Children of Parents with Mental Health Problems

1. 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.

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

The mental health of a parent or carer does not necessarily have an adverse impact on a child but it is essential to assess the implications for the child.

Many adults who suffer from mental health problems also have substance misuse problems, which 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 seek regular supervision whether the practitioner working with the child or the practitioner working with the parents, and consider in any assessments, information sharing or referrals to appropriate services.

2. 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;

• Whose parent(s) present with command hallucinations (these are hallucinations that the person has to act out on, a voice that tells them that their child is the devil/evil);

• Whose parent(s) have suicidal beliefs that include the child;

• Whose parent(s) have lack of insight into their mental health;

• Whose parent(s) do not engage with services or treatment;

• Who is included in his/her parent(s) obsessive compulsive behaviours;

• Where both parents have mental health problems;

• Who becomes a target for parental aggression or rejection;
• Who has caring responsibilities inappropriate to his/her age and should be assessed as a young carer;
• 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 any previous major mental illness.

Individual risk or stress factors, on their own, do not necessarily have a serious effect on an adult's parenting capacity or their children's mental health. However, some parents with mental health problems will face multiple adversities. Risk factors are also cumulative: the presence of more than one increases the likelihood that the problems experienced and impact on the child and parent will be more serious.

It is when three or more environmental and/or personal factors occur in combination that a negative impact on child and/or parental mental health is much more likely. For example, the presence of drug or alcohol dependency and domestic violence, 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 parents' mental health and wellbeing.

Risks can also change over time and create acute problems - for example, going into hospital can represent a significant crisis in terms of family life. Everyday routines are disrupted, other adults are overstretched and both parents and children often feel worried and powerless. An effective intervention needs to consider the outcomes for the whole family.

Risks to health and well-being will also vary from person to person - for example, people with the same mental health problem can experience very different symptoms and behave in different ways. Therefore, 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. A review of individuals' interactions with their social environment noted that inequality and poverty were significant stressors in families with mental health problems. Many studies have found that the stress of poverty - often due to parents with mental health problems being unable to work - are profound and can affect the health and wellbeing of both parents and their children. Similarly, a lack of community supports also impacts upon families and children. A study of black children's experiences of caring found an additional burden of care where there was a lack of culturally appropriate services.

3. Indicators

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

• 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 parent's mental health problem affect the development of a secure attachment with the child?
• 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 self-harm 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 does the family function, including conflict, potential family break up etc;
• Importantly we need to hear the voice of the child wherever possible; what is the child(s) story. THEY KNOW THEIR PARENT BEST!

4. 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 likely to suffer significant harm, a referral to Children's social care should be made in accordance with the Referrals Procedure. If there are 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 an Early Help Assessment taking place.

It is essential that staff working in adult mental health services and Children's social care work together collaboratively with a 'whole family' ethos to ensure the safety of the child and management of the adult's mental health.

• Treatment plans;
• Likely duration of any mental health problem;
• Effects of any mental health problem and medication on the carer's general functioning and parenting ability;
• Social Work Plans;
• Any concerns relevant to professionals entering the home or lone working concerns.

Children's social care must assess the individual needs of each child and within this incorporate information provided by mental health workers.

Mental health professionals should be invited to and must attend to provide information to 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. Children's social care professionals should be invited to and must attend Care Programme 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 professionals. The plan will also identify the process of communication and liaison between professionals. All professionals 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.

5. Issues

Contingency Planning. Child care and mental health professionals 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 a parent/carer disengages from mental health services, or is non-compliant with Treatment and the professional judgment is that there is on-going risk to the child in these circumstances, this should be referred to Children's social care.

Professionals need to consider carefully the implications for children when closing their involvement with a parent(s) with a mental health problem. Consideration should be given to informing the appropriate Children's social care team in order that the implications for the child are assessed.

Mental Health services, Children's Social Care and other relevant 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 always err on the side of caution.

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

Acquired Brain Injury

An acquired brain injury (ABI) is brain damage caused by events after birth rather than as part of a genetic or congenital disorder. ABI can result in cognitive, physical, emotional or behavioural impairments that can lead to temporary or permanent changes in functioning.

Impairment can result from:

• Traumatic brain injury - physical trauma due to accidents, assaults, neurosurgery, head injury etc.
  or
• Non traumatic injury - derived from an internal or external source e.g. stroke, brain tumour, infection, poisoning or substance misuse.

ABI does not include damage to the brain resulting from neurodegenerative disorders.

Impact upon parenting capacity

Further Information

Think child, think parent, think family: a guide to parental mental health and child welfare

Mind

RCPSYCH, Parental mental illness: the impact on children and adolescents: for parents and carers

NSPCC, Parental mental health problems