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

Part 5: Strengthening Services for Families

1. Problem alcohol- or drug-using families face many personal and social problems, and yet are often asked to live up to a standard that few parents could match. This section sets out advice for improving the range and quality of support available to families to help them succeed in bringing up children to achieve their full potential.

"Drugs services are always for the single person: they are not for the family."

Marion - mother of child placed with maternal grandmother

2. In the field of treatment, care and rehabilitation, children of alcohol or drug misusing parents have often been invisible. Professionals feel ill-equipped to manage the often complex needs of both parents and their children, and have focused on adults. Similarly staff in children's services have lacked the knowledge, skills and confidence to address parents' alcohol- or drug-related problems, even when these are clearly impacting upon the child with whom they are working.

3. For Scotland's Children encourages a more integrated approach that takes account of family as well as individual well-being, and requires work to focus on the family as a whole. Services for parents need to develop knowledge of the impact of substance misuse on children, and all agencies need to strengthen working links to tackle the problem more effectively. Children require sympathetic support and help from well-informed and well-trained staff, willing to work closely with colleagues in other agencies. This requires a high standard of professionalism and co-operation within and between the agencies involved.

4. NHS alcohol- or drug-treatment services and local authorities should collaborate to make sure that substance misusers have access to appropriate child care when they attend services, and should build assessment and support for children into drug users' care and treatment plans. Access to nursery provision, support for children, parenting education, and parent-child activities linked to treatment programmes can assist development and improve outcomes for children (Kaplan-Sanoff and Rice 1992; Barlow, J. 2000). In addition, local authority social work services should ensure that foster, residential or respite carers are equipped to work with children affected by families' substance misuse when they provide substitute care.

The Aberlour Child Care Trust runs three residential units in Scotland where women experiencing problems in relation to drugs and alcohol can undergo residential rehabilitation for up to 6 months with their children. During their stay the aim is to address the needs of the whole family. The service provides:

detoxification
relapse management
work on promoting independence and self-esteem
help to develop knowledge and skills in parenting
raising awareness of children's needs.

Staff also work with women whose children are looked after away from home to help them make long-term decisions about the future, with a view to families being reunited, or coming to terms with separation from their children.

Aberlour Child Care Trust has received funding from Lloyds TSB Partnership Drugs Initiative and the City of Edinburgh Council for an outreach service that will work with children and families in Edinburgh affected by parental drug problems.

Two existing posts, funded through the South Edinburgh Social Inclusion Partnership and SureStart monies, are also now part of the service.

The team consists of four practitioners and a project manager.

The service aims to:

improve the social functioning of parents and children
support the development of more consistent and positive parenting skills
reduce and/or stabilise parental drug use
facilitate access to, and uptake of, appropriate services by families including drugs treatment, childcare, health care, social work, schools, community resources and training and employment opportunities
reduce the risk of children being 'looked after' by the local authority.

This project joins Aberlour's Glasgow and Dundee bases in providing outreach services to children and families affected by drugs in Scotland.

The service is based in Craigmiller but operates on an outreach basis.

Support for parents and families

5. The Scottish Parliament's Social Inclusion Committee conducted a wide-ranging inquiry into the impact of substance misuse on deprived communities. ³³ The Committee concluded that local authorities need to increase investment in family support services and help for extended family carers to promote children's upbringing by their families. The Committee made a number of recommendations for development:

local authorities should provide mainstream funding to ensure that parents at severe social disadvantage have access to help and support, including parenting education, and this should be reflected in Scottish Executive funding (11)
interventions that provide accessible and effective support for parents with drug problems, and support and encouragement for grandparents with a carer's role, should be developed by local authority social work services in order to protect children, while at the same time minimising the likelihood of family break-up (12)
DSS and local authority mechanisms for providing financial support for carers should be reviewed with a view to including extended family members of substance misusers who take on parental responsibilities (13)
Drug and/or Alcohol Action Teams should ensure that there is a range of services in their area, including family support groups, to support the families and carers of problem alcohol or drug users (14).

6. The Scottish Executive endorsed the Committee's recommendations and made available 18 million additional funding to local authorities in 2001/2004. This funding was to support new developments through the Changing Children's Services Fund. Since April 2002 the Fund has included alcohol problems as well as drug misuse in its indicative list of primary objectives. The Executive encouraged local authorities to emphasise family support and assistance for extended families of drug using parents. These guidelines highlight the areas of activity and service gaps to which new investment could be usefully directed.

In Glasgow City, Addiction Services have developed Family Support Workers to provide core support services to vulnerable families with young children affected by parental drug and alcohol use. This support is focused on improving the home living environment and parenting skills. Through this type of intervention, Family Support Workers are also able to gain access to children who may be adversely affected by parental substance use. These workers are able to gain a valuable insight into these children's lives and home environment and in turn are able to access services for children.
In 2000/2001 - 196 referrals were made for family support services. 159 cases were allocated. 91% of these cases were women. 61% were aged 25-34 years with 5% of referrals aged 18-20 years. 42% of referrals lived alone with children under 5. Overall, 68% of individuals had children under 5. 7% of these families had 4 or more children. In total 296 children were living in the care of their parent(s). 43% of these children were under 3 years with 59% under 5 years. In 26% of cases children were on the Child Protection Register. Of this number we estimate that one in 10 registrations were avoided as a result of increased addiction intervention.
This service has been significantly expanded to 14 family support posts based in Glasgow City Council's Social Work Services (and the Homeless Addiction Team) Addiction Services.

7. Substance misuse is often a chronic relapsing condition, which may require continuing, long-term and flexible support to be effective. Support for substance misusers' parenting may also need to be continuous, long-term and flexible. Agencies should consider the family as a whole, not just mothers and children. Both mothers and fathers may need help to develop their parenting skills and discharge their responsibilities towards their children. Where two parents are bringing up a child together, helping agencies should also consider the impact of substance misuse on the parents' relationship. Parents may need additional help at critical transition points, such as entry to or exit from treatment programmes or residential rehabilitation or relapse.

"Don't assume that we have the parenting skills."

Helen - ex-drug-using parent reunited with her two sons

"It sometimes feels like the support is only there either for us or for our children but not for both of us. Somebody needs to realise that helping us be better parents does give our children a better chance."

Sheila - problem drinker with two children
(Castlemilk 1998)

In East Renfrewshire, SureStart funding, provided via Early Years and Special Needs Education, has enabled a project to be developed with parents who have substance misuse problems. Located within the Substance Misuse Team, the project aims to assist parents of pre-school children address their drug or alcohol misuse, while addressing parenting responsibilities. Intensive support is provided when appropriate, whether or not statutory supervision is involved. Joint work is undertaken with social workers providing parenting skills courses, and parents are encouraged and supported to take part in these and other relevant activities.

8. Parents worry about how their substance misuse affects their children. They look to family support services to provide help and advice about:

how to protect their children from knowledge about drugs and their parents' drug and alcohol use
talking to their children about their own drug or alcohol use and its consequences for the family
talking to children about their treatment and what they have to do to stop using drugs or alcohol
discussing with their children problems and risks such as illness, imprisonment and separation
how to look after their children safely and establish good child care and basic routines
providing consistent and appropriate discipline and control
child development and the possible impact of their problematic substance misuse and life-style on children's welfare
health care, nutrition and immunisation
welfare benefits and managing income
improving relationships with extended family.

Case example

A 30-year-old separated father of two children, aged 3 and 6, was referred to the NHS Community Alcohol and Drugs Service by his GP. He had asked for a methadone prescription to help him manage his drug problem. He is a long-term intravenous heroin user, and also uses benzodiazepines. His housing and material circumstances are poor. He has a history of persistent offending for which he is on probation. He does not always keep appointments.

The agencies' responses

The man's supervising social worker in criminal justice services strongly supported the GP's referral and the specialist services responded quickly. A rapid assessment indicated that the person needed urgent help to stabilise his drug use. He agreed that the drug agency could discuss his circumstances with his GP, the social worker and other helping agencies. The agencies prepared a care plan in which the GP agreed that the primary care team would take the lead role in providing support. The GP carried out a full health assessment of both the father and the two children. The practice health visitor arranged to have regular contact to provide the father with advice about the children's health needs and welfare, and how to improve his parenting and child care skills.

The person was started on a supervised methadone programme with close contact from a keyworker in the drug agency. The criminal justice social worker agreed to help the man tackle his problems with housing and money. The social worker referred the father to a local family centre, which could provide some childcare for the 3 year old and a place in a parents' support group for the father. The social worker contacted the older child's headteacher to ask her to contact him if she had any worries about the child's progress or attendance. Staff from the drug agency kept in regular touch with father and his criminal justice social worker with whom he kept more regular appointments. After 3 months he had made steady progress, there was no evidence of injecting and he had committed no new offences. Subsequently the GP took on responsibility for methadone prescription under local 'shared care' arrangements. The person's drug problem now appears stable and the specialist drugs agency has referred him to a local drugs counselling project for longer-term support to become drug-free.

Key issues

agencies sought and obtained the parent's consent to talk to other professionals early on
there was close and regular communication between the agencies and clarity about professional roles and tasks, written down in an inter-agency plan
all aspects of the family's problems were considered and tackled, the father's substance misuse and offending, the health needs of each family member, support for parenting, housing and social needs
specialist drugs services provided a quick response and continuing support and advice to the local primary care team and the social worker to equip them to deal with the family in a holistic way through local mainstream services
agencies talked honestly with the father about the impact of his drug use and lifestyle on such young children, arranged support for the family and set out arrangements for involving the social work service if the family circumstances deteriorated
family centre staff took responsibility for assessing each child's needs.

"We need someone with patience."

Focus group of recovering drug users

Support for children

9. While service development and delivery has been patchy and inconsistent across Scotland, and too often contact with children of substance misusers has been in response to crises, much is now being done to develop support services for children through projects funded from the Changing Children's Services Fund, Lloyds TSB Foundation for Scotland, SIP, SureStart and New Community Schools initiatives. These services for children can make a significant difference to their quality of life and subsequent development and adjustment.

Burnfoot Community School in the Borders has a School Liaison Group (SLG), which is now integral to meeting the needs of children experiencing difficulty in school or at home, including children where parents misuse substances. The Depute Headteacher chairs monthly meetings of the SLG attended by the integration manager, social worker, school nurse and learning support staff.

School staff refer children who experience behavioural problems, are unhappy, frequently unwell or face difficulties at home. This early identification and intervention supports a significant number of children who would be at risk of exclusion.

The protection of children is significantly enhanced through this integrated approach. A disclosure triggers an Emergency SLG attended by as many as possible of the interagency team. Information and knowledge are shared and this leads to better decision-making.

This initial response prompts an action plan:

what will happen next?
who will be involved?
who will do what?
when will an update meeting be held?

A lead professional is appointed to summarise and formally communicate information to the Child Protection Unit. Close monitoring and evaluation of referrals continues until the crisis is resolved.

The SLG process is of particular value in the school's ability to reach out and visit homes, to support and work with families. Partner agencies work together to provide the 'One-Stop-Shop' service envisaged in the Scottish Executive's vision for New Community Schools.

10. Pre-nursery children are particularly vulnerable and should be provided with an enhanced health visitor service during their early years. Attendance at nursery can ensure a child's health and welfare is closely monitored, provide important stimulation and contact with other children, and compensatory routines and experiences in contrast to that of their chaotic household. It may provide access to health care and other services such as speech therapy. Childcare services provide respite for the parent, but also offer the child a regular routine in a stable and predictable environment (Barton and Williams 1993). Children may need early help from special education staff in nurseries and schools to counteract the effects of emotional and behavioural problems and help them develop skills, such as persistence, attention span and social skills associated with better academic attainment. Initiatives like SureStart Scotland offer broad-based support for parents and children, which may include support to promote self-esteem and confidence; childcare; and support to parents in their parenting role.

The Alcohol Advisory and Counselling Service (AACS) was established in Aberdeen in 1971 and is a specialist charity working to prevent and alleviate alcohol misuse and its effects in the community.

Child and Family Services is one of a range of specialist services provided by AACS. AACS and social work childcare teams in Aberdeen and Aberdeenshire intend to develop this unique service to meet an identified need.

There is a steady increase in the number of young people and families of problems drinkers seeking advice and counselling support, and research suggests that children of problem drinkers will often develop problems themselves. AACS aims to provide early intervention and support to those at risk, with the aim of preventing further problems developing. In the past it has often been the drinker who has been given the most attention. It is increasingly recognised that the family's situation can be unbearable and that they should have access to services in their own right.

AACS has four trained dedicated child and family caseworkers who work with:

partners and children of problem drinkers
the drinking parent
children and teenagers who experience problems through their own use of alcohol.

The child and family caseworkers in Aberdeenshire are also funded to work with the children and families of people experiencing problems with drug use.

Govan Development Project

A local approach to improving the response to children and families affected by parental drug use has been undertaken by Greater Govan Social Inclusion Partnership. They commissioned Aberlour Child Care Trust to consult locally with children and families affected by parental drug use and those who work with these families in order to complete a needs assessment. This process has included the publication of a report, 'Keeping It Quiet', ³⁴ that highlights the issues faced by these families and those working with them. The report has been distributed and promoted within Govan to assist services in planning their response to children and families affected by drug use.

11. Young people affected by parental substance misuse are particularly vulnerable to mental health problems and developing problems with alcohol or drugs themselves. They need access to supportive and consistent adults, accurate information, education tailored to their particular needs and support in developing social and life skills to promote positive decision-making and enhance self-esteem. School-based peer support groups can be a factor in promoting resilience (Smith 1995).

Tayside Police Drugs Preventive Task Force works with three local Drug Action Teams to give young people involved in drug use, offending and other risk-taking behaviour positive alternatives that are ethical, cost-effective and efficient. They are embarking on joint commissioning with local statutory and voluntary agencies to set up 'diversion schemes', with funding from the statutory agencies and the Scotland Against Drugs Challenge Fund.

Young carers

"It was as if she was the child and I was the mum."

(Barnard 2002)

"My mum stopped looking after the weans when I was about 10. I used to get my wee sister up in the morning and make sure she got to nursery. Nobody knew."

Tracey - aged 17, daughter of a problem drinker
(Ayrshire and Arran NHS Board)

12. Many children caring for an adult with drug/alcohol problems receive little or no support. Levels of responsibility for household tasks, care for siblings and other forms of help for parents will vary widely according to children's age and stage of development and different family expectations. Children should not be expected to take on similar levels of caring responsibilities as adults or be responsible for the intimate care and supervision of their parents. The Carers (Recognition and Services) Act 1995 requires the local authority to assess the needs of young carers when asked to do so by their parents. Local authorities should also respond sympathetically when approached directly by children for advice and help, and should offer an assessment of their needs. Schools, community education and youth work services in particular should be alert to the possibility of young people taking on inappropriate levels of responsibility when parents or other family members are affected by substance misuse. Children of substance misusing parents describe the following difficulties as particularly stressful:

maintaining secrets
social stigma of having parents who use drugs or alcohol problematically
social isolation
caring for their parents when intoxicated.

13. Young carers' projects may be able to assist young people with some of these problems, by providing support, putting them in touch with other young people, helping them make friends and extending their experiences.

Ayrshire and Arran Drug and Alcohol Action Team /East Ayrshire Carers' Centre

The Young Carers' Initiative is jointly funded by the Partnership Drugs Initiative and East Ayrshire Council via the Changing Children's Services Fund. The Centre works with around 150 children and young people and more than 10% of these live in families where parents or siblings have substance misuse problems. The recruitment of a specialist support worker in January 2002 has allowed the Centre to expand its services to provide information, advice, drugs education, advocacy and intensive support to meet the specific needs of these young carers. Most referrals come from social work and through connections with existing Centre users. The children - primarily 8 to 12 year olds - are supported to access the mainstream services provided by the Centre such as activity groups, outings and holidays. One-to-one support is provided where appropriate and efforts are made to maintain ongoing contact with the family.

Placing a specialist worker in a generic children's service avoids stigmatising young people because of the problems of their parents, whilst recognising that there can be particular issues related to substance misuse. The project is able to address the broader needs of the children - including those not subject to formal child protection procedures - in an atmosphere of safety and mutual support. The Centre can help provide routine, structure and respite directly to the children and is not dependent on parental involvement in services.

14. Lloyds TSB Foundation for Scotland, in partnership with the Scottish Executive, is funding a number of projects across Scotland to work with children of drug misusing parents as part of the 'Partnership Drugs Initiative'. The Executive is funding an external evaluation of projects across the Initiative to identify evidence of effective approaches.

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