Resilience in children of parents with mental illness, alcohol or substance misuse—An integrative review

Abstract

Aim

The aim of this integrative review was to investigate how resilience has been researched and explore experiences of resilience, in children of parents with mental illness or alcohol or substance misuse.

Design

An integrative review.

Method

The search included three major electronic databases, PubMed, Scopus and PsycINFO with the aim of identifying peer‐reviewed studies where the concept of resilience was explored as resilience, coping, adaptation or protective factors.

Results

Out of 4016 studies, 14 were included after meeting predetermined criteria and methodological quality evaluation. The findings are presented in five categories: characteristics of the studies, operationalization and interpretation of resilience, individual resources, family resources and resources outside the family.

Patient or public contribution

Resilience in children of parents with mental illness or substance misuse refers to coping strategies, protective factors and absence of symptoms or risk behaviour despite being exposed to risk. We suggest a three‐level approach for mapping of resilience resources in the target group: the individual level, family level and outside of the family that includes both non‐professionals and professionals. The use of disengagement or avoidance strategies implies poor resilience but may be necessary in absence of support, as acts of self‐preservation during chaotic periods or harmful situations.

1. INTRODUCTION

Growing up with a parent with mental illness, alcohol or substance misuse is associated with several and varying difficulties. Children of parents with severe mental illness are at risk of feeling shame and sorrow and experience stigma and bullying and facing the negative effects of trying to keep the situation a secret from others (Dam & Hall, 2016). Children of parents with alcohol problems experience similar feelings, while longing for change and facing the burden of having to parent the parent or taking responsibility for household chores and younger siblings (Dam & Hall, 2016; Tinnfält et al., 2018; Yamamoto & Keogh, 2018). In a Swedish study (Wahlström, Magnusson, et al., 2023), adolescents (10–18 years of age) of heavy‐drinking parents have also been reported to show higher levels of somatic and psychological complaints and an increased likelihood of reporting stress, compared with those having moderate‐drinking parents. However, these living conditions imply a complex web of feelings that also involve compassion, affection and empathy when seeing the parent mentally unwell (Dam & Hall, 2016) and joy when doing fun activities together with a loving parent (Tinnfält et al., 2018).

Determining the prevalence of children of parents with mental illness or alcohol or substance misuse is a starting point for public health goals to improve and protect the health of this specified population. An Australian epidemiological study reported mental health problems in 37% of all primary carers of children 4–17 years of age (Johnson et al., 2018). The prevalence in an Australian Child and Adolescent Survey of Mental Health and Wellbeing, child anxiety disorders, major depressive disorder or attention deficit and hyperactivity disorder (ADHD) or conduct disorder was 3.5, 3.4 and 2.5 times higher respectively for children with parents with any mental disorder compared to children in which parents had no diagnosis (Johnson et al., 2018). A study of Swedish population‐based registers including more than 1.5 million children 0–17 years of age showed that the exposure of maternal or paternal mental illness was associated with higher rates of injuries than in children of parents without mental illness (Nevriana et al., 2020). Another nationally representative sample of Swedish youth aged 15–16 years (n = 5576) revealed that a total of 13.1% of the sample had at least one problem‐drinking parent during adolescence (Ramstedt et al., 2022), accompanied by an elevated risk of psychosomatic problems and poor general health compared with other children.

These studies from Western cultures and contexts show that the proportion of children growing up under these conditions is not negligible. Therefore, identifying these children requires collaborative efforts from psychiatric nurses, paediatric nurses, school nurses and nurses in general, but also teamwork with other health and social care professions. Nurses also play a pivotal role in identifying and supporting families facing adversity and have an obligation to intervene whenever a child may be at risk to meet the health and social needs of these children (Fraser et al., 2010; International Council of Nurses, 2021). The target group presented here is heterogenous regarding their parents' conditions but the similarities between these children are evident concerning their mutual challenges, risk and stress exposure and feelings involved (Hall et al., 2021).

From early on, children begin to develop skills needed to recover from stress and cope with traumatic events. The concept of resilience is used to describe this resistance (Hornor, 2017). Although the concept itself is given shifting descriptions in the literature, there is no universal empirically based definition of resilience. Instead, it is described as a contextual and dynamic process that is ever‐changing and not a static trait of an individual (Aburn et al., 2016). Hornor (2017) describes resilience as a dynamic concept, underlining that this view opens for responsiveness to interventions. According to Greenberg (2006), three types of protective factors are associated with resilience (i) individual characteristics, (ii) the quality of the relationship in the family and (iii) broader environmental characteristics (Greenberg, 2006). Rutter (2013) states that having good health outcomes despite facing adversity is an indication of resilience. Moreover, Rutter (1999) describes resilience in children facing adversity to be inclusive of protective factors and coping that function on the individual, family and environmental level. Hornor (2021) distinguishes between adaptive and maladaptive coping, where adaptive means active planning and reframing while maladaptive implies avoidance or distraction. There are, thus, nuances in the theoretical literature but also evident commonalities. Protective factors, coping and adaptation reappear in the literature and a multilevel perspective are commonly used to describe their function on resilience. Therefore, the aim of this literature study was to investigate how resilience has been researched and explore experiences of resilience in children of parents with mental illness or alcohol or substance misuse. The focus here lies on the age group between 6 and 24 years, and the terms children (6–9), adolescents (10–19) and youths (20–24) will be used to distinguish different periods within this group. The term children will be used with reference to the entire age span or when age is unspecified.

2. MATERIALS AND METHODS

The integrative review methodology described by Whittemore and Knafl (2005) was applied and chosen as it allows for the inclusion of primary sources of qualitative, quantitative and mixed method studies, enabling a comprehensive understanding of the topic of enquiry (Whittemore & Knafl, 2005). The integrative review methodology also commonly allows for inclusion of theoretical studies. However, the foci of this review was on the operationalization of resilience and not a further theoretical exploration of the concept of resilience itself.

Focus for this review was children, adolescents and youths 6–24 years of age to parents with mental illness or alcohol or substance misuse. The inclusion criteria were as follows: (i) studies where the concept of resilience was explored as resilience, coping, adaptation or protective factors, (ii) peer‐reviewed, (iii) original articles, (iv) written in English and published from 2014 to 2023. Exclusion criteria consisted of (i) literature reviews, (ii) study protocols, (iii) guidelines, (iv) articles using the umbrella concept of adverse childhood experiences (ACE) or adverse family experiences (AFE) to describe the context and where parents with mental illness or alcohol or substance misuse couldn't be distinguished from other variables included in ACE or AFE, (v) intervention studies where the target group of 6–24 years of age could not be distinguished within the study populations, (vi) studies where the concept of resilience and its synonyms were only mentioned in the background or discussion/conclusion.

2.1. Search strategy

Three major electronic health‐related databases were included for the literature search: Public Medline (PubMed), PsycINFO and Scopus. Qualified university librarians performed a systematic literature search in March 2020, preceded by a pilot search before the formal search was conducted. Three search blocks were used: (1) resilience (2) mental illness or alcohol or substance misuse and (3) parents. Truncation (*) was used to get all possible inflections to the stem of words. The Boolean operator OR was used to extend the search so that all relevant synonyms were covered and the operator AND was finally used to concatenating the three blocks in the search strategy. In PubMed, the Medical Subject Headings (MESH) with automatic explode were used, and the equivalent MAIN SUBJECT added with exact. explode was used in PsycINFO. An updated search with identical search strings was performed at the end of August 2023.

The following keywords were used for the first block: Resilien*, adaptation/adaptablity, protective factor*, coping, coping behaviour. The second block used: mental disorders, mental illness*, mental problem*, psychiatric disorder*, psychiatric illness*, psychiatric disorder*, psychiatric illness*, psychiatric problem*, alcohol abuse, alcohol addict*, alcohol problem*, alcoholic, alcoholism, drug abuse, drug addict*, drug problem*, substance abuse. The third block used: parent*, parents.

2.2. Study selection and assessment of methodological quality and content

As depicted in Figure 1, a flow chart diagram inspired by Moher et al. (2009) was followed. Database searches identified 4016 articles, whereof 576 were excluded as duplicates. By following inclusion and exclusion criteria for eligibility, two authors screened the remaining 3440 articles by reading titles and abstracts resulting in the exclusion of 3354 articles, and multiple rounds of author discussions were held to discuss any upcoming doubts about eligibility or exclusion. The remaining 86 articles were then screened by all four authors, and another 51 articles were excluded. Thirty‐five studies were read in full text and assessed for eligibility, resulting in the exclusion of 17 studies. Eighteen studies were then assessed for methodological quality by using the templates and checklists for observational and qualitative studies from the Swedish Agency for Health Technology Assessment and Assessment of Social Services (Swedish Agency for Health Technology Assessment and Assessment of Social Services, 2021). This assessment of the methodological quality of the included studies was done in pairs and resulted in the exclusion of four studies with poor quality. The evaluation of quantitative studies concerns risk of bias; sampling; drop‐out; quality of measurement; analysis; transparency. For qualitative studies, the evaluation concerns theoretical framework; participants; data gathering; analysis; transparency; reflexivity. The data analysis for integrative reviews as proposed by Whittemore and Knafl (2005) was applied in parallel with methods for content analysis suggested by Miles and Huberman (1994) for the data analysis of the 14 included articles. Data were sorted by variables and subgroups and displayed in a matrix to facilitate comparison between subgroups, for example, the aim of the studies, sample size and age of the children, how parental mental illness or substance misuse was identified, and which resilience factor was used. Qualitative and quantitative articles were initially analysed separately and then merged. In the final analysis, patterns and themes were discerned, which facilitated the structuring into the five categories. All authors were actively involved during the analysis and discussions were held regarding patterns and themes until consensus was reached.

FIGURE 1.

PRISMA flow chart diagram of the literature search and screening of articles published from January 2014 to August 2023.

3. RESULTS

The 14 included articles are summarized in Table 1. The analysis resulted in five categories describing: characteristics of the studies, operationalization and interpretation of resilience, individual resources, family resources and resources outside the family.

TABLE 1.

Characteristics and scientific quality of studies.

Authors (year), country	Study design	Sample size and study population	Aim	Questionnaire	Risk factor	Resilience factor	Scientific quality*
Bartsch et al. (2015), Australia	Qualitative Thematic analysis	64 clinicians	To explore the potential impact of a parental diagnosis of BPD on offspring and protective factors	—	Parental diagnosis of borderline personality (BPD)	Protective factors	Good quality
Collishaw et al. (2016), United Kingdom	Quantitative longitudinal	262 children and adolescents 9–17 years at baseline	To identify protective factors that predict sustained good mental health in adolescents with a parent with depression and to test whether this contributes beyond what is explained by parent illness severity	SDQ‐25, perceived social support scale, IYFP scale, generalized self‐efficacy scale	Parental diagnosis of recurrent major depression	Protective factors	High quality
Evans et al. (2015), USA	Quantitative longitudinal study	129 children‐parent, 7–17 years old.	Examine the relations among stressful life events, coping, and depressive symptoms in children at varied risk for depression	COPE inventory	Parental depression	Coping	Accepted quality
Kahl and Jungbauer (2014), Germany	Qualitative in‐depth interviews	34 children and adolescents 8–18 years old	To investigate challenges and coping strategies of children with parents affected by schizophrenia	—	Parental schizophrenia	Coping	Good quality
Küçük et al. (2020), Turkey	Quantitative quasi‐experimental and controlled pre‐test post‐test evaluation	40 adolescents, 20 in experimental and 20 in control group, 12–18 years old	To determine the effectiveness of a psychoeducation program that was developed to improve the coping skills and increase the psychological resilience and children/adolescents with a parental psychiatric disorder	Adolescent psychological resilience scale (APRS) and Kidcope	Parent psychiatric disorder	Resilience and coping	High quality
Monti and Rudolph (2017), USA	Quantitative longitudinal	n = 165, mean age = 12.43 years, SD 1.18.	To examine the independent and interactive contributions of maternal depression and youth stress responses to trajectories of youth depression in adolescence	Responses to stress questionnaire (RSQ‐PD)	Maternal depression	Coping	High quality
Nijjar et al. (2014), Canada	Quantitative cross‐sectional	74 offspring of parents with bipolar disorder and 75 control offspring. (Mean age 19.38 years, SD 3.56)	To examine differences in personality traits, coping style, and risk‐taking behaviour between the OBD and controls, and to compare these psychosocial profiles in offspring who have developed an affective disorder with those who have not	Coping Inventory for stressful situation (CISS)	Parental Bipolar disorder (DSM), no other current disorder	Coping	High quality
O'Connor et al. (2014), UK	Mixed method, in‐depth interviews and	Children and parents from 27 families 14–18 years old interviewed alone. 13–21 when with parents	To provide insights into children's experiences of growing up with substance misusing parents subject to statutory child protection interventions	SDQ‐25, Family Environment Scale	Parental substance use	Protective factors	Accepted quality
Palumbo et al. (2022), USA	Qualitative descriptive evaluation following intervention	9 adolescents, 12–17 years old	The purpose of this study was to better understand the experiences and needs of youth who have lived with a parent with opioid use disorder	—	Parental opioid use disorder	Resilience and coping	Good quality
Sipler et al. (2020), UK	Quantitative pre‐ and post‐intervention evaluation	199 children and adolescents, 8–19 years old	To explore whether the intervention can build resilience in children and young people affected by parental substance misuse and mental health problems	The Resilience Scale for Adolescents (READ)	Parental substance misuse and mental health problems	Resilience and coping	Accepted quality
Trondsen and Tjora (2014), Norway	Qualitative, action research framework and analysis of interviews through an inductive issue‐focused approach	13 adolescents, 15–18 years old (all girls)	To explore the role of a Norwegian online self‐help group for adolescents with a mentally ill parent	—	Parents suffered from severe mental illnesses such as bipolar disorder, experienced psychotic periods, and attempted suicide	Coping	Good quality
Van Loon et al. (2015), Netherlands	Quantitative Longitudinal	Children 11–16 years old of parents n = 112 Comparison group n = 122 One parent and one child per family participated	To get insight into factors that protect children with parents with mental illness from developing internalizing and externalizing problems	Coping list for adolescents, UCL‐A, Self‐esteem Scale	Parents with depression, anxiety disorder, and/or alcoholism	Protective factors and coping	High quality
Wangensteen and Westby (2019), Norway	Qualitative Narrative In‐depth interviews	Five young adults 21–24 y of age	To explore the narratives of young people regarding the circumstances that protected and supported them as they grew up around parental SUD during their childhood	—	Parental substance use disorder (SUD)	Protective factors	Good quality
Watson et al. (2014), USA	Quantitative longitudinal	180 parent‐child dyads 9–15 years old	To examine concurrent and prospective relations between observed parenting behaviours and children's coping strategies in the context of a preventive intervention designed to change both parenting and children's use of secondary control coping	Responses to stress questionnaire (RSQ‐PD)	Parental depression	Coping	High quality

^* Swedish Agency for Health Technology Assessment and assessment of Social Services template for evaluation of scientifical quality of qualitative and quantitative studies (Swedish Agency for Health Technology Assessment and Assessment of Social Services, 2021).

3.1. Characteristics of the studies

The articles were published between 2014 and 2022 and were conducted in the United States (4), Germany (1), Netherlands (1), Australia (1), Norway (2), Canada (1), Turkey (1) and the United Kingdom (3) (Table 1). Qualitative methods were used in five studies, whereof three were based on interviews with children and adolescents (Kahl & Jungbauer, 2014; Trondsen & Tjora, 2014; Wangensteen & Westby, 2019), one study was based on verbal response, field notes and observations (Palumbo et al., 2022) and in one study, 64 clinicians were interviewed (Bartsch et al., 2015). Eight studies used quantitative methods (Collishaw et al., 2016; Evans et al., 2015; Küçük et al., 2020; Monti & Rudolph, 2017; Nijjar et al., 2014; Sipler et al., 2020; Van Loon et al., 2015; Watson et al., 2014) and one study was mixed methods (O'Connor et al., 2014).

Children and adolescents growing up with parental alcohol or substance misuse were the target groups for three of the studies (O'Connor et al., 2014; Palumbo et al., 2022; Wangensteen & Westby, 2019) while two studies targeted mental illness or substance misuse (Sipler et al., 2020; Van Loon et al., 2015). The remaining nine studies focused on children of parents with mental illness. The parental mental illnesses included borderline personality (Bartsch et al., 2015), schizophrenia (Kahl & Jungbauer, 2014), schizophrenia and depression (Küçük et al., 2020), bipolar disorder (Nijjar et al., 2014), recurrent depression (Collishaw et al., 2016; Evans et al., 2015; Monti & Rudolph, 2017; Watson et al., 2014) and parents that had attempted suicide or diagnosed with bipolar disorder or psychotic events (Trondsen & Tjora, 2014).

3.2. Operationalization and interpretation of resilience

Eight quantitative studies investigated resilience in children of parents with mental illness or substance misuse. Resilience was operationalized in three distinct ways but used in different combinations between the studies. First, absence of symptoms, risk behaviour or mental illness, despite increased risk was used to operationalize resilience in the children and adolescents (Collishaw et al., 2016; O'Connor et al., 2014). Second, resilience factors or protective factors were described as individual resources and external facilitators for building resilience or mediating the impact of adversity (Collishaw et al., 2016; Küçük et al., 2020; O'Connor et al., 2014; Sipler et al., 2020; Van Loon et al., 2015; Watson et al., 2014). Examples of Individual resources or internal protective factors were self‐esteem and self‐disclosure (Van Loon et al., 2015), adaptation and empathy (Küçük et al., 2020) and personal and social competence (Sipler et al., 2020). The indicators used to assess external protective factors concerned family responsiveness or warmth (Collishaw et al., 2016; Watson et al., 2014), family support or cohesion (Küçük et al., 2020; O'Connor et al., 2014; Sipler et al., 2020; Van Loon et al., 2015) and peer relationships (Collishaw et al., 2016), peer support and school support (Küçük et al., 2020) and social resources (Sipler et al., 2020). Third, resilience was operationalized through three different forms of coping skills: primary control coping or active coping, secondary control coping or passive coping, and disengagement coping or avoidance (Evans et al., 2015; Küçük et al., 2020; Monti & Rudolph, 2017; Nijjar et al., 2014; Van Loon et al., 2015; Watson et al., 2014).

The studies based on qualitative methods interpreted resilience as either protective factors or coping strategies or both. All studies recognized the extensive and difficult conditions and risk factors for developing emotional and dysfunctional problems for children living with and growing up with parental mental illness or alcohol or substance misuse. However, to also recognize protective factors as transacted to the child and having a potential as mediators of a child's risk of dysfunction was the starting point for Bartsch et al. (2015), studying the context of children living with a parent with a diagnosis of borderline personality. Kahl and Jungbauer (2014) explored the available problem‐solving and emotion‐focused coping strategies that children growing up with a parent with schizophrenia applied when their daily life was challenged by unpredictability and escalating conflicts. Coping through the support of an online self‐help group for adolescents whose parents had a mental illness was the starting point for Trondsen and Tjora's (2014). Wangensteen and Westby's (2019) starting point on the other hand, was the concept of resilience in the sense that resilience is a result of the interaction of various protective factors. The target group in Wangensteen and Westby's (2019) was youths growing up with parental substance misuse. The study by Palumbo et al. (2022) explored resilience in children of parents with substance misuse disorder (SUD) and highlighted social support and ways to cope in their interpretation of resilience. Interventions promoting resilience in children and adolescents at risk of entering out‐of‐home care due to parental substance misuse were the basis for the study by O'Connor et al. (2014). The presence or absence of protective factors and the means of children's and adolescent's adaption and coping to their living conditions were all factors that were taken into consideration in this mixed method study. Only two of the eight quantitative studies used scales that explicitly measured resilience, the adolescent psychological resilience scale (Küçük et al., 2020) and the Resilience Scale for Adolescents (Sipler et al., 2020).

3.3. Individual resources

The individual resources that children and adolescents reported on and described as protective in relation to growing up with parents with mental illness or substance misuse were several. Resources such as self‐efficacy (Collishaw et al., 2016), self‐esteem and self‐disclosure (Van Loon et al., 2015) were found to be protective against mental health problems for children and adolescents of parents with mental illness or substance misuse. In the study by Bartsch et al. (2015), clinicians working with the target group described that a calm temperament, intelligence and good social skills characterized what they perceived to be resilient children. The use of different coping strategies as resources was investigated in four quantitative studies, making distinctions between primary control coping, secondary control coping and disengagement coping (Evans et al., 2015; Monti & Rudolph, 2017; Nijjar et al., 2014) or active and passive coping, or alternatively avoidance coping (Küçük et al., 2020; Van Loon et al., 2015). The results showed that children who exercised primary control (or active) coping also reported fewer depressive symptoms (Evans et al., 2015; Monti & Rudolph, 2017; Van Loon et al., 2015) but that this type of coping was less frequently used in children of parents with mental illness compared to controls (Monti & Rudolph, 2017; Nijjar et al., 2014). In the mixed‐methods study by O'Connor et al. (2014), children and adolescents described primary control coping strategies by taking on the role of the parent, caring for their own parent and sometimes their siblings. This was interpreted as a sense of agency that gave the adolescents strength. In the study by Kahl and Jungbauer (2014), similar problem‐solving strategies were described by children (8–18 years old) of a parent with schizophrenia, where they for example tried to guide their parent through episodes of hallucinations, taking on the caring role. Two studies (Küçük et al., 2020; Sipler et al., 2020) assessed the effect of interventions aimed to increase resilience in adolescents in the target group and found a statistically significant increase in personal competence and structured style after intervention (Sipler et al., 2020) and active and avoidance coping after the psychoeducation, compared to controls (Küçük et al., 2020).

Coping strategies such as denial or avoidance were found to predict mental health problems in children of parents with depression (Evans et al., 2015; Monti & Rudolph, 2017). Children who used disengagement coping strategies maintained elevated yet stable levels of depressive symptoms over time (Monti & Rudolph, 2017) but also reduced their risk of being exposed to stressors through this behaviour (Evans et al., 2015). In the study by O'Connor et al. (2014), the adolescents described how they avoided the chaotic home environment actively to protect themselves and their own mental health. Despite this, among the included adolescents of parents with a substance misuse, 38% reported levels of mental health problems synonymous with serious clinical problems (O'Connor et al., 2014). In the study by Kahl and Jungbauer (2014), children and adolescents described how they tried to ignore stressful situations and how daydreaming was used to distance themselves from their situation. An optimistic attitude, hope for the future and acceptance of one's situation were interpreted as protective individual resources (Kahl & Jungbauer, 2014). Adolescents also described how aspirations for the future, academic success, or job opportunities were coping strategies (Palumbo et al., 2022). Avoidance coping such as distraction and wishful thinking was also seen to increase among the adolescents who attended a psychoeducation intervention aimed to strengthen resilience (Küçük et al., 2020). Among children with a parent with schizophrenia, acceptance of one's situation predicted fewer depressive symptoms in adolescents (Evans et al., 2015). Adolescents that had a parent with bipolar disorder engaged in more sexual risk behaviour than adolescents in the control group, interpreted as a distraction strategy (Nijjar et al., 2014).

3.4. Family resources

Children and adolescents growing up with parental mental illness or alcohol or substance misuse pointed out family resources acting side by side with the difficulties these families go through. Protective parental characteristics were recognized in several of the studies (Bartsch et al., 2015; Collishaw et al., 2016; Kahl & Jungbauer, 2014; Watson et al., 2014) and family support and cohesion were highlighted in the two intervention studies, showing how psychoeducation programs may strengthen family resources (Küçük et al., 2020; Sipler et al., 2020). Bartsch et al. (2015) described protective parental characteristics comprised of the parent's capacity for self‐reflection on their own illness, and how this could have an impact on their child, but also parents' willingness to engage in treatment in relation to the severity of their symptoms. A co‐parent who didn't have a mental illness, a sibling, or another extended family member such as a grandparent or aunt were also described as protective resources. The adolescents in the study by Palumbo et al. (2022) had varying experiences of their substance‐using parent, but most described their parent as someone who managed to take care of their basic needs despite active drug misuse. Collishaw et al. (2016) and Kahl and Jungbauer (2014) mentioned the importance of the co‐parents support, while Collishaw et al. (2016) also declared the importance of the ill or diagnosed parent's ability to express emotions as associated with good mental health in the children growing up with parental mental illness. In the study by Kahl and Jungbauer (2014), children and adolescents described both parents as important resources when they were in difficult situations, i.e., this applied to the parent who was diagnosed with schizophrenia and the healthy parent since the attachment to both parents played an important role. In similarity to the study by Bartsch et al. (2015), siblings provided mutual support to each other and grandparents and uncles and aunts would offer to help whenever the sick parent was hospitalized (Kahl & Jungbauer, 2014). The extended family was described as resourceful also by playing a kind of survival role during certain periods when parents for example were using substances (Palumbo et al., 2022). O'Connor et al. (2014) described case examples where children were protected by living with grandparents during such periods. Wangensteen and Westby (2019) found that youth who were moved to foster homes or residential care saw this as a necessity that offered a relief from the insecurity and instability of their home while providing safe living conditions. They found it painful and complicated, but necessary. The youths furthermore stated that it was important to maintain close relationships with their biological parents, who were also described as loving, while grandparents and foster parents helped them to deal with their emotions. In the study by Van Loon et al. (2015), the findings stated that one in four adolescents who had a parent with mental illness did not live with both biological parents.

3.5. Resources outside the family

Supportive environments outside the family were also valuable protective and resilient factors for the children (Kahl & Jungbauer, 2014; Palumbo et al., 2022; Trondsen & Tjora, 2014; Wangensteen & Westby, 2019). This could be a person in the community that would function as an informal role model that offered a stable social connection, for example a schoolteacher, coach, youth worker or police officer. In contrast, adolescents described differing opinions about receiving more formal professional support (Kahl & Jungbauer, 2014). While some children did not want to be involved in the parental mental illness more than necessary, others judged family therapy as beneficial. Healthcare professionals were seen as resourceful for the children and adolescents of parents with schizophrenia by explaining facts about the diagnosis, thus increasing their mental health literacy, and they could also promote their ability to reduce stress. The findings of the two intervention studies (Küçük et al., 2020; Sipler et al., 2020) found increased overall resilience after children were given information and education about existing support and where further help could be reached.

In the study by O'Connor et al. (2014), the parents had a substance misuse of alcohol and/or different kinds of narcotic drugs and the families had experienced social protection interventions. The narratives by the adolescents went back eight to 10 years in time. Half of the children under the age of 18 years still had an allocated social worker and a quarter of all children had been permanently moved to kinship, foster or adoptive families. The participating adolescents valued support from friendly professionals with whom they had developed a relationship over time, but also the accessibility whenever needed. In similarity with the findings of Kahl and Jungbauer (2014), the importance of developing a better understanding of their parent's substance misuse was highlighted by the adolescents and the importance of having someone who was interested in their education and future aspirations. In the study by Wangensteen and Westby (2019), the participating five youths growing up with parental substance misuse highly valued professionals to talk to both during childhood and young adulthood. They explained it as necessary to be able to process adverse experiences, to strengthen their self‐esteem and to better understand their parents' substance misuse. However, they also stated that this help was initiated far too late in their life. Trondsen and Tjora (2014) investigated the resourcefulness of an online self‐help group for adolescents aged 15–18, where 13 participants who had a parent with severe mental illness met anonymously during a 2‐year period on the Internet. Through messages in the forum, the adolescents described a feeling of being able to share their experiences with “online peers” who in contrast to other peers genuinely understood their experiences. By recognizing others' experiences and feelings as like their own, it provided a sense of being “normal” despite living in an unusual family situation. The online forum's availability at all hours was particularly helpful for dealing with their own emotions, supported a more active opportunity to manage family situations and gave them hope. Several of the participants were also encouraged to seek help more actively from health professionals after the participation in the forum group.

4. DISCUSSION

This literature study explored and added to the research on resilience among children and adolescents who grow up with parents with mental illness or with alcohol or substance misuse. The main results revealed that resilience is regarded as a process where quantitative studies either focus on snapshot evaluations of children's situation compared to controls or aim to determine trajectories and what characterized the children's mutual differences related to protective factors or the use of coping strategies. In contrast, the qualitative studies put emphasis on depictions of protective factors and the use of coping strategies to describe variations in resilience. It is evident that a view of resilience as a journey through adversity is prominent in this research field.

4.1. Operationalizing and interpretation of resilience

As previously pointed out by Aburn et al. (2016) there is no commonly agreed definition of resilience used stringently in research, which was evident also in our integrative review. We identified three themes in the conceptualization of resilience in relation to the target group, in contrast to the five themes presented by Aburn et al. (2016), however, there were some commonalities. Resilience in the studies identified here was defined, assessed or interpreted through; absence of symptoms despite presence of risk; use of problem‐solving coping strategies, primarily distinguished between adaptive or maladaptive; and presence of internal and external protective factors. These themes resemble resilience as described by Rutter (2013) who points out that “Resilience is an interactive phenomenon that is inferred from findings indicating that some individuals have a relatively good outcome despite having experienced serious stresses or adversities – their outcome being better than that of other individuals who suffered the same experiences” (p. 474) and that coping, mental features and social relationships are features associated with resilience. Our findings reveal a particular interest in adaptive and maladaptive coping when investigating resilience in children of parents with mental illness or substance misuse. Although coping has been argued to be a concept separate from resilience (Compas et al., 2001), they are often used interchangeably to include both the process of adaptation and the outcomes of the same. The fact that many of the children and adolescents included in the studies in this review are currently living in an extended period of adversity, as opposed to being exposed to a single adverse event, may explain the interest in coping as a mean to identify vulnerability. Coping processes may, thus, serve as a good indication of striving towards resilience among these children. In contrast, when resilience is operationalized through snapshots of for example children's own mental health problems in comparison to control groups, this may lead to conceptually flawed conclusions due to its' disregard for the resilience process and past and future events. Furthermore, the influential and interactive nature of biological, cognitive and social factors on the development of coping (Compas et al., 2001) may be another explanation to the high interest of coping strategies for this target group since the gene–environment interactions are highly relevant in relation to both mental illness and substance misuse.

Disengagement coping, avoidance or maladaptive responses were described as a negative coping strategy in the results of our literature review, except in one study where avoidance was interpreted as a necessary coping strategy in a stressful environment (Küçük et al., 2020). The notion that disengagement coping is negative seems to be influenced by conceptual and empirical literature on coping strategies where adaptive coping or problem‐solving strategies are described as indicative of stronger resilience, while disengagement strategies are associated with lower competence (Compas et al., 2001). We concur that such strategies are negative from an objective perspective but that they may be a necessity in times of distress, and indicative of self‐preservation behaviour rather than something consciously self‐destructive. Although research speaks in favour of self‐efficacy and self‐esteem to be a prerequisite for engagement coping (Rodriguez & Loos‐Sant'Ana, 2015; Sagone et al., 2020), there is less convincing evidence of this association within this target group. If supportive resources within the family, among peers or from professionals are absent, this may deter the opportunity or ability to put internal resources to good use, especially since many children of parents with mental illness or substance misuse face long‐term adversity. We propose that a rhetorical shift is made when discussing coping strategies, that softens the view of maladaptive coping, to reduce potential victim‐blaming and existing stigma. This is perhaps especially important in children of parents with substance misuse since there likely exists unreported cases and that identification of these families may be more difficult than those dealing with mental illness. Research shows that parental substance misuse equates to a considerable risk for the child in terms of safety, health, and well‐being (Raitasalo & Holmila, 2017).

4.2. Resilience resources

Another finding of this study is the dual role of the family that crystallized from the analysis of the selected studies. Although the family was portrayed as a source of distress and uncertainty by the children in this context, the family also offered a supportive and protective environment, by holding resources that the children considered crucial for coping with life. This support could be provided by the co‐parent, a sibling, or close relative, but also the mentally ill or misusing parent. The findings show that ill or misusing parents that had the ability to express warmth and responsiveness towards their child during episodes of less severity positively impacted the child. This impact was described in interviews (Collishaw et al., 2016; Kahl & Jungbauer, 2014) and synonymous with lower self‐reported symptom load (Collishaw et al., 2016; Watson et al., 2014). This was corroborated by the findings of Palumbo et al. (2022) where adolescents described a desire to remain in the homes of their biological parents despite adversity. Many also felt betrayed by social workers or their relatives for relocating them to foster homes. These findings elucidate an ambiguity that children may experience towards the mentally ill or substance‐using parent, which is important to consider and acknowledge considering the combination of genetic and environmental factors that potentially transmit risk to children. Heritability, inclusive of both genetics and social behaviour, is a major factor for the understanding of risk in children of parents with mental illness (Beardslee et al., 2012; Rodriguez & Loos‐Sant'Ana, 2015) or substance misuse (Rhee et al., 2003). While the children suffer disproportionately from mental health problems, many manage to cope well despite presence of risk (Mowbray et al., 2004), which is reflected in our results as well.

The individual resources that were indicative of resilience in the children were self‐efficacy (Collishaw et al., 2016), self‐esteem and self‐disclosure (Van Loon et al., 2015). This link between self‐beliefs and resilience has been investigated and discussed in other research where coping strategies indicative of resilient adolescents, for example, engagement, are associated with self‐efficacy (Rodriguez & Loos‐Sant'Ana, 2015; Sagone et al., 2020), self‐esteem (Rodriguez & Loos‐Sant'Ana, 2015) and self‐disclosure (Zhen et al., 2018). Each type of self‐belief is believed to play a particular role in relation to resilience and coping, with implications for how vulnerable adolescents interpret situations as adversity or not, how they evaluate their response and whether they may benefit from them (Rodriguez & Loos‐Sant'Ana, 2015; Zhen et al., 2018). These children experience difficulties such as lack of information and openness; unpredictability and instability; fear; loneliness; and loss and sorrow, and while this group is often considered vulnerable, they are also portrayed as active agents in managing their life (Trondsen & Tjora, 2014). Our findings reveal, however, that internal resources may not be sufficient to protect adolescents from mental health problems, but that an accumulation of resources or protective factors is vital for their own well‐being and possibility to rise from adversity. Family, peer, and professional support enables the children to share, learn and cope together with others, each context contributing with unique features that help the children cope with their situation.

The findings of this integrative review are in accordance with other research that show parental mental illness to be linked to deficient family functioning, which is associated with more conflicts, less adaptability and cohesion and a disorganized pattern of everyday planning (Wiegand‐Grefe et al., 2019). Several of the studies here conclude that for this reason, interventions that target the family as a whole unit are necessary, as opposed to a focus on either the parent or the child (Bartsch et al., 2015; Collishaw et al., 2016; O'Connor et al., 2014; Trondsen & Tjora, 2014; Van Loon et al., 2015). However, the intervention studies included in this review (Küçük et al., 2020; Sipler et al., 2020) showed the potential in child‐focused psychoeducation to strengthen resilience.

While a family‐focused care is advocated in several of the studies, it is imperative that nurses who meet these children and adolescents in a nursing context, consider the child or adolescent's needs to be heard of and listen to, even without the parents' presence. This is because children have the right to express their opinion and be heard in all matters concerning them, according to article 12 in the United Nations Convention on the Rights of the Child (UNCRC; UNICEF, 1989). This can be done by inviting the child or adolescent to a health conversation, first without the parent's presence, and then having a conversation together with the parent. According to article 18 in UNCRC (UNICEF, 1989), both parents share responsibilities for the upbringing and development of the child and the best interests of the child will be their basic concern. Furthermore, authorities shall provide parents with appropriate support and assistance to care for their children. However, in article 19 it is also stated that protective measures should be considered whenever children face risk of for example neglect. The parents, thus, need to be empowered and offered support and resources to be able to practice good parenting despite a tough situation. Our findings show that a family focus would also imply giving children an understanding of what their ill parent is going through and give them a language to be able to communicate their concerns and, thus, increase their health literacy. Reupert et al. (2012) have demonstrated similar results that emphasize the importance of specific support to both children and parents within a family‐focused approach. The researchers studied children of parents with dual diagnoses i.e., both mental illness and alcohol or substance misuse, and found that children require support in developing adaptive coping strategies while their parent needs specific support to address their substance abuse.

A family focus may also be advantageous to identify and nurture internal resources of the child. A cross‐national evaluation of national strategies for family‐centred support reveals that long‐term planning of care and follow‐up provided by primary care mental health professionals with all members of the family (found in Australia and Finland for example) may have the greatest potential for empowering children, supporting families and for evaluation of offered interventions and treatment (Beardslee et al., 2012). The findings of this review add that offering targeted interventions to strengthen resilience in the child has good potential for empowering vulnerable children and adolescents.

4.3. Methodological considerations

The integrative review design, used in this study, was seen as a strength as it provided an opportunity to assemble a state‐of‐the‐art map of both quantitative and qualitative studies on resilience among children of parents with mental illness or alcohol or substance misuse. There are some limitations. One of these is the ambiguity of the concept resilience. Several of the initially identified articles were excluded because the concept of resilience was mentioned only briefly in the background, discussion, or conclusion (Figure 1). The inclusion of the terms; protective factors, coping or coping behaviour and adaptability/adaptation was based on their reappearance in literature on resilience (Aburn et al., 2016; Greenberg, 2006; Hornor, 2017; Rutter, 1999, 2013). There are, of course, other terms that could have been included to widen the array of studies within this research field. The terminology was, however, purposefully chosen for the identification of articles focusing on resilience in the target group, which may be considered a strength. Another strength of this study was that the analysis was conducted in a rigorous and systematic manner. The search procedure was assisted by librarians and undertaken in three major electronic health‐related databases, of which an initial pilot search was followed by the formal search. The inclusion and exclusion process included the reading of all titles and abstracts by two authors and the full text assessment for eligibility was made by all four authors. A further strength was that the remaining full‐text articles (n = 18) were assessed for methodological quality with recognized templates for quantitative and qualitative studies respectively (Swedish Agency for Health Technology Assessment and Assessment of Social Services, 2021). The review templates are a support in the assessment of methodological quality in quantitative and qualitative studies, for example to determine the risk of bias, i.e., the risk that the effect is over‐ or underestimated as a result of shortcomings in the implementation and reporting of the studies. This procedure resulted in four articles being excluded for different reasons, for example, small sample in quantitative design or poorly articulated resilience outcome. In the final included articles (n = 14), three had accepted quality, five had good quality and six had high quality. The predetermined criteria and the detailed description of the process strengthen the confirmability and trustworthiness of this review study, which also enhances its reproducibility.

A limitation of the study is that almost all studies and samples represented what could be labelled traditional Western cultures, which may have a limited transferability to other cultural settings where for example help‐seeking is viewed differently, and stigma is more or less strong. Other research has shown similar findings and concluded that intercultural differences are important to consider when studying resilience in multicultural settings (Blessin et al., 2022). There have been multiple studies over the past 25 years focusing on resilience and protective factors among children of parents with alcohol as shown by two systematic reviews (Park & Schepp, 2015; Wlodarczyk et al., 2017) but fewer studies of such character were evidently published over the time period applied in this study according to our findings. The transferability of our results to other cultures and the group of children of parents with substance misuse should therefore be interpreted with caution. We acknowledge the need for continued research on interventions and good practices to strengthen resilience in children with a parent with mental illness or substance misuse. Moving forward, cultural differences should be explored and highlighted.

5. CONCLUSIONS

The findings of this review support resilience as a multifactorial concept, with each factor contributing with valuable information in the exploration of children growing up with parental mental illness, alcohol or substance misuse. Considering that many of these children are living in ongoing and long‐term adversity, we concur that consideration of coping strategies offers important information and that problem‐solving or active coping may be indicative of strong resilience. On the other hand, the negative view of maladaptive coping needs to be nuanced and seen as a, sometimes, necessary act of self‐preservation in chaotic and harmful situations when external support is absent. Although the family itself is the very source of adversities for the child, the family also hold resilience resources that need to be acknowledged and mapped to be able to tailor interventions that targets the whole family. Resilience resources outside the family are not only limited to individual relationships but may also be attached to contexts such as schools, sports organizations, leisure activities or online platforms or groups. On the contrary, continuity in the personal therapeutic relationships seems to be of great importance for these children, highlighting the responsibilities of social services, nurse practitioners and politicians to create sustainable work conditions and sufficient financial resources. A view of resilience as the absence of mental health problems or risk behaviours despite the risk that these children are exposed to provides limited information by itself and needs to be accompanied by mapping of protective factors and/or coping strategies in the investigation of resilience.

5.1. Implications

This integrative review concludes that there are three primary levels of resources connected to resilience in the child: the individual child's resilient resources, the parent's and the family's resources, and resources outside of the family. We suggest that adopting this approach may be beneficial to the identification and mapping of resilience‐promoting resources and function as a contrast to the traditional assessment of risk and deficiency. Embracing this, along with a view of resilience as a process, is a starting point to enable the strengthening of resilience in these children in practice.

AUTHOR CONTRIBUTIONS

Conceptualization, M.G.A., J.M.N., P.S. and S.R.; Methodology, M.G.A., J.M.N., P.S. and S.R.; Screening of articles, M.G.A. and S.R.; Formal analysis, M.G.A., J.M.N., P.S. and S.R.; Writing—original draft preparation, M.G.A., J.M.N., P.S. and S.R. Writing—review & editing, M.G.A., J.M.N., P.S. and S.R; Funding acquisition; M.G.A. and J.M.N.

FUNDING INFORMATION

This research was funded by the Laholm municipality, grant number S2019/166.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest. The funders did not have any role in the study design, data collection, management, analysis, or interpretation of the data.

RESEARCH ETHICS COMMITTEE APPROVAL

Not applicable.

PATIENT CONSENT

Not applicable.

Ahlborg, M. G. , Nygren, J. M. , Svedberg, P. , & Regber, S. (2024). Resilience in children of parents with mental illness, alcohol or substance misuse—An integrative review. Nursing Open, 11, e2219. 10.1002/nop2.2219

DATA AVAILABILITY STATEMENT

Not Applicable.