3.3.6 Parents, Carers or Family Members with Mental Ill Health

1. Introduction

Mental ill health in a parent or carer does not necessarily have an adverse impact on a child's development. Just as there is a range in severity of illness, so there is a range of potential impact on families. The majority of parents with a history of mental ill health present no risk to their children, however even in cases of low level concern, the needs of the child/ren must be paramount.

It is important to recognise that other issues can exacerbate the risk presented by mental ill health. For example, the presence of drug or alcohol misuse, domestic abuse, parental conflict,in the household  with little or no family or community support could indicate an increased likelihood of risk to the child, and to the parents' mental health and wellbeing.

It is essential that the diagnosis of a parent/carer's mental health is not seen as defining the level of risk. Similarly, the absence of a diagnosis does not equate to there being little or no risk. An assessment should consider the impact on the child of the parents’ behaviour and consider what support services are in place or available for the family to access.

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

The term "mental ill health" is used to cover a wide range of conditions, from eating disorders, mild depression and anxiety, to psychotic illnesses such as schizophrenia or bipolar disorder.

2. Possible Effects of Parental Mental Ill Health

Parents with mental ill health may neglect their own and their children's physical, emotional and social needs. Their children may have caring responsibilities, which are inappropriate to their age and may have an adverse effect on the children's development. Some forms of mental ill health may blunt parents' emotions and feelings or cause them to be "unavailable" or not responsive to the child, or to behave in bizarre or violent ways towards their children or environment.

The stigma and oppression associated with mental ill health can mean that parents will not ask for support and children may carry the burden of covering for parental behaviour. Children, aware of the social stigma, may be reluctant to talk about family problems or seek support.

Protective Factors:

Parental mental ill health may be less likely to have an adverse effect on a child when:

• The mental ill health is mild,short-lived or managed;
• There is another parent or family member who can help;
• The child has wider support from extended family, friends, teachers or other adults;
• The child has a secure base, has a sense of belonging and security, good self-esteem and an internal sense of worth and competence;
• The child has a sense of self-efficacy and a sense of mastery and control, along with an accurate understanding of personal strengths and limitations;
• There is at least one secure attachment relationship;
• They have positive nursery, school and or community experiences.

Note: An older child may seem more resilient but they can also be vulnerable in other ways. The risk to an older child is a different risk but they are not necessarily at less risk.

Indicators of increased risk:

A significant history of violence within the household is a risk indicator for children, as is parental non-compliance with services and treatment.

Children most at risk of Significant Harm are those who:

• Feature within parental delusions (i.e. false beliefs);
• Are built into the parent's suicidal plans;
• Become targets of parental aggression or rejection;
• Are being profoundly neglected physically and/or emotionally as a result of the parent's mental illness;
• Are newborn infants whose mother has a severe mental illness or personality disorder;
• Have a parent who is expressing thoughts of harming their child;
• Are involved in his/her parent’s obsessive-compulsive behaviours;
• Have caring responsibilities inappropriate to their age;
• Witness disturbing behaviour arising from the mental health problems (e.g. self-harm, suicide, disinhibited behaviour, violence, homicide);
• Don’t live with the unwell parent, but have contact (e.g. formal unsupervised contact session);
• Are socially isolated because they feel unable to either bring other children home, or understand or have the words to explain what is happening at home to adults;
• Is an unborn child of a pregnant woman with any previous and/or post-partum major mental ill health.

The following factors may also impact upon parenting capacity and increase concerns that a child may have suffered or is at risk of significant harm:

• History of mental health problems with an impact on the adult's functioning; 
• Misuse of drugs, alcohol, or medication;
• Severe eating disorders;
• Self-harming and suicidal behaviour;
• Lack of insight into illness and impact on child, or insight not applied;
• Non-compliance with treatment;
• Poor engagement with services;
• Historical or current compulsory admissions to mental health inpatient units;
• Mental ill health combined with domestic abuse and/or parental conflict;
• Mental ill health combined with isolation and/or poor support networks;
• Mental ill health combined with criminal offending.

3. Responding to Concerns

The most effective response to children and families affected by mental ill health comes through all agencies adopting an holistic whole family approach. This is based on coordinating the support provided by adult and children's services to a family "at risk" in order to secure better outcomes for the children and adults through the use of targeted, specialised and whole family approaches in addressing family needs.

Fundamental to this approach is good inter-agency practice characterised by:

• Routine enquiry;
• Robust inter-agency communication and information sharing;
• Joint assessment of need;
• Joint planning; and
• Action in partnership with the family.

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 ill health, 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 their own health problems and needs as 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 2: Parents with Mental Illness - Useful Questions in Assessment contains useful questions to consider when gathering information about the impact of mental ill health on a person’s ability to safeguard a child or young person.

4. Key Points in the Child Protection Process

Care should be taken to consult and work with all relevant adult mental health professionals during each stage of the child protection process and to invite them to all relevant meetings.

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, Partners and Babies where there is Substance Misuse (MAPLAG) Procedure.

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. Consideration should be given to supporting the child or young person in accessing the Young Carers service

Appendix 1: Definitions and Common Terms of Mental Illness

The Health of the Nation booklet: "Mental Illness - What does it mean?" (HMSO) states:

"There are many different types of mental illness. Often these involve feelings of depression, anxiety and confusion - all of which most people get some time or other, particularly after a distressing life event such as bereavement. But with mental illness these feelings occur to such an extent for such a long period of time that they make it very difficult for a person to cope with everyday life."

Some of the definitions below are also taken from that booklet.

Anxiety

…phobic, panic and general anxiety disorders in which anxiety symptoms, such as worry, tension, overbreathing and giddiness, cause significant distress and disability.

Bi-polar disorder

…causes profound changes in mood, from severe depression and lethargy to elation and over-activity.

Borderline personality disorder (also known as emotionally unstable personality disorder)

A serious mental illness characterised by pervasive instability in moods, interpersonal relationships, self-image, and behaviour. This instability often disrupts family and work life, long-term planning, and the individual's sense of self-identity.

Dementia

…leads to a decline in a person's intellectual functioning and memory. People can become very confused. Their memory for current events is impaired, but they are often able to recall scenes from many years ago with great clarity.

Depressive Disorder

…a condition in which feelings like depression, loss of interest, reduced energy, suicidal thoughts, and sleep and appetite disturbance go beyond normal mood changes.

Dual diagnosis

The term 'dual diagnosis' covers a broad spectrum of mental health and substance misuse problems that an individual might experience concurrently. The nature of the relationship between these two conditions is complex.

Eating Disorders

…include Anorexia Nervosa, a condition that leads to severe weight loss, and Bulimia Nervosa, a condition that combines over-eating with vomiting and 'purging'. Both disorders are characterised by an extreme fear of being fat.

Personality Disorders

…are deeply ingrained patterns of behaviour which are inconsistent and inflexible responses to a broad range of personal and social situations. They may be associated with distress and problems in social functioning. There are several types of personality disorder. See Mind: Personality Disorders for further information.

For further information see Mind – Personality Disorders

Postnatal Mental Illness

• Depression can occur during and after pregnancy. It affects about one in 10 mothers. Severe depression is particularly common after childbirth, whereas mild depression is no more common after childbirth than amongst the general population. The onset may be sudden or gradual, and the effects vary from mild to severe. Risks during the postnatal period include suicidal acts and harm to the infant, which makes this an important disorder to identify and treat;
• Psychosis after childbirth: Psychosis is very much more common after childbirth and bipolar disorder is particularly common. The onset is often sudden and, in the case of bipolar disorder, particularly close to birth. Psychosis after childbirth affects about one mother in 500. The behaviour of the mother may become increasingly bizarre and disturbing to those around her and she may lose touch with reality.

Psychosis

The ability to distinguish between what is real and what is imaginary is seriously affected. People may hear people saying things when no one is speaking - 'hearing voices' - which sound quite real to them. Or they may develop strong persistent beliefs of 'delusions,' which are unbelievable to others around them.

Schizophrenia

…a condition that affects the most basic mental functions that give people their sense of individuality, uniqueness and direction. It can cause them to hallucinate (e.g. hear voices), develop feelings of bewilderment and fear, and to believe that their deepest thoughts, feelings and acts may be known to, or controlled by, others.

Appendix 2: 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 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 the 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?
   • Is the parent able to recognise risks to the child/ren, either through the child/ren’s own behaviour or risk from others?
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? Are there other family members that can provide emotional warmth and support to the child/young person?
   • 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 or 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?
   • 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 they 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 them to maintain a secure attachment to the primary caregiver(s)?
   • Is the child provided with a reasonably stable routine for their 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 their 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 their local and wider community?
   • Does the child witness bizarre or unusual social presentation by the parent, which may affect their understanding of their position in their society/community?
   • Is the child encouraged to have confidence in their 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 their 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/or 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 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.