Parental mental health
The Children Act 2004 identifies children whose parents suffer from mental illness as one of the key groups of vulnerable parents, who need to be targeted in order to provide appropriate support for parenting when it is required.
In the Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014, approximately 1 in 6 adults in England reported met the criteria for a common mental disorder (CMD) in 2014. Women were more likely than men to have reported CMD symptoms. One in five women (19 per cent) had reported CMD symptoms, compared with one in eight men (12 per cent). Women were also more likely than men to report severe symptoms of CMD - 10 per cent of women surveyed reported severe symptoms compared to 6 per cent of men.
This guidance refers to people with mental health problems, from mild and moderate to severe and enduring mental ill health and including eating disorders and personality disorders. It is important that all workers should be aware that the term ‘mental health problems’ covers a range of illnesses some requiring brief intervention in primary care, while others require referral to specialist mental health services. For the purposes of safeguarding children the mental health or mental illness of the parent or carer should be considered in the context of the impact of the illness on the care provided to the child.
Living in a household where parents or carers have mental health problems doesn't mean a child will experience abuse or negative consequences. Most parents are able to give their children safe and loving care and many children go on to achieve their full potential in life, particularly if their parents receive the right support at the right time (Hogg, 2013). However, mental health problems are frequently present in cases of child abuse or neglect. An analysis of 175 serious case reviews from 2011-14 found that 53% of cases featured parental mental health problems (Sidebotham, 2016).
Parental Mental health can result in children experiencing abuse, in particular emotional abuse and neglect. Mothers who experience mental ill health after birth may struggle to provide their babies with the sensitive, responsive care essential to their social, emotional and intellectual development. Family members can be reluctant to discuss mental illness with each other. Lack of communication can result in misunderstandings and children may feel worried or alone. They may not understand that their parent or carer's withdrawn behaviour is a symptom of mental illness. Gatsou et al (2017) stated they may feel responsible for their illness and obliged to try and fix it.
Parents and carers with mental health problems may:
- experience inappropriate or intense anger or difficulties controlling their anger around their children;
- have rapid or extreme mood swings, leaving children frightened, confused and hyper-vigilant;
- be withdrawn, apathetic and emotionally unavailable to their children. They may have trouble recognising children's needs and responding to cues;
- view their children as a source of comfort and solace, which may lead to children taking on too much responsibility for their age;
- have distorted views of their children for example, they may believe a child is to blame for their problems or a child has behavioural problems when there is no evidence for this;
- struggle with keeping to routines such as mealtimes, bedtimes and taking their children to school;
- neglect basic standards of hygiene and their own and their children's physical needs
- fail to seek medical care for their children;
- struggle to keep their homes clean, buy food and clothes and pay essential household bills;
- struggle to set boundaries, discipline and supervise their children, which could leave them in unsafe situations;
- In rare cases of severe mental illness, parents and carers may have delusions related to their children, for example they may believe they are possessed, have special powers or are medically unwell.
Parents and carers with mental health problems may go through other stressful life experiences like:
- divorce or separation;
- financial hardship;
- poor housing;
- a lack of social support.
Assessing the risk of parental mental health problems
There may be some family factors which increase the risks to children. There may also be other factors which protect children or reduce the impact of their parents' problems.
The NSPCC has compiled a list (non exhaustive) of the factors to consider when assessing risk. They are;
- the risk of harm to children increases when they‘re exposed to a number of problems at the same time or over a period of time. A thorough assessment of potential risks should be conducted if a family is experiencing domestic abuse or drug and alcohol problems alongside mental health difficulties;
- related stresses such as poverty, poor housing, family separation and lack of social support can also increase the risk of children suffering harm;
- young children rely on their parents and carers to give them the warm, nurturing care they need for healthy development. Children are most at risk of harm when their mother’s mental health problems begin in pregnancy or the first year of life, especially if they are long-lasting or severe;
- teenagers also need strong parental guidance and support as they transition to adulthood;
- the stresses of parenting can make it even more difficult for a parent or carer to cope and this may impact on a child’s welfare;
- always consider the severity of a parent or carer's mental health symptoms. If they are making threats to harm themselves, their children or other family members, or if they appear to be suffering from psychotic delusions, this should always trigger a thorough assessment of risks to the children’s safety;
- if a parent or carer isn’t accepting support offered by mental health services or attending appointments, this loss or lack of support may impact on their children’s wellbeing or safety;
- children may be more at risk of harm if the parent or carer experiencing difficulties is living alone with them without the support of another adult;
- consider if any of the children had to take on caring responsibilities for their parent, carers or siblings.
Furthermore they state that risks to children’s safety may be reduced by a number of protective factors, including:
- parents and carers who are willing to acknowledge their difficulties and accept support from services;
- friends or relatives who are able to care for children and help with household chores when needed;
- sufficient income support, benefits and advice available to families struggling with unemployment and poor housing;
- if children are regularly attending school or nursery the family will be able to receive additional support from education professionals who can also monitor their situation;
- children who have developed a range of approaches for solving problems and know how to ask for help in the event of a crisis with their parent;
- good facilities in the wider community such as young carers’ projects.
Practitioners from any agency may observe people with psychosis.
They may be experiencing:
- hallucinations – where people see, hear, smell, taste and feel things that are not there;
- delusions – where people have fixed false irrational belief; this may be paranoid, believing others may wish to harm them or their family;
- thought disorder- where people speak quickly and incessantly (pressure of speech) or switch topic mid-sentence (flights of ideas) or make irrational statements believing things around them have changed in some way.
Early signs of psychosis may include:
- unusual or erratic behaviour;
- severe deterioration of social relationships, social withdrawal or isolation;
- inappropriate laughter, unexplained euphoric mood, feelings of depression or anxiety.
Psychosis is a symptom of a variety of conditions, which can include mental illnesses such as schizophrenia or bipolar disorder, but can also be associated with drug or alcohol misuse and sometimes physical conditions such as Parkinson’s disease.
For some, a period of psychosis will last only a few days, for others, if untreated it can last for long periods. Some people only experience one episode of psychosis throughout their lives, while others may have several. Most psychosis is treatable.
If any practitioner believes that the person may be suffering from a delusion involving their children, which includes non-abusive thoughts, they must make a referral to First Response (social care).
If any practitioner believes a person may be at risk to children through other forms of psychotic ideas i.e. hallucinations they must also make an immediate referral to First Response (social care).
It is important that if a practitioner feels that a person may be a risk from an untreated psychosis they alert the GP in order for the GP to arrange a mental health assessment. This includes if the person is unwilling or unable to seek help themselves. In some situations the GP can arrange an assessment under the Mental Health Act 2007, if they believe the person to be a risk to themselves and/or others.
Any changes to medication should be seen as an increased risk factor therefore a period of monitoring may be required to assess if any changes in behaviour may increase the risk to a child(ren) or any other person.
Whole Family Approach to Parental Mental Health
The NSPCC captures why a whole family approach is necessary and states that;
- Parental mental health problems affect everybody in the family. Evidence suggests successful interventions involve a whole-family approach which address a parent's mental ill health in the context of each family member's needs and experiences and co-ordinates support from adult and children's services (Cleaver et al, 2011; Gatsou et al, 2017; Grove et al, 2015).
- Interventions which encourage families to communicate with each other can help everyone to understand the impact of the mental health problems (Grove et al, 2015). Supportive conversations between family members can help children feel less worried and isolated. They can also help parents and carers understand their children's experiences which may have a more positive effect on parenting (Coates et al, 2017).
- Whole family interventions can offer practical support. For example, helping family members to design and implement 'staying well' plans for the parent with mental health problems. This could include sign-posting to other services, setting goals, developing problem solving skills and offering advice on managing stress and recognising the early signs of a relapse (Gatsou et al, 2017).
- Evidence suggests that family-sensitive practice has a number of benefits including better relationships between family members, an increase in family members' levels of self-confidence and self-esteem and greater willingness to ask for help and support when needed (Gatsou et al, 2017).
Any assessment should measure the potential or actual impact of mental health on parenting, the parent/child relationship and the child as well as the impact of parenting on the adult’s mental health. Screening questions12 could include:
- On a scale of 0-10 (with 0 meaning ‘not at all worried’ and 10 meaning ‘very worried’), how would the individual assess their mental health and emotional wellbeing?
- Is the parent accessing mental health services (starting with the GP)?
- Does the parent need support in their parenting role?
- Are there any children in the household?
- How does the parent’s mental health impact on the children?
- What happens to the children if the parent is unable to care for them (i.e. is there a safety plan)?
- Is there a child in this family providing care (ie is the child a Young Carer)?
- Is anyone providing support for the children?
Perinatal Mental Health
The Perinatal Period includes pregnancy and the year following birth. During this period women can be affected by a whole range of mental health problems (Joint BSCB and BSAB Multi-Agency Protocol). These can range from mild anxiety such as panic attacks through to depression and sometimes severe mental illness after child birth such as Postpartum Psychosis (Puerperal Psychosis). All conditions can be prevented, treated or managed.
Mental illness can have a devastating effect on woman and their families. Effective and timely detection, intervention and support can prevent and minimise the harm that can be done. Illnesses such as this can be diverse and complex. A good understanding of the signs, symptoms, effects and consequences that mental health can have is vital. It is important to mitigate the effects it can have on the woman and their family and improve the wellbeing of children and their health. This is every professional’s responsibility and requires a well-defined coordinated Multi-Agency response.
Women that experience mental health issues in the perinatal period can often have no history of mental illness. Any women regardless of socio economic status can be affected. Others with pre-existing issues could experience a deterioration or reoccurrence of past health issues as a result of the changes to the woman’s body emotionally and physically or because of a change in medication.
Mental Illness during pregnancy, birth and the postpartum period can present itself in many different ways, each with their own symptoms but all requiring some form of support or intervention.
Women who are not currently experiencing mental health issues will receive support from universal services such as Midwives and Health Visitors through the universal visiting patterns outlined in their local procedures. These Universal Services are key in the early identification of mental health issues and signposting to the appropriate support (NSPCC 2013). Should a woman be identified as requiring additional support, for example expressing symptoms of mild depression and/or anxiety then additional support could be offered at a Level 1 Plus level by Health Visiting services, and Midwifery services. Alternatively, GPs can support women who have been identified by the Midwife or Health Visitor as needing additional support. Women can also self-refer to their GP for support. GPs can treat uncomplicated non-psychotic depression and anxiety. This may include prescribing medication or signposting to more specialist services. It is important for GPs and mental health workers to be aware of the potential risks associated with mental health needs.
GPs can refer women to Bristol Wellbeing therapies for further support, for example for educational courses on self-help and one-to-one therapies. The individual would also be able to self-refer to the wellbeing service. This service is designed to support individuals with mild to moderate depression and anxiety using a Cognitive Behavioural Model of therapy. Other self-help provision and charitable organisations are available for the individual to access. For example Mother’s for Mother’s and Bluebell Care (Bristol) service provides resources about common mental health issues during the perinatal period, amongst other support services such as groups and the ‘Buddy Service’ for 1:1 face to face support. If more specialist support and advice be required then GPs should refer to secondary mental health services for more complex or significant disorders. This specialist support can take three forms:
- The Specialist Perinatal Mental Health service can provide advice to the GP and or Midwifery service, with the GP and midwife remaining the lead professionals;
- Should the individual already be under Secondary Mental Health services then the Secondary Mental Health team continues leading on the mental health care provision whilst being supported by the specialist Perinatal Mental Health Team ,as an adjunctive service, on areas where perinatal expertise are required to manage the individual’s care;
- should the individual referred not be open to secondary mental health services, and meet the threshold for high risk mental health need (see attached care pathways) then the Specialist Perinatal Mental Health Team would coordinate care under non-CPA where the perinatal psychiatric illness is the primary need. Should the mental health concerns pre-date pregnancy or be expected to continue beyond perinatal period, referral to Recovery teams may ensue.
Red flag signs/activators
It is important for practitioners working with women within the perinatal period to be aware of ‘red flag’ signs/ ‘activators’ for action. These signs are indicative of severe maternal mental illness and require urgent assessment:
- Recent significant change in mental state or emergence of new symptoms
- New thoughts or acts of violent self-harm
- New and persistent expressions of incompetency as a mother or estrangement from the infant
- (MBRRACE-UK 2015)30
Should there be concerns around potential or actual risks to the unborn baby, practitioners are advised to follow recommendations set out in the Expected Baby Policy. Concerns relating to the unborn baby must be referred to First Response as soon as possible following the 12th week of pregnancy (The Expected Baby Protocol)
An additional consideration is that of concealed pregnancy (Concealed Pregnancy Protocol).
Concealed pregnancy is when:
- An expectant mother knows she is pregnant but does not tell any professional; or
- An expectant mother tells another professional but conceals the fact that she is not accessing antenatal care; or
- A pregnant woman tells another person or persons and they conceal the fact from all health agencies.
Whole Family approach to Perinatal Ill health
All services working with mothers affected by perinatal mental illness must ensure that they engage, support and work with their partners and other key family members. Perinatal mental illnesses can have a significant impact on the families of women who are affected. Family members are also important sources of support for the mother, and can mitigate the effect of her illness on the baby. Therefore it is important that mental health services ‘think family’. These services must also have processes in place to identify fathers who are suffering from mental illness themselves and ensure they have access to additional support.
Bristol Wellbeing Therapies follows a stepped care approach. There are five steps of psychological treatment within Bristol Mental Health. Bristol Wellbeing therapies offers treatments that sit within either step 2 or step 3. If at assessment they feel that treatment offered is needed at a higher step they refer on appropriately.
Primary Care Liaison Service is the initial point of contact for mental health services within AWP (Avon and Wiltshire Partnership NHS trust) for Primary Care and other agencies. The Primary Care Liaison Service provides advice and support to primary care, as well as specialist mental health assessments, working closely with a range of other teams such as the adult Support and Recovery Team, older adult Complex Intervention Team, Intensive (previously Crisis) Team, Memory Services, Drug and Alcohol, and Eating Disorder Services.
Community perinatal mental health service will offer advice to all professionals. To contact them e mail firstname.lastname@example.org Telephone 0117 919 5826
Bluebell –Support for Women and families.
Offering a variety of free, weekly activities designed to help parents manage feelings of anxiety and depression related to pregnancy and birth with group programmes including therapeutic, creative and pampering sessions with an occupational therapist and a Buddy worker including Dad’s support line.
Tel 0117 922 0746
Dads’ support line: Tel no. 07730 367 483
Bristol Sanctuary - Bristol Sanctuary is a place which feels safe, comfortable and welcoming, where people who are experiencing severe emotional distress can go for help outside of normal working hours.
Tel 0117 954 2952
Includes sections for children, parents and professionals http://www.antibullyingalliance.org.uk/
Childhood Bereavement Network
A national, multi-professional federation of organisations and individuals working with bereaved children and young people http://www.childhoodbereavementnetwork.org.uk/
Helpline offering counselling for children and young people, as well as publications and campaigns for professionals and carers http://www.childline.org.uk/
Eating Disorders Association - BEAT
Information and help on all aspects of eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder and related eating disorders https://www.b-eat.co.uk/
Family Lives is a listening, non-judgemental service which supports families with difficulties and challenges and supports happier family relationships and stronger communities. Tel Tel. 0808 800 2222 http://www.familylives.org.uk
Mental Health Foundation
UK charity for everyone's mental health, provides information and resources about mental health including people with learning disabilities http://www.mentalhealth.org.uk/
Resources, training and campaigning on mental health issues, plus local groups http://www.mind.org.uk/
Website for young people with a wide range of health related information including mental health issues such as bullying, relationships and more http://www.need2know.co.uk/
Nurture Group Network
A national charity promoting nurture groups and supporting the professionals who work in them, providing information on research, evaluation and resources www.nurturegroups.org/
Promoting Children's Mental Health
DfE (2016) Mental health and behaviour in schools https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2
DfE (2016) Counselling in schools https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/497825/Counselling_in_schools.pdf
PSHE Association (2015) Guidance on preparing to teach about mental health and emotional wellbeing
DfE (2015) Promoting the health and wellbeing of looked after children https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/413368/Promoting_the_health_and_well-being_of_looked-after_children.pdf
Royal College of Psychiatrists
Offers an information service and leaflets on common mental health issues including difficulties in adolescence http://www.rcpsych.ac.uk/expertadvice/youthinfo.aspx
Helpline open 24/7, 365 days per year. You do not need to be suicidal. Free telephone helpline: Tel. 116 123. www.samaritans.org
Charity which works to improve the quality of life for anyone affected by mental illness www.sane.org.uk
For young people who self harm and their friends, family and professionals. Be aware that this site contains sensitive information http://www.selfharm.org.uk/
Teenage Health Freak
Information and advice on health issues for young people, including dealing with stress plus answers to common questions http://teenagehealthfreak.org.
The Hideout - Women's Aid site for Children and Young People
Help, information and support for children and young people - whether they are currently living with domestic violence, have experienced violence in the past or know someone else going through it and are looking for help and information http://www.thehideout.org.uk/
Time to Change
Time to Change is England's biggest programme to challenge mental health stigma and discrimination http://www.time-to-change.org.uk/
Winston’s Wish offers practical support and guidance to families, professionals and anyone concerned about a grieving child. Giving the right support at the right time can enable young people to live with their grief and rebuild positive futures http://www.winstonswish.org.uk/
Free, confidential website for young people under 25 http://www.themix.org.uk/mental-health
Youth website of Cruse Bereavement Care http://hopeagain.org.uk/
Resources and training to improve children and young people's mental health.
Parents’ free telephone helpline: Monday - Friday 9.30am – 4.00pm
Tel. 0808 802 5544 http://www.youngminds.org.uk/