management Assessment of parenting for the family court What’s new? •There has been much concern about the quality of assessments conducted for the family justice system. Additionally, concern in the child care and family justice systems about delay and its consequences has led to pressure on mental health practitioners to proffer decisions that avoid prolonged uncertainty for the child David PH Jones •Courts now have much more specific requirements of expert witnesses Abstract •There is a need for a rational basis for the choice of assessments, and for the practitioner to make explicit the process of their assessment and decision-making, and to have demonstrated that alternative explanations have been considered Mental health practitioners have, potentially, much to offer the family justice system in its deliberations on the care of vulnerable children, especially where adult carers suffer mental health problems. This paper describes what comprises parenting, sets out principles, and describes a framework for carrying out assessments that are based on best available evidence and which may be submitted to the family justice courts. •There is greater interest in attachment research and practice, and its importance in child development. One result is an emphasis on parental support or kinship care for children who require out-of-home care Keywords child abuse and neglect; child maltreatment; expert witness; family justice courts; mentally ill parents; parenting assessment; parental mental ill health Family courts are concerned with children’s welfare, including safety from harm, and so may seek advice from mental health services concerning possible risks to children who are cared for by a mentally ill parent. Psychiatric disorder affects an individu­ al’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 mediated primarily through changes in the quality of parenting and family interactions, although environ­ mental and genetic influences also contribute.2 An assessment of ‘parenting’ can therefore be central to advice provided to the family justice system where a parent is mentally disturbed. This article provides an overview for such assessments, based on established principles for good practice, maintaining child welfare at centre stage. Elements of parenting Basic care Providing for the child’s physical needs, medical and dental care 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 Stimulation Promoting the child’s learning and intellectual development through encouragement, cognitive stimulation, and social opportunities Parenting Parenting comprises those activities and behaviours of caregiving adults that are needed by children to enable them to func­ tion successfully as adults, within their culture (Table 1).3 Guidance and boundaries Enabling the child to regulate his or her own emotions and behaviour. Demonstrating and modelling appropriate behaviour, control of emotions, and interactions with others, and providing guidance that involves setting boundaries. This will help the child to develop an internal sense of moral values and conscience, and social behaviour appropriate for the society within which he or she will grow up David PH Jones MBChB FRCPsych FRCPCH is Senior Lecturer in Child Psychiatry, University of Oxford, and part-time 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 Denver, USA, at the Henry Kempe Centre. His research interests include interviewing children, child maltreatment and its management, and children’s consent to treatment. Conflicts of interest: has received payment for providing evidence in family courts, and receives royalties on three of his books that relate to court work. PSYCHIATRY 8:1 Stability Providing a sufficiently stable family environment to enable the child to develop and maintain a secure attachment to the primary caregiver(s) Table 1 38 © 2008 Elsevier Ltd. All rights reserved. management accepted across ­professional groups, facilitating communication in ­multidisciplinary settings. Principles and assessment framework A human rights perspective guides assessment. The right to fam­ ily life applies to adults with parental responsibilities, and to chil­ dren. Parents have a right to family life unless there are good reasons to the contrary; 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, particu­ larly when younger, for their well-being. When there is a conflict of rights, child welfare considerations predominate, and ‘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 practitio­ ner to see both the benefits and disadvantages for each child in a particular family. This perspective helps to maintain objectivity 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 in context.4 Using the frame­ work, a child’s developmental status and needs are considered, as well as neighbourhood and family factors (Figure 1, left and lower sides of the triangle). Parental mental health is included under ‘family history and functioning’, on the lower side of the triangle. The three sides interrelate and influence an individ­ ual child’s welfare. The framework remains central to govern­ ment policy and procedures concerning children, and is widely Context for assessments The family courts in England and Wales now require mental health experts to answer specific questions when a child’s welfare is under consideration,5 in part as a response to growing concerns about the quality of expert evidence in family courts.6,7 Children’s lawyers will specify areas on which they seek advice from mental health experts. High-quality assessments of parenting will be one component of a full assessment. Parallel assessments of individual parents’ mental health status, family functioning and couple relationships, children’s attachment to their carers, and each child’s mental health and devel­ opmental status are all likely to be needed if a full picture is to be available to assist a Court’s decision-making. The type and scope of assessment will vary according to the expertise and professional training of the practitioner. It is vital that practitioners avoid overextending their opinions for the court beyond their area of expertise.7 Practitioners are also now required by the family courts to be explicit about the limits of their assessments and to show how decisions were arrived at, and are encouraged to discuss alternative conclu­ sions where appropriate.5,7 Advocacy by mental health practitioners is frowned upon, whereas neutral professionalism is encouraged. It is well established, however, that many mentally ill adults do not have their parenting capacity assessed while receiving mental health care – leaving some of their children vulnerable to harm. The approach to parenting assessment advocated here is equally applicable to situations that do not percolate through to family justice courts. The assessment framework Basic care s Self-care skills y ta en pm lo ve de ’s cit ild Stimulation pa CHILD Safeguarding and promoting welfare ca Ch g Education Emotional warmth in Emotional and behavioural development nt Identity Ensuring safety re Family and social relationships Pa ln e ed Social presentation Guidance and boundaries Health Stability Family and environmental factors y or g st in hi ion ily ct m un Fa d f an ily m fa er id W g in us nt Ho me oy pl Em e m l co cia In so ’s n ily io m rat Fa teg in ity un m es m rc Co sou re Adapted from: Department of Health, 2000.3 Figure 1 PSYCHIATRY 8:1 39 © 2008 Elsevier Ltd. All rights reserved. management Assessment process Schema for interviewing parents Mental health and parenting The first essential is a good-quality history of the parent’s men­ tal health and functioning, with accurate chronology. Although standard practice, this history needs to include particular atten­ tion 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 an individual has been over time. Parents should be asked how they 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 concerned, about their capacity to be a good parent during times of ill-health. Equally, they are frequently fearful that their children will be removed into care, but at the same time want help to prevent any ill-effects upon their children. This is a sensitive area for mentally ill parents, because of the stigma they face and possible attitudes from family or neighbours concerning their parenting. Furthermore, the very factors that raise the risk of vulnerability to mental illness also conspire to increase the risk of parenting problems (e.g. childhood experi­ ence of maltreatment; episodes of childhood spent living in care; exposure to inter-parental violence, disharmony, and disruption; drug and alcohol abuse). Enquiring about parenting capacity may also be sensitive because concerns about this will often have been raised already by social or primary health care services, and sometimes a child protection investigation is under way. If concerns are already explicit, 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 parent’s children is more effective. Aims, process of assessment, and confidentiality issues Area(s) of concern or presenting problems: •each parent’s perspective on care-giving •any episodes of harm to child(ren) •each parent’s view on any changes requireda Current health and psychological adjustment: •child(ren) •parent(s) Child(ren)’s personal history and development: •pregnancy •delivery •neonatal period •attachment and care-taking relationships •milestones •physical health •behaviour and mental health •parent’s views on child and his or her needsa Each parent’s personal and development: •childhood and adolescent years •education •work and training •parental experiences of care during childhooda •personal relationships (friendships and romantic) •history of antisocial behaviour and/or delinquency •substance abuse •mental health history 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 Schema for assessment Table 2 lists principal areas to cover in an assessment for fam­ ily courts. While essentially similar to a standard mental health approach, there is added emphasis in particular areas. Limits on confidentiality should be discussed with parents at the outset. The author normally establishes two intended outputs from the assessment –- one for the health system and another for family justice, the latter involving not normal medical confidentiality but a report for the Court. The approach to interviewing should be a combination of obtaining facts, 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 par­ ent 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 permissiongiving question is useful when assessing delay in parental affec­ tion and warmth for the newborn child, such as: ‘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 PSYCHIATRY 8:1 Family/social relationships: •friendships •relations with wider family •social support aConsider the six domains of parenting3,4 Table 2 of ­partners, other family members, and friends can usefully be enquired about at this stage too. The family history and an assessment of family interaction are particularly important. Disharmony and inter-parental violence affect the child directly and also potentially indirectly, creating a decline in an adult’s parenting capacity, which may be already compromised through mental illness. Examination and observations An essential component of a parenting assessment is examina­ tion of the mental state of parents and children. Observations 40 © 2008 Elsevier Ltd. All rights reserved. management Making decisions, where a child has been significantly harmed Observations of parent–child interaction Child •Attachment behaviour •Emotional state •General behaviour •Exploratory behaviour •Responsiveness to parent The following stages of decision-making are proposed: 1Data gathering 2Weigh relative significance 3Assessment of current situation 4Circumstances that may alter child’s welfare 5Prospects for change 6Criteria for gauging effectiveness 7Timescale proposed 8Child’s plan (child-in-need plan, child protection plan or care plan, depending on status of child) Parent Psychological aspects: •Emotional expression •Responsiveness and recognition •Warmth/empathy •Cognitive stimulation/verbal interaction •Play •Behaviour management •Distance/closeness regulation •Emotional management/containment Table 4 not only useful but become essential. When assessing the child’s mental health status, accounts from school and/or nursery provide a useful comparison with a parental account or observations. 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. Physical care: •Feeding •Bathing/changing •Sleep •Safety Analysis Dyadic interaction •Cooperation •Reciprocity/joint attention The assessment process must now shift from gathering data to analysing its salience and making plans for the child and family. Table 4 summarizes a structured approach to decision-making about parenting assessments for the family courts (for details see Jones et al.8). There is an evidence base for rational decisionmaking, 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 Table 4 also allows the practitioner’s prognosis to be assessed over time, and plans for the child and parent to be adjusted accordingly. Mental health input has the potential to make a major con­ tribution to managing risk of future harm to children and their carers in these situations, and there is now a reasonable evidence base for such work to benefit family courts. ◆ Table 3 of parent–child interaction are of particular importance. Table 3 lists the aspects of interaction that should be assessed in young children, aged less than 3 years, and their parents. Structured assessments Mental health practitioners increasingly use structured and stan­ dardized assessments. These have the advantage of encouraging objectivity, broadening scope, and reducing practitioner bias. Dis­ advantages include lack of flexibility and contextualization with respect to measures chosen and to their interpretation. It is import­ ant that such measures are not oversold to the courts as imparting greater scientific merit than is justified by the evidence base. Ben­ efit can accrue from careful and focused selection of assessment measures, tailored to individual case requirements, matched with good clinical work. Practitioners should be prepared to justify choice of instrument, and report benefits and, crucially, limita­ tions of any measures to the Court. Examples include assessment of the quality of the home environment, family structure and functioning, parenting stress, child’s developmental and attach­ ment status, mental health of adults and children, and structured approaches to risk assessment (see Further reading). References 1Ramchandani P, Stein A. The impact of parental psychiatric disorder on children: avoiding stigma, improving care. BMJ 2003; 327: 242–43. 2Stein A, Ramchandani P, Murray L. Impact of parental psychiatric disorder and physical illness. In: Rutter M, Bishop D, Pine D et al., eds. Rutter’s child and adolescent psychiatry, 5th edn. Oxford: Blackwell, 2008. 3Jones DPH. Assessment of parenting. In: Horwath J, ed. The child’s world: assessing children in need, 2nd edn. London: Jessica Kingsley, 2009. Complementary perspectives 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 PSYCHIATRY 8:1 41 © 2008 Elsevier Ltd. All rights reserved. management Department of Health. Assessing children in need and their families: practice guidance. London: Stationery Office, 2000. (Lists standardized assessments of child, family, parents, and home environment relevant to the assessment framework.) Jones DPH. Assessment of parenting. In: Horwath J, ed. The child’s world: assessing children in need, 2nd edn. London: Jessica Kingsley, 2009. (Contains detailed description of assessment process, with recommended observations of parent–child interactions, and standardized measures.) Reder P, Duncan S, Lucey C. Studies in the assessment of parenting, Hove: Brunner-Routledge, 2003. (Contains chapters that draw together theory and practice of undertaking parenting assessments, particularly those done for family courts.) Wall N. A handbook for expert witnesses in Children Act cases, 2nd edn. Bristol: Family Law, 2007. (Essential reading for those providing reports and giving evidence to family courts, written by a leading High Court Judge from the Family Division in England and Wales.) 4Department of Health. A framework for the assessment of children in need and families. London: Stationery Office, 2000. 5President of Family Division of the High Court of Justice. Practice direction - experts in family proceedings relating to children. HM Court Service, April 2008. 6Chief Medical Officer. Bearing good witness: proposals for reforming the delivery of medical expert evidence in family law cases – consultation. London: Department of Health, 2006. 7Wall N. A handbook for expert witnesses in Children Act cases, 2nd edn. Bristol: Family Law, 2007. 8Jones DPH, Hindley N, Ramchandani P. Making plans: assessment, intervention and evaluating outcomes. In: Rose W, Aldgate J, Jones DPH, eds. The developing world of the child. London: Jessica Kingsley, 2006. Further reading Budd KS. Assessing parenting competence in child protection cases: a clinical practice model. Clin Child Fam Psychol Rev 2001; 4: 1–18. (An excellent overview of practice, with useful suggestions for assessment methods, by a clinical psychologist who was central to the American Psychological Association guidelines, 1998.) PSYCHIATRY 8:1 42 © 2008 Elsevier Ltd. All rights reserved.
