Mental health assessments and treatment - advice
This advice provides information regarding the purpose of mental health assessments of parents and children and their usefulness in protective assessments.
Document ID number 2425, version 2, 1 March 2016.
This advice outlines:
- the definition of mental illness
- the prevalence of mental health issues in families that are reported to child protection
- identifying the need for, and requesting, parental mental health assessment
- utilising the mental health assessment to develop and achieve the permanency objective for the child
- mental health assessment of a child
- post natal depression.
Parental mental illness is a prevalent issue for a significant number of families and may be an issue for those who come into contact with child protection. Mental illness features as a primary parental characteristic for the associated risk factors of family violence and substance abuse.
Parental mental illness alone need not indicate significant risk to a child. The vulnerability of a child may be reduced when the parent receives effective treatment, or the primary carer is the well parent. However, research and literature indicate that parental mental illness may be associated with an increased risk of child abuse and neglect, as serious mental illness may disrupt and impair a parent's capacity to provide adequate care and protection for a child, or may include the child as part of a delusion. A child may suffer developmental delay and disturbance related to emotional neglect, disruption or trauma. Therefore, it is imperative that child protection practitioners develop an understanding of mental illness and its possible impact on parenting and child development in order to make decisions and implement interventions in the best interests of the child and support their decisions and actions with research findings and theory in court reports.
The term mental illness is defined in the Mental Health Act 2014 as a ‘medical condition that is characterised by a significant disturbance of thought, mood, perception or memory'.
Mental illnesses can be separated into two main categories, psychotic and non-psychotic.
The term psychosis describes conditions which affect the mind and there is some loss of contact with reality.
Non-psychotic illnesses include phobias, anxiety, some forms of depression and obsessive-compulsive disorder.
Determining the need for a mental health assessment
Where symptoms of mental illness are present, it is part of the child protection practitioner's role to assess the impact of the illness on a person's parenting capacity and possible harm to the child. The impact of a parent's mental illness on their level of functioning varies with the type, severity and phase of the mental illness.
There are five main areas which may affect a person's mental wellbeing. The following indicators are provided to assist the practitioner who is considering consulting with, or referring a child, adolescent or adult to a mental health service. These indicators include symptoms and behaviours which may be indicative of a mental illness, psychiatric disorder or emotional disturbance.
- Behaviours – avoidance, withdrawal behaviour, disorganised behaviour, deterioration in appearance, erratic behaviour, repetitive or seemingly compulsive behaviour, self destructive or high risk behaviour, aggressive or homicidal behaviour, neglect of dependents.
- Biological changes – marked changes in appetite, energy and activity levels, sleeping patterns, weight.
- Decreased level of functioning – lowered educational or occupational functioning reduced family, interpersonal or social functioning.
- Mood changes – frequent anger, irritability or tantrums, increased levels of anxiety and fear, reduced enjoyment and interest in usual activities, depressed behaviour including crying, despair or withdrawal.
- Thoughts – confusion, impaired judgement, delusions (including fixed false beliefs about oneself, other people, events or the environment), difficulties comprehending language, disorientation, hallucinations (either auditory, visual, movement or tactile), poor concentration, poor memory, suicidal thoughts, disturbed speech and communication patterns.
Some of the indicators are more typical in children, while others characteristically apply more to adults. It is important that these indicators are taken as guides, rather than confirmation of a mental illness.
When symptoms listed above are evident and the behaviour or symptom is atypical of the person, a mental health assessment may be required.
A mental health assessment is the most effective tool to develop a comprehensive understanding of a parent's mental wellbeing or psychiatric disorder. A mental health assessment may be helpful when:
- there is a known history of mental illness of a parent and there are indicators or symptoms to indicate possible current mental illness
- the parent is exhibiting or displaying symptoms or behaviour indicative of possible current mental illness, for example, paranoid thoughts, suicidal or homicidal ideation
- the parent has a suspected mental illness, however has never been assessed by a psychiatrist or the assessment is more than 12 months old
- the parent requires a review of their mental health status, including review of treatment or medication
- a comprehensive assessment and understanding of the parent's mental illness and impact on their parenting capacity is required
- an attachment and bonding assessment between the parent and the infant is required. The parent may have a mental illness
- there is a need to identify the most appropriate treatment for the parent's mental illness.
In its pure form, a mental health assessment is often requested to determine whether a parent has a mental illness under the Mental Health Act or meets the criteria of a psychiatric disorder under the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This is a narrow view of a mental health assessment and a parent is unlikely to meet this threshold unless the mental illness is acute or there have been previous assessments by a mental health service. On the other end of the continuum, child protection practitioners request a mental health assessment of a child or a parent who may display any slight change in behaviour, mood or thoughts and subject a child or parent to an unnecessary assessment.
It is important for the practitioner to develop a balanced preliminary view as to the need and purpose of a mental health assessment. For example, if a parent becomes aggressive after receiving information that the child will be removed from that parent's care, this does not necessarily indicate possible mental illness, particularly if there is an absence of prior indicators. Additionally, recent trauma or loss, intense fear for personal safety, physical illness or drug reactions can produce indicators similar to those that may be seen in a mental illness.
A mental health assessment can provide valuable information regarding a child or parent's mental and emotional wellbeing, coping skills and stressors which can be utilised in safety plans, identifying goals and preparing case plans.
It is important child protection practitioners ensure proper information is provided about the assessment process, and the consequences of giving or refusing consent, prior to seeking consent. If parents refuse to consent to an assessment of themselves or their child, child protection practitioners must consider the importance of the mental health assessment in the context of the parents' capacity to care for the child. In addition, if parents refuse to consent to an assessment of themselves or their child and a mental health assessment is significant to the child's safety and wellbeing, child protection practitioners should pursue an interim or final protection order which includes a condition that the parents or child participate in a mental health assessment.
There are some circumstances where a child may be assessed or treated in the absence of parental consent, under s. 597 of the CYFA. See advice Consent for medical examinations.
What a mental health assessment involves
A mental health assessment can involve a number of processes and procedures.
- An assessment may involve the child or parent undergoing a series of interviews with a mental health specialist, such as a psychiatrist, clinical psychologist or community psychiatric nurse.
- The mental health specialist is likely to interview extended family in order to develop an understanding of the symptoms or behaviour that the child or parent is displaying.
- The purpose of the interview process is to gather information about the child or parent's history of mental illness, current symptoms or behaviour that may indicate or confirm possible mental illness, impact on level of functioning, treatment undertaken previously and the effectiveness of this and to ascertain the most suitable treatment for the child or parent.
- Part of the assessment process may involve the child or parent undergoing a series of medical examinations, including blood tests, x-rays, CT scans, to exclude a physical cause for the symptoms or confirm a psychiatric disorder.
- Another aspect of a mental health assessment may involve the administration of standardised psychological tests, that is, MMPI, Beck's Depression Inventory. This will identify whether the child or parent meets the clinical criteria of a particular disorder or determine particular personality traits which may be useful in understanding how a person functions and the most effective manner of engagement.
Information obtained from the person experiencing the mental illness and the extended family, in conjunction with the results of the medical examinations and psychological testing will provide an assessment regarding the type of mental illness, the cause and the most appropriate treatment. Determining the best treatment will depend on the factors such as personal preference, how severe the symptoms are, how long they have been present and what the apparent cause is.
There are different types of mental health assessments that a child protection practitioner can request, each with its specific purpose.
- Psychiatric assessment – this form of assessment usually provides a diagnosis of a psychiatric disorder if the parent meets the criteria under DSM-IV. This form of mental health assessment can be restrictive as it assesses a parent's thoughts at any given time, that is, hallucinations, delusions, paranoia. If a parent denies such symptoms then the likely outcome is that the person may be assessed as not having a psychiatric disorder. A psychiatric assessment is more useful where a parent has been diagnosed with a psychiatric disorder and further information is required regarding the impact of the disorder on the parent's level of functioning, parenting capacity, prognosis and treatment plan. It is not usually useful when needing to assess possible mental illness, unless the parent is experiencing an acute episode.
- Psychological assessment – this assessment is most useful when requiring information about a parent's general mental health status, stressors or triggers, coping skills, personality traits, exploring the possibility of a mental illness, impact of symptoms and behaviour on level of functioning and parenting capacity. A psychological assessment conducted by a clinical psychologist can include information regarding diagnosis of a psychiatric disorder in accordance with the DSM-IV, prognosis and treatment.
- Assessment of post natal depression – this is specific to assessing the possibility of post natal depression (PND) of a mother following the birth of the infant. PND is a specialised area and there are mother-baby units that assess PND and the impact of this on a mother's level of functioning and parenting ability. Similarly, there are mother-baby units that assess the direct impact of a mother's mental illness (that is, schizophrenia, personality disorder, anxiety disorder, bi-polar) on her parenting capacity.
- Attachment and bonding – this assessment examines the attachment and bonding between the infant or child and the parent. This may relate to a parent's mental illness, which may or may not have an impact on their ability to be emotionally available to and bonded with the infant. This type of assessment may be required even if the parent does not have a mental illness, however may not be bonded or attached with the infant or child for various reasons.
- Infant mental health assessment – this is an assessment of the infant's mental wellbeing and is used to identify disorders of infancy and early childhood (0-36 months), factors that contribute to these and the need for early intervention.
- Child mental health assessment – this is an assessment of the child's behaviour and mental health status. This includes aggression, defiance, withdrawal, depression, suicidal risk assessment, risk-taking or self-harming behaviours. The purpose may be to provide a diagnosis, such as attention deficit hyperactivity disorder (ADHD), conduct disorder, oppositional-defiant disorder, or to obtain an understanding of the child's behaviour.
Requesting a purposeful mental health assessment
The purpose for which the mental health assessment is required and the specific circumstances of the case will inform what information or recommendations are required. When referring a child or parent to a mental health service, initial contact should be made with the duty or intake worker of the local mental health service. The practitioner should clearly indicate the reason for the referral, their expectations about the assessment or treatment process and the child or parent's attitude to the referral.
The disclosure of information to the mental health worker should be what is necessary and relevant to enable the mental health worker to undertake their role. See Information sharing in child protection practice.
The mental health intake worker may provide information and consultation, recommend another type of service for the child or parent, or accept the child or parent for assessment.
See Child, youth and family mental health services protocol.
Crisis mental health assessments
Crisis mental health assessments are most valuable in situations where the child or parent displays symptoms of acute psychosis, imminent potential suicide, homicidal ideation or severe depression or anxiety. The practitioner must be able to clearly articulate the concerning behaviour or symptoms that may warrant an urgent mental health assessment by the local Crisis Assessment and Treatment Team (CATT). For example, a parent is presenting with delusions or hallucinations which include the child, the thought processes of the parent are so florid or disorganised that a sense of reality has been lost, threats to commit suicide or kill the child, a child is engaging in self-harming behaviours which place their immediate safety at risk.
The purpose of a crisis mental health assessment is to determine the immediate risk of harm to a child or to the parents themselves. Therefore distinct areas that need to be covered include:
- an assessment of the child or parent's current mental health status
- an assessment of the child or parent's immediate risk to self or others
- the possibility of the onset of acute psychosis or relapse of an ongoing mental illness
- identification of triggers that caused the acute psychosis, anxiety, suicidal or homicidal ideation
- the immediate treatment for the child or parent, that is, medication, brief counselling, voluntary or involuntary hospitalisation
- the parent's capacity to provide immediate care and protection to the child
- the likelihood of risk of harm to the child's immediate safety and wellbeing, particularly if the parent was expressing thoughts to harm the child
- identification of short-term treatment options, that is, will CATT visit daily, refer to a mental health service for an urgent comprehensive mental health assessment.
This information will provide guidance to the child protection practitioner when determining the need for possible removal of the child to ensure their safety, possible legal intervention and in developing a safety plan and case plan with the parent if the child is to remain in the parent's care.
The child protection practitioner should be careful when assessing level of risk to the child in these situations and not necessarily accept that a parent does not pose a risk to the child if the mental health specialist has indicated this or is not willing to provide a professional opinion on this point. The role of the mental health specialist is to advocate for and support their patient, the parent, and may not necessarily consider the best interests of the child. For example, the mental health specialist may suggest that the removal of the child from the parent's care may lead to a deterioration of the parent's mental health or may recommend that the child be returned to the parent's care as this may assist the parent in their recovery. The mental health specialist is there to assess a parent's mental health status. It is the role of the child protection practitioner to assess and determine what is in the best interests of the child along with the level of risk the parent's mental health issue poses to the child.
Non-crisis mental health assessments
During the course of an investigation or in the period of a protection order, it may become apparent that a parent has symptoms associated with mental illness. The child protection practitioner may require a mental health assessment of the parent. The following are some likely areas to be covered in a mental health assessment:
- presenting problem, outlining the reason for the referral and including the symptoms observed or reported in the parent's behaviour, thoughts, mood changes
- psychiatric history, including the age of the parent at the onset of the psychiatric illness, relapses of acute episodes (pattern and frequency), admissions to psychiatric hospital, previous contact or involvement with mental health services
- triggers to deterioration, major social or psychological stresses, both current and past, management of stress and possible impact on ability to deal with stress
- diagnostic status
- recommendation of the most appropriate treatment plan for the parent, that is, hospitalisation, community treatment order, case management via mental health service or private psychiatrist, referral to another service, counselling
- possible side effects of treatment, for example, drowsiness, passivity
- prognosis with full treatment compliance
- prognosis with no treatment or compromised treatment
- degree of irritability and likelihood of violent behaviour
- the impact of the mental illness on the parent's general daily functioning and on their parenting capacity
- the parent's capacity to provide physical and emotional care to the child or ability to care for children of particular ages
- the effect of the parent's mental illness on the child.
Utilising the mental health assessment
A mental health assessment has the potential to provide the child protection practitioner with a comprehensive understanding of the parent's mental illness or emotional disturbance, inform risk and needs assessment for the child and provide a framework for planning interventions when working with families where one or both parents have a mental illness and decision making to protect the child.
The first priority of intervention for the child protection practitioner is to protect the child, as the child remains the primary client at all times. Concerns regarding the child's immediate safety are likely to arise when the need for an urgent mental health assessment is identified. Therefore, protective issues and the child's immediate safety must be dealt with initially. When the safety and wellbeing of the child is ensured, other issues, such as treatment planning, recovery and promotion of parenting can be addressed.
Risk and needs assessment
The mental health assessment is a valuable source of information that can be used by the child protection practitioner in articulating a risk assessment for the child, particularly for the purposes of a court report. The practitioner should utilise the information in a mental health assessment by incorporating the issues related to a parent's mental illness within risk and needs assessment which focuses on the child's immediate and longer term safety, development and need for permanency within the context of age, developmental stage, vulnerability, needs, family environment and historical information. The impact of a parent's chronic mental illness on the cumulative harm to the child's ongoing development and wellbeing needs to be considered. There is substantial literature to indicate that children of parents with mental illness are at an increased risk of adverse developmental outcomes and mental health issues. This may include the child assuming an unreasonable level of responsibility for self-care or the care of a parent or siblings (a role reversal sometimes referred to as 'parentification'), accepting the parent's delusions as reality, attachment issues for an infant or child and increased risk of mental health problems for young people.
When the child protection practitioner is formulating a risk and needs assessment regarding the possible risk of harm to the child, parental mental illness should be incorporated in a manner which attributes it with appropriate significance in relation to the child's needs, developmental stage and vulnerability. The assessment should consider each parent's perception and understanding of the mental illness, the treatment recommended, a parent's level of compliance with treatment and the implications of treatment, including side effects.
An assessment of the protective parent or family member is required when assessing possible risk of harm to the child. This should incorporate the well parent's level of awareness and insight to the mental illness and treatment, acknowledgement of the potential for harm to the child, physical availability and level of direct supervision of the child and preparedness and demonstrated ability to seek assistance when required.
A mental health assessment may assist with preparing the child's case plan, that is, determining the appropriate permanency objective and making other significant decisions concerning the child. To effectively implement the case plan, goals and tasks identified in the actions table need to be realistic and to reflect available mental health services’ diagnostic advice, recommendations and prognosis. It is important that the expectation of the parent with the mental illness for change or for acceptance and compliance with treatment and monitoring is clear and understood by all parties. Additionally, the role of the protective parent or family member in monitoring and supporting the parent with the mental illness and in ensuring the child's care and protection should be thoroughly assessed and clearly communicated. Good decision-making takes careful account of the severity of a parent's mental illness and capacity to comprehend, accept and adhere to court orders or commitments made by the parent, over time.
The prognosis of a parent's ability to manage the mental illness at a level where they are able to function adequately and care for the child is critical when assessing the plausibility of reunification, if the child is placed out of the parent's care. The prognosis for recovery may be dependent on the degree of severity of the parent's mental illness and their compliance with treatment. Particularly in cases of infants or young children, it is critical that the motivations, good intentions, cooperative attitudes or needs of the parent should not divert attention from the risk assessment and the possible risk of harm to the child. The child protection practitioner must always make timely decisions in the best interests of the child consistent with their age and stage of development. Therefore, if a parent has not been able to adequately address their mental illness issue within an appropriate timeframe, the possibility of reunification is questioned and the child protection practitioner is required to make a decision about seeking an order consistent with the child's long term care needs.
The mental health assessment can be used to assess parenting capacity and the parent's ability to ensure the child's safety and meet their developmental needs. The child protection practitioner can utilise the information regarding the parent's mental illness and impact of this on their level of functioning to articulate possible parenting capacity. The child protection practitioner should be conscious of the stage of development of the child when assessing parenting ability. For example, an infant or young child needs to attach and bond to a primary carer and achieve the developmental milestone of trust versus mistrust. Therefore, the parent's ability to be emotionally available to the infant is as crucial as providing physical care. In cases involving older children, protective intervention should include a strong focus on building the child's personal resilience and competence through the provision of positive peer and child/adult interaction and activity.
Different types of mental health assessments will incorporate and directly assess a mother's parenting ability of an infant when she has a mental illness. The child protection practitioner can utilise this information when articulating possible risk of physical and emotional harm to the child.
Referral to support services
A mental health assessment can assist in identifying the most appropriate treatment for the parent, including hospitalisation (voluntary or involuntary), medication and individual or group counselling or psychological therapy. The child protection practitioner can refer the parent to appropriate support services or encourage the parent to engage with the mental health service and to undergo relevant treatment to address their mental illness.
Post natal depression (PND)
When assessing possible risk of harm to an infant, the child protection practitioner should be conscious of the possibility that the mother may be experiencing PND and be aware of symptoms that the mother may be displaying indicative of possible PND. The onset of PND occurs following recent birth of a child. In general, depressive symptoms do not vary from the symptoms of other mood disorders, however psychotic features can be present. Hence, a mental health assessment of the mother is imperative if there are concerns that she is suffering PND. When delusions are present, they often concern the newborn infant (for example, that the child is possessed by the devil, has special powers or is destined for a terrible fate). In these situations, the infant would be assessed to be at significant and immediate risk of possible harm and the removal of the infant must be considered.
Mental health assessment of a child
Infant mental health assessment
The purpose of an infant mental health assessment is to identify disorders of infancy and early childhood and to enable accurate diagnosis and early intervention for these. When considering the need for an infant mental health assessment, the child protection practitioner should be aware of possible indicators, including:
- sad, weepy infant
- lack of contact with environment
- motor retardation
- poor response to stimuli
- loss of appetite, loss of weight
- symptomatology and facial expression similar to that of depressed adults
- complete emotional deprivation
- blank starring gaze aversion
- failure to thrive
- lack of social play, lethargy
- separation or attachment problems (inability to separate or separation without reaction)
- behaviour difficulties, feeding difficulties, sleep difficulties
- developmental delays.
It should be noted that the above are only indicators of possible depression in an infant and that a number of symptoms must be present for at least two weeks. A psychiatrist or psychologist specialising in infant mental health should undertake the assessment. An infant mental health assessment should involve observations of the infant alone and the interactions with the primary caregiver, in order to develop a comprehensive understanding of the infant's emotional wellbeing. This information is useful when developing plans in the child's best interests and that relevant support services are linked with the family to ensure the child's emotional development is not compromised.
Attachment and bonding assessment
Attachment and bonding issues do not necessarily relate to whether a parent has a mental illness. However, attachment difficulties are more common amongst children of mothers displaying major depression.
An attachment and bonding assessment is useful when determining possible reunification between a infant or child and parent (particularly when the child has not been in the parent's primary care for some time), assessing whether the parent is able to respond to the infant or child's emotional needs, the parent's emotional availability to the infant or child, the parent's nurturance and empathic responsiveness to the infant or child, to understand the source of relationship disturbance between the child and parent and the type of attachment the child has with the parent. An attachment and bonding assessment will identify if concerns exist and design appropriate interventions to ensure the healthy development of the infant or child and that their best interests are met.
Mental health assessment of child
A mental health assessment of a child may be useful where the child is presenting with challenging, difficult or concerning behaviours, including:
- prolonged unhappiness
- distracted easily
- unable to finish tasks
- having problems paying attention to instructions
- talking all the time
- unable to keep still
- serious sleeping or eating problems
- suffer physical complaints due to emotional stress
- frequent outbursts of anger
- social withdrawal
- refuse to attend school
- difficulties learning or concentrating
- behavioural problems (stealing, lying, fire lighting)
- changes in personality
- distress after a traumatic experience
- excessive disobedience or aggression
- display unusual or odd behaviours (hearing voices)
- suicidal thoughts
- self-harming behaviours
- risk taking behaviours.
The assessment will identify if the child has a mental health problem, which can include depression, anxiety disorders, grief, challenging or disruptive behaviour, post-traumatic stress reactions, eating disorders, drug and alcohol abuse or a serious mental illness (psychoses, personality disorders – attention deficit disorder, conduct disorder, borderline or impulsive/explosive disorder, obsessive compulsive disorder).
In their role, the child protection practitioner may be required to conduct a preliminary suicide risk assessment of a child. The purpose of this is to determine if there is a need to make a referral to the Youth Access Team (YAT) for a crisis mental health assessment.
The mental health assessment of a child is usually conducted by the local child and adolescent mental health service (CAMHS). The information obtained from the mental health assessment will assist the child protection practitioner in articulating possible risk of harm to the child, assess the parent's ability to ensure the child's safety and emotional wellbeing, ensure the child's bests interests are met and refer the child to relevant support services for treatment.
Whilst a child cannot be forced to undergo a mental health assessment, unless they are a risk to themselves or others, the child protection practitioner has a duty of care to act in the child's best interests and strongly encourage the child to do so and develop a safety plan for the child which ensures that they do not place themselves at significant risk of harm. This may include, accessing secondary consultations with CAMHS, referring the child to an outreach service for assertive engagement or placement at a secure welfare service.
It should be noted that in certain circumstances the Secretary has the power to consent to medical examination for the purpose of determining the child's mental health condition. See Instrument of delegation and revocation for delegations for consent for medical examinations and treatment.
Considerations for good practice
There is a significant co-morbidity of mental illness and substance abuse. Adults with dual diagnosis are more difficult to treat and their treatment outcomes are poorer than adults who either have only a mental illness or only a substance abuse problem.
The child protection practitioner may need to explore the possibility that the parent may be 'self-medicating', by abusing illicit substances or abusing prescribed medication. Severe substance abuse significantly reduces the efficacy of treatment for mental illness. The practitioner needs to be aware of the impact of the parent’s substance use on their mental illness. The major implication of the research literature is that dual diagnosis is an interactive phenomenon, placing people with a mental illness at increased risk of substance abuse and substance abusers at higher risk for mental illness. People who have a serious mental illness and abuse substances are likely to have a number of distinct and related clinical problems. Treatment approaches need to address individual issues while considering possible interactions between mental illness and substance abuse.
Assessment of intoxicated persons
Alcohol and drug intoxication may influence a person’s mental state presentation and may imitate or mask symptoms of an underlying mental or physical disorder. Additionally, excessive drug or alcohol consumption may result in 'drug-induced' psychosis. The resultant lack of inhibition and the depressant effect on a person's functioning may increase the risk of harm to self and others and exacerbate the risk of suicide. The child protection practitioner should be alert that a child or parent may be intoxicated and experiencing an acute episode of a mental illness. When negotiating with the mental health service for an assessment of such a person, the practitioner needs to be aware that the provision of mental health services is not dependent on sobriety and is not restricted to situations in which there is a perceived risk of suicide. The presence of alcohol or drug intoxication does not preclude early assessment by a CATT, although it may indicate the need for further assessment when the person is no longer intoxicated.
Associated risk factors
The emerging trend of multiple risk factors in child protection cases is concerning and something that the child protection practitioner must consider. The presence of family violence, substance abuse and social isolation are often associated with parental mental illness. The child protection practitioner should explore family violence, mental illness and substance abuse issues when investigating child protection cases. Situations involving multiple risk factors increase the vulnerability of the child and it is important that risk assessment and protective intervention address each issue separately while considering how they may be interrelated.