Think child, think parent, think family: a guide to parental mental health and child welfare
Introduction: Think Family as a concept, and its implications for practice
The Think Family agenda recognises and promotes the importance of a whole-family approach which is built on the principles of 'Reaching out: think family' (18):
- No wrong door – contact with any service offers an open door into a system of joined-up support. This is based on more coordination between adult and children's services.
- Looking at the whole family – services working with both adults and children take into account family circumstances and responsibilities. For example, an alcohol treatment service combines treatment with parenting classes while supervised childcare is provided for the children.
- Providing support tailored to need – working with families to agree a package of support best suited to their particular situation.
- Building on family strengths – practitioners work in partnerships with families recognising and promoting resilience and helping them to build their capabilities. For example, family group conferencing is used to empower a family to negotiate their own solution to a problem.
A family focus alone may not be enough to address the problems faced by some parents with a mental health problem nor will it necessarily prevent a child from suffering harm. The adults' problems need to be addressed through specific clinical expertise and services, just as children's problems need to be, or those requiring a whole family approach.
While the recommendations in this guide wholeheartedly support a family focus it should not be seen as an alternative to providing individual care, but must be considered alongside it. This means thinking about the child, the parent and the family, with adult and children's health and social care services working together to consider the needs of the individual in the context of their relationships and their environment. It should thus provide the optimum service that makes the best of what specialist training, knowledge and support is on offer. 'Think parent, think child, think family' is therefore the guiding principle for this guide.
The Family Model
The Crossing Bridges Family Model (Falkov 1998) is a useful conceptual framework that can help staff to consider the parent, the child and the family as a whole when assessing the needs of and planning care packages for families with a parent suffering from a mental health problem. The model illustrates how the mental health and wellbeing of the children and adults in a family where a parent is mentally ill are intimately linked in at least three ways (see Figure 1):
- parental mental health problems can adversely affect the development, and in some cases the safety, of children
- growing up with a mentally ill parent can have a negative impact on a person's adjustment in adulthood, including their transition to parenthood
- children, particularly those with emotional, behavioural or chronic physical difficulties, can precipitate or exacerbate mental ill health in their parents/carers.
The Model also identifies that there are risks, stressors and vulnerability factors increasing the likelihood of a poor outcome, as well as strengths, resources and protective factors that enable families to overcome adversity.
Figure 1: The Family Model
Risks, stressors and vulnerability factors
Individual risk or stress factors, on their own, do not necessarily have a serious effect on an adult's parenting capacity or their children's mental health. However, some parents with mental health problems will face multiple adversities. Risk factors are also cumulative – the presence of more than one increases the likelihood that the problems experienced and impact on the child and parent will be more serious.
It is when three or more environmental and/or personal factors occur in combination that a negative impact on child and/or parental mental health is much more likely. For example, the presence of drug or alcohol dependency and domestic violence in addition to mental health problems with little or no family or community support would indicate a increased likelihood of risk of harm to the child, and to parents' mental health and wellbeing.
Risks can also change over time and create acute problems. For example, going into hospital can represent a significant crisis in terms of family life. Everyday routines are disrupted, other adults are overstretched, and both parents and children often feel worried and powerless. An intervention needs to consider the effects on outcomes for the whole family to be effective.
Risks to health and wellbeing will also vary from person to person. For example, people with the same mental health problem can experience very different symptoms and behave in different ways. Therefore relying on a diagnosis is not sufficient to assess levels of risk. This requires an assessment of every individual's level of impairment and the impact on the family.
Strengths, protective factors and resources
The factors which can promote resilience in children – i.e. the factors which determine how well a child copes with their parent's mental health problem – are related to:
- their physical traits and personality
- their relationships with other family members
- the immediate environment in which they live
- life events.
People acquire whatever qualities of resilience they may have in two ways – by what they are born with through their genes, and by the effects of subsequent social experience. The surrounding environment and an individual's biological make-up will continually interact and influence each other in aiding or hindering children's ability to cope with living with a parent who has a mental health problem.
Risk to resilience
It may not be possible to easily change all the adversities which families experience.However, promoting and supporting protective factors can help reduce the negative effects when a parent is mentally ill.
For children, all protective strategies operate through one or more of the following processes (30):
- by altering the child's perceptions of, or exposure to, risk of harm
- by reducing the cumulative effect of risk factors compounding each other
- by helping the child improve her/his self-esteem and self-efficacy
- by creating opportunities for change
Link: Promoting resilience in fostered children and young people In addition there may be optimum situations or times to target specific interventions to boost resilience – for example, assistance with parental housing or financial problems or offering support at transition points in children's lives.
Promoting resilience does not mean minimising concerns about risk of poor outcomes. If a child is exposed to continuous and extreme stress, then they are very unlikely to develop resilience. It is therefore unrealistic and unhelpful to rely exclusively on a resilience-led approach (Fraser et al. 1999).
Implications for organisations and for practice
An approach based on the Family Model enables staff to:
- know what to look for
- take a holistic approach to assessment and consider the environment, family, cultural and social systems within which individuals live (e.g. housing, finance, employment, relationships).
- gain a better understanding of the links and relationships between risk of poor outcomes and resilience, adult and child, symptoms and parenting, the changing pattern over time, and what to do with the information they gather
- understand the risks to health and wellbeing that occur across generations and manage these risks to reduce their impact.
Implications for the frontline practitioner
Adopting this approach requires a change in attitude and practice which includes:
- switching from a focus on diagnosis or pathology to concentrate on individual strengths and interventions that are strongly associated with promoting mental health and recovery, sustaining families and promoting inclusion
- raising the expectations of people who use mental health services who are parents and taking seriously their views of their resource needs
- looking at the family as a unit and focusing on positive interdependency and supportive relationships
- helping parents to understand their mental health problems, their treatment plan, and the potential impacts of mental health problems on their parenting, the parent-child relationship and the child
- working with parents and children to enable the child to have age-appropriate understanding of what is happening to their parent and information about what services are available for them in their situation and how they can access these.
At the same time, practitioners need to remain aware and be prepared to intervene when their is evidence that the child is suffering or is likely to suffer harm.