6.3 Parenting Capacity and Mental Illness: Guidance

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:

• Parents have a right to confidentiality. However, where there are concerns about the welfare of a child, these must take precedence.
• Children are usually best brought up within their own families and support should be provided to enable this to be the case whenever possible.
• 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 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.
• Professionals working in Buckinghamshire to be aware of their responsibilities for working together to safeguard and promote the welfare of children and their families.
• Parents 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.
• Children should be actively included in the work, proportionate to their age and ability, and must receive information and support about a parent’s mental health issues.
• Proactive, positive links to be made with professionals in partner agencies in a timely and well-informed fashion. These links will also assist in the development of understanding in relation to child care and mental health responsibilities and processes.
• Child care 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.
• Mental health workers must help to identify all children who may need services.
• All workers must identify pregnant women and their partners who may need support or input because of a mental health issue and in such cases follow the Buckinghamshire Safeguarding Children Partnership (BSCP) Pre-Birth Procedures.
• All responses to enquiries and referrals are to be facilitated to reach an appropriate service, i.e. no ‘wrong door’ approach.
• Most parents, carers and pregnant women with mental health needs safeguard their children’s wellbeing. However, it is essential to always assess the implications for each child in the family. Many children whose parents have mental health needs may be seen as children with additional needs requiring professional support, and in these circumstances referral to early help services should be considered. Early Help in Buckinghamshire is now provided by the Family Support Service.
• Shared assessment of parents with mental health problems who are already known to agencies or are new referrals should be carried out. Integrated services, which are both effective and well-coordinated, should be provided to these families.
• 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 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:

• Are they receiving services for the mental health condition?
• Do they have children? If so, record details including full names, dates of birth, ethnicity and schools/nurseries.
• Do any of the children have caring responsibilities for their parent or younger siblings? Do you need to consider a referral for Young Carer's Support?
• Have the parents and, where appropriate, the children been involved in any assessment and their views sought?
• Have you considered the impact of their mental health on their ability to meet the needs of their children? (This will be determined by several factors: nature, severity and duration of the illness; involvement in, and exposure to, parental symptoms; alterations in parenting; changes in family structure or functioning; or the effects of parental treatment.)
• Is there a previous history of concerns in respect of parenting ability or the welfare of the children?
• Is the mother pregnant? If so, has she accessed antenatal care?
• Have you discussed the need for any additional services, or made a referral to another service, with them?
• Have they expressed views about harming themselves and/or the children?
• Is there anyone in the household with special needs or a disability? Are they receiving services/had an assessment?

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:

• 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
• 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 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, e.g. in severe depression
• are involved in his/her parent’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 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
• 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.

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.

• 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 a GP
• 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 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.

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. Early Help in Buckinghamshire is now provided by the Family Support Service.

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 which raised concern
• there are concerns about parental 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 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.

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.

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.

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:

• 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 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:

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

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:

• 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.
• 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.

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.

Decision-making Flowchart

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.