Children of Parents with Mental Health Difficulties

This practice guidance aims to assist all agencies working with children, with adults who are parents/carers or with pregnant women and their partners in identifying situations where action is needed to safeguard a child or promote their welfare as a result of the adult's mental ill health.

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 should be paramount.

It is important to recognise other issues that can exacerbate the risk presented by mental health issues. For example, the presence of drug or alcohol dependency and domestic abuse in addition to mental health problems with little or no family or community support would indicate an increased likelihood of risk of harm to the child, and to the parents' mental health and wellbeing. Relying on a diagnosis is not sufficient to assess levels of risk. This requires an assessment of every individual's level of impairment and the impact on the family.

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 behaviour and support services.

"A structured assessment of mother's ability and capacity to parent child x is not undertaken. The evidence that mother's parenting is compromised by her use of drugs and mental illness never feature in the work with mother."

Quote from a Manchester Serious Case Review

There is also a well-established relationship between mental ill health and domestic abuse. Between 50% and 60% of women mental health service users have experienced domestic abuse, and up to 20% will be experiencing current abuse. Domestic abuse is one of the most prevalent causes of depression and other mental health difficulties in women.

'Parent' may refer to biological and non-biological parents, carers including grandparents, pregnant women and their partners and any adult who has regular responsibility for the care of a child or young person (this may not necessarily mean that the adult in this context has Parental Responsibility in legal terms).

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. A glossary of some of the most common conditions is included in Appendix 1: Definitions and Common Terms of Mental Illness.

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

Early Help Assessment (EHA) processes should support this and, where necessary, Child in Need and Child Protection Assessment and planning processes.

In any situation where there is a perceived conflict between the interests of the adult and those of the child, all agencies must treat the child's needs and safety as paramount. Agencies also have a responsibility to adopt a non-discriminatory, open and supportive approach and ensure adequate advocacy is provided to the parent. While services should recognise diversity and respect an individual's ethnic, religious and cultural needs and personal preferences, but this should not excuse worrying behaviours as culturally normal.

Most children with additional needs due to an adult's mental ill health are considered under the EHA processes and without the intervention of Children's Social Care. However, all agencies must be alert to the potential risks to children of parental mental ill health and must consider its impact on the safety and well being of the children and the need for specialist assessment, consulting other agencies as necessary.

Agencies should also be sensitive to the fact that mental ill health may be only one of the factors affecting parenting and the children's well being. As stated above, there is an established relationship between mental ill health and domestic abuse. There is also a relationship between mental ill health and substance misuse.

Professionals working with adults experiencing mental ill health who are parent/carers or their partners should establish:

• Whether an EHA has already been completed and whether there is a Lead Professional, by contacting the relevant EHA Team (see Local Contacts);
• Whether Children's Social Care is already involved.

Where there is a Lead Professional or Social Worker, professionals working with the parent/carer or their partner should provide any additional information they may hold and contribute to the child's plan, including by attending relevant meetings.

Where there is no existing Lead Professional or Social Worker and the professional believes that the child has additional needs requiring some level of support from other agencies, they should consider the need for an EHA or a referral to Children's Social Care. In some cases, the child or young person may have additional needs because their life is in some way restricted as they are young carers, taking responsibility for a person who is experiencing mental ill health.

If an EHA is required, professionals should seek the parent's/carer's consent and follow the EHA process.

Where a non-urgent referral to Children's Social Care is being considered, professionals should discuss their concerns with Children's Social Care and proceed as agreed.

In any case where there is believed to be an imminent risk of Significant Harm, Children's Social Care must be contacted immediately in accordance with the Making Referrals to Children’s Social Care Procedure.

Please note that under this procedure, any telephone referral must be followed up within 24 hours with a written referral.

Professionals should follow their own agency's safeguarding procedures. They should consult their line manager or agency safeguarding lead if they are uncertain about the need to refer to Children's Social Care. Children's Social Care offers a consultation service about the appropriateness of making a referral.

Throughout their involvement with the adult and children, professionals must continually review the impact of mental ill health on parenting capacity and the safety and well being of the children.

When dealing with teenage parents or pregnant teenagers experiencing mental ill- health, it is important to consider and assess the needs of the teenage mother or father as well as the potential impact on the parenting of their child(ren) or unborn baby. Consideration needs to be given as to whether the teenager is a Child in Need or a child at risk of Significant Harm in their own right, as well as undertaking an assessment of the needs of their child or unborn baby.

Multi-agency assessment and planning should follow the processes outlined above for both the teenage parent(s) and their child. Where an EHA is required for the teenager, there may be agencies that can offer specific support to the teenager(s), such as CAMHS (Child and Adolescent Mental Health Service for 16/17 years olds), Teenage Pregnancy Personal Advisers or Mental Health Advisers.

Depression and anxiety are common and at any one time one in six adults may be affected. Psychotic disorders are much less common with about one in two hundred individuals being affected. 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.

Research has found that:

• Approximately 30% of adults with mental ill health have dependent children;
• At any one time, about 10,000 children and young people are caring for a parent with mental ill health;
• 25% of children subject to Child Protection Conferences has a parent with mental ill health;
• 33% of children with emotional and behavioural disorders have a parent with a mental health problem;
• Post-natal depression can be linked to both behavioural and emotional problems in the children of affected mothers.

The stigma and oppression associated with mental ill health can of themselves impair parenting capacity and children can 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.

At the extreme, a child may be at risk of severe injury, profound neglect, or even death. A study of 100 reviews of child deaths where abuse or neglect had been a factor in the death, showed clear evidence of parental mental illness in one third of cases.

Protective Factors:

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

• The ill health is mild or short-lived;
• There is another parent or family member who can help;
• There is no other family disharmony;
• The child has wider support from extended family, friends, teachers or other adults;
• A secure base – the child feels a sense of belonging and security;
• Good self-esteem – an internal sense of worth and competence;
• A sense of self-efficacy – a sense of mastery and control, along with an accurate understanding of personal strengths and limitations;
• At least one secure attachment relationship;
• Access to wider supports such as extended family and friends;
• 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 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;
• Has a parent who is expressing thoughts of harming their child e.g. in severe depression;
• Who is involved in their parent’s obsessive-compulsive behaviours;
• Who has caring responsibilities inappropriate to their age;
• Who may witness disturbing behaviour arising from the mental health problems (e.g. self-harm, suicide, disinhibited behaviour, violence, homicide);
• Who does not live with the unwell parent, but has contact (e.g. formal unsupervised contact session or the parent sees the child in visits to the home or on overnight stays);
• Who is 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 health problem.

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

• History of mental health problems with an impact on the sufferer’s functioning;
• Maladaptive coping strategies;
• 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;
• Previous or current compulsory admissions to mental health hospital;
• Mental health problems deemed long term ‘untreatable’, or untreatable within time scales compatible with child’s best interest;
• Mental health problems combined with domestic abuse and/or relationship difficulties;
• Mental health problems combined with isolation and/or poor support networks;
• Mental health problems combined with criminal offending (forensic);
• Non-identification of the illness by professionals (e.g. untreated postnatal depression can lead to significant attachment problems);
• Previous referrals to LA children’s social care for other children.

In relevant cases, close collaboration and liaison between the mental health professionals working with the parents or carers and Children's Social Care is essential.

When working with a parent, the mental health professional should contact Children's Social Care to establish if they are involved, seeking the parent's consent if appropriate.

They should also contact Children's Social Care if they are uncertain about whether a particular concern constitutes a safeguarding issue. If in doubt they should share their concerns.

Joint assessments and joint visits should be undertaken between the agencies to facilitate assessments and safeguard children. Where they are known to be involved, Children's Social Care should be invited to and attend relevant meetings, e.g. CPA planning and review, discharge meetings, etc.

Similarly, mental health professionals should be invited to meetings convened by Children's Social Care, either as part of an enquiry and assessment or as part of a continuing intervention. Such meetings can include Strategy Discussions; "professionals meetings"; Child Protection Conferences, Core Groups and other planning or review meetings. If invited, mental health professionals involved with the child's parent or carer should attend these meetings or, if this is not possible, contribute by means of a written report.

Please note that a strategy discussion should always be considered when a child might be at risk due to an adult's acute mental health needs.

Consistent with usual standards of good practice, where they have been involved in joint working, neither agency should cease their involvement without informing the other and without an assessment of the implications for the child. This is particularly the case where patients have delusional systems or suicide plans which include their children.

See also Pre-Birth Assessments Procedure.

There may be concerns about a pregnant woman's ability to provide safe and appropriate care to a child. These may arise from her current mental health, her past history and/or her family circumstances. In addition, or alternatively, the concerns may arise due to her partner's mental health or past history.

Parents who are concerned about their own mental health or the impact on their children should speak to their GP. Practitioners who have concerns about a parent or carer's mental health should consult with the Community Mental Health Teams. If this concern involves concern about the welfare of the child then a referral should be made as described above to Children’s Social Care.

Special consideration should be given to pre-birth planning for pregnant mothers who have a current severe and enduring mental illness, or a past history of a severe mental illness, whether this occurred after a previous childbirth or is unrelated to childbirth. These women are more likely to have parenting problems and to deteriorate after delivery.

The relevant Mental Health Trust should be involved with all pregnant women with a past or current episode of severe depression, bipolar disorder or schizophrenia. Professionals from other agencies working with such women should confirm that this is the case. They should be referred to the perinatal clinic as soon as the pregnancy is known, to obtain advice on treatment as early as possible in pregnancy and assessment of potential parenting problems.

Where the concerns are rooted in the pregnant woman's partner's mental health, the pregnancy should trigger a multi-disciplinary/multi-agency review and planning meeting arranged by the relevant Mental Health Trust under the CPA arrangements. Consideration should be given to the effect of the pregnancy and parenthood on expectant partners and risks and needs assessments should take account of the pregnancy.

Any concerns about potential parenting problems should be discussed with the parent(s), when appropriate, and support offered. In some cases the assessment of potential parenting problems will conclude that there is a need for Children's Social Care to be involved. The parent(s) should be made aware of any referrals to other agencies and their consent to engagement identified. However, where parents fail to consent and/or where there is a risk of Significant Harm to the baby, any necessary referrals to Children's Social Care must be made without their consent as set out in the Making Referrals to Children’s Social Care Procedure.

Where Children's Social Care is already involved with other children in the family, the responsible Social Worker should be informed of the pregnancy as soon as possible.

Where Children's Social Care is not already involved and a referral is considered appropriate, a completed Referral Form should be sent to them soon after 20 weeks gestation, to allow an Assessment to be completed. Where required, the aim will be to complete and, if necessary, convene an Initial Child Protection Conference by 32 weeks' gestation.

More detailed guidance can be found in the Pre-Birth Assessments Procedure.

Staff from all agencies should have regard for the safety of their colleagues in making a home visit or an assessment, and information about people who are known to represent a threat should be shared as part of any referral or joint working. This includes risk assessments being made and shared across agencies. Workers should seek advice from their managers and adhere to the Health and Safety Policy of their agency.

Where Children's Social Care staff are aware that an adult they wish to assess is vulnerable because of a current or previous mental disorder, they should take the precaution of discussing the implications with the relevant mental health professionals and vice versa.

• Bolton - to follow;
• Manchester;
• Rochdale;
• Salford;
• Stockport;
• Tameside;
• Trafford;
• Wigan - to follow.

There have been many attempts at defining mental illness and definitions vary depending on the severity of the symptoms. The Mental Health Act 1983 does not offer clear definitions of mental illness and as yet there is no university agreed definition.

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 states

…phobic, panic and general anxiety disorders in which anxiety symptoms, such as worry, tension, over breathing 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

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.

Originally thought to be at the "borderline" of psychosis, people with borderline personality disorder suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder, BPD is more common, affecting 2% of adults, mostly young women. There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases. Patients often need extensive mental health services and account for about 20% of psychiatric hospitalisations.

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. Examples are:

• Primary psychiatric illness leading to substance misuse;
• Substance misuse that alters or worsens the course of psychiatric illness;
• Intoxication and/or substance dependence leading to psychological symptoms;
• Substance misuse and/or withdrawal that leads to psychiatric symptoms or illness.

Although this definition talks about illness and substance misuse, the term is also used when two psychiatric illnesses are concurrent. It is sometimes applied in other health settings to convey the presence of two or more conditions e.g. learning disability and mental illness.

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.

Mental illness in pregnancy

Pregnancy does not protect from mild or severe mental illness. All disorders can occur during this time.

Neurosis

The booklet only briefly mentions neurosis and states that it is a broad term to describe anxiety and depression and that it has been used in such a vague way for so long that it is being used less and less.

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. For example, some people are so shy or dependent that they find it distressing and difficult to make friends.

Other helpful definitions:

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 not more common after childbirth. 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

Your ability to distinguish between what is real and what is imaginary is seriously affected.

You might hear people saying things when no one is speaking - 'hearing voices' - which sound quite real to you. Or you may develop strong persistent beliefs of 'delusions,' which are unbelievable to others around you who you know well.

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.

Severe and Enduring Mental Health Problems.

A mental disorder (i.e. psychotic disorders including schizophrenia, bipolar disorder or severe neurotic conditions and personally disorders) of such intensity that it disables people from functioning adequately as determined on the basis of their culture and background.

Children's Services Professionals

This first set of prompts is intended to assist all professionals delivering a service to children, adolescents and their families when they are assessing parenting capacity:

• Observation of behaviour of the parent where there is a mental health concern (prolonged depression);
• What are your observations? (Care of the child(ren), support from partner, care of self, support systems, environment, etc);
• Have you observed any concerning behaviour regarding the children?
• Have you consulted with other agencies which may be involved e.g. Young Carers, General Practitioner, Children's Centre, school nurse, Health Visitor?
• Does the parent have a known history of mental health problems?
• Ask the parent about their view of their mental health problem;
• Ask the parent it they have received treatment from their General Practitioner or a Consultant Psychiatrist for their mental health problem (record details of diagnosis, drug treatment, in-patient treatment).

NB: Children should be consulted about their thoughts and feelings. Have you spoken to the children? What do they feel about the situation? What support do they need? Have they been given an age appropriate explanation and reassurance about their parent/ carer’s mental health problem?

Mental health professionals

This second set of prompts is intended to assist all mental health professionals (i.e. all staff, both community and hospital based, involved in the delivery of mental health services) in assessing parenting capacity:

• What is the nature of the mental disorder or illness that affects the care of the child(ren), e.g. psychosis, depression, personality disorder?
• Does the effect of the mental disorder or illness impair the care of the child(ren) (e.g. physical care, emotional care, stimulation, appropriate care arrangements)?
• What awareness does the parent have about the effect of their mental health problem on the care and well being of their child(ren)?
• What informal support systems are available for the care of the child(ren)? (partner, family, voluntary agencies);
• What formal support systems are available for the care of the child(ren)? (Health Visitor, General Practitioner, Homecare, Child minder, Day Nursery, School nurse);
• Have you observed any concerning behaviour regarding the child(ren)?
• Have you considered whether an EHA is required?
• Have you checked whether an EHA has been completed and if there is a Lead Professional?
• Have you consulted with other agencies for example Young Carers' Project, Health Visitor, Midwife, Family Centre, General Practitioner or Children's Social Care when considering home leave from wards, discharge plans etc?
• Given that mental health professionals may have vital information that could explain things to the child you should consider giving an age appropriate explanation to the child, offering support or information that would help them understand and asking them what support they want and need.