10.1007/s10826-009-9289-z

37. Mental Health America. Invisible Childrens Project.
Alexandria, VA.
38. Women, Co-Occurring Disorders and Violence

AUTHOR:
Amanda Hopping-Winn, MSW, National AIA Resource Center
The author wishes to thank the members of the AIA panel

Coordinating Center. Parenting issues for women with

co-occurring mental health and substance abuse
disorders who have histories of trauma. Delmar, NY.

on Children of Parents with Co-occurring Disorders for

reviewing and contributing ideas to this publication.

National Abandoned Infants Assistance Resource Center

University of California, Berkeley
http://aia.berkeley.edu