Parental mental illness assessment tool
This parental mental illness assessment tool is a guide only. Its content and application need to be considered critically in conjunction with other literary sources, specialist consultancy and normal supervisory structures.
Parental mental illness alone need not indicate significant risk to a child. The vulnerability of a child may be reduced when the parent receives appropriate treatment, has supportive family and friends, and has access to adequate income and housing. However, if a parent’s mental illness is associated with other risk factors, such as substance abuse, family violence or social isolation, the child’s vulnerability will be increased. In situations involving multiple risk factors, it is important that risk assessment and protective intervention address each issue separately and consider how they may be interrelated.
Child or young person
Children of parents with a mental illness have an increased risk of developing some type of psychological or psychiatric disorder. This risk increases with the proportion of time the child spends interacting solely with the parent who has the mental illness, particularly if they have a discordant relationship.
- What proportion of time does the child spend interacting solely with the parent who has a mental illness?
- What proportion of time is spent interacting with the well parent and other well carers?
- What is the nature of the child’s attachment and relationship with the parent who has the mental illness? (e.g. bonding for babies and young children 0-6 years; includes openness of communication for older children and adolescents)
Risk to a child’s emotional and psychological well-being may be lessened through interaction with significant others who do not have a mental illness, and access to community supports, such as child care, and opportunities to participate in social activities, such as sports and after school programs.
- What is the nature of the child’s attachments and relationships with the well parent, siblings and extended family members? (e.g. bonding for babies and young children 0-6 years; includes openness of communication for older children and adolescents)
- What is the nature of spouse, extended family and/or social support for and supervision of the child?
A child’s needs include positive learning experiences, parental interaction and the setting of reasonable behavioural limits and control.
- To what extent is the child stimulated (physically, socially, intellectually) in their environment? (for young children and babies 0-6 years)
- What is the child’s physical care routine? Is it adequate?
- Does the child have adequate social boundaries? (i.e. consistency of structure, guidance and rule enforcement)
Adolescents who have a parent with a serious mental illness are likely to experience particular difficulties in self-identity, achieving independence from family and negotiating new relationships which allow self-responsibility. Potential problems include balancing individual needs against family responsibilities, managing entrenched parent/child role reversal, impaired self-esteem and self-concept, arrested emotional development and problems of trust and intimacy.
- What is the child’s understanding of the parent’s mental illness?
- What access does the child have to accurate and age appropriate information about the parent’s mental illness?
- What level of responsibility is taken by the child for the parent’s welfare and physical safety (e.g. concealing medications, kitchen knives, calling an ambulance)?
- What level of anxiety is experienced by the child with this role?
- Does the child display any role confusion or role reversal?
The environmental stressors encountered by children of parents with mental illness often means they require strong coping skills, yet paradoxically, these children often have weaker skills than the children of well parents.
- What are the child’s personal coping mechanisms regarding the symptoms and effects of the parent’s illness (including protective strategies or “escape routes”)?
- Are these adequate?
- What is the child’s level of resilience and competence?
- Does the child have any emotional/psychological problems? (e.g. sadness, depression, withdrawal, unresolved anger, self harming/suicidal behaviours)
- Does the child have any behavioural problems? (e.g. offending)
- Has appropriate expert opinion been sought by the protective worker? (i.e. paediatric developmental assessment)
Well parent or other carers
Strengthening and maintaining a child’s family connections is critical in any family situation. Where a parent has a mental illness, the primary client for child protection and, the first priority for intervention is the child. Therefore, where a well parent, grandparent or other well family member is critically involved in the care and protection of a child, a thorough assessment of their capacity to fulfil this role is required.
- What is the nature of their awareness and insight into the mental illness and treatment of the affected parent?
- Do they acknowledge the potential issues for the child?
- How is the well parent’s/carer’s general physical and psychological health?
- Are they physically available to provide direct supervision of the child?
- Are they prepared to seek assistance when required? Has this been demonstrated?
- How does the well parent cope with the affected parent’s illness?
Positive interaction, role modelling, and the opportunity to build social skills and self esteem are essential for a child to minimise potential developmental impairment linked to a parent’s mental illness. Even in a situation assessed as low risk for the child, mobilisation of comprehensive community based supports should be considered, particularly where secrecy and isolation from a family network exists.
- What is the child’s access to/contact with supportive, well adults and peers - extended family members, friends or positive support figures in their community?
- Is supportive counselling available/indicated?
Parent with mental illness
The impact of parental mental illness on a child’s development is related most directly to the ways in which the child is involved in the parent’s symptomatology, the modes of social interaction which the parent establishes and maintains with the child, and the quality of alternative child care and other supports available to the child and the family.
Is one parent, or are both parents, mentally ill? For each ill parent:
- Infants of a parent(s) with a mental illness are in one of the highest risk categories in relation to child abuse and neglect where the parent(s) have a dual diagnosis of mental illness and substance abuse.
- Parents with a dual diagnosis respond less well to treatment for either problem.
- Is substance abuse by the affected parent present?
Family violence is frequently associated with substance abuse, and may be the primary and most serious risk to a child’s physical and emotional safety.
- Is family violence perpetrated by the affected parent present?
Severe risk may be indicated where a parent experiences command hallucinations to harm a child. Babies and young children may be at extreme risk in these circumstances.
- Is the parent hallucinating or delusional? Is the child implicated directly in the parent’s hallucinations or delusional system?
Assessment of the parenting capacity of a parent with mental illness should not focus solely on psychiatric assessment, but should be linked to protective concerns. Critical information regarding a parent’s mental illness, history and treatment should be obtained, in the first instance, in a cooperative manner. A parent’s mental illness and protective concerns in relation to this should be discussed with the parent in a direct, open and sensitive manner.
- What is the history of the mental illness (e.g. age at onset, duration) with relevance to stage of family?
- What diagnosis, if any, has been confirmed? What is the prognosis?
- What is the nature, severity and current phase of the illness? (i.e. acute or chronic, transience or persistence over time, temporary or prolonged current phase, trigger/s if known)
- What are the specific symptoms and their impact on daily functioning and capacity to parent? (e.g. global impairment such as grossly disorganised behaviour associated with difficulty preparing meals, maintaining hygiene, dressing appropriately; and/or specific parenting capacities such as responsiveness, judgement, passivity, tolerance thresholds for stress and anxiety, anger management)
Issues of treatment compliance or refusal should be discussed with the treating practitioner, the parent with the mental illness and their spouse directly.
A parent’s non-compliance should not automatically be interpreted as irrational and symptomatic of mental illness. It is possible that there are practical problems associated with the treatment regime as well as legitimate health concerns.
- What is the history of treatment with relevance to impacts on the child? (e.g. sudden, frequent or prolonged separations from the parent)
- What treatment (nature and frequency) is currently available to/being received by the parent for the mental illness?
- Are there any unwanted side effects from medication? (e.g. sedation, drowsiness, dis-inhibition, flattened responsiveness or passivity, craving for sleep, impairment of judgement)
- What is the parent’s level of compliance with treatment?
- What is the parent’s level of awareness of their illness; capacity to comprehend implications for the safety and wellbeing of their child, and to accept and adhere to protective planning decisions?
It is important that workers do not allow the motivations, good intentions and needs of parents to divert attention from the risk of harm to a child. Particularly in the cases of infants and young children, it is vital that the focus of the risk assessment does not drift towards practical issues or parental needs.
- What are the parent’s beliefs about parenting? Are they rational?
- Is the mother disinterested in the baby or resentful towards it? (for post-partum mothers)
- Is the mother attending post natal services? (for post-partum mothers)
- What is the nature of the parent’s emotional availability and sensitivity to the infant? (including positive or negative affect; consistency; responsiveness; communication and interactions with the child)
- Does the parent have recurrent thoughts of death and suicidal ideas, plans or attempts? Do the suicidal thoughts, ideas and/or plans include their child?
Research indicates that the vulnerability of a child is strongly linked to the degree of family discord and psychological adversity within the family environment.
- What is the nature of the relationship between the affected parent and their partner?
- What is the impact of the parent’s mental illness on the marital relationship, decision making processes and child rearing practices within the family?
- How does the affected parent cope with their illness?
Psychiatric assessment for the purposes of risk assessment and protective planning should include:
- diagnostic status
- triggers to deterioration
- possible side effects of treatment (e.g. drowsiness, passivity)
- prognosis with full treatment cooperation
- prognosis with no treatment or compromised treatment
- possible impact on ability to deal with stress
- general daily functioning
- ability to care for children
- degree of irrationality
- likelihood of violent behaviour.
Has appropriate expert opinion been sought by the child protection practitioner?