Predictive neglect: programs may modify outcomes

In spite of awareness and education campaigns, mental illness still carries a stigma that can affect individuals in the community, workplace and home. For families, a mental health diagnosis can have devastating consequences when it leads to termination of parental rights under the “predictive neglect” doctrine.

A legal term, predictive neglect refers to the removal of a child from the home when there is reasonable certainty the child is in danger, says Barbara Claire, agency legal director for Connecticut’s Department of Children and Families (DCF). “But this is more about abuse. For instance, if three kids previously had been abused, we have reason to believe it will happen again,” she says. “Neglect would be a messy house and that is probably not going to lend itself to predictive neglect.” She notes that in Connecticut, abuse is a category of neglect.

If a judge orders a child removed from the home, he issues specific steps regarding what the agency has to provide in the way of services and what the family is expected to do, adds Claire. “Under federal and Connecticut law, you have up to a year to complete reunification or find some alternative. At nine months, you would start looking at future plans,” she explains. “If parents are participating and benefiting from services, they will be reunited with the child.”

Gary Kleeblatt, J.D., MA, Connecticut’s DCF communications director, emphasizes that children of parents with mental illness are not typically removed as a result of that illness. “There has to be something egregious and extreme,” he says.

Cindy H. Liu, Ph.D., director of multicultural research at the Commonwealth Research Center, instructor at Harvard Medical School and Beth Israel Deaconess Medical Center and program director of “Bringing Hope and Support to Parents and Families with Mental Illness,” acknowledges that a parent’s mental illness might adversely affect a child in several ways. She explains that when a woman is struggling with delusions or side effects from medication, she can barely take care of herself. “How much more challenging is it to care for a child?”

Moreover, when a mother has a flat affect, her children have no model for developing norms for social interaction. “There is no effective communication so children don’t learn social skills,” Liu says. “There is also an increased risk of developing psychiatric conditions, such as cognitive and emotional impairment, of rates between 40 and 50 percent. This is a public health issue.” School performance can suffer and secondary issues, such as poverty and unemployment, may enter the picture.

One of the best ways to avoid state intervention is prevention, says Liu. She explains that psychosis and schizophrenia symptoms tend to emerge during the childbearing years when stress triggers the illness. “Women with these mental illnesses know about predictive neglect and are vigilant about what might happen,” Liu notes. “They love their children. This is a major strength. But in the process of meeting the child’s needs, they ignore their own. The stakes are higher for these women.”

Elise C. Magnuson, Psy.D., private practitioner in Portland, Maine, treats parents once jeopardy has been detected. As part of treatment, she examines the history of parental trauma and administers a battery of tests, including the Minnesota Multiphasic Personality Inventory (MMPI), the Trauma System Inventory, the Parenting Stress Index, the Child Abuse Potential Scale and the Parent Awareness Skills Survey, some of which have limited usefulness, she admits.

For instance, Magnuson indicates that the Parent Awareness Skills Survey has “psychometric problems.” She says, “it has limited use as guided interview. It’s very much about knowledge and not the ability to implement solutions.”

Magnuson acknowledges that, after the fact, certain interventions may help the parent, but predicting the future is nearly impossible. She says, “There are too many variables involved. Even someone deeply mentally ill and unable to care for herself may turn around and pull it together once she has a baby. Having something more important than yourself can change your behavior.”

Although professional evaluation tools may be of some use, Joanne Nicholson, Ph.D., professor of psychiatry, Dartmouth Psychiatric Research Center at the Geisel School of Medicine, says that spending time with each family member separately and together in their natural environment provides a more accurate picture of the situation. “It’s about integrated data to give you a complete picture,” she says.

Nicholson suggests taking each case on its own merit to see how individuals are coping. “If you highlight what people are doing well, rather than focus on their shortcomings, you can create a package of services around that information to help.”

When the issue of predictive neglect does arise, the combination of legal and clinical services is key to successful outcomes. Katherine Nemens, Esq., supervising attorney, Clubhouse Family Legal Support Project, Mental Health Legal Advisors Committee, reports that her organization collaborates with a clubhouse in Marlboro, Mass. “I provide insight for the provider about the legal process, the next steps, what to focus on and why the process takes so long. I demystify the legal process for the service personnel,” she says.

At the same time, Nemens learns about the client’s strengths and weaknesses and changes in mental status from the clinician. “It’s useful in my work to speak with the provider for the client’s benefit. I can paint a good picture for the courts and take the focus off the mental health diagnosis,” she says. “It’s important to have lawyers and clinicians working together to try to produce the best outcomes for the client.”

Nemens points out assumptions that tie mental illness to poor parenting skills sometimes still influence judicial decisions. “There has been some improvement in the general public’s perception about stigma over the years. But things are slow to change,” she says. “Some of the newer judges, however, are more attuned. For instance, when asked for a restraining order against a parent with bipolar disorder, the judge will ask about the risk of harm to the child.”

Liu urges psychologists to consider preventative measures to help keep families together. Programs like hers and a similar one at UMass Medical School are attempting to help parents with mental illness. “Of all moms who need support programs, it’s new moms who need it most.”