Parental substance misuse and social worker intervention

Summary

This Outline explores the impact of parental substance misuse on children and identifies evidence around effective methods of intervention for social workers.

Multiple studies identifying the effects of parental substance misuse on children are identified, including physical and psychological impacts on aspects such as basic care, ensuring safety, emotional warmth, stimulation, guidance and boundaries and stability, parenting skills, parents’ perceptions, control of emotions, neglect of physical needs, and parent–child attachment relationships.

Parental substance misuse and its effects on children co-exist very often with a variety of other problems, such as poverty, mental health issues and unemployment. These other issues most often cannot be disentangled from the substance misuse. However, we identify several studies and reviews of studies that indicate positive outcomes from interventions and programmes. The resources outlined include recommendations around prevention, early identification, proportionate intervention and support to children and families.

The Outline also identifies forthcoming systematic reviews and research findings, and relevant Iriss resources for social workers supporting children affected by parental substance misuse.

Introduction

This evidence summary seeks to address the following key questions relating to the impact of parental substance misuse on children:

What is the impact of parental substance misuse on children?
What are effective methods of intervention?

About the evidence below

Parental substance misuse and its effects on children co-exist very often with a variety of other problems, such as poverty, mental health issues and unemployment¹. These other issues most often cannot be disentangled from the substance misuse². This means that much of the evidence around the impact of parental substance misuse is unable to determine a directly causal relationship between substance misuse and specific impacts on children (i.e. it is not clear whether substance misuse is the main or only reason for negative outcomes). There is a general lack of rigorous evaluation of interventions, which are often short-term pilots without sustainability³, and as a result it is extremely difficult to identify which approaches work the best. However, we have identified several studies and reviews of studies that indicate positive outcomes.

Accessing resources

We have provided links to the materials referenced in the summary. Some of these materials are published in academic journals and are only available with a subscription through the The Knowledge Network with a NHSScotland OpenAthens username. The Knowledge Network offers accounts to everyone who helps provide health and social care in Scotland in conjunction with the NHS and Scottish Local Authorities, including many in the third and independent sectors. You can register here.

Background

Iriss defines parental substance misuse as “a situation where a parent uses illegal or prescription drugs or alcohol to the extent where their judgement or behaviour is impaired and results in a detrimental effect on the children in the family”⁴. Parental substance misuse is frequently characterised in research as an ‘adverse childhood experience’. Adverse childhood experiences (ACEs) are situations which lead to an elevated risk of children and young people experiencing damaging impacts on health, or other social outcomes, across the life course. One ACE for people under the age of 18 is living in a household where drug and alcohol misuse takes place. In many cases multiple ACEs are experienced simultaneously⁵, as characterised by the ‘toxic trio’ concept⁶. It must also be acknowledged that “[n]ot all parents who drink or take drugs harm their children, but children living with parents with alcohol or drug problems can be at more risk of harm and neglect”⁷.

The impact of parental substance misuse on children

The following sources identify several negative impacts of parental substance misuse on children. However, it must be emphasised that due to the nature of substance misuse and the surrounding contexts it occurs in (including use of multiple substances and factors such as domestic violence), it is extremely difficult to isolate effects. Some of the sources presented below identify negative impacts of ACEs including parental substance misuse, and where possible, identify specific impacts of parental substance misuse. It should be emphasised that the evidence below does not focus on the impact of parental misuse of substances such as nicotine, alcohol, caffeine, and over-the-counter and prescription medications, which were not the focus of the enquiry.

Allan, G (2014) Working with Substance Users: A Guide to Effective Interventions. New York: Palgrave Macmillan (Available from National Library of Scotland and other libraries)

Chapter 1 of this book includes evidence around the influence of different substances and Chapter 14 includes some of the impacts on children affected by parental substance misuse.

Bellis M.A et al. (2014) National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Medicine, 12:72 (Open Access)

This paper reports on the findings of a national survey conducted in England in 2013 of a representative sample of 18-69 year olds. It found that of the 3885 respondents, 3.9% had witnessed parental drug misuse. It connects several health harming behaviours (early sexual initiation, unintended teenage pregnancy, smoking, binge drinking, drug use, violence victimization, violence perpetration, incarceration, poor diet, low levels of physical exercise) with parental drug misuse. The authors report that living with a drug user increased in prevalence with deprivation and reduced with increasing age. They found that “having one ACE (versus none) was associated with a significant increase in unintended teenage pregnancy, early sexual initiation, binge drinking, cannabis use, violence perpetration, violence victimization, and incarceration”. They also estimated that nationally 13.6% of poor diet and up to 58.7% of heroin or crack cocaine use is related to ACEs. However, causality could not be established in the study and the study did not isolate the relationship between parental drug misuse with specific health harming behaviours.

Holland, S et al. (2014) Parenting and substance misuse: understanding accounts and realities in child protection contexts. British Journal of Social Work, 44(6), pp.1491–1507
(Available with NHSScotland OpenAthens username)

This paper reports on the findings of qualitative interviews with parents in 27 families affected by substance misuse. Using motivational interviewing as a practice intervention, the researchers were able to sensitively explore the relationship between substance misuse and domestic violence, and encourage reflections on sub-optimal parenting, neglect and abuse. The authors identify implications for practice, including that “acknowledging strengths, or even just acceptable parenting, is important for engaging parents in promoting the welfare of their children” (p.1505).

Johnston, G (2013) Serious case review: overview report in respect of Child BDS12

This SCR reports on the death of a 2-year-old boy in March 2013, after he suffered a cardiac arrest. BDS swallowed his mother's methadone, which was in a child's beaker. Posthumous toxicology reports found traces of cannabis, crack cocaine, heroin, dia-morphine and alcohol in BDS' system, thought to have been directly ingested. The issues identified - including: lack of focus on the child; insufficient consideration of the social history of parents; lack of compliance with local multi-agency child protection procedures; lack of professional challenge and cynicism; overreliance by universal health services on specialist health professionals to inform them of child protection concerns; and lack of recognition of thresholds for referral to children's services - may be of relevance.

Recommendations include: exploring the feasibility of drug-testing children who are the subject of child protection plans and whose parents are known substance users; developing a pathway to ensure a multi-agency assessment is undertaken before methadone is taken home when children and young people live in or visit the residence; and prescribing services consider the parenting capacity of non-drug abusing partners and ensure that they are seen alone and referred to support services if necessary.

NSPCC (2013) Child sexual abuse: an NSPCC research briefing (pdf)

This briefing identifies risk factors for sexual abuse, which includes parental substance misuse. Drawing on the work of Goodyear-Brown (2012)⁸ the NSPCC explain:

Children of parents who misuse substances may have homes where lots of adults are coming and going or they may be left alone for long periods of time while their parents are out. This can leave those children vulnerable especially when the adults in the house may be under the influence of drugs or alcohol (p.4).

O’Connor, L et al. (2014) Perspectives on children's experiences in families with parental substance misuse and child protection interventions. Children and Youth Services Review, 38, pp.66-74 (Author preprint)

This paper presents data from a Welsh mixed methods study of a service for families whose children were at risk of entering out-of-home-care due to parental substance misuse. Using qualitative interviews with children and parents, the study explores the experiences of children in this context. The study concludes that children and young people may benefit from brief interventions during a period of crisis and longer term interventions which address cumulative effects and attachment complexities and promote sources of resilience.

OpenLearn (2017) Social work: Effective practice with substance abusing parents (website)

This piece explores the challenges and dilemmas for both social workers and other professionals when working with families where there is “problematic substance misuse affecting the lives of children”. It provides key references for further reading.

Taylor, A (2013) The impact of parental substance misuse on child development. Research in Practice - Frontline (pdf)

This briefing examines the degree to which parental substance misuse can affect children’s physical and emotional welfare at different levels. It uses evidence from research to identify the impact of parental substance misuse on children’s health, education and cognitive ability, emotional and behavioural development, identity and social presentation, family and social relationships, and self-care skills.

Velleman R and Templeton L (2016) Impact of parents’ substance misuse on children: an update. BJPsych Advances, 22(2), pp.108–117
(Available with NHSScotland OpenAthens username)

This review of the literature around parental substance abuse is an update to the 2007 review from the same authors. It summarises the negative effects it can have on children and provides an overview of the identification of risk factors for children in this context. It also identifies evidence of protective factors and resilience in children affected by parental substance misuse.

Velleman R and Templeton L (2007) Understanding and modifying the impact of parents’ substance misuse on children. Advances in Psychiatric Treatment, 13, pp.79-89 (Open Access)

This review of the literature on parental substance misuse identifies the potentially serious consequences for children, including: high levels of violence; experiencing or witnessing neglect or abuse – physical, verbal or sexual; poor and/or neglectful parenting; inconsistency from one or both parents; having to adopt responsible or parenting roles at an early age; feeling negative emotions such as shame, guilt, fear, anger and embarrassment; and possible neurodevelopmental consequences of substance misuse in pregnancy (e.g. foetal alcohol syndrome) that may contribute to developmental delays or intellectual disability. It identifies risk factors leading to generally worse outcomes, including general, substance-specific, and drug-related factors. Protective factors and resilience are also discussed. The authors identify ways in which practitioners can work to modify the impact of parental substance misuse, making recommendations drawn from research including recommendations that the practitioner needs to work directly with the children involved, enabling them to:

Maintain positive family rituals
Remove themselves from the disruptive behaviour of the problem parent or parents
Disengage from the disruptive elements of family life
Engage with stabilising people outside the family
Develop ‘confidants’ outside the family
Engage in stabilising activities (school, clubs, sports, culture,religion) within which the child can develop a sense of self and self-esteem
Develop a desire to be, and pride in being, a survivor (p.85)

Impact of specific drugs

It is extremely difficult to isolate the impact of different substances on children exposed to them in the context of Scottish social care, because substances are often used in conjunction with one another. It is also difficult to determine whether negative outcomes are the result of substance exposure or other factors in the home, such as domestic violence and neglect. It should also be emphasised that the evidence we searched for were those of specific interest to the enquiry for this summary, and as a result we did not search for evidence around substances such as nicotine, alcohol and over-the-counter and prescription medications.

Cleaver, C, Unell, I and Oldgate, J (2011) Children’s Needs - Parenting Capacity. Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence. 2nd edition. London: TSO (pdf)

This publication produced for the Department for Education provides an evidence-based update on the impact of parental problems including substance misuse, on children’s welfare. Chapter 2 focuses on how parental mental illness, learning disability, substance misuse and domestic violence affect parents’ capacity to meet the needs of their children. It emphasises the comorbidity of substance misuse and other issues, stressing that it is difficult to identify the impact and risk of substance misuse alone. It provides an overview of the physical and psychological impact of several drugs and the impact on parenting, for example around basic care, ensuring safety, emotional warmth, stimulation, guidance and boundaries and stability. The authors explore parenting skills, parents’ perceptions, control of emotions, neglect of physical needs, parent–child attachment relationships, separation of children and parents. Chapter 3 focuses on identifying which children are most at risk of significant harm. Part II explores issues affecting children of different ages, including evidence from research about the risks associated with parental substance misuse to children of different ages.

MacLeod, K et al. (2016) Understanding the patterns of use, motives, and harms of New Psychoactive Substances in Scotland: final report to the Scottish Government (pdf)

Section 5 of this report focuses on the consequences of use of various new psychoactive substances (NPS) and may provide a useful overview of the negative effects of different drugs, including intoxication effects and comedowns, mental health harms, physical health harms and social effects. Section 5.7.2 (p.56) identifies the impact of taking NPS on people’s ability to fulfill caring commitments.

Effective interventions

Because of the complex nature of parental substance misuse, there is not enough evidence from academic research to clearly identify what interventions are the best, for example to prevent parents from losing care of their children⁹. The resources below have been included in this summary because they contain examples that may be relevant to the enquiry and have been produced by authors and organisations with specialist expertise in the area.

Allan, G. (2014) Working with Substance Users: A Guide to Effective Interventions. New York: Palgrave Macmillan. (Available from National Library of Scotland and other libraries)

Chapter 14 of this book specifically explores the implications of parental problems for children and explores ways of helping adults affected by a relative's substance use. This book provides in-depth insight into the broad challenges of working with children and parents in this context as well as specific information about risks and interventions.

Caselman, T. (2015) Helping Children Affected by Parental Substance Abuse: Activities and photocopiable worksheets. London: Jessica Kingsley. (Available from the National Library of Scotland and other libraries)

This book identifies the multiple negative outcomes that can affect children whose parents misuse substances, including behavioral problems, low academic achievement, depression and anxiety, low self-esteem, and self-blame for their parent's substance abuse. It provides specific examples of activities that people working with children can use to facilitate group sessions to reduce feelings of shame and isolation, better understand the nature of addiction, increase self-care and create healthy interactions.

Fitzgerald, N, Heywood, S and Winterbottom, J (2013) Reducing harm to children and families affected by parental substance misuse: assessment of need and services in Midlothian and East Lothian (pdf)

This needs assessment aims to identify the prevalence of problematic parental alcohol and drug use and numbers of children (under the age of 16) affected across Midlothian and East Lothian. The authors acknowledge the difficulties around knowing when to intervene:

Fundamental to this difficulty is the recognition that it cannot be automatically assumed at any particular level of substance use that harm to children is inevitable. All parents who use substances (legally or illegally) do so on a continuum of risk of harm to their children. Some examples of risks from various levels of consumption are noted below. (p.18)

Higher Risk?

Chronic emotional neglect due to parental use (inclg alcohol/cannabis/benzos/ opiates/other drugs)
Illegal substance use exposing children to crime
Drug/alcohol use resulting in violence
Chaotic substance use resulting in chronic absence from school

Middle Risk?

Occasional drunkenness seen by children
Smoking around children
Drug/alcohol use resulting in aggression
Occasional miss school due to parent's alcohol/drug use at a party

Lower Risk?

Occasional alcohol consumption above guidelines posing bad example
Occasional cannabis use unknown to children
A parent smoking (even if not in presence of children)

The authors emphasise:

The placement of behaviours on the above continuum is highly subjective and could be subject to endless argument about the relative risks and dangers of different behaviours. This is because it is not the exact level of substance use that dictates the quality of parenting, and there are a whole range of other factors which may protect children or put them further at risk of harm from parental substance use.

This study highlights that “there was almost universal acknowledgement of how difficult it is to identify and engage” children affected by parental substance misuse who are in need of support (p.45). The authors identify “a general gap in literature on models of practice in discussing this issue” (p.47). They provide strategic recommendations around how services can support people who may be in need.

Forrester, D et al. (2016) Helping families where parents misuse drugs or alcohol? A mixed methods comparative evaluation of an intensive family preservation service. Child & Family Social Work, 21(1) pp. 65-75 (Open Access)

This paper reports on the findings of a mixed methods study evaluating the impact of Option 2, an intensive family preservation service for families with serious child protection concerns related to parental misuse of drugs or alcohol. Through conducting interviews with 34 parents or step-parents from 27 families. Although the sample size is small and it is not possible to make generalisations about the success of Option 2 in comparison to other interventions, the findings indicate that the service is of a high quality and helps families to achieve change. Most parents had considerably reduced their drug and alcohol use following being involved in the programme. Families that had received the Option 2 service seemed to do better than those who had not. The authors emphasise that this approach appears to work because of the heavy investment in the programme from skilled professionals (p.74).

Institute of Public Care (2015) Working with Families where there is Domestic Violence, Parent Substance Misuse and/or Parent Mental Health Problems: A Rapid Research Review (pdf)

This rapid review draws on evidence from a mix of academic research-based evidence, government commissioned reviews, and best practice guidance including observations from the field to to help inform practice in Hampshire, England. The review provides an overview of impacts of parental substance misuse on children and identifies examples of best practice for interventions in preventative social work.

Martins, C (2013) Research in Practice Strategic Prompt: Parental Substance Misuse (pdf)

This summary provides an overview of what works in addressing parental substance misuse and provides examples of promising initiatives, including The Family Drug Action Court (FDAC), Option 2, The Parents under Pressure (PUP) programme and Motivational Interviewing.

Iriss (2011) Leading for outcomes: parental substance misuse (pdf)

This toolkit produced by Iriss offers general evidence-informed advice and support for working with parental substance misuse. It explores the benefits of taking an outcomes-based approach: “The underlying principle of the guide is that by working in an outcomes focused way with parents, outcomes are improved for the child”.

Niccols, A et al. (2014) Integrated programs for mothers with substance abuse issues: a systematic review of studies reporting on parenting outcomes. Harm Reduction Journal, 9(14), pp.1-11 (Open Access)

This systematic review of integrated treatment programs s (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) for mothers with substance misuse issues in the USA. The findings suggest that the risks to parenting could be minimized with intervention in the form of integrated programmes, which could have long-term impact. The authors report that although the studies within the review find small impacts of integrated programmes in comparison to addiction treatment-as-usual, there is the potential for these programmes to have a large impact on associated financial and human burdens such as reducing the need for foster care placement, child treatment and psychiatric admissions.

Parents Under Pressure (PUP) Programme

We identified several publications relating to the Parents Under Pressure programme, home-based intensive treatment programme that started in Australia and is currently being tested in the UK by NSPCC in Blackpool, Coventry and Glasgow¹⁰. The following publications report the impact of the scheme, including significant reductions in problems and improvements in parental functioning, parent-child relationships, and parental substance use and risk behaviour. The exact degree of impact of the programme is unclear, but findings indicate that the programme has promise in terms of its flexibility and in enabling parents to learn to manage crisis events.

Dawe, S and Harnett, P (2007) Reducing potential for child abuse among methadone-maintained parents: Results from a randomized controlled trial. Journal of Substance Abuse Treatment, 32(4), pp.381-390 (Available with NHSScotland OpenAthens username)
Dawe, S. et al. (2003) Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme. Drug and Alcohol Review, 22(3), pp.299-307
(Available with NHSScotland OpenAthens username)
Harnett, P. and Dawe, S. (2008) Reducing Child Abuse Potential in Families Identified by Social Services: Implications for Assessment and Treatment. Brief Treatment and Crisis Intervention, 8(3), pp.226–235

Perth & Kinross Alcohol & Drug Partnership (ADP) & Child Protection Committee (CPC) (2014) A practitioner’s online toolkit to Getting Our Priorities Right: working together with children, young people and families affected by problematic alcohol and/or drugs use across Perth and Kinross (pdf)

This toolkit was developed from previous national and local GOPR/CAPSM guidance. It aims to promote prevention, early identification, proportionate intervention and support to children and families affected by problematic alcohol and/or drug use. It provides checklists for reflective practice, key GIRFEC questions, early observations of children, parents and carers, and further considerations for different agencies.

The Scottish Government (2013) Getting our priorities right: updated good practice guidance for all agencies and practitioners working with children, young people and families affected by problematic alcohol and/or drug use (pdf)

The guidance sets out the challenge of adult problematic alcohol or drug use, its possible impacts on children and families and how services should respond. It provides all child and adult service practitioners working with these vulnerable families – across the full range of sectors – with an overview of the supporting evidence base.

Chapter 2 gives advice to services – including those services providing treatment and care to problem alcohol and/or drug using adults – about what to look for when gathering early information about vulnerable children and families. It describes wider issues that services should take into account as these often co-exist with problematic alcohol or drug use.

Templeton, L et al. (2006) Looking beyond risk. Parental substance misuse: scoping study (pdf)

This review of international evidence from 1990 to 2005 found that although there is evidence to suggest that parental substance abuse can have negative impacts on children, there are studies that found “no evidence of heightened risk for children stemming from parental substance misuse alone” (p.1). It outlines characteristics of successful interventions, including: the family and social context, engagement, support, communication, therapeutic and educational support, and being needs responsive (for example, sessions out of hours, child care, transport and home visits). It provides details about the evidence around different types of interventions, including family-, child- and parent-focused approaches.

Tunnard, J (2002) Parental drug misuse: A review of impact and intervention studies. Research in Practice (pdf)

Children of substance misusing parents, whether or not they are acknowledged as being ‘in need’ may require in particular:

The identification of relatives, or a resource family, backed by financial support, to provide continuity in care, such as occasional or planned respite periods.
Home-based help to establish routines and boundaries, and provide practical help or advice.
Individual and/or family counselling to help parents and older children understand their difficulties, and work for positive change.
A volunteer befriender for school age children and a recreational activity so that they can enjoy and benefit from normal activities.
The opportunity to attend a group for children whose parents have a health problem (not necessarily mental health).

Forthcoming evidence

A Cochrane systematic review protocol¹¹ published by McGovern et al. (2017)¹²describes a systematic review that will assess the effectiveness of psychosocial interventions at reducing the substance misuse of parents with children from birth to 21 years old. The studies included in the review will explore the impact of interventions on people using different substances, and will examine whether interventions can: increase drug and/or alcohol treatment engagement, retention and completion; affect the welfare of the child; whether intervention effects differ by intervention type and duration or according to who receives them. This review has not yet been completed (the authors inform us it is likely to be published in summer 2018).

Another paper from the same research team¹³ is currently under review. This paper is based on a wider project funded by Public Health England. The authors expect the report from this project to be published in January 2018 and may be able to share the report with us prior to publication. The results of this project are is likely to provide valuable information relevant to the enquiry for this summary.

Other relevant Iriss resources

Clapton, G (2017) Insight 38: Good practice with fathers in children and family services (pdf)

This review includes evidence around paternal psychopathology, evidenced in substance misuse has demonstrable negative impacts on child and adolescent functioning and explores how fathers are often overlooked in social work interventions. It also identifies how to respond to risk from parents, and connects involvement in the family to the avoidance of reoffending.

Furnivall, J (2011) Insight 10: Attachment-informed practice with looked after children and young people (pdf)

This review examines attachment-informed practice with looked after children and young people. This includes evidence of relevance to parental substance misuse. For example, “[f]or many looked after children their parents' substance misuse can be key to the failures in attachment and consequent impairments of children's development” (p.6).

Iriss.fm (2010) Substance misuse and social work – the essential contribution "It’s everyone’s job" - Joy Barlow (podcast)

This podcast is a recording of a Glasgow School of Social Work Research Seminar focusing on substance misuse.

Morrison, F (2016) Insight 34: Social workers' communication with children and young people in practice (pdf)

This insight presents what research tells us about social workers’ communication with children and young people in everyday practice. It also introduces key findings from a UK-wide study of social workers’ communication with children and young people.

Footnotes

Iriss (2011) Leading for outcomes: parental substance misuse (pdf)
Cleaver H, Unell I and Aldgate, J (1999) Children’s needs - parenting capacity: The impact of parental mental illness, problem alcohol and drug use, and domestic violence on children’s development. London: The Stationery Office (pdf)
Velleman, R and Templeton, L.J (2016) Impact of parents’ substance misuse on children: an update. BJPsych Advances, 22, pp.108–117 (Available with NHSScotland OpenAthens username)
Iriss (2011) Leading for Outcomes: parental substance misuse (pdf)
UCL Institute of Health Equity (2015) The impact of adverse experiences in the home on the health of children and young people (pdf)
Institute of Public Care (2015) Hampshire County Council: Working with Families where there is Domestic Violence, Parent Substance Misuse and/or Parent Mental Health Problems: A Rapid Research Review, p.3 (pdf)
NSPCC (2017) Parents Under Pressure™: Improving parenting in families with drug or alcohol problems (pdf)
Goodyear-Brown, P. (ed.) (2012) Handbook of child sexual abuse: identification, assessment and treatment. Hoboken, New Jersey: Wiley.
Canfield, M et al. (2017) Maternal substance use and child protection: a rapid evidence assessment of factors associated with loss of child care. Child Abuse & Neglect, 70, pp.11-27 (Available with NHSScotland OpenAthens username)
NSPCC (2017) Parents Under Pressure™: Improving parenting in families with drug or alcohol problems (pdf)
A systematic review presents the results of a comprehensive search that collects and critically analyses studies that relate to a specific research topic. A systematic review protocol describes the rationale, hypothesis, and planned methods of the systematic review.
McGovern R, Addison MT, Newham JJ, Hickman M, Kaner EFS (2017) Effectiveness of psychosocial interventions for reducing parental substance misuse. Cochrane Database of Systematic Reviews 2017, Issue 10. Art. No.: CD012823. (Open Access)
McGovern R, Gilvarry E, Addison M, Alderson H, Carr L, Geijer-Simpson E, Hrisos N, Lingam R, Minos D, Smart D, Kaner E. The health, psychological, educational and social impact of non-dependent parental substance misuse upon the child age 0-18 years: a rapid evidence assessment (under review)