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3.30 Protocol for Assessing and Managing Children and Unborn Children at Risk Who Have Parents or Carers with Mental Health Issues


Contents

  1. Context
  2. Aim and Principles of the Protocol
  3. Assessing the Impact of the Parent or Carer’s Mental Health Issues on Their Children
  4. Risk Assessments
  5. Guidelines for Joint Working
  6. Contingency Planning


1. Context

Effective safeguarding arrangements in every area should be underpinned by two key principles:

  • Safeguarding is everyone’s responsibility: for services to be effective each professional and organisation should play their full part;
  • A child-centred approach: for services to be effective they should be based on a clear understanding of the needs and views of children (1).

Approximately one in four adults will experience a mental illness during their lifetime. At the time of their illness, at least a quarter to half of these will be parents.

The mental health of a parent does not necessarily have an adverse impact on a child but it is essential to assess the implications for the child. While adults may succeed in obtaining treatment for mental health difficulties, health and social care services often fail to consider the impact upon their family members. The Think Family Agenda underpins all work with parents with mental health difficulties (2).

(1) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. March 2013.
(2) Think Child, Think Parent, Think Family: A Guide to Parental Mental Health and Child Welfare. Social Care Institute for Excellence


2. Aim and Principles of the Protocol

This protocol has been written to improve the co ordination and communication between all agencies working in Oxfordshire who are engaged with children and families and with parents who have mental health needs. The protocol should be applied whenever there are concerns about the well being or safety of children whose parents or carers have mental health needs, specifically where the difficulties are impacting or likely to impact on their ability to meet the needs of the children in their care. This protocol also applies to pregnant women who have mental health problems or whose partners are known to have mental health problems.

2.1 Principles

The protocol is underpinned by the following principles:

  • Parents have a right to confidentiality, but where there are concerns about the welfare of a child, these should take precedence;
  • Respect and sensitivity should be given to differing family patterns, lifestyles and child rearing practices, but abuse and neglect of children cannot ever be condoned, and this includes for religious or cultural reasons;
  • To ensure the provision of a collaborative and co-ordinated approach, by services,to families in which there are dependent children of parents, carers with mental health problems, or pregnant women with mental health problems;
  • Shared assessments of parents with mental health problems should be undertaken for new referrals and with parents already known to agencies;
  • Children should be actively included in agency work, proportionate to their age and ability and should receive information and support about a parent’s mental health issue. They should not be exposed to inappropriate levels of care and responsibility that undermine their developmental outcomes;
  • Children’s services will help to identify parents who may have mental health needs and will use links with other agencies to find help and support for them;
  • Adult services will help to identify children who may need additional services;
  • All services will identify pregnant women and their partners who may need support because of mental health issues;
  • The rights of children to be safeguarded are paramount, even when they are perceived as challenging the therapeutic relationship between the adult patient and the professional (3).

(3) Parents as Patients: Supporting the Needs of Patients who are Parents and their Children. Royal College of Psychiatrists CR164 January 2011


3. Assessing the Impact of the Parent or Carer’s Mental Health Issues on Their Children

When working with a parent with mental health issues, drug or alcohol abuse or deliberate self harm, it is important to establish whether they have current contact, the level of that contact, or whether they will be resuming contact with their own or with other children.

To determine how a parent’s mental health may impact on their parenting ability and the child’s development consideration should be given to both the child and the parent’s perception of their situation and any collaborative accounts. The following questions need to be considered within an assessment:

  • How does the child feel about their parent’s illness and how it may affect them?
  • Are there any concerns about the health and wellbeing of the child?
  • Is the child taking on roles and responsibilities within the home that are age inappropriate?
  • Are the child’s emotional and physical needs being met? Does the child witness acts of aggression or is the child subject to aggressive behaviour or violence?
  • Is there an adequate structure within the home in terms of meal times, washing and bedtime routines?
  • Is the child attending and performing as expected at school?
  • Is there a lack of the recognition of safety for the child?
  • Does the parent understand the impact of their mental health problems on their parenting capacity and on their child?
  • Are there repeated incidents of separation from the child eg hospitalisation?
  • Does the parent misuse alcohol or other substances?
  • Does the parent feel the child is responsible in some way for their mental health problem?
  • Is the child included within any delusions of the parent?
  • Does the parent’s mental health problem result in them rejecting or being unavailable to the child?
  • Does the wider family understand the mental health problem of the parent, and the impact of this on the parent/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?
  • Is there someone that the child can go to for support eg grandparent or teacher?
  • 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?
  • Are their significant problems in the family including conflict, potential family break up, problems with siblings etc?

In circumstances where a parent has mental health problems it is likely that there will be a number of professionals involved from different services. It is important that these professionals work constructively together within enquiries and assessments to identify any links between the parent’s mental health, their parenting, and the impact on the child. Therefore any assessment should include an understanding of the needs of the family and children and an identification of the services required to meet these needs, including early intervention services.

3.1

Children are at greatest risk when:

  • The child features within parental delusions;
  • There is potential to harm the child as part of a suicide plan;
  • The child becomes the focus of the parent’s aggression or is rejected;
  • The mental health issue causing them to neglect the child either physically or emotionally.

In these circumstances the child should be considered at immediate risk of harm and a referral made to Children’s Social Care Services in accordance with the Referrals (Including Referrals Pathway) Procedure.

Generally professionals should seek and discuss any concerns with the family and where possible seek their agreement to making referrals to Children’s Social Care. This should normally be done where such discussions and agreement making will not put the child at increased risk of Significant Harm or lead to interference in criminal investigations. The child’s best interest must be the overriding consideration in making such a decision.
3.2

Where it is believed that a child of a parent with mental health problems may be likely to suffer Significant Harm, a Strategy Discussion/Meeting should be held and consideration should be given to undertaking a Section 47 Enquiry as would happen with any child considered likely to suffer Significant Harm.

3.3 Consideration should also be given as to whether the child is a young carer and a referral to young carers made if appropriate (4).

(4) Parents as patients: supporting the needs of patients who are parents and their children. Royal College of Psychiatrists CR164 January 2011


4. Risk Assessments

4.1 It is important to be aware that risk assessment in mental health work and risk assessment in child protection work are two different concepts and care must be taken not to confuse the two.
4.2

Risk assessment in mental health is concerned with predicting the likelihood of a patient’s mental health deteriorating to the point where he or she poses a risk to him or herself or to others.

Risk assessment in child protection work involves the analysis of information to consider whether or not the children’s likely experiences are acceptable in terms of risk to either physical or sexual assault, of omission of care or neglect, or threat to emotional wellbeing.
4.3 Newly identified risk or changes in the risk assessment in any agency must be communicated to other relevant agencies in order that they can consider if this new information impacts on their own risk assessments. Staff must always consider that a change for one member of the family might have impact on another member, and that a Think Family approach is essential.


5. Guidelines for Joint Working

It is essential that staff working in adult mental health and children’s services work together to ensure the safety of the child and the management of the adult’s mental health.
5.1

Information Sharing – See the OSCB Information Sharing Protocol

There is an expectation in adult mental health teams that an experienced member of the clinical team will be involved with parental cases where children are ‘at risk’. Where there are concerns about the wellbeing of the children, the need to share information will take precedence over the patient’s right to confidentiality. Joint work will include mental health workers providing all information with regard to:

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

Parents with mental health issues entrust professionals with, or allow them to gather, sensitive information relating to their health and other matters as part of their seeking treatment. They do so in confidence and they have the legitimate expectation that staff will respect their privacy and act appropriately.

Practitioners need to consider what information is and is not confidential, and the need in some circumstances to make a judgement about whether confidential information can be shared, in the public interest without consent. The sharing of such sensitive information can be shared, if to do so, has a clear and justifiable purpose and is based on considerations of the safety and well-being of the child and others who may be affected. The more sensitive the information, the greater the child focus needs to be in order to justify sharing. The practitioner needs to be mindful that information may need to be shared with a number of agencies therefore the ‘need to know’ and ‘proportionality to the risk of harm’ principles apply. Where a practitioner is considering the inclusion or exclusion of sensitive information, or consent has been refused, they must discuss this with their safeguarding lead within their organisation.
5.2 Child protection workers must assess the individual needs of each child and within this, incorporate information provided by mental health workers.
5.3

Mental health professionals must attend and provide information to any meeting regarding the potential impact of parental mental health concerns on the child. These will include:

  • Multi-professional meetings;
  • Strategy Meetings;
  • Initial and Review Child Protection Conferences;
  • Core Group Meetings.
5.4 Relevant professionals from Children’s Services must attend Care Programme Approach (CPA) and other meetings related to the management of the parent’s mental health.
5.5 All plans for a child including Child Protection 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. All professionals should work in accordance with their own agency procedures/ guidelines and seek advice and guidance from line management when necessary.


6. Contingency Planning

Crisis and contingency plans should be developed and include how many children the parent has, their ages and gender, and the arrangements for their care to be put in place if the parent is not able to care for them. Contingency plans are not just for the times of crisis but are an option for early interventions.

This may include:

  • Relapse in the parent’s mental health or hospitalisation;
  • Failure to comply with medication and or treatment plan;
  • Change in family dynamics or relationships.
6.1 Professionals need to consider carefully the implications for children when closing their involvement with a parent with a mental health problem. Factors to consider are the wider family support network and informing the appropriate Children’s Social Care Services team in order that the implications for the child are considered and an assessment made.

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