Parental Mental Illness & Child Safety

1. Parental Mental Illness & Child Safety Working with Families Impacted by Mood, Anxiety and Psychotic Disorders to Reduce Risk & Improve Protective Factors Mickey Kander MSW MPH PA-C Micah Kurtz MSW MDiv

2. Agenda • Introductions, • Learning Objectives • Definitions, • Diagnosis & Research • Stigma • Engagement • Assessment • Case Planning & Soft Skills • Ending Services • Practice

3. Section I Introductions, Learning Objectives Definitions, Diagnosis & Research

4. Learning Objectives • Describe own bias and feelings towards MI & parents with MI • Agree on basic definitions associated with MI & child safety • Apply criteria in diagnosing specific psychiatric disorders • Define the current landscape of parental MI and impacts to safety (data & research) • Identify assessment strategies that can focus on the intersection between MI & child safety • Draft assessment and case plan objectives & tasks that can achieve child safety and promote the health of the parent • Practice use of interventions that promote the reduction of risk associated with parental MI and enhance protective factors for family well-being • Establish own personal development goal for use of tools / skills during the day’s training

5. Introductions • Trainers • Participants What would you like to cover during this training?

6. Brave Space | Safe Space • Mental illness is everywhere, including here in this room • While not everyone has a mental illness, most people are affected in some way • Safe Space | No Hurt Feelings • Brave Space | Risk of Hurt Feelings, but Perhaps Growth

7. Assumptions • You would like to improve your practice of managing cases involving parental MI • You have opinions about working with mental illness • Parental mental illness is related to child maltreatment • Trauma informed assessment, care and treatment is important in this work • Depending on circumstance, you could be doing work differently and could be doing more work • The issue of parental mental illness is very complex • Casework is creative, there is no one “best” way to do it • There is a range of mental health assessment skill in this room • You prefer to use critical thinking rather than a prescriptive approach to case work

8. Mental Health Mental health is more than the absence of mental disorders. ~ WHO, 2013

9. Question Mental Illness Mental Health How would you define mental health and mental illness?

10. Our Working Definitions • Mental Health - A state of well-being in which every individual: • realizes her, his [or their] own potential, • can cope with the normal stresses of life, • can work productively and fruitfully, and • is able to make a contribution to her, his [or their] community • Safety Threat – current dangerous family condition • Risk – the likelihood of future maltreatment Mental Health (WHO), Safety & Risk (DSHS)

11. Working Definitions Continued Mental Illness A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. ~ DSM V

12. Working Definitions Continued Post Traumatic Stress Syndrome Occurswhen one is directly, or vicariously exposed to traumatic events or traumatic situations, and when this exposure continues to overwhelm the ability to cope with the experience after the trauma ceases ~ NCTSN

13. Trauma Approach Trauma Informed Approach • Safety • Trustworthiness & Transparency • Peer Support • Collaboration and Mutuality • Empowerment, Voice & Choice • Cultural, Historical & Gender Issues ~ SAMHSA, 2014 Internet Search TIP 57: Trauma-Informed Care in Behavioral Health Services

14. Diagnoses DSM V • In 2013, the multiaxial system was removed (no longer separate categories for mental disorders, subcategories of mental retardation / personality disorder, physical health problems, environmental / interpersonal stressors & a Global Aptitude of Functioning score) • All diagnoses are listed with the most prominent at the top • V / Z codes are NOT diagnoses (however they are critical to telling the story)

15. Diagnostic Categories • Neurodevelopmental Disorders • Schizophrenia Spectrum & Other Psychotic Disorders • Bipolar & Related Disorders • Depressive Disorders • Anxiety Disorders • Obsessive-Compulsive Disorders • Trauma and Stressor-Related Disorders • Dissociative Disorders • Feeding & Eating Disorders • Elimination Disorders • Sleep-Wake Disorders • Sexual Dysfunctions • Gender Dysphoria • Disruptive, Impulse-Control & Conduct Disorder • Substance-Related and Addictive Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders

16. Common Disorders in Child Welfare Settings Handout A: Common Psychiatric Illnesses in Child Welfare

17. Traumatic Events & Mental Illness Adverse Childhood Experiences Study • Hallucinations 5 X • Depression 2.5 – 2.7 X • Suicide Attempts 2 – 5 X • Substance Use 2 – 4 X • Eating Disorder 3 – 4 X ~ Anda (CDC) & Felitti (KP)

18. Data & Research General Mental Illness Parental Mental Illness Knowledge is of no value unless you put it into practice ~ Anton Chekhov Parental Mental Illness Impact on Child Safety Handout B: Pop Quiz

19. Pop Quiz: Mental Illness What is the percentage of the US population that would be / has been diagnosed with a mental illness in their lifetime? • 20% • 38% • 50% • 61% ✔️

20. Pop Quiz: Mental Illness Adults living with mental illness die an average of __ years earlier than those who do not carry a psychiatric diagnosis • 5 Years • 10 Years • 15 Years • 25 Years ✔️

21. Pop Quiz: Mental Illness What percentage of those in Washington state who are homeless identified as having a severe mental illness (N = 21,112, data from 2017)? * hint what is the prevalence of SMI in the US among adults? • 4% • 8% • 17% • 24% ✔️

22. Pop Quiz: Mental Illness What percent of women & men (respectively) with mental illness are parents? • 68% & 54.5% • 85% & 41% • 22.5% & 65.5% • 51% & 52% ✔️

23. Question Does parental mental illness compromise child safety? Mental Illness is Dangerous Mental Illness is not Dangerous but Often Discriminated Against

24. Dangerous Is a Loaded Word… • The term “dangerous" was used intentionally • EVERYONE has bias, it is a matter of implicit vs. explicit • Not all parents who have mental illness will compromise their child’s safety • However it is ALWAYS a RISK factor (and MAY elevate to SAFETY factor) • RCW 13.34.132 & 13.34.050 do not include parental mental illness as rationale for custody or termination of parental rights

25. Parental Mental Illness • 46.8% of mothers and 29.5% of fathers have a mental illness sometime in their lifetime (Nicholson et al 2002) • Children followed from 1993 – 2009. New report rates ranged from 80–90% for children of mothers with MI, 67% for general CPS population (Kohl, 2011) • Adult respondents reporting a parental history of depression, mania, or schizophrenia had a two to threefold increase in the rates of physical, sexual, or any abuse (Walsh, 2002) • Mothers with a diagnosed psychiatric illness were 3 times more likely to come to the attention of child welfare systems than those without (Park, 2006)

26. Sexual Abuse & Parental Mental Illness Research by Whitaker et al (2008) • Meta-analysis of 89 Studies • Large effect (risk): Loneliness & Antisocial Personality Disorder • Medium effect : Depression, Paranoia / Mistrust, Low Self-Esteem, Cluster A & B Personality Disorders • Small effect: Anxiety, Poor Coping

27. Physical Abuse & Parental Mental Illness NCANDS Data, Dakil et al 2012 • Clinically diagnosed mood or attachment disorder • About 1 / 20 (5%) cases had a parent with emotional / mental health concerns • High for substance use: 1 / 4 cases

28. Neglect and Parental Mental Illness Stoltenborgh et al 2013 • Complains there isn’t enough research on neglect • 16 studies for emotional neglect • 13 studies for physical neglect Mulder et al 2018 • More complaints (36 studies) • Risk Factors: • Hx of antisocial behavior/criminal offending (r = .372) • Hx of mental/psychiatric problems (r = . 259) • Current mental/physical problems (r = .207)

29. Clinical Activity Example: • Parental Depression • Increased aggravation with parenting role Step 1: Your table will be assigned a mental illness Step 2: Using Handout A as a reference, discuss all the ways this mental illness could compromise parenting Step 3: Be ready to report out and discuss

30. What was the point ofthat last exercise? Behavior Mental Illness Compromised Child Safety? Handout C: Psychiatric Diagnoses & Compromised Parenting Behavior

31. Section II Stigma, Engagement & Assessment

32. A Few Words* about Stigma… Rational and Irrational Fears in Mental Illness • Media • Personal Experience • Community / Culture * It will be more than a few words.

33. Media

34. Stigma Stigma is when someone, or even you yourself, views a person in a negative way just because they have a mental health condition. Some people describe stigma as a feeling of shame or judgement from someone else. Stigma can even come from an internal place, confusing feeling bad with being bad. ~ NAMI, 2018

35. If Compared to Diabetes… • A Celebrity is Not Taking His Insulin…It’s So Sad • Suspect Was Declared Pre-diabetic After Attacking His Own Mother • Diabetic Recharged in 2013 Pioneer Square Slaying • Poor Glycemic Control Woman Sues Cop She Says Kidnapped, Sexually Assaulted Her • Magna Mother Who Killed Child Struggled with Good Glycemic Control

36. Media & Mental Illness • At some point in the life of a U.S. based American – nearly 50% will have been diagnosed with a mental disorder • MacArthur Study: comparison between released patients diagnosed with severe MI. Prevalence of perpetrated violence by MI Group: 4.7%. Prevalence of perpetrated violence by Community Group: 3.3% (not statistically significant) • Study reviewing articles from 1995 – 2014 (McGinty et al, 2016) • 74% of articles described an act of violence perpetrated by someone with mental illness • 57% made clear statements that mental illness puts one at risk for committing violent acts • < 10% discussed risk factors for violence (substance / alcohol use, stress, abuse / trauma hx)

37. Brief Tangent: Mental Illness Alone Is Not a Cause There are other precursors to violence, just not mental illness: • Substance Use (biggest) • Antisocial Personality • Victimization / Violence Violence by those with mental illness influenced by: • Bizarre/ Annoying Symptoms • Threat / Control Override Symptoms

38. What Does this Mean? Means that you’ll assess for: • Bizarre / Annoying Symptoms • Threat / Control Override (these are command symptoms) • Substance Abuse • Trauma History But we’re getting ahead of ourselves… Take Home Point: Formula for violence is mental illness + exacerbation of the condition rather than just mental illness alone

39. Professional Perceptions • Unconscious Bias • Generalized Professional Experience • Burnout

40. Culture & Community

41. Culture & Community • CDC study demonstrated 25% of LatinX individuals reported that treatment would absolutely NOT help with mental illness (CDC, 2012) • Some Native American / American Indian tribal members throughout history have had psychiatric labels placed up on them by Western medicine, thus causing them to fear formal mental health treatment (Grandbois, 2005) • Evangelical Christians endorsed more beliefs that mental illness have spiritual causes/treatments (Wesselman, 2010)

42. Does a Mental Illness Bias Influence the Care We Provide? • Belief in a “just” world (Bizer et al, 2012) • Those with mental illness are significantly less likely to seek out care (Mojtabai, 2011) • Patients with mental illness and a history of a heart attack were less likely to receive cardiovascular procedures than those without a psychiatric condition (Druss, 2000)

43. Stigma & Care Personal Provider & System Level Lack of knowledge about mental health treatment Focus on disease rather than person Less aware of other health needs Not believing patients Insurance coverage (poverty) General lack of resources • Label = Shame • Poor treatment initiation • High treatment drop-out • Mental health literacy • Acceptance of cultural stigma • Negative experiences via social network • Family guilt by association

44. Personal Perceptions • Review your handouts • Rate each item for you as yes, somewhat or no • Do not disclose your responses, but we will talk about how the exercise made you feel Handout D: Personal Feelings about Mental Illness

45. Addressing Personal Perceptions • The first step is admitting you might have a problem… • Pave the way for brave discussions (staff meetings, client discussions) • “We’ve had lessons before about implicit bias and racism, I have recent information that this is true for mental illness as well. By virtue of having these discussions, it means it is a good faith effort that I want to improve my practice but I may make mistakes along the way…are you okay with that?” • Use supervision wisely (prepare your supervisor that you want to work on your bias…otherwise they may write you up)

46. Addressing Personal Perceptions • Survey: https://implicit.harvard.edu/implicit/user/pimh/selectastudy.html (implicit bias validated survey) Question: Out of these options, which is the most helpful in reducing stigma?: 1) live education, 2) informational video or 3) contact?

47. Recommended Strategies from NAMI • Use respectful language • Challenge misconceptions • See the person not the condition • Offer support – address barriers

48. Engagement Engagement is the strengths-based process through which individuals with mental health conditions form a healing connectionwith people that support their recovery and wellnesswithin the context of family, culture and community ~ NAMI, 2016

49. Engagement | Why Does it Matter? • 70% of those with mental illness will be lost to follow up after 1 – 2 professional appointments • Higher for those with a first psychotic episode: 80% • Repeated research findings: relationship with clinician / professional is highly correlated with optimal psychotherapeutic outcomes • DBHS Study: 758 women enrolled in PCAP, 458 included in analysis. Not engaging in services associated with reduced reunification among women with psychiatric illness

50. Given the definition – what barriers to engagement of a parent with mental illness can you think of?