Judges’ views on making decisions in family law cases that feature a parent with a mental illness

Abstract

This study explores the complexities and challenges Australian judges face when making decisions in Family Court cases involving parents with a mental illness under the Family Law Act 1975 (Cth). Within an Interpretative Phenomenological Analysis framework, interviews were conducted with six Australian family court judges. Findings highlight the primary focus on child safety, the intricate interplay of mental illness, substance abuse and family violence, and the critical role of evidence from mental health professionals. The results underscore the need for accessible mental health treatment, robust support systems and evidence-based assessments, as well as efforts to address barriers such as stigma and affordability that hinder parents’ access to care. The findings of this study suggest that further research on parental mental illness in family law cases would be beneficial for both professionals and users of the family law system.

Introduction

Family court cases involving children often include complex issues, such as parental mental illness (Kaspiew et al., 2015). Given that judges are the decision-makers in these cases, it is important to explore how they approach evidence of parental mental illness when considering parenting orders.

This article reports on a study that explored the challenges that family court judges face when making decisions about children’s post-separation care and their views about the needs of the parents with mental illness and their children. The article begins by outlining the legislative provisions that guide judicial decision-making in Australian family law and the theoretical framework used by the research team to interrogate the empirical data collected. The methodology and findings are then presented, followed by a discussion of their implications for policy and practice.

The legislative framework for decision-making in parenting cases

Judicial decision-making in litigated matters is shaped by legislative frameworks and professional inputs. Judges of the Federal Circuit and Family Court of Australia (FCFCOA) Courts are required to apply the provisions of Part VII of the Family Law Act 1975 (Cth) when making orders about the children’s post-separation care. Section 60CA sets out the guiding principle that ‘the court must regard the best interests of the child as the paramount consideration’. This ‘paramountcy principle’ is further supported by a list of factors in Section 60CC, which judges must consider when determining appropriate parenting arrangements. While there is no reference to a parent’s mental health, the list contains several factors of potential relevance to this issue. At the time of the interviews for this study, these included the benefit to the child of having a meaningful relationship with both parents (s 60CC(2)(a)); the need to protect children from harm (s 60CC(2)(b)); any views expressed by the child (s 60CC(3)(a)); the capacity of each parent to provide for the child’s emotional needs (s 60CC(3)(f)); and the attitude to the responsibilities of parenthood demonstrated by each of the child’s parents (s 60CC(3)(i)).

In assessing these legislative factors, judges are typically supported by family reports prepared by Court Child Experts (CCEs) or external consultants with relevant qualifications (Federal Circuit and Family Court of Australia, FCFCOA, 2024b). These reports draw on interviews with the parents and, depending on their age, interviews with, or observations of, the children. Where a parent’s mental health is alleged to pose a risk to a child’s safety or wellbeing, judges often receive a report and hear testimony from the person’s treating health professional as well as independent expert witnesses (FCFCOA, n.d.-b). Judges may also benefit from input provided by an Independent Children’s Lawyer appointed by the relevant Legal Aid Commission to represent the child’s interests (FCFCOA, n.d.-c). These inputs are critical features of the decision-making process in parenting matters, as judges’ deliberations are otherwise constrained by the evidence presented by the parties to the dispute.

Parenting arrangements typically involve decisions about living arrangements, decision-making responsibilities, and maintaining parent–child relationships. In Australia, most arrangements are resolved informally (69%) or through mediation (10%) (Kaspiew et al., 2015). Despite the public attention that litigated cases attract, only around 3% of applications for final orders proceed to court (Kaspiew et al., 2015). Those that reach a final hearing tend to involve a mix of co-occurring concerns, including allegations of family violence, substance abuse and mental illness (FCFCOA, 2024a; Kaspiew et al., 2015).

The theoretical framework for exploring judicial decision-making

Scholarly analyses of judicial decision-making have tended to reflect a mix of normative and descriptive accounts of legal reasoning (Riesthuis, 2023), with a focus on how judges interpret and apply the law (Barry, 2020). Recent family law scholarship has also incorporated analyses that pay attention to the influence of social science knowledge on parenting decisions (Rathus, 2018), while the Australian Law Reform Commission (Australian Law Reform Commission (ALRC), 2021) has investigated the influence of heuristics and social biases.

Risk-based reasoning can become a central organising principle for decisions related to children, particularly in matters involving family violence, mental illness and/or parental capacity (Bastian et al., 2022; Eriksson et al., 2022). In the Australian family courts, the concept of risk can be seen in measures such as the Family Law Act 1975 (Cth) requirement to prioritise children’s safety from harm, and in early risk screening and specialist court lists for family violence and child abuse matters (FCFCOA, n.d.-a).

Given the complexity of influencing factors and the potentially long-term consequences of family law decisions, this study uses life course theory as a conceptual lens to situate judicial decision-making within broader social, developmental and institutional contexts (Laub et al., 2016). Life course theory emphasises the interplay between individual characteristics, social structures and historical contexts (Elder et al., 2003) and can be used to highlight how key events, such as parental separation, shape life trajectories over time. In this study, it supports an understanding of how judicial decisions affect families beyond the immediate case, by considering the timing, sequence and context of events, as well as the broader constraints that influence outcomes.

It is important to note that the conduct of this study occurred at a time of significant change in the Australian family law system. The interviews were conducted shortly after the introduction of the Federal Circuit and Family Court of Australia Act (2021), which brought together the former Family Court of Australia and Federal Circuit Court of Australia under a single administrative structure called the FCFCOA. It also renamed the two federal family courts, with the Family Court becoming the FCFCOA (Division 1) and the Federal Circuit Court becoming the FCFCOA (Division 2). The Act also created a single point of entry to the two courts for family law cases. This shift saw the Courts introduce a new case management pathway, which prioritised early risk assessment and reports on children and triaged matters into the Evatt List (for high-risk cases) or dispute resolution conferences as appropriate (FCFCOA, n.d.-a).

The interviews were also completed before the 2023 amendments to Part VII of the Family Law Act 1975 (Cth.) came into effect in May 2024, which simplified the list of factors used to assess children’s best interests. These reforms were designed to address the complications associated with the previous 13-factor list of considerations while maintaining its focus on children’s safety from harm. While the core concerns raised by judges remain relevant, the timing of the study may have influenced how they described their role and priorities.

Parental mental illness in family law

Research on parental mental illness highlights its prevalence and potential impact on families. Approximately 23% of children have a parent with a mental illness (Maybery et al., 2015), while around 3.8% of parents are affected by more severe mental illnesses such as schizophrenia and personality disorders (Stambaugh et al., 2017). Mental illness can affect parenting capacity and is often compounded by other challenges, including family violence, substance misuse and socioeconomic disadvantage (Adjei et al., 2022; Pierce et al., 2020). Children who have a parent with a mental illness are at increased risk of social, emotional and behavioural vulnerabilities (Dean et al., 2018) and of developing a mental illness themselves (van Santvoort et al., 2015). However, parental mental illness does not inherently undermine parenting capacity, and appropriate supports and interventions can enhance parenting and child outcomes (Seeger et al., 2022).

Parents with a mental illness are disproportionately represented in family court proceedings. The most recent Annual Reports of the FCFCOA Courts indicated that 61% of parenting cases in the previous year involved allegations that a party’s mental health issues had caused harm to a child or posed a risk of harm (FCFCOA, 2024a). A North American study by Salzer et al. (2021) found that 39% of 596 surveyed parents with a serious mental illness were involved in parenting disputes in the family courts; among this group, 88% reported that their mental health was raised as an issue in the proceedings. Recent research also indicates that the fear of losing custody was a significant concern for parents who experience mental health challenges (Harries et al., 2023; Reupert et al., 2021). This fear exists among parents who had previously experienced child removal as well as those who were anxious about the possibility (Harries et al., 2023).

Stigma and systemic barriers contribute to the challenges parents with a mental illness face in engaging with the court. Court processes can exacerbate distress, particularly when mental illness is shaped by experiences of family violence (Holford et al., 2023). Parents often report both internal and external stigma in court settings and express concern that their mental illness could affect the outcome of their case (Holford et al., 2023; Powell et al., 2020). These concerns may reduce disclosure and help-seeking (Harries et al., 2023; Reupert et al., 2021). Viewed through the lens of life course theory, these experiences reflect how cumulative disadvantage can shape trajectories and constrain agency (Dannefer et al., 2016).

A scoping review by Holford et al. (2023) noted a small but growing body of research on parental mental illness in family law, highlighting that only one study to date (Powell et al., 2020) has focused specifically on parents with a mental illness. While other studies have analysed published judgments in parenting cases, there remains limited empirical research on judges’ experiences of decision-making (Holford et al., 2023). This study, which forms part of a larger project examining how parents and professionals perceive and navigate challenges in family law cases involving parental mental illness, aims to address this gap.

Method

The following section outlines the methodological approach for this study, including the research design, participant recruitment, data collection and analytic process.

Research design

Interpretative phenomenological analysis (IPA) was used to guide this study, selected for its capacity to facilitate rich and flexible data collection (Smith et al., 2009). This qualitative research methodology focuses on exploring participants’ experiences while acknowledging that the researcher’s interpretation is crucial to the analytical process (Larkin & Thompson, 2012). It has previously been used for studies involving complex decision-making (Anderson et al., 2019).

Recruitment

Participants were invited to take part in the study via a formal letter written by the authors and distributed through the FCFCOA’s email system. To be eligible for the study, participants were required to have at least five years’ experience as a judge, a criterion set by the FCFCOA ethics committee to ensure an adequate breadth of judicial experience. Upon receiving the invitation, six family court judges contacted the researchers and volunteered to participate in the study.

IPA’s idiographic approach means small sample sizes (3–10 participants) are recommended to facilitate in-depth analysis of individual experiences (Smith et al., 2009). The sample size of six participants aligns with IPA guidelines, ensuring rich data collection while accounting for the relatively small number of eligible judges in the FCFCOA. A larger sample size could risk diluting the depth of individual experiences, which would be contrary to the aims of IPA (Eatough & Smith, 2017).

Participants

Interviews were conducted on the basis that participants would not be identified. For this reason, only limited demographic information is included. The participants came from four Australian states. They reported that between 50 and 80% of their cases involved matters related to children. Most participants indicated that about 50% of these cases involving children featured allegations or evidence of parental mental illness, with approximately 15% involving serious mental illness. As previously mentioned, all participants had over five years of experience on the bench, with some possessing significantly more.

Participants were asked about the training they had received regarding mental illness. Four described both formal and informal training opportunities, such as plenary sessions at judicial conferences and professional development events. Participants noted that informal discussions with colleagues were another way of sharing knowledge. Additional training methods included conferences, reading scholarly papers, participating in webinars and attending judicial education sessions. Reflecting the range of issues judges face in parenting matters, the content of this training covered a range of topics, such as recognising the signs of mental health conditions in both adults and children, understanding trauma, specific personality disorders and the implications of mental illness within the context of family violence.

Data collection

An interview schedule was developed based on prior research, the researchers’ professional experiences and IPA guidelines. Semi-structured interview questions were refined following a pilot interview and subsequent discussions with the FCFCOA ethics committee. The final interview schedule (refer to Appendix A) centred on the participants’ experiences of hearing specific cases, the kinds of issues that arise in cases involving parental mental illness, decision-making outcomes of these cases and recommended supports for judges, parents and children.

Prior to the interviews, participants were asked to sign a consent form online. The interviews were then conducted by the first author, with four taking place online and two in person, depending on the location and preferences of the participants. Each interview lasted between 40.17 and 59.11 minutes (M = 48.66, SD = 7.18). One participant was interviewed twice, initially as a pilot and subsequently to clarify points discussed during the pilot interview based on the final interview schedule. All scheduled questions were asked, supplemented by open-ended follow-up questions to allow participants to clarify and expand on their responses. The interviews were transcribed by the first author.

Following transcription, member checking was conducted by sending de-identified transcripts to each participant, along with an invitation to make necessary amendments and additions and to remove any potentially identifying details. Three transcripts were returned with minor edits, which were adopted, two were returned without edits, and two participants did not reply. The interview data were stored on a secure, password-protected drive.

Data analyses

IPA was used to analyse the transcripts, aiming to produce a detailed and interpretive account of participants’ experiences (Smith et al., 2009). The process began with familiarisation of the interviews, during which each transcript was read alongside the audio recording to provide close attention to tone, phrasing and emphasis, and to deepen engagement with participants’ accounts. Descriptive, linguistic and interpretive comments were recorded using Microsoft Word’s comment function, allowing analytic observations to be linked directly to the data. Transcripts were revisited multiple times to support increasingly interpretive engagement (Larkin & Thompson, 2012; Smith et al., 2009). Each interview was first analysed as a standalone case to maintain idiographic focus, before themes were compared and integrated across participants.

Themes were developed by interpreting initial analytic notes and identifying shared experiential or conceptual content. This involved moving between individual extracts and the broad narrative, focusing on how meaning was conveyed and what appeared significant to participants (Eatough & Smith, 2017; Larkin & Thompson, 2012). This approach reflects IPA’s double hermeneutic, in which the researcher seeks to make sense of how participants make sense of their experiences, while also recognising that the researcher’s own perspective inevitably shapes the interpretation (Smith et al., 2009).

Themes were refined through iterative reading and comparison, with attention to convergence and divergence across accounts (Nizza et al., 2021). As the analysis progressed, the development of new themes ceased, indicating that sufficient conceptual depth had been reached and the data were considered saturated. Saturation was understood not as the absence of new material, but as the point at which further analysis no longer yielded additional interpretive value (Low, 2019).

Themes were then reviewed, reorganised or merged to ensure clarity and coherence, while preserving the nuance of individual accounts. The final analysis was structured into a narrative, supported by illustrative quotes tagged by participant number (i.e. P1, P2), and refined through repeated engagement with the data and analytic notes to support consistency, transparency and fidelity to participants’ accounts (Nizza et al., 2021).

Results

Five main themes were constructed: (a) Theme 1, complexity of cases, (b) Theme 2, decision-making: a safeguarding exercise, (c) Theme 3, the role and sources of evidence, (d) Theme 4, having a mental illness during the court process, and (e) Theme 5, judicial recommendations. The main themes and the corresponding subthemes are summarised in Table 1.

Table 1.

Themes and subthemes.

Theme	Subtheme
Theme 1. Complexity of cases
Theme 2. Decision-making: a safeguarding exercise	2.1. Safeguarding and risk mitigation
	2.2. Treatment and insight
	2.3. Parental capacity and functioning
Theme 3. The role and sources of evidence	3.1. Evidence from the parents’ treating health professional
	3.2. One-off assessments from psychiatrists and psychologists
	3.3. Family reports
	3.4. Observing parents and legal presentation in court
Theme 4. Having a mental illness during the court process	4.1. Mental illness can impact engagement
	4.2. Stigma
	4.3. Inequity and engagement
	4.4. Litigation as an exacerbating factor
Theme 5. Judicial recommendations	5.1. Support for parents
	5.2. Support for children
	5.3. Accessible and quality mental health assessments

Theme 1. Complexity of cases

Participants noted the complexity of parenting cases that reach a final hearing in the FCFCOA courts. This complexity took several forms, including cases that involved multiple risk factors. As one participant described, mental illness was rarely the only issue of concern present, highlighting, ‘It’s rare . . . that it’s just mental health. There are usually other risk factors that arise [and] they’re often part of a bigger picture’ (P2). Other participants highlighted that family violence and substance abuse often co-occur with mental illness, creating what one judge called a ‘three-way cocktail’ (P5). Participants suggested that these co-existing issues tended to exacerbate the parent’s mental illness, creating ‘a picture of dysfunctionality’ (P2).

Several participants indicated that it was not uncommon for both parents to be affected by poor mental health. As one judge explained, ‘In the majority of cases where mental health issues arise, both parents will have had some form of mental health issue’ (P6). It is important to note that participants indicated it was relatively rare for such cases to involve a serious mental health condition. However, P5 highlighted that cases concerning parental mental illness nevertheless consume a significant amount of court time, noting, ‘In terms of the amount of time they take in court, and the amount of time they take in writing judgments, they’re the most complex matters to deal with’.

Theme 2. Decision-making: a safeguarding exercise

This section discusses the key issues that were identified as important when determining the best interests of the child in cases involving parental mental illness. As noted above, at the time of the interviews, the Family Law Act required judges to consider a large number of factors, including the benefit to the child of having a meaningful relationship with both parents, the need to protect children from harm (including from family violence) and the capacity of each parent to provide for the child’s emotional needs. The considerations highlighted in the interviews, along with the contexts in which they arise, are discussed across three subthemes: 2.1. safeguarding and risk mitigation; 2.2. treatment and insight; and 2.3. parental capacity and functioning.

2.1. Safeguarding and risk mitigation

The interviews showed that participating judges, consistent with the legislative framework, prioritised protecting children from harm by assessing risk and considering whether it could be mitigated. In parenting cases featuring parental mental illness, participants suggested that their primary concern was to ensure children’s physical, psychological and emotional safety and wellbeing. As P6 stated, ‘At the end of the day you need to make a decision on the best interest of the child not the parent and you need to protect the child from harm’. As part of this exercise, participants described considering the protective measures needed to ensure a safe environment for children. In doing so, they assessed whether it was possible to preserve the parent–child relationship without compromising the child’s safety. For example, P2 described cases where a parent’s mental illness is not being appropriately managed:

Where mental health issues raise their head, when they’re untreated, and there’s behaviours that are a real concern . . . [we need to consider] are there interventions and protections that you can put in place that ameliorate that risk to a level that that relationship can continue?

Participants explained that in cases where they were not satisfied protections could be put in place to safeguard the child, parents might have reduced time, or in some cases no time, with their child. Participants were aware of the difficulties this can cause for families, particularly where there is a close relationship between the child and their parent. One participant, for example, spoke of a case in which the parent ‘was really genuine in her love for the child, but she just couldn’t manage’ (P1). Participants described cases where the parent’s genuine bond with the child was evident, but concerns about their capacity remained, as particularly difficult for them.

2.2. Treatment and insight

As required by the Family Law Act, another key consideration for judges in parenting cases is the attitude to the responsibilities of parenthood demonstrated by each parent (s 60CC(3)(i)). In line with the requirement, participants described considering whether the parent had engaged meaningfully in treatment for their mental illness, with engagement being closely tied to perceptions of insight and risk reduction. As one participant explained, ‘I think somebody who’s getting some counselling assistance . . . that’s a positive, because it’s somebody showing “I need some help’’’ (P1). Participants viewed active participation in mental health care as an indication of a parent’s commitment to their own wellbeing and, by extension, their child’s welfare. The consensus among participants was that willingness to engage in treatment markedly reduces the risks to the child, as it demonstrates that the person has some insight into their illness and its impact on their parenting capacity. As P2 put this, it shows the parent is ‘being honest . . . and being open to accepting what’s being suggested in the context of [their] treatment’.

In a similar way, participants described the adverse implications of a lack of willingness to engage in treatment. As P4 observed, ‘Without insight, and willingness to be treated, it’s very difficult for improvements to be made’. The concept of insight was primarily discussed in terms of understanding the flow-on benefits of treatment adherence for the child’s wellbeing. For example, one participant noted, ‘There are often those who don’t get it and are reluctant to engage or pursue the treatment. Sadly, for them and, you know their kids. It impacts everything’ (P4).

Participants also noted that a person’s refusal to continue treatment can sometimes be the trigger for the other parent’s application for parenting orders, as P3 explained, ‘When people aren’t compliant with therapy . . . what happens is that the other parent just says, sorry, you’re not seeing the kids’ (P3). The interviews indicate that participants considered not only the parent’s past treatment adherence but also their future commitment to therapy. In their experience, a history of harmful or risky behaviours combined with an unwillingness to engage in treatment often resulted in orders limiting the person’s time with their child. As one participant explained the reasoning for this, ‘Primarily, because they aren’t going to be able to change and bring to the table what it is that the kids need for them to be a positive influence in their lives’ (P2).

Participants noted that a lack of insight can often be a symptom of a severe mental illness, such as borderline personality disorder or schizophrenia. P5 observed that parents with such conditions may struggle to appreciate the need for treatment simply ‘because they’re suffering from mental health issues’. Similarly, P6 reported that some parents with schizophrenia ‘lack insight into the needs of their children to be protected from the recurrence of their illness’. Reflecting the concern that treatment refusal can often be the impetus for the other parent’s application to the courts, P2 indicated that ‘the ones that have the insight have the treatment, and we don’t see them is the reality’.

2.3. Parental capacity and functioning

In addition to risk and treatment engagement, participants also considered the impact of mental illness on a parent’s day-to-day functioning and capacity to meet the child’s needs. At the time of interview, the list of relevant Family Law Act factors that decision makers were required to consider included the capacity of each parent to provide for their child’s emotional needs (s 60CC(3)(f)). In accordance with this requirement, a key question for participants was whether ‘the nature of this illness is such that it prevents a person from being an effective parent?’ (P3).

Rather than focusing on whether the person’s specific diagnosis impacted their parenting capacity, participants reported being concerned with the ‘implications of a diagnosis’ (P6). This included how the illness impacted the parent’s practical and emotional availability to their child, whether the parent’s behaviour presented risks, whether these risks could be mitigated and whether the illness could be managed effectively. P3 explained that the impacts of mental illness on parenting capacity could present on a spectrum, from ‘emotionally blank with the children, to terrible things like abducting them and frightening them’. However, participants noted that mental illness did not necessarily affect a person’s ability to function as a responsible parent. P1, for example, noted that mental illness is not always a ‘a serious issue going to parental capacity’.

As part of their assessment of parental capacity, participants also considered the fluid and changeable nature of mental illness. Decisions were shaped not only by the parent’s current presentation, but by the likelihood of future changes and the need to create orders that could respond over time. Thus, in their decision-making, participants acknowledged that some mental illnesses may fluctuate over time, and that their orders needed to plan for this. P4 stressed the importance of ‘tailor[ing] a result for the fact that there are likely to be issues that arise from time to time’. Similarly, P6 emphasised the need for outcomes that supported the ‘sustainability of parenting capacity’, considering both the parent’s historical behaviour and anticipated future scenarios.

Participants differed in their approaches to ensuring a child’s wellbeing in the context of changes in a parent’s mental health. Some, such as P6, described the use of orders that required parents to maintain contact with mental health professionals as a risk mitigation measure, suggesting, ‘You might have to make an order contingent upon first maintaining the professional relationship with a treating practitioner’. P3 noted that Australian therapists are mandated to report if they believe a child is at serious risk of harm, commenting, ‘Quite frequently [they] will report [that] this person is decompensating, something is going wrong, they could be a danger to the children’. Conversely, P1 did not favour the use of such orders, arguing that tying a parent’s time with their child to therapy adherence could ‘undermine’ the therapeutic relationship. P1 continued by stressing that decisions on parental access should be judicial, not therapeutic, stating, ‘That’s my job, not their job’. Instead of making therapy a condition for seeing their children, P1 suggested that families could return to court if circumstances changed.

When assessing changes in a parent’s mental health, the presence of informal supports, such as trusted family and friends, were viewed as a protective factor for the child. P1 related that in some cases ‘the difference can be if there’s a supportive family member’. This was especially true if the family member understood the presentations of the mental illness, was trusted by the other parent and was ‘prepared to come forward’ (P3) and ‘let [the other parent] know if the parent becomes unwell’ (P1). Although the presence of family support positively influenced outcomes for the parent, participants recognised that those with mental illness often lacked such supports. P3 described cases where a parent’s family supports have ‘just given up on them, saying I can’t do this anymore,’ describing these situations as some of ‘the worst cases’ they encountered in their role.

Theme 3. The role and sources of evidence

Participants emphasised that sound decision-making was contingent on the quality and type of information available to them. As one participant explained, ‘I can’t assume I understand any of this stuff. I have to have evidence’ (P3). More importantly, P3 highlighted that ‘the evidence has to come from people who are actually experts in the field of mental illness, and we’re not’. To demonstrate this, P1 recounted a situation where a mother regained primary care of her children after a severe episode of mental illness, suggesting that without ‘medical reports . . . it would have been hard for me to be satisfied it was safe to return the children to the mother’s care’. P3 also highlighted the critical role of expert evidence in fashioning protective arrangements for children, explaining that if they did not ‘know how [they] can put in place a regime that will protect this child from the parents’ mental illness . . . it’s probably going to be a no contact case, and that’s really tragic’. Continuing this theme, P3 noted that when there is a lack of evidence about the parent’s mental illness, decision makers tend to err on the side of caution.

Across the interviews, participants reflected on the strengths and limitations of various evidentiary sources, including mental health professionals, one-off assessments, family reports and courtroom observation. These reflections are presented across four subthemes: 3.1. evidence from parents’ treating health professionals; 3.2. one-off assessments from psychiatrists and psychologists; 3.3. family reports; and 3.4. observing parents and legal presentation in court.

3.1. Evidence from parents’ treating health professionals

Five participants discussed their experiences of obtaining evidence from parents’ treating mental health professionals, namely a psychologist or psychiatrist who had worked directly with the parent. Some considered this evidence particularly valuable, as it could offer a longitudinal view of the parent’s mental health and treatment progress. As P6 stated, ‘I’m usually more helped by a . . . psychiatrist [who knows the parent], if I can get their notes or their evidence’. They suggested that having treating professionals present evidence allowed for a historical understanding of the parent, including ‘how regularly they’ve been going [to treatment], whether they’re confident that the client has been taking their medication or following up in recommendations’ (P6). The significance of this evidence was not in the content of the sessions with the treating professional but in the parents’ attendance record and adherence to medication.

Other participants were more cautious about the reliability of treating professional’s evidence. Several participants raised concerns that treating practitioners could present a one-sided view. P3 commented that, ‘There are circumstances where treating doctors can be really useful and frankly, they can be the opposite’. Some voiced frustration with professionals who appeared biased in favour of their patients, becoming a ‘barracker for the client’ (P2). There was also a suggestion that some service providers prioritised the parent’s wellbeing over the child’s. P3 pointed out that the evidence that treating health professionals present is ‘only as good as that which the parent gives them’. P3 elaborated that while treating professionals give a singular perspective, judges can evaluate all evidence, including discrepancies in the data provided to the court from different sources of evidence.

Participants also noted an ethical tension in requesting evidence from treating professionals. On one hand, their input could provide critical insight into parental functioning; on the other, involving them might compromise the therapeutic relationship. For example, P2 emphasised that while evidence from the treater is often crucial for the case, the client’s long-term wellbeing remained paramount ‘because [treatment is] the one thing that has to keep going’. Nonetheless, evidence of treatment adherence was essential to make informed decisions. One participant noted that relying solely on the service provider for evidence could create a dilemma, particularly ‘if involving them is going to undermine their clinical relationship’ with the parent (P6). Nonetheless, P6 added, ‘sometimes, that’s really the only evidence we can get’.

3.2. One-off assessments from psychiatrists and psychologists

Participants also discussed the use of one-off psychiatric and psychological assessments as a source of evidence. These were typically conducted by professionals who were not the parent’s regular treating practitioner. Some participants regarded these as particularly valuable. For P3, having a ‘child and family psychiatrist’ appointed by the court, who prioritises the best interests of the child, was the most valuable form of evidence. Similarly, P1 emphasised the usefulness of psychiatric reports and having ‘someone with that expertise conducting the assessment’.

Not all viewed one-off psychiatric reports as valuable. Participants raised concerns that the limited time spent with the assessor would not provide information useful for making parenting orders. P6 queried the validity of one-off psychiatric and psychological assessments, as a client may ‘present for a 2- or 3-hour interview with a psychiatrist and not exhibit any behaviour or responses to questions that would establish they have a mental health illness’. Some participant raised concerns about the validity of some quantitative assessment tools, suggesting they may not be well suited to the court environment, where individuals are often distressed and responding under pressure. As P4 noted, such tools were not ‘developed in a litigation context where people are under the stresses of litigation’. P4 argued that parents are also more likely to show a response bias and try to appear favourably given the family court context.

Notwithstanding these concerns, P1 stated that ‘psychological assessments can give you indications about functioning and vulnerabilities’. Likewise, P4 acknowledged that ‘[one-off assessments are] better there than not there’. As with evidence from service providers, participants emphasised that even limited or imperfect assessments were often preferable to having no information at all, particularly given the need to make timely decisions about children’s safety and wellbeing.

3.3. Family reports

Family reports, prepared by court appointed CCEs or external Family Consultants, also contributed to participants’ understanding about a parent’s mental illness. These reports were considered valuable for exploring how the mental illness interplayed with wider family dynamics and the parent–child relationship. P5 indicated that, ‘Reports give us a great deal of insight in relation to the family dynamic, but particularly to the children’s perspective, and in terms of mental health issues, that can be gold, really, from our point of view’.

Participants noted that those who write family reports may not have expertise in mental health issues specifically and thus focused less on the presentation of a parent’s mental illness. Family reports instead focused on how the symptoms of the parent’s mental illness affect family dynamics, especially the child–parent relationship. Some participants expressed the view that family reports should be used in conjunction with an assessment from a mental health professional. However, they noted this was not always feasible due to financial and accessibility constraints.

3.4. Observing parents and legal presentation in court

As part of their reflections on evidentiary sources, participants discussed the information available through observing parents directly in court and the ways that lawyers presented mental health evidence during proceedings. Accordingly, participants valued observing parents in court, noting that direct interaction often helped to illustrate the parent’s current mental state. This kind of direct access was not always easy to obtain, with one participant suggesting that ‘it’s almost a situation where, if they weren’t being filtered through their lawyer, I would have a better insight into their assessment of their condition’ (P5). P5 described a case where a mother, managing long-term mental illness and representing herself, spoke directly to the participant about her health. The participant noted how helpful it was for the mother to articulate ‘the condition and the impact that had upon her parenting’.

Participants discussed the different approaches employed by lawyers when presenting evidence about mental illness in court. P6 found ‘an increasing awareness from lawyers [about the need] to raise the issue [of parental mental illness]’ and attributed this to an increase of mental illness knowledge in wider society. P5 also pointed out that lawyers are now ‘more attuned to trying to get some proper evidence’ when discussing mental illness.

Not all participants felt that lawyers discussed mental illness in a helpful or well-informed manner. P1 noted that some lacked competence in handling mental illness evidence, citing a ‘problematic’ case where a lawyer took therapy notes out of context, stating, ‘It was just clear he just didn’t understand how therapy works’. Another participant suggested that some lawyers appeared to play an active role in limiting the amount of information the court received about their client’s illness, noting that there are ‘legal representatives who do everything they can to make sure that I don’t get a proper view of them’ (P6).

Theme 4. Having a mental illness during the court process

This theme outlines the practical and systemic challenges that participants identified for parents with mental illness when navigating family court proceedings. These challenges are explored across four subthemes: 4.1. mental illness can impact engagement; 4.2. stigma; 4.3. inequity and engagement; and 4.4. litigation as an exacerbating factor.

Mental illness can impact engagement

Participants identified multiple ways that mental illness symptoms could hinder a parent’s ability to engage with their case. P4 noted that some parents with mental illness struggled with tasks such as ‘picking up a phone’ or ‘filing their documents’. According to participants, while these were seemingly minor issues, their impact in court proceedings could be significant.

Participants discussed the impact mental illness could have on the parent’s relationship with their lawyer. P2 observed that some parents with a mental illness will not ‘take the advice of their lawyer . . . or they’ll have gone through half a dozen lawyers if they’re not hearing what they want to hear’. While not engaging with their lawyer can negatively impact their involvement, P1 remarked that it is not always clear whose responsibility this was, stating, ‘Is it just not, you know, engaging with their lawyers? Is it lawyers not chasing things up?’

Moreover, participants noted that a parent’s mental illness could lead to ‘a sort of disengagement by litigants generally’ (P4). While they were uncertain why parents disengaged from their parenting case, P1 suggested it could be because parents found the court processes ‘overwhelming’. Two participants discussed parents with narcissistic personality disorder who disengaged because they disagreed with the recommendations of the judge. As P4 put this, ‘It’s like, “well if I’m not getting what I want, I’m just going to pick up my bat and ball and go home and never have anything to do with the child’’’.

Stigma

The impact of public mental illness stigma on parents’ engagement with the courts was also noted by several participants. P2 commented on negative perceptions surrounding mental illness still held in the wider community, stating, ‘I think there really is still a stigma around mental illness, and that somehow or other that makes you more of a risk and more of a problem’.

Participants stated that the parent’s perception of stigma may prevent them from discussing their mental illness in court. As P4 explained, ‘Parents can have a tendency not to make a full disclosure as to their health and that creates difficulties as well’. Participants elaborated by indicating that a reluctance to disclose information related to a mental illness can hinder the collection of adequate evidence, making it challenging to make informed decisions when mental health issues emerge later.

In the context of family law, participants described actively working to mitigate the stigma and misconceptions surrounding mental illness within their courtroom. P2 emphasised the non-exclusionary nature of their approach to mental illness in parenting cases, stating that ‘having a mental health issue, doesn’t prevent you from being a good parent, doesn’t prevent you from having a good relationship with your children’. According to participants, such assertions served to reassure parents that their mental illness would not negatively bias the judicial evaluation of their parenting. Nonetheless, P4 indicated that ‘I think as judges, we need to be really careful to understand that mental illness is in fact an illness. It’s not some sort of character flaw that people have’.

Inequity and engagement

Another barrier to engagement discussed by participants was socioeconomic disadvantage. Participants noted the impact that limited financial resources can have on a parent’s ability to effectively navigate the court system. As P5 stated, ‘People who have better access to resources are perhaps better able to find the support they need. That’s an equity issue in society that we can’t really control for’.

This disparity was particularly problematic when accessing appropriate mental health treatments and mental health assessments. As P2 explained, ‘There is a lack of services out there for people with complex mental health issues and limited means’. P4 further highlighted the association between severe mental illness and economic disadvantage, noting, ‘I don’t often get cases of cashed up people with schizophrenia and other mental health issues’.

Litigation as an exacerbating factor

Finally, participants emphasised that the court process itself could intensify stress and distress for parents with a mental illness. Participants noted that undergoing family court proceedings was stressful for any parent, but for parents with a mental illness it can be particularly challenging:

The difficulty of course is that family law is such an emotional area for people, even people without any significant mental health conditions have trouble regulating their emotions at court, but it’s made a lot worse if they have an underlying condition. (P6)

Participants acknowledged that heightened emotions were a natural response to participating in a court case and were concerned about how these emotional responses could be misinterpreted. P2 reported, ‘Often a party attends the assessment incredibly distressed and that’s turned into a mental illness’.

Participants suggested that part of the courtcraft in parenting cases included adapting their approach to alleviate stress for parents with mental illnesses. P6, for example, explained, ‘When [parents] are agitated, I just work hard to affirm them as they are, and to just let them know that I am listening to what they’re saying. And usually, I get a pretty good response’ (P6).

P1 highlighted the importance of a sensitive approach, noting, ‘I think it’s really important to be gentle . . . particularly in matters involving kids, it’s like, no matter what the outcome is, they’re still parents to these kids’. Participants also described taking time to explain the legal processes to parents in relation to their mental illness. As P6 recounted, ‘I try to explain to them the court process and how I need to go on evidence, and this is the evidence that’s before me’.

Theme 5. Judicial recommendations

Building on the challenges outlined in the previous themes, participants proposed a range of recommendations aimed at enhancing support for parents with mental illnesses and their children within the family court system. These suggestions are explored through three subthemes: 5.1. support for parents; 5.2. support for children; and 5.3 accessible and quality mental health assessments.

Support for parents

Participants suggested the need for increased therapeutic support for parents. P2 highlighted the need for ‘interventions . . . that are available and affordable’, stating that this would make a ‘huge difference’ in the court. P3 suggested these interventions should be ‘prepared to realistically help the [parent] work with the court process’.

Participants also proposed the inclusion of additional support workers to assist parents during this process. Distinct from legal or mental health professionals, these workers could provide support in other practical and relational aspects of the parenting case. Their roles might include offering emotional support in court for individuals with mental health conditions. P6 noted that support workers could ‘really just be there for people with mental health illnesses’, suggesting their role would be to provide consistent, non-legal support throughout the court process. Additionally, it was suggested that support workers could offer practical assistance, such as reminding parents about court dates or providing referrals.

More generally, participants highlighted the need for more supervised contact centres to help parents maintain contact with their children. These centres provide an opportunity for parents to have ‘low-cost supervised time’ (P4) with their children, mitigating risk and allowing parents time to engage with other recommended supports, such as mental health treatment. While families can sometimes provide this support, participants noted that in its absence, the answer often ‘has to be no’ (P5) to contact between the parent and child where identified risks cannot be mitigated.

Support for children

In addition to supporting parents, participants also identified the importance of addressing the needs of children. They emphasised the importance of providing children support in the context of the court case, and that ‘giving the children age-appropriate information about what’s happening might ease some of their fears’ (P6). They considered it important to have independent support available for children going through the family courts, as some parents ‘may not be able to [talk about the other parent’s mental illness] or may have a vested interest in how they talk about it with the children’ (P5).

Accessible and quality mental health assessments

As discussed in Theme 3, participants emphasised the need for more mental health assessments in family court proceedings, particularly from psychiatrists. They pointed out that the current cost and limited availability of these assessments was prohibitive for many parents. Participants suggested that this restricted judges’ access to essential information and often led to a more cautious approach regarding parental access to children. To address this, they advocated for ‘more resourcing . . . to get evidence from psychiatrists and from psychologists as well’ (P6).

P6 highlighted the concern about allocating funds for assessments for selected families, stating, ‘If we’re not properly selective about which cases should get them, then we are effectively wasting public money’. Moreover, P3 noted, ‘[Assessments] are very hard to find, and they are very expensive, and they are very hard to book’. This was a sentiment repeated by most participants. Moreover, P2 remarked that the professionals preparing the reports often failed to meet the court’s standards, suggesting the need for a greater ‘level of professional control’ in the assessment process. P4 elaborated by suggesting that, for psychologists, there could be a ‘degree [with] a specific stream for family law cases’.

Discussion

This study explored the decision-making experiences of a sample of Australian judges in family law cases involving parents with mental illness. It examined judges’ perceptions of parental mental illness and their approach to hearing and determining parenting orders under the Family Law Act 1975 (Cth). The judges in this study identified several challenges, particularly in relation to protecting the child from harm, as required by the legislation, and the difficulties involved in securing reliable mental health evidence. Additionally, they highlighted the obstacles faced by parents with mental illness in parenting cases.

Figure 1 presents a conceptual framework integrating the study’s five themes within a life course theory perspective, which shows how judicial decision-making is shaped by social, developmental and institutional contexts over time. Case complexity (Theme 1) influences how judges make decisions (Theme 2) and engage with evidence (Theme 3). Themes 2 and 3 reflect a bidirectional relationship, where the considerations of the judge, and the methods used to gather information, impact one another. Theme 4 highlights how experiences of mental illness can affect evidence presentation and court engagement, shaped by stigma and systemic pressures. Theme 5 captures judicial recommendations in response to these challenges. The framework illustrates how judicial reasoning, evidence and court experiences are shaped by broader life course contexts.

Figure 1.

Conceptual framework.

The complexity of cases noted by judges in this study is consistent with earlier research (Family Law Council, 2015; Kaspiew et al., 2015) and existing court data (FCFCOA, 2024a). The most recent FCFCOA reports indicate that over 70% of parenting cases allege four or more risks, with the most common risks identified being family violence, substance use and mental illness (FCFCOA, 2024a). Moreover, previous reports have suggested that families facing multiple sources of risk are more likely to engage with the courts to settle parenting arrangements than those with fewer safety issues (Family Law Council, 2015). Viewed through a life course lens, such complexity reflects the tendency for adversities to cluster, with multiple challenges often occurring together over time (Diewald et al., 2016). In the current study, judges’ reflections on overlapping issues such as mental illness, family violence and substance use highlight how this accumulation can intensify case complexity and decision-making demands.

Risk was a central consideration for judges in this study, as required by the law. This reflects a shift in child and family policy where risk-based reasoning has become a guiding framework for decision-making (Bastian et al., 2022; Eriksson et al., 2022). However, the judges in this study described a contextual approach that did not rely on diagnostic labels when making decisions around risk, instead focusing on how mental illness affected parenting capacity, a central consideration in the legislative list of decision-making factors. This included consideration of symptom severity, support systems, and the parent’s ability to meet the child’s needs, aligning with calls for non-diagnostic, family-sensitive assessments (Eriksson et al., 2022; Reupert & Maybery, 2016). While risk assessment is central to judicial decision-making, overly rigid approaches can reinforce stigma and discourage parents from seeking help. Boursnell (2014) argues that some tools focus too much on diagnosis and risk, rather than support needs or recovery, which may lead parents to hide mental health concerns for fear of losing access to their children.

Judges in this study identified parents’ willingness to engage in meaningful treatment as a crucial consideration in cases involving mental illness. They noted that such engagement demonstrated the person’s insight into their illness and led to reduced risk to the child. Judges did not specify the type of treatment parents should receive and instead focused on compliance with attendance and medication. The positive impact of meaningful treatment on parent and child wellbeing is well supported by literature (Barrett et al., 2024). Treatment has been shown to be helpful for parents in terms of alleviating mental illness symptoms and distress (Nillni et al., 2018). Moreover, treatment, if delivered in a family sensitive manner, can also promote parental identity and competence, with flow-on effects to the child and the family dynamic (Afzelius et al., 2018; Foster et al., 2016). However, such family-focused approaches remain uncommon in Australia and internationally, despite longstanding advocacy for services to adopt an inclusive, family-oriented practice (Reupert et al., 2022). Viewed through a life course lens, judges’ emphasis on sustained treatment engagement highlights how access to support can influence long-term family trajectories beyond immediate risk considerations.

Even more basically, however, judges noted that (any) mental health treatment was often inaccessible for parents. In Australia, individuals with mental illness frequently face barriers to accessing healthcare, with affordability being a primary issue (Corscadden et al., 2019). Additionally, many parents face unique barriers that can increase their difficulty in accessing treatment for their mental illness. Practical challenges, such as limited time, low income and the demands of caring for children, can make it challenging to attend appointments, follow through with treatment or access support services (Tapp et al., 2018).

Judges emphasised the importance of evidence when making risk assessments in parenting matters but differed in their views on which sources were most useful for them. Some valued one-off psychiatric assessments for their clinical expertise, while others questioned their relevance due to limited contact and generic content. These concerns align with broader critiques of forensic mental health assessments, which have been found to be susceptible to bias, inconsistency and non-evidentiary practices (Guarnera et al., 2017), prompting calls for greater standardisation and scientific rigour. To address these concerns, Neal et al. (2022) outline eight best practice principles for improving forensic psychological assessments, including the need for foundational and applied validity, bias mitigation strategies and clearer communication of limitations and assumptions. Their framework aims to improve the transparency, reliability and evidentiary value of psychological assessments used in legal decision-making, an issue that directly relates to the concerns raised by judges in this study (Neal et al., 2022).

Evidence from a parent’s treating practitioner was often regarded as valuable by judges in this study due to its longitudinal insight into the parent’s mental health. However, concerns were raised about potential bias, particularly when providers prioritised the client over the child’s best interests. Similar tensions have been identified in previous research, where adult mental health workers have been shown to underplay child-related risk (Cousins, 2004) or struggle to balance the needs of both parent and child (Tchernegovski et al., 2018). These findings underscore that judges are not only exercising professional discretion but are also constrained by the type and quality of evidence available to them.

Implications

The implications highlighted in this study incorporate recommendations from judges and previous research. The study emphasises the need for additional support for parents with mental illness and their children involved in parenting matters in family courts. This includes initiatives to promote accessible mental health treatment, aiding in managing mental illness and supporting judges’ efforts to mitigate risks. For example, research indicates that interventions that are family-focused have been shown to improve the wellbeing of parents with mental illness and their children (Afzelius et al., 2018; Reupert et al., 2022). Foster et al. (2016) identified six core elements that promote family-focused practice: family care planning and goal setting, liaison between families and services, the provision of instrumental, emotional and social support, assessment of family members and family functioning, psychoeducation, and a coordinated system of care between families and services. This support should address not only the mental health needs of parents and other family members but also co-occurring issues such as family violence and substance use (Allen et al., 2022).

Findings also support broad policy reforms that reduce procedural stress and improve engagement for parents who are navigating family court proceedings with mental illness. Previous research and inquiries have highlighted the benefits of case management programmes and court-integrated mental health supports to address these barriers (ALRC, 2019; Powell et al., 2020). Embedding mental health professionals within court settings and expanding services can provide timely, targeted support for families at risk.

Improved access to supervised contact services was also a recommendation in this study. In line with previous work, expanding availability and affordability of supervised centres supports safe parent–child contact while other interventions are implemented (ALRC, 2019). Non-legal support roles suggested by judges in this study, such as court support workers or liaisons, have also been proposed to assist with practical and emotional tasks, including reminders of court dates, help navigating systems, and referrals to support services (ALRC, 2019; Powell et al., 2020). These roles could reduce the procedural and cognitive burden experienced by parents with mental illness.

Another recommendation is for therapeutic and information support services for children, including age-appropriate explanations about the proceedings and their parents’ mental health to alleviate fears. While not specific to court settings, research in family mental health highlights the importance of age-appropriate communication and emotional support for children affected by parental mental illness (Reupert & Maybery, 2016).

Judges noted that parents continue to feel stigma related to their mental illness within the courts. Although individual judges made efforts to reduce this, additional measures are necessary to decrease stigma. This includes raising mental health awareness through professional training and information dissemination (Shahwan et al., 2022). Professional development that embeds anti-stigma training and strength-based practice has been recommended to promote more inclusive practice and reduce systemic bias (Reupert et al., 2021).

The study highlighted the crucial role of evidence from mental health professionals. However, the quality of this evidence, whether from one-off assessments or ongoing treatment providers, must adhere to best practices (Neal et al., 2022). Clearer guidelines for functional, parenting-focused mental health assessments, rather than diagnostic assessments alone, have been proposed to improve the utility and reliability of expert evidence (Guarnera et al., 2017; Neal et al., 2022). Funding to ensure these assessments are affordable and accessible is also essential (ALRC, 2019).

Limitations and future areas of practice

This study contained a deliberately small group of participants, in line with IPA methods (Smith et al., 2009). While this approach helps focus on the phenomenon by reducing the influence of individual background differences, it also means the findings cannot, and should not, be generalised to all judges’ experiences (Larkin & Thompson, 2012). The study did not seek to provide significant contextual information about the clients, due to privacy concerns and the nature of participants’ roles. As such, the positioning of the participants is unknown, which likely influenced their decisions and opinions.

Although the study offers valuable insight into judicial reasoning, focusing primarily on judges means the findings reflect only one perspective within the system. Decisions about parenting arrangements involve multiple stakeholders, including parents, children and professionals who provide evidence to the court. Without input from these other groups, there is a risk that some aspects of the court experience or systemic barriers may remain underexplored. Also, as discussed in the introduction, the study was conducted before the 2024 amendments to the Family Law Act 1975 (Cth). As such, judicial perspectives captured here reflect practices and legal considerations under the pre-reform framework.

Understanding how judges make decisions in cases contributes important knowledge to our understanding of parental mental illness in the family court system. Future research might consider the experiences of the parents and the perspectives of children and other professionals involved in parenting matters, such as report writers and mental health practitioners. This study did not explore the unique experiences of minority populations such as First Nation families, which could be the subject of future investigations.

Conclusion

This study offers insight into how judges in the family courts approach parenting matters involving a parent with mental illness. The findings highlight the central importance placed on child safety and the complexities judges face in balancing risk with maintaining parent–child relationship. Judges described the challenges of working with limited or inconsistent evidence, the influence of treatment engagement (and availability) on risk assessment, and the structural barriers parents face, including stigma and service inaccessibility. The study underscores the need for accessible, family-focused mental health services, high-quality functional assessments and more targeted support for families navigating the court system. These findings contribute to the small but growing body of research on parental mental illness in family law and point to the importance of ongoing research and policy reform to support parents with a mental illness and the professionals who work with them.

Appendix A.

Interview schedule for judicial officers

1. In your experience as a judge, how often would you hear parenting cases where a parent has a mental illness?

According to the American Psychiatric Association, a mental illness involves changes in emotion, thinking or behaviour, or any combination of these, that are associated with distress and/or problems functioning in social, work or family activities. For the purposes of this study, the mental illness may be either self-diagnosed or diagnosed by a professional. The mental illness does not have to have influenced the case. [wait for response] I’m also interested in cases where the one parent has alleged the other parent has a mental illness.

( prompt: how many clients/cases do you think you’ve had in the past six months?)

2. How often would you hear parenting cases that involve a parent with a severe mental illness that is severe (with significant adverse impacts on functioning) and chronic (long lasting or reoccurring)? This illness typically includes a diagnosis such as schizophrenia, bipolar and personality disorders.

2.1. Can you describe/give me a (non-identifying) example of a recent case that involved a severe mental illness?

3. Can you describe the kinds of issues that these cases raise for you as a judge?

4. In your experience, does the person’s mental illness tend to affect their capacity to engage with the court process? (if so) In what ways?

5. In your experience, does the person’s mental illness tend to have an impact on the outcome of the case? (if so) In what ways?

6. What could be done to better support your work in cases where a parent has a mental illness?

7. What could further assist parents with mental illness to better engage with the court process?

8. What could be done to better support children in cases where a parent has a mental illness?

Ethical standards

Declaration of conflicts of interest

Taegan A. Holford has declared no conflicts of interest.

Andrea E. Reupert has declared no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of Monash University Human Research Ethics Committee, project number 27473, and the FCFCOA Research and Ethics Committee, and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.