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Assessing Parenting Capability for Parents with Psychiatric Disorders Laura J. Miller MD Vice Chair for Academic Clinical Services Director, Womens Mental.

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Presentation on theme: "Assessing Parenting Capability for Parents with Psychiatric Disorders Laura J. Miller MD Vice Chair for Academic Clinical Services Director, Womens Mental."— Presentation transcript:

1 Assessing Parenting Capability for Parents with Psychiatric Disorders Laura J. Miller MD Vice Chair for Academic Clinical Services Director, Womens Mental Health Division Department of Psychiatry Brigham and Womens Hospital Harvard University




5 There can be substantial risks to children who Remain with a mentally ill parent Are separated from a mentally ill parent Judges and child welfare personnel must rely on experts to assess aspects of mental illness that relate to parenting capability How can one know which expert testimony is reliable?

6 In the context of parental mental illness, we will address: What is parenting capability? What is an evidence-based way to assess parenting capability? How can parenting assessment results be presented in an adversarial context while preserving their scientific integrity and validity?


8 Capable parenting is not the same as optimal parenting signifies low risk of abuse or gross neglect Assessment of parenting capability means systematic evaluation… using validated methodologies… of factors that have been empirically demonstrated to correlate with a high risk of (or protection against) child abuse and/or neglect

9 Commonly used tests with no demonstrated link to parenting capability Brodzinnsky DM: Prof Psychol Res Pract 24:213-9, 1993; Budd KS, Holdsworth MJ: J Clin Child Psychol 25:1-14, 1996

10 Measurable factors that affect risk of child maltreatment Factor linked with maltreatment risk Assessment tools Parenting behaviorsCrittenden Index Insight into mental illnessScale for Assessment of Insight Working knowledge of child development Parent Opinion Questionnaire Internal representations of the child Expressed Emotion scored interview Parenting stressParental Stress Index Maternal early traumaChildhood Trauma Index Social supportArizona Social Support Inventory

11 Direct observation of parenting behaviors: the role of attachment Key tenets of attachment theory Children must develop emotional attachment to at least one caregiver in order to have healthy social and emotional development Consistency, sensitivity and responsiveness in a caregiver promote attachment Empirical data Different patterns of attachment correlate with risk of child maltreatment and strongly affect childrens prognosis These patterns are reliably measurable and cant be faked

12 How attachment patterns are measured Videotaped separation and reunion Parent and child, alone in a room, are asked to play Parent is asked to leave for 3 minutes; a stranger (clinician or research assistant) stays with the child Parent returns This separation and reunion are repeated Scoring (Crittenden Index) Childs behaviors on reunion Parents behaviors on reunion



15 Caveats about attachment assessments Attachment observations are best used to understand a childs current feelings about a parent, and whether a child shows at risk attachment patterns that need to be addressed. A common error is to infer parenting capabilities from attachment observations (e.g, Ms. A lacks minimal parenting capability because her children were all insecurely attached to her). Separations can create high levels of insecurity in a child. It is relatively rare for a foster child who has experienced prolonged separations to show secure base behavior with a non-custodial parent. If a child shows secure behavior despite separations, it may be evidence of exceptional parenting.

16 Parenting Assessment Team (PAT) A multidisciplinary team of health professionals with expertise in assessing the influence of mental illness on parenting capability and risk of child maltreatment. Uses the most methodologically sound, culturally congruent assessment tools available. Gathers and uses relevant records (e.g. medical, psychiatric, child welfare, criminal). Provides unbiased assessments that are not linked to only one side of adversarial court cases. Presents findings and recommendations in clear, succinct reports for decision makers who are not health professionals. Conducts follow-up evaluations to assess adherence to, and effects of, recommended interventions. Educates decision makers about assessment methodology.

17 Initiating the PAT process Referrals are accepted only from child welfare personnel Team coordinator (social worker) helps requester articulate the question(s) to be addressed Process is explained to the parent(s), including role of the evaluators and limitations on confidentiality Records are obtained and reviewed (medical, obstetric, pediatric, mental health, criminal, child welfare)

18 PAT evaluation Psychiatrist Psychiatric interview Scale for Assessment of Insight Psychologist Semi-structured parenting interview Validated questionnaires Systematized, videotaped, scored direct observation of parent-child interactions Psychological and developmental assessment of children (interviews and standardized measures) Social worker Collateral history from significant others Direct observation of, and in, the home environment Structured and clinical assessment of social support network

19 PAT psychiatric evaluations Determine the psychiatric diagnosis or diagnoses, if any Assess the parents insight into the psychiatric condition In conjunction with other parts of the parenting assessment, assess the specific impact of psychiatric symptoms on parenting At baseline During acute episodes of illness Treatment considerations Assess the efficacy of the parents current mental health treatment Assess the parents adherence to the current mental health treatment Determine whether any change in the mental health treatment plan is likely to improve parenting capability

20 PAT psychiatric evaluations: insight into mental illness Four major components Acknowledgement of illness Acceptance of treatment Initiative in seeking treatment Explanation for illness Correlates with effective parenting behavior; diagnosis does not Scale for Assessment of Insight can be used Mullick M et al: Psychiatric Services 52:488-492, 2001

21 Example of conclusions from a PAT psychiatric evaluation Ms. Booth has taken her medication as prescribed, and has attended her day program regularly. These interventions have substantially improved her ability to care for herself, and have decreased the frequency of her hospitalizations from an average of four per year to about one per year for the past two years. However, even with her sustained commitment to treatment, she continues to have delusions that she cannot distinguish from reality. She continues to act on her delusions sometimes, in a way that would pose risks for her son Thomas if she were his primary caregiver. For example, when she believes the CIA is spying on her, she stops going out to buy groceries and stops allowing anyone into her home. In the past, similar delusions and their resultant behavior caused Thomas to become dehydrated.

22 PAT psychological evaluations: Parenting Interview The parent as a child Experiences with caregivers How those have affected well-being and parenting Current state of mind about early traumas The parent as a parent Feelings, thoughts and attitudes toward the parenting role Self-appraisal of parenting strengths and weaknesses Reasons for allegations/custody loss, including what the parent would do differently How parent would handle different situations with children of different ages

23 PAT psychological evaluations: internal representations of the child Parents internal representation of a child reflect parents sensitivity to the child as an individual recognition of the childs needs. Internal representations can be balanced or skewed Realistic or unrealistic Detailed or sparse How internal representations are measured Parent is asked to speak for 5 minutes about the child, including what the child is like as a person, and on the parents relationship to the child. Parents speech is recorded, transcribed and scored according to a standard system.

24 PAT psychological evaluations: validated tools Questionnaires Childhood Trauma Inventory Parental Stress Index Parent Opinion Questionnaire Direct parent-child observation Videotaped separation/reunion Crittenden Index scoring

25 PAT: interpreting and reporting data Each clinician interprets and reports on individual findings Team reviews findings and reaches consensus Coordinator prepares a summary report Answers the specific question(s) asked Makes recommendations Draft report is reviewed by team and revised Coordinator reviews final report with parent(s) child welfare worker parents and childrens therapists Clinicians testify in court if subpoenaed Follow-up assessments are conducted on request

26 Methodologic features of assessment types used by child welfare courts in Cook County IL FeaturePsychiatric Evaluation Psychological Testing Bonding Assessment PAT Number, location and setup of sessions Mean # of sessions0.961.161.054.94 In-home assessment0.0%2.5%4.8%83.3% Documented purpose and disclosures 41.7%17.3%9.5%77.8% Sources of history Children interviewed 4.2%0.0%28;.6%77.8% Worker/therapist interviewed 16.7%28.4%19.0%83.3% Collateral informant12.5%7.4%28.6%83.3% Record review95.8%38.3%47.6%100.0% Budd KS et al: Law Hum Bev 25:93-108, 2001

27 Methodologic features of assessment types used by child welfare courts in Cook County IL FeaturePsychiatric Evaluation Psychological Testing Bonding Assessment PAT Measures not validated for assessing parenting capability Cognitive0.0%97.5%0.0% Projective tests0.0%96.3%52.4%0.0% Personality tests0.0%75.3%19.0%0.0% Measures directly relevant to assessing parenting capability Parent-child observation 0.0%1.2%95.2%100.0% Parenting questionnaires 0.0%53.1%33.3%100.0% Budd KS et al: Law Hum Bev 25:93-108, 2001

28 Percent of reports describing findings by assessment type FeaturePsychiatric Evaluation Psychological Testing Bonding Assessment PAT Parents personal attributes Strengths25.0%48.1%33.3%83.3% Weaknesses83.3%96.3%38.1%100.0% Impact on parenting45.8%61.7%52.4%100.0% Parents caregiving skills and beliefs Strengths4.2%33.3%76.2%88.9% Weaknesses25.0%54.3%47.6%94.4% Individualized to child(ren) 4.2%6.2%23.6%77.8% Childs relationship with parent Strengths4.2%4.9%85.7%77.8% Weaknesses8.3%6.2%52.4%88.9% Budd KS et al: Law Hum Bev 25:93-108, 2001

29 Case example Ms. A is a 21 year old mother of 3 children, ages 5, 4 and 1. She has a history of 2 psychiatric hospitalizations. After a knife fight between Ms. A and the father of her children, the children are removed from her custody. Two years later, the child welfare agency wants to learn more about her current parenting capability to assess the safety of returning the children to her custody

30 Ms. As standard psychological evaluation Instruments used Wechsler Adult Intelligence Test (WAIS) Projective tests (Inkblot, Incomplete Sentence, etc.) Conclusions Reasoning is poor (based on WAIS) She has schizophrenia (based on inkblots) She is denying her illness (because she does not think she has schizophrenia) She cannot tolerate being alone, lacks connection with others and might therefore become suicidal, and might think the child was someone else, perhaps someone threatening (based on projective tests) Recommendation: terminate parental rights

31 Parenting Assessment Team evaluation of Ms. A Ms. A had had 2 episodes of major depression with psychotic features – no schizophrenia Each episode was exacerbated by hypothyroidism, physical abuse by her boyfriend, and pregnancy When she received treatment for her hypothyroidism and left her abusive boyfriend, symptoms remitted and had not recurred Testing showed Excellent working knowledge of child development Responsiveness to childrens verbal and nonverbal cues Each child was securely attached Solid support network Conclusion: no risk of child maltreatment

32 Parenting assessments for service planning Conducted as soon as possible after entry into the child welfare system Identifies risk factors that are amenable to treatment or intervention Identifies protective factors that could be strengthened Attempts to align the child welfare service plan with the clinical treatment plan

33 Parenting rehabilitation Targeted mental health care Parenting classes Parenting coaching Parent support groups Co-parenting Therapeutic nurseries

34 Principles of parenting coaching Hands-on intervention Identifies and builds on strengths Goals Increase ability to read nonverbal cues Increase ability to respond appropriately to cues Increase empathy with the childs experience Decrease distorted perceptions of the child

35 Parenting rehabilitation: supportive measures Standby guardianship Mental Health Treatment Preference Declaration Family planning

36 Parenting assessments as guides to legal decision-making What they should be able to do Explain the parents specific risk and protective factors, and how these were evaluated Identify the likelihood and expected time frame of improvement in parenting capabilities, relative to the needs and developmental trajectory of the child What they should not do Provide a yes-no answer (e.g. say that it is safe or unsafe for a parent to have custody of a child The attorneys job The judges job

37 Parenting assessment conclusions Okay: If Ms. Neal were to become the primary caregiver of her child, Linda, at this time, there would be a high risk that Lindas behavior problems would dramatically increase as a result of Ms. Neal misinterpreting Lindas cues and failing to set developmentally appropriate limits on Lindas behavior. Due to Ms. Neals belief that she is already an exemplary parent, and her failure to respond to prior parenting coaching and psychotherapy, there are no clinical interventions that are likely to significantly improve Ms. Neals parenting capability. Not okay: Ms. Neals parental rights should be terminated.


39 The forensic psychiatrist functions as an expert within the legal process. Although he may be retained to one party … he adheres to the principals of honesty and striving for objectivity. His clinical evaluation and the application of the data obtained to the legal criteria are performed in the spirit of such honesty and striving for objectivity. His opinion reflects this honesty and striving for objectivity. American Academy of Psychiatry and the Law Ethical Guidelines for the Practice of Forensic Psychiatry

40 Parenting assessments in an adversarial context Ethical obligation to remain objective, comprehensive, honest and evidence-based This includes within-rules attempts to add unrequested information that could correct misperceptions

41 How parenting assessors can prep attorneys Help attorneys reword questions Attorney: Is Ms. Mullen capable of being a good parent? Social worker: If you ask me that way, Ill say, It depends or Sometimes. If you ask me, What is the likelihood that Ms. Mullen can sustain a primary parenting role over time?, then Ill say, The likelihood is very low. Highlight missing information: Psychologist: I notice you havent asked me about the interactions I observed between Ms. Ramos and her daughter. I think these observations tell us a great deal about Ms. Ramos parenting capability. Attorney: Okay - Ill ask you whether you performed a bonding assessment. Psychologist: The phrase bonding assessment is used loosely, with no consensual definition. The phrase attachment assessment has a specific meaning, and corresponds to what I did. I would recommend that you either ask whether I conducted an attachment assessment, or ask whether I systematically observed mother-daughter interactions.

42 How parenting assessors can maintain accuracy on the stand If an attorney implies misinformation by a question, clarify/correct before answering. Example: Attorney: Are you aware that Mr. Girard made a suicide attempt? Psychiatrist: Yes. Attorney: In your expert opinion, do suicidal people make good parents? Psychiatrist: Let me make sure I understand what you are asking with regard to Mr. Girard. Are you asking whether Mr. Girards suicide attempt at age 17 relates to his parenting capability now, at age 42? Even if the attorney objects or insists that the psychiatrist answer the original question, the psychiatrist has signaled the misinformation.

43 How parenting assessors can maintain accuracy on the stand If highly relevant information is not asked for, look for opportunities to introduce it Attorney: When you assessed Ms. Young three years ago, what diagnosis did you conclude she had? Psychiatrist: Schizophrenia Attorney: Is schizophrenia curable? Psychiatrist: No. And you concluded that her prognosis for achieving minimal parenting competency is poor, right? Psychiatrist: Please clarify your question. Do you mean her prognosis with the treatments that were available three years ago, or her prognosis if she had access to the new treatments that have become available since then?

44 How parenting assessors can maintain accuracy on the stand If an attorney implies misinformation by raising a hypothetical question, make explicit that it is hypothetical Attorney: Lets say a woman with schizophrenia has a lot of negative symptoms, and therefore has a lot of difficulty conveying nonverbal messages to her toddler. Because of that, she has trouble setting limits with her toddler. Couldnt she become really frustrated, in fact, so frustrated that she would start hitting the toddler? Psychiatrist: In the hypothetical situation you raise, which differs from Ms. Diamonds situation, that could indeed happen.


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