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Assessment of parenting for the family court
OTHER ISSUES
Assessment of parenting for the family court
Dimensions of parenting capacity Basic care Providing for the child’s physical needs, medical and dental care
David P H Jones
Ensuring safety Ensuring the child is adequately protected from harm or danger Emotional warmth Ensuring the child’s emotional needs are met, and giving the child a sense of being especially valued and a positive sense of own racial and cultural identity
Psychiatric disorder affects an individual’s social and psychological functioning. It leads to difficulties in work and family life, including parenting.1 The effects are seen in children’s physical, cognitive, social, emotional and behavioural development. Effects are primarily mediated through changes in the quality of parenting and family interactions, although environmental and genetic influences also contribute. Assessing parenting is equally important for family courts, and children’s health and welfare. Here we describe the constituent parts of ‘parenting’, provide a framework for assessment and describe the process of assessing, in order to provide a comprehensive and fair methodology for this kind of clinical work.
Stimulation Promoting child’s learning and intellectual development through encouragement, cognitive stimulation and promoting social opportunities Guidance and boundaries Enabling the child to regulate his or her own emotions and behaviour. Demonstrating and modelling appropriate behaviour and control of emotions and interactions with others, and guidance that involves setting boundaries so that the child is able to develop an internal value of moral values and conscience, and social behaviour appropriate for the society within which he/she will grow up
Parenting Figure 1 sets out a consensus of what qualities are necessary from parents/carers in order to meet the child’s developmental needs and promote his or her welfare.2
Stability Providing a sufficiently stable family environment to enable the child to maintain and develop a secure attachment to the primary caregiver(s) in order to ensure optimal development
Principles and framework A human rights perspective guides assessment. The right to family life applies to adults with parental responsibilities, and to children. Parents have a right to family life unless there are good reasons to the contrary. Equally, children have a right to family life, and a childhood free from abuse and neglect. Children, by definition, are in a dependent state and reliant upon their carers, particularly when younger, for their wellbeing. When there is a conflict of rights, the child welfare considerations predominate, and effectively trump the parents’ right to family life, where a child is at significant risk of harm. Balancing these fundamental rights and holding them in perspective can aid difficult decision making, especially where a parent would be likely to suffer if not permitted to care for their child, yet a child would be likely to be harmed if cared for by a mentally ill parent. Clinically, it is useful to adopt a ‘child’s eye’ perspective when evaluating these complex situations. This permits the practitioner to see both the benefits and disadvantages for each child in a particular family. This perspective helps to maintain objectivity
1
where one might well be swayed by an understandable tendency to sympathize with the anguish of a mentally ill parent. The Assessment Framework provides a practical model through which to place parenting functions in context.3 Thus, the child’s developmental status and needs can be considered along with other significant influences upon a parent’s capacity, such as family interaction, extended family, neighbourhood, and poverty. The framework is widely accepted across professional groups, facilitating communication in multidisciplinary settings (Figure 2). The framework places the child in the centre of a triangle comprising: a child’s developmental status and particular needs; the parenting capacity of each carer; and the mental health status of caretaking adults, family interaction variables, and contributions from a family’s social setting.
Assessment process Sadly, not all adult parents with mental illness are identified as such. Even when identified, their special needs, or those of their children, are all too frequently insufficiently responded to. Similarly, the parenting role of patients with mental illness often goes unrecognized and unsupported. These concerns apply both within community and hospital settings.
David P H Jones is Consultant Child and Family Psychiatrist at the Park Hospital, Oxford, UK. He trained in paediatrics and child psychiatry in the UK and has worked in the USA at the Henry Kempe Centre. His research interests include interviewing children, child maltreatment and children’s consent to treatment.
PSYCHIATRY 5:1
29
© 2006 Elsevier Ltd
OTHER ISSUES
The assessment framework Self-care skills
ds
Basic care
pm lo ve de
Stimulation
ci ty
's
pa
CHILD Safeguarding and promoting welfare
ca
ild
g
Ch
Emotional warmth
in
en
nt
ta
re
Identity
Ensuring safety
Pa
Family and social relationships Emotional and behavioural development
ln ee
Social presentation
Guidance and boundaries
Education Stability
Health Fa mily and environmental fac t o rs
y or g st in hi ion ily ct m un Fa d f an ily m fa er id W g in t us n Ho me oy pl Em e m al co ci In so ’s n ily tio m ra Fa teg in ity un m es m rc Co sou re
2
Adapted from: Department of Health, 2000.3
Enquiring about parenting capacity may also be sensitive because concerns about parenting may well have been raised by social services or primary health care already, and sometimes a child protection investigation is under way. If concerns are already overt then history-taking can start with an enquiry as to the patient’s perspective and feelings about each concern raised. Sometimes a direct approach is too difficult or emotionally fraught, in which case starting with a family tree and a detailed history about each of the patient’s children can be a more indirect way of approaching concerns about their care.
Once a patient is recognized as being a parent too, we can set about assessing parenting. A comprehensive assessment of parenting will include an assessment of each parent, each child and family functioning, as well as specific assessment of parenting capacity and parent/child interaction. In this paper we concentrate on the assessment of parenting and parent/child interaction, under the assumption that additional assessments of the adults, children and family will be undertaken. Mental health and parenting The first essential is a good quality history of the individual’s mental health and functioning, with accurate chronology. Although standard practice, this history needs to include particular attention to the chronology of all partners, pregnancies, and births. Corroboration from case records and/or from another informant is likely to be required in order to obtain an objective picture of how impaired or otherwise the individual was during the course of his/her illness. Patients should be asked how he/she felt that their ability to care for their child was affected during each episode of illness, and in relation to each child. Most mentally ill parents have been acutely aware, and themselves concerned, about their capacity to parent during times of ill health. Equally, they are frequently fearful that their children will be taken away into care, but at the same time want help to prevent any ill effects upon their children. This is a sensitive area for the mentally ill parent, because of the stigma they face and possible attitudes from family or neighbours concerning their parenting capacity. Furthermore, the very factors that raise the risk of vulnerability to mental illness also conspire to elevate the risk of parenting problems (e.g. childhood experience of maltreatment, exposure to inter-parental violence, disharmony, and disruption; drug and alcohol abuse; or episodes of childhood spent living in care).
PSYCHIATRY 5:1
A schema for assessment Figure 3 sets out an overall schema for history-taking. This is essentially similar to the standard mental health approach but with added emphasis in specific areas. The approach to interviewing should be a combination of factual information, together with the parent’s feelings and thoughts about each child at different stages of his or her development. In doing so, it is important to start with the time when the parent first realized they were pregnant, tracing through changes in parental feelings and views through pregnancy, birth and child development. The practitioner should try to elicit feelings of close affection and the timing when these first emerged during the antenatal and post-birth periods. Most mothers can remember their child’s first movements, especially with their first born. A permission-giving question is useful when assessing delay in parental affection and warmth for the new born child, e.g. ‘not everyone feels close to their baby immediately after birth, how long did it take you to feel close to X?’. The feelings, help and support of partners and other family members can usefully be enquired about at this stage too. The family history and an assessment of family interaction are of special importance. Disharmony and inter-parental violence not only affect the child directly but also have the potential to do so indirectly, creating a decline in an adult’s parenting capacity, 30
© 2006 Elsevier Ltd
OTHER ISSUES
of parent/child interaction are of particular importance. Figure 4 contains the aspects of interaction that should be assessed in young children, under 3 years of age, and their parents. Structured assessments have a place, e.g. narrative approaches to a child’s attachment, modified Ainsworth assessment of attachment status and the adult attachment interview. Standardized assessments can also assist. For example, the Child Abuse Potential Inventory (Milner) and the Parenting Stress Index (Abidin) can augment clinical assessment.
A schema for parenting assessment Confidentiality issues Area(s) of concern or presenting problems • Each parent’s perspective on caregiving • Any episodes of harm to child(ren) • Each parent’s view on changes needed • Understanding of child’s future needs/ ability to plan ahead
Corroboration Sometimes a corroborative account is essential; for example where parents are suspected of personality disorder, or harm such as emotional abuse, or where fabricated or induced illness is suspected. In these circumstances other sources of information are not only useful but become essential. When assessing child mental health status, accounts from school and/or nursery provide a useful comparison with a parental account. It will often be important to obtain original records in order to clarify past health status, educational achievement or criminal activities. These will need to be obtained with the patient’s full written consent or, if this is resisted, by order of the Court.
Current health/adjustment • Child(ren) • Parents Child(ren)’s personal history and development • Pregnancy • Delivery • Neonatal period • Attachment and caretaking relationships • Milestones • Physical health • General behaviour • Mental state observations • Parent’s views and attitudes towards child and child’s needs
Making sense It is fine to gather data and often from multiple sources. However, how do we make sense of it all, in order to contribute to case
Family structure, history and functioning • Family structure and history Partnerships, pregnancies and births • Family relationships Parent/child relationships Parental relationship (including any violence) Type of communication within the family
Observations of parent/child interaction Child • Attachment behaviour • Emotional state • General behaviour • Responsiveness to parent
Family/social relationships • Friendships, social isolation Each parent’s personal history and current status • Personal history and development Mental health history Past behaviour and current attitudes to illness Understanding of effects of illness on child Evidence of personality disorder/dysfunction History of anti-social behaviour and/or delinquency Substance abuse Parental experiences of care during childhood • Family history • Mental state • Physical examination
Parent Psychological aspects: • Emotional expression • Responsiveness and recognition • Warmth/empathy • Cognitive stimulation/ verbal interaction • Play • Behaviour management • Distance/closeness regulation • Emotional management/containment Physical care: • Feeding • Bathing/changing • Sleep • Safety
3
which may be already compromised through mental illness. This too is adversely affected by relationship difficulties.
Dyadic interaction • Co-operation • Reciprocity/Joint attention
Observations An essential component of a parenting assessment is examination of the mental state of parents and children. Observations
PSYCHIATRY 5:1
4
31
© 2006 Elsevier Ltd
OTHER ISSUES
Making decisions, where a child has been significantly harmed The following stages of decision-making are proposed: 1 Data gathering 2 Weigh relative significance 3 Assessment of current situation 4 Circumstances which may alter child’s welfare 5 Prospects for change 6 Criteria for gauging effectiveness 7 Timescale proposed 8 Child’s plan (child in need plan, child protection plan or care plan, depending on status of the child) 5
planning or child protection decisions? Figure 5 summarizes a structured approach to decision-making about parenting assessments for the Family Courts (for a full exposition see Jones et al., in press).4 There is an evidence base for rational decision-making, but nonetheless clinical evaluation of the relative weight to be placed on different factors, positive or negative, remains a key function of the practitioner. Hence, it is important to set out explicitly how one has reached a decision for the Family Court, in the interests of fairness, and to permit scrutiny. The approach suggested in Figure 5 also allows the practitioner’s prognosis to be assessed over time and plans for child and parent adjusted accordingly. After all, the central function of the practitioner in this area is normally one of risk management rather than mere risk assessment, because it is rare for any such situation to involve no risk.
REFERENCES 1 Ramchandani P, Stein A. The impact of parental psychiatric disorder on children: avoiding stigma, improving care. BMJ 2003; 327: 242–3. 2 Jones D P H. Assessment of parenting capacity. In: Horwath J, ed. The child’s world: assessing children in need. London: Jessica Kingsley, 2001. 3 Department of Health. A framework for the assessment of children in need and families. London: Stationery Office, 2000. 4 Jones D P H, Hindley N, Ramchandani P. Making plans: assessment, intervention and evaluating outcomes. In: Rose W, J Aldgate J, Jones D P H, eds. The developing world of the child. London: Jessica Kingsley, in press. FURTHER READING Reder P, Duncan S, Lucey C. What principles guide parenting assessments? In: Reder P, Duncan S, Lucey C, eds. Studies in the assessment of parenting. Hove: Brunner-Routledge, 2003. Reder P, Duncan S, Lucey C. How are assessments conducted for family proceedings? In: Reder P, Duncan S, Lucey C, eds. Studies in the assessment of parenting. Hove: Brunner-Routledge, 2003. (A pair of chapters which draw together theory and practice of undertaking parenting assessments, particularly those done for family courts.)
PSYCHIATRY 5:1
32
© 2006 Elsevier Ltd
Assessment of parenting for the family court
Dimensions of parenting capacity Basic care Providing for the child’s physical needs, medical and dental care
David P H Jones
Ensuring safety Ensuring the child is adequately protected from harm or danger Emotional warmth Ensuring the child’s emotional needs are met, and giving the child a sense of being especially valued and a positive sense of own racial and cultural identity
Psychiatric disorder affects an individual’s social and psychological functioning. It leads to difficulties in work and family life, including parenting.1 The effects are seen in children’s physical, cognitive, social, emotional and behavioural development. Effects are primarily mediated through changes in the quality of parenting and family interactions, although environmental and genetic influences also contribute. Assessing parenting is equally important for family courts, and children’s health and welfare. Here we describe the constituent parts of ‘parenting’, provide a framework for assessment and describe the process of assessing, in order to provide a comprehensive and fair methodology for this kind of clinical work.
Stimulation Promoting child’s learning and intellectual development through encouragement, cognitive stimulation and promoting social opportunities Guidance and boundaries Enabling the child to regulate his or her own emotions and behaviour. Demonstrating and modelling appropriate behaviour and control of emotions and interactions with others, and guidance that involves setting boundaries so that the child is able to develop an internal value of moral values and conscience, and social behaviour appropriate for the society within which he/she will grow up
Parenting Figure 1 sets out a consensus of what qualities are necessary from parents/carers in order to meet the child’s developmental needs and promote his or her welfare.2
Stability Providing a sufficiently stable family environment to enable the child to maintain and develop a secure attachment to the primary caregiver(s) in order to ensure optimal development
Principles and framework A human rights perspective guides assessment. The right to family life applies to adults with parental responsibilities, and to children. Parents have a right to family life unless there are good reasons to the contrary. Equally, children have a right to family life, and a childhood free from abuse and neglect. Children, by definition, are in a dependent state and reliant upon their carers, particularly when younger, for their wellbeing. When there is a conflict of rights, the child welfare considerations predominate, and effectively trump the parents’ right to family life, where a child is at significant risk of harm. Balancing these fundamental rights and holding them in perspective can aid difficult decision making, especially where a parent would be likely to suffer if not permitted to care for their child, yet a child would be likely to be harmed if cared for by a mentally ill parent. Clinically, it is useful to adopt a ‘child’s eye’ perspective when evaluating these complex situations. This permits the practitioner to see both the benefits and disadvantages for each child in a particular family. This perspective helps to maintain objectivity
1
where one might well be swayed by an understandable tendency to sympathize with the anguish of a mentally ill parent. The Assessment Framework provides a practical model through which to place parenting functions in context.3 Thus, the child’s developmental status and needs can be considered along with other significant influences upon a parent’s capacity, such as family interaction, extended family, neighbourhood, and poverty. The framework is widely accepted across professional groups, facilitating communication in multidisciplinary settings (Figure 2). The framework places the child in the centre of a triangle comprising: a child’s developmental status and particular needs; the parenting capacity of each carer; and the mental health status of caretaking adults, family interaction variables, and contributions from a family’s social setting.
Assessment process Sadly, not all adult parents with mental illness are identified as such. Even when identified, their special needs, or those of their children, are all too frequently insufficiently responded to. Similarly, the parenting role of patients with mental illness often goes unrecognized and unsupported. These concerns apply both within community and hospital settings.
David P H Jones is Consultant Child and Family Psychiatrist at the Park Hospital, Oxford, UK. He trained in paediatrics and child psychiatry in the UK and has worked in the USA at the Henry Kempe Centre. His research interests include interviewing children, child maltreatment and children’s consent to treatment.
PSYCHIATRY 5:1
29
© 2006 Elsevier Ltd
OTHER ISSUES
The assessment framework Self-care skills
ds
Basic care
pm lo ve de
Stimulation
ci ty
's
pa
CHILD Safeguarding and promoting welfare
ca
ild
g
Ch
Emotional warmth
in
en
nt
ta
re
Identity
Ensuring safety
Pa
Family and social relationships Emotional and behavioural development
ln ee
Social presentation
Guidance and boundaries
Education Stability
Health Fa mily and environmental fac t o rs
y or g st in hi ion ily ct m un Fa d f an ily m fa er id W g in t us n Ho me oy pl Em e m al co ci In so ’s n ily tio m ra Fa teg in ity un m es m rc Co sou re
2
Adapted from: Department of Health, 2000.3
Enquiring about parenting capacity may also be sensitive because concerns about parenting may well have been raised by social services or primary health care already, and sometimes a child protection investigation is under way. If concerns are already overt then history-taking can start with an enquiry as to the patient’s perspective and feelings about each concern raised. Sometimes a direct approach is too difficult or emotionally fraught, in which case starting with a family tree and a detailed history about each of the patient’s children can be a more indirect way of approaching concerns about their care.
Once a patient is recognized as being a parent too, we can set about assessing parenting. A comprehensive assessment of parenting will include an assessment of each parent, each child and family functioning, as well as specific assessment of parenting capacity and parent/child interaction. In this paper we concentrate on the assessment of parenting and parent/child interaction, under the assumption that additional assessments of the adults, children and family will be undertaken. Mental health and parenting The first essential is a good quality history of the individual’s mental health and functioning, with accurate chronology. Although standard practice, this history needs to include particular attention to the chronology of all partners, pregnancies, and births. Corroboration from case records and/or from another informant is likely to be required in order to obtain an objective picture of how impaired or otherwise the individual was during the course of his/her illness. Patients should be asked how he/she felt that their ability to care for their child was affected during each episode of illness, and in relation to each child. Most mentally ill parents have been acutely aware, and themselves concerned, about their capacity to parent during times of ill health. Equally, they are frequently fearful that their children will be taken away into care, but at the same time want help to prevent any ill effects upon their children. This is a sensitive area for the mentally ill parent, because of the stigma they face and possible attitudes from family or neighbours concerning their parenting capacity. Furthermore, the very factors that raise the risk of vulnerability to mental illness also conspire to elevate the risk of parenting problems (e.g. childhood experience of maltreatment, exposure to inter-parental violence, disharmony, and disruption; drug and alcohol abuse; or episodes of childhood spent living in care).
PSYCHIATRY 5:1
A schema for assessment Figure 3 sets out an overall schema for history-taking. This is essentially similar to the standard mental health approach but with added emphasis in specific areas. The approach to interviewing should be a combination of factual information, together with the parent’s feelings and thoughts about each child at different stages of his or her development. In doing so, it is important to start with the time when the parent first realized they were pregnant, tracing through changes in parental feelings and views through pregnancy, birth and child development. The practitioner should try to elicit feelings of close affection and the timing when these first emerged during the antenatal and post-birth periods. Most mothers can remember their child’s first movements, especially with their first born. A permission-giving question is useful when assessing delay in parental affection and warmth for the new born child, e.g. ‘not everyone feels close to their baby immediately after birth, how long did it take you to feel close to X?’. The feelings, help and support of partners and other family members can usefully be enquired about at this stage too. The family history and an assessment of family interaction are of special importance. Disharmony and inter-parental violence not only affect the child directly but also have the potential to do so indirectly, creating a decline in an adult’s parenting capacity, 30
© 2006 Elsevier Ltd
OTHER ISSUES
of parent/child interaction are of particular importance. Figure 4 contains the aspects of interaction that should be assessed in young children, under 3 years of age, and their parents. Structured assessments have a place, e.g. narrative approaches to a child’s attachment, modified Ainsworth assessment of attachment status and the adult attachment interview. Standardized assessments can also assist. For example, the Child Abuse Potential Inventory (Milner) and the Parenting Stress Index (Abidin) can augment clinical assessment.
A schema for parenting assessment Confidentiality issues Area(s) of concern or presenting problems • Each parent’s perspective on caregiving • Any episodes of harm to child(ren) • Each parent’s view on changes needed • Understanding of child’s future needs/ ability to plan ahead
Corroboration Sometimes a corroborative account is essential; for example where parents are suspected of personality disorder, or harm such as emotional abuse, or where fabricated or induced illness is suspected. In these circumstances other sources of information are not only useful but become essential. When assessing child mental health status, accounts from school and/or nursery provide a useful comparison with a parental account. It will often be important to obtain original records in order to clarify past health status, educational achievement or criminal activities. These will need to be obtained with the patient’s full written consent or, if this is resisted, by order of the Court.
Current health/adjustment • Child(ren) • Parents Child(ren)’s personal history and development • Pregnancy • Delivery • Neonatal period • Attachment and caretaking relationships • Milestones • Physical health • General behaviour • Mental state observations • Parent’s views and attitudes towards child and child’s needs
Making sense It is fine to gather data and often from multiple sources. However, how do we make sense of it all, in order to contribute to case
Family structure, history and functioning • Family structure and history Partnerships, pregnancies and births • Family relationships Parent/child relationships Parental relationship (including any violence) Type of communication within the family
Observations of parent/child interaction Child • Attachment behaviour • Emotional state • General behaviour • Responsiveness to parent
Family/social relationships • Friendships, social isolation Each parent’s personal history and current status • Personal history and development Mental health history Past behaviour and current attitudes to illness Understanding of effects of illness on child Evidence of personality disorder/dysfunction History of anti-social behaviour and/or delinquency Substance abuse Parental experiences of care during childhood • Family history • Mental state • Physical examination
Parent Psychological aspects: • Emotional expression • Responsiveness and recognition • Warmth/empathy • Cognitive stimulation/ verbal interaction • Play • Behaviour management • Distance/closeness regulation • Emotional management/containment Physical care: • Feeding • Bathing/changing • Sleep • Safety
3
which may be already compromised through mental illness. This too is adversely affected by relationship difficulties.
Dyadic interaction • Co-operation • Reciprocity/Joint attention
Observations An essential component of a parenting assessment is examination of the mental state of parents and children. Observations
PSYCHIATRY 5:1
4
31
© 2006 Elsevier Ltd
OTHER ISSUES
Making decisions, where a child has been significantly harmed The following stages of decision-making are proposed: 1 Data gathering 2 Weigh relative significance 3 Assessment of current situation 4 Circumstances which may alter child’s welfare 5 Prospects for change 6 Criteria for gauging effectiveness 7 Timescale proposed 8 Child’s plan (child in need plan, child protection plan or care plan, depending on status of the child) 5
planning or child protection decisions? Figure 5 summarizes a structured approach to decision-making about parenting assessments for the Family Courts (for a full exposition see Jones et al., in press).4 There is an evidence base for rational decision-making, but nonetheless clinical evaluation of the relative weight to be placed on different factors, positive or negative, remains a key function of the practitioner. Hence, it is important to set out explicitly how one has reached a decision for the Family Court, in the interests of fairness, and to permit scrutiny. The approach suggested in Figure 5 also allows the practitioner’s prognosis to be assessed over time and plans for child and parent adjusted accordingly. After all, the central function of the practitioner in this area is normally one of risk management rather than mere risk assessment, because it is rare for any such situation to involve no risk.
REFERENCES 1 Ramchandani P, Stein A. The impact of parental psychiatric disorder on children: avoiding stigma, improving care. BMJ 2003; 327: 242–3. 2 Jones D P H. Assessment of parenting capacity. In: Horwath J, ed. The child’s world: assessing children in need. London: Jessica Kingsley, 2001. 3 Department of Health. A framework for the assessment of children in need and families. London: Stationery Office, 2000. 4 Jones D P H, Hindley N, Ramchandani P. Making plans: assessment, intervention and evaluating outcomes. In: Rose W, J Aldgate J, Jones D P H, eds. The developing world of the child. London: Jessica Kingsley, in press. FURTHER READING Reder P, Duncan S, Lucey C. What principles guide parenting assessments? In: Reder P, Duncan S, Lucey C, eds. Studies in the assessment of parenting. Hove: Brunner-Routledge, 2003. Reder P, Duncan S, Lucey C. How are assessments conducted for family proceedings? In: Reder P, Duncan S, Lucey C, eds. Studies in the assessment of parenting. Hove: Brunner-Routledge, 2003. (A pair of chapters which draw together theory and practice of undertaking parenting assessments, particularly those done for family courts.)
PSYCHIATRY 5:1
32
© 2006 Elsevier Ltd