Children of incarcerated parents: Insights to addressing a growing public health concern in Australia

In Australia, the children of incarcerated parents are a growing and vulnerable population at risk for life adversity and social inequity. There is little understanding of these children's experiences, perceived risks, reported outcomes and needs. There is also a lack of knowledge regarding evidence-based interventions that can address the multiple risk factors to which these children may be exposed. The aim of this study was to provide insight into the multiple perspectives of children with incarcerated parents, their carers, par- ents and service providers so that social and health programs may be tailored to best serve their needs. We undertook an integrative literature review of qualitative research studies using a narrative synthesis method- ology to explore the effect of parental incarceration upon the social and health outcomes of children and perceptions of interventions designed to support them. Findings revealed that children of incarcerated parents grieved their parent's absence which they reported had a profound effect on their behavior and resulted in exposure to discrimination, violence and abuse. However, resiliency was manifested by a number of coping strategies that could be harnessed to better support the children and young adults of incarcerated parents. Rigorous and innovative intervention studies are required to better inform comprehensive evidence-based policy and practice.


Introduction
There is a small but growing body of research investigating the effects of parental incarceration upon children; however, the gaps remain large. Murray, Farrington, and Sekol (2012) systematic review demonstrates that the children of incarcerated parents are at a higher risk for antisocial behavior; however there is no strong evidence for child mental health problems, drug use, or poor educational performance. A number of reviews by other authors indicate that among children of incarcerated parents living in America, the risks for criminality (Poehlmann, 2009) and disrupted home environments (Dallaire, 2007) are high. However there are few reviews that shed light into children's experiences, perceived risks, reported outcomes and needs that come from the multiple perspectives of affected children and their parents, carers and service providers. There is also a lack of "insider" knowledge regarding evidence-based interventions that can address the multiple risks factors to which these children may be exposed. Reviews of programs involving the children of incarcerated parents often focus on offenders needs (Corston, 2007), including maintaining links with children and parenting programs that develop the skills and self-efficacy of mothers and fathers (Newman, Fowler, & Cashin, 2011;Sheehan, McIvor, & Trotter, 2007), rather than the skills or self-efficacy of children.
In order to address these knowledge gaps, we sought to synthesize the qualitative empirical research to identify how the experiences, attitudes and life circumstances of children of incarcerated parents affect their needs and behaviors. We wanted to gain an understanding of these experiences and perceptions from multiple "insider" viewpoints in order to determine the requirements of children and how interventions can best meet their needs. The aim of this review therefore is to build qualitative evidence for strategies that could be best harnessed for interventions to address the needs of children with incarcerated parents. Specifically, the review aims to: 1) review the qualitative research literature to understand the effect of parental incarceration and sentencing upon the social and health outcomes of children from their perspectives, as well as from the perspectives of the incarcerated parent, caregivers, and service providers; 2) identify strategies children use to address their needs and cope with adverse events and, 3) identify interventions targeting children and the impact they have had upon adverse social and health outcomes. Children and Youth Services Review 34 (2012)

. The Australian context
The children of incarcerated parents are a vulnerable and growing population in Australia. There are an estimated 60,000 children under 16 years of age in the state of New South Wales (NSW) who have experienced parental incarceration; at least one in five are Indigenous children (Quilty, Levy, Howard, Barratt, & Butler, 2004). Over the last two decades, the number of prisoners in Australia rose by 31%, which is greater than the average increase in all other countries that are members of the Organization for Economic Co-operation and Development (OECD) (ABS, 2009). Unfortunately, nearly half are parents, with a higher proportion of mothers (49%) incarcerated as compared with fathers (43%), with Aboriginal female inmates more likely than non-Aboriginal female inmates to have children under 16 years (68% vs. 43%, p b 0.01) who were dependent upon them prior to incarceration (43% vs. 25%) ).

Incarcerated parents experiences of disadvantage
Incarcerated parents report a history of parental imprisonment, unstable home environments, unemployment and poor health (Geller, Garfinkel, Cooper, & Mincy, 2009) that has a devastating effect on employment, financial stability (Kling, 2006). Australian Aboriginal inmates in particular, are three times as likely to have had a parent incarcerated during their childhood than non-Aboriginal inmates (Indig, McEntyre, Page, & Ross, 2009). Furthermore, greater numbers of Aboriginal female inmates report childhood parental incarceration compared to male Aboriginal inmates (36% vs. 10%, p b 0.01) (Indig, McEntyre, Page, & Ross, 2009). The home environments of inmates as children are often characterized by changes in caregiving arrangements particularly for Aboriginal inmates. Twice as many Aboriginal men (46% vs. 22%, p b 0.01) and nearly twice as many Aboriginal women (45% vs. 27%, p b 0.05) had been placed in care before the age of 16 years compared to non-Aboriginal inmates. Educational achievement of prisoners is low. Three in four Australian prisoners have not studied past year 10 (AIHW, 2011), contributing to the difficulties incarcerated parents face securing stable, well-paid work after release; all of which affects family income and home environments (Brooks-Gunn, Duncan, & Aber, 1997). Furthermore, the health of incarcerated prisoners is also reportedly poor. One in four prison entrants have a chronic condition, 1in 2 have increased risk of depressive disorders before prison, and 66% of all prison entrants reported using illicit drugs in the 12 months prior to prison entry (AIHW, 2011).

The health outcomes of children of incarcerated parents are socially determined
The children of incarcerated parents face family instability and risks of criminality similar to those of their parents before them (Cuomo, Sarchiapone, Di Giannantonio, Mancini, & Roy, 2008;Goodwin & Davis, 2011;Mullings, Hartley, & Marquart, 2004). A child's attachment to their parent is threatened by parental incarceration resulting in enforced separation, infrequent and restricted visits and other contact, and inconsistent caregiving arrangements. Children and young adults of incarcerated parents 15-24 years of age with an increased risk of depressive disorders are likely to be exposed to psychosocial and behavioral risk factors affecting their access to optimal material or environmental resources, social cohesion and health care, thereby increasing the risk of health-damaging conditions and differential vulnerability (Viner et al., 2012). Research into adverse childhood experiences (ACEs), including familial incarceration, has been found to be associated with use of illegal drug use (Roettger & Swisher, 2011), and a 2-3 fold increase in the use of alcohol in adolescence (Dube et al., 2006), an increased risk of intercourse by age 15, increased number of sexual partners (Hillis, Anda, Felitti, & Marchbanks, 2001) and increased risk of physical violence in adolescent dating relationships (Miller et al., 2011). Studies have found a strong graded relationship between ACEs and a self-reported history of sexually transmitted diseases among adults (Hillis et al., 2001), increased risk of depressive disorders (Chapman et al., 2004) and an increased risk of premature death (Brown et al., 2009).

Method
A narrative synthesis methodology was selected for this integrated review of qualitative literature detailing the experiences of children and young adults of incarcerated parents, defined as being between the ages of 5-24 years. Narrative synthesis is an approach to analyzing the findings of research studies included in a literature review in order to answer predefined questions by synthesizing the textual data in the results sections and exploring relationships in this data. Narrative synthesis is well suited to providing a picture of current knowledge that can be used to inform policy and practice decisions (Popay et al., 2006). This design was appropriate for this review given that we sought to combine and compare qualitative studies to gain an emic perspective. We wished to identify predominant themes in order to inform the design of social and health interventions for children of incarcerated parents. Seven bibliographic databases were searched to retrieve the peer-reviewed literature for this review and subsequent analysis.

Search protocol
A systematic search of the literature published from 2000 to 2012 was undertaken using seven bibliographic databases, databases (MEDLINE, CINAHL EBM Reviews: Cochrane Database of Systematic Reviews, PubMed, Scopus, ProQuest Health & Medical PsycINFO (OVID)) Google Scholar and hand searching. The following keywords were employed for the search: children, adolescents, parents, incarceration, prison, imprisonment.
Retrieved records were screened for their focus on children of incarcerated parents and duplicates removed. Inclusion and exclusion criteria were developed, based upon a checklist derived from this review's aims, the contemporary nature of the research, and the quality of methods, findings and interpretation (Eakin & Mykhalovskiy, 2003) to assess the literature identified through the search strategy. We excluded discursive papers, those older than ten years, papers whose focus was not on the experiences of children with incarcerated parents or interventions for them and papers without primary research involving qualitative methods and those not published in peer reviewed journals. PRISMA guidelines (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009) were used to report the review process ( Fig. 1).

Appraisal of quality
Ten papers were appraised to ascertain if the research aim and the methodology used were aligned and to evaluate the recruitment, settings, data analysis, ethics, findings and contribution to knowledge. The papers were assessed for quality using the Critical Appraisal Skills Program (CASP) tool for qualitative research (NHS, 2006), involving the use of 10 questions designed to assess the rigor of the approach and methods applied to the study being appraised, the credibility of the findings and their relevance. One item was discarded as there was no mention of ethical processes such as informed consent or the involvement of an ethics committee as required in question seven of the CASP tool. Further, it was not published in a peer reviewed journal as per the inclusion-exclusion criteria.

Data abstraction and synthesis
The papers comprised six qualitative study designs (Beck & Jones, 2007;DeHart & Altshuler, 2009;Laakso & Nygaard, 2012;Nesmith & Ruhland, 2008Phillips & O'Brien, 2012) and three mixed method designs (Dallaire, Ciccone, & Wilson, 2010;Shlafer & Poehlmann, 2010;Shlafer, Poehlmann, Coffino, & Hanneman, 2009a). A narrative synthesis approach was conducted as per guidelines (Popay et al., 2006). The results sections of each qualitative paper and the qualitative results only of the three mixed methods papers were analyzed to identify evidence of the experiences and interventions addressing the needs for children of incarcerated parents. A thematic analysis was initially conducted by the first author using tables and concurrence with other authors was reached. The relationships within and between studies were explored and coded under each theme. Concept maps were used to plot patterns and relationships across the themes and sub themes. Fig. 2 illustrates the themes and sub-themes identified in this study and the relationships between them.

Findings
Nine papers based upon research undertaken in American settings were included in the narrative analysis (see Table 1). In total, six papers provide insight into the experiences of children affected by the incarceration of parents, two solely from the perspective of the children of incarcerated parents (Beck & Jones, 2007;Nesmith & Ruhland, 2008), one paper examines teachers experiences of the children of incarcerated parents (Dallaire et al., 2010), one paper describes caregiver experiences (Nesmith & Ruhland, 2011), one presents incarcerated mothers' views about their children (DeHart & Altshuler, 2009), while the last paper outlines multiple perspectives (Shlafer & Poehlmann, 2010). Three papers were retrieved that provided qualitative insight into interventions for children whose parents had been incarcerated (Laakso & Nygaard, 2012;Phillips & O'Brien, 2012;Shlafer et al., 2009a). Five themes emerged from the synthesis of all qualitative results and are described below. These are: children's relationships with incarcerated parent/s; caring attitudes of children towards both their incarcerated parent and their carer; adverse experiences; children's coping strategies and resilience; and interventions designed for supporting children.

Children's relationships with incarcerated parent/s
The research studies shed light on the different relationships children have with their incarcerated mother and father pre-and post-arrest, as facilitated through a variety of means including prison visits, letters and phone calls. Visits through glass were described as frustrating and the length of a phone call is dependent on available credit on phone cards (Beck & Jones, 2007). Children reported feeling unsafe during visits to prison; they noted security procedures and a depressing atmosphere (Nesmith & Ruhland, 2008). Children can face difficulty maintaining a relationship with their imprisoned parent as the support of caregivers or a relatives are required to facilitate communication (Shlafer & Poehlmann, 2010), and so many children attempted to establish contact that would allow their relationships with their incarcerated parents to continue in secret.
In one study, a stepfather did not allow the children in his care to make phone calls or to visit their incarcerated father and only when the children turned 18, did they resume contact without the stepfather's knowledge (Beck & Jones, 2007). Another young adult under the age of 18 disclosed a plan to give her aunt her phone number so her incarcerated father could call her (Nesmith & Ruhland, 2008), while another asked a mentor to pass on a letter to her incarcerated father without her caregiver's awareness (Shlafer & Poehlmann, 2010).
Children described being reliant on their caregivers to help coach them on how to communicate with their incarcerated parent or interpret their parent(s)' behavior (Nesmith & Ruhland, 2008). Caregivers assisted in letter writing, and accepting and coordinating phone calls (Nesmith & Ruhland, 2011). However, communication with their incarcerated parent was reported as awkward or strained. For example, a caregiver described a child's embarrassment at their incarcerated parent's use of language that was inappropriate to her age, while another expressed reluctance to adhere to their parent's demands for affection after release (Nesmith & Ruhland, 2011). Caregivers also reported financial barriers to visiting the child's incarcerated parent as well as transport difficulties or problems getting time off work to enable children to be taken on visits to prisons (Nesmith & Ruhland, 2011).
In a study by Beck and Jones (2007), children discussed their relationship with their father who was either on death row, or close to execution. Despite the level of contact with their fathers, all but two of the children reported that they love or felt close to their parent. The declaration of their father's love was the highlight of the prison visit according to one child. For most children, their father had ceased being their "Dad" in day-to-day terms, and as a result, their parental role was limited. Some children provided support to their father by helping with their legal appeals, others had formed friendships (Beck & Jones, 2007). For other children, despite violence and fear, they still missed their incarcerated fathers (Nesmith & Ruhland, 2008).

Caring attitude of children towards both their incarcerated parent and their carer
Children of fathers on death row described wanting protection and care for their fathers and kept the interaction positive. They reported being loath to give their fathers any news of their difficulties for fear of upsetting them in the short time they had left. For other  children, news of celebratory milestones such as the birth of their own child was withheld as this was thought to provoke sadness (Beck & Jones, 2007). Some children were concerned that their fathers lacked adequate clothing and basic items; they asked caregivers to send socks and food (Nesmith & Ruhland, 2008).
Many children credited the caretaking adults in their lives with providing strength and guidance (Beck & Jones, 2007) and some referred to their careers as role models while others reported having no role models (Nesmith & Ruhland, 2008). Children were sensitive to, and attentive of their caregivers' needs and emotions; some children described their mother's anxiety of their impending fathers' release with fear related to a reoccurrence of violence or domestic disruption (Nesmith & Ruhland, 2008). In response children reported trying to alleviate the stress of their caregivers by taking on adult responsibilities at home or by adopting a role as protector of the family (Nesmith & Ruhland, 2008).

Stigma and discrimination experienced by the children of incarcerated parents
Children described the stigma and discrimination they faced with having a parent in jail and were fearful of others knowing as exposure might lead to abuse or marginalization (Beck & Jones, 2007). Children said that they were not always sure whether to tell people that their parent was in prison, and preferred that the information remain private' sometimes they even resorted to lying to hide the fact that their parent was incarcerated (Nesmith & Ruhland, 2008). One child said he told people that dad was at work when asked his whereabouts. (Nesmith & Ruhland, 2008), while others reported that their caregivers had instructed them not to tell (Shlafer & Poehlmann, 2010). Confidentiality was important and regarded as disastrous when breached and could lead to confrontations with other children at school over the crime their parent had committed (Beck & Jones, 2007;Nesmith & Ruhland, 2008).
Caregivers reported being concerned about their poor financial situation since the incarceration of their child's father might lead to embarrassment of the child from their friends when there was no food in the house (Nesmith & Ruhland, 2011). Teachers admitted to lowering their expectations of children with incarcerated parents and one teacher felt it was not wise to include information about the child's parent on their permanent record as it may affect others reactions to those children (Dallaire et al., 2010).

Violence, abuse, stress and fear
DeHart and Altshuler' (2009) study provides insight into the violence that children were exposed to prior to their mothers incarceration. Women described their children bearing witness to verbal and physical abuse from their partners that they felt had a devastating effect on their children. In response to violence in the home, mothers reported that their children would hide from their fathers in fear, state that they hated their father, attempt to intervene to protect their mother or siblings from violence, or prevent their mother from To explore the unique parenting challenges the caregivers of children of incarcerated parents faced, from their perspectives.
Descriptive qualitative study using interviews and thematic analysis with a template.
DeHart and Altshuler (2009) To examine women's accounts of their children's exposure to violence prior to maternal incarceration.
USA Incarcerated women (n = 60) included 52% African Americans and 48% Whites, ranging in age from 18 to 70, with a median age of 31 years.
Grounded theory using open-ended interview recorded using notes during the session.

Shlafer and
Poehlmann (2010) To assess caregiver, child and incarcerated parent, child relationships, contact with incarcerated parents, and children's behavior problems.
USA Children (n = 57) 4 to 15 years, 34 female, 49 had incarcerated fathers, 4 mothers, 4 both parents. Nearly all children were from minority racial or ethnic groups. Caregivers (n = 57), mentors (n = 57) Mixed methods. Descriptive qualitative study using interviews and thematic analysis. Quantitative design using Inventory of Parent and Peer Attachment and a Child Behavior Checklist.

Laakso and
Nygaard (2012) To describe effects of a mentoring program for children of prisoners.
Descriptive qualitative study using semi-structured interviews and thematic analysis.

Shlafer et al. (2009a)
Describe the effects of a mentoring program for children of prisoners.
Mixed methods. Descriptive qualitative study using semi-structured interviews every month for 6 months. Quantitative descriptive design. Mentors completed a survey at 6 months. Children's behavior problems measured at intake and 6 months using caregivers' responses to the Child Behavior Checklist. Inventory of Parent and Peer Attachment administered to children 9 years + at intake and at 6 months. Phillips and O'Brien (2012) To identify perceived benefits of an early intervention program with case management, referral, and advocacy from the perspective of family members and service providers.

Chicago, USA
Family members (n = 4) and agency staff and vignettes from 6 families.
Collective case study using interviews and analysis of children's program records as vignettes.
injuring their father. Some children had suffered physical harm from violence and sexual abuse perpetrated by their fathers. Children in other studies recalled domestic violence in their homes but some had found a way to reconcile the love for their parents with the terror they felt. One child described knowing that her father loved her very much despite scaring her during his drunken rages (Beck & Jones, 2007). Children reported feeling unsafe during visits to prison (Nesmith & Ruhland, 2008) and were fearful of their impending father's release (Shlafer & Poehlmann, 2010) due to the threat of violence and possible police intervention (Nesmith & Ruhland, 2008). Mothers expressed the fear they and their children felt when witnessing the arrest of the father of their children and were concerned about the effect this might have on the child (Nesmith & Ruhland, 2011). Children outlined the stress they felt when there was friction between their caregiver and incarcerated parent and described feeling the emotional and financial stress of their caregivers (Nesmith & Ruhland, 2008). Children stated that they had difficulties trusting people (Beck & Jones, 2007), or finding trustworthy people to share their problems with (Nesmith & Ruhland, 2008) which was also echoed by teachers (Shlafer & Poehlmann, 2010).

Behavioural issues of the child
Children were described by their mothers as becoming physically aggressivethe result of living in a violent home environment (DeHart & Altshuler, 2009), while other caregivers mentioned drug use and early sexual activity of children as a release from their problems (Shlafer & Poehlmann, 2010). Fighting at home and at school was common with teachers reporting bullying, arguing, defiance as well as withdrawal and development regression for children aged 5 to 15 years (Shlafer & Poehlmann, 2010). Impulsiveness, sadness, low self-esteem and difficult relationships with peers were also described by teachers (Shlafer & Poehlmann, 2010) who issued concerns over unstable home environments and constantly changing carers (Dallaire et al., 2010).
The majority of children in Beck and Jones' study (2007) had histories of significant emotional problems and had been referred to treatment for emotional distress or psychiatric concerns. Some of these children described feelings of desperation and abandonment of hope regarding what happens to them that had led in some cases to attempted suicide and self-harm (Beck & Jones, 2007). Anger and resentment was also reported by children; in one study, this was heightened after the execution of one child's father (Beck, 2007). Teachers noted that academic difficulties were common when child's parent was about to be released stating that some children were angry while others apprehensive (Dallaire et al., 2010). Some children experienced confusing feelings; feeling positive towards their incarcerated parent one day and negative the next (Shlafer & Poehlmann, 2010). Teachers described some children's temperaments as fragile some demonstrating a "low threshold for frustration" (Dallaire et al., 2010) or easily upset by other students (Phillips & O'Brien, 2012). This could be externalized in class room disruption or internalized whereby students reported feeling sick without any visible physical symptoms (Dallaire et al., 2010).

Children's coping strategies and resilience
A number of the children highlighted by Beck and Jones (2007) reported the need to be "working hard not to end up in prison". These children did not want to disappoint their fathers. One child described being proud that he had not been arrested, despite assault charges which he attributed to a promise he had made to his father to stay out of jail in order to care for his paternal grandmother and carer. The children whose fathers were on death row describe particular approaches to coping including treasuring each moment of contact, emotionally distancing themselves in order to protect themselves in anticipation of their father's death or denial of the possibility of execution (Beck & Jones, 2007). Emotional disconnection was also described by other children who did not want to discuss their incarcerated parent (Shlafer & Poehlmann, 2010).
Children also discussed strategies to take their mind off negative thoughts associated with their parent's incarceration. These included focusing on school (Beck & Jones, 2007) or taking part in sports, theater and church (Nesmith & Ruhland, 2008). For one child, boxing helped to deal with their anger and some children sought out other children with incarcerated parents for support and friendship (Nesmith & Ruhland, 2008). Other children described the positive effects of taking on responsibilities and developing the confidence necessary to help them move forward (Nesmith & Ruhland, 2008). In one case, a young adult respondent became the carer of his incarcerated father and assisted him with legal issues and his appeal (Beck & Jones, 2007).
Just over half of the children described themselves as doing "well" or "really well" in school, with most of the remainder doing, "okay" (Nesmith & Ruhland, 2008). However some children felt they had to drop out of school. As a consequence of their reduced income since the incarceration of their father, some children described the need for their mother to work two jobs and their own subsequent exit from school to take on home duties and care for siblings (Beck & Jones, 2007). One child noted that their hopes and dreams for their future have been limited by their father's death sentence (Beck & Jones, 2007).
Nevertheless, these children often used their imagination to cope with their parent being incarcerated. Caregivers reported that children often developed fantasies about their incarcerated parent and how they will return from prison soon and be involved in the children's lives (Nesmith & Ruhland, 2011). Children also described dreams such a tearing down prison walls so they could be with their dad (Shlafer & Poehlmann, 2010). Teachers reported that older children coped better than younger ones at school as they had time to adjust to their parents' incarceration and that maternal imprisonment had a greater effect upon children than paternal incarceration, as mothers were generally the primary caregiver (Dallaire et al., 2010).

Interventions designed to support children
Three papers presented qualitative findings from interventions designed to support the children of incarcerated parents. Two focused on mentoring programs (Laakso & Nygaard, 2012;Shlafer et al., 2009a) while a third outlined the result of an early intervention program with case management, referral, and advocacy from the perspective of family members and service providers (Phillips & O'Brien, 2012).
The early intervention program described by Phillips and O'Brien (2012) identified children's feelings and concerns about their parents' absences and allowed them to articulate these through individual and family therapy. It also assisted caregivers with parenting, meeting children's material needs and addressing problems children were having with their academic performance and relationships with peers and teachers at school (Phillips & O'Brien, 2012). Mentors also provided academic support and educational role modeling in two programs described in studies by Laakso and Nygaard (2012) and Shlafer, Poehlmann, Coffino, and Hanneman (2009b) that served children aged 4-16 years. The fathers of children whose mothers were in prison reported that the mentors of their daughters were important to help support their journey into puberty and act as female confidants (Laakso & Nygaard, 2012). There were also reports of mentors counseling children against violence reactions and saving money (Laakso & Nygaard, 2012). Mentors also introduced children to and engaged them in social and sporting activities, providing support, building trust and friendship (Laakso & Nygaard, 2012;Shlafer et al., 2009a).
In terms of outcomes, caregivers noted changes in children's behaviors as a result of these interventions. These included children reporting being more in control (Shlafer et al., 2009a), happier, safe and sharing their feelings (Laakso & Nygaard, 2012). Mentors stated that children (10-16 years) were more confident, had fun and built skills such as wood carving or learning a musical instrument (Laakso & Nygaard, 2012). Elements of successful mentoring programs included weekly contact with bonding of mentor and child (Laakso & Nygaard, 2012). Barriers to building successful mentoring relationships included problems scheduling times to meet due to clashes with planned visits to parents in prison or frequent change of carers which resulted in house moves to locations that made travel more difficult. Mentors also noted difficulties maintaining relationship was linked to costs associated with taking mentees out that they (mentees) were not always able to afford. In addition different expectations and poor personality matches adversely affected the mentor/mentee relationship. (Shlafer et al., 2009a).

Discussion
The qualitative research findings synthesized in this review provide evidence of children's efforts to maintain contact with their incarcerated parent, their experiences of loss, stigma, violence and abuse, the ramifications of these factors upon their behavior at home and at school, and the coping strategies that they employed.

Interventions and future research
This review identified an early intervention and two mentoring programs that have attempted to meet the needs of children and address the profound effects of parental incarceration. However, these studies and others included in this review are based upon research undertaken in the United States indicating that there is a lack of qualitative insight into the experiences, needs and perceptions of children in other countries. Intervention research in other developed and developing countries would be useful to identify further lessons that could be transferrable to other contexts to support children. The review also identified limited data concerning the long term health and social outcomes of interventions suggesting that longitudinal research is required beyond brief process evaluations. This could not only shed light on the impact of interventions but also identify the on-going support needs of children as they progress into adulthood.

Potential strategies and approaches to better support children
This review provides insight into how children of incarcerated parents might be better supported by building on their coping strategies and resilience. Children's desire to maintain or make contact with their parent was reported across a number of studies (Beck & Jones, 2007;Nesmith & Ruhland, 2008;Shlafer & Poehlmann, 2010). For some children, contact was necessary to demonstrate their progress to their parent in revealing the child's determination to not repeat the mistakes of their parents (Beck & Jones, 2007). This concurs with the finding of several research dissertations For example, Posley (2011) revealed adolescent participants aged 16-19 years expressed a desire to get to know their parents despite their incarceration, while Muhammad (2012) found that children 7-18 years old were positive towards improved communication with their incarcerated parent.
For some children, contact with their parents has been found to have a positive effect. Block and Potthast (1998) noted that following the prison visiting program "Scouting Beyond Bars" enhanced mother prison visits lead to a decrease in girls' problem behaviors. This program also facilitated the needs and questions of both sons and daughters surrounding puberty. Questions about menstruation and relationships were discussed during visits and healthy information was given to the mothers to provide to both daughters and sons (Newell, 2012). In other studies, more contact with parents was associated with positive outcomes including increased self-esteem (Landreth & Lobaugh, 1998) and less child school drop outs (Trice & Brewster, 2004).
However this review also found studies where children were scared visiting their parents in prison and noted that the surroundings were not child friendly. A review by Poehlmann (2005) also notes negative outcomes associated with parental contact including children's insecure attachment. More research is clearly needed to better understand parent child visitation in prisons and decisions made on an individual basis.
A focus on pursuing academic success was another coping strategy identified in the review. Student engagement is an important component of academic resilience (Finn & Rock, 1997) and motivation to progress at school is not only related to an optimistic outlook but also a sense of self control and clear goals. Research suggests that it is critical to reward at risk students who demonstrate cognitive engagement in order to build academic resilience (McMillan & Reed, 1994). This has an effect on health outcomes as demonstrated in Gavin's review whereby interventions that focused on building cognitive competence as well as prosocial bonding, social competence, emotional competence, belief in the future, and self-determination showed evidence of improving at least one adolescent sexual and reproductive health outcome (Gavin, Catalano, David-Ferdon, Gloppen, & Markham, 2010).
In this review children reported focusing on academic progress as well as developing new skills and engaging in social activities in order to move forward (Beck & Jones, 2007;Nesmith & Ruhland, 2008). Opportunities to support these activities featured strongly in both mentoring programs (Laakso & Nygaard, 2012;Shlafer et al., 2009a) and the early intervention initiative (Phillips & O'Brien, 2012) that aimed to build self-efficacy and positive attitudes. However, the early intervention program was the only initiative that actively engaged caregivers and children, allowing internalizing coping behaviors. Useful insights into addressing these issues may be gleaned through Landers work in Forgiveness Therapy (Lander, 2012). In addition, issues associated with children taking on additional responsibilities that may negatively impact upon them emotionally or their school work are also likely to be better addressed through the more comprehensive program outlined by Phillips and O'Brien (2012). Group based school based interventions (Lopez & Bhat, 2007) and goal setting therapy (Springer, Lynch, & Rubin, 2000) may also provide children of incarcerated parents with strategies to realistically plan with the support of others.
Another area that deserves attention is the use of innovative youth/child-centerd strategies. Quintanilla's (2010) program for youth with incarcerated parents using hip hop music as a therapeutic tool shows promise. Other tools such as mobile phone text messaging and social media could be harnessed to support youth and provide appropriate health education. However, these are untested strategies which require rigorous evaluation to provide evidence to determine which interventions best support children and youth while their parents are incarcerated and post release.

Relevance to the Australian context
Parental visitation as well as academic and social strategies to support the children of incarcerated parents identified in this review have relevance to the Australian context, but the high numbers of incarcerated indigenous parents in Australia demands approaches that are tailored to the unique cultural context of Aboriginal children who are over represented in the child welfare system (Tilbury, 2009). Programs involving indigenous children and youth will need to consider models that focus on Indigenous collaboration, community development, community participation and community control (Libesman, 2004). Meaningful partnerships with indigenous communities and organizations are critical to ensure that responses take a "whole of community" approach rather than individual responses to supporting and nurturing vulnerable children. These approaches could involve increased investment in school based programs, particularly where there are high numbers of Aboriginal children and focus on identifying and engaging children, teachers, health workers families and elders in the implementation of collaboratively designed initiatives. Inclusive family-based approaches such as the Port Augusta Aboriginal Families Project have been found to benefit vulnerable indigenous children resulting in the return of children to the education system, increased stability of accommodation and improved child health outcomes (McCallum, 2001). As the Council of Australian Governments (COAG) implements its strategic plan for child protection that aims to coordinate and support a national shift towards prevention through the provision of safe and supportive families and communities (COAG, 2009) these approaches will be vital for improved child outcomes.
In line with the need for continuous quality support for vulnerable children and young people that builds on their strengths is the importance of solid relationships between providers and agencies across a number of sectors to facilitate referral. According to Parkinson (2011), Australia can learn from US policy in its efforts to support vulnerable children, such as the CDC's (2009) Strategic Direction for Child Maltreatment Prevention. This supports a comprehensive approach to addressing a range of protective factors such as nurturing and attachment, knowledge of parenting and youth development, parental resilience, social connections and concrete supports for parents.
This narrative synthesis has a number of limitations. The review includes only published peer-reviewed studies in English, and is thus susceptible to publication bias. It excluded gray literature (reports, conference proceedings, theses or dissertations) and was limited to a ten year time period due to funding and time constraints. Hand searching was undertaking using the reference lists of articles which enabled published peer-reviewed studies that were not retrieved through the search to be collated and analyzed.