Parental mental health and child welfare: A guide for adult and children's health and social care services
Problems with current practice
Many staff lack confidence in making an assessment of the impact of mental health problems on a family. Staff from children's services may have only a limited knowledge of mental health problems, particularly their impact on parenting. They may not consider that parenting also has an impact on a person's mental health. Adult mental health staff can provide valuable information in support of these assessments, but it is not their responsibility to make a final judgement.
Families facing multiple adversity (e.g. depression, drug and alcohol misuse, and homelessness) need careful multi-disciplinary and multi-agency assessment and support. People who use services have commented that assessments are only 'partial' because they are too fragmented and 'only the service user holds the whole picture'.
Assessments rarely explore a family's strengths in the same amount of detail as any areas of concern. The concept of resilience is not generally well understood. At the same time, some practitioners can be overly optimistic, and fail to recognise the need to protect children from harm.This has been a serious problem in some cases where children have died.
Assessments can be based on limited information if not shared appropriately across agencies:
- Different professional groups may not share the right information because they work to different criteria for information-sharing, use a different language and lack sufficient understanding of each others' roles. This means they may not understand what information is important for other agencies to have and so do not ask the right questions or pass the information on.
- Adult mental health staff are concerned that children's social care staff may make important decisions based on limited information such as a mental health diagnosis, or may over- or under react because they do not have a good understanding of mental health problems.
- Children's social care staff report that it is sometimes difficult to get reliable information from their adult mental health colleagues, particularly psychiatrists.
Criteria to access services currently act as a barrier to providing services to these families because:
- There are separate local criteria for adult and children's services which work against identifying the needs of the family as a whole.
- Criteria are set very high which can lead to some families falling through the service net.
- Local eligibility is based on weaknesses and problems. This means families must present themselves in ways which hide their strengths and resources and means they need to exaggerate their difficulties to get access to a service. This also makes it extremely difficult to identify and prioritise opportunities for early intervention and prevention.
In a successful service:
- The assessment takes account of the whole family's full range of needs – including those of young carers.
- The assessment takes account of present and future needs. For example, whether intervening in the present can help to avoid crises or prevent future ill-health for any member of the family.
- The assessment considers what support can be provided to maintain family wellbeing.
- Local eligibility criteria for services take account of the complex and varied needs of the whole family.
- Staff quickly identify the most vulnerable families, and intervene to prevent a crisis. All assessments comment on the mental health of both parents and any other adult member of the household, and record whether the parents live together and the degree of contact with children.
- All staff are equipped to identify cases where children are suffering, or are likely to suffer, significant harm and are able to respond quickly and effectively.
Recommendations for change
Staff need to:
- Take a systemic and socially inclusive approach to assessments. This is essential because parents often need advice on other matters such as housing and financial problems that would otherwise add stress and limit their chances of recovery.
- Involve all members of the family including the children in the process of assessment (as well as subsequent care planning and review). Staff may need to support children to be involved. They should also identify whether there is an adult or young person carrying out caring responsibilities in the family and where appropriate carry out a carer's assessment as soon as possible.
- Develop good working relationships with their counterparts in other agencies to support information-sharing and joint assessments. Staff need to gain a better understanding of other professionals' roles and their differing perspectives. They need to feel confident enough to challenge other agencies where appropriate.
- Be very clear about what information can be shared and with whom, also seeking parents' and children's permission for information-sharing wherever possible.
- Be able to recognise the most vulnerable groups and know from where to access appropriate advice, including: young mothers, women in the perinatal period, fathers, black and minority ethnic families, asylum seekers, parents with dual diagnosis or personality disorder, parents experiencing domestic violence, families who are separated and looked-after children.
- Be better informed about what forms of adult mental health problems and their symptoms and associated behaviours could present a risk of harm to children. Staff also need to be aware of their responsibilities for safeguarding children (see below).
Safeguarding children in families with a parent with mental health problems
The responsibility for safeguarding children does not only lie with children's services. It is a requirement of safeguarding children policy that adult services, including mental health services, know whether their service users have children or are in contact with children. This again highlights the importance of routinely identifying and recording which people who use mental health services are parents and which children have parents with mental health problems.
This is not to imply that adult mental health problems are the only serious risk factor for children's safety. The research evidence suggests that other factors (e.g. parental drug and alcohol misuse, domestic violence, and/or learning disability) are often present in serious child abuse or neglect situations. It is therefore important to be able to recognise and understand what contribution adult mental health problems make to an assessment of overall risk of harm to children.
The lessons from cases where children have been killed by their parents, or suffered significant harm, suggest it is also important to train and support for staff so that they are:
- constantly vigilant
- open and inquisitive, regardless of any assumptions based on previous assessments
- aware of the need to reassess following new or increasing numbers of incidents and following changes in circumstances
- able to challenge colleagues within partner agencies if required
- aware of their responsibility to pass on concerns about the welfare of a child to Children's Social Care.
Organisations need to:
- Adapt and develop existing assessment and recording processes to take account of the whole family. Link: Mental Health outcomes and training tool (MHOAT)
- Provide staff with assessment tools (or amend existing tools) that identify the needs of parents, children, carers and young carers and take account of a family's strengths as well as their difficulties. These tools also need to be acceptable and accessible to families. They should be applied in universal, targeted and specialist, maternity and secondary care services. Link: Mental Health outcomes and training tool (MHOAT)
- Develop information-sharing and joint working policies/protocols to improve communication, coordination and collaboration within their organisation and across agencies.
- Train and support their staff in making joint assessments. Training should include how to interpret the information gathered in assessment and support should include clear signposting to specialist consultation and advice for complex cases (e.g. child and family mental health, risk assessment and culturally sensitive services).
- Develop and implement 'family' threshold criteria for access to services to take into account the individual and combined needs of parents, carers and children. They also need to ensure that vulnerable families meet necessary service thresholds, to ensure better access to services regardless of setting and agency.
- Train all their staff to increase their knowledge and understanding of adult mental health problems and their impact on the family in the present, over time and across generations, to help them identify when to intervene early or as a preventive measure.
- Train and support their staff to recognise the signs of adult mental distress so that they are aware of the risk of neglect, abuse and domestic abuse and are equipped to follow the local safeguarding procedures laid down for their services within their area.
Managers need to:
- Increase their knowledge of all parts of the professional network.
- Develop strong working relationships across divisions, particularly at senior management level.
- Foster a culture of respect for staff in different disciplines.
- Agree and record strategies for the management of joint cases (case files) where the situation is complex or there is a risk of poor outcomes.
- Develop new or adapt existing management information tools to ensure the quality and timeliness of assessments as part of their day-to-day supervision of staff