Parental Mental Health Guidance
This chapter was updated in March 2020 and replaces a previous chapter: Working with Parents with Mental Health Problems.This chapter is currently under review.
This practice guidance aims to assist all agencies working with parents or with pregnant women and their partners in identifying situations where action is needed to safeguard a child or promote their welfare as a result of the adult's mental ill health.
2. Statistics and Prevalence of Parental Mental Health Issues
- Approximately 68% of women and 57% of men with mental health problems are parents (1);
- The most common mental health problems experienced during pregnancy and after birth are anxiety, depression and post-traumatic stress disorder (PTSD) (2);
- Rates of perinatal psychiatric disorder per thousand maternities:
- Postpartum psychosis: 2 per 1,000;
- Serious mental ill health: 2 per 1,000;
- Severe depressive illness: 30 per 1,000;
- Mild-moderate depressive illness and anxiety states: 100-150 per 1,000;
- PTSD: 30 per 1,000;
- Adjustment disorders and distress: 150-300 per 1,000 (3).
- A 2013-2014 study found that 38% of first-time fathers are concerned about their mental health (4);
- Around 10% of all new fathers worldwide experience postnatal depression (5);
- Perinatal mental health problems carry a total economic and social long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK (6).
3. Responding Proportionately
Mental ill health in a parent or carer does not necessarily have any adverse impact upon a child's development. Just as there is a range in severity of illness, so there is a range of potential impact upon families. The majority of parents with a history of mental ill health present no risk to their children, however even in cases of low level concern; the needs of the children should be paramount. It is essential that the diagnosis of a parent or carer's mental health is not seen as defining the level of risk. Similarly, the absence of a diagnosis does not equate to there being little or no risk.
It is important to recognise other issues that can exacerbate the risk presented by mental health issues. For example a child is at greater risk when there is also problematic drug or alcohol use (see Safeguarding Children Affected by Problematic Drug and Alcohol Use (Parental and Child use) Procedure) and domestic abuse alongside mental health problems. There is a well-established relationship between mental ill health and domestic abuse. Between 50% and 60% of women mental health service users have experienced domestic abuse, and up to 20% will be experiencing current abuse. Domestic abuse is one of the most prevalent causes of depression and other mental health difficulties in women. If you are concerned about domestic abuse please refer to the LSCP Multi-Agency Domestic Abuse Protocol.
4. Parenting Capacity
As stated above, relying on a diagnosis is not sufficient to assess levels of risk. This requires an assessment of the impact of the adult's mental illness or disorder on their 'parenting capacity' and the impact this has on the family unit. A simple definition of parenting capacity is: "the ability to parent in a 'good enough' manner long term" (Conley, 2003). There should also be recognition that recent research including that by Susan S. Woodhouse (2019), has found that caregivers need only "get it right" 50 percent of the time when responding to babies' need for attachment to have a positive impact on a baby. Securely attached infants are more likely to have better outcomes in childhood and adulthood, and based on the work of Woodhouse, there is a recognition that there is more than one way to get there.
Understanding and consideration of parenting capacity is imperative to ensure that the best possible support is provided to children and families. Where indicated there should always be an early assessment of need considering the child's developmental needs the family and environmental factors and parenting capacity. This assessment should be through Early Help Assessment however it is also helpful to consider the Common Assessment Framework below to inform this assessment and evidence the possible impact of mental ill health upon parenting capacity. This assessment may also identify strong family and community support which can build levels of resilience into families where there are parental mental health problems.
5. Factors that may Impact Parenting Capacity
The following factors may impact upon parenting capacity:
- Unhelpful coping strategies i.e. binge drinking, drug use, not prioritising own safety and basic needs
- Medication with an intended effect or side effect of sedation or other side effects that may exacerbate symptoms;
- Disordered eating;
- Self-harming and suicidal behaviour;
- Lack of insight into illness and impact on child, or insight not applied;
- Not engaging with agreed treatment or support plan;
- Previous or current admission to a mental health hospital, where a person's mental ill health can only be assessed or treated in hospital this indicates a greater level of severity or impairment of the person's functioning;
- Mental health problems combined with or caused by domestic abuse or relationship difficulties;
- Mental health problems combined with isolation or poor support networks;
- Mental health problems combined with criminal offending;
- Previous referrals to local authority children's services for other children;
- Dual diagnosis (Co-existing mental health and alcohol and drug misuse problems).
6. Possible Effects of Parental Mental Ill Health on Children
When a parent is experiencing symptoms of their mental illness some parents may struggle to focus on the needs of their children as effectively as they do when these symptoms are reduced or not present. This can result in them neglecting their own or their children's physical, emotional and social needs. Their children may have caring responsibilities, which could be inappropriate to their age and could have an adverse effect on the children's development. Some forms of mental ill health may impair a parents' ability to consistently demonstrate emotions and feelings or could cause them to be appear "unavailable" or unresponsive to the child. In some circumstances children could be exposed to behaviour from the parent that they find confusing or distressing.
Research has found that:
- At any one time, about 10,000 children and young people are caring for a parent with mental ill health;
- 25% of children subject to Child Protection Conferences has a parent with mental ill health;
- 33% of children with emotional and behavioural disorders have a parent with a mental health problem;
- Post-natal depression can be linked to both behavioural and emotional problems in the children of affected mothers.
Stigma towards those with mental ill health can impact upon and impair parenting capacity and children can also experience abuse or bullying from others as a result. Children, aware of this stigma, may be reluctant to talk about family problems or seek support.
7. Indicators of Increased Risk
Children most at risk of Significant Harm are those who:
- Feature within parental delusions (i.e. false beliefs);
- Are built into the parent's suicidal plans;
- Become targets of parental aggression or rejection;
- Are being profoundly neglected physically or emotionally as a result of the parent's mental illness;
- Have a parent who is expressing thoughts of harming their child;
- Are involved in their parent's obsessive-compulsive behaviours;
- Have caring responsibilities inappropriate to their age and or meeting parents personal care needs;
- May witness disturbing behaviour arising from the mental health problems (e.g. self-harm, suicidality, sexually disinhibited behaviour, violence, responding to hallucinations);
- Are 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;
- Are experiencing paranoid delusions;
- Where the parent has factitious disorder (a serious mental disorder in which someone deceives others by appearing sick, by purposely getting sick or by self-injury. Factitious disorder also can happen when family members or caregivers falsely present others, such as children, as being ill, injured or impaired).
8. Protective Factors for Children Living with Parental Mental Ill Health
Parental mental ill health will be less likely to have an adverse effect on a child when:
- The ill health is mild or short-lived;
- There is another parent or family member who can help;
- There is no other family disharmony;
- The child has wider support from extended family, including grandparents friends, teachers or other adults;
- A secure base – the child feels a sense of belonging and security;
- Good self-esteem – the child has an internal sense of worth and competence;
- A sense of self-efficacy – the child has a sense of mastery and control, along with an accurate understanding of personal strengths and limitations;
- The child has at least one secure attachment relationship;
- Access to wider supports such as extended family and friends;
- Positive nursery, school and or community experiences.
Note: An older child may seem more resilient but they can also be vulnerable in other ways. The risk to an older child is a different risk but they are not necessarily at any less risk.
9. Responding to Concerns and Providing Support to Parents
The most effective response to children and families affected by mental ill health comes through all agencies adopting a holistic, whole family approach. This is based on coordinating the support provided by adult and children's services to a single family "at risk" in order to secure better outcomes for the children and adults through the use of targeted, specialised and whole family approaches to addressing family needs.
Many children whose parents or carers have mental health problems go on to achieve their full potential in life, particularly if their parents receive the right support at the right time (Hogg, 2013).
Fundamental to this approach is good inter-agency practice characterised by:
- Routine enquiry by all agencies of the parent's experience of their mental ill health;
- Robust inter-agency communication and information sharing;
- Joint assessment of need;
- Joint planning; and
- Action in partnership with the family.
Early Help processes with use of the Signs of Safety model should support this and, where necessary, Child in Need and Child Protection assessment and planning processes.
In any situation where there is a perceived conflict between the interests of the adult and those of the child, all agencies must treat the child's needs and safety as paramount. Agencies also have a responsibility to adopt a non-discriminatory, open and supportive approach and ensure adequate advocacy is provided to the parent, if required.
Some children and families will need some additional help, primarily from one professional or agency to prevent needs escalating. We refer to this as Early Help. Early Help is working with families to come to their own solutions to the problems they are facing as early as possible, so they can work together with agencies to stop these getting worse.
Agencies should also be sensitive to the fact that mental ill health may be only one of the factors affecting parenting and the children's wellbeing. As stated above, there is an established relationship between mental ill health and domestic abuse. There is also a relationship between mental ill health and substance misuse. Understanding a person's life experiences can assist in supporting the family and understanding where additional needs may arise from. People may present with symptoms such as a fear response or avoidant behaviours but this could be due to living in unsafe circumstances or previous unhelpful experiences and may not be a symptom of mental ill health.
Where mental ill health is identified for a parent or person providing care to a child other adults in that child's life or the wider support network should be involved in support plans.
Where there is no existing Lead Professional or Social Worker and the professional believes that the child has additional needs requiring some level of support from other agencies, they should consider the need for Early Help or a referral to Children's Services in line with the Meeting the Needs Threshold document. When this is screened by the Customer Service Team or the Early Help Front Door, a referral may be made to Social Care, Early Help or Future4Me. Future4Me work primarily with 14 – 18 year olds who are at risk of homelessness, criminilisation, exploitation or being accommodated by the local authority. Professionals internal to Children's Services can request a case formulation with Future4Me to discuss wrap-around support for the existing worker. Recognising the complex lives of young people and the challenges that adolescence can bring, Future4Me work to ensure the right support is provided at the right time by the right worker, whether that be through direct one-to-one work, case consultation or community engagement and group work.
Professionals should follow their own agency's safeguarding procedures. They should consult their line manager or agency safeguarding lead if they are uncertain about the need to refer to Children's Services. Children's Services offers a consultation service about the appropriateness of making a referral.
Throughout their involvement with the adult and children, professionals must continually explore with the person, and family where appropriate, about the relationship between mental ill health and their parenting capacity and the safety and wellbeing of the children.
10. What Parents with Mental Ill Health Want
Mothers and fathers with mental ill health have expressed that the following things are helpful from agencies in supporting and engaging with them.
If the parent's mental ill health is impacting in any way upon their parenting ability then they are likely to already feel like they are a failure. Be positive in your communication and engagement. Even when things may seem difficult genuine excitement and interest in the child or the pregnancy can help people to feel more at ease. Agencies who point out a positive in a person's parenting can help them to feel like they are achieving and being 'good enough'. This becomes more meaningful when this is explained in terms of the positive impact their parenting behaviour will be having upon the child.
A full explanation of agency roles and sufficient explanations of services, procedures and available choices is essential. Take the time to check understanding and allow and encourage questions. Do not assume that people understand how your service works and why decisions are being made for example if a mother is receiving universal plus or consultant led care during pregnancy then explain what this is and why they are receiving it.
Ask questions about a person's mental ill health, show interest and be open and honest. Hear what is being said and don't interpret it on behalf of the person. Even if you think a view or belief stems from someone's mental ill health don't dismiss it. Try and work collaboratively on it with the individual. Consider how and when complex or difficult information is imparted on the person and how you will support them afterwards. Remember to treat the person as an individual with interests and not just as a parent. Engage with them about other subjects not just parenting.
Advocating on behalf of a parent at difficult times can be really important. This could be through liaison with other services to guide them on how to interact or even when they may need to reduce intensity of support or withdraw.
Treat the parent as the expert in their own mental health. If you are unsure be curious and ask what it is they experience and how this impacts upon them on a day to day basis. Vague questions can lead to vague answers it is okay to be direct and respectfully curious. Believe what you are being told and validate the persons experience and perspective.
Do not make assumptions that the parents responses and decisions, particularly in stressful situations, are as a result of their mental health problems.
Empower parents to make their own decisions based on the information provided and using a problem solving approach.
Do not exclude other supportive people in the environment who provide support and care to the person with a mental health problem and the children. Involve them in planning and consider their needs and worries as part of the plan of care.
Take ownership of any concern at the time it is raised with you. If the parent is sharing a concern with you then they are trusting you with that information. It may be about their mental health but don't tell them it is not your role or to just discuss that with their mental health worker. Explore it and offer what support you can then continue to work collaboratively with any involved mental health worker.
Where there is an awareness of mental ill health prior to birth be proactive. Provide practical support and advice early. The parent might not need the advice when the time comes but it can be comforting to know there are solutions if needed. For example 'baby wearing' can help with attachment if a mothers mood is low post birth. Be honest about possible reactions and normalise them prior to the event not afterwards when a person may be less able to take information on board and believe it.
Emphasise the importance of Early Help as a mechanism of support for the entire family. Explain the benefits of drawing involved professionals closer around the family to reduce stress and build resilience.
Ensure plans and expectations of parents are clear and focussed. Long complex plans can be overwhelming. Take the time to collaboratively produce and explain the plans to ensure they are realistic and attainable.
11. Complex Post Traumatic Stress Disorder (PTSD) and Personality Disorder
An area of increased complication for professionals can include those who may be diagnosed with Personality Disorder or Complex PTSD. These disorders are likely to be diagnosed in those who have repeatedly experienced traumatic events, such as violence, neglect or abuse. Working with someone who has Complex PTSD or a Personality Disorder diagnosis can present difficulty as the person may exhibit behaviours or responses that are confusing or challenging to effectively risk assess. The following information aims to assist agencies to understand the background and basis for some of these behaviours and responses.
11.1 Complex PTSD is thought to be more severe if:
- The traumatic events happened early in life;
- The trauma was caused by a parent or carer;
- The person experienced the trauma for a long time;
- The person was alone during the trauma;
- There's still contact with the person responsible for the trauma;
- Adults with complex PTSD may lose their trust in people and feel separated from others.
11.2 Symptoms of complex PTSD may include:
- Similarities to symptoms of PTSD;
- Feelings of shame or guilt;
- Difficulty controlling emotions;
- Periods of losing attention and concentration (dissociation);
- Physical symptoms, such as headaches, dizziness, chest pains and stomach aches;
- Cutting off from friends and family;
- Relationship difficulties;
- Destructive or risky behaviour, such as self-harm, alcohol misuse or drug abuse;
- Suicidal thoughts.
12. Anecdotal Impact of Complex PTSD on Parenting
Behaviours displayed by children can be similar to the actions of abusers, even if the intentions are completely different. A toddler, for example, might scream and throw objects against the wall if they don't get their way. A teen might yell, "I hate you!" and slam the door. When someone has a trauma history this behaviour can trigger a PTSD response The problem isn't who triggers the PTSD, it's about what triggers it.
Complex PTSD during pregnancy can causes problems. For example, labour and birthing pains might trigger body memories of sexual abuse. Loss of control during some procedures can mirror the loss of control during a sexual assault.
Due to their own trauma a person may experience fear that someone may think they are hurting their children when simply changing nappies, applying rash cream, bathing them, clothing them, etc. Alternatively they may become hypervigilant to risk as a result of their own trauma and overprotect their child or become preoccupied with perceived risks and harm that could impact upon their child.
What can help (alongside that outlined in sections 9 and 10 above) when working with parents experiencing Complex PTSD is ensuring that there is a single clear plan with one or two achievable goals for the parents. The Signs of Safety framework will assist with the identification and development of a worry or danger statement and related goals. There should be a focus upon good enough parenting and what that looks like for the parent. Having too many involved workers can be confusing and may lead to different and unclear information being gathered. This can make it harder to accurately assess risk and therefore parents will benefit from fewer involved workers.
13. Collaboration Between Health and Children's Social Care
Collaboration and liaison between mental health professionals working with the parents or carers and Children's Social Care is essential. Wherever there is doubt over risks or concerns the services should work closely together to resolve these and achieve a shared understanding.
Joint assessments and joint visits should be undertaken between the agencies wherever possible to facilitate engagement and reached a shared understanding of the current needs and potential risks. Where they are known to be involved, Children's Social Care should be invited to and attend relevant meetings, e.g. Care Programme Approach (CPA) meetings. CPA is a package of care that is used by secondary mental health services. Under CPA a person will have a single care plan and someone to coordinate their care. The care plan will also include a crisis plan. Social Care should also be invited to any review and discharge meetings for an individual accessing mental health services.
Children's Social Care should always seek advice from Lincolnshire Partnership NHS Foundation Trust either through the identified mental health worker or via the Trust Corporate Safeguarding, Public Protection and Mental Capacity team. Where appropriate they should request access to a parents care and treatment history to understand them as an individual and assess the best way to work with them. This approach assists with formulating how a person's history and life experience may impact upon their parenting capacity and therefore where support should be directed.
Mental health professionals should be invited to meetings convened by Children's Social Care, either as part of an assessment or as part of a continuing intervention. Such meetings can include Strategy Discussions; "professionals meetings"; Child Protection Conferences, Core Groups and other planning or review meetings. If invited, mental health professionals involved with the child's parent or carer should attend these meetings or, if this is not possible a written report should be shared.
Where there is evidence to indicate that the parent has delusional beliefs that incorporate the child or there is potential for the parent to harm the child as part of a suicide plan immediate liaison with mental health services should take place and a referral to Children's Social Care should be made.
Consistent with usual standards of good practice, where they have been involved in joint working, neither agency should cease their involvement without informing the other and without an assessment of the implications for the child.
14. Safeguarding Children Before and Immediately After Birth
Please refer to the Pre-Birth Protocol.
There may be concerns about a pregnant woman's ability to provide safe and appropriate care to a child. These may arise from her current mental health, her past history or her family circumstances. The concerns may also arise due to her partner's mental health or past history. Time must be given at the earliest opportunity in pregnancy to develop a plan of care and robust support. Professionals should never assume that a parent will become unwell given the right opportunities and levels of support.
Parents who are concerned about their own mental health or the impact on their children should speak to their GP. Practitioners who have concerns about a parent or carer's mental health should consult with any involved mental health worker.
Special consideration should be given to pre-birth planning for pregnant mothers who have a current severe and enduring mental illness, or a past history of a severe mental illness, whether this occurred after a previous childbirth or is unrelated to childbirth. These women are more likely to need support with parenting and after delivery.
- Royal College of Psychiatrists (2016) Parental mental illness: The impact on children and adolescents. Information for parents, carers and anyone who works with young people. Retrieved from rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/parentalmentalillness.aspx;
- Ayers, S., & Shakespeare, J. (2015). Should perinatal mental health be everyone's business? Primary Health Care Research and Development, 16(4), 323-325;
- Joint Commissioning Panel for Mental Health (2012) - Guidance for Commissioners of Perinatal Mental Health Services. Retrieved from jcpmh.info/wp-content/uploads/jcpmh-perinatal-guide.pdf [accessed 13/07/16];
- National Childbirth Trust (2015) Dads in distress: Many new fathers are worried about their mental health. Retrieved from nct.org.uk/press-release/dads-distress-many-new-fathers-are-worried-about-their-mental-health [accessed 14/09/16];
- Paulson, J.F., & Bazemore, S.D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: A meta-analysis, The Journal of the American Medical Association, 303(19), 1961-1969;
- Bauer, A., Parsonage, M., Knapp, M., Iemmi, V., & Adelaja, B. (2014). The costs of perinatal mental health problems. Retrieved from everyonesbusiness.org.uk/wp-content/uploads/2014/12/Embargoed-20th-Oct-Summary-of-Economic-Report-costs-of-Perinatal-Mental-Health-problems.pdf;
- Conley, C. (2003) A review of parenting capacity assessment reports.