Patients as parents. Addressing the needs, including safety, of children whose parents are mentally ill

This document provides a fully-referenced and practical summary of key issues involving the interactions and influences between parental psychiatric disorder and child mental health and well-being. It promotes an ecological approach, in which mental illness is firmly embedded within a family and social context. The links between poverty, mental ill health, discrimination and social exclusion are compelling, and any attempt to improve the life chances for patients who are parents and their children must be based on a good understanding of the needs of children and their mentally ill parents.

There is an introduction followed by six sections that cover: Family Influences; Parenting; Child Maltreatment; Special Circumstances (parental self-harm and hospitalisation); Implications for Practice; and Improving Services. A reference list together with a list of additional key texts is included. Practice guidelines provide concise, practical summaries of important topics.

The intention is to raise awareness and promote good practice nationally — how psychiatrists can help in a situation where people who have a psychiatric disorder or abuse drugs or alcohol also have childcare responsibilities or contact with dependant children. The emphasis is on roles and responsibilities for psychiatrists across all faculties, and the need for closer, more effective collaboration within teams and between other services and agencies.

The fact that services for children and adults are currently delivered quite separately means that this report will be of relevance to a wide readership, including those in non-mental health services, those with responsibility for supporting families, the voluntary sector, service users and all those with service planning and policy development responsibilities.

The introduction provides an overview of key issues, such as the scale of the problem (for example, the number of patients who are parents), the impact of parental mental illness on children's adjustment and a consideration of possible mechanisms. The broad continuum in the quality of child—parent—professional interaction is described. While many parents cope exceptionally well, despite the presence of significant mental health problems, and some children show few, if any, adverse effects, the presence of a mental illness in a parent can adversely affect the way in which that parent accomplishes the tasks and responsibilities of parenthood, and similarly the stresses of parenthood can precipitate or exacerbate mental ill-health. Furthermore, children, especially those with chronic physical, developmental or emotional disorders, can precipitate or exacerbate parental mental illness.

A systemic conceptual framework is provided in the family section to contextualise interactions between parents and children — the Family Model. This integrated, ecological model of influences and interactions between mental illness, parenting, family relationships, child development, and environmental risk factors and protectors was developed in the Department of Health-sponsored training materials on the impact of parental mental illness on children, entitled ‘Crossing Bridges’. This model emphasises the relevance of a systems approach to assessment and intervention. How these core components interact and influence each other determines the quality of an individual's adjustment within his or her family, as well as the adequacy of the whole family's adaptation to living with a mentally ill member. This model includes consideration of family-of-origin experiences and the transition to parenthood, as well as quality of current family relationships and child—parent interactions.

Different parenting patterns and styles are then described to demonstrate the broad range of interactions, including quantitative and qualitative extremes where direct or indirect consequences of psychiatric disorder impair or preclude parental capacity to meet the needs of children, including their safety.

In the context of child maltreatment, emotional abuse and neglect is particularly emphasised. Depression, substance dependence and personality disorders occurring together in various combinations and at various points in time are the most frequently reported psychiatric conditions affecting parents who abuse their children, including fatalities. All psychiatrists need to be constantly aware of the possibility of abuse or neglect when children are involved and the general duty to patients, including that of confidentiality, is over-ridden by the duty to protect children.

Parental self-harm and hospitalisation are two common situations that provide good opportunities for early intervention.

The section on implications for practice includes practical approaches for all psychiatrists and members of multi-disciplinary teams (such as ensuring familiarity with: legal and policy frameworks; young carers; child protection procedures; named doctor and nurse; availability of local services as well as developing collaborative links across teams and services, use of shared protocols and training). There are also specific recommendations for adult and child psychiatrists, as well as those working in learning disability, forensic and substance misuse services.

Opportunities to improve services include prevention; working together to promote family relationships and positive contact between children and parents; audit; liaison; and education and training. For example, psychiatrists are well placed to initiate and facilitate preventive interventions, such as systematic identification of the ‘hidden’ children of patients who are parents to enable earlier referral for support or specialist intervention. Similarly, systematic recognition of the mental health needs of parents will assist with earlier treatment, which in turn can reduce parental burden and promote parenting capacity.

Mental illness in adulthood is thus one of a number of long-term outcomes associated with trauma and adversity in childhood. The fact that many childhood-onset psychiatric conditions show considerable continuity into adulthood lends additional weight to the preventive opportunities of earlier support and intervention for families in which mentally ill parents/carers live with dependant children.

Promoting positive mental health across the lifespan and between generations will require broader approaches to assessment and treatment, an incorporation of a prevention perspective into daily practice, and good collaboration between all mental health services and a wide range of other agencies.