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

Part 2: Deciding when Children need Help

"Reaching the children is very difficult. The children who say least are of most concern."

(For Scotland's Children, Scottish Executive 2001)

1. This section gives advice to agencies, including those providing treatment and care to substance misusing adults, about what to look for when assessing needs and risks in families.

2. When working with parents who misuse substances, agencies should consider the impact on children, be alert to their needs and welfare and respond to any emerging problems.

Children in need are likely to include children of parents who have problems associated with their use of either drugs or alcohol or both, and young people who provide care or support for parents who misuse drugs or alcohol, often termed "young carers".

Section 93 (4) of the Children (Scotland) Act 1995 defines a child in need as:

Being in need of care and attention because

• s/he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development unless there are provided for him/her, under or by virtue of this Part, services by a local authority; or
• his/her health or development is likely significantly to be impaired, or further impaired, unless such services are so provided.

Guiding principles

3. Local authorities, health services, housing agencies, courts and children's Hearings, and other agencies in contact with families have a range of responsibilities to promote the welfare of children and protect them from danger. These responsibilities are included in children's legislation, most recently set out in the Children (Scotland) Act 1995. National guidance for all agencies describes how these responsibilities should be discharged. The report For Scotland's Children (2001), stresses the importance of agencies working together to meet children's needs. It emphasises that initiatives such as SureStart Scotland, New Community Schools, Healthy Living Centres and Social Inclusion Partnerships are already in place to promote a more integrated approach to providing services to children. This document should be read in conjunction with other national guidance on supporting families and inter-agency child protection. ¹⁸ Some key themes and principles underpin legislation and apply to all families with children. They should inform all agencies' work with families in which parents misuse substances, whether the agencies focus is on the parents' problems or those of the child.

The welfare of the child is the paramount consideration
When working with families affected by drugs and/or alcohol, the welfare of children should always come first.

Every child has a right to be treated as an individual
Parental substance misuse should not be seen in isolation, but needs to be placed in a wider context. Assessment should take into account the uniqueness of each family and its circumstances.

Every child who can form a view on matters affecting him or her has the right to express those views if s/he wishes
Children should be considered and consulted when parents and professionals make important decisions about things that affect them, including where, and with whom, they should live, their schooling, their relationships and lifestyle. Their rights should be respected.

Every child has the right to protection from all forms of abuse, neglect or exploitation
All agencies in contact with families affected by substance misuse should consider the safety and welfare of the children of those families.

Parents should normally be responsible for the upbringing of their children and should share that responsibility. So far as is consistent with safeguarding and promoting the child's welfare, local authorities should promote the upbringing of children by their families
Agencies should help parents to acquire necessary parenting skills and put children's welfare first. Where a child cannot be looked after safely by his or her own parents, local authority social work services should try to help extended family to care for the child if that is possible. Where a child's welfare cannot be promoted or safeguarded in his or her birth or extended family, local authorities should make alternative arrangements promptly.

Any intervention by a public authority in the life of a child must be properly justified and supported by services from all relevant agencies working in collaboration

Parental substance misuse will often be a cause for concern. Local authorities, normally through social work and other support services and other agencies, should assess the child's and family's circumstances and offer help and support to enable substance misusing parents to provide the necessary care for their children at home.

What agencies should look for - gathering information

"There were so many things I had to keep quiet so I just didn't bother to say anything in case I let something slip out that I shouldn't have done so whenever they started talking about things I'd just say I didn't know."

Fixy, aged 15
(Barnard and Barlow 2002)

4. Not all substance misusers' families experience difficulties. It is also true, however, that parents and children hide problems, sometimes very serious ones. Children are often wary of talking about their needs for fear of losing their parents. Parents on the other hand may have concerns about their children being taken into care.

5. There is concern that there may be long-term harm to children, whether or not there is obvious short-term harm. This may come from a variety of factors, including neglect, disrupted schooling, anxiety in children for their parents' safety, and children becoming young carers. Therefore, it should not be assumed because a child shows no obvious sign of need, harm or distress, that problems do not exist. If one or more adults in a family are misusing drugs or alcohol and their life is disorganised, this will be detrimental to the welfare and/or safety of any children in the family. Identification and assessment is often a difficult sensitive and complex task and can be further complicated by the fact that alcohol consumption is legal, potentially increasing the possibility of missing signs of neglect.

"I thought my mum and dad drank because of me. They used to shout at me and tell me it was all my fault. If my nan interfered they got really angry."

Ann - 20-year-old daughter of problem drinking parents
(Ayrshire and Arran NHS Board 2002)

6. All agencies have a part to play in helping to identify problems at an early stage. They should gather basic information about the family and household circumstances of substance misusers.

7. Alcohol- and drugs-related agencies or child welfare services, working with parents who use alcohol or drugs, either illegally or to excess (including misuse of alcohol or prescribed drugs), should be aware of potential risks to children in the care of those adults. They should be equipped to provide information and advice to parents about the possible impact of their substance misuse on dependent children, alongside other information and advice about alcohol/drugs and their effects. They should always explore how substance misuse may affect their responsibilities for child care. Criminal justice agencies providing arrest referral and diversion schemes, preparing court reports, supervising probation orders or planning prisoners' release should consider the impact of a parent's alcohol or drug problems on any children, and collaborate with other agencies in assessing risk.

8. Staff in all agencies should be alert to changes in families' circumstances and whether children appear to be well cared for and thriving. Those particularly well placed to make sure that children in families of adult substance misusers are thriving include:

• specialist alcohol/drugs workers or counsellors
• social workers, including criminal justice social workers
• health visitors and midwives
• nursery staff
• class teachers and guidance staff
• GPs
• community psychiatric nurses
• police
• pharmacists.

How parental substance misuse might affect children

9. Part 1 highlighted that parental substance misuse is associated with a range of potential risks to children. These may include:

• harmful physical effects on unborn and new-born babies
• impaired patterns of parental care with a higher risk of emotional and physical neglect or abuse
• chaotic lifestyles, which disrupt children's routines and relationships, leading to early behavioural and emotional problems
• family income may be diverted to buy alcohol or drugs, leading to poverty, debt and material deprivation
• unstable accommodation or homelessness as a consequence of anti-social behaviour orders, rent arrears or conviction for alcohol or drugs related offences
• children having inappropriately high levels of responsibility for social or personal care of parents with problem substance use, or care of younger siblings
• isolation of children and inability to confide in others for fear of the consequences
• threat of domestic abuse
• disrupted schooling
• children's early exposure to, and socialisation into, illegal substance misuse and other criminal activity
• parents' reduced awareness or loss of consciousness may place children at physical risk in the absence of another adult who is able to supervise and care for them
• careless storage of medication and disposal of needles and syringes may cause accident or overdose
• repeated separation from parents when parents attend detoxification or rehabilitation facilities, or are in prison, or leave children looked after by multiple or unsuitable carers
• multiple episodes of substitute care with extended family or foster carers.

10. Those professionals in regular contact with families should be alert to increases in stress, changes in parents' substance misuse or other changes in their circumstances, and should consider any potential detrimental impact on their ability to look after children. These changes may signal a need for more help.

11. While all agencies are responsible for identifying problems and gathering information, agencies will vary in their ability to assess harm to children. Therefore, agencies must have arrangements in place to pass on information and work with social work services in helping to assess and continuing to work with the family.

12. Each agency working with substance misusing parents should have child protection procedures in place. They should consult with Child Protection Committees about the content of these procedures.

Assessments

13. When assessing the well-being of any family, agencies must look at the parent's substance misuse from the perspective of the child to understand the impact this has on the child's life and development. Agencies should consider each child in a household separately.

"When I reached 14 my mum used to send me for her fags and carry-out."

Sandra, aged 16
(Ayrshire and Arran NHS Board 2002)

"I hate having to take my kids to the chemist to get the methadone - it isn't right for them to see all this."

Jo - parent on methadone maintenance programme

"I think everyone should be assessed when they are a parent."

Mark - father seeking to be reunited with his children in foster care

14. Parents with problem substance use should be assessed like other parents whose personal difficulties may affect their parenting and care of children. Professionals should always attempt to involve parents, and where appropriate children and young people, as partners in the assessment. Assessments will vary in their complexity and the time they will take to complete. They should consider a family's strengths and skills as well as weaknesses.

15. A checklist for gathering information concerning parental substance misuse and its impact on families is available at Appendix II. Any professional in touch with a family affected by parental substance misuse can use this checklist. Answers to these questions will enable the professional to identify alcohol- or drugs-related risks and problems likely to affect the child's welfare and development, and highlight areas of strength within the family that may be harnessed to tackle problems with parenting. It should supplement, not replace, generic frameworks for assessment of family functioning and children's welfare used by social work services and specialist children's services and support agencies. ²⁰

16. Some models already exist: for example, Glasgow City Council has developed an assessment framework and Dundee University has worked with several Scottish local authorities and the Scottish Executive to develop a common assessment framework for professionals working with families where children may be neglected. Following a recommendation in For Scotland's Children, it is intended to develop a single assessment format for use by all agencies working with children in Scotland with community care services, the Single Shared Assessment is being developed. The Scottish Executive has issued advice - 'Integrated Care for Drug Users - Principles and Practice', ²¹ to develop better practice in assessment and care planning.

Comprehensive assessment

17. If an agency's initial assessment suggests that the parent's substance misuse is impairing, or likely to impair, a child's health or development, or that the child is suffering, or may suffer, significant harm, they should refer the child and family to the social work service. The social work service should respond and where necessary carry out a comprehensive assessment of the family to inform a plan for family support and, if necessary, child protection.

18. A comprehensive assessment provides a sound basis for effective planning and support to the family. An assessment of a child and family involves gathering information purposefully to:

• identify a child's needs within his or her family and community
• identify the needs of other family members including parents, siblings and extended family involved in supporting the family
• describe any risks to the child's healthy development and welfare
• help the family find ways of tackling problems to ensure that the child's needs can be properly met
• decide what help or services, if any, the agency should provide.

"You need even more support when you come off the drugs."

Helen - ex-heroin addict and single parent

19. The ability of a parent to care adequately for his/her children may vary depending on the amount of substance use, treatment undertaken, withdrawal from alcohol or drugs and other circumstances. Parents who stop misusing alcohol or taking drugs should not necessarily be assumed to be better or safer parents, in the absence of other evidence. Some parents who use drugs or use alcohol in harmful ways have poor parenting skills for reasons other than their substance misuse. If parents stop using alcohol or drugs suddenly, withdrawal can increase stress and anxiety and decrease the ability of parents to care for children. Nor should it be assumed that if the substance misuse is controlled, the parents will immediately be capable of looking after children safely or satisfactorily. Any change in the parents' substance use will warrant re-assessment of the impact of the change on other family members, and in particular dependent children.

Substance misuse problems and mental health

20. It is important to assess the mental and physical health of parents with drug or alcohol problems. There is evidence of a rising trend in the number of people with both alcohol/drug problems and mental illness. This is commonly referred to as 'dual diagnosis'. Recent information about people admitted to psychiatric hospitals shows that 1,231 admissions among young people aged 15-44 were related to drug use. Surveys show that about a third of acute psychiatric inpatients with severe and enduring mental health problems also have alcohol problems. ²² In general practice, conditions such as anxiety, depressive illness and some psychotic disorders are known to be more common among people who use drugs than amongst those who do not (ISD 2000).

21. People with dual diagnosis are particularly vulnerable and may have additional complex needs. They need well co-ordinated care from both drug/alcohol and mental health services but are less likely to receive services than people with drug, alcohol or mental health problems alone. The Care Programme Approach should be considered in managing health and social care for people with dual diagnosis. Lead clinicians in local mental health and drugs or alcohol services should agree which service should co-ordinate the person's health care, and appoint a keyworker to ensure smooth communication between health professionals.

Regular reviews

22. Agencies should regularly re-assess and review their clients' family and living circumstances. Parents using alcohol or drug services should be asked routinely about how they are coping with parenting responsibilities and given the opportunity to talk about stresses or worries. When visiting families at home, staff, including specialist alcohol or drugs workers, should observe and record the conditions in which children are living. If the worker feels able, they should discuss any worries about the safety or welfare of the children with the parents. If problems persist they should refer the child and family to the social work service for help and any protection needed. If a specialist worker is uncertain about whether the care of, or conditions for, the child(ren) are adequate, they should seek advice from a senior colleague with responsibility for child protection, or from one of the child protection agencies listed in Part 3. If in doubt, seek help from an agency with responsibility for protecting children's welfare - the social work service, the Reporter or the police.

"We need someone who can build a relationship - it's honesty that matters."

John and Carol - drug using parents

23. Throughout their involvement with families in which parents have substance misuse problems, all agencies should consider:

• the extent to which parents may try to conceal their illegal drug taking/harmful drinking from agencies because they fear the negative consequences; and
• how difficult parents may find it to change their substance misuse and associated behaviours despite those negative consequences.

24. Agencies should acknowledge with parents that they recognise these factors, and will test the accuracy of information provided. Parents may also find support and advice about their parenting, and possible risks to their children, difficult to accept. Professionals should be open about these difficulties and talk to parents about the importance of tackling problems early on.

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