Level 3 Multi-Agency Child Protection

Understanding the impact of

parental mental illness on the safety

and wellbeing of children

improving …the lives of vulnerable people

developing …the staff who work with them

transforming …how services work together

Housekeeping

• Time-keeping

• Break times

• Facilities

• Phones off

• Emergency procedures

3

Example of email with links to course materials

4

Group Agreement

• Start on time and finish on time

• Value diversity and learn from our differences

• Give each other good attention

• Take care of ourselves and try hard not to

make assumptions

• Take away the learning but leave the detail

• Be serious but also have some fun

• Remember confidentiality in the room with the

exception of live safeguarding issues which we

will support you in taking back to your agency.

Legislation and guidance

• Children Act 1989

• Children Act 2004

• Children and Families Act 2014

• Education Act 2002

• Counter Terrorism & Security

Act – March 2015.

• UN Rights of the Child (UK law

from 1992)

• Disqualification by Association

– February 2015.

• South West Safeguarding and

Child Protection Procedures

http://www.swcpp.org.uk/

• Keeping Children Safe in

Education – September 2016

• Working Together to Safeguard

Children – March 2015.

• What To Do If You Are Worried

A Child Is Being Abused –

March 2015.

• Information Sharing – March

2015.

• Changes to Female Genital

Mutilation Act 2003 - arising

from the Serious Crime Act

2015.

• Multi-agency statutory guidance

on female genital mutilation

Learning outcomes:

The overarching aim of todays training is to investigate

the definitions of mental illness and to identify possible

developmental challenges for those children living in

family contexts where mental illness exists.

7

And …

• To investigate the effects of parental mental health problems on child development.

• To facilitate improved multi-agency practice.

• To develop an understanding of legislation, guidance and procedures in relation to mental health and children and families.

• To reflect on local practice and procedures in relation

to those children deemed to be at risk of significant

harm.

• To make reference to current messages from

research.

8

Challenges in engaging with the

subject area

• To identify which children need help.

• To agree the level of concern.

• To assess which areas of their development are

suffering

• To decide the type of services that are needed

9

What do we know about mental

health?

• Quiz

10

What’s in a diagnosis?

Definitions

Mental illness is

“A term used by doctors and other health

professionals to describe clinically recognisable

patterns of psychological symptoms or behaviour

causing acute or chronic ill-health, personal distress

or distress to others”

WHO 1992

12

Different types of mental ill health

• ORGANIC- where there is a clear biological cause

(e.g. Dementia)

• FUNCTIONAL- where no biological cause can be

found.

• NEUROSES-severe forms of normal experiences

(e.g. depression, anxiety)

• PSYCHOSES - Unusual Experiences which are not

shared by others (e.g. Delusions “hearing Voices”)

• PERSONALITY DISORDERS - present throughout

life where patterns of thinking or behaviour cause

difficulties for a person

13

Causes of mental ill health

• Biochemical

• Genetics

• Environmental Causes.

Mental Mental Mental Mental

good Distress Disorder Illness

health

14

Exercise

Mental illnesses: rank 1 – 4 which is more

risky to children? Why?

Depression

Anxiety disorder

Personality disorder

Schizophrenia

15

• The chronic nature of some forms of depression can

affect parenting and the wellbeing of children,

especially if symptoms are associated with: parental

irritability, inability to demonstrate warmth, social

isolation or socio economic deprivation.

16

Depression

Personality disorders

Professionals should note evidence of -

• Exposure to hostility & violence

• Living in chaotic unpredictable environments.

• Experiencing emotional or physical neglect

• Exposure to parental substance misuse

• Lack of safety in the home

17

Anxiety disorder

• Overwhelming feelings of anxiety can prevent

parents from ensuring children's needs are met.

• Some parents may fear being at home alone and so

keep a child from attending school.

18

Schizophrenia

• Can result in the lack of interest and thus neglect of

children's needs e.g. a two year old without food.

• Can manifest itself in bizarre and frightening

behaviour. In extreme cases delusional thinking from

the parent may result in the death of the child.

19

Important issues

• Having a mental illness does not in itself equal being

a poor parent

• Society still allows and tolerates stereotypes and

prejudices thus maintaining the stigma attached to

mental illness, though this is improving

• Research shows that a total of 2.3 million people with

a mental health condition are on benefits or out of

work (Work, recovery and inclusion HM Gov. 2009)

20

Messages from research

• Mental health problems are very common

• Possible negative consequences on a child’s

development will increase with severity of illness

• Social class and situation is relevant; unskilled &

manual workers have higher rates and unemployed

and lone parents higher still

• Joint working is crucial

• Think Child, Think Parent, Think Family

21

Prevalence

1 in 4 people will experience some kind of mental

health problem in the course of a year

Mixed anxiety and depression is the most common

mental disorder in Britain

Women are more likely to have been treated for a

mental health problem than men

About 10% of children have a mental health

problem at any one time

Suicides rates show that British men are three times

as likely to die by suicide than British women

Self-harm statistics for the UK show one of the

highest rates in Europe: 400 per 100,000 population

22

Prevalence

• Approximately one in 10 non-elderly women and one

in 20 non-elderly men are parents of dependent

children and have mental health problems.

• As many as 25% of children between the ages of 5

and 16 will have a mother who is at risk for a

common mental health problem such as depression

or anxiety.

23

Prevalence

• Most parents have common mental health disorders

such as depression or anxiety but a very small

proportion (0.5% or fewer) have a psychotic disorder

such as schizophrenia.

24

Prevalence

• Of this small number over ¼ live with children as

couples or lone parents.

• The evidence shows that 25% of adults in acute

psychiatric hospital settings, and possibly more, are

parents.

• Overall more women than men have mental health

problems, more younger women than older women,

more lone parents than couples. Lone parenthood,

particularly for women, appears to be a risk factor for

mental health problems, but is often associated with

other factors such as socio-economic disadvantage

and the interaction of other risk factors.

25

Prevalence

• Parents with mental health issues among black and

minority ethnic communities are difficult to pick out

and interpret – but its unlikely that the number of

parents from minority communities with mental health

problems will be any lower. Additional risk factors are

likely to be present and there is some suggestion that

BME communities are reluctant to identify

themselves as having mental health problems.

(source: Professor Gillian Parker et al, Research Reviews on prevalence, detection and interventions in parental health and child welfare: summary report 2008)

26

Toxic Trio

• What about the Co-morbidity factors

• Lets consider the toxic trio

• What would this mean for the child?

• What would this mean for the professional ?

27

Cant see the wood for the trees?

• Complex cases are multi-layered and presenting

issues often compete and are difficult to separate.

• For example Co-morbidity.

• When two or more disorders or illnesses occur in

the same person, simultaneously or sequentially,

they are described as co-morbid. Co-morbidity also

implies interactions between the illnesses that affect

the course and prognosis of both.

(source: NIDA- National Institute on Drug Abuse)

28

Prevalence

• 700,000 children are living with a parent who is

dependent on alcohol

• 100,000 children are living with parents receiving

treatment for hard drug use

• 130,000 are living in domestically violent homes

• 17,000 are living with a parent with a severe or

enduring mental illness

Ofsted Social Care Annual Report 2013

29

Analysing Child Deaths And Serious

Injury (Brandon et al 2008)

Parental Violence

Substance misuse

Mental health issues

9%

34%

15% 13%

6% 6% 4%

30

NSPCC - All babies count June 2013

• Perinatal mental illnesses affect at least 10% of women

and, if untreated, can have a devastating impact on them

and their families

• Universal services – particularly midwives, GPs and

health visitors – have an important role in identifying

mothers who are at risk of, or suffering from, perinatal

mental illness, and ensuring that these women get the

support they need at the earliest opportunity

• Women with perinatal mental illnesses and their babies

have specific needs, and it is important that they are

given expert specialist care

• Without this support, maternal mental illness can have a

negative impact on infant mental health

31

Factors associated with increased risk

of perinatal mental illnesses

• history of mental illness

• family history of mental illness

• psychological disturbance during

pregnancy (e.g. anxiety or

depression)

• lone parent or poor couple

relationship

• low levels of social support

• recent adverse or stressful life

events

• socio-economic disadvantage

• teenage parenthood

• early emotional trauma/childhood

abuse

• unwanted pregnancy

Edge, D. (2011)

32

The Importance of Parenting

and Healthy Attachment

33

Attachment

Intimate attachments to other human beings are the hub

around which a person’s life revolves, not only as an infant

or a toddler or a schoolchild but throughout adolescence

and years of maturity as well, and on into old age. From

these intimate attachments a person draws strength and

enjoyment of life and, through what she/he contributes,

gives strength and enjoyment to others. These are matters

about which current science and traditional wisdom are at

one.

John Bowlby 1980

34

Why is attachment so important?

• Basic security/safety, trust and positive world view

• Emotional regulation

• Capacity to relate/social interaction

• Cognitive function/language

• Self esteem/self concept and identity

• Healthy independence

We are social beings, hardwired for connection and

relationships with others

35

Process of Attachment

• I’ll love you

• I’ll take care of you

• You are important to me

• I’ll keep you safe

• I’ll keep you warm

• I’ll keep you fed

Bonding

The feeling and

capacity of the parent

to nurture; be

responsive and be

protective

• You’ll take care of me

• I need to stay close to you

• I rely on you to keep me safe

• You’ll teach me about me and the world

• I’m ok and loveable

Attachment

Enduring affectionate

bond to a person who

provides protection

36

• Is not fully mature at birth

• Requires an extended period of development whereby

experience plays a crucial role

• An important component of this development is a baby’s

attachment to their caregivers

• A baby’s stress response system is unstable and reactive; it

will produce high levels of cortisol if the baby’s needs are

not being met, or if the baby is in an environment which is

aggressive or hostile.

• Persistent and unrelieved chronic stress in infancy results in

the baby’s brain being flooded by cortisol for prolonged

periods

• This can have a toxic effect on the developing brain, with

detrimental consequences for future health and behaviour

37

The stress response

Impact of mental illness on the child

Not straight-forward to measure

Dependent on:

• Parent’s personality

• Type of mental illness

• Severity

• Treatment

Note, treatment has been shown to ease symptoms but

may not totally prevent them

38

• Film: Blank face experiment www.youtube.com/watch?v=apzXGEbZht0

39

How does it feel to live with a

parent who is mentally ill,

addicted or violent?

Isolation DVD

40

Risk and protective factors (parental ill health)

Vulnerability

• Severe, chronic,

recurrent, early onset

illness

• Poor adherence,

comorbidity, treatment

resistance

• Poor coping

• Low self esteem

• Fragmented services

Resilience

• Circumscribed, time

limited illness

• Good engagement and

adherence

• Good knowledge,

understanding illness

• Effective, accessible

services

Risk and protective factors (family relationships)

Vulnerability

• Marital/partner discord,

domestic violence,

separation

• Lone parent, ill,

unsupportive partner

• Quantitative, qualitative

extremes in parental/child

interaction – neglect,

abuse, insecure

attachment

Resilience

• Supportive, harmonious

interparental relationships

• Secure attachment

• Good awareness,

understanding and

communication about

mental illness

Risk and protective factors

(child mental health and development)

Vulnerability

• Intrauterine – stress

hormones, alcohol,

drugs, medication, diet

• Prematurity

• Low birth weight

Resilience

• Older age at onset of parental MI

• More sociable, able to engage adults,

easier temperament

• Greater cognitive abilities

• Discrete episodes of parental illness

with good return of skills and abilities

between episodes

• Alternative support from adults with

whom child has positive, trusting

relationship

• Experience of success outside the

home (educational, social, sporting,

hobbies)

Themes from serious case reviews relating to

child neglect (Brandon et al 2008, 2009; Rose and Barnes

2008)

• Dangers of ‘start again syndrome’ concentrating on one-off recent events rather than historic systemic family difficulties

• Lack of analysis

• Over concentration on measuring parental capacity rather than child welfare

• Cumulative difficulties over time compounding problems for the child

44

44

Lessons learnt from Local SCR

• Agencies failed to understand each others statutory

and legal obligations where a parent with mental

health needs is having contact with a child

• No ‘team around the child’ approach

• Lack of effective multi-agency communication

• Focus on the adult’s mental health needs not on the

impact on the young person

• Reliance on the mother

• Lack of engagement with young person

• Presence of DA

45

The importance of chronologies

Recommendations following Serious Case Reviews:

• All cases need a detailed chronology when

Fabricated Illness or Induced Illness is being

considered to ensure robust analysis of risk and

identification of patterns of behaviour.

• Where possible a multi-agency (integrated)

chronology should be used to establish patterns of

behaviour, share information and identify risk.

Harm exercise

• In your groups rank the scenarios

provided according to level of

concern.

47

Let’s think about assessment

48

Need to consider the child’s:

• Level of awareness, knowledge

• Concepts about the illness

• Feelings

• Relationships & any changes

• Changing role in family

• View of the future

49

Safety and wellbeing of children

What do you think are the key parenting tasks which are

the prerequisites for a child’s wellbeing and

development?

• Basic care

• Ensuring safety

• Emotional warmth

• Stimulation

• Guidance and boundaries

• Stability

50

Assessment

51

Health

Education

Identity

Family & Social

Relationships

Social Presentation

Emotional &

Behavioural Development

Selfcare Skills

FAMILY & ENVIRONMENTAL FACTORS

Basic Care

Emotional Warmth

Stimulation

Guidance &

Boundaries

Ensuring Safety

Stability

CHILD Safeguarding

& promoting

welfare

Parental mental

health concern

How does this

manifest itself in

relation to…..

What evidence

have you of

impact in relation

to

Some pointers for assessment

Measuring impact

• the more dimensions of domains that show difficulty;

• the more frequently those difficulties are manifest;

• the longer the difficulties have existed;

• the less the difficulties are modifiable;

Then the greater the severity of the problem

53

Cleaver et al 1999

• Parents have difficulty organising their lives

• Parent’s neglect their own and their children’s

physical needs

• Parents have difficulty controlling their emotions

• Parents are insensitive, unresponsive, angry and

critical of their children

54

Key messages

• Children growing up with parents who experience

problems such as mental illness, learning disability,

substance misuse and domestic violence are at

greater risk of being maltreated.

• Not all parents with these problems will abuse or

neglect their children; however these factors interlock

in complex combinations which substantially increase

the likelihood of maltreatment.

55

Protective factors that can substantially reduce the

likelihood of maltreatment include:

• presence of a non-abusive partner and/or a supportive

extended family,

• parents’ ability to understand and overcome the

consequences of their own experiences of childhood

abuse,

• their recognition that their adverse behaviour patterns

constitute a problem and

• their willingness to engage with services

Key messages

56

Where there are insufficient protective factors, parents’

problems can negatively impact their ability to meet the

needs of their children and inhibit the child’s capacity to

form secure attachments.

Healthy child development depends on the child’s

relationships, and particularly their attachment to the

primary caregiver.

The process of attachment formation begins at birth. The

four basic attachment styles: secure, insecure ambivalent,

insecure avoidant and disorganised illustrate different

adaptive strategies in response to different types of

caregiving.

Key messages

57

Exercise

Case Study

Group 1

Imagine you are Joshua. What would it feel like to live in that

household?

Group 2

Imagine you are Daisy. What would it feel like to live in that

household?

Group 3

Imagine you are Ben. What would it feel like to live in that

household?

As a professional, how would you assess the risk to

him/her?

What would reassure you?

What would escalate the risk for you?

What are the implications for your practice?

58

0-4 yrs from the child’s perspective

• Physical development

– Massive brain development

– Motor skills

• Cognitive development

– Magical thinking

– Guided participation

• Psychosocial development

• Emotional development - attachment

59

Impact of parental behaviour 0-4 yrs

Risk of physical harm or death –

• Children under the age of one are particularly

vulnerable. They are nearly three times as likely to be

the subjects of child protection plans due to physical

abuse and over twice as likely to be the subjects of

child protection plans for neglect. Almost half (45%)

of all serious case reviews in England involve a child

under one, and they face around eight times the

average risk of child homicide

• Non-accidental head injury is the most common

cause of infant death or long-term disability following

maltreatment

60

5-11 yrs from the child’s perspective

• Physical development

– Slower physical growth but impacted by genetic

and environmental factors

– Puberty

• Cognitive development

– Making sense of themselves and their

environment

– Understanding the rules

– Mentalising

– Language providing the scaffolding

61

5-11 yrs from the child’s perspective

(continued)

• Psychosocial development

– Understanding of self

– Understanding of how the social world works

– Standards and expectations of ones own behaviour

– Strategies for managing one’s own behaviours

• Emotional development - attachment

62

Impact of parental behaviour 5-11 yrs

• Socially, emotionally and behaviourally impeded

development attributed to abuse and neglect in the

early years continues into middle and later childhood.

• Because subsequent development builds on previous

milestones, abused and neglected children can

continue to be challenged by normal developmental

tasks.

63

• Short film: Impact on young people.

64

Adolescence

Adolescence is a period of preparation for adulthood,

when several key developmental tasks are

encountered. These include physical and sexual

maturation; movement towards social and economic

independence; the development of identity; the

acquisition of skills needed to carry out adult

relationships and roles; and the capacity for abstract

reasoning. Adolescence can be a time of tremendous

emotional, social and physical growth and potential,

however for young people who have experienced abuse

and neglect either in their past or present, this is a time

of particular vulnerability.

65

Abused and neglected adolescents are

more likely to…?

• Start drinking alcohol at a younger age and more likely to use alcohol

as a way of coping with stress than for other social reasons.

• Smoke

• Use illicit drugs

• Have an eating disorder

• Indulge in high risk sexual behaviour

• Have trouble maintaining supportive social networks have a higher risk

of - school failure, gang membership, unemployment, poverty,

homelessness, violent crime, incarceration, and becoming single

parents

• Have poor health outcomes such as cardiovascular disease; viral

hepatitis; liver cancer; asthma; chronic obstructive pulmonary disease;

autoimmune disease; poor dental health; and depression as a result of

toxic stress in childhood

66

Adolescence

• The neglect of adolescents is a major issue that

frequently goes unnoticed. Adolescents can be

neglected by services as well as by their families

• Teenagers are the second most likely group of

children to be the subject of a serious case review.

67

Children are more likely to cope with

adversity if…

• Supportive relationships with at least one parent

• Supportive relationships with siblings and extended family

• Committed non-parental adult – mentor, role model,

champion

• Capacity to develop and reflect a coherent story

• Talents and interests

• Positive experiences at school

• Positive friendships

• Capacity to think ahead and plan life

68

Implications for professional practice

• Decision making within the child’s timeframe is very

important. Most children placed for adoption are aged

two or older before they reach their adoptive families.

• Delayed decisions mean that children experience the

cumulative jeopardy of lengthy exposure to abuse and

neglect – therefore joint assessment and planning in

Parental Mental Health essential

• There is a relatively short window of opportunity in which

decisive actions should be taken to ensure that children

at risk of future harm are adequately safeguarded.

69

What works?

• Keep thinking of the whole family

• Keep looking for the strengths and protective factors

• Avoid assumptions

• Focus on parenting behaviour not just a diagnostic label

70

Responding to Concerns: Inquiries

and Referrals

The Multi-Agency Advice Team (MAAT) is a multi-disciplinary

team within the MARU/Integrated Hub.

The Multi-Agency Referral Unit (MARU) provides a multi-

disciplinary response to concerns about the safety of a child

• Cornwall referrals: 0300 1231 116

• Email: MultiAgencyReferralUnit@cornwall.gcsx.gov.uk

• Website: http://www.safechildren-cios.co.uk

• In an emergency always dial 999

• Isles of Scilly referrals: Children's Social Care - 01720

424354

71

The process

• MARU contact worker will take an initial contact referral

and consults with the Principal Social Worker or Team

Manager within 10 minutes of receipt of the information.

A decision is made as to whether the Contact worker

continues with the enquiry or is passed to a Social

Worker

• The Contact Worker /Social Worker will immediately

begin to gather further information to add to a referral on

MOSAIC

• Where additional information is required the case will be

passed to the Multi Agency Advice Team (MAAT)

• Review meetings

72

Response and Intervention:

Child Protection Process

• Child Protection strategy

discussions/meetings

• Initial Child Protection Case Conference

• Core Group meetings

• Child Protection Review meetings

73

Signs of Safety as a basis for

Case Conferences

All social workers involved in child protection

use Signs of Safety, a constructive process

which:

• Ensures professionals focus on strengths

and weaknesses

• Ensures professionals talk to the family – not

the chair or the report

• Helps agencies devise and support the plan

with the family

74

Child Protection Analysis Framework

• What are we worried about?

• On scale of 0-10, how safe is the child?

• What are the historic factors?

• Experience of the child/young person – views

and understanding of the child – their narrative

• What is going well?

• What would help improve the situation and the

child’s experience?

• What are the safety factors?

75

What are we

worried

about?

Historical

concerns

Experience

of the

child/young

person

What is

going well?

Grey areas/

complicating

factors

What would

reduce our

concerns?

(includes

plan)

Scale: 0 (serious concerns about the safety of the child) –

10 (being totally safe) 0 1 2 3 4 5 6 7 8 9 10

The child’s viewpoint (lived experience) must be

included in all aspects of this process (UN

Convention article 12)

Conference Process

• Agencies share their report with families at least 3 days

prior to conference

• CPC Chair meets with child and social worker prior to

conference of child’s views or sought via Viewpoint (this

will be incremental)

• Chair meets with parents and /or child 30 minutes prior to

conference to explain conference process

• Parent and child are asked to score on the scale the rating

of safety for the child

• Advocates accompany parents and/or child to conference

• Professionals meet 10 – 30 minutes prior to conference to

exchange information

77

Conference Outcome

• Chair identifies what goes into the plan based upon what

parents and agencies contribute and sets out timescales

and professional accountability

• Differentiates between what are child protection issues

and single agency issues

• Chair has deciding vote on whether a CP Plan is

required

• Parents take ownership of plan – it is their plan for their

children

• Plan may be 10/20/30/40 days dependent on individual

case and level of risk to child

78

Evaluation

What key changes will you make to your

practice as a result of this training?

Challenge your colleague to identify at least

one, and how they will make sure they do this?

79

Follow on Information

• Certificate - your certificate will be emailed to you

upon completion of the Reflection in Action post-

course evaluation.

• Reflection in Action - the link to this short post-

course evaluation will be emailed to you 6 weeks

from today.

• Course resources - handouts, presentation, etc. to

support today's training will be found online using the

link included in the email sent to participants about 2

weeks ago.

• Any important comments for the CIOSSCB

80