6.3 Parenting Capacity and Mental Illness: Guidance
- Context and aims
- Possible effects of parental mental III health
- Guidance for referral to adult mental health services
- Guidance for referral to children's social care
- Pregnant Women
- Dual diagnosis
- Joint working
- Risk Assessments
- Resolution of disputes and differences
- Related guidance and further information
- Related Policies, Procedures, and Guidance
Context and aims
This procedure has been written to improve the coordination and communication between all agencies in Buckinghamshire engaged with children and families and parents who have mental health needs.
The procedure should be applied whenever there are concerns about the well-being or safety of children whose parents or carers have mental health needs, specifically where these difficulties are impacting, or are likely to impact, on their ability to meet the needs of their children. This procedure also applies to pregnant women who have mental health problems or where their partners are known to have mental health problems.
The National Biennial Review of Serious Case Reviews (2003–2005) reported that 53% involved parents with mental health problems. In these cases the mental illness of the parent had a significant impact on their parenting capacity, resulting in the death or serious injury of the children. However, it remains the case that the majority of mentally ill parents do not harm their children. It also does not mean that parents who experience mental health problems have poor parenting skills.
However, the impact of parental mental health problems can, on some occasions, lead to children and families needing additional support; or, in a small number of cases, support and multi-agency action to prevent significant harm.
The guidance is underpinned by the following principles:
The following set of questions are designed to guide decision making about how best to meet the needs of children and adults in families experiencing mental health problems:
Possible effects of parental mental III 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 their 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 impair parenting capacity and children can carry the burden of covering for parental behaviour. Children 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.
Parental mental ill health will be less likely to have an adverse effect on a child when:
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:
The following factors may impact parenting capacity and increase concerns that a child may have suffered, or is at risk of suffering, significant harm:
Guidance for referral to adult mental health services
If there is concern about the mental health needs of a parent/carer, the GP should be contacted in the first instance, to ensure that the full background is obtained regarding any existing or previous diagnosis of mental illness, and previous or current treatment or referrals.
If there is an imminent danger to the person or others, including a child, the police must be contacted. Staff must ensure that their decision and agreed course of action is fully and accurately documented, signed and dated.
Triggers that may indicate a referral to adult mental health services for initial assessment is needed are listed below. However, this is not an exhaustive list and is provided to assist professional decision-making.
Concerns should be discussed with the person’s GP in order to agree the most appropriate course of action. It would be usual practice for the GP to assess the client in the first instance and make a referral to mental health services if appropriate. However, in some circumstances another professional may make the referral, or the client may self-refer.
A past history of mental health problems will not necessarily mean a referral is required; this will depend on what the particular diagnosis was, current mental state, how long an individual has been stable and the level of support at home.
Guidance for referral to children's social care
In any instance where there is a concern about the welfare of a child, professionals should consult the BSCP Thresholds document and follow the advice set out in should follow the BSCP's Neglect Guidance.
A referral to Children's Social Care for an initial assessment or pre-birth assessment should always be made if a parent, carer or pregnant woman is considered to have significant mental health problems, as indicated by the triggers given below. A referral should always be discussed with a manager.
If there is an imminent danger to the person or others, including a child, the police must be contacted.
Consideration should be given to a referral to Early Help in order to provide additional support and safeguard children at an early stage.
Triggers that indicate referral to Children’s Social Care are listed below. However, this is not an exhaustive list and is provided to assist professional decision-making.
Where a parent or carer expresses thoughts of self-harm, an assessment of risk to the child or unborn baby must be made and consideration given to a referral to Children’s Social Care based on the level of risk. Management of self-harm risk by adult mental health services staff must include in the plan actions to support the needs of the child/children/unborn baby and there should be discussion with the organisation’s lead for child safeguarding. Where necessary, advice should be sought from First Response. Consideration must always be given to the care arrangements for the children should the parent need to be admitted to hospital.
When a parent or carer has been receiving inpatient services, in whatever setting, consideration must be given to discharge arrangements to ensure provision for the children is appropriate, and their welfare and safety has been properly assessed. A formal meeting with Children’s Social Care should be held where they are already involved or if concerns are identified. If a parent or carer discharges themselves out of hours, a referral to the Emergency Duty Team should be made to ensure the children's welfare is protected.
Newly identified risk or changes in the risk assessment in any agency must be communicated to other relevant agencies in order that they can consider if this new information impacts on their own risk assessments. Staff must always consider that a change for one member of the family might have impact on another member, and that a Think Family approach is essential.
Where the need for referral to Children’s Social Care is unclear, this must be discussed with a line manager and/or safeguarding lead. Children’s Social Care can be consulted for advice. Staff must ensure that all decisions and the agreed course of action are signed and dated, and that a written referral using the MARF (multi-agency referral form) follows any telephone conversation or referral. If a referral is not made, the reasons must also be clearly documented.
When an agency identifies a pregnant woman experiencing mental health problems, an assessment must be undertaken to determine what services she requires and the BSCP Pre-Birth Procedures must be followed.
This must include gathering relevant information from their GP, in addition to any other agencies involvement, to ensure that the full background is obtained about any existing or previous diagnosis, or treatment for mental illness or substance misuse. This is especially important where service awareness of earlier births may need to be clarified, for example, in the case of older or overseas children. If a person has moved recently, it is advisable to seek out health records from the previous GP. It is also important to identify partners of pregnant women who have mental health or substance misuse problems.
Research has shown that pregnant women with a previous history of mental health needs are particularly vulnerable to breakdown during the later stages of pregnancy and following the birth of their baby.
When a parent has a substance misuse problem, as well as mental health needs, this can put the child at particular risk, especially where the potential for dealing with the substance misuse problem is limited. Where a parent/carer has mental health and substance misuse issues, the assessment of the parent should ideally be conducted in partnership between the Mental Health Care Management Team and the Adult Substance Misuse Care Management Team.
It should be noted that mental health needs can also be associated with high-risk behaviour or difficulties, such as substance misuse or domestic violence. The National Triennial Review of Serious Case Reviews (2011-14) found that mental health needs co-existed with domestic abuse and substance misuse in 22% of cases.
In addition, both the triennial review (2011-14) and previous biennial reviews of Serious Case Reviews have shown that the three issues of domestic abuse, parental mental ill health, and alcohol or substance misuse are not the only parental risk factors that may contribute to cumulative risk of harm. Other parental risk factors often co-exist with these factors, and potentially interact with them to create harmful environments for the children. These include issues such as adverse experiences in the parents’ own childhoods, a history of criminality - particularly violent crime, a pattern of multiple consecutive partners, and acrimonious separation. Professionals should be aware of this when undertaking an assessment of risk.
It is essential that staff working in adult mental health and children’s services work together to ensure the safety of the child and the management of the adult’s mental health.
There is an expectation in adult mental health teams that an experienced member of the clinical team will be involved with parental cases where children are ‘at risk’. Joint work will include mental health workers providing all information with regards to:
Parents with mental health issues entrust professionals with, or allow them to gather, sensitive information relating to their health and other matters as part of their seeking treatment. They do so in confidence and they have legitimate expectation that staff will respect their privacy and act appropriately.
Where there are concerns about the wellbeing of a child, the need to share information will take precedence over the patient’s right to confidentiality. However, practitioners need to consider what information is and is not confidential, and the need in some circumstances to make a judgement about whether confidential information can be shared, in the public interest, without consent.
Sensitive information can be shared if there is a clear and justifiable purpose, and consideration has been made of the safety and wellbeing of the child and others who may be affected. The more sensitive the information, the greater the child focus needs to be in order to justify sharing.
The practitioner needs to be mindful that information may need to be shared with a number of agencies, therefore the ‘need to know’ and ‘proportionality to the risk of harm’ principles apply. Where a practitioner is considering the inclusion or exclusion of sensitive information, or consent has been refused, they must discuss this with their safeguarding lead within their organisation.
Child protection workers must assess the individual needs of each child and, within this, incorporate information provided by mental health workers.
Mental health professionals must attend and provide information to any meeting regarding the potential impact of parental mental health concerns on the child. These will include:
Relevant professionals from Children’s Services 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, 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 when necessary.
Key examples of good practice in joint working:
It is important to be aware that risk assessment in mental health work and risk assessment in child protection work are two different concepts, and it can be dangerous to confuse them.
The former is concerned with predicting the likelihood of a patient’s mental health deteriorating to the point where she/he poses a risk to self and/or others. The latter involves the analysis of information to consider whether or not the children’s likely experiences are acceptable, in terms of risk of physical or sexual assault, omission of care or neglect, or threat to emotional wellbeing.
Newly identified or changes in risk in one agency’s assessment must be communicated to other relevant agencies, so that they too can consider if this new information impacts on their own risk assessments. Staff must always consider that a change for one member of a family might have impact on the other member – a ‘think family’ approach is essential.
Resolution of disputes and differences
In the event of a dispute or disagreement arising between professionals, the BSCP Procedure for Escalation, Challenge and Conflict Resolution should be followed.
Any disagreements or differences should be recorded on the case file, including the views of the other party.
Related guidance and further information
- NSPCC, Parenting with a mental health problem
- Ofsted (2013) What about the children?
- Social Care Institute for Excellence. Think child, think parent, think family: A guide to parental mental health and child welfare
- Royal College of Psychiatrists (2011) Parents as Patients: supporting the needs of patients and their children
Oxford Health NHS Foundation Trust provide services such as psychological services, Adult Mental Health Teams (AMHT), complex needs service, Bucks Community Eating Disorders Team (BCEDT) and adult mental health inpatient services.
This flowchart is relevant to all services in Buckinghamshire which are treating or providing any kind of service to parents, carers or pregnant women with mental health problems.