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Background
Substance misuse is currently seen as problematic within Scotland. Findings from the most recent survey of attitudes (2004) towards drinking and smoking in Scotland indicate that nearly two thirds of 1,600 interviewed thought that drinking was a major part of life, yet 46% felt that alcohol caused more harm than drugs. This survey showed that there were particular concerns arising from binge-drinking, drinking by young people and alcohol-related crime. Another national opinion survey of 1,001 adults (2004) found that 96% thought that drug misuse was a serious problem, and 69% a very serious problem. There are about 5 million people in Scotland, about 20% of whom are aged 16 and under. It is extremely hard to calculate how many people might be affected by substance misuse in the family (this will be further discussed in the prevalence section of this report). However, it has been estimated that there are millions of affected family members in the UK (this includes children).
Parental substance misuse can result in a considerable number of negative effects on the family (both children, and other family members such as grandparents), as well as on the parents themselves. Co-existing mental health problems and/or domestic violence can be additional problems faced by this group of families. Substance misuse (particularly alcohol) contributes significantly to the number of children and families on social work caseloads (Forrester & Harwin, 2004). Families may cope differently with parental substance misuse as a result of a number of variables, for example, ethnicity, geographical location (urban versus rural), social class, and age / development of child. There is also growing evidence that some children appear to be more resilient to the negative impact of parental substance misuse.
However, the needs of family members have largely been neglected within an historical focus on the treatment of those individuals with the alcohol or drug problem (see Orford et al., 2005 for a review). Family members including children can be hard to engage with, because they feel too ashamed about their situation, are used to keeping the substance misuse a secret, or simply do not know where to go for help or what to do if help is available to them. Professionals, either specialists working in the addiction field or generic staff working in children and family services, schools or primary care for example, can feel uncertain, and lack training and confidence in how to respond to the needs of children and families of substance misusers.
Political attention (and therefore resources) has been similarly focused towards the individual alcohol or drug misuser, although the impact of substance misuse on the family, and the needs of family members, has in recent years been slowly climbing up the political agenda, within a broader recognition of the importance of working in a more holistic and systemic way. Policy initiatives (either UK-wide, such as Hidden Harm ( ACMD, 2003), or specific to Scotland such as Tackling Drugs in Scotland: Action in Partnership (Scottish Executive, 1999), the Scottish Plan for Action on Alcohol Problems (Scottish Executive, 2002), Getting our Priorities Right (Scottish Executive, 2003), and It's Everyone's Job to Make Sure I'm Alright (Scottish Executive, 2002) set the agenda for research, practice and policy within Scotland. Research and service development has also been on the increase, and there is a range of research and evaluation projects, and service developments in this area, that are indicative of the potential for supporting children and families affected by substance misuse (Copello et al., 2005; Williams, 2005).
However, there is still evidence that the needs of children and families are often sidelined. A recent profile of all 840 studies published in Addiction Abstracts 1994-2001 (Short, Stevens & Crome, 2005) made no reference to research and practice with children and families. The Alcohol Manifesto for Scotland (2005) has as part of its vision a desire to see, "fewer families break-up and have children taken into care because of parental drinking", yet its ten proposals for change are of a general nature and do not specifically mention children and families. A report from the Registrar General for Scotland concludes that the number of drug-related deaths has increased by 12% to 356 in 2004; yet the needs of bereaved family members are not mentioned (Registrar General for Scotland, 2004). Similarly, a review of residential detoxification and rehabilitation services makes little mention of the provision of services to pregnant clients and mothers, or children and families, but it is unclear if this reflects a realistic lack of services in this sector to children and families (Griesbach D et al., 2004).
The death of 11 week old Caleb Ness in Edinburgh in 2001, however, prompted discussion and movement across Scotland in the area of substance misuse and the family, with particular regard to the role of social services and the wider issue of inter-agency working. As Caleb was the subject of Child Protection procedures at the time of his death (his mother was a long-term heroin addict and his father had a criminal history of drug-related offences), a formal inquiry was commissioned and completed (O'Brien, Hammond & McKinnon, 2003). The inquiry concluded that no one person could be scapegoated, but that blame should be shared amongst a range of professionals and organisations, at every level. Communication (intra- and inter-agency) and contextual and historical assessment (including risk assessment) of the family were particular areas of concern highlighted by the inquiry. Concerns were also raised about the CPCC (Child Protection Case Conference) process. Whilst many of the conclusions and recommendations made were not new, the report triggered a great deal of debate and activity (for example, at least three areas of Scotland have produced child protection guidelines that consider how to work with children in families with problem substance use), and it is hoped that further improvements will be made and such devastating consequences avoided in the future.
The scoping review: aims and objectives
The key aims were to:
- Undertake a comprehensive literature search to scope how much work has been done on the topic of parental substance misuse.
- According to the amount of literature identified, adopt an appropriate methodology to further scope the literature, to identify key themes and gaps, focusing in particular on evidence of effective practice, and the identification of priorities for future work.
The objectives were to focus on the following areas of the literature:
- The impact of parental substance misuse on i) children, ii) other family members and iii) the parents themselves.
- The needs of these three groups.
- Evidence of the direct views and experiences of these groups.
- Effective interventions in this area.
- Service needs and service provision, with a specific focus on Scotland.
- Consideration of the issues of risk and resilience.
- Incidence and prevalence.
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