6.3 Impact of adults with mental illness on children they care for: Guidance

• This document has been developed to assist all agencies in Buckinghamshire who are working with families of children under eighteen where an adult has mental health needs.
• Parents/carers with mental health needs have the right to be provided with timely care and support that enable them to meet the needs of the child/children.
• Children have the right to be protected from harm and to receive timely services when their health or development is at risk.
• All professionals, whether working with the adult or with a child within the family, have a responsibility to THINK FAMILY and to consider both the needs of the child and those of adults with mental health difficulties and refer to other agencies. Guidance on referral is included in this document.
• No one professional is an expert on the needs of both the adult and the child and so joint working between agencies is crucial.
• Medical confidentiality should not be a barrier to appropriate and timely sharing of information between professionals. Guidance on information sharing between agencies is included in this document.
• The lived experience of both the child/children and the adult should be central to the assessment of a family’s needs, risks and the support offered.

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 (2014-2017) 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:

All those who come into contact with children, their parents and families in their everyday work, including practitioners who do not have a specific role in relation to child protection, have a duty to safeguard and promote the welfare of the child as set out in Working Together to Safeguard Children.

• The welfare of the child must take precedence over Parents/Carers right to confidentiality.
• Children are usually best brought up within their own families and support should be provided to enable this to be the case whenever possible. Most parents, carers and pregnant women with mental health needs safeguard their children’s wellbeing.
• Respect and sensitivity should be given to differing family patterns, lifestyles, and child-rearing practices, which can vary across different racial, ethnic, and cultural groups. However, all professionals must be clear that child abuse and neglect, caused deliberately or otherwise, cannot be condoned for religious or cultural reasons.
• Coordinated and timely services must be provided to families in which there are dependent children of parents, carers, or pregnant women with mental health problems.
• There should be good cooperation and collaborative decision-making between services that promote the well-being and safety of adults and children.
• Parents/Carers should be seen as the experts on their children and, wherever possible, plans are to be developed with them for times when they are unwell. Consideration to include the extended family should be given.
• Children should be actively included in the work, proportionate to their age and ability, and must offered information and support about a parent’s mental health issues.
• Childcare workers must help to identify parents who may have mental health needs and use links with other agencies (including primary healthcare) to find help and support for them. Practitioners need to consider the ‘think family ‘approach.
• Mental health workers must help to identify all children who may need services.
• Shared assessment of parents with mental health problems who are already known to agencies or are new referrals should be carried out where there are concerns.

Here are some messages to mental health professionals written by young people from a Barnardo’s project in Liverpool². The messages show how important it is to keep children informed. 

Introduce yourself. Tell us who you are and what your job is. 

Give us as much information as you can. 

Tell us what is wrong with our parents. 

Tell us what is going to happen next. 

Talk to us and listen to us. Remember it is not hard to speak to us; we are not aliens. 

• Ask us what we know and what we think. We live with our parents; weknow how they have been behaving.
• Tell us it is not our fault. We can feel really guilty if our mum or dad is ill.We need to know we are not to blame.
• Please don’t ignore us. Remember we are part of the family and we live there too.
• Keep on talking to us and keep us informed. We need to know whatis happening.

Tell us if there is anyone we can talk to. MAYBE IT COULD BE YOU.

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.

Informed assessments and effective multi-agency/disciplinary working are the key to ensuring that children and families receive the appropriate services to meet their identified needs and manage risk.

The key to ensuring children are safe, protected, and their needs are being met where parents/carers have additional needs, is to assess parent’s/carers capacity and ascertain if additional support is required. Consider the following areas:

• Basic care 
• Ensure they are safe.
• Able to provide emotional warmth.
• Stimulation 
• Appropriate boundaries and stability 

 Key questions  

 Are parents/carers able to provide the following: 

 BASIC CARE 

• How are the children being cared for?
• Are they receiving basic care?
• Providing for the child’s physical needs, and appropriate medical and dental care. Includes provision of food, drink, warmth, shelter, clean and appropriate clothing, and adequate personal hygiene.

 ENSURING SAFETY 

• How are the children kept safe?
• There should be recognition of hazards and danger both in the home, online and elsewhere.
• Is safety planning for the children included in the mental health care plan if a parent’s mental health deteriorates.

 EMOTIONAL WARMTH 

• Ensuring the child’s emotional needs are met, giving the child a sense of being specially valued, and a positive sense of own racial and cultural identity.
• Includes ensuring the child’s requirements are met for secure, stable, and affectionate relationships with significant adults.
• There should be appropriate physical contact and comfort and affection sufficient to demonstrate warm regard, praise, and encouragement.

 STIMULATION  

• Promoting child’s learning and intellectual development through encouragement and cognitive stimulation and promoting social opportunities.
• Ensuring school attendance or equivalent opportunity.
• Facilitating the child to meet the challenges of life.

GUIDANCE & BOUNDARIES 

•  Enabling the child to regulate their own emotions and behaviour through demonstrating and modelling appropriate behaviour, control of emotions and interactions with others.
• Guidance which involves setting boundaries, so the child develops an internal model of moral values, conscience, and appropriate social behaviour.

STABILITY 

• Providing a sufficiently stable family environment to enable a child to develop and maintain a secure attachment to the primary caregiver/s, to ensure optimal development.
• Parental responses change and develop according to child’s developmental progress.
• In addition, ensuring children keep in contact with important family members and significant others. 

 See Continuum Of Need for further information

If there is concern about the mental health needs of a parent/carer, the adult’s Primary Cary Team/ GP should be contacted in the first instance and a request made for information to be shared regarding any existing or previous diagnosis of mental illness, and previous or current treatment or referrals.

In order for timely sharing of this information, the Primary Care Team will need to know why the information is needed, in what timescale it needs to be provided, with whom the information will be shared (within health professionals or with other agencies), what information is being asked and whether the patient has consented to this information being shared.

Practitioners should be aware that women in Buckinghamshire who are temporarily placed in refuges may be additionally vulnerable to their mental health needs not being met and patient information between systems may be limited.

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.

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.

• recent history of assessment and treatment by secondary adult mental health services, including hospitalisation and/or community mental health team involvement
• previous history of mental illness during pregnancy or the post-partum period
• current/recent treatment for mental health needs by the Primary Care Team
• previous history of self-harm, or current expression of an inability to manage their own or their child/children’s safety.
• expression of apparently unreal fears about their own safety or that of others
• evidence of significant withdrawal from people, family, or activities, i.e., showing signs of depression or anxiety
• fluctuations in mood and activity, e.g., excessive crying, inappropriate expression of anger, over activity, or increased suspicion
• concerns about self-neglect
• a child’s or other’s expression of concern regarding change in a parent and/or carer’s behaviour or attitude.
• chaotic households against a background of significant social stressors such as inadequate housing, unemployment, or low income.

Concerns should be discussed with the person’s Primary Care Team/GP in order to agree the most appropriate course of action. It would be usual practice for the Primary Care Team/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.

In any instance where there is a concern about the welfare of a child, professionals should consult the BSCP Continuum of Need Incorporating Threshold 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.

Speak to the family to discuss the concerns and reasons for referral. Gain a better understanding of the situation and gain consent to refer if possible

Think family – consider all family members including all the children. Risks may be relevant to some or all of the children in the family.

Consideration should be given to a referral to Early Help in order to provide additional support and safeguard children at an early stage. Early Help in Buckinghamshire is now provided by the Family Support Service.

Consider schools involvement – what support is school offering? Are they aware of the family situation? Is the school counsellor involved? Is the child’s school attendance level a concern?

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.

• a parent/carer expresses thoughts of harm to a child – in such cases the referral should include any safety planning completed for the child and /or parent/carer.
• any parent/carer exhibiting signs of mental illness, or who are already the subject of a continued psychiatric assessment, where there are concerns surrounding the impact on a child’s wellbeing.
• there has been a previous death of a child or serious harm caused to a child whilst in the care of either parent/carer which raised concern.
• there are concerns about the parent/carer’s ability to self-care and/or to care for the child, e.g., unsupported young or learning-disabled mother.
• the child may be at risk of significant harm, including a parent/carer previously suspected of fabricating or inducing illness in a child
• urgent concerns as a result of parents or carers being assessed under the Mental Health Act
• parents or carers with mental health or substance misuse problems who are caring for a child with a chronic illness, disability, or special educational needs.
• children who are caring for parents or carers with mental health or substance misuse problems (young carers)
• children who have been the subject of previous child protection investigations, a Child Protection Plan, local authority care, or alternative care arrangements

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.

All information should be shared in line with the BSCP Information Sharing Code of Practice and HM Government advice.

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.

 Joint work will include mental health workers providing all information with regards to:

• treatment plans
• likely duration of any mental health problem
• the effects of any mental health problem and/or medication on the parent’s general functioning and parenting ability.

Parents/Carers 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.

If an adult’s clinical information is shared without their consent, the adult should be notified of this.

For further guidance please see:

Information Sharing - Buckinghamshire Safeguarding Children Partnership (buckssafeguarding.org.uk)

Child protection workers must assess the individual needs of each child and, within this, incorporate information provided by mental health workers. They must assess the risk and impact on each child in accordance with information provided by mental health workers and the assessment framework.

Mental health professionals must attend and provide information to any meeting regarding the potential impact of parent/Carer mental health concerns on the child. These will include:

• Multi-agency meetings
• Strategy meetings
• Initial and Review Child Protection Conferences
• Core Group meetings

Relevant professionals from Children’s Services and other agencies supporting the child should attend Care Programme Approach (CPA) and other meetings related to the management of the parent/carer’s mental health where concerns about capacity to parent have been raised.

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:

• No major decisions (such as the removal of children, closure of a case or move to discharge or home leave from hospital) should be made without the consultation of other services, unless urgency requires immediate action. In these circumstances, other parties should be informed as soon as possible.
• Social Care must be informed if a parent/carer is being hospitalised or other treatment is taking place which might impact on their ability to care for their children.
• The mental health worker must be informed if a child is returning home following a period of being in care, and the children and families social worker must be informed of any changes in treatment for the parent/carer, such as a trial period on reduced or no medication.
• The health visitor should be invited to all CPA meetings where the service user has a child under five years.
• Written documentation or minutes must be sent to all professionals involved and put on the respective case files and a copy sent to the patient’s Primary Care Team/GP.
• Regular communication by telephone, fax, email, or letter should be maintained, particularly if there are any concerns or changes in the situation.
• If appropriate and practical, it is good practice to arrange joint visits from time to time. Otherwise, agencies should coordinate visits from adult mental health teams and child social work teams to ensure families are seen regularly.
• When any service is considering that they should close a case, discussion must take place with other involved services first. This will help to ensure that the full implications of closing the case are understood and considered collectively.

Consideration to be given to the adult’s accommodation history, have they always lived in Buckinghamshire, have the child/children been known in another local authority?

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.

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.

Mental ill health can sometimes lead to  neglect of both the adults and their children’s physical, emotional and social needs. The children may have caring responsibilities, which are inappropriate to their age and may have an adverse impact on their development. Some forms of mental ill health may cause adults to be ‘unavailable’ or not responsive to the child; or to behave in bizarre, unpredictable or violent ways towards themselves, their children or environment

The stigma and oppression associated with adult mental ill health can impair the adult’s ability to care for the child/ren and children can carry the burden of covering for parental behaviour. It can be difficult for adults to share their situation and struggles. Children may be reluctant to talk about family problems or seek support. Practitioners need to be sensitive to this. Refer to the ‘Child’s Experience’ section

At the extreme, a child may be at risk of severe injury, profound neglect or even death.

An adult carer’s 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/who is assessed as a safeguard
• there is no other family disharmony
• the child has wider support from extended family, friends, teachers or other adults.
• the child feels a sense of belonging and security
• the child has at least one secure attachment relationship
• the child has access to wider supports such as extended family and friends
• the child has positive nursery, school and or community experiences.

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 the adult’s delusions (i.e., false beliefs)
• are built into the adult suicidal plans.
• becomes the target of the adult’s aggression or rejection.
• are being profoundly neglected physically and/or emotionally as a result of the adult’s mental illness.
• are newborn infants whose mother has a severe mental illness or personality disorder
• have a parent/carer who is expressing thoughts of harming their child, e.g., in severe depression.
• are involved in his/her carer’s obsessive-compulsive behaviours.
• have caring responsibilities inappropriate to his/her age 
• may witness disturbing behaviour arising from mental health problems (e.g., self-harm, suicide, disinhibited behaviour, violence, homicide)
• do not live with the unwell parent, but have contact (e.g., formal unsupervised contact session or the parent sees the child in visits to the home or on overnight stays)
• are socially isolated because they feel unable to bring other children home, or understand or have the words to explain what is happening at home to adults
• are an unborn child of a pregnant woman with any previous and/or post-partum major mental health problem.

The following factors may impact the ability of an adult to provide appropriate care 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
• non-compliance with treatment
• poor engagement with services
• previous or current compulsory admissions to mental health care
• mental health problems deemed long term ‘untreatable’, or untreatable within timescales 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
• non-identification of the illness by professionals
• previous referrals to Children’s Social Care for other children

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 Primary Care Team/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 Primary Care Team/GP. It is also important to identify partners of pregnant women who have mental health or substance misuse problems.

Pregnant women in Buckinghamshire now book their maternity appointments online and these are coordinated by midwives based at the hospital and not by Primary Care Teams/GPs. As such, it is possible that a pregnant woman may not see her GP during the pregnancy and the first contact with their GP may be at the face-to-face six-week post-natal appointment. It is important that those working with pregnant women do not assume that the pregnant women are being routinely seen by their GP.

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.

In addition, both the triennial review (2014--17) 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 risk factors that may contribute to cumulative risk of harm. Other 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 parent/carer’ 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.