33.2 Parenting Capacity and Mental Health Difficulties

When considering the safeguarding of children, mental health or mental illness of any parent or carer should be considered on a continuum. This continuum may range from someone experiencing anxiety or depression to an affective (mood) disorders or psychotic illness for example. Mental illness in a parent or care giver is not a predictor of harm in and of itself to others, including any child or children. Any mental illness should be thought about in the context of any impact the illness may have on the care provided to the unborn, child / children. Mental health support may be provided through a range of services which may include primary health, psychological support services, charitable organisations such as Mind and secondary care and specialist services.

The procedure should be applied where there are concerns about the well-being or safety of children whose parents or carers have mental health needs, and consider how these difficulties are impacting, or are likely to impact, on their ability to meet the needs of their children. This guidance also applies to thsoe who are pregnant who have mental health problems developed during pregnancy, previous to pregnancy or where their partners have mental health problems.

The Triannual report of Serious Case Reviews (2017-2019) reported that 55% of reviews involved parents with mental health problems. In these cases the mental health of the parent had a significant impact on their parenting capacity, resulting in the death or serious injury of the children.  The majority of parents who suffer mental illness are able to care for and safeguard their child(ren) and / or unborn child. However, some children of parents with mental illness may be seen as children with additional need who require support.

There is a risk to children where a parent has an enduring and/or severe mental illness, that they may be more likely to suffer significant harm. This could be in relation to all categories of abuse.

Where a child has suffered or is at risk of suffering significant harm as the result of act or omission on the part of the parent/ carer, in relation to their mental illness then the welfare of the child must be paramount.

Where professionals believe that this may be the case a referral must be made to Children's Social Care using the Making a Referral Procedure.

When a parent is under the age of 18 they may also need a referral to children’s services for support in their own right

When social workers or other partner agencies believe that there is parental mental illness that has not been previously recognised consultation with the GP should be considered for referral for ongoing mental health support.

It should be noted that the procedures relating to parental capacity and mental health difficulties should be read and implemented in conjunction with the guiding policy, principles and values as set out  in 1.2 Underlying Policy, Principles and Values

It may be necessary to seek consultation with specialist mental health practitioners in some circumstances regarding parents experiencing mental health difficulties. This is in order to gain an understanding of the nature, degree and context of their behaviours and potential impact on parenting capacity for example:

• Parental OCD where thoughts to harm a child are being verbalised –guidance should be sought about the presentation and likelihood of harm in line with national guidance and safety plans initiated 
• If a child is involved in their parent's obsessional compulsive behaviours
• Parents/carers diagnosed with disordered eating

Adult and child mental health professionals, child care social workers, health visitors and midwives, school nurses, education services, GPs and other relevant services must share information in order to be able to assess risks - see Information Sharing and Confidentiality.

All children have a right to be protected from abuse and neglect. Protecting a child from such harm takes priority over protecting their privacy, or the privacy rights of the person(s) failing to protect them:  Information Sharing Advice for practitioners providing safeguarding services for children, young people, parents and carers

Where appropriate, children should be given an opportunity to contribute to assessments as they often have good insight into the patterns and manifestations of their parent's mental ill-health.

Any care planning meetings and discussions about parents who have mental health difficulties must include consideration of any needs or risk factors for the children concerned. Children's Social Care along with other relevant agencies should be involved in planning discharge arrangements. Changes to risk assessments should be communicated to the multi agency involved partners in line with the information sharing guidance. Practitioners should always consider that a change for one member of the family might have impact on another member, including children therefore a whole family approach is essential.

It is also important for Children's Social Care to share any relevant information regarding child protection processes with adult mental health practitioners.  This may have a direct impact on a parent's mental state and form a vital part of risk assessment processes.

Where a parent,/ carer, of a child is deemed to be a danger to self or others by agency professionals, a referral must be made to  Children's Social Care, who should be invited to any relevant planning meetings. The management of self harm and risk to self should always consider the impact and potential risk to children.

Mental health professionals should be invited and attend meetings regarding the potential impact of parental mental health concerns on the child. They will also be expected to provide information of their engagement and interventions with families. Meetings will include:

• Multi-agency meetings
• Strategy Disucssions*
• Initial and Review Child Protection Conferneces *
• Core Group Meetings 

* Strategy Discussions and Child Protection Conferences must include any psychiatrist, community psychiatric nurse, psychologist and adult mental health social worker involved with the parent / carer.

If a parent or carer has been receiving inpatient services, in whatever setting, consideration must be given to discharge arrangements to ensure provision for the children is appropriate, and their welfare and safety has been properly assessed. A formal meeting with Children’s Social Care should be held where they are already involved or if concerns are identified. If a parent or carer discharges themselves out of hours, a referral to the Emergency Duty Team should be made to ensure the children's welfare is protected.

Children's Social Care may be requested to assess whether it is in the best interests of a child to visit a parent or family member in a psychiatric hospital. (See Visits by a Child to High Secure Hospitals and Prisons Procedure). Mental health hospitals and inpatient settings should have written policies drawn up in consultation with Children's Social Care regarding visiting of patients by children. Visits should only take place following a decision (regularly reviewed) that such a visit would be in the child's best interests.

Resolution of professional difference or need for escalation should be undertaken in line with the Pan Sussex Child Protection and Safeguarding Procedures Resolving Professional Differences Policy and Escalation Policy

Parents with mental health difficulties may be more at risk of neglecting their own wellbeing at times. The impact of this on their children’s physical, emotional and social needs must be considered. Their children may have caring responsibilities (see also 8.48 Young Carers), which are inappropriate to their age and may have an adverse effect on their development. Some forms of mental ill health may cause parents to be less emotionally available or responsive to their children when they are in a period of ill health. In periods of illness parents may behave in bizarre or violent ways towards their children or environment placing children at potential risk.

The stigma associated with mental ill health can impair parenting capacity and children may be reluctant to talk about family problems or seek support. It is also notable that mental health difficulties can be associated with other vulnerabilities such as historic adverse childhood experience, poverty and health inequalities. Health matters: reducing health inequalities in mental illness - GOV.UK (www.gov.uk)

At the extreme, a child may be at risk of severe injury, profound neglect or even death.

A significant history of violence is a risk indicator for children, as is parental non- compliance with services and treatment.

The following factors indicate a child who may be at higher risk of suffering significant harm:

• An unborn child or baby of parents with severe and enduring mental health problems.
• A child where there is evidenced impact on their growth, development, behaviour and/or mental health as a result of parental mental illness.
• A past history of social care involvement.
• A child who features within parental delusions.
• A child who is involved in their parent's obsessional compulsive behaviours;
• A child who becomes a target for parental aggression or rejection;
• A child who may witness disturbing behaviour arising from the mental illness (e.g. self-harm, suicide, uninhibited behaviour, violence, homicide);
• A child who is neglected physically and / or emotionally by an unwell parent;
• A child where the parent has both mental health and substance misuse problems.
• A child 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);
• A child who has caring responsibilities inappropriate to their age - Young Carer Procedure  

The following factors indicate a child who may be at higher risk of suffering significant harm:

• An unborn child or baby of parents with severe and enduring mental health problems.
• A child where there is evidenced impact on their growth, development, behaviour and/or mental health as a result of parental mental illness.
• A past history of social care involvement.
• A child who features within parental delusions.
• A child who is involved in their parent's obsessional compulsive behaviours;
• A child who becomes a target for parental aggression or rejection;
• A child who may witness disturbing behaviour arising from the mental illness (e.g. self-harm, suicide, uninhibited behaviour, violence, homicide);
• A child who is neglected physically and / or emotionally by an unwell parent;
• A child where the parent has both mental health and substance misuse problems.
• A child 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);
• A child who has caring responsibilities inappropriate to their age - Young Carer Procedure  

Adult mental health services should have named nurses / doctors / professionals for safeguarding children within their agency where practitioners can seek advice, if necessary.

The following set of questions are designed to guide decision making about how best to meet the needs of children and adults in families experiencing mental health problems:

• Are they receiving services for the mental health condition? This may be from primary, secondary, independent or third sector providers.
• Do they have children or live in a household with children? If so, record details including full names, dates of birth, ethnicity and schools/nurseries. Include children they are not living with but retain caring responsibility
• Do any of the children have caring responsibilities for their parent or younger siblings? Do you need to consider a referral for 8.48 Young Carers support?
• Have the parents and, where appropriate, the children been involved in any assessment and their views sought?
• Have you considered the impact of their mental health on their ability to meet the needs of their children? This will be determined by several factors: nature, severity and duration of the illness. Child involvement in, and exposure to, parental symptoms. Changes in family structure or functioning or the effects of parental treatment.
• Is there a previous history of concerns in respect of parenting ability or the welfare of the children? This may or may not be related to mental ill health.
• Is the mother pregnant? If so, has she accessed antenatal care? Are we aware of the father and is he engaged with antenatal services?
• Have you discussed the need for any additional services, or made a referral to another service, with them?
• Have they expressed views about harming themselves and/or the children?
• Does anyone in the household adult or child have a disability or additional needs. Do they require assessment of these needs?

Our Time Website:  https://ourtime.org.uk/ For children of parents with mental illness - Includes resources for children, parents and professionals.