Joint Working Practice Guidance

Safeguarding children and young people whose parents/carers’

parenting capacity is impacted by mental health, substance misuse,

learning disability and domestic abuse

January 2017

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“Safeguarding children is everybody’s business” Lord Laming

This multi-agency guidance has been written for any professional working with adults whose complex problems might impact on their ability to care for children and for those working with children whose parents or carers have complex problems.

It gives information about research and guidance for good practice and also specific advice depending on the particular needs within the family.

Whilst professionals should adhere to this guidance if their concerns are about immediate neglect or harm to a child, whether emotional, physical or sexual the London Safeguarding Children Board procedures should be followed without delay http://www.londoncp.co.uk/index.html

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ContentsKey Messages 5

Part 1 Introduction 71.1 Purpose 71.2 Scope 71.3 Background 7

1.3.1 Key principles 71.4 Whole family working 81.5 Equalities 81.6 Confidentiality and sharing information 91.7 Partnership working 101.8 Commitment from services 10

1.8.1 Children’s Social care 101.8.2 Services working with adults 111.8.3 Services working with children 111.8.4 Working with parents and families 11

1.9 Case management 121.10 Planning meetings 12

1.10.1 Team around the family meetings 121.10.2 Other planning meetings 121.10.3 Child in need meetings 121.10.4 Child protection conferences 131.10.5 Parents and family attendance at meetings 13

1.11 Supervision 131.12 Training 13

Part 2 General guidance 142.1 Risk 142.2 Psychosis 142.3 Young carers 152.4 Parental treatment – effects on children 152.5 Psychological or emotional distress 16

2.5.2 Domestic abuse 162.5.3 Parents who kill their children 17

Part 3 Specific/additional guidance: mental health 183.1 Definition 183.2 Implications for and effects on parenting 183.3 Prenatal and postnatal period 19

Part 4 Specific/additional guidance: substance misuse 214.1 Definition 214.2 Guidance 214.3 Implications for and effects on parenting 224.4 Pregnant women who misuse drugs and/or alcohol 22

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Part 5 Specific/additional guidance: learning disability 245.1 Definition 245.2 Guidance 245.3 Implications for and effects on parenting 245.4 Prenatal and postnatal period 25

Appendix A Summary of potential impact on child of primary and secondary behaviours associated with parental mental ill health

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Appendix B Mini toolkit – working with parents with mental ill health 27Appendix C Summary of potential impact of parental drug misuse 29Appendix D Summary of potential impact of parental alcohol misuse 30Appendix E Summary of protective factors in relation to parental

substance misuse32

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Key messagesThis practice guidance has been written for any professional working with parents or adults with caring responsibility for children whose complex problems might impact on their ability to care for children and for those working with children whose parents or carers have complex problems.

If concerns are about immediate neglect or harm to a child, whether emotional, physical or sexual the London Safeguarding Children Board procedures should be followed without delay http://www.londoncp.co.uk/index.html.

Practitioners working with adults should identify and record at an early stage details of:

The adult’s relationship with any child Parenting/caring responsibilities Family structure, relationships and dynamics Which other agencies they need to work with if they have concerns about

unborn babies, children or young people

Practitioners should discuss concerns with the family and seek their agreement to making referrals to services for children and families unless this places a child at increased risk of significant harm. The best interests of the child must be the overriding factor in such decisions.

The data protection law should not be used as a barrier to appropriate information sharing between professionals to protect children or adults from harm.

Mental health, substance misuse problems and/or learning disability can increase the risk of harm to children, especially when combined with domestic abuse or other violent crime.

If a service user expresses delusional beliefs involving their child and/or they may harm the child as part of a suicide plan, a referral to Children’s Social Care must be made immediately.

It is important that if a practitioner thinks that a person and/or a child may be at risk due to an untreated psychosis they alert the GP or psychiatric liaison to arrange mental health assessment.

Other triggers such as pregnancy, separation, divorce, bereavement, incarceration, changes in family structure and relationships as well as discharge from prison and financial difficulties may cause emotional distress and are associated with increased risks to the whole family. Any changes in family circumstances should trigger a re-assessment of risk to children.

Stereotypes and prejudices which exist about adults who use drugs/alcohol or have a mental health need or learning disability must not influence assessments.

Supervision, guidance and support from someone with knowledge of safeguarding is essential for people working with adults who are in contact with children.

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Young carers need to be identified to ensure an assessment is carried out as this can have detrimental effects on young people’s education, health and emotional well-being.

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1. Part 1: IntroductionFor the purpose of this guidance, ‘parents/carers’ includes anyone who has access to the child, for example, members of the extended family and friends or acquaintances. The parent or carer may not live with the child.

The term ‘children’ refers to those aged 0-18 years of age. The needs of unborn babies must also be considered and this guidance should be read in conjunction with Croydon’s Pre-birth Protocol.

1.1Purpose1.1.1 To safeguard and promote the welfare of unborn babies, children and young

people, including young carers, whose lives are affected by parents/carers using drugs/alcohol or by parents/carers with mental health problems, learning disabilities, or other complex needs such as experiencing domestic abuse that may adversely affect their ability to parents or care.To promote effective communication between adult substance misuse services, mental health services, learning disability services, primary health care, children’s early help services, educational settings, domestic abuse services, Children’s Social Care other services involved with the family.To set out good guidance for the professionals and services involved to enable working together in the assessment and care planning for families with problematic substance misuse, mental health, learning disability or other complex needs and to ensure their full participation in the process wherever possible.

1.2Scope1.2.1 These guidelines have been written for use by the many statutory, non-

statutory, voluntary, independent sector and primary care services working with parents/carers who may have a mental health need, a learning disability, drug/alcohol issues or other complex problems including domestic abuse. All services represented on Croydon’s Safeguarding Children’s Board will be expected to know of this guidance and be able to recognise when it should be used.

1.2.2 All practitioners are expected to refer to this guidance when they come in to contact with either an adult with mental health, learning disability, drug/alcohol issues or other complex problems who is caring for or has significant contact with a child; or a child whose life is affected by parents/carers who may have mental health, learning disability, drug/alcohol issues or other complex problems.

1.3Background1.3.1 Key principles1.3.1.1 Local authorities have specific duties under the Children Act 1989 in

respect of children in need (Section 17) and children at risk of significant harm (Section 47). Those working in all health, social care and voluntary settings with adults and children where parental substance misuse, mental health needs and learning disability are an issue have a responsibility to safeguard

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children when they become aware of a child at risk of harm, following the LSCB procedures which are based on Working Together to Safeguard Children 2015.

1.3.1.2 Working Together 2015 states that Children’s Social Care is the lead agency with responsibility for the safety and welfare of children but is clear that everyone who comes in to contact with children and their families also has clear safeguarding responsibilities

1.3.1.3 All agencies involved in the care of such adults or children are expected to work closely together, share information and thoroughly assess to promote the welfare of a child and to protect a child from significant harm.

1.4Whole family working 1.4.1 Services for both adults and children need to work in partnership to meet the

needs of the family.1.4.2 Parenting at any stage, from pregnancy to when the child becomes an adult,

can be a challenge for any parent or carer, requiring a great deal of physical and emotional effort. Most parents and carers have the capability to provide good or good enough care for their children most of the times and are able to access universal services to support their health, education and social needs. Sometimes a usually capable parent will have such overwhelming needs of their own that they may not have the capacity to be such a capable parent. If this is very short term then providing their physical and safety needs are met, most children have the resilience to overcome the stress of this with the support of their friends and family. If the parent’s needs are chronic or enduring there may be a need for intervention to ensure the child’s needs are met and any risks addressed.

1.4.3 Universal services such as health, housing and education have a key role in identifying children and adults with additional needs and signposting or referring families to specialist or other universal services. Staff in specialist adult services dealing with vulnerable parents should be alert to the needs of children and young people, considering who they need to work with to help identify or meet their needs. All agencies working with children, young people and their families are potentially involved in providing early prevention and/or intervention work in safeguarding children and their families.

1.5Equalities1.5.1 This guidance applies in all situations irrespective of the race, gender, age,

sexual orientation, class, cultural and religious beliefs or disability of those involved.

1.5.2 In order to make sensitive and informed professional judgments about a child’s needs and the capacity of parents/carers to respond to those needs, professionals should be sensitive to differing family patterns, lifestyles and child-rearing practices. However all professionals must be clear that child abuse or neglect, caused deliberately or otherwise, cannot be condoned or dismissed on religious or cultural grounds.

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1.5.3 All professionals should be aware of stereotypes and prejudices which exist about adults who use drugs/alcohol or have mental health needs or a learning disability. It is essential that these do not influence assessments. Any assessment should be thorough, based on observation of and discussion with the parents and children involved and should be undertaken jointly or in liaison with relevant specialist workers whose views should be taken in to account.

1.6Confidentiality and sharing information1.6.1 “Whilst the law rightly seeks to preserve individuals’ privacy and

confidentiality, it should not be used (and was never intended) as a barrier to appropriate information sharing between professionals. The safety and welfare of children is of paramount importance, and agencies may lawfully share confidential information about the child or the parent, without consent, if doing so is in the public interest. A public interest can arise in a wide range of circumstances, including the protection of children from harm, and the promotion of child welfare. Even where the sharing of confidential medical information is considered inappropriate, it may be proportionate for the clinician to share the fact that they have concerns about a child.” The Protection of Children in England: a Progress Report; The Lord Laming; 2009.

1.6.2 It is critical that all practitioners working with children and suspect that a child may be suffering or at risk of suffering significant harm, they must refer their concerns to Children’s Social Care. While a practitioner’s primary relationship may be with the parent where there is a cause for concerns information needs to be shared.

1.6.3 Practitioners should seek to discuss any concerns with the family and where possible, seek their consent to making referrals to other services or Children’s Social Care. Referrals can be made in the absence of consent if the practitioner feels acquiring consent may increase risk of significant harm to the child. The child’s interest must be the overriding consideration in making any such decisions.

1.6.4 However where a child is not suffering or at risk of suffering significant harm parental consent is needed to be able to share information. This should be raised with parents at the beginning of professional involvement following the agency’s guidelines. In general information sharing is in the best interests of the person and supports delivery of effective support and intervention.

Where the threshold is not met for a referral to Children’s Social Care consideration should be given to an early help approach where there is parental consent (see early help pathways guidance for further information https://www.practitionerspacecroydon.co.uk/wp-content/uploads/2014/05/Proof-E-140067-Early-help-guide-spreads.pdf).

1.6.5 Everyone should ensure that the information shared is proportionate and necessary and is only shared with those people who need to have it. The information must also be accurate and up to date and shared securely. If in doubt seek advice; this may be done without disclosing the identity of the

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person. Consent or the refusal to give consent to information sharing about children should always be recorded.

1.7Partnership working1.7.1 Safeguarding and promoting the welfare of children and protecting them from

significant harm is dependent on effective joint working.1.7.2 Sharing information is essential to enable early identification to help children

and their families who need additional services to achieve positive outcomes. See ‘What to do if you’re worried a child is being abused’ – a guide for practitioners 2015.

1.7.3 Think Family: multi agency approach identifies the need to take into account the combined needs of the family. Focus on Early Help and continuing care, beyond crises. Social Care Institute for Excellence report 2009 (updated 2011) outlines the following guidance:

o Promote resilience and the wellbeing of all family members, now and in the future. Building on the family’s strengths:

offer appropriate support to avoid crises and will manage them well if they rise. Providing support beyond crisis;

secure child safety; reassure parents that identifying a need for support is a way of

avoiding rather than precipitating child protection measures; develop care plans that aim to increase resilience, in particular

by increasing every family member’s understanding of the parent’s mental health problem;

a thorough understanding of the developmental needs of children, the factors that impact parenting capacity, the impact of parental mental health problems on children, and the impact of parenting on a parent’s mental health;

take account of the whole family and their individual and collective needs

1.7.4 Systems should be in place to ensure thato Managers working with adults can monitor those cases which involve

dependent childreno There is regular, formal and recorded discussion about such cases with

Children’s Social Care staffo Professionals working with the child, family or adult communicate and

agree interventionso Appropriate staff are invited to relevant planning meetings

1.8Commitment from services1.8.1 Children’s Social Care 1.8.1.1 Children’s Social care will receive and record any contacts expressing

concerns about risk to children. They will be clear with other agencies about their threshold for involvement and give feedback on what will happen as a result of the contact. Children’s Social Care are able to having discussions with other services regarding their concerns prior to a referral being made if required.

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1.8.1.2 All contacts about concerns will be recorded and in the event of subsequent contacts being received will contribute to the decision making about the referral and further intervention.

1.8.1.3 Children’s Social Care willo Assess the unborn or child’s needs and identify desired outcomes for

the childo Ensure the wishes and feelings of the child are ascertained and taken

in to accounto See the child alone where appropriateo Liaise with the appropriate adult services (e.g. the drug and alcohol

service)o Invite professionals from adult services to Child in Need Meetings and

Child Protection Conferences and support them to contribute to the information sharing, planning and intervention

1.8.2 Services working with adults 1.8.2.1 Services and practitioners working with adults will

o Identify at an early stage any children within the adult’s family especially where they have a caring responsibility and record on their client record system

o Ensure when assessing the adult’s needs they take in to account any support needed with their caring role of children

o Retain a family focuso Recognise that parental mental ill-health, learning disability or

substance misuse especially where domestic abuse is also a factor may increase the likelihood that a child may be at risk of being physically or emotionally harmed

o Invite professionals working with the adult’s family to relevant care planning meetings ideally with the agreement of the service user

o Attend meetings about any children linked to the service user and contribute to the information sharing, planning and intervention

1.8.3 Services working with children 1.8.3.1 Professionals working with children will

o Undertake or contribute to early help assessmentso Convene or attend team around the family meetingso Contribute to children and family assessments completed by Children’s

Social Careo Attend Child in Need Meetings and Child Protection Conferences and

contribute to the information sharing, planning and intervention1.8.4 Working with parents and families 1.8.4.1 Unless it places the child at increased risk it is important to engage with

and involve families to reduce risk of harm. 1.8.4.2 If it there is a change of circumstances or the adult is not engaging with

services and this raises concerns about the child’s welfare or safety a referral should be made to Children’s Social Care. These concerns may include:

o Failure to attend for appointments

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o Failure to allow for home visitso Avoidance of practitionerso Homelessness of family o Network breakdown o Deterioration in mental health, physical health, more chaotic substance

misuseo Introduction of a new adult or child in to the home situationo Change of circumstance which may impact on risk or resilienceo Concerns about domestic abuse or relationship difficultieso Economic crises

1.9Case management 1.9.1 Effective inter-agency communication and multi-agency cooperation is crucial

to the management of on-going work with adults with mental health needs, a learning disability, substance misuse or other complex needs including domestic abuse and their families. There must be clarity about the different roles and responsibilities undertaken by different workers and a decision made regarding coordination.

1.9.2 Practitioners in adult and children’s services are expected to share expertise in completing assessments or for specific pieces of work.

1.9.3 Where a child is subject of a child protection plan or is identified as a child in need adults’ and children’s services must maintain a continuous dialogue and the involved professionals should participate in the meetings outlined below.

1.10 Planning meetings1.10.1 Team around the family meetings 1.10.1.1 These meetings are convened about a child and their family where an

early help assessment has identified a need for a multi-agency plan but the threshold for intervention by Children’s Social Care has not yet been met. It brings together services to meet the identified needs and enable information sharing and multi-agency contribution to planning and intervention.

1.10.2 Other planning meetings 1.10.2.1 Practitioners should be aware of any other protection plans or meetings

concerning the family including MAPPA, MARAC, CPA and other multi-professional planning meetings and be involved in these processes as appropriate.

1.10.3 Child in Need Meetings 1.10.3.1 Where Children’s Social Care is working with a child and their family

under Section 17 of the Children Act 1989 the social worker will complete a child and family assessment and will then convene a multi-professional meeting to formulate a child in need plan. These meetings will be held regular to continue to review the plan and share new information.

1.10.4 Core Group Meetings 1.10.4.1 When a child is subject of a child protection plan the key professionals

working with the child, family or adult will attend Core Group Meetings to

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review the plan and share new information. The first one is held within two weeks of the Initial Child Protection Conference and then every six weeks.

1.10.5 Child Protection Conferences 1.10.6 Child Protection Conferences will be conducted in line with the London Child

Protection Procedures. It is expected that representatives from the appropriate agencies will attend and provide a written report. They may also be required to attend the Core Group Meetings.

1.10.7 Parents and family attendance at meetings 1.10.7.1 Parents and where appropriate children should be encouraged to

attend all meetings although they may be excluded if there are concerns about their presentation or behaviour.

1.10.7.2 They may bring an advocate or someone to support them. It may also be appropriate for one of the professionals attending the meeting to also support the adult or child.

1.11 Supervision1.11.1 Supervision, guidance and support from someone with knowledge of

safeguarding is essential for people working with children, families or parents where there may be concerns that a child may be at risk of harm or neglect. Issues may be raised in formal structured supervision or unplanned discussions.

1.11.2 It is crucial that all agencies establish a clear framework for supervision guidance and support. Those supervising staff working with adults should always ask about the care of the child and those managing child care cases should always ask about collaboration with adult workers if there are concerns about parental substance misuse, mental health needs, learning disability or domestic abuse.

1.11.3 Staff should also be aware of who their agency’s lead for safeguarding is so they can also access support and guidance from them. Staff in Children’s Social Care should also be aware of the expert practitioners for parental mental health and substance use and for domestic abuse.

1.12 Training1.12.1 All staff working with children, families or adults should receive child

safeguarding training. All staff working with children, families or adults should also receive training on mental health needs, substance misuse, learning disability and domestic abuse. There should be awareness raising regarding this guidance across all agencies. This training and awareness raising should be multi-agency where possible.

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2 Part 2: General Guidance

2.1Risk2.1.1 The needs and issues facing some parents and carers are known to be

associated with greater risks to both them and their child. This may relate to particular health or social behaviours of the adult or the danger to their physical health or well-being. This may be made worse by the social stigma attached to the problem of the parent or carer or by professionals being as overwhelmed as the parent/carer is by the complexity of dealing with the problems that they face.

2.1.2 The risks particularly associated with mental health, substance misuse, learning disability and domestic abuse are referenced to within their specific sections further in the guidance. The risks for the child and parent are known to increase considerably when these factors combine with each other or with domestic abuse or other violent crime.

2.1.3 Assessing these risks is important and requires the practitioner not only to rely upon any standard risk assessment used in their particular field but to think broadly about risks to others and how these may be lessened through joint working.

2.1.4 Family members and other children living with a person with complex needs may be assessed as being a protective factor for a child. Whilst their opinion of risk is important, practitioners must assess the risk independently as the family member may not be objective about their circumstances.

2.1.5 “Risk management cannot eradicate risk; it can only try to reduce the probability of harm”. (The Munro Review of Child Protection; DoE; 2010)

2.1.6 The parents or carers of most children who are seriously harmed or killed are not involved with specialist mental health, drug and alcohol or probation services. They are much more likely to be receiving help and support through universal services

2.1.7 The circumstances of people’s lives and health can change frequently meaning that the stresses and risks both for individuals and the family also change and need frequent holistic reassessment.

2.2Psychosis2.2.1 A number of Serious Case Reviews have highlighted the risk parents, carers

or members of the household with psychosis may pose to the children, in rare cases leading to filicide. It is believed this could be prevented by good mental health care which detects relapse earlier. An adult with psychosis can lead to emotional stresses in a family, which may have a negative effect on children in the family home.

2.2.2 Staff from any agency may encounter people with psychosis.They may be experiencing:

o Hallucinations – where people see, hear, smell, taste and feel things that are not there

o Delusions – where people have fixed false irrational belief; this may be paranoid, believing others may wish to harm them or their family

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o Thought disorder – where people speak quickly and incessantly or switch topic mid sentence or make irrational statements.

Early signs of psychosis may include:o Odd or bizarre behaviourso Severe deterioration of social relationships, social withdrawal or

isolationo Inappropriate laughter, unexpected euphoric mood, feelings of

depression or anxiety.2.2.3 Psychosis is a symptom of a variety of conditions, which can include mental

illnesses such as schizophrenia or bipolar disorder. Symptoms may also be associated with substance misuse and sometimes physical conditions such as Parkinson’s disease. The severity and duration of psychosis is variable.

2.2.4 If any practitioner believes that the person may be suffering from a delusion involving children, which includes non-abusive thoughts or psychotic experiences (e.g. hallucinations) they must make a referral to Children’s Social Care.

2.2.5 If a practitioner thinks that a parent or child may be at risk from an untreated psychosis they should alert the GP so a mental health assessment can be undertaken even if the person is unwilling or unable to seek help themselves.

2.3Young carers2.3.1 A young carer can be vulnerable when the level of care-giving and

responsibility to the person in need become excessive or inappropriate for the child. This can have an impact on their emotional or physical well-being or educational achievement and life chances.

2.3.2 Young carers are entitled to an assessment of their needs separate from the needs of the person for whom they are caring.

2.3.3 Identification of young carers can be problematic. Many children live with family members with stigmatised conditions. In many cases families are worried about what action professionals may take and may also have concerns about being assessed under children’s legislation.

2.3.4 Services for young carers should adopt a whole family approach. Children’s and adults’ services must therefore have appropriate arrangements in place to support these children and ensure good joint working to ensure better outcomes for children.

2.3.5 The assessment and support plan should consider the needs of the person in need of care, the child who is caring and the family.

2.4Parental treatment – effects on children2.4.1 Consideration of the needs of parents in relation to access to treatment e.g.

for their substance misuse or mental health problems, should be seen in the wider context of the effect on the whole family. Whilst accessing treatment is a positive step for the parents it may have a negative impact on children; for a child it may mean taking on more caring responsibility for their parent or be separated from their parent.

2.4.2 Workers therefore need to consider

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o Does the parent need childcare support to access treatment?o What care arrangements need to be in place for the parent to access

hospital, a detox/rehab unit or home detox?o Who is offering the child support?o Does the adult’s crisis or contingency plan include a plan for the care of

the childo Will the parents need support getting the child to and from

nursery/school?o Do they need to liaise with the nursery, school or early help services?o What is the child’s understanding of the parent’s condition/treatment?o Is a referral needed to young carer services?o Is the child at risk of harm and is a referral needed to Children’s Social

Care?o Is the child likely to be cared for by someone outside their immediate

family for more than 28 days? If so has a referral for a private fostering assessment been made to Children’s Social Care?

2.4.3 Staff should also be aware that successful treatment of parents, allowing them to resume their caring responsibilities might mean a loss for the child of the role they had previously undertaken or a change in the dynamics of the relationship between the child and parent which may have an adverse effect on the child.

2.5Psychological or emotional distress2.5.1 In addition to mental health, substance misuse and learning disability, the

following situations which may case psychological or emotional distress are associated with increased risks to the whole family and for most will require support from friends, family and possibly services:

o Transitions and unexpected life eventso Social isolationo Hate crimeo Pregnancy (a common trigger for the start of or escalation of domestic

abuse)o Financial and/or housing difficulties.

2.5.2 Domestic abuse

Domestic abuse is defined as threatening behaviour or abuse (psychological, physical, sexual, financial or emotional) between adults who are having or have been intimate partners or family members regardless of gender or sexuality. The cross-government definition of domestic violence and abuse is: any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to: psychological, physical, sexual, financial and emotional. This also includes issues of concern such as honour based violence, female genital mutilation and forced marriage. Domestic abuse frequently co-exists with child abuse. The main

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characteristic of domestic abuse is that the behaviour is intentional and is calculated to exercise power and control within a relationship.

2.5.2.1 Domestic abuse rarely exists in isolation and may contribute to drug or alcohol misuse and poor physical and mental health. Parents may also have a history of poor childhood experiences themselves. Domestic abuse compounds the difficulties parents experience in meeting the needs of their children and even if there is no physical violence it has been shown to have a serious negative impact on children at each stage of their development leading to health, behavioural, educational and social difficulties.

2.5.2.2 The presence of domestic abuse in a family increases the likelihood that children will experience abuse and/or neglect. The risk of physical harm to both the victim and children increases around the time of separation and may continue as subsequent contact arrangements are made.

For detailed guidance see the relevant section in the London safeguarding procedures and local strategy (Croydon Domestic Abuse & Sexual Violence Strategy 2015-2018)

2.5.3 Parents who kill their children 2.5.3.1 Parents who kill or seriously harm their child are not always known to

services. 2.5.3.2 Men are more likely to kill their child than women. The additional risk

factors may relate to:o Having a history of violent behaviour and/or known to have committed

a violent crimeo Being a perpetrator of domestic abuseo Undergoing or there being a threat of separationo Being emotional distressed and having difficulties that bring feelings of

loss, shame or hopelessness.2.5.3.3 The killing of children is often linked to the mother of the children being

killed at the same time2.5.3.4 Although such murders are often unpredictable many are thought to be

pre-meditated. It is therefore important to offer additional support to fathers, recognising the importance of their role within the family.

2.5.3.5 There is a higher proportion of infanticide by females after the time of the baby’s birth. This appears related to puerperal psychosis or the mother being unable to face the reality of being pregnant or a mother.

2.5.3.6 Most of the Serious Case Reviews related to these issues identified that there needed to a better understanding of the child and the family, including fathers and extended family and needed to consider the history. This information needs to be considered in relation to the family’s cultural and religious background and relevant research.

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3 Part 3: Specific/additional guidance: mental health

3.1Definition3.1.1 This guidance refers to people with mental health needs, from mild and

moderate to severe and enduring mental ill health. This includes eating disorders and personality disorders. It is important that all workers should be aware that the term ‘mental health needs’ covers a range of illnesses some requiring a brief intervention by primary care while others require referral to specialist mental health services.For the purpose of safeguarding children the mental health or mental illness of the parent or carer should be considered in the context of the impact of the illness on the care provided to the child.

3.1.2 World Health Organisation Definition of Mental Health: Mental health refers to a broad array of activities directly or indirectly related to the mental well-being component included in the WHO's definition of health: "A state of complete physical, mental and social well-being, and not merely the absence of disease". It is related to the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders. (WHO 2012)

3.2Implications for and effects on parenting3.2.1 Research indicates that 10-15% of children in the UK live with a parent who

has a mental disorder and about 30% of those are cared for by a lone parents with a mental disorder.

3.2.2 Estimates suggest that between 50% and 66% of parents with a severe and enduring mental illness live with one or more children under 18. That amounts to about 17,000 children and young people in the UK.

3.2.3 “Most parents with mental illness so not abuse their children and most adults who abuse children are not mentally ill.” However there are well-established links between parental mental disorder and poor outcomes for children (Parents as patients: supporting the needs of patients who are parents and their children; CR 164, January 2011).

3.2.4 Whilst it is recognised that many parents with mental illness and their children can be very resilient it can also mean adverse outcomes for children. Mental health professionals must therefore consider the family context of the service user and take in to account the well-being and safety of any children. This will involve working with other agencies, sharing information and remembering that the child’s needs are paramount even when the necessary safeguarding action may adversely affect the adult.

3.2.5 All parents find parenting challenging at times and being a parent with a mental health need can be additionally challenging. Many parents are aware their disorder impacts on their child to some extent.

3.2.6 Any assessment should consider the possible or actual impact of the adult’s mental health on parenting, the parent/child relationship and on the child’s care, behaviour and development. The impact of parenting may also affect their mental health.

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3.2.7 Parental personality factors (pre-existing and/or exacerbated by the illness) may mean parents have difficulty controlling their emotions, have an inability to cope or be self-pre-occupied. Violent, irrational and withdrawn behaviour can frighten children.

3.2.8 An adult with mental health needs’ parenting capacity may not be the only factor impacting on the child’s outcomes. Factors such as poor housing, financial difficulties, domestic abuse and isolation may be a significant factor in parental stress and illness.

3.2.9 Fear of being stigmatised and of their child being removed from their care has been described by parents as a reason for not seeking help for mental health needs or for not engaging. Children may also share these fears and the family may therefore struggle with a high level of stress until there is a crisis situation.

3.2.10 All children including very young children can be affected by their parent’s state of mind. This can be helped if the parent is aware of this as they are more receptive to their child’s needs for support and there is help for the child to understand and be supported.

3.2.11 Strengths in the family such as the ameliorating effects of another adult can also minimise the effects on the child.

3.2.12 Identifying the impact of the stresses on the child and the parents/carer’s needs are important elements of the assessment of the child and their family and in the development of an appropriate care plan. This reinforces the need to see mental health needs of parents/carers in the context of family life and functioning.

3.2.13 To safeguard children of parents with whom they are working mental health practitioners should routinely record details of parents’ responsibilities in relation to children and consider the support needs of parents and of their children in all aspects of their work. This should include consideration of whether the adult is likely to resume contact with a child from whom they have been separated.

3.2.14 In cases where service users express delusional beliefs involving their child and/or may harm their child as part of a suicide plan a referral must be made immediately to Children’s Social care. The referral must include information about the following where known:

o Does the service user live with any children?o Do they have contact with children in their working or social networko If there is no current contact with children will it occur in the futureo In secondary care a consultant paediatrician should be directly involved

in clinical decisions if the service user may pose a risk to children

3.3Prenatal and postnatal period3.3.1 Specific concerns apply to the pre- and post-natal periods. It is vital that there

is joint working between the general practice, midwifery, health visiting and if appropriate mental health services. It is essential to identify needs, assess and prepare safeguarding plans for both mother and child.

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3.3.2 Post-natal depression is very common among new parents and may affect as many as 1 in 6 new mothers, typically in the first three months after birth. It can last for up to a year if left untreated. Maternal post-natal depression can be significantly harmful to young babies particularly from birth to 12 month of age with increased evidence of insecure attachment. It is not the depression itself which causes damage but the impact on the mother’s ability to interact with and respond to her child. Prolonged non-availability of the primary carer can lead to emotional and cognitive difficulties, social withdrawal, negativity and distress.

3.3.3 Puerperal Psychosis is a disorder which affects 1-2 women per 1000. It is potentially a very serious illness often requiring hospitalisation. The onset can be very rapid within hours of birth although it often develops over days sometimes weeks. Women with an existing diagnosis of bi-polar disorder or who have a close family member with this are at significantly greater risk and should be referred to a perinatal mental health service during pregnancy to agree a post delivery management plan.

3.3.4 Workers need to be aware of and follow the National Institute for Excellence (NICE) Antenatal and Postnatal Mental Health pathway ( Dec 2014).This pathway makes recommendations for the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth) and in women who are planning a pregnancy. The pathway covers depression, anxiety disorders, eating disorders, drug and alcohol-use disorders and severe mental illness (such as psychosis, bipolar disorder, schizophrenia and severe depression). It covers sub threshold symptoms as well as mild, moderate and severe mental health problems.

3.3.5 In order to ensure early identification of mental health needs professionals should ask every expectant mother if they have during the previous month experienced feeling down, depressed or hopeless or have had little interest or pleasure in doing things.

3.3.6 It is important that staff recognise the resistance and barriers to raising concerns with Children’s Social Care so that they can effectively deal with them. These include:

o Fear of losing a positive working relationship with the adulto Divided duties to the adult and child and breaching confidentialityo Discomfort of disbelieving, thinking ill of, suspecting or wrongly blaming

a parent or carero An understanding of the reasons why the maltreatment might have

occurred, and there was no intention to harm the child. Therefore worrying he parented will be ‘blamed’

o Losing control over the child protection process and doubts about its benefits

o Stresso Personal safetyo Fear of complaints

(NICE guidelines; When to suspect maltreatment; 2009)

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4 Part 4: Specific/additional guidance: substance misuse

4.1Definition4.1.1 When referring to substance misuse this guidance will apply to the misuse of

alcohol as well as ‘problem drug use’, defined by the Advisory Council on the Misuse of drugs as drug use which has: ‘serious negative consequences of a physical, psychological, social and interpersonal, financial or legal nature for users and those around them’.

4.1.2 ‘Substance’ is used to refer to any psychotropic substance (capable of affecting the mind – changing the way we feel, think and/or behave) including:

o Alcoholo Tobaccoo Drugs sold as ‘legal highs’o Illegal drugso Illicit use of prescription drugso Volatile substances such as solvents (gases, lighter and other fuel)o Some plants and fungi (magic mushrooms)o Over-the-counter and prescribed medicines that are used for

recreational rather than medical purpose.4.1.3 It is important that all workers should be aware that the term ‘substance

misuse’ covers a range of usage, from minor recreational through to more serious use and physical addiction. In common usage then, not ‘substance misuse’ by parents leads to risk of significant harm to their children but may be indicative of potential risk. All cases should be assessed on their individual circumstances.

4.1.4 Substance use/misuse by parents/carers does not on its own automatically mean that children are at risk of abuse or neglect but it must be recognised that children of problematic substance users are a high-risk group. These parents/carers may also experience other problems including homelessness, accommodation or financial difficulties, difficult or damaging relationships, lack of effective social and support systems, issues relating to criminal activities and poor physical and/or mental health.

4.1.5 Parents or carers who experience domestic abuse my use substances as a coping mechanism. Substance misuse may cause or exacerbate abuse within a relationship. Assessment of the impact of the stresses on the child is as important as the substance misuse. It reinforces the need to see substance misuse by parents/carers in the context of family life and functioning, and not purely as an indicator or predictor of abuse and neglect.

4.2Guidance4.2.1 Hidden Harm 2011: https://pathways.nice.org.uk/Search?

q=drug+misuse&pwbu4.2.2 NICE guidance: https://www.nice.org.uk/guidance/CG514.2.3 Voice of the child: http://www.starsnationalinitiative.org.uk/

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4.2.4 parenting capacity and substance misuse: http://www.scie.org.uk/publications/briefings/briefing06/

4.3Implications for and effects on parenting4.3.1 Research shows that more than 2.6 million children in the UK live with

hazardous drinkers and over 700,000 live with a dependant drinker. 25% of Serious Case Reviews feature parental substance misuse. Many of these children were not known to Children’s Social Care.

4.3.2 Having children may lead some parents to enter treatment and stabilise their lives, but in other cases their children may be at risk of neglect or serious harm or take inappropriate caring roles.

4.3.3 The following situations relating to a child should raise suspicion and will need further investigation/referral:

o Abnormal or delusional thinking about a childo Persistent negative views expressed about a childo Hostility, irritability and criticism of a childo Inconsistent and/or inappropriate expectations of a childo Emotional detachment from the childo Lack of awareness of child’s needs that might require attention e.g.

illnesso Keeping a child at home to provide careo Family income used for drug/alcohol purchase rather than basic

essentialso Child’s safety compromised by drugs, alcohol and paraphernalia not

safely stored in the homeo Child exposed to criminal activity connected to substance misuseo Child exposed to contact with substance misusing adults who pose

risks to the childo Domestic abuseo Disruption to relationships within the extended family, reducing the

protective factor for children

4.4Pregnant women who misuse drugs and/or alcohol4.4.1 The objective of these guidelines is to ensure the physical well-being of both

the mother and the baby and ensure the baby will be safe in the mother’s care. Addressing the issues early in pregnancy will give greater opportunity for attendance at antenatal appointments, engagement with substance misuse services and modification of lifestyle. Workers should refer to Croydon’s Pre-birth Protocol for further guidance and the referral pathway.

4.4.2 Substance misuse is often associated with other social problems and general health issues. Therefore a pregnant woman who misuses substances may be at higher risk of:

o Having a premature babyo Having a baby with low birth weight

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o The newborn suffering symptoms of withdrawal from drugs used by the mother and requiring medication or other treatment

o The death of the baby before or shortly after birtho An irritable and less responsive babyo The newborn acquiring HIV, hepatitis C and/or hepatitis B infectiono ‘Sudden infant death syndrome’o Physical and neurological damage to the baby, particularly if violence

accompanies parental use of drugs or alcoholo The baby suffering from ‘foetal alcohol spectrum disorder’ or foetal

alcohol syndrome’ when the mother drinks excessively.4.4.3 It is possible for mothers who are substance misusers to be able to safely

breastfeed their baby including if they have HIV, hepatitis C and/or hepatitis B infection but always with specialist advice.

4.4.4 Drug withdrawal symptoms at birth (‘neonatal abstinence disorder’) can occur in infants born to mothers dependent on certain drugs. They may make the baby more difficult to care for in the post-natal period and the baby or the mother may require additional support.

4.4.5 The pregnant substance misuser is likely to feel guilt about the harm she may be causing to the baby and fearful of the judgement of others so may present late for ante-natal care or not be open about her substance misuse. The mother may need to be reassured that the baby will not automatically removed or be made subject of a child protection plan because of her substance misuse.

4.4.6 As soon as agency comes in to contact with a pregnant woman who is misusing substances, they should inform maternity services of their involvement, highlighting any concerns. An early help assessment or a referral to Children’s Social Care for a children and family assessment may be needed.

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5 Part 5: Specific/additional guidance: learning disability

5.1Definition5.1.1 The British Psychological Society defines learning disability as assessed

impairments of both intellectual and adaptive/social functioning which have been acquired before adulthood. Each learning disability condition or syndrome has different symptoms and behaviours associated with it and the way in which these manifest themselves can and do depend on the individual.

5.1.2 Research estimates that there are 985,000 adults in England with a learning disability, 2% of the adult population. Estimates of the number of adults with learning disabilities who are parents vary widely from 23,000 to 250,000.

5.2Guidance5.2.1 See Good practice guidance on working with parents with a learning disability

2007

5.3Implications for and effects on parenting5.3.1 Parents with learning disabilities face a high risk (50%) of having their children

removed from their care, usually as a result of concerns for the children’s well-being and/or absence of appropriate financial, practical and social support to perform their parenting role effectively.

5.3.2 Parents will need support and reasonable adjustments to develop the understanding, resources, skills and experience to meet the needs of their children. Such support is particularly important when parents experience additional stressors such as having a disabled child, domestic abuse, poor physical and mental health, substance misuse, social isolation, poor housing, poverty and a history of growing up in care. Such additional factors impact on parenting capacity further.

5.3.3 Parents with a learning disability are likely to need the support of an independent advocate especially when attending meetings about their child.

5.3.4 Parents with a learning disability may struggle to adjust to developmental changes in the child, for instance eating solid food, walking, starting school and reaching puberty and may need additional support at these times.

5.3.5 Older children can also become more able than their parent and are therefore likely to take on the parenting role. It is important that they are seen as young carers so that their needs can be assessed and appropriate support and services provided.

5.3.6 If workers have any concerns about the children of adults with a learning disability they should liaise with the Adult Services learning disability team to establish if the adult is known or if a referral is needed.

5.3.7 Staff completing an early help assessment or a Children’s Social Care children and families assessment should take into account the parent’s learning difficulty and use appropriate tools to assist the parent during the process.

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5.4Prenatal and postnatal period5.4.1 Specific concerns apply to the pre- and post-natal periods. It is vital that there

is joint working between, GPs, midwifery and health visiting services and if involved any learning disability specialist. It is essential to identify needs, assess and if needed prepare safeguarding plans for both mother and child.

5.4.2 Parents with a learning disability will require additional support before the baby is born to understand what is happening, with easy to read information and understandable antenatal classes and support at check-ps.

5.4.3 Parental learning disability may impact on the unborn child because it affects parents in their decision-making and preparation for the birth. The quality of the woman’s antenatal care is often impacted by late presentation and poor attendance. When women with learning disabilities do attend antenatal care they may experience difficulty in understanding and putting in to practice the information and advice they receive.

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Appendix A: Summary of potential impact on child of primary and secondary behaviours associated with parental mental ill healthParental behaviour Potential impact on child

(in addition to attachment problems)Self preoccupation Neglected

Emotional unavailability Depressed, anxious, neglected

Practical unavailability Out of control, self-reliant, neglected, exposed to danger

Frequent separation Anxious, confused, angry, neglected

Threats of abandonment Anxious, inhibited, self-blame, neglected

Unpredictable/chaotic planning Anxious, inhibited, neglected

Irritability/over-reactions Inhibited, physically and/or emotional abused

Distorted expressions of reality Anxious, confused

Strange behaviour/beliefs Embroiled in behaviour, shame, confusedPhysically and/or emotionally abused, neglected

Dependency Caretaker role

Pessimism/self-blame Caretaker role, depressed, low self esteem

Blames child Emotionally and/or physically abused

Unsuccessful limit-setting Behaviour problem

Marital discord and hostility Behaviour problem, anxiety, self-blame

Social deterioration Neglect, shame

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Appendix B: MINI TOOL KITConsiderations to take into account when assessing the impact of mental health problems on parenting and on child development & safety.

Assess, plan, implement and evaluate a think family approach to your work with the parent/child/unborn.

Keep child and adult risk assessments up to date

Regular observation of parent with child in home environment

Relationship & attachment between parent & child

Systemic factors - eg. age, race, gender, beliefs & values, ethnic, religious aspects, multi-agency relationships, housing/education/health

Young Carers: Is a young person/child caring for a parent a with a mental health problem?

Child’s view/presentation

Adult’s view/presentation

Significant other’s view

Symptoms – how they affect behaviour and relationships

Pattern of illness eg periods of stability and relapse, nature, duration and severity of symptoms

Evidence of resilience to potential impact of parental mental health problem

Engagement with treatment and help

Parental insight into their mental health condition and understanding of this in relation to their child/children.

Previous mental health problems, particularly when assessing perinatal mental health

Risk history - violence, self harm, suicide

Presence of any prior/co-existing difficulties eg, domestic abuse, drugs, alcohol, learning difficulty.

Quality of social supports eg. partner / significant family / school

Quality of relationship with partner. Do they have any difficulties eg mental health/substance misuse, is there domestic abuse?

Evidence of resilience in dealing with adversity both for parent & child eg. Utilising a support network, going to stay with a trusted carer.

What has been learnt from past experiences?

Extent and nature of care provided by the ill parent including safety - refer to parenting capacity indicators

Is the child incorporated into any abnormal parental beliefs?

How is care different when the parent is well / ill, if it is different at all? ( Not all parenting difficulties may be due to mental health symptoms)

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Intrusiveness of the illness on parental functioning

Is there a treatment available and is parent willing/understanding of their symptoms and behaviours and any need for treatment?

Pervasiveness of symptoms and behaviours

Child’s involvement in, and exposure to, parental symptoms

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Appendix C: summary of potential impact of parental drug misuse(Taken from Hedy Cleaver. The Child’s World; DoH 2000)

Age (years)

Health Education and cognitive ability

Relationships and identity

Emotional and behavioural development

0 – 2 Substance misuse during pregnancy may result in symptoms of withdrawal.

Missed medical check-ups and immunisations.

Unsuitable clothing, very poor hygiene.

Cognitive development may be delayed through the parents’ inconsistent, under-stimulating and neglectful behaviour.

Care of child by different strangers at different times can lead to insecure attachments.

A lack of commitment and increased unhappiness, tension and irritability in parents may result in inappropriate responses and emotional insecurity in the child.

3 – 4 Child may be placed in physical danger by excessive parental drug misuse, and by the presence of drugs in the home.

Child’s physical needs may be neglected.

Lack of stimulation.

Nursery or pre-school attendance may be irregular.

Child may take on responsibilities beyond their years because of parental incapacity.

Child may be at risk because they are unable to tell anyone of their distress.

5 – 9 School medicals and dental appointments missed.

Psychosomatic symptoms e.g. sleep problems, bed wetting.

Academic attainments may be negatively affected and child’s behaviour in school may become problematic.

Child may develop poor self-esteem and self-blame.

Child may curtail friendships and social interactions due to feelings of shame and embarrassment.

Conduct disorders e.g. hyperactivity and inattention.

Depression and anxiety.

Child may in denial of their own needs and feelings.

10 – 14 Little or no support during puberty due to parental emotional withdrawal.

Early experimentation with substances more likely.

Continued poor academic performance due to caring for siblings or parents.

Higher risk of school exclusion.

Restricted friendships.

Poor self image and low self-esteem.

Child at increased risk of emotional disturbance and conduct disorders. They are also at risk of becoming drug misusers themselves.

15+ Increased risk of problem substance misuse.

Risk of pregnancy, STIs and relationship breakdowns.

Poor life chances due to poor school attainment or exclusion because of behavioural problems.

Lack of appropriate role models.

Emotional problems may result from self-blame and guilt, and lead to increased risk of self-harm and vulnerability to crime.

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Appendix D: summary of potential impact of parental alcohol misuse

Age(years)

Health Education and cognitive ability

Relationships and identity

Emotional and behavioural development

0 – 2 Health risks include direct physical harm (including overlaying parents).

Unsafe home environment and inconsistent care due to parents impaired ability to parent whilst under the influence of alcohol (e.g. poor feeding routine).

Possible delay in cognitive development due to a lack of appropriate and consistent stimulation.

Insecure/ problematic attachment to parents due to inconsistent and chaotic behaviour and emotional withdrawal.

Child can feel loss and abandonment if drinking behaviour is placed above child’s needs.

Unsuitable clothing and poor hygiene.

Parent unable to respond to their child in an appropriate manner. Child may therefore feel unloved.

3 – 4 When parent is intoxicated the ability to care may be impaired.

Risk of direct physical harm and neglect.

Child may be left home alone or with inappropriate carers.

Child may be delayed due to insufficient emotional stimulation and interaction.

Nursery or pre-school attendance may be irregular due to parent being disorganised or inactive.

Child may blame themselves for the family’s problems and attempt to put things right.

Child may be more at risk of emotional disturbance as they cannot easily articulate emotions. The level of this disturbance may be missed as child’s behaviour does not always reflect their mental state.

5 – 9 Child may experience head and stomach aches, allergies, sleeping problems and bet-wetting.

Academic performance may be negatively affected with school attendance, punctuality, preparation and concentration also potentially affected. In contrast, some children may immerse themselves in their studies and attain well.

Child may suffer from low self-esteem and not feel in control. They may find it harder to see themselves as an individual separate to the family problems.

Child may internalise the depression, fear, anxiety and stress caused by the parent’s inconsistent and chaotic behaviour.

Child may externalise the distress, resulting in conduct problems, hyperactivity and lack of concentration.

10 – 14 Child may receive no support during puberty because of parental emotional withdrawal.

They may have difficulty developing a healthy and balanced attitude to

Academic performance may be negatively affected due to child’s concern about parental problem drinking, which can lead to the child staying at home to care for the family.

Child may develop low self-esteem and blame themselves for parent’s alcohol use.

Impact of finance problems on child’s clothing

Child may externalise the distress caused by parental drinking problems resulting in conduct problems.

Child may be labelled as the ‘problem’ by family

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alcohol.

Experimentation with alcohol and other drugs more likely.

and appearance. or others.

15+ Can lead to alcohol misuse.

Risk of pregnancy, STIs and relationship breakdowns.

Caring responsibilities can impact negatively on their education and employability.

Risk of school exclusion.

If parent’s behaviour is inconsistent and chaotic child may have low self-esteem, feel rejected, isolated and not in control.

They may show extremes of behaviour and be beyond parental control.

Risk of criminality and anti-social behaviour.

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Appendix E: summary of protective factors in relation to parental substance misuse

Age(years)

Health Education and cognitive ability

Relationships and identity

Emotional and behavioural development

0 – 5 Good regular antenatal care.

Support of at least one caring adult.

Sufficient income and good physical living standards.

Regular supportive help from primary health care team and children’s services.

The presence of a caring adult who respond appropriately to the child’s needs.

The presence of a caring adult who respond appropriately to the child’s needs.

5 – 9 Attendance at school medicals.

Regular attendance at school.

Sympathetic, empathetic and vigilant teachers.

A supportive older sibling, friend and/or social network.

Belonging to organised out of school activities.

Having different ways of coping and knowing what to do when parents are incapacitated.

The presence of an alternative, consistent and caring adult who respond appropriately to the child’s cognitive and emotional needs.

10 – 15+ Factual information about puberty, sex and contraception.

Regular school/college attendance.

Sympathetic, empathetic and vigilant teachers.

A champion who acts vigorously on behalf of the child.

A mentor or trusted adult with whom the child can discuss sensitive issues.

Practical and domestic help.

A mutual friend.

Non-judgmental support of relevant professionals.

The ability to separate themselves either psychologically or physically from stressful family situations.

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