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3.22 Parents, Carers or Family Members with Mental Health Issues


Contents

  1. Introduction
  2. Collaborative working amongst Children’s and Adult Services
  3. Key Points in the Child Protection Process
  4. Young Carers

    Appendix 1: Parents with Mental Illness - References

    Appendix 2: Think Child, Think Parent, Think Family: A Guide to Parental Mental Health and Child Welfare

    Appendix 3: Think Family Toolkit

    Appendix 4: The use of whole Family Assessment to identify the needs of Families with Multiple Problems

    Appendix 5: Joint Protocol Flowchart

    Appendix 6: Working Together to Support Young Carers

    Appendix 7: Parents with Mental Illness - Useful Questions in Assessment


1. Introduction

This procedure is for all agencies who come into contact with adults, children or young people who have mental health issues which may impact on other children or young people. This would usually, but not exclusively be a parent, carer or other family member.

It contains practice guidance and procedural information about what to do if you are concerned about a child or young person, if their well being is being affected by someone’s mental health (see Related Guidance). It is written with the understanding that there can be powerful tensions between those advocating on behalf of parents, and those working to safeguard and promote the well-being of children and young people. It is also written in the spirit of acceptance that in the vast majority of cases, their needs are best met, sometimes with additional support, from within their families.

As in all areas of child welfare, it is vitally important that workers from all agencies and disciplines work together to undertake clear assessments and implement effective plans. In the interface between adult mental health services and services for children and families, this may involve a greater understanding of each other’s perspectives.

The mental health and well-being of children and adults in families where an adult carer has a mental health problem are linked in the following ways:

  • Possible impairment in the development of a child, and in some cases a threat to the safety of a child;
  • An adverse effect on the child’s adjustment to adulthood if s/he grows up with a parent with mental ill health;
  • Children can precipitate or aggravate the mental ill health of a parent/carer, particularly if s/he has emotional, behavioural or chronic physical health problems;

Some key factors associated with mental ill health which could potentially increase the risk to a child’s well being are:

  • The specific symptoms and characteristics of the parent’s disorder, or disorders e.g. symptoms that impinge directly on a child, such as a parent who self harms, or has delusions which threaten a child’s safety and well-being or distort the child’s experience;
  • Any ill effects which the mental illness, or side effects of the treatment, may have on the parent’s functioning, particularly on his/her capacity to relate to and care for the child e.g. if the parent is emotionally detached or unavailable to the child, or unable to be reliable in providing physical care such as routines, meals or getting the child to school, then the child is more likely to be affected;
  • Any effects such as loss of concentration that prevent the parent ensuring the child’s safety;
  • Both parents having mental ill health;
  • Any associated changes in the family structure or functioning e.g. separation due to the parent’s hospital admission, additional strain on a well parent, parental relationship difficulties due to the mental ill health of one parent.

These must be balanced against protective factors such as:

  • One or more other adults in the household/family network who can meet the child’s needs;
  • Cognitive skills or temperament of the child that enables him/her to understand and cope better than others with the adverse effects of the parent’s illness;
  • Good socioeconomic circumstances e.g. financial security, supportive social influences.

All agencies need to be alert to signs that children and parents need help and to the signs that a child or parent may be at risk.


2. Collaborative working amongst Children’s and Adult Services

There are some barriers in working with parents with mental health problems, which should be overcome by collaborative working. Mental illness is often stigmatised and sufferers may fear being labelled as an unfit parent and conceal the full extent of their problems. Similarly, workers may misinterpret this as concealing child maltreatment or may feel reluctant to raise issues of childcare.

Abuse or neglect could be an unintentional consequence of the parent’s symptoms and professionals may have insufficient knowledge to assess the impact of the parent’s behaviour on a child’s health and development. Therefore close liaison between adult and Children’s Social Care is essential in the interests of children and their carers. This requires sharing of information where it is necessary to safeguard the health and welfare of a child. (See Section 3, Information Sharing and Confidentiality of Underlying Principles of Values). This should also be the approach, with the consent of the family, for children and their families in order to ensure holistic and preventive interventions.

An assessment under the Framework for Assessment of Children in Need and their Families will take account of all the dimensions of the child and family’s needs and the parental capacity to respond to those needs. In the case of a parent with mental health difficulties, the assessment should include the contribution of the adult mental health services and the impact of the parent’s symptoms and the family’s experiences on the child’s welfare and safety.

Additional needs of the child should also be taken into account in the context of the parent’s mental illness, for example, if a child has a condition which is not attributable to the parent’s illness, but impacts on the child’s development and family life, such as physical illness, physical disability, sensory impairment, or developmental delay or disorder.

The needs of a partner should also be taken into account, e.g. the additional stress or any of his/her own health problems and needs of a carer of the child and an adult with mental health difficulties. The difficulties may be aggravated if the other parent is not able to offer positive protective factors to the child or is a perpetrator of domestic abuse or is abusive or neglectful to the child.

Appendix 7: Parents with Mental Illness - Useful Questions in Assessment contains useful questions to consider when gathering information about the impact of mental health issues on a person’s ability to safeguard a child or young person.


3. Key Points in the Child Protection Process

Care should be taken to consult all relevant adult mental health professionals during each stage of the child protection process.

There should be explicit and ongoing links between the Child Protection Plan for the child and the care plan for the parent, e.g. in relation to hospital admissions and discharges and child placement and contact issues.

If a mentally ill woman is pregnant and there are concerns about the unborn baby there should be joint planning between Children’s Social Care, ante-natal/midwifery and adult mental health services. The additional vulnerability of babies and young children should be given particular safety consideration. See Pregnant Women and Babies where there is Substance Misuse (MAPLAG) Procedure.


4. Young Carers

Many children and young people who live with parents with mental ill health take on caring and domestic responsibilities for the parent and/or siblings/other family members. These may include personal care, administering medication, checking up on or taking out the carer, domestic chores, and paperwork. 


Appendix 1: Parents with Mental Illness - References

‘Child Protection: Messages from Research’ HMSO, 1995

National Service Framework for Children, Young People and Maternity Services. Department of Health and Department for Education and Skills, 2004

Ofsted (2008) Learning Lessons, Taking Action: Ofsted’s evaluations of Serious Case Reviews 1 April 2007 to 31 March 2008.

Parents with Mental Health Problems and their Children Care Programme Approach (CPA) Briefing:Department of Health 2008

Cleaver H et al, ‘Children’s Needs - Parenting Capacity: the impact of parental mental illness, problem alcohol and drug use and domestic violence on children’s development’ HMSO London 1999

Cowling, V.R. (1996) 'Meeting the Support Needs of Families with Dependant Children Where the Parent has a Serious Mental Illness'

Falcov, A. (1995) Study of Working Together 'Part 8' Reports, Fatal Child Abuse and Parental Psychiatric Disorder: Department of Health. London: HMSO.

Falcov, A (1998) Crossing Bridges: Parental Mental Illness and its Implications for Children. London, Department of Health, Pavilion Publications.

Reder P et al, eds, ‘Family Matters: interfaces between child and adult mental health services’, Routledge 2000

Royal College of Psychiatrists ‘Patients as Parents: addressing the needs, including safety, of children whose parents have mental illness’ RCN 2002

Social Care Institute for Excellence Think Child, Think Parent, Think Family 2009


Appendix 2: Think Child, Think Parent, Think Family: A Guide to Parental Mental Health and Child Welfare

Click here to view Appendix 2: Think Child, Think Parent, Think Family: A Guide to Parental Mental Health and Child Welfare.


Appendix 3: Think Family Toolkit

Click here to view Appendix 3: Think Family Toolkit.


Appendix 4: The use of whole Family Assessment to identify the needs of Families with Multiple Problems

Click here to view Appendix 4: The use of whole Family Assessment to identify the needs of Families with Multiple Problems.


Appendix 5: Joint Protocol Flowchart

Click here to view Appendix 5: Joint Protocol Flowchart.


Appendix 6: Working Together to Support Young Carers

Click here to view Appendix 6: Working Together to Support Young Carers.


Appendix 7: Parents with Mental Illness - Useful Questions in Assessment

These questions are a useful guide to a holistic assessment. Clear analysis of what the information means for the child/ren and their family should be undertaken in consultation with line manager, supervisor and the multi-agency network.

  1. Health
    • Do any delusions include children?
    • Do the delusions include thoughts that children are evil/need saving from evil, which may involve harming or killing the children?
    • If the parent has indicated that they are contemplating suicide, have they also contemplated taking the life of their children?
    • Is the parent’s medication kept safely? Do parents appreciate safety implications?
    • Does behaviour/mood involve aggression/over-chastisement/domestic abuse, which could put children at physical risk?
    • Are parents physically available for children, ensuring that they are given age-appropriate supervision at all times?
    • What plans are made for care of children before/during emergency admissions to hospital?
    • Do parents understand the need for, and are able to provide, an adequate diet?
    • Is there any pattern of coercive interaction between parents with eating disorders and their children, particularly around meal times?
    • Are parents able to keep children’s medical/dental appointments?
    • Is the family’s home suitable to meet the child’s needs for hygiene, safety, cleanliness, etc. (including if a child has special needs arising, for example, from a disability)?
    • Are there financial implications of the parent’s illness that make maintaining adequate diet and levels of hygiene and safety difficult?
    • Is the child exposed to risk from other adults or visitors to the house?
  2. Education
    • Are school aged children regularly attending education?
    • Are children kept at home to care for siblings/parents?
    • If parent is emotionally unavailable to the child, is there adequate stimulation/attention from elsewhere?
    • Does the child have access to other children, books and play opportunities?
    • If a child is involved in delusions/altered thinking, does this affect their cognition, development and reasonable understanding of life?
  3. Emotional and behavioural development
    • If the parent is emotionally unavailable, is this to the extent that the child is likely to feel unloved and therefore experience poor or inappropriate attachment?
    • Is the parent’s behaviour violent, unpredictable or chaotic, leading to the child feeling frightened, inhibited, anxious or aggressive?
    • Is the parent aware of the nature and extent of the child’s emotional needs?
    • Does the parent express consistent negative views about/to the child, including rejection?
    • Is the parent able to respond appropriately to the requests for love and attention that the child presents?
    • Does the parent demonstrate and model appropriate behaviour and control of emotions and interactions with others in order that the child is able to develop an internal model of moral values and social behaviour suitable for the society in which s/he will grow up?
    • Does the parent regularly feel unable to guide the child’s behaviour by instilling appropriate guidance and boundaries?
    • Does the parent’s anxiety or delusion entail over-protection of the child of the imposition of unreasonable routines or expectations?
    • Is the child expected to take on an adult role by undertaking an inappropriate level of responsibility for self, siblings or parents? YORK
    • Is the child given appropriate explanations, by parent or others, about the parent’s illness and about significant events, such as hospitalisation, visits from professionals, etc?
    • Is the child’s development of a stable attachment likely to be affected by inconsistent parenting?
    • Is the child misusing substances, bed wetting, self-harming or displaying other problematic behaviour or emotional problems?
  4. Identity
    • Does the parent have a distorted sense of reality that affects the child’s growing sense of self as a separate and valued person?
    • Does the parent’s behaviour in the community cause the child to feel different, ashamed or confused?
    • Is the parent able to interact with the child in a way that enhances their self-esteem and feelings of self-worth?
    • Is the parent able to help the child develop a positive sense of individuality, including issues of race, religion, gender, sexuality and disability?
    • Does the child understand key issues about their parent’s mental health that may affect him/her?
    • Does the child have an anxiety that s/he may also become mentally ill in later life?
  5. Family and social relationships
    • Does the family situation provide the child with sufficient stability to enable him/her to maintain a secure attachment to the primary caregiver(s)?
    • Is the child provided with a reasonably stable routine for his/her daily life, e.g. mealtimes, bedtimes, being taken to school, etc?
    • Is the child encouraged to develop satisfying and healthy relationships with wider family members, friends and local community groups, appropriate to their culture?
    • Does the parent’s behaviour mean the child is reluctant to engage in normal friendships or invite friends to the house?
    • Does the child witness or have awareness of domestic abuse of one or both parents?
  6. Social presentation
    • Does the parent’s depressed mood or distorted thought patterns impair his/her ability to provide the child with appropriate dress, hygiene care or guidance?
    • Does a parent’s strange behaviour or beliefs impair the child’s presentation in his/her local and wider community?
    • Does the child witness bizarre or unusual social presentation by the parent, which may affect his/her understanding of their position in their society/community?
    • Is the child encouraged to have confidence in his/her ability to overcome difficulties in their society and wider community that may be related race, gender sexual orientation, disability, etc?
    • Are there financial implications of the parent’s illness which make maintaining an adequate standard of the child’s dress and/or cleanliness difficult?
  7. Self care skills
    • Is the parent able to encourage age-appropriate independence?
    • Does the parent’s behaviour, e.g. extreme dependence, threats of abandonment or suicide, erratic outbursts, etc. lead to the child becoming anxious about separation?
    • Has the child been given inappropriate responsibility for any aspects of the adult role in respect of his/her own care or that of their siblings?

1.1 Protective Factors

  1. The nature of the illness itself

    For any illness, consider:
    • Pattern - frequency of episodes, length of episodes. In general, an illness that has longer and more frequent episodes will have a greater impact than illnesses of short duration;
    • Severity - the impact of an illness will not be directly related to its severity, e.g. a parent with a short severe illness may be hospitalised and substitute care provided for the child with little impact on parenting;
    • Chronicity - a less severe illness that is chronic may lead to substandard care or neglect of the child, if long term medication or the illness itself leads to cognitive and/or personality changes;
    • Specificity - what are the symptoms of the illness and their likely impact?
  2. Factors within the child, family and wider networks
    • The child is older at the onset of the parent’s illness and has less exposure to, and fuller understanding of, the illness and a greater range of potential coping resources;
    • The child is more sociable, or of easier temperament, and is able to form positive relationships;
    • The child is of average, or above average, intelligence;
    • The child has a sense of self-esteem and self-confidence, with a range of approaches for solving problems;
    • There are discreet episodes of parental mental illness with a good return of skills and abilities between episodes;
    • The parent understands the need for support and that there may be some difficulties in the family for which they may need help at times;
    • There is alternative support from adults with whom the child has a positive, trusting relationship and who can respond to the developmental needs of the child;
    • There is take-up of regular supportive help from primary health care, good quality child care and good school attendance;
    • There is sufficient income and good physical standards in the home;
    • There are supportive siblings, family members and friends;
    • The family receives practical and domestic help;
    • The child receives regular medical and dental checks, including school medicals;
    • The child has information on how to contact relevant professionals/others in the event of a crisis regarding the parent;
    • The parent complies to a significant degree with treatment and advice;
    • Care plans are in place which take account of all appropriate factors, including the needs of children and the needs of the adult as parent;
    • Specialist services are accessible for the family at key times of need.

Please note: whilst it is important to recognise and develop strengths within the family and their network, workers must be careful that they are remaining objective about risks to the children.

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