https://pubmed.ncbi.nlm.nih.gov/29083536/

 

 

·      34-year-old single mother.

 

·      Diagnosed bi-polar, family history of schizophrenia.

 

·      16 weeks postpartum, daughter Krystal.

 

·      On Child Protection Plan due to severe domestic violence.

 

·      3 sons aged 9,7 and 6. Removed from her care and adopted 5 years ago due to severe domestic violence and neglect. Left their father 2 years ago, no contact since.

 

·      Left recent partner, Aaron, near the end of this pregnancy, he has no contact with Rebecca or Krystal. Restraining order in place.

 

·      Stopped seeing GP, missing appointments for Krystal. On edge, unkempt, lied about seeing Aaron.

 

·      Conversations jumping from one thing to another, seems agitated, lying to professionals.

 

·      Krystal is 16 weeks old and meeting milestones.

 

·      Lying about missing appointments, does not like to be challenged on this.

 

·      Core group meeting: Aaron’s probation officer attended and disclosed that Rebecca and Krystal have had contact with Aaron.

 

 

 

·      What other professionals are involved? Assuming due to the Child Protection Plan that there is a multi-disciplinary support network in place. With the limited information available, it is apparent that Rebecca has a social worker, support worker and a health visitor as part of this support network.

1.     Local domestic abuse organisation.

2.     Peer support groups for survivors of domestic abuse.

3.     Programmes / courses relating to moving on from abuse and healthy relationships.

·      At 16 weeks postpartum, Rebecca could be feeling down, lonely or isolated. Does Rebecca have any mother and baby groups to attend? Does she have any friends or family for support? Could she be feeling isolated?

·      Is Rebecca still receiving treatment for bi-polar? We know she has not engaged with her GP for a few months. 

 

 

 

 

Unable to prioritise the care of her previous children which led to them being removed from her care due to neglect. 

Rebecca is a vulnerable adult.

Not in a stable relationship.

Previous severe domestic abuse.  Possible current domestic abuse and coercion.  

What was the plan from MARAC?

Which professionals are offering support to Rebecca? What is the child protection plan?

Any adverse childhood experiences for Rebecca? Does she understand the impact of adverse childhood experience for her baby?

Aaron and Rebecca not compliance with restraining order. 

Reducing engagement with professionals. 

Mental health concerns. Is Rebecca engaging with mental health support? 

What support is the Health Visitor offering? 

Has bonding between Mum and baby been assessed? 

Is GP aware of lack of engagement with professionals? Is Rebecca medicine compliant?

Is personal appearance changing?

Conversation jumping and lying to professionals. 

Is Rebecca isolated?

Does Rebecca have a support network in place?

Are all of Krystels needs being met? 

Is Rebecca being heard by anybody?

 

Bipolar and schizophrenia.

Domestic abuse.

Coercive relationships.

Rebecca activity 1

34 year old single mother.

Has 3 boys that were removed from her care and adopted 5 years ago, due to severe DV and neglect.

H/O schizophrenia and bi polar.

Has a 16 week old daughter named Krystal, following a new short relationship with Aaron, which ended due to DV.

Krystal on child protection plan.

Aaron placed on restraining order and to have no contact with Rebecca or Krystal.

Appears on edge and unsettled when Margaret arrived unplanned to her home.

Lied about why she didn’t attend clinic.

At core meeting Rebecca still appeared on edge, looked unkempt and conversation jumped from one thing to another with no clear path.

Aarons probation officer was in attendance at the core meeting and reports that Aaron has stated he has been having contact with Rebecca and Krystal.

Is Rebecca taking her medication?

Is Rebecca experiencing symptoms of bipolar?

How is she adjusting to mother hood/being a single parent?

Has Rebecca’s change in appearance/mood impacting her ability to care for Krystal?

Is Aaron having contact with Krystal/Rebecca and if so what form of contact?where is this taking place if face to face? how long for? and is there DV/coercive control?

If found to be true, how will the breach of restraining order be dealt with?

What are Rebecca’s thoughts and feelings?

What support is Rebecca receiving from other services?

Does she have friends and family support?

Is she isolated?

Lying to professionals.

What does child protection plan state.

Vulnerable.

Starting to avoid engaging with professionals.

Areas to develop:
Schizophrenia 

Bipolar 

Domestic violence 

 

·       Single mother – 34 years old

·       Bipolar - medicated

·       Family hx of Schizophrenia

·       3 boys aged 9, 7 and 6 all removed from Rebecca’s care 5 years ago due to neglect and DV relationship

·       16 week old daughter, Krystal

·       Recent DV relationship with father of Krystal. Restraining order in place

·       On CP plan

·       Krystal reaching her milestones

·       Recently missed HV apt and lied about where she was

·       Aaron’s probation officer aware that Rebecca and Aaron are seeing each other again

 

What would I want to know / what are the issues:

·       Is Rebecca still taking her medication for Bipolar?

·       Is she under a mental health team? Women with Bipolar are high risk of postpartum psychosis, would fit the criteria for support with a Perinatal Mental Health Team.

·       What is the interaction between Rebecca and Aaron? Is he visiting her home? Spending time with Krystal? Living with her?

·       Is Rebecca aware of ACE’s and the impact this has on a child’s development.

·       Is Rebecca bonding with Krystal? What is her parent – infant interaction / relationship like? Is she meeting Krystal’s emotional needs?

·       What family support does Rebecca have?

·       What did the DV consist of? Has Rebecca got an IDVA?

·       What are the rules of Aaron’s restraining order? Will the probation officer pursue the break in these rules and look at prosecuting?

Issues for consideration:

Questions!:

-          34 year old single mother 

-          Three older children who have been removed and have been adopted

-          Previous domestic violence and evidence of neglect

-          Family history of schizophrenia

-          Diagnosed and receives treatment for bipolar disorder

-          New short relationship with infants’ father and domestic violence again

-          Restraining order in place for Krystal’s father

-          Krystal placed on a child protection plan

-          Krystal is now 16 weeks old and meeting milestones

-          Rebecca did not attend a weight clinic as planned

-          Rebecca appears on edge and unsettled upon visit

-          Probation officer discloses that Aaron and Rebecca have had contact

 

-          Is Rebecca receiving any CMHT/PMH input? And is Rebecca actively engaging?

-          Concordant with bipolar medication?

-          Rebecca may be “unsettled and on edge” due to previously having her older children removed from her care and worries this may reoccur?

-          What kind of contact have Rebecca and Aaron had?

-          Drugs and alcohol involved? Or hx of?

-          Was Rebecca’s bipolar treatment altered during pregnancy, mood stabilisers? And if so could this be reviewed? As might not be having the same effect

-          What has the health visitor reported from earlier visits/appointments? And any extra support arranged?

-          What does the CP state?

-          Support network?

-          Lying to professionals, does Rebecca know the implication of doing this in regard to the CP?

-          Could Rebecca be encouraged to “open up “to CPN/health visitor specialist in PMH who has a good rapport with Rebecca to identify key factors/issues?

-          Postpartum psychosis? High prevalence within individuals with pre-existing bipolar disorder. 

 

Rebecca -Activity 1.

Facts and observations –

Rebecca is a 34 year single mother 

Has 16 week old daughter-Krystal -Child protection plan in place due to evidence of DV in late pregnancy from the father of the baby- Aaron. 

Krystal observed to be meeting milestones 

Supported to end the short relationship, restraining order in place, detailing no contact with mum and baby.

3 sons aged 9,7,6 – removed from Rebecca’s care and adopted due to severe DV and neglect

Family history of schizophrenia , diagnosis and treatment for Bi-polar

Professionals involved;

 Family support and assessment worker, is aware of family/medical/social history

Health Visitor-telephone contact , weight clinic 

Health, social care professionals 

GP

Police

Aarons probation officer 

 

Current/ evolving risks 

Change in level of engagement with professionals- DNA weight clinic, hasn’t attended GPs for a few months? 

Rebecca appears on edge /unsettled, unkempt, conversation jumping from one topic to another 

Rebecca unable to explain rational for why she lied re non attendance at clinic 

Probation officer states Aaron is having contact with Rebecca 

 

Initial thoughts/issues 

Need for integrated MDT response and communication to develop risk assessments and formal management plan. Are Perinatal services involved? Who is co-ordinating ?

Timely exploration /assessment and review of treatment re Bi-polar diagnosis –consider rapid onset of symptoms and associated risks, what are Rebecca’s relapse signatures? Is Rebecca compliant with medication? When was this last reviewed and by whom? Consider impact of stress, sleep deprivation and social isolation, risk of suicidality, risk to baby. What contingency planning is in place?

What is Rebecca’s experience of being parented? Did she experience any childhood adversity? How is she adjusting to motherhood? What support does she need re parenting? Consider bonding and attachment -possible impairments as well as strengths 

What safety plans are in place re DV? Is Rebecca having face-to-face contact with Aaron? What does the contact look like, Is there an immediate risk to safety for mum/baby? 

Does Rebecca have any family/friends that are supportive? 

What is experience (consider through eyes of the child’ ? Safety Triangle, are all of her needs being met?

Facts of this case-study

A mental health disorder where someones mood swings from one extreme to the other. Either depression or mania. Formerly know as manic depression.

Pregnant women with a diagnosis of Bi-polar disorder should be under obstetric-led care.

Risks should be discussed about whether to continue or discontinue psychotropic medications… risk to fetus vs benefit to mum.

Evidence-base is lacking for the treatment of Bi-polar in pregnancy.

Psychotrophic drugs are not licensed for use in pregnancy due to the ethical complications of testing on pregnant women/fetus in utero.

Significant increased risk of psychotic episode during the postnatal period. Careful discussion around breast-feeding should be given to forward plan treatment/medications.

Important not to switch medications for breastfeeding. The amount of medication secreted into the breast milk is thought to be less than the utero-placental exposure.

Maintenance treatment is important throughout the pregnancy, as morbidity is increased with the abrupt discontinuation of medication.

There is a need for co-ordinated care/communication within the multidisciplinary team to ensure early recognition and intervention if there is a relapse or psychosis presents (Marsh, W and Viguera, A: 2012)

I found an interactive learning tool for health professionals. Unfortunately it is now out of action but will share when it is working again, but can be found here if you are interested.

https://www.ncmh.info/resources/online-tools/ National Centre for Mental Health (2021)

https://www.nice.org.uk/guidance/CG192 Antenatal and postnatal mental health: clinical management and service guidance (02/2020) NICE

Research shows that quality of inter-parental relationships and ability to resolve conflict have a substantial influence not only on parental mental well-being but also the long-term life chances for children.There is strong evidence to support the link between healthy couple relationships and improved outcomes for children.

My thoughts are that Rebecca may be having a psychotic episode following the birth. This in turn is leading to her partaking in risky behaviours, as such, being in contact with Aaron and putting herself and the baby at risk. As above, Rebecca is at very high risk of psychosis due her diagnosis of Bi-Polar disorder. I query if she is taking her regular medications.