AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
Serving the children of parents with a mental illness: barriers,
break-throughs and benefits
Carlie Dean and Coralie Macmillan, South Eastern Sydney Area Health Service
Summary
Introduction
Aims
Barriers
Implementation
Evidence
Conclusions
References
This paper describes what has been learnt within the Children in Families Affected by Mental Illness project in South Eastern Sydney Area Health Service in regard to introducing a systematic approach in adult mental health services to children where parents have a mental illness. It looks at the barriers encountered, the strategies required to overcome them; and mechanisms to incorporate children's issues into the routine practice of adult mental health services. A report is given on what has been achieved in practice, which is as follows: the routine identification of dependent children, the identification of the care needs of children, the identification and reporting of child protection concerns, and increased referral rates to child and family health and community services. A number of intervention options are also discussed, including telephone counselling support groups and a school consultation model.
We know that the children of parents with a mental illness are one of the groups at highest risk for developing mental illness themselves. This makes them a priority group for mental health prevention activities, especially as opportunities exist to reach them, through health service contact with the parent.
South Eastern Sydney Area Health Service has had a project for the children of parents with a mental illness running for the past 2 years. Most of the work has been done in one part of the Area, the Sutherland sector, where a project coordinator has been based. This paper will share with you what we have achieved, what barriers were encountered, and some of the benefits seen already.
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2. What we aimed to achieve in the project:
One of the most important goals of the project was to increase the capacity of the Adult Mental Health Services to respond to the needs of their consumers as parents and to be able to address the needs of their children. This meant being able to identify consumers with dependent children and to determine if the children needed services in their own right.
We also wanted the Adult Mental Health Services to be able to make effective referrals of identified children and families to appropriate child health services and to other relevant community agencies.
Finally, we sought to increase the range of intervention options available for these
children and families, in regard to both clinical treatment and support services.
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- Organisation structure
Families with a mentally unwell parent and dependent children often need the combined expertise of both Adult Mental Health and of Child, Youth and Family Services. As is the case in many organisations, in Sutherland. these services are quite separate, both geographically and organisationally, and report to separate Service Directors.
The first issue encountered was where to place the coordinator for the project: with
the Adult Service or the Child, Youth and Family Service as the coordinator needed to
straddle these services. It was decided to place her with the Child, Youth and Family
Service, whilst at the same time reporting to the Adult Mental Health Director. The
resultant tensions, and feeling of not really belonging to either service, we think have
mirrored the difficulties families can experience in getting integrated care across these
two health services.
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3.2 Barriers from Adult Mental Health Services
- The view some Adult Mental Health workers had of their role
Some adult mental health workers began with the view: 'The adult is our consumer not the family'; 'The children are not our responsibility'.
The dominance of the medical model of treatment and an almost exclusive focus on the seriously mentally ill certainly contributed to this view.
- Competing demands
Where resources are constrained there is the tendency to revert back to 'core business', which is seen as the assessment and treatment of the unwell adult rather than helping the family as a whole.
- Lack of knowledge and skills in working with children and parents
Many of the adult workers had little understanding of children's issues and their development, and even of how to talk to children. They also did not know how to assess how the adult consumer was doing as a parent beyond looking for obvious indicators of abuse and neglect.
- Ethical conflicts
The adult workers often felt that their loyalties were to the parent and that a separate worker was needed to work with the child and advocate for their issues, including making child protection reports.
- The perception that there is a lack of intervention options or the families won't accept help
Another barrier was the view and sometimes the experience of some workers that the children would not receive help even when they were identified.
1. Barriers from child focussed services (health and community agencies)
2. Barriers from the families themselves
- Fear that the children will be removed if they admit help is needed for the children or for themselves in their parenting role.
- Reluctance to want others involved with the children to know about the parental mental illness eg the child's school.
- These families often have chaotic family situations, especially when the parent is
unwell.
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4. What has been implemented in the Sutherland project:
4.1 In Adult Mental Health Services
- Intake / Triage form
A standard intake /triage form now includes the following questions:
- Children under 18 years in household?
- Where are children and who are they with now?
These two questions have been made "required fields" in the consumer data base and so must be completed in order to register the consumer.
The triage form includes an assessment of risk and of support available and has prompts to consider any children in considering these issues. The form also has an Action Plan which has a prompt to identify plans for children's care.
- Comprehensive Assessment Form
A standard comprehensive assessment from is used in the Adult Mental Health Service which has one page for family and child information. A Genogram is required showing the ages of children. For dependent children this page contains a checklist to screen for the needs of the children.
Child Risk Checklist
- Is the child / children exhibiting a behavioural / emotional / learning problem?
- (If yes) Is the problem persistent and /severe? If yes, please give details
- Is the child /children receiving help? If yes, where?
- Is the mental illness of the family member both severe and long term?
- Is there a reliable caregiver during periods of acute parental mental illness?
- Is there or has there been abuse / neglect /contact with DOCS?
- Is the child /children involved in the family member's delusions?
- Do you as a clinician have any other concerns pertinent to the child /children?
(eg severe ongoing conflict in the family). If yes, please give details - Is there immediate safety risk for this child /children?
The first 3 questions are about current emotional, behavioural and learning problems,
whether they are severe and persistent and whether the child is receiving help already.
The other questions are about risk factors and safety issues. If any concern emerges from
this screening checklist the worker is asked to write a management plan for the child as
well as for the adult consumer. This includes specifying referrals made. A range of
services, both health and community agencies, may be the destination of these referrals.
The care and safety of dependent children is included in the treatment plan for the adult
consumer.
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4.2 What else we have done
- Increasing the awareness and understanding of the needs of these children and impact of the parental mental illness on them
- Use of screening instruments
- Knowledge of child and adolescent mental health services, other community resources for children and families (Resource Pamphlet produced to assist with this)
- Child Protection training
- There have been some case presentations where parents had a mental illness and a collaborative approach was needed between different teams/services
- Joint meetings between Adult and Child, Youth and Family services staff have been important in helping these services understand each other better. When new staff commence orientation to each other's services is included in the orientation program.
- The Project Coordinator has been working closely with the Child, Youth and Family Services
- The Project Coordinator has been actively working with a range of community agencies outside health, to achieve better cooperation around these families. Part of this work has been to support specific families, and some work is towards the development of collaborative ventures to try to have a greater range of needs met eg recreational and support needs. These agencies include: Department of Education, Sutherland Department of Community Services, and Non -Government Organisations such as Sutherland Family Support Service Inc., The NSW Carer's Association, the Carer Respite Centre, ARAFMI NSW, our local HACC (Home and Community Care) via the HACC Carer Support Worker and Engadine District Youth Service.
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4. 3 Interventions:
It soon become apparent within our project that these children and families have a broad range of unmet needs. The project has been trying to increase the range of intervention options available in health and across the community for these families, often in partnerships with other agencies.
We have already mentioned collaborative treatment approaches between Adult and Child, Youth and Family Mental Health Services. We will now briefly mention some examples of other interventions we are providing or seeking to set up.
- Telephone Support Groups for children
We ran 2 of these last year with groups of children between 8 and 12 years of age. They work by having a group of around 6 children connected by a telephone conference link-up with 2 facilitators. The group is scheduled at a set time each week and is conducted over 7 weeks. The aim is to provide the children with support, peer contact and to build on current coping skills. One advantage of telephone groups over face to face services is that access difficulties should be reduced.
Despite this we still had trouble recruiting the numbers necessary for the groups, with 5 children in one group and 3 in the other.
So far, evaluation has been limited to qualitative feedback from the children and parents. The feedback was that the children enjoyed the experience, found the group very supportive and thought they had learned some new ways of coping with difficulties. They all wanted to stay in touch and identified a wish to do recreational activities together.
The NSW Carers Association has produced guidelines for telephone support groups and also offers training for facilitators.
- School Consultation model
This is a model which has been used in some cases when the family will not accept a referral to child and family mental health services. Instead, consultation is provided to school personnel, so that they are in a better position to know how to best support the child. The school might request assistance for a child who is not attending school, or who is having serious difficulties in coping, and parental mental illness is a contributing factor. School personnel can play a very important role in supporting the child and managing their difficulties but they need some understanding of the parental mental illness and how to help the child and family. The Adult Mental Health services may be treating the parent and can provide helpful information to the school about mental illness.
The consultation model is one where a worker from the Child and Adolescent Mental Health Services and sometimes from the Adult Mental Health Service, attend a case conference at the school. Others at the case conference can be relevant teachers, the Principal and school counsellor, the Home-School Liaison Officer (if attendance is an issue) and in some cases a Department of Community Services officer. If possible, one or both parents are also involved in part of the meeting.
Confidentiality of health information and consent to have health workers involved are
two of the tricky issues that must be negotiated within this model. The onus is on the
Principal to discuss the involvement of health staff with parents and to gain consent.
Where Adult Mental Health services are already involved the onus is also on the mental
health worker to negotiate with the parent what information can be given to the school. In
some cases where there are child protection issues, the exchange of information may occur
without parental consent.
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It is all very well to have policies and procedures in Adult Mental Health Services which require workers to ask about children and their needs, but are they actually doing this in practice?
A file audit has recently been undertaken to examine what is being implemented at the Intake/Triage and Assessment phases in the Sutherland Adult Mental Health Service. 50 files of adults assessed by the Mental Health Service where there were dependent children were examined.
All adults are now asked at Intake/Triage if there are dependent children under 18 years in the household, and who are they with now.
At the next stage of Comprehensive Assessment genograms were completed in 39 of the 50 files which show family structure and the ages of the children. The other 11 files did not include the genogram but
the ages of children were documented in the file. In about only one third of cases is the Child Risk Checklist being used. However, staff are documenting child protection concerns and sometimes problems with parenting in other parts of their assessment. There was evidence that for 80% of the adults assessed, the worker had specifically asked questions about risk factors for the children. The adult workers are making reports to the Department of Community Services about these child protection concerns. Of the 50 files examined, in about 40% of cases child protection concerns were noted and acted upon. The file audit also showed that children were being referred to a variety of health and community agencies for services.
Follow up with the Child, Youth and Family Service and other health and community agencies showed that these referrals were accepted and acted upon. We are now following up the child protection cases up with the Department of Community Services to find out the outcome of these reports.
This project has increased the capacity of the Adult Mental Health Services to address
the needs of parents in their services and of those of their children. It has also
achieved closer collaboration between the mental health services for adults and for
children and adolescents, and between health services and other community agencies, such
as schools. However, there is still a lot to be done in finding out what interventions
will really help these children and families - reducing the risk to these children and
enhancing their resilience.
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Einfeld, S. & McLaughlin, K. (1998) Services for Children of Parents with Mental Illness in South Eastern Sydney Area Health Service: Background Report and Recommendations. South East Health, Sydney.
Acknowledgments:
Thanks to the steering committee for this project: Dr Grant Sara, Dr Chris Rikard-Bell, Kay Vine, Fernando Gomez, Kerrie Gill, , Evelyn Chandler, Joy Pennock, Helen Sowey, Sue Flatt, Lee Love, Lyn Hayes, Graeme Marsten, Gloria Pepper, Marie Miller, Rosemarie Marsden, Dyanne Moxham.
Thanks too to A/Professor Stewart Einfeld
The efforts of many agencies who have made a large contribution to this project or client group are also gratefully acknowedged:the Division of Mental Health, Sutherland, the Child Youth and Family and Drug and Alcohol staff at Sylvania, Engadine, Menai and Possum Cottage, Sutherland District Office of Department of Education and Training and school staff, Sutherland Family Support Services Inc Staff, Sutherland Family Network staff, Carers NSW Inc., Rotary, HACC, Engadine District Youth Services, and the NSW Network Supporting Children and Young People of Parents with Mental Health Problems.
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