Parent / Carer Mental Illness and the potential impact for dependant children

1. Parent / Carer Mental Illness and the potential impact for dependant children Vicky Finch Jo Farthing-Bell

2. Ground Rules Respect Confidentiality responsibility

3. Aims and Objectives Aim: To be introduced to the key features associated with common mental health problems and consider how parent/carer mental health problems may impact on the child and family. By the end of the training participants will: Have a basic understanding of common mental health problems and be able to describe some of the associated features. Have an opportunity to explore the impact of parental/carer mental illness on children through the use of practical activities and case scenarios. Consider their role in supporting and working in partnership with families and agencies to promote good outcomes for children living in families where parent /carer mental illness is present. Be able to identify factors associated with parent /carer mental illness that indicate a child or young person may be at risk of significant harm and know what procedures to follow.

4. Learning lessons, taking action: Key messages from SCR’s Parental mental health problems were identified as a factor in over half of a sample of 33 serious case reviews in England from 2009-2010 (Brandon, 2011) Mental illness was a feature in families with long standing concerns but also in the background of families where there were no current concerns Learning difficulties and/or disabilities were often linked with mental health issues for both parents and the children. Poor mental health affects 25% - 40% of adults with a learning disability Concerns about drug and alcohol misuse were identified in 17 reviews. Concerns about domestic violence featured in 15 serious case reviews. Some parents were receiving support from agencies in their own right, including from services for adult social care, adult mental health, substance misuse, housing and probation. These agencies were found to have held important information about the family circumstances, but too often this was not shared early enough.

5. What is Mental Illness ? ‘Mental illness is a mental physical, social, existential experience in which the individual is making sense of and working out how to survive’ (Seedhouse ,2002) ‘...mental health is not simply the absence of disease’ (WHO, 2006) any of various disorders in which a person's thoughts, emotions, or behaviour are so abnormal as to cause suffering to himself, herself, or other people (collins english dictionary) ‘ those whose symptoms are ‘sub-threshold’ are often viewed as having poor prognosis’ (Middleton and Shaw, 2000)

6. Prevalance About a quarter of the populationwill experience some kind of mental health problem in the course of a year, with mixed anxiety and depression the most common mental disorder in Britain Women are more likely to have been treated for a mental health problem than men and about ten percent of children have a mental health problem at any one time Depression affects 1 in 5 older people

7. Suicides rates show that British men are three times as likely to die by suicide than British women and self-harm statistics for the UK show one of the highest rates in Europe: 400 per 100,000 population Only 1 in 10 prisoners has no mental disorder. Anxiety is one of the most prevalent mental health problems in the UK and elsewhere, yet it is still under-reported, under-diagnosed and under-treated. (source: Mental Health Foundation)

8. Types of Mental Health difficulties that people face

9. Anxiety Features Feeling Tense/ inability to relax Worrying / apprehension/ feeling unable to cope Physical Symptoms of arousal Cardiovascular – palpitations, chest pain, rapid heart beat, flushing Respiratory – hyperventilation, shortness of breath Neurological – dizziness, headache, sweating, tingling and numbness Gastrointestinal – chocking, dry mouth, nausea, vomiting diarrhoea Musculoskeletal – aches, pains, restlessness, tremors, shaking Phobias – anxiety is evoked only, or predominantly by certain well defined situations or objects.

10. Associated behaviours / difficulties Avoidance Reassurance Seeking /Needing physical presence of another Introspection / preoccupation Poor concentration Fear of death of self or other Depressive disorders Can vary from mild unease to extreme terror Anxiety becomes worse during intercurrent depressive episodes

11. Anxiety • Treatment • CBT • Psychological therapies • Psychosocial interventions • Exposure Therapy • Exercise • Medication

12. DepressionReactive depressionEndogenous depression Key Symptoms Persistent low mood/sadness Loss of interest or pleasure Decreased energy and/or increased fatigue Associated symptoms Disturbed sleep Appetite disturbance Tearfulness Reduced concentration & attention, self esteem and self confidence Agitation or slowing of movement Ideas of guilt or unworthiness Bleak & pessimistic views of the future Ideas and or attempts of self harm or suicide Decreased libido

13. Depression • Treatment • Talking therapies • Counselling • Psychosocial interventions • Medications

14. Bi-Polar DisorderCharacterized by repeated (at least two) episodes in which the patient’s mood and activity levels are significantly disturbed Hypomania Elevation of mood Increased – activity / restlessness Difficulty concentrating / distractible/ flight of ideas Pressure of speech Decreased need for sleep Increased sexual energy Disinhibition Overspending / reckless behaviour Psychosis Grandiosity

15. Depression Often unresponsive to circumstances Exacerbation or pre-existing phobic or obsessional symptoms Irritability / agitation Lowering of mood Decreased energy Loss of interest / enjoyment Decreased energy Fatigue Diminished activity Marked tiredness after only slight activity Ideas of self harm and / or suicide

16. Bi-polar disorder • Treatment • Psychosocial Interventions • Counselling • Medications • Mood stabilisers

17. Obsessive Compulsive Disorder.Recurrent obsessional thoughts or compulsive acts Ideas, images of impulses that enter the individuals mind over and over again. Recognised as the individuals own thoughts Almost invariably distressing Originate from within the mind of the client Repetitive and unpleasant Client tries to resist but is unsuccessful No pleasure derived from obsession / carrying out ritual Obsession causes distress/ interferes with functioning Anxiety symptoms often present Depression often present

18. OCD • Treatment • CBT • Medication • Support mechanisms • Specialist placements

19. Personality DisorderDeeply ingrained and enduring behaviour patterns, manifesting as inflexible responses to a broad range of personal and social situations Pervasive and persistent Associated with personal and social disruption Extreme or significant deviations from the way the average individual in a given culture perceives, thinks feels and particularly relates to others. Developmental condition Appear in childhood or early adolescents and continue to manifest in adulthood. Not secondary to other mental disorder or brain disease / injury

20. Personality Disorder Additionally • Deviation is pervasive • Personal distress and /or adverse impact • Of long duration (onset late childhood / adolescence) • Unexplained by another disorder • No organic cause • Falkov (1996) reported that 28% of the parents in his sample of fatal child abuse had identifiable personality disorder.

21. Personality Disorder Abnormal behaviour pattern is enduring, not limited to episodes of mental illness. Poor regulation of emotions / poor impulse control Negative coping strategies / self harm / substance misuse / constant reassurance seeking Can lead to considerable personal distress Cluster A: Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder

22. Cluster B: Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Cluster C: Avoidant Personality Disorder Dependent Personality Disorder Obsessive Compulsive Personality Disorder

23. Personality Disorder • Treatment/ Management • Talking therapies • DBT –Dialectical Behaviour Therapy • Mindfulness • Specialist placements

24. SchizophreniaCharacterized in general by fundamental and characteristic distortions of thinking and perception Positive Symptoms: • Psychosis – a lack of contact with reality • Perception disturbed • Hallucinations – auditory • Colours or sounds may seem unduly vivid or altered • Thought insertion or withdrawal • Delusions may develop to make sense of these experiences. • Thought Disorder / Breaks in the train of thought, resulting in incoherence or irrelevant speech Negative Symptoms: • Blunting of emotions • Social withdrawal • Lowering of social performance • Loss of interest / aimlessness

25. Schizophrenia • Treatment • Medication • Psychosocial interventions • Insight work (Assessing insight) • Family Therapy • Exercise • Physical health promotion • Early Intervention in Psychosis

26. Maternal Mental Health • Post Natal Depression • Post Partum Psychosis • Perinatal mental health covers the period from conception to 1 year as studies note the impact on the foetus of anxiety and depression • 11.8% women probably depressed (EPDS > 13) at 18 weeks pregnancy ( Evans et al 2001) • 10%-15% women suffer from postnatal depression ( Cox et al 1996, Wisner 2012) • 33% of women continue to suffer from postnatal depression into their second year • 10% continue into their third year

27. Maternal Mental Health Suicide leading cause of maternal morbidity in developed countries(Oates 2003) Nearly all these were an early abrupt onset of psychotic illness. 85% were receiving treatment and had psychiatric problem identified. Previous history of a serious mental illness, post partum psychosis or family history poses a risk of re-occurrence following child birth of between 1 in 4 to as high as 1 in 2 (RCP 2014)

28. Maternal mental health Post partum Psychosis (suicide risk) Post partum Psychosis can result in confusion, hallucinations, irrational behaviour. Sudden in onset, usually within the first 2 weeks post delivery 7 in 10 women will attempt to hide their symptoms of PND or underplay their significant impact Prolonged symptoms of PND can lead to poor outcomes for children

29. Maternal mental health Treatment For psychosis, hospital admission usually required Medication CBT/ counselling Extended support due to major changes of having had a child and dealing with these difficulties Exercise therapy

30. MENTAL ILLNESS, PARENTING AND INDIVIDUALISED ASSESSMENT Illness Pattern Severity Chronicity Specificity Individual Insight Treatment Concordance Violence / aggression/ offending history Coexisting substance misuse Family / Social Support Domestic abuse Child Resilience Vulnerability

31. Stress and resilience factors in parents with mental health problems and their children: Over one third of all UK adults with mental health problems are parents. (With most parents with MH problems parenting their children effectively). Children’s resilience is enhanced by a secure and reliable family base in which relationships promote self esteem, self efficacy and a sense of self control. A parent’s resilience is enhanced by family (particularly children’s) understanding, satisfactory employment, good physical health, community and personal support.

32. Potential Stressors: Lack of money Breakdowns in valued relationships Bereavement Loss of control at work and long working hours. Age of Child

33. Psychiatric disorder: The level of ‘dangerousness’ that stems from psychiatric disorders relates to history and mental state. Previous violence Substance misuse Domestic Violence. Poor compliance (recent discontinuation of psychiatric treatments) Recent severe stress Unstable Lifestyle 70% of parents who seriously harm their children were themselves abused as children (Dale & Fellows 1999 ; Oliver 1993).

34. Risk in relation to Mental State: Agitation Hostile and / or suspicious behaviour Angry mood Thought disturbances (such as delusions of persecution / jealousy) Impulsive and Aggressive behaviours.

35. Group Activity Consider mental disorder and possible impacts for dependant children

36. ANXIETY possible impacts Socially isolated/ withdrawn/ social avoidance Low self esteem – projected onto children Reassurance seeking Caring role Inconsistency in care Learnt behaviours Behaviour issues

37. Depression: Possible Impacts Too much sleep/inability to sleep Supervision/ routines may be affected Neglect (own needs and children) Low self esteem Caring role Feelings of gloom, worthlessness and hopelessness, everyday activities left undone (Cleaver 2011). Poor stimulation Suicidal intent including child

38. Bi-Polar Possible Impacts Delusions/hallucinations including the child Instability – routines affected Over/under stimulated Inhibitions affected – associated risks Neglect Financial issues carer

39. OCD: Possible Impacts Rituals – children may be involved Learnt behaviour Insecurities Developmental opportunities may be reduced Neglect Stigma Caring role School attendance

40. Personality Disorder: Possible impacts Developmental delay Impaired judgement/risk taking behaviour leading to risk of harm Introspection Poor coping strategies Reassurance seeking Associated anxiety/self harm Behaviour issues Neglect bullying Parents poor emotional regulation leading to emotionally immaturity with child(Cleaver 2011) Caring role Lack of stability

41. Schizophrenia: Possible Impacts Neglect Low self esteem Unstable mood, poor routines/ boundaries Caring role Hallucinations/ delusions/ suicidal ideation may involve children Delusions / hallucinations can result in significant preoccupation (Cleaver et al 2011). Risk of associated concern ie drugs, alcohol Periods of absence from parent Stigma School attendance Attachment difficulties

42. Maternal mental health possible impact • Increased behavioural and emotional problems • Hospital admission for mum in psychosis and therefore separation from baby effecting bonding • Impaired cognitive and language development due to lack of stimulation • Insecure attachment • involvement in delusional thoughts with psychosis • Neglect • Responsiveness to needs • Risk of physical abuse • Social isolation • Suicidal intentions involving the child

43. Break time

44. Assessment Framework 2000

45. Parenting Capacity Basic Care providing for physical needs, medical ,dental , hygiene, food warmth etc Ensuring Safety from harm or danger in and out of home; from unsafe adults, other children and self etc Emotional Warmth sense of being specially valued, of racial and cultural identity , comfort ,cuddles, praise etc Stimulation promoting learning via cognitive stimulation, social opportunities, ensuring school attendance, communication, responding to questions and joining in play etc

46. Parenting Capacity cont... Guidance and Boundaries enabling the child to regulate own emotions and behaviour by demonstrating emotional and behavioural control in emotions and interactions with others e.g. social problem solving, anger management. Setting boundaries which enable the child to internalise pro social behaviour as opposed to being rule dependant. Stability providing a stable family environment which enables secure attachments with consistency of warmth over time, maintaining appropriate and similar responses to similar behaviour according to child's development. Enabling positive family contact

47. Early Help Providing early help is more effective in promoting the welfare of children than reacting later Effective early help relies upon local agencies working together to: • identify children and families who would benefit from early help; • undertake an assessment of the need for early help; and • provide targeted early help services to address the assessed needs of a child and their family which focuses on activity to significantly improve the outcomes for the child. Professionals should, in particular, be alert to the potential need for early help for a child who: is in a family circumstance presenting challenges for the child, such as substance abuse, adult mental health problems and domestic violence

48. Continuum of Need Model CHILDREN/ YOUNG PEOPLE WELFARE CONCERNS/ FAMILIES WITH COMPLEX PROBLEMS CHILDREN/YOUNG PEOPLE WITH ADDITIONAL NEEDS CHILDREN/YOUNG PEOPLE IN NEED OF PROTECTION CHILDREN/YOUNG PEOPLE WITH NO IDENTIFIED ADDITIONAL NEEDS

49. Protecting the child – NPSA Rapid response Report 2009 • Referrals must be made to Children's Social Care if : • Service Users express delusional beliefs involving their children and / or • Service Users might harm their child as part of a suicide plan • A consultant psychiatrist should be directly involved in all clinical decision making for clients who may pose a risk to children • All assessment, CPA monitoring, review, and discharge planning documentation and procedures should prompt staff to consider if the service user is likely to have or resume contact with their own child or other children in their network of family and friends, even when the children are not living with the service user. • If the service user has or may resume contact with children, this should trigger an assessment of whether there are any actual or potential risks to the children, including delusional beliefs involving them, and drawing on as many sources of information as possible, including compliance with treatment. • Children should never be considered a protective factor for parents who feel suicidal. In some cases professionals inappropriately viewed the child as a protective element who could help to reduce the parent’s risk of self -harm. This belief significantly increases the risk to the child. (NSPCC 2015)

50. Self Harm • Majority of self harm occurs between 11-25 yrs old. • Also known to occur in very young and adults. • Why?? • controlling mood • a way of expressing themselves • control/punishment - a form of trauma re-enactment