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Definition

Mental health problems are proportionately common in the overall population, the term does not in itself have one clear definition, and therefore the existence of mental health problems should not be taken as a risk factor without contextual information.

It is estimated that as many as 9 million adults, 1 in 6 of the population, experience mental ill health and that 30% of adults of those adults have dependent children (Ofsted 2013).

It is estimated that 144,000 babies less than 1 year old live with a parent who has a common mental health problem (NSPCC 2011).

Many adults who suffer from mental health problems also have substance misuse problems, this is described as Dual Diagnosis and there may be several agencies and services, for both adults and children, who are working with the family.

National Serious Case Reviews and Domestic Homicide Reviews have identified domestic abuse, parental mental ill health and drug and alcohol misuse as significant factors in families where children have died or been seriously harmed. Where all three concerns are present they have been described as the ‘toxic trio’, which practitioners should be alert to and consider in any assessments.

The state of a person’s mental health is usually not static and can vary according to several factors, correspondingly their ability to parent safely may also be variable, and therefore, an understanding of the factors which may impact on the child’s welfare and  increase risk is an important part of any assessment.


Risks

A child who has suffered, or is likely to suffer, significant harm or whose well-being is affected by parental mental illness could be a child:

  • Who features within parental delusions;
  • Who is involved in his / her parent’s obsessional compulsive behaviours;
  • Who becomes a target for parental aggression or rejection;
  • Who has caring responsibilities inappropriate to his / her age;
  • Who may witness disturbing behaviour arising from the mental illness;
  • Who is neglected physically and / or emotionally by an unwell parent;
  • Who does not live with the unwell parent, but has contact (e.g. formal unsupervised contact sessions or the parent sees the child in visits to the home or on overnight stays);
  • Who is at risk of severe injury, profound neglect or death;
  • Who is an unborn child of a pregnant woman with previous mental illness;

Indicators and Assessment

The Royal College of Psychiatrists (2008) has described how mental health problems can seriously affect the capacity of parents/carers to provide safe and effective care to their children and also have adverse effects on the parent/child relationship. Parental mental health problems may also place children at risk of significant harm.

Effects of Mental Health Problems on Parenting Capacity

PARENTAL MENTAL HEALTH

PARENTAL SYMPTOMS

EFFECT ON PARENTING & THE PARENT - CHILD RELATIONSHIP

DEPRESSION
Unipolar Affective disorder

Lack of energy, lethargy
& low mood, disturbed sleep, appetite loss, concentration becomes difficult and decisions impossible

Physical and/or emotional neglect
(insufficient involvement)
Irritability, criticism (negative involvement)
Lack of communication and emotional support for child; Inconsistent parenting
(over and under involvement)

Bipolar affective disorder

Extreme physical and mental energy, argumentative, dictatorial and haughty

 

Depressive disorder

Guilt, despair, helplessness
hopelessness, self-blame, tearfulness, hopelessness
Mother seeks comfort from child
Inconsistent parenting (over and under involvement)

Psychotic depression

Delusions of guilt, despair, hallucinations, suicidal and/or homicidal thoughts or plans

Severe neglect
Involvement in delusions

BORDER PERSONALITY DISORDER

Unstable relationships, hostility & violence, impulsiveness, recklessness, associated alcohol & substance misuse, lack of empathy, self-harm, symptoms associated with other mental illnesses.

Over involvement (intrusive interactions, positive or negative), for example, harsh discipline and criticism, lack of empathy, modelling antisocial behaviour.
Exposure to discord/violence
Inconsistency
Inappropriate expectations for self care by child
Comfort seeking from child
Neglect (emotional and/or physical) and intolerance of child’s need for care

SCHIZOPHRENIA

‘Positive’ Symptoms-
(delusions & hallucinations)

 

‘Negative’ Symptoms
(apathy & withdrawal

Inconsistency
Over involvement (positive or hostile)
Involvement in delusions

 

Neglect (unresponsive to child’s needs-physical and/or emotional

ANXIETY DISORDERS

Poor concentration, irritability, vigilant, poor impulse control, tension, agitation, avoidance.
Physical symptoms inc. sweating, pressured speech
Irritability, criticism (negative involvement)
Inconsistent parenting
(over and under involvement)
Comfort seeking from child
Royal College of Psychiatrists 2008

Children whose parents have mental health problems may take on the role of young carer, helping out with a range of everyday chores: cleaning the house, shopping, cooking or looking after younger siblings. In addition, some young carers provide significant emotional support and may take responsibility for making sure their parent takes medication or attends appointments with professionals. The level of responsibility a young person takes on can change rapidly as their parent’s mental health improves or deteriorates.

All professionals who work predominantly with adults, including adult mental health services, have a duty to include an assessment of children’s welfare in the assessment of adult patients and clients.

To determine how a parent/carer’s mental health problem may impact on their parenting ability and the child’s development the following questions need to be considered within an assessment:

  • Does the parent’s mental health problem affect the development of a secure attachment with the child?
  • Does the child take on roles and responsibilities within the home that are inappropriate?
  • Does the parent/carer neglect their own and their child’s physical and emotional needs?
  • Does the mental health problem result in chaotic structures within the home with regard to meal and bedtimes, etc?
  • Does the parent/carer’s mental health have implications for the child within school, attending health appointments etc?
  • Is there a lack of the recognition of safety for the child?
  • Does the parent/carer have an appropriate understanding of their mental health problem and its impact on their parenting capacity and on their child?
  • Are there repeated incidents of hospitalisation for the parent/carer or other occasions of separation from the child?
  • Does the parent/carer misuse alcohol or other substances?
  • Does the parent/carer feel the child is responsible in some way for their mental health problem?
  • Is the child included within any delusions of the parent/carer?
  • Does the parent/carer’s mental health problem result in them rejecting or being unavailable to the child?
  • Does the child witness acts of violence or is the child subject to violence?
  • Does the wider family understand the mental health problem of the parent/carer, and the impact of this on the parent/carer’s ability to meet the child’s needs?
  • Is the wider family able and willing to support the parent so that the child’s needs are met?
  • Does culture, ethnicity, religion or any other factor relating to the family have implications on their understanding of mental health problems and the potential impact on the child?
  • How the family functions, including conflict, potential family break up etc.

Confidentiality and Sharing Information

Confidentiality can never be an absolute principle and it is generally accepted that where children need protecting, their needs are paramount and information may be shared without their parents’/carers’ permission. It is critical that all practitioners working with adults, children and young people are in no doubt that where they have reasonable cause to suspect that a child or young person may be suffering significant harm or may be at risk of suffering significant harm, a referral to Children’s Social Care must be made without delay. Practitioners should seek to discuss any concerns with the family and, where possible, seek their agreement to making referrals to Children’s Social Care.

This should only be done where such discussion and agreement seeking will not place a child at increased risk of significant harm. The child’s needs are paramount and must be the overriding consideration in making any such decisions.

Where a child is not considered to be suffering significant harm, or at risk of suffering significant harm, consideration needs to be given to whether parental permission is required for the sharing of information. This should be considered on a case by case basis. This issue should be raised with parents at the beginning of professional involvement following agency guidelines, with emphasis on the help and support which can be accessed by the family as a result of sharing information with other agencies. In the process of finding out what is happening to the child, it is important to take into consideration their wishes and feelings.

The Overarching Information Sharing Protocol (OAISP) for the Pan-Dorset area and other Information Sharing Protocols may also give a framework to support this.

Each agency/organisation will have its own system with regards to undertaking an assessment using the Common Assessment Framework (CAF)/ Early Help assessment. Parents should be asked if one has already been done and if so, it will mean that they have agreed to information being shared.

Practitioners should be aware of any protection plan around family members e.g. MAPPA, Child Protection Plans, MARAC, Vulnerable Adult Meetings and identify the need to be involved in those processes. These should be clearly documented with in the adults or child’s records.

Practitioners should always be mindful of risk and any risk assessment process and documentation should always be continually reviewed and updated to ensure that the information is always current and live.


Protection and Action to be Taken

Where it is believed that a child of a parent with mental health problems may have suffered, or is at risk of suffering significant harm, a referral to Children’s Social Care should be made in accordance with the Referrals Procedure. If there are lower level concerns, it may be the case that the child and family will find early help services supportive and an assessment of the needs of the child should take place at an early stage for example by a Common Assessment Framework (CAF) taking place.

It is essential that practitioners in adult mental health services and Children’s Social Care work together collaboratively to ensure the safety of the child and the management of the adult’s mental health.

On request from Children’s Social Care, adult mental health practitioners should:

  • Compile a summary of adult mental health involvement and concerns;
  • Send the summary, formulation of the case and adult mental health management plan, together with any other relevant facts or concerns to the social worker;
  • Contribute to the assessment by CSC as required;
  • Offer their professional opinion regarding the impact of the parental mental health problem on the children’s wellbeing.

Children’s Social Care must assess the individual needs of each child and within this incorporate information provided by mental health practitioners.

Mental health practitioners should be invited to and should attend, any meeting concerning the implications of the parent/carer’s mental health difficulty on the child, including Child Protection Conferences and Child in Need meetings. A report should be prepared for Child Protection Conferences, using the local authority report template, which sets out and analyses what is known about the child and family. Relevant information should be provided for other multi-agency meetings regarding the child. Children’s Social Care practitioners should be invited to and should attend Care Planning Approach (CPA) and other meetings related to the management of the parent’s mental health.

All plans for a child, including Child Protection Plans and Child in Need Plans, will identify the roles and responsibilities of mental health and other practitioners. The plan will also identify the process of communication and liaison between practitioners. All practitioners should work in accordance with their own agency procedures/ guidelines and seek advice and guidance from line management or the organisation safeguarding lead, when necessary.


Issues

Contingency Planning

Child care and mental health practitioners should always consider the future management of a change in circumstances for a parent/carer and the child and how concerns will be identified and communicated.

If adult mental illness deteriorates, adult mental health practitioners should consider how the deterioration may impact upon the wellbeing of the child and inform social workers who are working with the family of any increased risks, without delay.

When practitioners make a decision to end their involvement with a parent/carer with mental health problems or a child who is living with a parent/carer with mental health problems, they should always discuss their plans with the other services who are working with the family, before the case is closed. This is to ensure that any on-going needs can be addressed, particularly if there is on-going risk to the child.

If a parent/carer disengages from mental health services, or is non-compliant with treatment, services should refer to the Working Harder to Engage with Children, Young People or Their Families More Effectively, Practice Guidance to Agencies.

If there is on- going risk to the child in these circumstances, this should be discussed with Children’s Social Care.

Mental health services should always use ‘respectful uncertainty’ and not readily accept parent/carer’s assertions that their mental health problems are not affecting the care they provide to their children. Where there is any doubt in these situations, services should explore other evidence to support or challenge the view being expressed by parents/carers.

Confidentiality is important in developing trust between parents with mental health problems and practitioners in agencies working with them, however, practitioners must always act in the best interest of the child and not prioritise their therapeutic relationship with the adult.

It is crucial that all agencies establish a clear framework for supervision as practitioners need to feel, and be, properly supported to make their safeguarding practice effective. Those supervising practitioners working with adults should always ask about the care of children in the family and vice versa. Those managing child care cases should always ask about collaboration with adult workers if there are substance misuse or mental health issues affecting parents.

When in doubt as to what action to take when managing cases involving adult mental illness and children’s welfare, practitioners should seek appropriate advice and support. When practitioners from different agencies cannot agree on a course of action, the LSCB escalation protocol should be used (see Documents Library).



Amendments to this Chapter

This chapter was reviewed and updated in February 2017. It has been amended throughout and should be read in its entirety. A chart from the Royal College of Psychiatrists showing the impact of parental mental health issues on children has also been added.

End.