Assessing Parenting Capability for Parents with Psychiatric Disorders

Laura J. Miller MDVice Chair for Academic Clinical ServicesDirector, Women’s Mental Health Division

Department of PsychiatryBrigham and Women’s Hospital

Harvard University

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?

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?

“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

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

Measurable factors that affect risk of child maltreatment

Factor linked with maltreatment risk

Assessment tools

Parenting behaviors Crittenden Index

Insight into mental illness Scale for Assessment of Insight

Working knowledge of child development

Parent Opinion Questionnaire

Internal representations of the child

Expressed Emotion scored interview

Parenting stress Parental Stress Index

Maternal early trauma Childhood Trauma Index

Social support Arizona Social Support Inventory

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 children’s prognosis

These patterns are reliably measurable and can’t be “faked”

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) Child’s behaviors on reunion Parent’s behaviors on reunion

Parent-Child Attachment Patterns

Attachment pattern

Parenting style

Child behavior in “Strange Situation”

Secure

Responsive

Approach

Insecure - avoidant

Rebuffing

Avoid

Insecure - ambivalent

Inconsistent

Alternately approach and avoid

Disorganized

Intrusive

Erratic, unpatterned

None

Separations

Behaves the same with parent and stranger

Parent-Child Attachment Patterns in Parents with Major Mental Illness who Lost Custody

Attachment pattern

Parenting style

Per cent

Secure

Responsive

9%

Insecure - avoidant

Rebuffing

17%

Insecure - ambivalent

Inconsistent

4%

Disorganized

Intrusive

35%

None

Separations

35%

Jacobsen T, Miller LJ, in Attachment Disorganization, NY, Guilford, 1999

Caveats about attachment assessments

Attachment observations are best used to understand a child’s 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.

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.

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)

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

PAT psychiatric evaluations

Determine the psychiatric diagnosis or diagnoses, if any Assess the parent’s 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 parent’s current mental health

treatment Assess the parent’s adherence to the current mental health

treatment Determine whether any change in the mental health

treatment plan is likely to improve parenting capability

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

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.”

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

PAT psychological evaluations: internal representations of the child

Parent’s internal representation of a child reflect parent’s sensitivity to the child as an individual recognition of the child’s 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 parent’s relationship to the child.

Parent’s speech is recorded, transcribed and scored according to a standard system.

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

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 children’s therapists

Clinicians testify in court if subpoenaed Follow-up assessments are conducted on request

Methodologic features of assessment types used by

child welfare courts in Cook County IL

Feature Psychiatric Evaluation

Psychological Testing

Bonding Assessment

PAT

Number, location and setup of sessions

Mean # of sessions 0.96 1.16 1.05 4.94

In-home assessment 0.0% 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 informant 12.5% 7.4% 28.6% 83.3%

Record review 95.8% 38.3% 47.6% 100.0%

Budd KS et al: Law Hum Bev 25:93-108, 2001

Methodologic features of assessment types used by

child welfare courts in Cook County IL

Feature Psychiatric Evaluation

Psychological Testing

Bonding Assessment

PAT

Measures not validated for assessing parenting capability

Cognitive 0.0% 97.5% 0.0% 0.0%

Projective tests 0.0% 96.3% 52.4% 0.0%

Personality tests 0.0% 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

Percent of reports describing findings by assessment type

Feature PsychiatricEvaluation

PsychologicalTesting

BondingAssessment

PAT

Parents’ personal attributes

Strengths 25.0% 48.1% 33.3% 83.3%

Weaknesses 83.3% 96.3% 38.1% 100.0%

Impact on parenting 45.8% 61.7% 52.4% 100.0%

Parents’ caregiving skills and beliefs

Strengths 4.2% 33.3% 76.2% 88.9%

Weaknesses 25.0% 54.3% 47.6% 94.4%

Individualized tochild(ren)

4.2% 6.2% 23.6% 77.8%

Child’s relationship with parent

Strengths 4.2% 4.9% 85.7% 77.8%

Weaknesses 8.3% 6.2% 52.4% 88.9%

Budd KS et al: Law Hum Bev 25:93-108, 2001

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

Ms. A’s 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

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 children’s verbal and nonverbal cues Each child was securely attached Solid support network

Conclusion: no risk of child maltreatment

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

Parenting rehabilitation

Targeted mental health care

Parenting classes Parenting coaching Parent support groups Co-parenting Therapeutic nurseries

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 child’s experience Decrease distorted perceptions of the child

Parenting rehabilitation: supportive measures

Standby guardianship Mental Health Treatment Preference

Declaration Family planning

Parenting assessments as guides to legal decision-making What they should be able to do

Explain the parent’s 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 attorney’s job The judge’s job

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 Linda’s behavior problems would dramatically increase as a result of Ms. Neal misinterpreting Linda’s cues and failing to set developmentally appropriate limits on Linda’s behavior. Due to Ms. Neal’s 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. Neal’s parenting capability.”

Not okay: “Ms. Neal’s parental rights should be terminated.”

“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

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

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, I’ll 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 I’ll say, “The likelihood is very low.”

Highlight missing information:Psychologist: I notice you haven’t 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 - I’ll 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.

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. Girard’s 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.

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?

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: Let’s 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. Couldn’t 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. Diamond’s situation, that could indeed happen.