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, 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 also 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.

Some adults who suffer from mental health problems may also have substance misuse problems, which is described as ‘Dual Diagnosis’ and there may be several agencies and services, for both adults and children, who are working with the family.

National Serious Case Reviews and Domestic Homicide Reviews have identified domestic abuse, parental mental ill health and drug and alcohol misuse as significant factors in families where children have died or been seriously harmed.

Parental mental ill health does not necessarily impact adversely on their parenting however, a child 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 features within parental delusions
• who is involved in his/her parent’s obsessional compulsive behaviours
• who becomes a target for parental aggression or rejection
• 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
• who may witness disturbing behaviour arising from the mental illness
• who is neglected physically and/or emotionally by an unwell parent
• 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)
• who is at risk of severe injury, profound neglect or death
• 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

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?

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