Adult mental health service engagement with patients who are parents: evidence from 15 English mental health trusts

Objectives. Ascertaining whether mental health service users have children is a clinical requirement in UK health services, and acknowledgement of a patient’s parenting role is necessaryto enable engagement with their parenting experience and to facilitate support, both of which are associated with improved outcomes for the parent – child dyad. The current study sought to investigate the practice of mental health practitioners working in UK adult mental health services with regard to the following: Ascertaining whether patients have children; engagement with the parenting role of patients; engagement with the construct of ‘think patient as parent’. Methods. Self-report online/paper survey of 1105 multi-disciplinary adult mental health practitioners working in 15 mental health trusts in England. Results. A quarter of adult mental health practitioners did not routinely ascertain whether patients had dependent children. Less than half of practitioners engaged with the parenting experience or the potential impact of parental mental health on children. Conclusions. The parenting role of patients is not routinely captured by large numbers of practitioners working in adult mental health settings. This is despite it being a mandatory requirement and an integral component of the systematic care of the adult, andpreventativecarefortheoffspring.Failuretoengagewithpatientswhoareparentsisa missed opportunity with profound downstream public health implications. The practice deﬁcits identiﬁed in this study should be viewed in terms of broader structural failures to address the intergenerational transmission of poor mental health.

Objectives. Ascertaining whether mental health service users have children is a clinical requirement in UK health services, and acknowledgement of a patient's parenting role is necessary to enable engagement with their parenting experience and to facilitate support, both of which are associated with improved outcomes for the parent-child dyad. The current study sought to investigate the practice of mental health practitioners working in UK adult mental health services with regard to the following: Ascertaining whether patients have children; engagement with the parenting role of patients; engagement with the construct of 'think patient as parent'.
Methods. Self-report online/paper survey of 1105 multi-disciplinary adult mental health practitioners working in 15 mental health trusts in England.

Results.
A quarter of adult mental health practitioners did not routinely ascertain whether patients had dependent children. Less than half of practitioners engaged with the parenting experience or the potential impact of parental mental health on children.
Conclusions. The parenting role of patients is not routinely captured by large numbers of practitioners working in adult mental health settings. This is despite it being a mandatory requirement and an integral component of the systematic care of the adult, and preventative care for the offspring. Failure to engage with patients who are parents is a missed opportunity with profound downstream public health implications. The practice deficits identified in this study should be viewed in terms of broader structural failures to address the intergenerational transmission of poor mental health.

Practitioner points
Some parents who have mental health difficulties may struggle to provide appropriate and effective care to their children. The parenting role can also exacerbate mental health difficulties. Identification of dependent children is a mandatory component of adult mental health clinical practice and is necessary to understand a parent's support needs.
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A quarter of adult mental health practitioners are failing to do so. A missed opportunity to engage with the support needs of the parent-child dyad.
At any given moment, an estimated one in six adults in England will meet the criteria for a psychiatric disorder and up to half of these adults will also be parents (Maybery & Reupert, 2018;Mcmanus, Bebbington, Jenkins, & Brugha, 2014), which corresponds to one in four children experiencing maternal mental illness (Abel, Hope, Swift, et al., 2019). While many parents who struggle with their mental health provide excellent, nurturing care, there is also a clear relationship between parental mental health difficulties and impaired child outcomes, across a wide range of domains including educational attainment, social connectedness, and physical and mental health (Argent, Kalebic, Rice, & Taylor, 2020;O'Donnell et al., 2015;Pierce et al., 2020;Sidebotham & Heron, 2006). In particular, a parent's mental ill health is associated with increased risk of their child developing a mental disorder (Santvoort et al., 2015). This intergenerational transmission operates in a non-specific wayparental mental disorder places the child at increased risk of developing all forms of psychiatric disorder, but there is also specific transmissiondisorders such as anxiety and depression, as well as complex mental health disorders such as psychosis and borderline personality disorder, run in families (Lawrence, Murayama, & Creswell, 2019;Rasic, Hajek, Alda, & Uher, 2014;Santvoort et al., 2015). To use depression as an example, in studies carried out by Weissman and colleagues over a 30year period, children born to a depressed parent were three times as likely to have a major depressive episode and were at greater risk of premature mortality, compared to offspring of non-depressed parents (Weissman et al., 2016).
While heritability plays a role in this intergenerational transmission of psychopathology, environmental factors are also clearly implicated and offer greater opportunity for intervention (Eley et al., 2015). For example, poor parental mental health can be associated with behavioural, emotional, and relational deficits, which can be detrimental to the child. A highly anxious parent, for example, may encourage avoidant behaviour in their child (Darryl et al., 2015;Van Loon, Van de Ven, Van Doesum, Witteman, & Hosman, 2014). There is, additionally, a bi-directional component: While the parenting role can be a positive experience for parents and contribute to their recovery, it can also be a source of stress and be implicated in poorer parental outcomes, particularly when parenting a child with behavioural or emotional difficulties (Dolman, Jones, & Howard, 2013;Dunn, Cartwright-Hatton, Startup, & Papamichail, 2020;Floyd & Gallagher, 1997). However, these challenges can be moderated through the provision of adult mental health support.
The impact of parental mental health problems can be moderated through the provision of appropriate support, which engages with the parenting role. Adult mental health services are commonly the primary source of support for these adults and, as such, provide an arena for preventative approaches that take into account the individual as both patient and parent. In practice, for this to be the case, services and clinicians would need to: recognize the parenting and familial role of service users; offer assessment and treatment based on an awareness of the family context and the role the family can play in recovery; and provide care that is sensitive to the challenges and risks experienced by children of parents with mental health difficulties. At a service level, this type of approach would improve outcomes beyond the manifest mental health struggle, to include improvements in the quality of parenting behaviours, as well as prevention of child mental health struggles (Siegenthaler, Munder, & Egger, 2012). Strikingly, this approach is already recommended by clinical organizations and is present within UK government policy and legislation (Care Act, 2014;Children, Schools, & Families Act, 2010;Diggins, 2011;RCPsych, 2011). Despite the clear benefits for parent and child, and the policy and legislative impetus, there is scant evidence of this approach being translated into routine practice (Gatsou et al., 2016;Ofsted, 2013). A survey of five NHS sites across England in 2009 revealed that the family perspective was largely absent at a strategic level in adult mental health services. At a practice level, assessment and care planning failed to take into account the family context; in fact, adult mental health staff were not routinely asking whether an adult using a given service had children. Perhaps inevitably, there was limited consideration of the impact of adult mental health on parenting and, at a supervisory level, there was a deficit in conceptualizing the whole family's needs (SCIE, 2009). These findings were mirrored in a localized case-note review carried out in 2011, where adult mental health services showed minimal engagement with the effects of parental mental health on parenting capacity and child well-being (Gatsou et al., 2016). Reporting in 2013, Ofsted also found that adult mental health services did not clearly record the presence of children and failed to adequately consider the needs of the family in the assessment of care (Ofsted, 2013). In the intervening period, the extent to which UK adult mental services identify or engage with a patient's parenting responsibilities has been subject of limited further scrutiny.
This paper reports on a survey of adult mental health practitioner understanding of, engagement with, and attitudes towards the concept of 'think patient as parent'. It was carried out in 15 adult mental health trusts in England and was designed with the specific aim of rectifying the dearth of research on this important area of practice.

Ethics
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human subjects/patients were approved by HRA and Health and Care Research Wales [19/HRA/0092].

participants were recruited from 15 Adult Mental Health Trusts in England between
June 2018 and March 2019. Participants were recruited within their NHS local trust by email, poster, and localized face-to-face campaigns. Participants were invited to complete the survey online or in paper format. Written informed consent was obtained from all participants. The host trust, Sussex Partnership Foundation NHS Trust, recruited for the full period of the study with further trusts joining in three subsequent waves. There was an average of 74 participants per trust (M = 73.67, SD = 38.74, range 23-139). Of the 28385 professionally qualified clinical staff employed across the 15 trusts, 4.15% completed the survey (NHS, 2019).

Participants
Participants were eligible if they worked directly with service users and were employed by the given trust. The majority of participants classified themselves as female 806 (72.9%), and the average age was 41 (SD = 11.26, range 19 to 70). Inpatient and Assessment and Treatment teams had the largest number of respondents (n = 271 and n = 249) and Nursing was the most common role (n = 423). Professional characteristics are reported in full in Table 1.

Materials
A 31-item questionnaire was developed by the study team to investigate adult mental health practitioners' practice in, and attitudes towards, supporting patients who are parents.
The instrument was developed as follows: An initial set of items was developed, informed by policy recommendations, good practice guidance, and literature on practice, attitudes, and barriers. This long-list was iteratively reduced by the study team with a series of rounds of external consultation from an expert panel comprising: a developmental child psychologist; a research design specialist; three clinical psychologists (x2 Adult Mental Health, x1 Child and Adolescent Mental Health); a social worker; a lead parenting practitioner; and a panel of mental health service users who are parents. Feedback was solicited until all parties felt that the scale items had acceptable face validity and captured a sufficiently broad range of behaviours and beliefs/attitudes, while being sensitive to the need to minimize response burden for practitioners. Mental health practitioners tested the final scale for usability and acceptability.
The final 21-item scale comprised three domains: Routine practice behaviours; Attitudes and beliefs about practice; and Attitudes and beliefs about barriers to practice. Items 1-18 took the form of Likert-type questions (example rating: strongly agree to strongly disagree) with three optional free-text questions. Only results from the first two of these three domains are reported in this paper. The data on the third domainperceived barriers to practicewill be reported separately.

Analysis
The data were screened and of 1178 participants, 73 cases were removed (43 duplicate cases, 10 participants who identified as administrative professionals, which was not an included professional group, and 20 participants who did progress beyond demographic questions). Descriptive characteristics for 1105 participants were examined, and scores for the Practice and Attitudes subscales were calculated for the sample. Subscale items responses for the sample are reported represented in Figure 1 and Figure 2.
The internal consistency of the Practice and Attitudes subscales was calculated. The Practice scale was found to have good internal consistency (Cronbach's a = .84). For the Attitudes subscale, one item, 'many parents do not consider their illness to be a problem for their children', was removed due to its low item-total correlation and its depressive effect on the alpha score. Upon removal of this single item, the Attitudes subscale had an acceptable level of internal consistency (Cronbach's a = .74).
Mean subscale scores, disaggregated by professional characteristics and demographics, are reported in Table 2.
Data were analysed in IBM SPSS 25 for Windows with secondary data visualization in Tableau 2020.2 for Windows. Figure 1. Practice subscale items. The scale on the x axis refers to the percentage of participants in each response category (see key on right-hand side). +% indicates % participants who 'strongly agreed/agreed' with the statement, -% indicates % participants who 'somewhat agreedstrongly disagreed'.

Results
'Think patient as parent' practice Routine monitoring for presence of children in patients' families Three-quarters (n = 837, 75.7%) of participants indicated (via either agreement or strong agreement) that they routinely asked whether a service user had children.

Family-focused activities
The results from this section of the survey indicated that fewer than half of all respondents routinely (as indicated by agreement or strong agreement) asked service users to tell them about their experience of having children (n = 438, 39.6%), or routinely asked service users about the quality of their relationships with their children (n = 483, 43.7%), or routinely asked service users if their children have emotional and/or behavioural difficulties (n = 326, 29.5%) or routinely assessed the needs of the children of their service users (n = 317, 28.7%). For all items, 'somewhat agree' was the modal response. Slightly over half (n = 632, 57.6%) did report routinely considering a service user's role as a parent when making an assessment or care planning (see Figure 1).

Attitudes towards and beliefs about 'Think Patient and Parent' practice
Attitude towards parental mental health Of the 1088 practitioners who responded, the majority agreed or strongly agreed that challenges related to being a parent can affect a service user's mental health (n = 991, 91.1%) and that a service user's mental health can affect the way they parent (n = 988, 89.4%). About half of respondents agreed or strongly agreed that talking about parenting can be upsetting for service users (n = 588, 53.2%). Ambivalent categories (somewhat agree/somewhat disagree) were the most common response to the statement 'many parents do not consider their illness to be a problem for their children' (n = 615, 56.5%). Attitude towards support for service users who are parents The majority of participants (n = 762, 69.0%) strongly agreed/agreed with the statement that 'it is important to talk to service users about their parenting' and that 'assessment and care planning should take into account the role of service user as parent'.

Attitude towards own 'Think Patient as Parent' practice
Half of respondents (n = 578, 53.1%) agreed or strongly agreed that they felt confident talking to service users about parenting. Two-thirds (n = 728, 66.9%) of practitioners strongly agreed/agreed that, with training, they would be keen to provide support for their service users' parenting. Less than half of practitioners (n = 482, 43,6%) agreed with the statement 'I would like to engage more with the parenting of my clients'. Interdisciplinary and inter-team differences in 'Think Patient and Parent' practice and attitudes Mean scores disaggregated by professional team, professional role, and parental status indicate lower levels of engagement in 'patient as parent' practice amongst workers in inpatient settings, those working as support workers or research assistants, and those without children. Inpatient workers, along with support workers, CBT therapists, care coordinators, and 'other (team and role categories), were least engaged with the concept (see Table 2.) Formal sub-group analyses were not carried out because there was insufficient power for the very large number of comparisons that would be required for this secondary analysis.

Discussion
This study was designed to investigate the extent to which adult mental health practitioners in England are engaging with their patients as parents. The results allow us to take stock of the support that is currently being offered to parents with mental health difficulties and their children. The Care Act 2014 gives clear instruction that adult mental health practitioners should routinely record details of the patient's responsibilities in relationship to dependent children as a matter of routine practice (Care Act, 2014), but there has been limited investigation into the delivery of this objective (Care Act, 2014). Furthermore, only when a practitioner has obtained this information can they engage with the parenting needs of their patients.
The results of this study provide evidence that within adult mental health services in England, even the most basic level of engagement with 'patient as parent'asking if a service user has a childis not routine. By their own account, a quarter of practitioners are failing to do this. When it comes to engaging with parents in terms of their parenting, their relationship with their child, or their child's needs, the picture worsens, with less than half of practitioners routinely undertaking this form of engagement. These findings echo the case 2016 note review conducted by Gastou which found that only two-thirds of patients were asked if they had dependent children (Gatsou et al., 2016). The results also indicate that in the decade since SCIE published its landmark 'Think Child, Think Parent, Think Family' report and practice survey, little has changed (Diggins, 2011).
By not engaging with a patient's parenting role, adult mental health services are failing parents and their children in multiple ways: Patients who are parents are being denied recognition of a significant aspect of their lives; they are being denied the contribution towards recovery that this form of engagement can offer; and they are being denied support that could enable them to address any impact their mental health may have on their offspring (Swartz et al., 2008). This places their children at heightened risk of wideranging and well-documented negative outcomes including the intergenerational transmission of psychopathology (Santvoort et al., 2015). Abel and colleagues have furthermore drawn attention to the need to increase understanding of the risk and resilience factors of these children and provide co-developed support which meaningfully engages with child-identified outcomes (Abel, Hope, Faulds, & Pierce, 2019). As discussed, these approaches are only possible when children living with parental mental illness are given visibility. Given the numbers of parents who have mental health difficulties, this should be viewed as both a tragedy to the individual and to society. The failure of mental health services to engage in this way has clear public health and economic implications (Mihalopoulos & Reupert, 2015).
There will need to be a shift in the stance of our mental health organizations to enable parenting to become more of a priority amongst practitioners. Maybery and Reupert's hierarchical framework of barriers to patient-as-parent practice emphasizes the need for organizational conditions to be met before the workforce can engage (Maybery & Reupert, 2009). As such, a practitioner's skill, confidence, and willingness to engage must be underpinned by structural conditions including policy, guidelines, allocation of resource, and managerial support. Within this sample, the majority of practitioners agreed that mental health and parenting are interrelated; that it is important to talk to patients about their parenting; and that a patient's parenting role should be factored into assessment and care planning. Strikingly two-thirds of participants indicated that, with training, they would be keen to provide support for service users who are parents, indicating a clear need for professional capacity building. However, while it is essential that practitioners have the ability and desire to engage with their patients as parents, it is to fail them to expect them to do this in isolation: For change to come, it must be embedded across the service context. This is not a pipedream. Integrated approaches to embed 'think patient as parent' have been applied in local and national contexts. For example, Norway and Finland, amongst others, have legally mandated that services treating adults must acknowledge and respond to the needs of their offspring. In Norway, one initiative involved a two-stage clinical process: First, templates were used to ensure child identification at assessment, followed by the offer to parents of 'Child Talks', a short intervention focused on child resilience and information provision (Lauritzen, Reedtz, Van Doesum, & Martinussen, 2014). This was mirrored in Portugal where increased acknowledgement of the children of psychiatric patients following the implementation of practitioner training was coupled with organizational change (Doesum et al., 2019). It should be noted that transforming service provision is effortful and sustaining innovation generates ongoing challenges (Greenhalgh & Papoutsi, 2019). For example, five-year follow-up at one Norwegian site that had deployed the two-stage approach revealed that practice change was unstable and engagement declined after the project team withdrew (Lauritzen, Reedtz, Rognmo, Nilsen, & Walstad, 2018). While disappointing, these results are a salient reminder that change needs to be embedded within an organization.
Initial efforts to embed 'family-focused practice'(FFP) in Northern Ireland have generated similarly mixed results with high levels of concept recognition across health and social care services but low levels of practice (Grant et al., 2018). However, considerable inter-role and inter-team variation in practice was identified in the project evaluation for example, lower levels of FFP were present in inpatient teams and greater levels of engagement found amongst social workers, both of which findings were reflected in the current study. This indicates that projects need to be solidly embedded within the organization but should be responsive to team and role-specific barriers and opportunities for engagement.
An alternative example of a parent being seen and supported within mental health services is the ring-fenced investment in perinatal mental health care in England, which will see £365 million invested in services for women in the antenatal and postnatal period (NHS England, 2014). This is a national initiative developed to increase access to services and reduce regional service variation. It appropriately focusses on the needs of mother and child during a period of vulnerability, but also one in which there is a substantial opportunity for recovery. This programme has already generated benefits for thousands of women, children, and their families and demonstrates that change can be achieved. However, support during the perinatal period does not ameliorate the situation for the fathers and mothers of older children whose ranks will realistically be joined by mothers who continue to struggle with their mental health in the post-perinatal period and this number is increasing year on year (Abel, Hope, Swift, et al., 2019). Furthermore, prioritizing the perinatal period should not be at the expense of families of children at later developmental stages in which a parent has mental health problems. Explicit identification of support for parents with mental health difficulties has been noticeably absent from key government publications outlining the preventative agenda and on transforming the mental health of young people (Department of Health & Department of Education, 2017; Haslam, 2014). Within a financially straitened and understaffed system such as adult mental health services, and in the absence of clear guidance or funding, it is unsurprising that local commissioners, providers, and practitioners fail to engage in a meaningful way with patients as parents or indeed to fulfil their basic mandated requirements.

Clinical implications
Many adult mental health practitioners are failing to identify the parenting responsibilities of their patients and so are not engaging with these parents' experience of parenting or considering the vulnerabilities of their children. This means that a core opportunity to intervene is missed and parents and their children are being failed. The downstream outcome of this is the continued intergenerational transmission of mental health disorder.
The importance of engaging with patients as parents is well-recognized and has long been the recommendation of a broad church of professional bodies as well as a component of government policy. Despite this, over a decade since the publication of 'Think Family', services are not providing the essential ingredients to engender change in practice. While individual practitioners may fail to engage for a range of individual factors such as skill and confidence and also quite simply not having sufficient time because of the pressures of working in underfunded teams, this situation must be seen as a systemic deficiency generated by a failure to incorporate the concept of 'patient as parent' at a structural level. As such there is clear need to unpick the barriers to implementation of this approach in England and develop a coherent and realistic strategy to embed 'think patient as parent' within adult mental health services.

Limitations
This study was designed with the objective of investigating adult mental health service practice related to the support of the parenting role of a patient with offspring. The findings should be interpreted as a 'snapshot' of the practice and attitudes of a self-selecting sample of clinicians. As such, care must be taken with regard to the representativeness of the data. Whilst the overall sample size is reasonable given the scope of the study, the low response rate relative to the number of clinical staff working in the participating trusts is a clear limitation. The diffuse recruitment approach, which was pragmatically motivated, did not generate data on how many clinicians were invited compared with the number who took part. However, it is likely that clinicians who were willing to respond to this survey were more engaged with the approach, which may have skewed the results in the direction of a higher reported level of engagement with parents than is typical.
An additional limitation of this study is the potentially differing levels of engagement that practitioners may have with male and female patients in terms of their parenting role.
We have used the term parent to refer to any gender, but it is possible that practitioners are more focused on mothers in this context. The relationship between parent gender and mental health practitioner engagement is one which would benefit from further research.