Invited Commentary on the Paper: ‘Risk and Protective Factors for Burnout Among Parents of Children With Complex Care Needs: Parents' Perspectives’

The excellent study by Patty et al. (2025) and colleagues from the Netherlands, exploring burnout in parents raising children with complex care needs(Patty et al. 2025), has brought to our attention aspects of the lives of families that are central to, but go far beyond, the biomedical dimensions of their children's conditions. Important contributions of this paper are that the findings report parent voices and that the authors have made a strong effort to offer a balanced view of both potential risk factors and possible protective factors. As an invited reviewer of both the original submission and its revised version, I had the opportunity to reflect on aspects of our work, and our field, that I feel are worthy of additional consideration. I believe that there is potential value for frontline service providers and health services researchers to think about how we might frame the issues highlighted by this study. The questions that arose as I read the paper included the following: ‘How can I, as a busy service provider, recognize, conceptualize, and incorporate parents’ challenges into my clinical formulations? What can I do to be more supportive?’ The study identified three categories of issues associated with burnout: (i) those directly related to ‘the parent,’ encompassing factors intrinsic to them, such as emotional issues, internal drivers and physical health; (ii) factors in ‘the environment’ external to the parents but interacting with them, including the organization of services and care, social support and socio-economic factors; and (iii) ‘the sum of all factors’—themes underscoring the collective, transactional and potentially compounding impact of these contextual forces, including caregiving and parental responsibility, and the perception of no option but to endure. To address the first question, an approach that all aspects of our field could—I believe should—use involves thinking in terms of the World Health Organization's framework for health as presented in its International Classification of Functioning, Disability and Health (known informally as the ICF) (World Health Organization 2001). The ICF ideas have been brought to life in a fun way (Figure 1) with the ‘F-words for Child Development’, now widely used around the world. (Rosenbaum and Gorter 2012) Although the authors of the paper on which this Commentary is based did not cite the ICF, their three key findings can be recognized as reflecting this broader view of health beyond the child's biomedical issues. In contrast to our classic and important biomedical ‘rule out’ approach to reach a diagnosis, the ICF framework represents what might be thought of as a ‘rule in’ way of identifying and incorporating into our thinking the many strands of people's lives that together impact specific issues (such as burnout). The ICF provides an opportunity to include the details of ‘the parent’ with their many realities: the myriad ‘environmental factors’ that affect all of us, often without formal acknowledgment, and the ‘interactive’ impacts of these (and other) elements of people's lives that represent a ‘whole’ bigger than the sum of the individual parts. As we work with children and young people with neurodisabilities, we must recognize both the ‘foreground’ of what we bring to each clinical encounter, namely, our skills, knowledge and resources that families expect from us and our services; and the ‘background’ (context) in which our services are offered (the clinical ‘environment’). Are we and our services truly ‘family-centred’ (Rosenbaum 2025), or do structural and administrative factors—such as long waitlists, selective acceptance of ‘cases’, limited human resources, challenges imposed by limitations on our scope of practice—contribute to parental stress and increase the likelihood of burnout? (King et al. 2025). By consciously considering ‘family’ as central to all our work in child health, including the well-being of parents, we can have a richer understanding of the human ‘environment’ of the child whose issues bring them to our attention. Thus, in this ‘family-centred’ way of thinking and acting, we can both directly support parents by identifying their stresses and engage skilled members of our clinical teams to offer counselling and interventions that may be beyond our own skills. We can also pay attention to the human resources and structural aspects of our services that may be contributing to parental distress and advocate with administrative leadership to address barriers to care and services. A second schema that service providers may find helpful is the ‘4 Ps’ to be considered in any complex situation (Warren et al. 2024). What are the predisposing, precipitating, perpetuating and protective factors that we can try to identify to understand a situation more fully, and to recognize opportunities for intervention and ultimately to minimize or prevent challenges? In the context of parental burnout, for example, can we try to identify predisposing aspects of people's lives (whether related directly to their child or to personal or family events) by asking about parents' well-being and offering services when they express concerns? Has something happened in the recent past (e.g., financial or work-related events or changes in their child's status) to precipitate a crisis? What aspects of people's personal and family lives—including but not limited to their child's predicament—may be perpetuating their stresses (e.g., marital stress, health concerns in the extended family)? What factors in their personal and family life do parents identify as protective of their well-being (e.g., human supports from family, friends and religious leaders)? Empathic listening to these elements of parents' concerns sends a powerful message to them that we are interested in their predicaments; in fact, the process of asking, and demonstrating caring, is itself an intervention. For many frontline service providers, thinking about and trying to manage this area of ‘family’ or ‘parental’ health may be frightening—a bridge too far! One might argue, however, that when a service programme claims to be ‘family-centred’ (as most do!) that programme is implying that it is committed to and able to discuss aspects of families' lives such as are exemplified briefly above. It is a statement of the obvious that parental and family well-being are essential to the well-being of the children and young people we serve and that the best of our formulations and advice about the child will be more effectively received and acted upon when parental well-being is also factored into our work. Finally, for people interested in exploring these issues in further and more detailed research, I believe that there are opportunities to use frameworks like these as a guide to understanding how parents raising children with complicated lives think about these concepts. In particular, what can we learn from families who appear to be coping well and not burning out? How do they manage the stresses of life with a disabled or chronically ill child, and what can they teach us—and other families—about strategies to prevent some of the ‘morbidity’ to which families like them are known to be at risk? I thank the authors of this excellent paper for ‘precipitating’ these reflections! I hope that they continue to pursue this area of research and add to our understanding of the well-being of families and our opportunities to support them. The author declares no conflicts of interest. The author has nothing to report.

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