2.12 Children of parents with mental health problems

Mental health problems are proportionately common in the overall population, can vary in severity and impact differently on people’s day to day lives.  The term does not in itself have one clear definition, and therefore the existence of mental health problems should not be taken as a risk factor without contextual information.

Mental health is a spectrum and not all mental health issues lead to a formal diagnosis. ‘Mental Health’ is often used as a generic term but it is important to consider if there is a specific diagnosis and consider the needs and behaviours which are being displayed and the impact this may have on the child(ren).

Parental mental illness does not necessarily have an adverse impact on a child's developmental needs, but it is essential to always assess its implications for each child in the family. Particular concerns may arise alongside other stressful life experiences.  Coping with lots of challenges at one can make it difficult for parents to provide their children with the care that they need.

Mental illness may also impact on Mental Capacity and result in enduring or fluctuating capacity, this includes when a person's ability to make a specific decision changes, long-term or frequently or occasionally. Such changes could be brought on by the impact of a mental illness, physical illness, the use or withdrawal of medication, the use of illicit substances or alcohol and consideration may need to be given to undertaking a mental capacity assessment.

Adverse effects are less likely when appropriate supervised treatment is provided, and when the mental health problem is managed, lasts a short time, is not associated with family disharmony and does not result in the family breaking up. Children may also be protected from harm when the other parent, or another family member, can respond to the child’s needs, and when the child or young person has the support of friends and other caring adults.

In some cases, especially with regard to enduring and/or severe parental mental ill health or where there is associated family disharmony / break-up, the parent's condition will seriously affect the safety, health and development of children. Practitioners must take into consideration that the absence of a formal diagnosis does not mean there is an absence of risk.  If a psychiatrist cannot make a diagnosis to treat their condition with therapeutic interventions (e.g. medication) that does not mean there is no danger for the child, and in some cases the danger is greater.

The state of a person’s mental health is usually not static and can vary according to several factors, correspondingly their capacity to parent safely may also be variable, and therefore, an understanding of the factors which may increase risk is an important part of any assessment.

The National Panel Annual Report 2022-2023  have identified a theme arising from the rapid reviews, local child safeguarding practice reviews (LCSPRs)  and letter from the Panel to safeguarding partnerships following the panels consideration of partnerships rapid reviews. In terms of working with parents with poor mental health, the Panel raised concern about the lack of whole family approach to risk assessment and support.  It was apparent that ‘information and assessment between adult mental health and children’s services was not effectively joined up.  The analysis of reviews further highlighted significant challenges for practitioners concerning the lack of communication pathways between services that provide support for children and services that provide support for adults. It is for this reason practitioners are encouraged underpin their assessments of families with the lens of the ‘Think Family’ approach: (using holistic assessments to identify vulnerabilities for each family member and their impact on the family dynamics), which can in turn facilitate the multiagency development of robust safeguarding plans.

The NSPCC April 2023 published a briefing: ‘Parents with a mental health problem: learning from case reviews’ found, that in the case reviews considered, professionals sometimes lacked knowledge about mental health, were not aware of parental mental health concerns or did not fully understand how poor mental health had affected parenting capacity. This had meant that the impact on children went unrecognised, and potential safeguarding issues were not identified.

It is important to recognise other issues that can exacerbate the risk presented by mental health issues. For example, the presence of drug or alcohol dependency and domestic abuse in addition to mental health problems with little or no family or community support would indicate an increased likelihood of risk of harm to the child, and to the parents' mental health and wellbeing. 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.

Parental mental ill health does not necessarily impact adversely on their parenting however, children most at risk of harm  (who has suffered, or is likely to suffer significant harm) or whose well-being is affected by parental mental illness could be a child who:

• feature within parental delusions
• are built into the parent's suicidal plans
• become targets of parental aggression or rejection
• who is at risk of severe injury, 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;
• has a parent who is expressing thoughts of harming their child
• is involved in his/her parent’s obsessional compulsive behaviours
• who is subject to a lack of parental supervision due to parental illness
• who has caring responsibilities inappropriate to his/her age and should be assessed as a young carer
• may witness disturbing behaviour arising from the mental health problems (e.g. self-harm, suicide, disinhibited behaviour, violence, homicide);
• who does not live with the unwell parent, but has contact (e.g. formal unsupervised contact sessions or the parent sees the child in visits to the home or on overnight stays)is socially isolated because they feel unable to either bring other children home, or understand or have the words to explain what is happening at home to adults;
• who is an unborn child of a pregnant woman with any previous major mental illness, during which her behaviour or capacity to parent would have been a concern (also see Pre-Birth procedure).
• who has experienced or is at risk of fabricated or induced illness

Children most likely to suffer Significant Harm are those who feature within parental delusions and children who become targets for parental aggression or rejection, or who are neglected as a result of parental mental illness.

A referral must be made to Children Social Work Services multi-agency safeguarding hub (MASH) if a parent expresses delusional beliefs involving a child (under 18) and/or if a parent includes harm to a child as part of a suicide plan.

To determine how a parent/carer’s mental health problem may impact on their parenting ability and the child’s development the following questions need to be considered within an assessment and alongside the local threshold document:

• Does the child take on roles and responsibilities within the home that are inappropriate?
• Does the parent/carer neglect their own and their child’s physical and emotional needs?
• Does the parent/carer’s mental health problem affect the development of a secure attachment with the child?
• 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?
• 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 of the parent/carer?
• Does the parent express any intention to harm the child or fear of doing so? This should always be taken seriously and its meaning rigorously explored;
• Does the parent/carer’s mental health problem result in them rejecting 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 does the family function, including conflict, potential family break up, the impact of medication (such as sedation), ability to store medication safely etc?

Pre-Birth

Pre-birth procedures must be considered when it is known that someone with mental health problems is expecting to become a parent / have another child. Consideration must be given to the ability of the parents to obtain adequate antenatal care and subsequently provide good care for the baby. If a referral to Children Services   MASH is justified, it must be undertaken as soon as concerns are identified, to enable early assessment, support and planning to be put in place.

Teenage Parents and Pregnant Teenagers

When dealing with teenage parents or pregnant teenagers experiencing mental ill- health, it is important to consider and assess the needs of the teenage mother or father as well as the potential impact on the parenting of their child(ren) or unborn baby. Consideration needs to be given as to whether the teenager is a Child in Need or a child at risk of Significant Harm in their own right, as well as undertaking an assessment of the needs of their child or unborn baby.

Multi-agency assessment and planning should follow the processes outlined below for both the teenage parent(s) and their child. Where an EHA is required for the teenager, there may be agencies that can offer specific support to the teenager(s), such as CAMHS (Child and Adolescent Mental Health Service for 16/17 years olds), Teenage Pregnancy Personal Advisers or Mental Health Advisers.

Those working with adults with mental health problems and /or children of these adults must be familiar with this Practice Guidance for professionals: Parents of children with Mental Health Problems hosted on West Midlands Regional child protection procedures website and the need for assessment, liaison and appropriate sharing of information. 

All practitioners within Adult Mental Health Services have a duty to ensure that their clients are assessed in the context of their family responsibilities always taking into account that the welfare of children is paramount. They should consider the:

• Impact of the parent’s mental health difficulties on their ability to meet their children’s physical and emotional needs;
• Impact of treatment, hospital admission or any other intervention from the Mental Health Services on the parent’s dependent children;
• Implications for children in circumstances where the parents have refused co-operation or have withdrawn from treatment;
• Physical safety of the parent’s children in the case of violent, aggressive or unpredictable behaviour.

When an adult, who is also a parent / carer or significant other with access to children, is deemed by agency professionals, to be a danger to her/himself or others, a referral should be made in accordance with the Referrals Procedure. Consultation must be held with Childrens Services MASH / Front Door and/or the children’s social worker.   Consideration must be given for an invite to any relevant planning meetings. This should not prevent a referral being made in emergency (for more information refer to Royal College of Psychiatry’ document ‘Patients as Parents' (2011).

Mental health professionals assessing actual or suspected abusers should ensure that any report produced, particularly for another agency or child protection conference, makes a clear statement of assessment of risk to any child with whom the abuser has contact regardless of diagnosis or treatability.

Strategy Discussions and Child Protection Conferences must include any health professional (psychiatrist, nurse, psychologist, therapist or Adult Mental Health Services (AMHS) – social worker) involved with the parent / carer as well as a health representative for the childs health ie health visitor, community paediatrician, school nurse or GP.

If there are concerns, it may be the case that the child and family will find early help services supportive and an assessment of the needs of the child should take place at an early stage for example by an Early Help (EH) Assessment taking place.

Where it is believed that a child of a parent with mental health problems may have suffered, or is likely to suffer significant harm, a referral to children’s social care should be made in accordance with the Referrals procedure. 

It is essential that staff working in adult services (this may include mental health, social care, primary care, e.g. GP’s) and children’s services work together collaboratively to ensure the safety of the child and management of the adult’s mental health, taking a Think Family approach. 

Joint work will include adult services, mental health workers or primary care (GPs) providing all information with regard to:

• Treatment plans
• Effects of any mental health problem and medication on the carer’s general functioning and parenting ability.

Children’s workers must assess the individual needs of each child and within this incorporate information provided by staff working with the adult. There are resources below (under further information) on how to talk to children about parental mental health needs.

Professionals working with the adult (e.g. support staff, health workers, GP) must be invited to and should attend, to provide information, to any meeting concerning the implications of the parent/carer’s mental health difficulty on the child including Early Help  / Team Around the Family, Child Protection Conferences, Core Groups  and Child in Need Meetings. Children’s social care professionals should be invited to and should 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 and Child in Need 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. Consideration should also be given to whether the child is a young carer and the possible need for a young carers assessment.

All professionals should work in accordance with their own agency procedures / guidelines and seek advice and guidance from line management or the organisation safeguarding lead, when necessary.

Professionals working with the child and those working with the adult should always consider the future management of a change in circumstances for a parent/carer and the child and how concerns will be identified and communicated.

Contingency Planning

If a parent/carer disengages from support services, or is non-compliant with treatment and the professional judgment is that there is on-going risk to the child in these circumstances, this should be referred to Children’s social care.

Professionals need to consider carefully the implications for children when closing their involvement with parents with a mental health problem. Consideration should be given to informing the appropriate Children’s social care team in order that the implications for the child are assessed.

Professionals working with the family should always use ‘respectful uncertainty’ and not readily accept parent / carer’s assertions that their mental health problems are not affecting the care they provide to their children. Where there is any doubt in these situations, services should always err on the side of caution.

Confidentiality is important in developing trust between parents with mental health problems and practitioners in agencies working with them, however, practitioners must always act in the best interest of the child and not prioritise their therapeutic relationship with the adult.

Review meetings (e.g conferences and core groups) should be aware of the fact that a mental health problem can fluctuate over time. Its impact on the parent’s capacity to care for the child must be reviewed regularly, and this should be specifically considered at each review meeting. These reviews should include health professional challenge and issues should be escalated, if necessary using the dispute resolution or escalation procedure.

• Talking to children about their feelings (NHS)
• Children's Needs - Parenting Capacity report
• Mental Health and Growing Up (Royal College of Psychiatrists)
• NSPCC: Learning from Reviews (NSPCC)
• MIND: Parenting with a mental health problem
• How to talk to kids about parental mental illness
• Talking to children about parental mental illness - study