SCOPE OF THIS CHAPTER
This chapter outlines the key points in relation to parental and carers' mental ill health.
Derby and Derbyshire Multi Agency Protocol for Pre-Birth Assessments and Interventions (see Documents Library, Protocols)
In July 2017, this guidance was reviewed throughout and updated as required. Section 2, Assessment of the Child's Needs, was updated to include guidance on how to assess the likely impact of a parent/carer's mental ill health and its treatment on their parenting ability and the child's development. A reminder was also added that whenever practitioners identify that a child or children are living in a household where there is domestic abuse, parental/carer mental ill health and parental/carer substance misuse (drugs and/or alcohol), the interaction between these complex issues, also known as the 'toxic trio', must be fully considered.
- Assessment of the Child's Needs
- Referral to Children's Social Care
- Children Visiting Psychiatric Hospitals
- Special/High Security Hospitals
The majority of parents / carers who suffer mental ill health are able to care for and safeguard their children and/or unborn child without additional services. However in some cases, significant, enduring and/or severe parental / carer mental ill health will seriously affect the safety, health and development of children. Where practitioners believe that this may be the case a referral must be made to Children's Social Care (see Making a Referral to Social Care Procedure).
In other cases, the period of ill health may be transient or episodic and the illness maybe influenced by circumstances. The adult may also have links with other services. In some cases the parent may not see themselves as being mentally ill and this will require practitioners to be particularly sensitive in their approach when working with the family.
The adverse effects on children of parental / carers mental health are less likely when problems are mild, last only a short time and are not associated with family conflict. The effects are also less when parents / carers have insight and understanding of the potential impact and take steps to reduce them. Children may also be protected when the other parent / carer or a family member can respond to the child's needs, understand the problems and explain them to the children.
The adverse impact on the child's welfare increases when:
- The parent / carer becomes so pre-occupied by their own needs that they cannot empathise with the child in the usual way;
- When the child features in the adult's delusions;
- Other risk factors such as substance misuse and/or domestic abuse are also present.
In all cases it is important that practitioners from children's agencies and adult agencies work together using a Think Family approach to ensure the needs of the child and parent / carer are considered. At all times the welfare of the child remains paramount.
2. Assessment of the Child's Needs
Adult service practitioners should ascertain whether the adult with whom they are working is a parent / carer and whether there are children in the household or elsewhere. Adult services practitioners should always be alert to the impact that a mental health issue has upon a parents' or carers capacity to meet the needs of a child. Children's services practitioners should always be alert to the impact of the mental ill health of parents / or carers on the child and the family.
All agencies and practitioners should refer to the Derby City and Derbyshire Thresholds Document (see Documents Library, Guidance Documents) to identify the level of need and the appropriate assessment and interventions.
The Early Help Assessment can be used by any agency to identify emerging needs and meet the needs of a child arising from parental mental ill health issues, through coordinated multi agency services. See Providing Early Help Procedure.
Children's practitioners will need to check with parents/carers if they are currently or were previously known to mental health support services, including care via their GP's/Primary Care, and with consent liaise as appropriate (see Derby and Derbyshire Safeguarding Children Partnership Information Sharing Protocol and Guidance (Documents Library, Guidance Documents)). If parents/carers aren't in receipt of services a referral is likely to be needed. Adult mental health services and GP's can provide valuable input to assessment of children's and adults needs.
There should be a discussion about the best way to establish services and support for the parent/s or carer. Where parents/carers have worries or concerns about mental health or social issues they can access early informal support and help in Derby via community Talking Points and in Derbyshire via Caring for Someone.
Practitioners can also seek information and advice about adult mental health and support services from either the duty worker at Derby Adult Social Care - Your Life your Choice, Derbyshire Mental Health and Wellbeing, or Derbyshire Health Care foundation Trust.
Practitioners in children's and adults services must proactively work together to ensure there is a full understanding of the parents needs and the potential impact of this on their ability to care for their baby or child.All practitioners should ensure that needs of a child who has a mentally ill parent / carer are recognised and assessed using the best available skills. It is important for all practitioners to remain child focused and gain a clear perception of the individual child's experience of life, being mindful not to collude with or be over sympathetic with parents / carers. Mental health staff play a crucial part in both recognition and assessment and should take an active role in any intervention to safeguard the child. This includes those situations where there are specific risks arising from the mental ill health.
In particular thorough consideration should be given to the implications for a child of:
- A mother's perinatal and/or postnatal depression;
- A parent / carer's disordered perceptions, particularly of the child/ren;
- When a parent / carer appears to be suffering psychosis;
- When parent / carer presents as hopeless/sees no hope for the future;
- Where there are concerns in relation to impact of parent/carer's mental health on the child and family;
- The extent to which they are a young carer.
Any assessment of the child's needs should involve the Adult Mental Health practitioners. Specific professional knowledge and skills must underpin the competence of an assessment of parental mental ill health. Parental / carer non-compliance with, or active resistance to, treatment plans should raise particular concerns about the wellbeing of children.
To determine how a parent / carer's mental problem and its treatment 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, their child's or anyone one else's physical and emotional needs?
- 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? Are suitable care arrangements made during these periods?
- 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, symptoms or dysfunctional behaviours of the parent/carer?
- Does the parent / carer's mental health problem result in them perceiving the child negatively, rejecting the child or being unavailable to the child?
- Does the child witness acts of violence 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 the family functions, including conflict, potential family break up etc.
When adult service providers are unable to provide a service or withdraw service from a household where there are children, the other services working with the child and family should be informed. Adult services should also be informed of changes to service provision from children's services.
The Welfare of Unborn Children
Any concerns about the pregnant woman's mental health (or her partner's)should be raised with the midwife and GP. It is important to assess the needs and give support to parents /carers with mental health needs as early as possible. Close liaison between Midwifery Services and Children's and Adults Services should ensure that Early Help Assessments or Social care pre-birth assessments are undertaken whenever there is concern about a pregnant woman's ability to care for her expected child (and jointly with her partner where applicable). See Derby and Derbyshire Multi Agency Protocol for Pre-Birth Assessments and Interventions (Documents Library, Protocols).
From an early age children may assume the responsibility of looking after their parent / carer. As young carers these children should be offered an Early Help Assessment to ensure their needs are identified and any services which are required. Young carers who are not coping and/or have needs which cannot be met by early help assessment as they are complex or serious should be referred to Children's Social Care.
Note: If practitioners identify that a child or children are living in a household where there is domestic abuse, parental/carer mental ill health and parental/carer substance misuse (drugs and/or alcohol), the interaction between these complex issues, also known as the 'toxic trio', must be fully considered. The 'toxic trio' are indicators of increased risk to children and the likelihood of poor outcomes into adulthood, therefore effective assessment to clearly identify risk, strengths and resilience is required. Practitioners must ensure that all cases where the 'toxic trio' are present are discussed with their line manager and/or designated safeguarding lead to ensure that appropriate support and interventions are identified. See the procedures for children in these specific circumstances: Domestic Abuse Procedure, and Working with Parents who Misuse Substances. These should be read in conjunction with the Derby City and Derbyshire Thresholds Document and Information Sharing Agreement and Guidance for Practitioners both of which can be found in the Documents Library, Guidance Documents.
3. Referral to Children's Social Care
If any practitioner or agency has any concerns about the capacity of the parent / carer to meet the needs of their child, or where there are serious or complex needs or there are Child Protection concerns they must consult with their designated lead for Child Protection and make a referral to Children's Social Care. Concerns should be discussed with a parent / carer unless it is judged that this action will jeopardise the child's safety.
Where there are concerns that a child may be or is likely to suffer Significant Harm Social Care will convene a Strategy Discussion / Meeting involving, health, police and other relevant agencies. See Child Protection Section 47 Enquiries Procedure, Strategy Discussions / Meetings.
In addition to considering whether or not the threshold for a Section 47 Enquiry has been met, a strategy discussion may also look at appropriate multi-agency interventions early in the process and seek to minimise risk.
Practitioners working with the parents / carers should be involved in the Strategy Discussion / Meeting.
The Strategy Discussion / Meeting should give particular consideration to:
- Ensuring that there is sufficient information about the parents / carers mental health needs or other risk factors such as domestic abuse or drug and/or alcohol misuse on their ability to care for their child/ren and the impact on the child/ren;
- Whether specialist advice or assessment should be sought, who should undertake the investigation, where and how it will take place.
Given the potentially complex nature of Section 47 Enquiries it may be appropriate to hold additional strategy discussions to ensure that informed decisions are made. Expertise in both safeguarding children and adult mental health must be brought together to ensure that there is appropriate assessment and planning of services.
In addition to the information gathered and analysed within the Single Assessment adult mental health services and/or the GP/Primary Care should be requested to provide information in relation to:
- Parental mental health issues;
- Their assessment on the impact of the mental ill health on the ability of the adult to effectively look after and meet the child's needs;
- The parents' / carers views about their mental ill health and the impact it has on them and their child/ren;
- What support and services are needed, if any, to enable the adult to effectively look after the child/ren.
Where there is no involvement of a specific mental health service, Children's Social Care should seek general advice if they have concerns about a parent's / carers mental health. The vast majority of adults who require psychiatric assessment and treatment do so on a voluntary basis and some may require support to access appropriate services.
Some Adults however may need to be formally assessed under the Mental Health Act 1983, amended 2007 when it is considered necessary to admit a person to hospital or provide them with alternative support in the community to ensure the right care and treatment. It is important that Children's Social Care remain involved while the assessment takes place as the child may require alternative arrangements for their care if the parent requires compulsory admission to hospital; see also Section 4, Emergencies.
Practitioners who participate in the formal child protection process do so as a representative of their agency. They will be involved in the decision making process in which the welfare of the child remains paramount. They may be identified as important members of a Core Group which will develop and implement a protection plan for the child.
Parents / carers are also entitled to be accompanied by a supporter or advocate at child protection conferences and in core groups.
The safety of both the child and adult with mental ill health should be explicitly discussed between practitioners and specific areas of risk should be identified and suitable strategies agreed.
Whether or not the adult meets the statutory threshold for vulnerable adults, joint discussions should be held so that adults and children's services can work together to meet the needs of the whole family. All practitioners working with families where there is a parent / carer with mental health needs must also be mindful that they could be an adult at risk and may be unable to protect themselves from abuse or exploitation. See also Derby and Derbyshire Safeguarding Adults Procedures.
Where urgent action needs to be taken under the Mental Health Act or the Children Act, a Strategy Discussion should take place between managers from the mental health services, Children's Social Care and the Police to plan the intervention. The legal responsibilities of each agency are different but should be co-ordinated to ensure that relevant information is shared and that disruption to the family is minimised. It is important for the safety of the children that each service is clear about the planned intervention and timescales of the other. Any professional differences should be recorded in writing and communicated to the other service as a matter of urgency to ensure that no one is placed at risk.
5. Children Visiting Psychiatric Hospitals
Psychiatric hospitals should have written policies regarding visiting of patients by children, which should only take place following a decision (regularly reviewed) that such a visit would be in the child's best interests.Where there are child welfare concerns regarding visits to patients detained under the Mental Health Act, the trust may ask Children's Social Care to assess whether such a visit is in the child's best interests.
6. Special/High Security Hospitals
It is only in very unusual circumstances that a child would visit a patient in a special or high security hospital. When such a visit is proposed practitioners involved with the family should be clear of the purpose of the visit, the wishes of the child, and whether it is in their interests to undertake such a visit. Any assessment should take account of the welfare and emotional wellbeing of the child.