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Good Practice Guidance for working with Children and Families affected by Substance Misuse

Part 1: Describing the Problem

1. This section gives some definitions of substance misuse and a snapshot of substance misuse in Scotland. It summarises some of the effects on, and risks to, children's and families' welfare, of parental substance misuse.

Who are we talking about?

2. Estimating the nature and extent of drug use and problem alcohol use in Scotland is complex. Substance misuse is associated with a large variety of drugs from all major groups, illegal, prescribed and legal. There is equally wide variation in their impact and effects on individual users and their families. For ease of description, substance misusers have been grouped into four broad categories.

Experimental drug users who use illegal drugs or other substances once or rarely, and whose use may have little apparent impact on their present functioning or lifestyle. The risk of developing drug dependency and related problems amongst this group may be low. Nevertheless, there is the risk of physical harm and, occasionally, death that may result from ingestion of certain substances, accidental overdose or drugs-related infection.

Recreational drug users who use illegal drugs regularly, who run similar risks as experimental users, and in some circumstances may be at higher risk of developing drug-related problems.

People who use legal substances, such as alcohol, tobacco or prescribed drugs, to levels which significantly impair their health or social functioning. There are recommended sensible limits for alcohol use, which can be described in weekly or daily limits. For women drinking 2-3 units of alcohol per day (up to 14 units per week) it is unlikely that problems will occur. Similarly, men drinking 3-4 units of alcohol per day (up to 21 units per week) are unlikely to experience impairment to health or social functioning. Regular use above these limits is liable to impair health or social functioning.

People who are dependent on illegal drugs or alcohol, whose use significantly impairs their health and social functioning. Their usage is usually characterised by addiction to the substance.

3. All drug use, and alcohol use above sensible limits, carries risk. These categories imply a hierarchy of likely problems. Nevertheless, within each of these groups there may be some users who are experiencing problems and some who are not. For the purpose of these guidelines, we refer to substance misuse as the stage when the use of drugs or alcohol is having a harmful effect on a person's life.

The substance use may become the person's central preoccupation, to the exclusion of significant personal relationships. A person may need to take a substance to cope with everyday events. Their substance misuse may affect their physical or mental health. They may lose their friends, have money problems and get into trouble with the law.

4. Problem drug and alcohol users who are parents may find that their substance use affects how well they are able to look after their children and their relationships with their families. Much substance misuse is currently associated with the illegal misuse of opiates and benzodiazepines. These drugs, and their trade, can cause considerable harm both to individuals and communities, and serious problems for the parenting of dependent children.

5. The misuse of alcohol is to some extent tolerated in our communities, which often makes the assessment of the problems caused by alcohol misuse difficult. The children of problem drinkers are therefore often a hidden population whose needs are not recognised.

How do drugs and alcohol affect individuals?

6. Use of illegal drugs affects people in different ways and causes different kinds of problems. The effects of drug use and its impact on individuals and their lifestyle will vary according to:

• the individual's physical and psychological state
• the nature of the drug(s) used and how they are obtained
• the pattern and degree of drug use
• the method of administration (e.g. injection)
• the circumstances in which the drug is used
• whether a drug is used in combination with other drugs, or with alcohol.

7. The use of alcohol similarly affects people in different ways. The impact of alcohol will vary on single occasions (there is particular concern over 'binge' drinking identified in the Plan for Action on Alcohol Problems) and over longer timescales according to:

Single occasions:

• gender
• weight
• tolerance to alcohol
• whether taken with food or on an empty stomach
• whether the alcohol is taken with fizzy mixers.

Longer periods:

• frequency of use
• individual's physical and psychological state
• pattern and amount of use
• circumstances in which it is consumed.

8. Drug or alcohol use may alter or reduce appetite. It may dull reactions to discomfort and pain. This can lead to self-neglect. Social relationships may narrow down to a small group of people with similar habits. Finding or keeping work and housing may be difficult. Heavy or chaotic substance use may increase conflict and damage family relationships.

9. Illegal drug users may run the risk of contracting drugs-related infections, including blood-borne viruses such as HIV or hepatitis as a result of sharing injecting equipment or other paraphernalia (see Appendix IV), or septicaemia, through injecting contaminated drugs, in unsterile conditions. The Scottish Centre for Infection and Environmental Health reports increasing levels of Hepatitis C infection and estimates that 60% of current injectors are Hepatitis C positive. This figure is substantially higher in some parts of Scotland (SCIEH 2000).

10. In the year 2000 there were over 3500 hospital admissions for acute intoxication for those aged 20-44. Recorded alcohol-related deaths in Scotland in 1999 numbered approximately 1595. ¹ Alcohol misuse contributes to coronary heart disease, a number of cancers and can lead to psychological disorders, psychiatric and severe neurological problems (Scottish Executive) 2002 (a).

11. Overdose of drugs may cause physical or psychological distress, or damage to physical and/or mental health. In some circumstances overdose may result in death. In 2001, 322 drug-related deaths were recorded in Scotland. ²

Drug users in Scotland

12. Information collected by the Scottish Substance Misuse Database on new clients in contact with services ³ provides a useful insight into the treatment population in Scotland. In 2001/2002, 10,798 people with drug problems made contact with services and were reported to the Database ⁴ (ISD 2002):

• a third (33%) were women
• more than four-fifths (85%) were unemployed
• half (50%) reported they were aged under 20 years when their drug use became a problem
• nearly one in five (19%) were living with dependent children
• 29% lived with a partner or spouse and a further 29% lived with their parents.

13. The proportion of clients reporting heroin use has increased year on year since 1995/1996. In 2001/2002 almost 80% of new clients presenting to treatment services reported using heroin. The proportion of people reporting that they had injected drugs in the previous month also increased during this period to 36% in 2001/2002. Of these, one in three reported that they had shared needles. Two in five had begun injecting drugs in their late teens. Psychostimulants are an increasing problem and the Scottish Advisory Committee on Drug Misuse commissioned a report on Psychostimulants. ⁵

Alcohol use in Scotland

14. Currently, there is no national database of problem alcohol users in Scotland, therefore data on alcohol use come from a number of sources:

• in 2000, 26% of all women and 44% of all men drank more than twice the daily benchmark on their heaviest drinking day ⁶
• the proportion of women aged 16-64 drinking more than the weekly recommended limits increased from 13% to 15% from 1995 to 1998 ⁷
• young people, aged 16-24, in Scotland are drinking more; average weekly consumption in young people aged 16-24 has risen from 1995-1998 for both sexes ⁸
• men living in the most deprived areas of Scotland are seven times more likely to die an alcohol-related death than those in the least deprived areas ⁹
• 72% of victims of violent crime reported that their assailant was under the influence of alcohol ¹⁰

Drug misuse and pregnancy

15. National statistics on drug misuse during pregnancy are available from maternity inpatient and day case records (SMR02), and neonatal special care discharge records (SMR11) collected by the Information and Statistics Division (ISD) Scotland. It is accepted that these statistics are under-reported and as such represent only a proportion of the true number of cases ¹¹. The position is similar in relation to alcohol misuse. It is hoped the introduction of a revised SMR02 form in April 2002, with new questions on drug use, will lead to improved information recording in future.

Maternities ¹²
In 2000/2001, of 51,165 recorded maternities, there were 228 cases (4.4 per 1,000 discharges) in which the mother had a diagnosis of drug misuse. ¹³ Of these, 81 cases (36%) were in the Greater Glasgow Health Board area, and 39 cases (17%) were in Grampian.

Neonatal Discharges ¹⁴
In 2000/2001 there were 17,222 neonatal special care discharges in Scotland. 326 included a diagnosis of drug misuse. This total included 94 cases (29%) in Greater Glasgow, 98 cases (30%) in Grampian and 29 cases (9%) in Argyll and Clyde.

Information and advice on substance misuse and pregnancy is contained in Appendix III.

How many children are affected by their parents' substance misuse?

16. Informed policy making and planning at local and national level should be based as far as possible on sound assessment of the extent of the problem in different areas, as well as an understanding of the consequences. Data about the numbers of children living in families in which parents or other family members misuse substances is patchy. However, most recent estimates would suggest that perhaps 40,000-60,000 children in Scotland are affected by their parents' drug use ¹⁵ and 80,000-100,000 are affected by parental alcohol misuse. ¹⁶ The following examples give data from two urban areas - Glasgow and Dundee - and from a project based in Glasgow ¹⁷ working with women drug users. These kind of snapshot data can assist local estimates of the minimum numbers of children who may need support from local services and identify the type of help they may need.

17. A local study of children's cases, in which Glasgow City Council had sought Child Protection Orders between 1998 and 1999, found that of 111 Orders made on children in 62 families, 44 (40%) cited drug-related risk. 47 of the children were named on the local child protection register, 27 because of concerns about neglect and 16 for physical injury (Quinlan, 2000).

18. In Dundee the proportion of children subject to child protection case conferences whose parents were recorded as having problems with alcohol and/or drug misuse, rose from 37% in 1998/1999 to 70% in 2000. Of the 30 children on the child protection register in October 2000, 53% had parents with problems associated with drug and/or alcohol misuse.

19. The Turnaround Project's statistics record that of 470 women who used their service in 2000, nearly two-thirds had one or more children. Only a fifth of the children were living with their mother. Two-fifths were living with extended family rather than their parent and more than one in ten were in foster or residential care or living with an adoptive family. The living situation of the children was as follows:

The impact of parents' substance misuse on their children

"The children are more at risk - there are more risks in the home."

Annette - parent using drugs

"I hated weekends when [mum] had all her friends round drinking all night."

Sarah - daughter of problem drinker
(Ayrshire and Arran NHS Board - 2002)

20. Parental substance misuse alone is neither a necessary nor sufficient cause of problems in children (Mountenay, 1998). Nevertheless, we know that both alcohol (Sher, 1991) and substance misuse (Zeitlin, 1994) greatly increase the risk of family problems. Substance misuse by parents can become the central focus of the adults' lives, feelings and social behaviour. Child and adolescent mental health services report that a parent's long-standing drug and/or alcohol misuse is a substantial risk factor for poor mental health in their children (Mountenay 1999). It is more likely to be associated with poor outcomes for children in the longer term (Rutter and Rutter, 1992). Although alcohol dependence may cause similar problems for households, the illegality of drug use creates additional difficulties. In her contribution to Orford and Harwin's Alcohol and the Family, Clare Wilson wrote that researchers were prone to describe the children of problem drinkers as 'forgotten children', a 'hidden tragedy', or 'unseen casualties'.

"She was just always dead moody, she was always in her bed all the time and she would never go out and buy food and she would never have money to go out and get it."

(Barnard 2002)

21. A wide range of research, predominantly North American, indicates the range of problems associated with parental substance misuse. Many of these 'risk' factors also occur in families where parents do not use drugs or alcohol. A parent's substance misuse may not be the sole predictor of these risks.

• Children may be at high risk of maltreatment, emotional or physical neglect or abuse, family conflict, and inappropriate parental behaviour (Famularo, Kindscherff and Fenton, 1992; Wasserman and Levanthal, 1993, Barlow, 1996). Children may be exposed to, and involved in, drug-related activities and associated crimes (Hogan, 1998). They are more likely to display behavioural problems (Wilens et al, 1995), experience social isolation and stigma (Kumpfer and De Marsh, 1986), misuse substances themselves when older (Hoffman and Su, 1998; McKeganey 1998).
• Parents with chronic drug addiction spend considerable time and attention on accessing and using drugs, reducing their emotional and actual availability to their children. Conflicting pressures may be especially acute in economically deprived, lone-parent households and where there is little support from relatives or neighbours (Rosenbaum, 1979). Households headed by problem drug users may be poor, unstable and characterised by criminal activity. Violence may also be a feature of such environments (Hogan 1998).
• Relationships between drug-dependent parents and their children have been found to be difficult and conflictual. Parents may often provide inconsistent and lukewarm care, ineffective supervision and overly punitive discipline (Kandel, 1990; Boyd, 1993). Deficiencies in parenting skills might, however, also be an outcome of poor role models provided by the parents of drug users themselves. In the long-term children of problem drug using parents may have severe social difficulties, including strong reactions to change, isolation, difficulty in learning to have fun and estrangement from family and peers (Barlow, 1996).
• The impact of parental substance misuse will vary according to the age and developmental stage of children. Some children, for example children with physical or learning disabilities or health problems, may be particularly vulnerable and parents who misuse substances may have difficulty in meeting their additional needs. Assessment of the quality of care parents are providing must take into account the needs of each child individually (Barnard 1999).

Infancy and pre-school years

"Baby Adele was carried along the harbour wall by her father who was under the influence of alcohol. Neighbours thought this carried the risk of dropping her in the water."

(Scottish Executive 2002) (c)

22. Babies in general are particularly vulnerable to the effects of physical and emotional neglect or injury, and this can have damaging effects on their long-term development. Neglect in these forms can occur while the parent/carer is in a drugged state, unaware of what is going on around him/her. Unhappiness, tension and irritability in drugged or intoxicated parents, coupled with a lack of commitment to parenting when preoccupied with drug or alcohol misuse, may lead to inappropriate responses to the child. Poor or inconsistent parenting may damage the attachment process. Poor childcare, little stimulation or inconsistent and unpredictable parental behaviour may hinder the child's cognitive or emotional development. Lack of contact with other children when attendance at nursery is irregular or erratic may compound early deficits in social and emotional development. The financial demands of problem substance misuse may mean that the child's material environment is poor.

23. Physical or emotional rejection may prevent children from developing a positive sense of identity and self-esteem. Children may have their physical needs neglected, for example they may be unfed or unwashed. They may be subjected to direct physical violence by parents, and learn inappropriate behaviour through witnessing domestic abuse. When parents' behaviour is unpredictable and frightening, children may display emotional symptoms similar to those of post-traumatic stress disorder.

"My parents started giving me alcohol when I was 1 (year old) to put me to sleep. I got taken into hospital to have my stomach pumped."

Helen, aged 12
(Ayrshire and Arran NHS Board 2002)

Primary school years

"When I used to feel angry like when ma Mum was on drugs 'cause I used to think how could this have happened to me? I was just sad all the time and then I would get angry. And we would have arguments all the time."

Anne, aged 11
(Barnard and Barlow 2002)

"I used to get really embarrassed at school when mum turned up drunk to collect me. I knew that I would have to make the tea when I got in."

Billy, aged 9
(Ayrshire and Arran NHS Board 2002)

24. As children grow older, early problems may be compounded. They may be at increased risk of injury, and show symptoms of extreme anxiety and fear of hostility. The identity, gender and age of the child may affect outcomes: boys more quickly exhibit behavioural problems, but girls may equally be affected if parental problems endure. Children may develop poor self-esteem, and blame themselves for their parents' problems. Parental neglect or disinterest negatively affects academic attainment and irregular routines may make children's attendance erratic or irregular. Unplanned separation can cause distress and disrupt education and friendship patterns. Parents' behaviour can make children feel embarrassment and shame, and as a consequence they curtail friendships. Children may take on too much responsibility for themselves, their parents and younger siblings.

Secondary school years

"I knew they loved me but they just didnae care that I was there and I needed stuff as well."

Elaine, aged 14
(Barnard and Barlow 2002)

25. Children coping with puberty without adequate parental support may be at increased risk of psychological problems. Children may become increasingly beyond parental control and run a greater risk of injury by parents. There is an increased risk of emotional disturbance and conduct disorders, including bullying, and adolescent boys may become sexually aggressive. They may be increasingly embarrassed and anxious about how to compensate for physical neglect.

"See at school, see if your pals know your ma's on drugs you get called a junkie."

(Aberlour 2002)

26. If children's family problems affect concentration, attainment in school may not match ability. They may truant. Children looking after their parents or siblings are particularly disadvantaged and experience significant disruption to their education. They may fear family break-up, or reject their family altogether. They are often wary of exposing family life to outside scrutiny, so friendships are restricted, and they become isolated with no one to turn to.

27. Young people in families where other family members misuse drugs or alcohol may be socialised into substance misuse and may have an increased risk of developing early problems with drugs and alcohol.

Protective factors

28. Some children and young people are extremely resilient. This helps them get over difficulties and limits the damage caused by exposure to risk, neglect or abuse. International literature on the children of drug users does not support an assumption that child abuse and neglect automatically follow when a parent uses drugs (Hogan, 1998). It does highlight the importance of well informed, comprehensive assessments of substance misuse in a family and its effect on all its members, and effective support to promote children's resilience and repair harm caused by damaging substance misuse.

Risks associated with parental drug use can be mitigated by other, protective factors (Cleaver, Unell and Aldgate (1999). These include:

• sufficient income and good physical standards in the home
• a consistent and caring adult, who will provide for the child's needs and give emotional support
• regular monitoring and help from health and social work professionals, including respite care and accommodation
• an alternative, safe residence for mothers and children subject to violence and the threat of violence
• regular attendance at nursery or school
• sympathetic and vigilant teachers
• belonging to organised out-of-school activities, including homework clubs.

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