THE TOXIC TRIO: Assessing & Responding to the Impact on Children, Young People and their Families

1. THE TOXIC TRIO:Assessing & Responding to the Impact on Children, Young People and their Families David Glover-Wright

2. The term 'Toxic Trio' has been used to describe the issues of domestic abuse, mental ill-health and substance misuse which have been identified as common features of families where harm to children has occurred. They are viewed as indicators of increased risk of harm to children and young people.

3. Workshop to include: • The key aspects of contemporary practice when working with ‘the toxic trio’ • Assessing and evaluating the impact on children & young people • How to work with families where these problems exist, promoting ‘systemic’, child and family centred approaches • Safeguarding children through the application of holistic risk assessments, ongoing risk management and positive inter agency practice

4. Social learning/ peer group influences Psycho social factors, gender roles PARENTAL DOMESTIC VIOLENCE PARENTAL SUBSTANCE MISUSE cognitive/ behavioural impact child/ young person increased vulnerability, self medication, negative coping strategies ) Interdependency, emotional stress, trigger points established PARENTAL MENTAL ILL HEALTH Personal values/ cultural influences/ factors/ / religion

5. Happy families?

6. What are some of the key concerns? Take five minutes to talk with your neighbour and identify three key concerns in your working practice for families where there is domestic violence (historic/ present), alcohol/ drug dependency and mental health vulnerability.

7. The Family Model ( after Falkov 1998) Risks: environmental, social, economic, & family stressors = vulnerability Parenting & the parent-child relationship Adult mental/ physical health Child emotional health & development Protective factors and resources: family & social network, coping strategies, emotional resilience We have an ongoing responsibility to balance risk factors against protective factors when working with families. For this to be done effectively, there needs to be a family centred assessment process which focuses individually on the children and adults’ needs and then considers these in the ongoing parent/ child relationship. Introduction to Mental Health

8. Signs of Safety: • What’s working well? (strengths and positive coping strategies) • What are we worried about? (concerns impacting directly on the children’s wellbeing) • What needs to be done? • Drawing up a safety plan and working in partnership • ‘The ecological model’

9. Information gathering and analysis is critical: • The behaviours exhibited by children experiencing problems in their home environment are often similar, e.g. poor attachment to parents due to emotional unavailability or poor attendance at school or nursery. • While mothers’ parenting appears to be adversely affected by domestic violence, there is evidence that their parenting can recover once they are no longer living with domestic violence (Stanley, p54) • Cassell and Coleman (1995) suggest that, when assessing the risks of harm for children, professionals should consider the following factors: • The warmth of the parent-child relationship • The parent’s responsiveness to the child’s needs • The content of any delusional thinking • The parent’s history of anger management • The availability of another responsible adult (Stanley et al p.334) Stanley N, Cleaver H, Hart D (2010) “The Impact of Domestic Violence, Parental Mental Health Problems, Substance Misuse and Learning Disability on Parenting Capacity” The Child’s World. 2nd edition, London: Jessica Kingsley Publishers Cassell, D. and Coleman, R. (1995) Parents with psychiatric problems. In: Reder , R. and Lucey, C. (eds.) Assessment of parenting: psychiatric and psychological contributions. London: Routledge)

10. Reflective practice

11. Reflective practice • How can you ensure you are reflective in your practice? • What do you need in your working life to ensure this happens? To be reflective you need to develop your specialist knowledge and increase your practice experience.

12. KEY HEALTH CONCERNS & INDICATORS • How do we know if children are at risk with parents where there is evidence of the toxic trio?

13. HEALTH CONCERNS & INDICATORS: • Has the baby failed to thrive? Is the baby showing any of these symptoms - irritation and high-pitched crying, often for long periods; rapid breathing and heart rate; disturbed sleep patterns; sweating and fever; vomiting and diarrhoea and feeding difficulties? • Babies of women whose use of opiates, cocaine or benzodiazepines during late pregnancy is heavy are likely to experience withdrawal symptoms. • Do children have accidental or non-accidental injuries? • Children are at increased risk of physical injury during an incident [of domestic violence], either by accident or because they attempt to intervene. • Poverty and a need to have easy access to drugs may lead families to live in unsafe communities where children are exposed to harmful anti-social behaviour and environmental dangers such as dirty needles in parks and other public places • Neglect involving denial of critical care and lack of supervision was most likely to be the sole form of maltreatment in those families with the most severe forms of domestic violence • When intoxicated, parents may fail to hear their child’s cries or notice he/she is unwell; they may accidentally smother them when unconscious due to drugs; they may leave the child unattended when seeking money or drugs

14. HEALTH CONCERNS & INDICATORS contd • Do young children present with stomach-aches and bed-wetting (psychosomatic symptomology)? • Hester et al note that pre-school children are more likely to show physical symptoms such as stomach-aches and bed-wetting [as a result of living with domestic violence]. (Stanley et al, p.331) • Are adolescents involved in problem alcohol or drug use or unsafe sex? • Adolescents may become involved in drugs or early pregnancy [as a result of living with domestic violence] (Stanley et al, p.331) (Stanley N, Cleaver H, Hart D (2010) “The Impact of Domestic Violence, Parental Mental Health Problems, Substance Misuse and Learning Disability on Parenting Capacity” The Child’s World. 2nd edition, London: Jessica Kingsley Publishers)

15. Education concerns: • Are younger children meeting developmental milestones? • Parents may not have the practical or emotional reserves to engage with their children in order to provide stimulation to support their development. (Stanley et al, p.337) • Are appropriate toys available at home? • Finding money for drugs may reduce what is available to meet basic needs • Do children attend school or nursery regularly? If they attend do they arrive on time? • Education can suffer when adolescents stay home to protect their parent or themselves from an abusive partner. • For a variety of reasons including disorganisation and lack of self-esteem, drug misusing parents may fail to enable the child to attend pre-school facilities. • Are children alert at school or nursery? Are children failing to achieve their educational and developmental potential? • Research suggests that children’s education and performance in school may suffer because parental problems dominate the child’s thoughts and can affect concentration(young carers)

16. Emotional & behavioural development concerns: • Is there poor attachment with parents? • For babies and infants post natal depression may hamper the mother’s capacity to empathise with, and respond appropriately to, her baby’s needs. A consistent lack of warmth and negative responses increases the likelihood that the infant will become insecurely attached. Mood swings, a common feature in mental disorders, can result in inconsistent parenting, emotional unavailability and unexpected and unplanned for separations. • The all consuming nature of significant substance misuse problems may mean it becomes the user’s primary attachment, distorting other relationships, including the ability to show children emotional warmth and make them feel valued. (Stanley et al, p.337) • Are children expressing anxiety or stress? • Primary age school children may present a wide range of behavioural and emotion problems [as a result of living with domestic violence] (Stanley et al, p.331) • It is widely accepted that boys are more likely to act out their distress with anti social and aggressive behaviours while girls tend to respond by internalising their worries. • Is there evidence of detachment and dissociation in the child/ young person’s behaviour? • Witnessing domestic violence affects children’s emotions and behaviour and can lead to temper tantrums and aggression which are directed at family and peers, and cruelty towards animals

17. Child identity concerns: • What happens when there is lack of support for adolescents going through puberty? • Parental problem drug misuse may mean parents are unaware of children’s worries over their changing body/ personality and fail to provide support and advice • Is there an acceptance of domestic violence (and what happens as a consequence?) • Men participating in Stanley et al’s (2009) study of men’s views and experiences of domestic violence undertaken in northern England described how their perpetration of domestic violence was interwoven with other forms of community violence encountered in childhood and with traditional and persistent conceptions of masculinity (football!) • Does the child or young person have low self-esteem? • Studies undertaken from the perspectives of children and young people also draw attention to the effects of the secrecy and stigma surrounding domestic violence on young people’s self-confidence, self-esteem and consequent capacity for making

18. Family and social relationships concerns: • Does the child have irregular meal and bed times? • Difficulty in organising day to day living [as a result of parental substance misuse] means that important events such as birthdays or holidays are disrupted and family rituals and routines such as meal or bed times, which cement family relationships, are difficult to sustain. • Adolescents with few friends: • Many adolescents cope with the stress of domestic violence by distancing themselves from their family or friends. • Studies undertaken from the perspectives of children and young people also draw attention to the effects of the secrecy and stigma surrounding domestic violence on young people’s self-confidence, self-esteem and consequent capacity for making relationship with peers. (Stanley, p.31)

19. Social presentation concerns: • Are children unwashed and wearing dirty clothes? • Difficulty in organising day to day living [as a result of parental substance misuse] means that important events such as birthdays or holidays are disrupted and family rituals and routines such as meal or bed times, which cement family relationships, are difficult to sustain.

20. Level of self care skills • Are the older siblings caring for their younger siblings? • Education may also be interrupted while parental mental health problems become severe and young people stay home in order to look after their parent or younger siblings. • Do adolescents present as “older than their years?”: • When parents are unable to look after adolescent children adequately [as a result of substance misuse], the normal pace of emotional maturity can be accelerated and for some the relationship between parent and child is reversed.

21. Good multi agency practice – the key to keeping children safe Partnership working • Research findings (Ward et al 2010) indicate that social workers rarely consult or collaborate with services for substance misuse and domestic violence in carrying out assessments or planning • Collaboration should be given greater priority because practitioners in domestic violence units, alcohol and drug services will have a better understanding of how these issues impact on adult family members and family functioning. • The expertise of practitioners in these specialist services should be used to inform the social work assessments, judgements and planning. How can we promote more effective multi agency practice? (Ward H, Brown R, Westlake D, Munro ER (2010) Infants suffering, or likely to suffer, significant harm: A prospective longitudinal study, London: Department for Education)

22. Parental mental health • Mental health vulnerabilities are going to be present if there are abusive/ violent parental relationships and if there is substance misuse/ alcohol dependency.

23. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Organic, including symptomatic, mental disorders (dementias) Mental and behavioural disorders due to use of psychoactive substances (substance misuse) Schizophrenia, schizotypal and delusional disorders Mood [affective] disorders (bipolar, depression) Neurotic, stress-related and somatoform disorders (anxiety/ agoraphobia) Behavioural syndromes associated with physiological disturbances and physical factors (eating disorders, nightmares) Disorders of personality and behaviour in adult persons (BDP, pyromania, transsexualism, paedophilia) Mental retardation (mild, moderate, severe) Disorders of psychological development (dyslexia, language disorders) Behavioural and emotional disorders with onset usually occurring in childhood and adolescence (ADHD) Unspecified mental disorders (nobody knows…)

24. Diagnostic labels……… Acute psychotic depression Schizoaffective disorder Schizophrenia Long term depression with psychological problems Primary depressive disorder Recurrent psychotic depression Bi-polar disorder Personality disorder (s) 24

25. ‘Would you go behind the blinds, take off your personality and put this label on …?’ Illustration by Fran Orford 25

26. Impact of Parental Mental HealthProblems on Children Children of mentally ill parents are an ‘at risk group’ Higher prevalence of emotional and behavioural difficulties in children with a parent with a psychiatric disorder- about a third of these children have a persistent disorder and a further third have transient psychiatric difficulties compared to 10% of a community sample. (Rutter & Quinton,1984, ONS data, 1999, Research in Practice, 2009)

27. Impact of Parental Mental HealthProblems on Children Increased rates of disorder in children results more from greater psychosocial disadvantage experienced in families affected by parental mental health problems than from the illness per se. Children’s problems appear to be exacerbated by factors such as marital discord, family disruption and the quality of parent-child interaction. Recent studies show a more complex relationship between specific disorders in parents and disorders in children.

28. Early Years • Children develop quickly in their early years and the impact of parental mental health problems can be significant if key developmental stages are affected or impaired

29. Impact of The Toxic Trio on Children - Feelings Distress Anger Worries – fear for themselves Fear for parents Confusion about the situation & the parent’s difficulties. Not understanding the nature of the parent’s illness. Guilt & Blame – blaming themselves or being blamed Experiencing hostility and scape-goating for parents’ problems

30. Impact of The Toxic Trio on Children Missing school Missing leisure opportunities eg outings, having friends home Young carers ‘Loss of childhood’

31. But…..How many parents in the UK actually have mental health problems?

32. Approximately one in 10 mothers and one in 20 fathers are thought to have mental health problems impacting on their children • At least one in four adults in contact with mental health services is a parent. • As many as 25% of children between the ages of five and 16 have a mother who is at risk of a common mental health problem such as depression or anxiety. • In an average primary school class six or seven children will be living with a mother with a mental health problem; many of these will be lone mothers who are statistically more at risk .

33. How many parents in the UK have mental health problems? • Overall more women than men have mental health problems. • More younger women and more lone parents than those in couples have mental health problems. • Lone parenthood, particularly among women, seems to be a risk factor for mental health problems. • This is often associated with socio-economic disadvantage and the interaction of other risk factors.

34. Working together? Once identified, it is clear that in many cases parents with mental health problems fall through the net and their needs are not met. Services often fail to work holistically with families (despite the ‘Think Family’ approach); poor collaboration and service coordination, together with confusion over professional roles and responsibilities, make the difficulties worse. Introduction to Mental Health

35. Case scenario 1 • Putting the pieces together

36. Children's Social Care received a referral from Weavers School due to concerns for a mother's emotional wellbeing and her problems in getting one of her children to school on time. This seems due to current mental health concerns centring on her anxiety and depression. The family have recently moved to MK from Luton. Gina has become emotionally distressed due to her partner (and children’s father) Joe leaving the family home a few weeks earlier. School have assisted Gina in seeking medical support from the GP. Joe has since returned to the family home but continually comes and goes leaving for a few weeks at a time. Gina is not willing to accept support from the local CFP but has a good relationship with her GP. Gina is struggling to sort out her relationship with Joe and has suffered violence and aggression from him in the past. Both Gina and Joe have had difficult childhoods. Gina suffered physical and sexual abuse whilst Joe had a very unhappy childhood with his father dying from alcohol poisoning when he was 11 years. There was also a significant level of domestic violence in his family home. Introduction to Mental Health

37. Case scenario 1 contd • Joe and Gina confirm relationship problems exist between them. Gina's anxieties and depression impacts on family life and makes it difficult for her to prioritise her 3 young children’s needs. • Joe finds it difficult to cope with ‘family life’ and struggles particularly to have any feelings for Justin (6years). He often shouts at him when things are going wrong in the family. He sometimes loses his temper and will physically damage things by punching and hitting etc. Gina feels her depression is not out of control and doesn’t think its affecting her children in any negative way. She admits she sometimes struggles to get Justin to school as she often feels low and wants to remain in the safety of her home. • The family are isolated and have few contacts in their new area of MK. The other two children (Joshua, 3ys and Jaidon, 1yr) seem to remain in the family home for long periods of time and they seem to seldom leave the family home. 1. What are the key issues and priorities in this case? 2. How can we work with this family?

38. A Family-Centred Approach • Talk to children & help parents talk to children, promoting good communication & attachment. • Use child-centred language. Always consider the age • and developmental stage of the child(ren) • Drawing, toys and play can help children communicate (signs of safety) • Check out the child’s understanding of parent’s illness. • Provide a child centred explanation of parent’s illness sufficient to help child (ren) make sense of the situation but not so much that it overwhelms.

39. A Family- Centred Approach Services should plan & work proactively with the family: • Children may want to know about prognosis • Children’s understanding of their parent’s needs can help to pick up on ‘relapse indicators’ • Contingency plans need to be in place for when parent is unwell • There needs to be a positive response to young carer issues • Interventions should promote normal opportunities for children • Supportive relationships need to be engendered in the family’s wider networks (FGCs).

40. Working in partnership with the family (systemic approaches) – how can we address the needs of parents and their children using safe and child centred approaches? Introduction to Mental Health

41. Think Family Approach Introduction to Mental Health

42. And not………….

43. Circled by Agencies! Introduction to Mental Health

44. The ecological model • Where are the strengths and where are the weaknesses? • How do we determine what is ‘safe’ and what is risk laden?

45. APPLYING SYSTEMIC THEORY TO SOCIAL CARE SITUATIONS Social and cultural constraints GP Carol friends Roger Social pressures Mental Health Alice Grandad Liam Craig school friends Introduction to Mental Health

46. Case Study 3 Craig 14ys, Alice 12ys and Liam 11ys live together with their mother (Carol) and father (Roger) in a small mid-terraced house in Bletchley. Roger and Carol have had a stormy relationship for some years. Roger has begun to spend an increasing amount of time away from the family home staying late at his job as a mechanic in the local garage. When he’s not working he is usually down the local pub and often comes home in a drunken state, which usually sparks off arguments and noisy exchanges. Roger’s behaviour towards his wife has deteriorated and he has begun punching and shoving her when they argue. Carol has become increasingly stressed by the situation and has begun to experience incessant headaches and feelings of panic. She has found it difficult to go to the shops after recently experiencing a panic attack whilst she was waiting in the check out queue. Roger has got in to a dispute with a neighbour and there are regular angry exchanges after complaints were made about the noisy late night rows. The two boys have started to target local families and there are regular incidents of vandalism and criminal damage. The community safety team are already involved with the family as a consequence. The local Age Concern day centre are concerned about Roger’s father and he has been attending with bruising evident to his arms and legs. Carol seems to be her father-in-law’s main carer and she has put this down to his ‘bruising easily’. Craig is persistently truanting from school. He has been hanging out in the city centre and has a pending court case for assault and criminal damage. Both boys are heavy smokers and Carol has found evidence of ‘drugs paraphenalia’ in their bedroom. Liam has been suspended from school for swearing at a teacher and Carol finds it increasingly difficult to discipline the two boys. Introduction to Mental Health

47. Case Study 3 contd. Carol recently went to her GP and was prescribed tranquillising medication which makes her feel much worse. Alice attends school on a regular basis and has made good progress in her new secondary school. She seems to want to stay on late at school and seldom talks about life at home. Teachers describe her as a very serious intense child who finds it hard making friends. One evening after a particularly violent row with Roger, Carol took a serious over dose necessitating her admission to a medical ward for a few days. Roger attempts to keep the family together as best he can but has frequent angry exchanges with Craig who accuses him of trying to kill their mother. Things reach crisis point later in the week when Craig has a major row with his dad and leaves the house. Carol returns home from hospital to find her husband distraught and upset, Liam has gone out after his brother and Alice is alone in her bedroom. Roger’s father appears to be oblivious to it all and is sitting in his chair from which he seldom moves. 1) What plan of action can you put together which encompasses the needs of this family? 2) What are the key issues you need to address with the family? David Glover-Wright Introduction to Mental Health

48. The container theory Rubbish bin or safe container?

49. The container-contained relationship (Bion 1962) • “Mother is receptive to the baby’s feelings - feeling the baby’s feelings in herself,.Through this the baby’s state of mind and feelings can be tolerated and known by the mother and some sense can be made of them (meaningful attachment). Therefore feelings that were too powerful for the infant to hold within himself can be thus made tolerable…and can be contained by the mother who acts as a container” . • The mother is open to emotional communication- has space for uncertainty and ambiguity in communication, and to think about meaning. Workers should develop this capacity through focused work with parents. • Developing reflective practice and countering the ‘fight or flight’ mechanism. • “Having a sense of being kept in mind provides an opportunity to reflect on emotional experiences” – taking the young person’s thoughts and predicament seriously encourages communication of inner states to take place (Briggs 2002) • The absence of containment leads to children experiencing reduced hope or faith in the possibility of communicating to others about their state of mind; ultimately withdrawal and an emotional shut down will occur • The experiences of being contained in childhood influences the adolescent’s capacity to make sense of and contain the anxiety, ambiguity and uncertainty of adolescence. Having a containing relationship helps one to understand and develop one’s individuality. • Achieving a secure identity can only take place through and within a relationship with others. 49

50. Developing a containing relationship with a child/ young person This will involve: • accepting and respecting the child/ young person’s circumstances • striving to be reliable, attentive, empathic, sympathetically responsive and encouraging the child/ young person to talk about their thoughts and feelings • recognising the importance of emotional communications • providing psychological space and keeping him/her in mind • having a ‘psychological space’ to reflect & think Because: • Containing relationships has a transformational impact on adolescent turbulence. Being kept in mind enables the adolescent to develop and bear the emotional impact of his/her thoughts and feelings. • Developing their capacity to make intimate emotional bonds with others, enables effective personal functioning and stable mental health 50