Child Protective Service Disparities and Serious Mental Illnesses: Results From a National Survey

Parenting is among the most significant experiences that one can have, but parenting among persons with serious mental illnesses is poorly understood and infrequently discussed (1, 2). Supporting parents with serious mental illnesses is critically important. On the one hand, research suggests that people with a serious mental illness are no less likely to love their children and report positive meaning than parents without mental health issues (3, 4). Parenting promotes a positive identity, sense of personal pride, and satisfaction with life, and it can lead to improved feelings of self-esteem and competence and serve as a buffer against issues related to stigma (5).

On the other hand, custody loss has been shown to have devastating psychological impacts on parents (6–8), including parents with a serious mental illness (9). Familial involvement with child protective services (CPS), particularly if children are removed from parental custody, can have serious and long-lasting implications for the health and well-being of children and families. Although CPS can play a valuable role in protecting children from abuse and neglect, involvement in child welfare systems is associated with poorer mental health, developmental, and social outcomes among children (10–17). Findings from previous research have demonstrated that for children who are on the margin of being placed in temporary protective care, remaining in the custody of birth parents predicts better outcomes (12).

There is very limited, and dated, research on the prevalence of parenting among individuals with a serious mental illness in the United States, as well as on their experiences with CPS. Data from almost 30 years ago demonstrated that the prevalence of parenthood among individuals with a serious mental illness is similar to that in the general population (18). Data from Michigan in the late 1980s found that almost one-third of mothers with a serious mental illness lost custody of their children (19). A Philadelphia study conducted in the early 2000s demonstrated that mothers with a serious mental illness were more likely than mothers without a serious mental illness to have contact with CPS and were at an increased risk of losing parental rights and custody of their children, after the data were controlled for poverty, ethnicity, and age (20). The disparity in contact with CPS and custody loss is disconcerting because there is some debate about the extent to which rates of child abuse and neglect are demonstrably higher for parents with a serious mental illness (21), especially after efforts are made to control for factors unrelated to mental health that also predict CPS involvement.

The purpose of this study was to provide an up-to-date and contemporaneous estimate of the prevalence of parenthood in a national sample of individuals with serious mental illness compared with a general population sample and to determine whether there were differences in CPS involvement between the two groups. Specific research questions included, What is the current prevalence of parenthood among individuals with and without serious mental illnesses? Are parents with serious mental illnesses at greater risk than parents without serious mental illnesses of having involvement with CPS? Does the level of intensity of CPS involvement, including custody loss, differ depending on whether a parent has a serious mental illness?

Methods

Procedures

Data came from the Truven Health Analytics’ PULSE Survey, conducted in the United States. PULSE is the largest privately funded national survey covering a variety of health care topics. The PULSE survey involves multimodal sampling conducted via telephone (landline and cell) as well as the Internet. The survey involves contacting a geographically stratified random sample of the U.S. population every month, approximately 7,400 individuals, by phone (landline and mobile; 65%) or online (35%). The telephone and online surveys are conducted by a leading market research firm. Landline phone calls consist mainly of random-digit dialing, but a small percentage (no more than 10%) target people who responded to the previous year’s survey. Cell numbers are obtained from a multinational survey firm, cover the full set of phone exchanges assigned in the United States, and are optimized to enhance representation of results. The online survey is conducted with a prominent technology provider that sends out e-mails with links to the survey, with methods intended to achieve a sample that is nationally representative. Individuals participating in the survey may receive rewards in the form of points that may be redeemed for prizes, gift certificates, or cash. Since 2014, the PULSE survey topics have included medical tourism, the Ebola virus, birthing decisions, high-deductible health plans and their impact on utilization, vaccinations, and health care and flexible spending accounts. Their samples are representative of the overall U.S. population in terms of geography, race, ethnicity, income, marital status, employment, and education. A number of reports and news articles on various health-related topics have been published by using the Truven PULSE data.

Truven allows custom topics to be added to the PULSE survey for a fee. To conduct this study, questions were added to identify persons with a lifetime history of a serious mental illness and ask about parenting and CPS involvement. The presence of a lifetime history of a serious mental illness was based on the 1992 ADAMHA Reorganization Act (P.L. 102–321) and was defined as a “diagnosable mental, behavioral, or emotional disorder [that] has resulted in functional impairment which substantially interferes with or limits one or more major life activities.” After consultation with several psychiatric epidemiologists about brief approaches to assessing whether a serious mental illness is present, the following yes-no sequence of questions was developed and added to the Truven survey: “Have you ever been told by a psychiatrist or other mental health professional that you have major depression, bipolar disorder, manic depression, schizophrenia, or schizoaffective disorder?” “Have you ever been hospitalized for this mental health or emotional problem?” and “Has this mental health or emotional problem substantially interfered with or limited your ability to participate in any major life activities such as work, school, recreation, social activities, religious activities, family relationships, or caring for yourself?” Respondents who answered yes to all three questions were determined to have a lifetime history of a serious mental illness. Another study using this approach resulted in estimates that were comparable to those found by other methods (22).

To assess parenting status, respondents were asked, “Do you now or have you ever had any children?” Those who answered yes were then asked the following questions regarding involvement with CPS: “Has CPS ever contacted you with concerns about your parenting of your children?” If so, they were asked, “Did any contact by CPS result in your receiving in-home services?” “Did any contact with CPS result in your receiving out-of-home services?” and “Did any contact with CPS result in a change of living arrangements for your children?”

Research Participants

The sample of parents with serious mental illness was generated by using data from 42,761 individuals between the ages of 18 and 65 who were contacted by Truven between September 2014 and December 2015. Demographic data for the population from which the sample was obtained, including age, gender, race, education, income and marital status, can be found in a previous publication (22). A diagram outlining how the sample of parents with a serious mental illness was determined is shown in Figure 1.

The general population sample was generated by using Truven data from a single month (September 2014) because it was expected that a large sample of parents could be obtained in a single month. Of 4,661 individuals between ages 18 and 65 who were contacted that month, 3,765 (81%) responded no to the diagnosis question, meaning they would not meet the lifetime serious mental illness criteria. A diagram outlining how the general population of parents was determined is shown in Figure 2.

Analysis

The proportions of individuals who were parents, who were contacted by CPS, and who had various types of CPS involvement were calculated for both groups. Chi-square tests were used to assess whether any group differences were statistically significant. PROC GENMOD in SAS was used to compute relative risks of CPS involvement and change in living arrangements; these computations were made by using a robust error variance (23, 24).

Results

Parenting Prevalence

Demographic characteristics of the parenting samples are provided in Table 1. The groups did not differ significantly by gender, but parents with a serious mental illness were less likely to be white, were younger, and were less likely to be married, to have more than a high school education, and to have a household income above $50,000 at the time of the survey. There was no statistical difference between the two groups in the likelihood of being a parent (serious mental illness, N=1,682, 69%; general population, N=2,656, 71%).

CPS Contact and Services

Of the 1,665 parents with a serious mental illness who answered the question about CPS contact, 597 (36%) reported contact. Of the 580 parents with a serious mental illness who answered all three questions about specific CPS services, 452 (78%) received in-home services, 456 (79%) received out-of-home services, and 435 (75%) had a change in living arrangements. Of the 2,645 parents in the general population who answered the question about CPS contact, 120 (5%) reported contact. Twenty-four (20%) received in-home services, 22 (18%) received out-of-home services, and 27 (23%) had a change in living arrangements.

The rate of CPS contact was nearly eight times greater for parents with a serious mental illness compared with parents in the general population (relative risk [RR]=7.90, 95% confidence interval [CI]=6.56–9.52, z=21.76, p<0.001) and did not change substantially after the analyses controlled for gender and race (RR=7.94, 95% CI=6.60–9.57, z=21.88, p<0.001). Fathers were more likely than mothers to have CPS involvement (RR=1.53, 95% CI=1.36–1.72, z=7.05, p<0.001), but there were no significant differences in CPS involvement rates for whites and nonwhites. Within-group analyses showed that gender and race were not associated with CPS involvement in the general population, but among parents with serious mental illness, fathers (N=299, 47%) were significantly more likely than mothers to have CPS involvement (N=298, 29%) (χ²=57.50, df=1, p<.001).

Among all parents, those with a serious mental illness were much more likely to receive CPS services (RR=20.00). For parents with a serious mental illness, the risk of receiving in-home and out-of-home services was 29.8 and 32.8 times greater, respectively, compared with the risk for parents in the general population, whereas the risk of having a change in living arrangements was 25.6 times higher. No differences by race were found. Fathers were more likely than mothers to experience a change in their children’s living arrangement (RR=2.05, 95% CI=1.75–2.40, z=8.84, p<0.001), but the difference was due to outcomes among parents with serious mental illness. Among those parents, fathers were significantly more likely (N=242 of 623, 39%) than mothers (N=189 of 1,025, 18%) to have a change in living arrangements (χ²=83.54, df=1, p<0.001).

Parents without a serious mental illnesses were much more likely to receive no CPS services (RR=2.58, 95% CI=2.01–3.31, z=7.42, p<0.001). Parents with a serious mental illness were 3.8 and 4.2 times more likely to receive in-home and out-of-home services, respectively, and 3.3 times more likely to report a change in living arrangements.

After we controlled for gender and race, the adjusted RR of having a change in living arrangements following CPS contact was greater among parents in the serious mental illness group compared with parents in the general population (RR=3.18, 95% CI=2.28–4.45, z=6.79, p<0.001). Among all parents with CPS contact, fathers were more likely than mothers to have a change in living arrangements (RR=1.29, 95% CI=1.17–1.43, z=5.22, p<0.001), and whites had marginally lower rates of change in living arrangements than nonwhites (RR=.91, 95% CI=.82–1.00, z=−1.95, p=0.051). Among parents with CPS contact in the serious mental illness sample, fathers (N=242 of 289, 84%) were significantly more likely than mothers (N=189 of 291, 65%) to have a change in living arrangements (χ²=26.81, df=1, p<0.001).

Discussion

This study provided contemporary and contemporaneous data on the prevalence of parenthood among adults with and without a serious mental illness, the first comparative national results on parental involvement with CPS, and the first results involving the CPS experiences of fathers. Adults with a serious mental illness were as likely as the general population to be parents. Parents with a serious mental illness were eight times more likely to have a CPS contact compared with parents in the general population. In addition, among parents with a serious mental illness, contact with CPS was upwards of 30 times more likely to result in some type of service and 25 times more likely to result in out-of-home placement compared with similar contacts among parents in the general population. This disparity continued even when the focus was solely on parents with a CPS contact. Among parents with a CPS contact, parents with a serious mental illness were much more likely to receive CPS services compared with parents in the general population, and they were more than three times more likely to report a change in living arrangements. One previously unexplored finding was that among parents with a serious mental illness, fathers were more likely than mothers both to have CPS contact and to experience a change in living arrangements. Given that parenting is consistently found to be a positive and meaningful experience, these results underscore the importance of attending to parents’ experiences, especially as they relate to mental health and recovery outcomes.

These results offer two perspectives on the magnitude of CPS involvement. First, compared with all parents in the general population, a parent with a serious mental illness is exceedingly more likely to have a CPS contact, be viewed as requiring some type of intervention, and lose custody. Such a finding indicates a need to pay further attention to parenting issues experienced by individuals with serious mental illness, as discussed later. Second, our findings indicate that when the analysis was limited to parents with a CPS contact, parents with a serious mental illness remain at elevated risk of receiving services and experiencing a change in living arrangement, although the disparities decreased. This comparison somewhat controlled for some social and environmental risk factors for CPS involvement, including poverty, unemployment, and housing and food instability, which parents with serious mental illnesses are known to experience at greater levels than the general population (2, 19, 25). A study conducted in Denmark (26) also found that accounting for some of these factors was associated with reduced CPS involvement for parents with serious mental illness. The remaining disparity, however, supports the call for greater attention to addressing parenting among persons with a serious mental illness (27). Finally, fathers with a serious mental illness, a relatively ignored group, are at even greater risk than mothers of CPS involvement, including custody loss.

Implications

The fact that parents with serious mental illnesses experience greater CPS contact and custody loss does not necessarily mean that they are more likely to abuse and neglect their children or that a mental health diagnosis is a sole or direct contributing factor. Research rarely disentangles factors that are associated with greater CPS involvement and custody loss, such as poverty and unemployment (28–30), unaffordable housing, inaccessible health care, community violence, social isolation, substance abuse, and criminal involvement (28, 30–32), which are more prevalent among persons with serious mental illness (33).

Parents with serious mental illnesses may also experience overt bias from CPS workers, judges, and clinicians that also might account for higher rates of CPS involvement. Parenting with a significant impairment, whether it is physical, sensory, cognitive, developmental, or psychiatric, places these populations at risk of CPS involvement. Overt discrimination toward parents with disabilities is well documented, including a sterilization law influenced by the eugenics movement that was applied to individuals with disabilities, “incurable” illnesses, and epilepsy as well as to criminals and orphans. This law was adapted by Virginia and upheld by the Supreme Court in Buck v. Bell, establishing the precedent that resulted in over 60,000 procedures performed on those with health impairments and disabilities (34–36). Although eugenics has since been discredited, Buck v. Bell has yet to be overturned and has been used as precedent as recently as 2001 by a federal appeals court (37). Federal and state statutes continue to limit parental rights by either allowing a mental illness as grounds to terminate parental rights in 36 states (37) or expediting the process to terminate parental rights, and some states allow for a mental illness as grounds to not provide reasonable efforts to reunify a family (38). In numerous cases, parenting competency has been questioned on the basis of presence of a parental health condition or disability (37).

More recently, following a rise in discrimination-based complaints from parents with disabilities, the Department of Health and Human Services (DHHS) and Department of Justice (DOJ) released a joint technical assistance statement in which they reported, “In the course of their civil rights enforcement activities, OCR [DHHS Office for Civil Rights] and DOJ have found that child welfare agencies and courts vary in the extent to which they have implemented policies, practices, and procedures to prevent discrimination against parents and prospective parents with disabilities in the child welfare system” (39). They went on to offer technical assistance for state and local child welfare agencies and the courts regarding requirements of Title II of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act.

Prejudice and discrimination toward parents with a serious mental illness are likely to occur throughout the child welfare system, and more work is needed to help child welfare and courts do a better job of supporting the rights of parents with disabilities. As a result of such biases, it is not surprising that parents with serious mental illnesses may be less likely to seek assistance or support from others because it increases their engagement with mandated reporters. Increased surveillance by mandated reporters likely raises the probability of both increased CPS contacts and loss of parental custody experienced by parents with serious mental illnesses through two mechanisms (20, 40). First, increased surveillance leads to greater detection of actual abuse or neglect among parents with serious mental illnesses, but lower surveillance of parents without a serious mental illness results in less detection of actual abuse and neglect that they are involved in, creating a disparity. Second, increased surveillance combined with prejudicial beliefs about the parenting abilities of individuals with a serious mental illness may lead to greater false positives in reporting that, when combined with biases present elsewhere in the child welfare system, may also contribute to the disparities. The end result is that parents with serious mental illnesses may be less inclined to engage with any type of services, including mental health services, as a result of fears about the effects of increased surveillance.

This is problematic because effective parenting programs and supports within a mental health service context exist (41, 42), including online programs (43), and should be utilized. Supported parenting programs may meet the needs and concerns of parents, improve self-esteem and motivation for treatment, and enhance parenting abilities and experiences (27). Adapting existing mental health services to better address the role of parenting and support parents and families would be more cost-effective than a reliance on child welfare systems, given that CPS involvement is associated with higher economic costs and poorer developmental outcomes (12).

Still, these parenting programs are few and far between, and findings suggest that most practitioners are poorly equipped to address issues related to parenting (1, 44). Mental health professionals rarely attend to whether or not someone is a parent and do not inquire about CPS involvement, plausibly because they are not adequately prepared in their professional training to focus on parenting issues as part of treatment or familial reunification. Furthermore, evidence points to poor communication and collaborative treatment planning between mental health practitioners and CPS workers, leading to fragmented service delivery (7).

Additional work is needed to inform other pertinent `systems about the issues surrounding parenting, mental illness, and CPS involvement. Increased opportunities for education and training in these topics are particularly important among professionals who work in child welfare, legal systems, and courts as well as attorneys and educators. These efforts should focus on increasing awareness and understanding of the prejudice pertaining to parents with a serious mental illness and developing and sharing strategies for working with the unique challenges faced by these families.

Limitations

Surveys tend to have an overrepresentation of women and more educated respondents (45), as was the case here. Our general estimates of CPS involvement for those with a serious mental illness may, therefore, be an underestimate, given our finding that men with a serious mental illness may experience more CPS involvement.

The presence of a serious mental illness was assessed without a structured diagnostic interview. This approach produced estimates of serious mental illness that were very comparable to previous and concurrent findings (22). There was limited opportunity to use demographic characteristics to control for age, education, income (i.e., poverty), employment, family size, child characteristics, and other factors known to be associated with CPS involvement. Comparing groups that had CPS contact somewhat controlled for these factors. Embarrassment and other social desirability factors may have led to an underreporting of CPS involvement and types of involvement, although this would have likely affected both populations, suggesting that our RR estimates would be minimally affected. Participants’ recall of types of CPS involvement or understanding of the various types of involvement about which they were asked may also produce some error, but again, these factors would not affect RR estimates.

Conclusions

The results of this study showed that individuals with a serious mental illness are just as likely as individuals in the general population to be parents. Despite similar rates of parenthood, parents with a serious mental illness were much more likely to have experienced a CPS contact, to have received services, and to have had an out-of-home placement. These comparative and current results, involving a national sample, further support the urgent calls for advancements in both research and practice in this area. Important next steps include addressing possible biases in reporting that results from prejudice and discrimination toward parents with a serious mental illness, developing strategies and priorities for training staff and practitioners who come into contact with these families, and bolstering the availability and accessibility of resources that practitioners can use to better support families.