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Assessment of Parenting Competency in Mothers with Mental Illness

Assessment of Parenting Competency in Mothers with Mental Illness

Author: Teresa Ostler Ph.D.   Foreword Author: Patrick Tolan Ph.D.   Chapter Authors: Niki Grajewski M.S.W., Heather Hasslinger

ISBN: 978-1-55766-665-9
Pages: 208
Copyright: 2008
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Size:  6.0 x 9.0
Stock Number:  66659
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The stakes are undeniably high when it comes to deciding whether a mother with mental illness can raise her child in a safe, nurturing environment. Now, mental health professionals will have sound assessment strategies—refined over 10 years of study—that fairly evaluate the parenting competency of mothers with a wide range of mental illnesses, from "baby blues" to schizophrenia.

Going beyond measuring only the mother's degree of mental illness, the safety of the environment, or the rate of child development, this groundbreaking resource integrates multiple approaches so that professionals understand the full picture of parenting competency.

Mental health professionals will

  • Assess with confidence. This program is backed by more than 10 years of refinement and testing, and has been shown to produce superior evaluations.
  • Accurately profile parenting strengths and weaknesses with state-of-the-art methodology.
  • Enhance every part of their parenting evaluation process, including interviews and observations, home visits, report writing, sharing results with the family, and testifying in court.
  • Discover the eight critical principles for ensuring that an assessment is sound.
  • Learn about available assessment instruments and get guidance on when to use each.
  • Limit bias by recognizing factors that can influence assessment results, such as cultural differences and high stress levels of parent and child.
  • Get keen insight into life with mental illness through the compelling stories of mothers and children.

With this much-needed resource, psychologists, social workers, nurses, and child welfare professionals will be primed to conduct more accurate assessments, make informed decisions, build stronger mother–child relationships, and facilitate family preservation whenever possible.

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Review: Families in Society: The Journal of Contemporary Social Services
"The book emphasizes the importance of assessing parenting directly and the reality that mental illness affects parenting behavior versus focusing on the mental illness. This point is extremely important, often overlooked, and an excellent contribution of the book."
Review: Book News, Inc.
Review by: Denise Kane, Inspector General, Illinois Department of Children and Family Services
"An indispensable reference . . . should be required reading for child welfare, mental health, and legal professionals who serve the children and families of our child protection courts."
Review by: Meghan Kirshbaum, Founder & Executive Director, Through the Looking Glass
"An invaluable resource for practitioners involved with mothers with mental illness and their children."
Review by: Joanne Nicholson, Professor of Psychiatry, Licensed Psychologist Provider, Center for Mental Health Services Research; Department of Psychiatry, University of Massachusetts Medical School
"An essential guide, drawing from an extensive review of the scientific literature, exhaustive consideration of relevant assessment tools and strategies, and years of research and clinical practice."
Review by: Cindy Lederman, Presiding Judge, Miami-Dade Juvenile Court
"What we can learn about the parent, the child, and the relationship with the help of Dr. Ostler's work can form the basis of individual case plans that can provide the case specific interventions we need to provide the best chance of keeping the family together."
About the Author
Foreword Patrick Tolan

  1. Assessing Parenting in Mothers with Mental Illness: A Daunting Task
  2. Mental Illness: Types and Effects on Parenting
  3. Guidelines for Assessment
  4. The Assessment Process
  5. Assessing Caregiving Capabilities
  6. The Psychiatric Evaluation
  7. Social and Environmental Influences
    Heather Hasslinger
  8. Children’s Perspectives and Needs
  9. Growing Up Crazy
    Niki Grajewski


Appendix A Instruments for Assessing Risk of Child Maltreatment
Appendix B Resources for Clinicians


Excerpted from Chapter 5 of Assessment of Parenting Competency in Mothers with Mental Illness, by Teresa Ostler

Copyright © 2008 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.


After assessors have a grasp on a mother's past parenting skills, they can turn to what is known about the current skills that a mother brings to the parenting role. Table 5.1 provides an overview of critical domains of which assessors should gather information in the caregiving assessment.

Ability to Care for Self and Others

It is important to assess to what extent the mother can provide for herself and meet her own needs, especially if the mother's illness is chronic and severe. This includes determining whether a mother is able to maintain adequate housing for the child, hold down a job, or have enough income to make ends meet and whether she is able to get meals for herself and to provide for her own need for safety. If a mother cannot meet her own needs for shelter, safety, and food, it is highly unlikely that she will be able to provide for her children. Sorting out whether the difficulties are due to poverty alone, or to seriously compromised adaptive living skills, is essential.

Scales of adaptive living, such as the Vineland Adaptive Behavior Scales, Second Edition (Sparrow, Balla, & Cicchetti, 2005), use a structured questionnaire format to obtain objective information on a mother's overall level of adaptive functioning in various domains, including communication skills, daily living skills, socialization skills, motor skills, and maladaptive behavior.

Closely linked to a mother's ability to care for her own basic needs is her ability to meet her children's basic needs, including their needs for food, shelter, clothing, and safety. Other basic abilities to assess include whether the mother can ensure that her children's health and educational needs are met (see Appendix A).

Parenting Behavior

Observing how a mother interacts with her children is another essential part of the caregiving assessment (Barnum, 1997; Budd & Holdsworth, 1996; Reder & Lucey, 1995b). Observations can provide direct evidence of a mother's ability to protect her children and to supervise their whereabouts. The following features of parenting behavior are especially valuable to assess because they reveal information about the parent–child attachment relationship (Bowlby, 1988): how a mother comforts her child when the child is ill, hurt, or frightened; how she reads and responds to her children's cues; whether and how she prioritizes her children's needs; and whether she values the child and helps the child to feel safe and secure.

Questionnaires are another way that clinicians can assess parenting behavior. Because many measures have questions that ask a mother to report on her own behavior, they may have limited validity, especially if the mother is seeking to regain custody of a child. The validity of questionnaires is improved if they are part of an integrative assessment that examines patterns across data sources and time periods.

Rating scales that are based on independent observations of behavior are preferable to self-report measures because they provide a more objective measure of parenting behavior. Rating scales that have proven reliability and validity (i.e., those that can be replicated and measure what they purport to measure) should be selected whenever possible. Scales that are selected should also provide a representative sample of the parent's behavior and not just a narrow aspect of the parent's activities or attitudes (Jordan &Franklin, 2003). Clinicians should check information from rating scales with information from other sources to determine if the behavior and findings are characteristic of the parent's behavior in other settings.

Several rating scales can provide rich information on the quality of parent–child interactions. Standard rating scales, such as the Home Observation for Measurement of the Environment (HOME) inventory (Caldwell & Bradley, 2001), for instance, can help clinicians to identify at-risk parenting behavior (see also Chapter 8 and Appendix A). This measure has been used with high-risk populations (Totsika & Sylva, 2004) and can be used for a variety of age levels. Direct observational systems can provide information on parental discipline in the home (Forehand, Wells, & Griest, 1980; Reid, 1978), clinic, or laboratory (Kochanska, Kuczynski, Radke-Yarrow,& Darby-Welsh, 1987). Clinicians should keep in mind that many measures require specialized training and reliability before they can be used. Other issues to consider in deciding which tools to use are the time and cost it takes to code behavior and how well the tool distinguishes the standard of parenting under scrutiny.

Records (e.g., mental health, school, child welfare) and interviews with collateral historians who are familiar with the child and family can provide rich information about parenting behavior beyond what is observed from direct observations and questionnaires. Information on parenting behavior can also be gleaned from interviews with others familiar with the family, including neighbors and relatives. In each case, permission should be obtained before reviewing records or interviewing collateral historians about a child and parent.

Clinicians should be alert to situational influences as they interpret parenting behavior. For instance, a parent and child's behavior can change profoundly during prolonged separations (Clyman, Harden, &Little, 2002; Heinicke & Westheimer, 1965). In such instances, the interpretation of parent–child interactions will turn on several factors: the current age of the child, when the child was removed from his or her parent's care, the nature of the parent–child relationship prior to and after the separation, the regularity of parent–child visits and their quality, the child's experiences with substitute caregivers, and the attitude of substitute caregivers toward the child and toward visits (Jacobsen & Miller, 1998b).

Understanding Child Rearing and Development

A child would be at considerable risk if a mother lacked the most basic sense of what can be expected of a child at different ages. A young infant, for instance, needs to have his or her head supported in the early months of life. Similarly, toddlers can tumble down stairs or wander outside unless necessary precautions are taken in a timely manner. If a mother does not see an older child as having a need to grow up, he or she may curtail independence during middle childhood and adolescence or expect the child to provide too much care for others in the family. To successfully raise a child, then, a mother needs to have a basic understanding of child-rearing practices and of child development.

In inquiring into a mother's understanding of child rearing and development, clinicians should determine whether the mother uses excessive discipline or whether her disciplinary responses are age-appropriate and measured. In addition, they should assess how she responds to the stresses of parenting (Abidin, 1990) and whether she is able to alter her caregiving abilities in a flexible manner so as to meet the changing needs of her children as they grow older.

Paper and pencil measures can provide rich information on a mother's cognitive understanding of child-rearing techniques (Azar, Robinson, Hekimian, & Twentyman, 1984; Bavolek, 1987; Bavolek, Kline, & McLaughlin, 1979) and disciplinary measures that she endorses (Arnold, O'Leary, Wolff,& Acker, 1993). Structured interview formats can be used to identify counterproductive discipline practices (Forehand & McMahon, 1981; Patterson, Reid, Jones, & Conger, 1975; Webster-Stratton & Spitzer, 1991).

Mother's Internal Representations of Child

Attachment theorists place particular emphasis on a parent's internal representation of a child as playing an important role in influencing caregiving quality (Bowlby, 1988; Solomon & George, 1996). Mothers who can see a child's individual needs and strengths are likely to be more sensitive in meeting their needs than a mother whose understanding of the child is either highly idealized or negative (Bowlby, 1988). Part of a parent's internal representation of a child includes his or her empathy for the child and his or her ability to see his or her own needs as separate from the child's needs.

Several measures can provide rich information on a parent's internal representations of the child and on the nature of the parent's relationship to the child (George & Solomon, 1996; Zeanah, Mammen, & Lieberman, 1993). Usually, the measures ask the parent to describe the child's characteristics as well as the nature of the parent–child relationship. These interviews also inquire into whether the parent planned for this child, how she felt about the child at birth, how she chose the child's name and why, and how the relationship has changed or evolved over time.

A measure of expressed emotion (Magana et al., 1986; Magana-Amato, 1993) can supplement the information on a mother's internal working model by articulating aspects of dysfunctional parenting. This measure specifically establishes whether the parent is overly critical or overly involved in a specific child or relationship. High expressed emotion (e.g., an overly critical and/or overly involved relationship) has been associated with family conflict at home (Hibbs, Hamburger, Kruesi, & Lenane, 1993), marital difficulties, parental coldness toward a child (Stubbe, Zahner, Goldstein, & Leckman, 1993), disorganized attachment status in children (Jacobsen, Hibbs, & Ziegenhain, 2000), and symptom exacerbation in children of different ages (Hibbs et al., 1991; Schwartz, Dorer, Beardslee, Lavori, & Keller, 1990; Stubbe et al., 1993).

Some mothers may be reluctant to reveal ambivalent feelings about a child in an assessment. This is sometimes the case in very young mothers or in mothers who have had a child under traumatic experiences. Family and societal pressures may contribute to these mothers insisting that they have only positive feelings toward a specific child. Getting at ambivalence in such cases can often be challenging and difficult. Sometimes this information is only revealed by a mother later on. One mother, for instance, insisted that she wanted to regain custody of both of her children. However, she consistently spent more time with her younger child. Her interactions with the younger child were also more positive and rewarding. The mother revealed only much later that the child she spent little time with was conceived from the man who raped her.

Personality Influences

Several characteristics of a mother's personality have been associated with risk for child maltreatment. Poor impulse control, difficulties in relating to and confiding in others, and difficulties in verbalizing one's feelings about children, for instance, have been linked to risk for child neglect (Gaudin, Polansky, & Kilpatrick, 1992). Chronic coping difficulties, a chronic sense of hopelessness, deep-seated deficits in caring for children in the past, poor coping skills, and poor problem-solving abilities are factors that have been shown to bode poorly for future parenting (Adshead, Falkov, & Göpfert, 2004). These areas are another aspect of parenting capacity to assess.

Attachment Influences

Experiences of abuse, neglect, trauma, loss, or major separations make a parent more vulnerable to maltreatment, although they do not, in themselves, determine whether a mother will abuse or neglect her children (Bowlby, 1988). Some parents who were maltreated in childhood may struggle in prioritizing their children's needs especially if they as parents are under stress. In such situations, a mother may turn to her children for comfort or help or may abdicate the parenting role until her own stress and emotional needs are assuaged (Solomon & George, 1996).

Inquiring into the childhood experiences of a mother is, therefore, an important part of the caregiving assessment. The Life Events and Difficulties Scale (Bifulco, Brown, & Harris, 1994) is one measure that can be used to assess a mother's childhood experiences. This measure provides information on a mother's quality of relationships with parenting in childhood, past trauma, the consequences of loss of a parent in childhood, discord in the home, physical and sexual abuse, as well as parental indifference and parental control and antipathy.

The Adult Attachment Interview (AAI; George & Main, 1984) provides rich information on a parent's current state of mind about attachment relationships, both past and present. In evaluating the AAI, the clinician first reviews critical experiences that could influence parenting (e.g., loss of caregiver, witnessing violence, disruptions in care, positive experiences, support) and looks for major contradictions from other sources and reports. The assessor then reviews what the mother says about her caregivers (e.g., "great," "cruel, " "abusive") and examines the fit between her descriptions and the evidence (or lack of it) she provides to support the descriptions. Other parts of the evaluation look at how coherent the mother's account of her childhood attachment experiences are, whether she values attachment relationships, and whether she can see how attachment experiences in childhood have affected her own development, including her parenting of her own children. The following types of questions can help an evaluator to elucidate these effects: Does the mother acknowledge that past attachment experiences exert an effect on who she is today? Does she focus only on positive experiences at the expense of negative experiences? Does the mother state that she wants to do things differently from what she experienced in childhood?

The AAI distinguishes a mother's state of mind about attachment. Four groups are distinguished: dismissive, preoccupied, unresolved, and autonomous (Hesse, 1999). Parents who dismiss past effects are more likely to repeat problems from the past, especially if caregivers are idealized. They may be less prone to read and respond to their child's distress and may reject the child at vulnerable moments. A mother who is preoccupied with past experiences may be at a higher risk for experiencing separation anxiety; have difficulties reading the child's cues, especially if she is preoccupied with her own thoughts; and strongly rely on a child to meet his or her own attachment needs. Mothers who are unresolved about the past are likely to repeat past mistakes because they are not aware of the effects of the past. Mothers with an autonomous state of mind value attachment experiences, but recognize the effects on the self.

Not surprisingly, the autonomous state of mind is most typically associated with secure attachment in children. Such mothers are comfortable with their own and with their children's attachment needs. The dismissive, preoccupied, and unresolved states of mind are associated with insecure child–parent attachment patterns. Although providing rich clinical information on adult states of mind regarding attachment (Sagi et al., 1994), the AAI takes considerable training, and the classification process is time consuming.

The Attachment Style Interview (ASI) inquires into an individual's support network and how he or she relates to his or her partner or romantic relationship (Bifulco, Moran, Ball, & Bernazzani, 2002). Questions are asked to obtain information on how much the informant confides in his or her partner, how much active emotional support the partner gives, and the quality of interaction. Inquiries are also made into the parent's experiences with caregivers in his or her family of origin and his or her relationship with friends and siblings. A classification system also rates parents as enmeshed, dismissive, fearful, or withdrawn. A standard category is used for mothers who have a good ability to make and maintain attachment relationships. The ASI requires training, but it can be scored relatively quickly. It provides valuable information on a parent's ability to establish and maintain supportive relationships.

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