Beyond risk: Rethinking harm for children of parents living with mental health and addiction challenges

Abstract

Objective

I propose a rethinking of harm experienced by children of parents living with mental health and addiction challenges.

Conclusion

Drawing on expertise by experience and interdisciplinary practice, I offer a conceptual framework that points out that harm cannot be understood through a singular, risk-focused lens, but requires attention to the intersecting family dynamics, social attitudes, and systemic conditions.

Drawing on my expertise by experience and informed by my work as a philosopher, social worker, and clinician, I offer a conceptual framework for understanding harm in children of parents with mental health and addiction challenges. Moving beyond a solely one-dimensional risk-focused perspective, it points out how family dynamics, societal attitudes, and systemic structures intersect to shape children’s welfare. The framework supports interventions that strengthen family relationships, address societal and structural barriers, and safeguard children. It reframes families as networks of care rather than sites of risk.

Throughout, I use the phrase ‘children of parents with mental health and addiction challenges’. This phrasing acknowledges the overlap between mental health and addiction, avoids defining families by diagnosis, and aligns with a relational understanding of harm.

Consider the fictitious case of a child whom I will call ‘C’. C’s parent experiences severe depression and faces the challenge of alcohol dependence. C often takes on responsibilities that are beyond their years, such as preparing meals for the family, caring for their younger siblings, and managing household tasks. C is frequently absent from school. When at school, C appears withdrawn, avoids being with their peers, and struggles to concentrate on their academic work. Despite these challenges, C rarely complains, and their peers see C as mature and independent. Is C at risk of being harmed? If so, is it the parent’s mental health and addiction challenges or the social responses surrounding it, such as stigma, neglect from services, and societal judgement, that constitute the harm?

The question of what constitutes risk of ‘harm’ in the lives of children with parents who experience mental health and addiction challenges is complex. It is not only a clinical or policy question, but also a moral one, about how we see, listen, and respond to families living with love and struggle in the same breath.

Clinical systems often frame risk of harm as collective. For example, a position statement by the Royal Australian and New Zealand College of Psychiatrists on ‘Children of parents with mental illness’ notes that:

These children have a higher risk of developing mental illnesses than other children. Risk is often heightened due to the ways mental illness can complicate parenting and care of infants, children and adolescents including through reduced emotional availability, changed perception of the child and impaired ability to support child development. These parenting difficulties may be episodic or enduring. Parents with mental illness may experience disruptions in their relationship with their child, social isolation, disadvantage, and the effects of stigma. The emotional sensitivity and responsiveness of a parent is usually a key factor in outcomes for the child. Parental substance dependence in particular considerably increases the risk of poor outcome for the children1.

This framing provides guidance for service delivery and protocols.

However, if the risk of harm is not distinguishable from the broader social, relational, and structural conditions in which families live, then our understanding of ‘risk’ itself becomes ethically and practically unstable. The worry, then, is that by focusing too narrowly on parental deficit, we risk overlooking how harm is produced through stigma, inadequate service responses, poverty, and systemic neglect. These are factors that both shape and are shaped by the lived realities of families navigating mental health and addiction challenges.

I suggest a rethinking of harm in the context of children with parents with mental health and addiction challenges. I offer a framework that is more nuanced in differentiating harm. By differentiating harm, we can reimagine interventions not as protecting children from ‘risky’ parents, but as supporting family relationships and broader welfare to guide policymakers and service providers.

Differentiating harm also reveals where the protective factors lie. Families are not static. Instead, they move between being at risk, experiencing harm, and moving on from harm. Attending to these transitions allows us to see harm not as a fixed state but as a dynamic process shaped by relationships, resources, and social context.

To deepen this rethinking, I propose a framework that differentiates harm along three interrelated dimensions.

Differentiating risk of harm

My aim is to promote a layered discourse of risk of harm along at least three interrelated dimensions.

Developmental harm: measurable outcomes, such as cognitive, emotional, or behavioural difficulties in children.

Relational harm: arising from disruptions in trust and mutual understanding within families.

Structural harm: emerging from the societal and institutional contexts in which families live, such as a broad range of stigma, poverty, and fragmented support services.

These three dimensions are not mutually exclusive. Instead, they intersect in the lived experience of families. For example, structural harms, such as stigma, can amplify relational harms, while relational repair can mitigate the effects of developmental harms.

Although this framework may resonate with multilevel approaches, which have been advocated to emphasise family and parental factors in understanding children’s welfare (for example, 2), it departs from them in important ways. Multilevel analysis commonly accounts for the nested positioning of children within families, with a focus on predicting and managing parental risk. By contrast, rather than treating relational and structural factors as contextual modifiers of individual risk, the framework offered here treats them as independent sites in which harm may be generated, mitigated, or repaired. It therefore calls for rethinking to differentiate harm across developmental, relational, and structural dimensions, drawing attention to how harm may arise not only within families but also through, for instance, poverty, stigma, and service responses. This reframing shifts the focus from family and parental risk factors to supporting family relationships and shared responsibility for care.

At the same time, while child protection systems provide a prominent context in which risk-based conceptions of harm are operationalised (for example, 3), the framework offered here is not intended as a child protection assessment model. Rather, it is a conceptual lens for understanding harm across both statutory and non-statutory settings, including services that support families affected by mental health and addiction challenges outside investigative or coercive systems.

Examining ‘C’

The fictitious case of C, from the start of this paper, provides an opportunity to explore how the framework I propose shapes our understanding.

Developmental harm

A developmental harm lens would emphasise the likelihood that C will experience emotional or behavioural harm, develop a mental illness, and experience academic disengagement. In this view, the parent’s depression and alcohol challenges represent risk factors, and C’s absenteeism, withdrawal, and premature maturity are risk indicators.

Harm refers to what is likely to happen if action is not taken, and intervention refers to mitigating exposure to the risk. This may include monitoring C’s school attendance, or referring the family to social or child protection services. The benefit of this approach is to mobilise resources for support.

However, this lens allocates risk of harm primarily within the family and, often implicitly, within the parents’ experiences. C’s parent becomes the source of potential damage, and C the passive recipient of risk. What this misses is the ethical and relational texture of C’s everyday life, including the ways in which care, love, and struggle coexist within the same family system.

Relational harm

A relational lens places attention on what happens between people rather than within them. The question shifts from ‘is C at risk?’ to ‘what is happening in the relationship between C and their parent?’

In C’s situation, the risk of harm is understood as role reversal. C is taking on caregiving responsibilities that disrupt the flow of dependence and protection between parent and child. This experience constitutes relational harm not because of the parent’s challenges per se, but because patterns of trust and mutual recognition are unsettled.

The lens of relational harm also exposes the ambivalence of what might otherwise appear as ‘resilience’. C’s maturity and self-sufficiency can be read as adaptive responses to relational imbalance. The question becomes less about preventing dysfunction and more about repairing relational ruptures. Supporting C, then, would involve creating spaces where family members can re-establish communication, share emotional burdens, and sustain mutual recognition.

However, within these relationships, love often remains the unspoken element. Systems tend to frame families through deficits, while overlooking the persistence of love, even when it is inconsistent or strained. C’s story reminds us that love and harm are not opposites but intertwined experiences. Recognising this ambivalence is not sentimental. It is ethical. To understand harm fully, we must also make space for the ways in which love endures within it.

However, a solely relational lens can risk overlooking the broader impacts, such as poverty, stigma, and inadequate services, that constrain families’ capacity for connection. For that, a structural perspective is needed.

Structural harm

When we widen the lens further, C’s situation appears not merely as a family problem but also as one that is socially influenced. From a structural perspective, risk of harm emerges through the interaction of families with systems, such as peer groups, education, welfare, and healthcare, that may stigmatise, neglect, or fragment support.

For instance, C’s frequent absences from school may be read by teachers as truancy rather than as an impact of caring responsibilities. The family may be reluctant to seek help due to fear of judgement, reflecting broader societal stigma surrounding mental health and addiction challenges. Services designed to ‘protect’ children can unintentionally amplify harm when they treat parents as risks to be managed rather than as people in need of care and inclusion.

This structural harm is cumulative. It arises when policies fail to recognise interdependence between parental and child welfare, when systems are under-resourced, or when social narratives cast families like C’s as morally deficient. C’s difficulties, then, cannot be separated from the institutional and social conditions that shape the family’s possibilities for support.

Structural harm reframes responsibility. That is, rather than locating it solely in the parents’ challenges, it places it in the collective arrangements, such as policy, service design, and public attitudes, that enable or prevent flourishing.

A differentiated understanding of harm

Differentiating harm across developmental, relational, and structural dimensions invites a more responsive and contextually aware understanding of children’s lives. It shifts focus to the complex interplay of relationships, environments, and systems that shape welfare. This approach recognises families as sites of both vulnerability and care, struggle and resilience.

This differentiation matters because when harm is treated as a single, undifferentiated risk category, it obscures the multiple pathways through which children and parents experience both suffering and strength. It also leads to service responses that manage rather than transform, protect, and empower.

To differentiate harm, then, is not merely a conceptual exercise. It is an ethical commitment. It is to see families not through the lens of deficiency but through one of interdependence. It asks clinicians, policymakers, and communities to listen differently: to hear the echoes of love within struggle, to recognise the harms enacted by systems as much as those that occur within families, and to design supports that hold both children and parents within networks of care.

Ultimately, differentiating harm helps us move from risk management to relationship repair. That is, from systems that intervene on families to systems that work with them. It invites us to imagine a future where care is collective, stigma is reduced, and children and parents alike can flourish within the same circle of support. I offer this not as the final word, but as an opening for further conversation.

1. Royal Australian and New Zealand College of Psychiatrists. Children of parents with mental illness, https://www.ranzcp.org/clinical-guidelines-publications/clinical-guidelines-publications-library/children-of-parents-with-mental-illness (March 2016, accessed 5 December 2025)

2. Giannouli V. On the importance of focusing on family and parent factors in multilevel analyses regarding psychopathology of adolescents with an intellectual disability who present to general hospital services. Australasian Psychiatry 2018; 26: 325–326.

3. Barlow J, Fisher JD and Jones D. Systematic review of models of analysing significant harm. Research report, Department of Education, UK, March 2012.