This chapter was updated in June 2020 in order to remove references to the term 'toxic trio'.
Mental health problems are proportionately common in the overall population, 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.
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.
Many adults who suffer from mental health problems 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.
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 their parent's obsessional compulsive behaviours;
- Who becomes a target for parental aggression or rejection;
- Who has caring responsibilities inappropriate to their 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 or who is significantly mentally unwell during her pregnancy.
To determine how a parent/carer's mental problem may impact on their parenting ability and the child's development the following questions need to be considered within an assessment:
- 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'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 have an eating disorder which could affect an unborn baby or impact on a parent's ability to provide safe care including adequate nutrition for a child?
- 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/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 the family functions, including conflict, potential family break up etc.
4. Protection and Action to be Taken
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. 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 completing an Early Help assessment and/or coordinating regular Team around the Family meetings.
It is essential that staff working in adult mental health services and Children's Social Care work together collaboratively to ensure the safety of the child and management of the adult's mental health.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 carer's general functioning and parenting ability.
Children's Social Care must assess the individual needs of each child and within this incorporate information provided by mental health workers.
Mental health professionals should be invited to and must attend to provide information to any meeting concerning the implications of the parent/carer's mental health difficulty on the child including Child Protection Conferences and Child in Need meetings. Children's Social Care professionals should be invited to and must 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. 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.
Contingency Planning - Child care and mental health professionals 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.
If a parent/carer disengages from mental health 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.
It is important that mental health professionals and others working with the parents continue to log safeguarding concerns which could impact on children and to report them to Children's Social Care so that information sharing is effective over time.
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.
Mental health services 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.