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Discussion³

A great deal of research has been undertaken in the area of parental substance misuse. However, this has tended to focus on certain issues, leaving some major areas where limited work has been done. The following summarises some of the key issues to have emerged from our review.

Differentiation between substances: There is evidence that different types of substances and patterns of misuse, and related negative behaviours, impact differently on people, both between individuals and within the same individuals at different times. It might also be expected that such differences might have a differential impact on children and other affected family members. However, although there are some general findings that are pertinent, the scoping review that we undertook did not reveal any material that examined this issue. Partly this was because there were no papers that specifically addressed this issue. But also it was because the literature frequently does not discriminate between different substances of patterns ( e.g. 'catch all' terms are used to describe parental misuse such as substance misuse, abuse, addiction etc.). Furthermore, the rising rates of both polydrug use and co-existing mental health and other problems makes it hard to isolate the 'cause' of an impact.

The general findings mentioned above ( e.g. Dore et al., 1995; Kolar et al., 1994; Murphy et al., 1991; Velleman, 2001) suggest that, although there are large personal differences in how alcohol or any other drug affects individuals, there are also commonalities: some types of drug or patterns of drug (mis)use are more associated behaviourally with some types of behaviour, which then are associated with how these affected individuals behave towards their children. Hence for example, related to type of drug, there are quite strong findings that parents who misuse alcohol are more likely to demonstrate aggression and violent behaviour than are parents who misuse opiates, whose behaviour is more commonly associated with neglect. An example related to patterns of use is that there are quite strong findings that binge drinking patterns of consumption are more commonly associated with violent and aggressive behaviour than are patterns of very regular or constant heavy drinking over very long periods, which are associated with greater individual physical damage for the drinker but with less anti-social and violent behaviour towards others.

Nevertheless, it would be wrong to over-emphasise these differences in type of drug and pattern of misuse. The core dimensions (psychological, physical, inter-personal, social, academic, behavioural) of the experience of living with a parent (or other family member) with substance misuse are believed to be very similar (Orford et al., 2005; Velleman, 2001), and further work would be needed to explore how different substance and patterns of misuse affect children. Moreover, research has also demonstrated (Velleman & Orford, 1999) that often it is the behavioural impact of the substance misuse (family disharmony and disruption), rather than the substance misuse itself that causes the greater problems.

Prevalence: Clear and methodologically sound attempts to measure and validate the numbers of children and families affected by substance misuse are severely lacking. Estimates about specific issues relating to parental substance misuse, such as domestic violence, are also lacking. Similarly, child protection statistics do not always consider the role of issues such as parental substance misuse (it was not mentioned in the statistics for Scotland for 2004-2005). Estimates of the cost to society of having a relative with a substance misuse problem (for example, school days lost, illness, unemployment, use of health / social care service) are also lacking (Prime Minster's Strategy Unit, 2004). Given that parental substance misuse impacts upon children in terms of school days lost and developmental problems, it is fair to assume that the financial and social costs to families and communities is high, but firmer evidence is needed to convince policymakers, commissioners and other influential stakeholders to push forward the practice, research and policy agenda. However, uncertainty remains about the best way to calculate such estimates and this must be addressed.

A focus on risk: Much of the literature is biased towards the biochemical and pharmacological impact of addiction, and on genetics, and on specifically negative aspects of parental substance misuse, focusing on negative impact and risk, including inter-generational transmission and the development of own substance misuse (or other) problems. Given the number of previous reviews of work in this area, this is not one of the areas that we have explored in depth. However, it should be highlighted that, despite the predominance of this focus on negative impact, we have seen studies that found no evidence of heightened risk for children (compared to control groups who lived with other family problems or were not identified as having any family problems at all). Furthermore, it is clear from these studies that it is often the problems that are associated with or arise from the (parental) substance misuse, along with a wide range of environmental factors, which can have a stronger negative impact than does the misuse per se. Hence there is a need to view parental substance misuse as part of a far wider, multi-dimensional, picture.

Resilience: There is evidence that a shift has been taking place over the last decade or so, away from the over-emphasis on risk discussed above, and towards an understanding that many of these children are resilient, or have the capacity to develop resilience (either naturally or with stimulation within or external to the family). This is an important shift and one that can potentially alter the attitudes of those delivering services, allowing them to become much more hopeful as to the possibilities of supporting children and families, and improving parenting and the parent-child relationship. Perhaps more importantly, such a shift could alter the quality of services for those who receive them: a focus on what they are 'doing right' as opposed to emphasising what they are 'doing wrong' could make them feel more valued as clients, and as parents and children. Whilst it is commonly recognised that the primary resilience (protective) factor is the presence of a safe and stable adult - parent, other family member, teacher, social worker etc., there is still a considerable lack of clarity over what many of the resilience factors are which determine these positive outcomes, and whether the factors which relate to resilience in this area are similar to or different from those factors which have been shown to be effective in more general resilience research. It is also the case that very few interventions have been developed to alter the social dynamics within families such that protective factors are increased and risk factors are reduced. The gap here is to consider how interventions to promote resilience can be integrated into service delivery. There are some examples in the UK social care field of the development of guidelines to support professionals to work within a resilience framework (Newman, 2002; Gilligan, 2000), but further work and evaluation is needed.

Children: Ultimately, there has been an overall lack of inclination, until fairly recently, to put the child first and this is where one of the biggest philosophical shifts needs to occur. The Scottish based work of McKeganey, Barnard and colleagues is a notable exception, and is thus an important contribution, but it is focused on drugs. Furthermore, the work that has been done has focused on the impact on children of having a parent with an alcohol or drug problem. There is a need for further work that incorporates children's views in relation to, for example, resilience factors, service needs, service provision, and evaluations of interventions and services. Further work is also needed at all levels with children from particular groups, for example, living in rural areas, living with domestic violence, children who have a parent who has died (as a result of substance misuse) or who is in prison (for a substance misuse related offence), and children from black and minority ethnic groups. The differing experiences, views and needs of siblings is a final area where further work is needed.

Mothers: Inevitably, a dominant theme in the literature is parenting or, perhaps more accurately, mothering. A popular area of research and intervention, largely from the USA, is on mothers, before, during and after pregnancy, how parenting affects them and their children, and the implications that this has for treatment of substance misusing mothers. Many women report unresolved feelings of guilt and shame associated with their perceptions of their failure in the maternal role because of their substance misuse. This can be both a critical issue and also a barrier to successful treatment, and needs more research attention. Pregnancy and motherhood bring ideal windows of opportunity to try and engage and work with mothers, but this must also include children and other family members (particularly fathers). Similarly, evaluation work must include attention to outcomes for children and other family members, such as fathers. There are strong links between this theme and that of issues relating to child protection. Of particular note for Scotland is one statistic, contained within the 2004-2005 children's social work statistics (Scottish Executive, 2005), that for children who were subject to a case conference, the primary known or suspected abuser was the mother in just over half (55%) of total known cases. However, it did not state whether she was a single mother or whether the father was also present, and given our findings that parental responsibility often means maternal responsibility, this statistic needs further exploration.

Fathers: There is a great deal of literature available that explores the impact of paternal substance misuse on children, but there is a major lack of research into fathering and fatherhood in relation to this area. Debates around the role of fathers within substance misusing families occur as part of a broader societal debate around the role of fathers in relation to social exclusion, perpetration of domestic violence, environmental factors, and the role of the wider family and social networks. Thus, there is a need for further work and understanding, influenced by these broader, fundamental, debates on how fathers and the fathering role is recognised. There are a number of areas for further investigation, including the ways in which substance misuse contributes to a 'compromise of fathering', and how this contributes to psychological distress in these men, and the ways in which intervention might be used to minimise the harm associated with paternal substance misuse, and to stimulate positive parenting (fathering) and father-child relationships.

There did not appear to be much literature that made comparisons about the impact of maternal versus paternal substance misuse on children or on mothering and fathering. This is an area where further work would be helpful, including a more focused and in-depth review of the literature.

Complex issues: Parental substance misuse rarely occurs in isolation. In addition to a range of environmental factors that increase both the risk of parental substance misuse but also the negative impact on children and the family, there are several particularly serious factors that might be present. Most notably, domestic violence, parental mental health problems and being pregnant (with the latter having the associated risk of fetal alcohol spectrum disorder or neonatal abstinence syndrome). The co-existence of parental substance misuse with any of these other issues can bring additional challenges for the professionals who work with or come into contact with children and other family members where substance misuse is a problem. The challenge is not just in how to identify, engage, assess and therapeutically work with these children and families, but in how professionals from different organisations can support and learn from each other, and work together to respond to these complex needs.

Service needs and provision: Substance misuse services often have no tradition of working with young people, and many specifically exclude children. Other services that encounter children, such as teachers, social workers, youth and community workers, and medical and nursing staff, are not well equipped to recognise or respond to substance misuse. This picture becomes more complex when the often co-existing problems of mental health problems of domestic violence are present, or when the needs of sub-population groups, such as children living in rural areas or who are from minority ethnic groups, are considered. There is an urgent need for both specialist and non-specialist agencies to recognise their responsibility to children affected by parental substance misuse, and for extra resources to be made available. Such a response should more equally include the earlier identification of families where substance misuse is a problem, and where children and family members might be affected, and hence early intervention and prevention, rather than the current reactive climate that is biased towards children and families in crisis, and who have come to the attention of social services, hospitals, the police and prison service, or addiction treatment services. Of equal importance is the need to talk to children and families about what their needs are and how these could best be met. There are no guidelines on whether addiction services, or child and family services, should take the lead with regard to working with children and families affected by parental substance misuse. Rather, each agency should acknowledge that both problems (as with many others that might arise through the course of therapeutic work, such as illness, relationship difficulties or bereavement) are part of the broad remit to helping children and families. Training, support and guidance on joint-working and information sharing should help this process.

However, care must be taken not to assume that generic services will, and are able to, respond to the needs of children affected by parental substance misuse. There should be specifically negotiated access for children and families who are affected by a relative's substance misuse, as opposed to the assumption that generic services will automatically be able to respond to the needs of these children. In the absence of any such agreement, many generic services do not see children and families affected by someone else's substance misuse: this is why there is work ongoing in other parts of the UK to try to involve generic professionals in such work. If such generic services were to orientate themselves more to assisting children and other family members affected by a relative's substance misuse, then there would be implications for those services in terms of increased caseload, resources, staff training, and supervision. There is also a danger that, if DATs and other commissioners feel that children and families will be seen by other services, they may not see them as a major priority to fund specific services and interventions, nor to fund existing drug and alcohol services to broaden their remit.

Interventions: Whilst there is evidence of the benefits of a wide range of responses, the literature is largely focused on individualistic responses to substance misuse, usually geared towards the misuser to the exclusion of children and other family members. There is a need for further development of, and then further rigorous testing of, interventions and services for the wider family, particularly children, as has tended to be the case in the social care field. Ways of responding that include children, concentrate on resilience and focus on the whole family, with the express aim wherever possible to keep that family together, are gaining in popularity, unless extenuating circumstance such as domestic violence, serious mental health problems or neglect dictate otherwise. The key messages are that, rather than recommending any one intervention over another, there is a need to consider national and local need, and to be prepared to be creative and flexible and try to offer a range of interventions. It is also important to remember that children and families often need help with problems other than the substance misuse, and that help should also continue beyond cessation of the alcohol or drug misuse (and resolution of, or improvement in, any other problems). Life after substance misuse may be new, uncertain and daunting, and support may be needed during this time in order to ensure that the person does not return to the more familiar substance misusing environment. Support pre- and post-cessation of substance misuse is crucial in increasing the likelihood of the maintenance of positive change.

Finally, it is important to emphasise the need for monitoring and evaluation of interventions and services. This can take the shape of basic internal monitoring and audit, or of a larger scale evaluation, perhaps undertaken externally and with additional financial backing. Wherever possible, monitoring and evaluation should be built in and seen as core to any new intervention or service. There is some guidance available in this area in Scotland, for example the Scottish Executive Effective Interventions Unit guide (2004) on supporting families and carers of drug users.

Professionals: For many professionals, working with children and families of substance misusers will be a new area of work, and as such progress in this area must consider the knowledge, training and support needs of staff, whether they work in specialist or generic services. Often, confidence in working with substance misuse, and other co-existing issues, is the main barrier to progress. How to respond to co-existing issues, for example, domestic violence or parental mental health problems, can bring additional challenges and training and supervision needs. On an organisational level, information sharing, joint-working, policies and procedures, training, supervision and monitoring are all areas that might need attention. Offering a diversity of therapeutic services beyond standard office hours, providing home visits, child care and transport are all important; and this again has implications for staff, in terms of training, contractual obligations and their expectations of their role. Identification of families where there are substance problems is also important, and supporting a range of people to respond to parental substance misuse is important, for example, primary care, education, probation and initiatives such as Sure Start.

Particular population groups: Children themselves, and fathers, have already been identified as two populations groups requiring particular attention. Other groups include grandparents, siblings, black and minority ethnic groups, the gay and lesbian population, children and families living in rural areas, children and families of those who are in prison or who have died, and children who are looked after or who are in care.

Families in which grandparents are raising their grandchildren have become a widespread distinctive familial structure. This reconfiguration of the family occurs across many socio-economic and ethnic groups, and for many reasons (including parental substance misuse). In one study, only 3% of these grandparents received consistent, reliable familial support in their role as surrogate parents (Burton, 1992). Although grandparents find parenting their grandchildren emotionally rewarding, and their involvement can be pivotal in preventing a child being removed / looked after (Barnard, 2003), they incur psychological, physical and economic costs in doing this. They have many service needs, although what these are has not yet been clarified. There is a clear need, therefore, for further exploratory work, followed by consideration of how to adapt traditional intervention methods to this population. However, Barnard's (2003) qualitative study in Glasgow identified that the involvement of grandparents, " whilst often critical", is not always positive and is not without its " tensions and difficulties" (p291).

A fifth of the Scottish population (one million people) live in rural Scotland, 6% of them in remote rural areas ( EIU, 2004). A Scottish Executive EIU report (2004) on effective approaches to delivering integrated care for drug users concluded that, "many of the issues….were not peculiar to service provision for drug users in rural and remote communities……issues….common to drug services regardless of the nature of the area they covered, or issues which were common to providers….regardless of the nature of the service…". Key issues to consider are: community denial, financial resources, higher unit costs, availability of premises, level and range of services, anonymity and confidentiality, travel and transport, and staff recruitment and retention. All of this is true in terms of service provision for people affected by their own misuse of substances; but it raises the question of whether these population groups have particular experiences or needs with regard to substance misuse and the family? Is there a potential for particular areas of service delivery, for example, via online counselling, websites or self-help books? Staff skills, flexibility, partnership working, innovation, devolved decision making and acceptance could contribute to development of rural services.

Scotland

Progress and Gaps

This review has identified many gaps in the literature surrounding parental substance misuse, and particular areas where further work is needed and where attention and resources should be directed. However, it is important to highlight that Scotland is already quite far advanced in terms of work in this area. Key policy initiatives, along with the response to the death of Caleb Ness, demonstrate this. However, much of the work across Scotland has focused on children in need or at risk, and of the needs of children identified via treatment or social services populations. There is a need to consider the wider picture of how parental substance misuse affects children across Scotland.

In prioritising children affected by parental substance misuse, a lot of work undertaken in Scotland has focused on finding the best way to estimate prevalence (particularly the work of Hay and colleagues), and of talking to children themselves (particularly the work of Barnard, McKeganey and colleagues). However, the latter has focused largely on impact, and particularly on child welfare and parenting, and on drugs. Bancroft et al. (2004) identified that parental drug problems are particularly associated with anxiety and social stigma for the children whilst parental alcohol problems are particularly associated with violence and parental absence. Thus, care must be taken to consider separately the impact of, and associated needs from, alcohol and drug problems. Some further work on the impact of parental substance misuse is needed with some population groups (for example with siblings, children from black and minority ethnic groups, children living with parental mental health problems, domestic violence or in rural areas, and children who have a parent who has died or who is in prison). On a broader level, work is needed that considers how best to meet the needs of children, and to evaluate services and interventions that are developed. One qualitative study has focused on resilience in young people affected by parental substance misuse (Bancroft et al., 2004). This is an important growing area, and one that needs further work.

It is important to recognise that a great deal of what services should be doing is already known and has already been summarised in Scotland. For example, Getting our Priorities Right (2003) provides guidance for agencies in Scotland involved with families affected by parental substance misuse, looking at current knowledge about the extent of parental substance misuse and its impact on children:

• Explaining what agencies need to ask of families when they present with drug or alcohol problems;
• Providing guidance to staff on identifying risks;
• Offering advice on what kinds of help may be needed and on how to work together more effectively;
• Addressing issues of confidentiality and offering advice to agencies about when and how to share information;
• Identifying the need to strengthen services for families and offering advice on how this might be done.

We contacted (via the DAT Association Administrator) all 23 Scottish DATS and asked them to provide service directories (or where this was not possible any information they could give us about services for this group); 9 responded. Each of the 9 has at least one service in place for children and families affected by parental substance misuse. However, generally service provision is lacking, and rarely explicitly includes children. Few of the services available to family members directly specify children or young people as their target group (in fact a number of support groups and counselling services on offer are available only to young people aged 16 and above). However, a small number of services have no age limit for those wishing to access their services, and provide a service for children in their own right.

Provision tends to come in the form of support/ advice/ counselling services provided to family members, children and friends of individuals misusing substances alongside the substance misuse services that are available to the users themselves. However, there is limited information available on the services that are there, in terms of counselling orientation, offer of other services or forms of help. A small number of services offer family oriented support where children and parents are given support in parallel. The promotion of positive and safe parenting is as a key aspect of such services.

Examples of particular projects that focus on children and families are the Sunflower Garden Project (a Church of Scotland service in Edinburgh, two projects developed by the Family Services Unit (Harbour Project that covers some areas of Edinburgh, and Hearth Project in West Lothian), the Aberlour Child Care Trust and the Fraserburgh Families Service in Aberdeenshire (the latter has been nominated in the drugs and alcohol category of the 2005 Community Care Awards).

In working with children, services need to be supported in working together, and this includes having jointly agreed policies, procedures, and practice guidance, together with sound training, supervision and support. Additionally, it is not clear how, and even if, services are being monitored or evaluated with respect to their work with children (and other family members). Ensuring this is essential in our opinion, and must include the assessment of outcomes for children.

With regard to drugs, there have some moves to address the issue of drugs, communities and families in response to the Drugs Strategy (Young People, Treatment and Availability, with work yet to be undertaken to respond to the Communities pillar). The Review of Drug Treatment and Rehabilitation Services (Summary and Actions, 2004) recognises that, " families play a key role in treatment and rehabilitation and we need to seek innovative solutions for involving them in sensitive ways in the delivery of drug treatment programmes". However, this has not been translated into concrete action points, though vulnerable children are highlighted as in need of help through the Executive's response to Hidden Harm. The Criminal Justice Plan has a section focusing on drugs, with particular acknowledgement of the need to respond to the needs of vulnerable children, including those affected by parental substance misuse. There has not been so much movement with regard to alcohol, with the updated Alcohol Action Plan due to be published shortly after the completion of this scoping review.

It is vital that responses to substance misuse and the family across sectors, and within and between key organisations and governmental departments, are as integrated and complementary as possible. They need to give more than lip service to the needs of children and families, with SMART (sustainable, measurable, attainable, realistic and time-limited) goals as far as possible. It is unclear to what extent checks will be made on recommendations listed in key documents such as Getting our Priorities Right, Keeping it Quiet or the Scottish Executive's response to Hidden Harm. It is known that at least three regions of Scotland have responded to Getting our Priorities Right and the Caleb Ness Inquiry, by developing child protection guidelines, all or part of which pay particular attention to children affected by parental substance misuse. The work of key groups, such as the Alcohol Misuse Co-ordinating Committee, and the Hidden Harm New Agenda Steering Group should include representation that ensures full consideration and inclusion of children and families. The key sections of Getting our Priorities Right are a useful framework for taking this work forward, namely: 1) knowledge review; 2) what do agencies need to ask and assessing risk; 3) working together; 4) confidentiality and information sharing; 5) the need to strengthen services for families; and 6) building a foundation to work from. This, in turn, sits within the tiered levels of service suggested by the four-tiered framework in the Alcohol Problems Support and Treatment Services strategy (2003). The needs of children and families must be part of this, both in terms of mapping need and service response and in improving in joint-working and support/training from other agencies. Monitoring and evaluation of work should be fully integrated.

Conclusion

"…children formulate important opinions about their social, political and cultural contexts that are not simply reflective of their parents' ideas…..if children had greater access to a public voice through vehicles such as research, they would be able to contribute to the social structures that concern them" (Irwin & Johnson, 2005 p821).

The impact of and risks associated with parental substance misuse appears to have been well mapped, though a need for further exploratory work with particular population groups has been identified. Parental substance misuse is not the only, and sometimes not even the major issue and this wider picture must be acknowledged. Accumulation of risk associated with certain factors, such as domestic violence, marital break-up, unemployment, deprivation etc., has been highlighted. Particular risks and opportunities associated with pregnancy, motherhood and parenting have been emphasised. A philosophical shift towards resilience is occurring and this has clear potential when applied to children, and other family members, affected by parental substance misuse. There is growing evidence for a range of services and interventions for children and families, but there is a need for further expansion of such responses, and for their rigorous evaluation, with both service development and delivery being sure to include views of and outcomes for children. Threaded through all of this is a need to consider environmental factors, such as domestic violence, ethnicity, sexuality, geographical location, gender, age, substance of misuse, and the potential for responding to the needs of all those affected by substance misuse, not just children. Fathers, siblings and grandparents are three particular groups where further work is needed.

Diverse, flexible and creative ways of working with children and families are needed, delivered by a range of professionals who are well trained and supported, and able to work together, and who are able to respond to the diverse needs of children and families, and particular population groups, affected by parental substance misuse. The response to children and families affected by parental substance misuse should be focused on early intervention, with services and interventions that are proactive as well as responsive. A service should also be ready to support families when they reach crisis point, with services and interventions that are crisis driven and reactive. This drive to intervene as early as possible, well before child protection issues and social services involvement arise, is a cornerstone of Getting our Priorities Right. The potential for grounding services and interventions in the key messages to emerge from the work that has been done on resilience should be broadly recognised. Agencies must work together in planning and delivering services, in assessment and care planning processes with families, and in multidisciplinary training.

Whilst many gaps have been identified in this review, it is to Scotland's credit that, in several cases (for example, policy, policy guidance, own views, some practice guidance) work exists that is often part of a minority literature to address such gaps. In Scotland, one of the most important steps has already been taken, namely for the Scottish Executive to recognise and prioritise parental substance misuse. Care must be taken to ensure that this recognition does not just remain with the Executive, and other key organisations and stakeholders. It needs to be owned by all those who have a remit, at whatever level, to work with or come into contact with children and families affected by parental substance misuse and co-existing issues. We sincerely hope that Scotland can continue to be innovative in this way, using this review as another step in the right direction.

Recommendations

Identification of priorities for future research in this area:

1. Identify the most appropriate methodologies with which to estimate prevalence, and the definitions with which to work.
2. Estimate the prevalence, nationally and locally, of children (and other family members) affected by parental substance misuse, and of associated costs.
3. Future research, evaluation and service development should include, where possible and appropriate, the views and needs of children, both to map their experiences but also to establish their particular service and support needs.
4. Conduct further research on the experiences and needs of particular groups of children. For example, siblings, those living in rural areas, those from black and minority ethnic groups, those who have a parent who has died or is in prison as a result of substance misuse, those living in care, and children living with domestic violence or parental mental health problems, and children who have been exposed to alcohol or drugs in utero.
5. Conduct further research on the views, needs, roles and responsibilities of others central to parental substance misuse, particularly fathers and grandparents.
6. Ensure that the development and introduction of new services and interventions are properly and fully evaluated.
7. Undertake a review of 'what works' in relation to child protection, especially with overlapping issues of substance misuse, and of domestic violence.

Some of the recommendations could be partially met by further, more focused reviews of the evidence. In other cases, further exploratory or evaluative work is needed on a larger scale.

On effective practice:

Commissioners and providers of services in Scotland should:

8. Increase service delivery to the children and families of those affected by (parental) substance misuse, involving a range of service and intervention options. This includes services and teams that respond to the particular needs of pregnant mothers and their neo-nates, as well as services that more holistically meet the needs of children and families together.
9. Commission service provision that takes account of the broader context of substance use and parenting including involvement of the wider family.
10. Recognise and respond to local need where this differs from national need and national priorities.
11. Ensure that services are provided more holistically, focusing on all aspects of parenting, substance misuse and co-existing issues (such as domestic violence, mental health problems, or women who are pregnant and where children might have been exposed to drugs or alcohol in utero).
12. Reflect the equal importance of promoting resilience and reducing risk in the development of interventions and services for children affected by parental substance misuse.
13. Investigate how addiction services, and child and adult services could best be integrated and encouraged to work together.
14. Organisationally, ensure that joint working protocols, and information sharing procedures, are in place.
15. Ensure that professionals in all services are well supported through managers and supervisors who have been trained in working with substance users and their families.
16. Improve qualifying and post qualifying social work training to ensure that it includes training on alcohol and drug use and how this relates to working with children and families. The training of child and family social workers should be a priority; the role of adult social workers was not a focus of this review and would need further investigation.
17. Take steps to develop the means by which data about child-related issues can be collected and collated from clients of services within Scotland whose primary problem is alcohol misuse.
18. Establish a database and directory of services that respond to the needs of children and families.

Limitations

There were two limitations to this review. First, the review topic of parental substance misuse was an extremely broad one. This meant that we identified a large amount of literature, and that we were therefore unable to review all this literature, and its quality, in detail. Secondly, the quality of many of the abstracts that we reviewed was poor and this brought additional challenges. We had to be flexible and creative in our implementation of the search strategy, to account for different levels of complexity and sensitivity, particularly within the major electronic databases that have been searched. Applying the search strategy with too many layers of complexity resulted in key literature being missed. Further testing suggested that a broader search strategy, with more key terms and fewer levels of complexity, was more likely to include the literature that we would expect but was also more likely to include irrelevant literature. Librarian support at the University of Bath indicated that searches of such breadth would not normally be undertaken and that the problems that arose were understandable given the size of the task. The sheer size of the database, based on a very broad topic area, along with the volume of literature to emanate from the USA, meant that we had to plan very carefully how we scoped the database, ensuring that we covered both breadth and depth. This was a hard balance to achieve, but one that we hope we have achieved.

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