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4.8 Children of Alcohol/Substance Misusing Parents/Carers

SCOPE OF THIS CHAPTER

This is a generic chapter for Greater Manchester. See also Section 9, Additional Local Information.

AMENDMENT

In June 2016, a link was added to Bury’s local information.


Contents

  1. Background
  2. Parental Alcohol/Substance Misuse
  3. The Impact on Children and Families
  4. Assessments
  5. Maternal Alcohol/Substance Misuse in Pregnancy
  6. Newborn Babies and Children
  7. Importance of Working in Partnership
  8. The role of Urine Screening, Hair Strand Tests and Breathalysers
  9. Additional Local Information


1. Background

In 2003, the Advisory Council for the Misuse of Drugs (ACMD) published Hidden Harm, a report on the impact of parental drug use on children. The key messages of the report were that:

  • There are significant numbers of children affected by parental problem drug use in the UK;
  • Parental problem drug use causes serious harm to children of all ages;
  • Reducing this harm to children should be a main objective of policy and practice;
  • Effective treatment for the parent/carer can have significant benefits for children;
  • Services should work together to take practical steps to protect the health and well-being of affected children; and
  • The number of children affected is unlikely to decrease until the number of problem drug users decreases.

More recently in 2012, the Children’s Commissioner for England published Silent Voices, a report on the impact of parental alcohol misuse on children. The key messages of this report were that:

  • The misuse of alcohol by parents negatively affects the lives and harms the wellbeing of more children than does the misuse of illegal drugs;
  • Too often, parental alcohol misuse is not taken as seriously, in spite of alcohol being addictive, easier to obtain, and legal;
  • The effects of parents’ alcohol misuse on children may be hidden for years, whilst children try both to cope with the impact on them, and manage the consequences for their families;
  • Policies and strategies should take into account the impact on children who may be affected by a range of levels of parental alcohol consumption and not just dependent drinkers.


2. Parental Alcohol/Substance Misuse

Not all families affected by drug and/or alcohol use will experience difficulties. However research indicates that parental drug and/or alcohol misuse can have significant, damaging, and long lasting consequences for children. Serious Case Reviews (SCRs) repeatedly show that parental substance misuse, mental health issues and domestic abuse are the three most common features. When these combine, as they often do, the impact on children is deemed to be so damaging it has been called the “Toxic Trio”. Research by Brandon, 2013 (Neglect and Serious Case Reviews, University of East Anglia/ NSPCC, 2013) also highlights that neglect was present in 60% of recent SCRs, and there are strong links between parental substance misuse, child protection plans, care proceedings and adoption, and being cared for by extended family.

N.I.C.E Definition of substance misuse (2007)

“Intoxication by or regular excessive consumption of and/or dependence on psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances)”

NICE Definitions of alcohol misuse (2010)

  • Increasing risk drinking is defined as regularly consuming between 22 and 50 units per week (adult men) or between 15 and 35 units per week (adult women). Also known as ‘hazardous drinking’, a pattern of drinking that increases the risk of health and social harms to the individual or to those around them”;
  • Higher risk drinking is defined as regularly consuming over 50 units per week (adult men) or over 35 units per week (adult women). Also known as ‘harmful drinking’, a pattern of drinking that is highly likely to be causing health and social harms to the individual or those around them”;
  • Alcohol dependence is defined as a cluster of behavioural, cognitive and physiological factors that typically includes a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking despite harmful consequences. They will also give alcohol a higher priority that other activities and obligations”;
  • Binge drinking is a pattern of alcohol consumption characterised by drinking to get drunk or drinking large quantities of alcohol on a single occasion. In terms of units, for men it is defined as drinking more than 8 units of alcohol in a single session and for women, drinking more than 6 units in a single session”.

The children of such parents are entitled to help, support and protection within their own families wherever possible. 

Drug and/or alcohol using parents are entitled to expect that they will be treated in just the same way as other parents whose personal circumstances lead them to seek help. Parents and carers need to be encouraged to seek help, support, and treatment to address their drug and/or alcohol use and to reduce the harm it causes to them, their children, family, and society. Assessments must focus on the needs of children and their parents’ and carers’ ability to provide for them. Each family should be assessed individually and non-judgementally, and offered appropriate support and service provision - with safeguarding / child protection referrals made where necessary.

The current picture

Clearly it is impossible to know just how many adults misuse substances and how many children are affected. Any figures are likely to be under-estimates, particularly if gleaned only from numbers accessing treatment.  However, high levels of poly-substance use remain a feature and it is very important to note that the profile of drug use is ever changing, particularly in the light of substances that can be bought online, including “legal highs” as well as performance enhancing drugs such as steroids. It is important therefore to focus on the impact of the substance on parenting.

According to the Home Office survey for 2011/2012 cannabis was the most commonly used type of drug used (6.9% of adults), followed by powder cocaine (2.2%), the use of which has risen in the long term. Alcohol concern (2010) highlights that “drinking habits have changed significantly. Alcohol is 75% more affordable than in 1980 and alcohol consumption has more than doubled over the past 50 years with 1 in 4 adults drinking regularly above lower risk guidelines. Drinking has moved out of the public domain – pubs – and into the private sphere – home. Thousands more children now grow up in homes where alcohol is misused by one or both parents. Current estimates suggest 30% of children in the UK live with at least one adult binge drinker, 22% live with a hazardous drinker, 2.5% live with a harmful drinker and 6% live with a dependent drinker (Manning et al, 2006). This equates to 3.3 million children affected - 2.6 million children in the UK living with a parent/carer who drinking at increasing or higher risk levels (this includes binge drinking and regular drinking) and a further 705,000 are living with a parent/carer who is alcohol dependent.

Another serious hidden consequence is the complex relationship between alcohol and domestic abuse and the increased risks for children. Perpetrators of domestic abuse may choose to use alcohol as a socially acceptable excuse to minimise, deny or blame their behaviour to avoid being held responsible for their actions. Alcohol consumption has been found to be associated with increased frequency and severity of physical violence but does not reflect the wider picture of controlling, coercive and threatening behaviour. Perpetrators may also actively encourage or coerce a partner to use alcohol to increase control over them or to shift responsibility away from them to humiliate and degrade their partner as a parent. Victims may also use alcohol as a coping mechanism and judgemental attitudes from professionals can further traumatise a person through secondary victimisation. Therefore as there is no direct causal link, it is important for practice to be informed by the true nature of the relationship between alcohol and domestic abuse to avoid misleading assumptions that reducing or stopping drinking will mean relationships, domestic abuse and outcomes for children will automatically improve (Humphreys, 2005; Galvani & Humphreys, 2007).

Early Help is crucial for children and families affected by alcohol and other substance misuse, Inter-agency communication and co-ordination is essential for safeguarding and protecting children from harm and consultation between staff from specialist drug and/or alcohol, child health and child protection services should occur as part of good practice.

Parents and carers can use alcohol or other substances and still prioritise the safety and welfare of their children. However it is essential that staff recognise that this is a higher risk group. Alcohol and/or substance misuse is a cause for concern when it adversely affects the quality of care that a child receives and consequently poses a risk to their health and development, or has the potential to do so.

Adults who misuse alcohol or other substances may also be faced with multiple problems including homelessness or financial problems, difficult or destructive relationships, lack of effective social and support systems, issues relating to criminal activities and poor health. Assessment of the impact of these stresses on the child is important. It reinforces that parents/carers should be seen in the context of family life and functioning, not purely as an indicator or predictor of child abuse and neglect.

Parents and carers may not be honest with professionals about the extent of their alcohol or drug use and its impact is therefore often underestimated. Sometimes professionals are “over-optimistic” and too keen to believe in progress, failing to see or predict that continuing alcohol/substance misuse will impact on the children. Criticisms within SCRs also include an over-reliance by professionals on self-reporting. Parents may simply lack awareness of the impact of their alcohol/substance misuse (or other factors) on their children, or they may “disguise compliance” by providing an over-optimistic or completely inaccurate picture.

The profile and incidence of problem drug use is subject to constant change.

The Advisory Council on the Misuse of Drugs (ACMD) has identified three key characteristics of parental problem drug use - the high level of poly-drug use, the prevalence of intravenous use, and the existence of other factors affecting parenting capacity (poverty, social exclusion, mental health problems, and environment). The report [1] also identified that heavy dependent drug use often results in chaotic and unpredictable behaviour, which can be as damaging as the drug use itself.

The harms to children from parental alcohol misuse are wide ranging, from physical effects such as damage to the foetus, neglect, plus emotional, sexual and physical abuse, to complex psychological and social problems. Different levels of consumption (not just parents/carers who are dependent drinkers) and particular styles of drinking (such as binge drinking) can affect children and it cannot be assumed that  higher levels of consumption equates to greater harm (Office of the Children’s Commissioner, 2012)

Alcohol Concern has identified [2] that the misuse of alcohol can be associated with significant harm to children, even more so when combined with co-existing issues  such as domestic violence and abuse, other drug misuse as well as parental mental ill health. The risk to children may arise from:

  • Adverse impact of growth and development of an unborn child resulting in birth defects, lifelong learning disabilities and neurological disorders;
  • Falling asleep with a baby in a bed, chair or sofa leading to overlay;
  • Use of the family resources to finance the parents/carers’ drinking habits, characterised by inadequate food, heat and clothing for the children;
  • Exposing children to unsuitable care givers or visitors or total lack of supervision;
  • Children’s absenteeism from school, other school related issues or health appointments;
  • Children taking on the role of carer either for other siblings or the Parent/carer(s);
  • Effects of alcohol which may lead to uninhibited behaviours e.g. inappropriate display of sexual and/or aggressive behaviour and reduced parental vigilance;
  • Unsafe storage of alcohol thus giving children ease of access or ‘permissive parenting’ where children are allowed or encouraged to drink.

In addition, alcohol is a factor in family problems related to social exclusion. Also, heavy drinking is a common factor in family break-up, and marriages where one or both partners have an alcohol problem are twice as likely to end in divorce as marriages where alcohol problems are absent [3].

[1] Hidden Harm – Responding to the needs of children of problem drug users; ACMD 2003
[2] Child Protection issues for professionals working with parents/carers who misuse alcohol; Alcohol Concern 2006
[3] Velleman, R. (1993) ‘Alcohol and the family’, London, Institute of Alcohol Studies


3. The Impact on Children and Families

A child's growth and development depends on a variety of interacting social and biological factors, which can be broadly grouped into three categories - conception and pregnancy, parenting, and the wider family and environment. Hidden Harm and Silent Voices outline the way in which alcohol and drug use can impact on the development of children in affected families.

Throughout their lives children may need the services of various professionals. Positive interventions at different stages of their growth and development can contribute to children and young people reaching their full potential. Effective collaboration, good joint working and a sharp focus on the family as a whole are essential if children of alcohol/substance misusing parents/carers are to receive appropriate care and support.

It is recognised that there may be barriers to agencies working together; however, these must be addressed to ensure that all agencies act together appropriately and at the right time in accordance with the needs of children and young people. All agencies have a part to play in helping to identify problems at an early stage. Basic information should be gathered about the family and household circumstances of those who use alcohol or other substances.


4. Assessments

  • When assessing the well-being of a family, agencies must look at the parents’ drug  and/or alcohol use from the perspective of the child to understand the impact this has  on the child’s life and development. Each child should be considered on an individual basis. It is important to consider that parents often do not stop using drugs or alcohol when they have children although it can often be a strong motivator for change;
  • Professionals should aim to establish what it feels like for the child(ren) to live in that household and to establish whether the child(ren) need information and/or support in dealing with the issues that impact upon and affect them;
  • In doing so, the worker should approach the child(ren) in a way which is appropriate to their age and development which enables the child to tell a story without putting them on the spot and forcing them to “tell tales.” The worker should attempt to establish the child’s level of awareness and understanding about substance misuse and the willingness of the child to provide information or answer questions. It is also important for the worker to try and establish what support the child(ren) needs and who might be an acceptable source for that help e.g. a friend or friend’s parent, family member, concerned other and so on;
  • While there is a clear need for specialist drug/alcohol agencies to consider the potential impact of parental alcohol/substance misuse from a child’s perspective, adult workers are not in a position to approach or assess the child(ren) directly. Therefore routine communication between specialist drug/alcohol agencies and children’s health/family services is essential to ensure that the needs of each individual child is considered as part of early help, safeguarding as well as child protection.

Analysis: making sense of the information

This is the most important part of the assessment process as a poor analysis of the information that has been collated will invariably lead to poor decision making and care planning. In making sense of the information that has been gathered, where that information should take the worker is framed in terms of the following questions:

  • Is the parents’ drug or alcohol use significantly affecting parenting capacity?
  • Is the parents’ drug or alcohol use and associated behaviour significantly impacting upon the child’s health and safety, social, emotional and educational development?
  • What are the resources and strengths in this family and how might they impact on the care of the child?
  • What is the parents’ understanding and attitude on the need for change?
  • What change might be acceptable and attainable?
  • What types of professional intervention will help reduce the harm to the children?
  • Where, on the continuum of children in need/children in need of protection, does this particular family sit?

Outlined below are some suggestions which may assist the analysis component of the assessment:

  • A chronology of significant events;
  • Who else is involved and why – a synthesis of current information, observations and any other assessments;
  • The views and perspectives of all interested parties, including children, parents, family, neighbours and members of the community and other professionals/agencies;
  • Checks to test the reliability of information/evidence and its sources, professionals can rely on the parent’s self-reporting and develop an over-optimistic view of progress made;
  • Identify any other factors that may influence the assessment e.g. values of individual worker; parental attitudes and level of co-operation and honesty;
  • Evidence based judgements underpinned by research and theory relating to drug and/or alcohol use, child welfare and parenting;
  • Completion of the Graded Care Profile or equivalent assessment tool for neglect used in your area.


5. Maternal Alcohol/Substance Misuse in Pregnancy

Maternal substance misuse in pregnancy can have serious effects on the health and development of the child before and after birth. Many factors affect pregnancy outcomes, including poverty, poor housing, poor maternal health and nutrition, domestic violence and abuse, and mental health. Assessing the impact of parental alcohol/substance misuse must take account of such factors. Pregnant women (and their partners) must be encouraged to seek early antenatal care and treatment to minimise the risks to themselves and their unborn child.

Women who experience problems with substances (and who often face other pressures) don’t always realise that they are pregnant until later in the pregnancy - their periods may have stopped and they may have believed they couldn’t get pregnant. They may present and book late to maternity services, and be fearful of being judged and stigmatised. It is vital that women who use misuse substances have informed consent, receive support in their pregnancy, a prompt referral to treatment services where needed, and  crucially after the birth, are supported to enable the baby to remain with them whenever it is safe and appropriate.

The Department of Health recommends that women should avoid alcohol altogether during pregnancy because alcohol passes freely through the placenta so can affect the growing baby right the way through until birth. While guidance is provided for women who wish to drink during pregnancy, to not drink more than 1 or 2 units once or twice a week, this is to ‘minimise the risk of harm’ rather than eliminate the risk of harm. Therefore, no alcohol = no risk of alcohol harm. When alcohol does cause harm, the effects may not be limited to Foetal Alcohol Spectrum Disorder (FASD) alone, alcohol consumption is associated with infertility, miscarriage and stillbirth. The adverse effects of alcohol consumption on the developing foetus represent a spectrum of physical, behavioural and neurocognitive impairments. The range of disorders associated with FASD varies in severity and clinical outcomes depending on the level, pattern, and when the mother consumes alcohol.

Any women with suspected alcohol dependence should always get specialist advice before stopping completely or reducing suddenly as it can be dangerous to do this too quickly without proper support. Sudden and severe alcohol withdrawal can vary from mild problems, such as sleeping badly and feeling shaky and anxious, to much more serious, sometimes life-threatening problems like seizures or delirium tremens (DTs). Therefore it is crucial that specialist advice is sought and the amount of alcohol consumed is reduced gradually and safely.

Drug use is associated with increased risk of miscarriage and pre-term labour, low birth weight babies and stillbirths.

Stimulants (e.g. crack) can cause an increased risk of placental abruption, (The placenta normally separates from the wall of the uterus after the baby has been born. In placental abruption, part or all of the placenta separates from the uterus before the baby has been delivered. The condition is potentially life-threatening, especially for the foetus).

Not every woman who uses substances will need additional support or a referral to specialist services. If you are unsure and need advice contact your local specialist midwifery service or the midwifery safeguarding team.


6. Newborn Babies and Children

6.1 Newborn Babies

Newborn babies may experience withdrawal symptoms (e.g. high pitched crying and difficulties feeding), which may interfere with the parent / child bonding process. Babies may also experience a lack of basic health care, poor stimulation and be at risk of accidental injury (including overlay) and poor supervision.

6.2 Children

The risk to child(ren) may arise from:

  • Substance misuse affecting their parent/carers' practical caring skills: perceptions, attention to basic physical needs and supervision which may place the child in danger (e.g. getting out of the home unsupervised);
  • Substance misuse may also affect control of emotion, judgement and quality of attachment to, or separation from, the child;
  • Parents/carers experiencing mental states or behaviour that put children at risk of injury, psychological distress (e.g. absence of consistent emotional and physical availability), inappropriate sexual and / or aggressive behaviour, or neglect (e.g. no stability and routine, lack of medical treatment or irregular school attendance);
  • Children are particularly vulnerable when parents/carers are withdrawing from drugs or alcohol;
  • The risk is also greater where there is evidence of mental ill health, domestic violence and abuse and when both parents/carers are misusing substances;
  • There being reduced money available to the household to meet basic needs (e.g. inadequate food, heat and clothing, problems with paying rent [that may lead to household instability and mobility of the family from one temporary home to another]);
  • Exposing children to unsuitable friends, customers or dealers;
  • Normalising substance use and offending behaviour, including children being introduced to using substances themselves;
  • Unsafe storage of injecting equipment, drugs and alcohol (e.g. methadone stored in a fridge or in an infant feeding bottle). Where a child has been exposed to contaminated needles and syringes Most  drug and alcohol services give locking boxes for medication;
  • Children having caring responsibilities inappropriate to their years placed upon them;
  • Parents/carers becoming involved in criminal activities, and children at possible risk of separation (e.g. parents/carers receiving custodial sentences);
  • Children experiencing loss and bereavement associated with parental ill health and death, parents/carers attending inpatient hospital treatment and rehab programmes;
  • Children being socially isolated (e.g. impact on friendships), and at risk of increased social exclusion (e.g. living in a drug using community);
  • Children may be in danger if they are a passenger in a car whilst a drug / alcohol misusing carer is driving.

Children whose parent/carers are misusing substances may suffer impaired growth and development or problems in terms of behaviour and / or mental / physical health, including alcohol / substance misuse and self-harming behaviour.

See the National Patient Safety Alert (November 2009) Preventing harm to children from parents/carers with mental health needs.


7. Importance of Working in Partnership

Alcohol/substance misuse professionals must identify those adults who are parents/carers, or who have regular care giving access to children, and routinely share the information with key professionals in universal services as early as possible (e.g. midwife, health visitor or school nurse). Routine communication with universal services is an essential part of good interagency working, safeguarding practice and promoting early help. There is also evidence that when service users are disengaging from alcohol/substance misuse treatment there may be an increased risk to children.

Routine Communication therefore takes place to offer information to NHS colleagues when alcohol/drug services are engaging and disengaging with parents/carers or adults in regular contact with children. Where there are no apparent concerns, no specific details need to be shared other than that the service is involved (or no longer involved) with the family. Even where there are no concerns from the point of view of alcohol/substance misuse services it is important for universal services to know because concerns may be identified by other partner agencies who may wish to make contact with adult keyworkers to discuss these concerns.

Early identification of parental alcohol/drug use by frontline staff working with children and families will also greatly assist in providing support for children. Some areas promote the use of drug and alcohol screening questionnaires for frontline staff to incorporate into their assessments with parents/carers to support early identification and intervention.

LA children's social care, alcohol/substance misuse services and other agency services must undertake a multi-disciplinary assessment using the Assessment Framework including specialist alcohol/substance misuse and other assessments, to determine whether or not parents/carers with alcohol/substance misuse problems can care adequately for their child(ren). Such assessment should include whether they are willing and able to lower or cease their alcohol/substance misuse, and what support they need to achieve this.

Professionals in all agencies must recognise that their primary duty is to safeguard and promote the welfare of the child(ren).

All care programme meetings for adults who are a parent/carer must include ongoing assessment of the needs or risk factors for the child(ren) concerned. LA children's social care should be invited to such meetings if appropriate and contribute.

Strategy meetings / discussions, child protection conferences and core group meetings, must include professionals from any drug and alcohol service involved with the subject child and their family.

Local Safeguarding Children Boards are responsible for taking full account of the challenges and complexities of work in this area by ensuring that inter-disciplinary / agency protocols and training are in place for the co-ordination of assessment and support and for close collaboration between all local children's and adult's services.


8. The role of Urine Screening, Hair Strand Tests and Breathalysers

While tests can help in the assessment of parental alcohol/substance use, it is really important to understand that they are only one tool. Choice of methods for drug or alcohol testing depend on what they aim to establish as well as over what length of time and what test, if necessary, provides a legally defensible chain of custody. An over-reliance on and an increased frequency of testing is not always helpful. Urine tests are not observed, and can therefore be tampered with, they can only show the presence of substances used in the previous days - they cannot show accurate levels of usage. Breathalysers again, can only show very recent alcohol use, with ankle bracelets (currently being piloted) offering the only ‘continuous’ testing method to demonstrate continued abstinence from alcohol and ‘sober’ days. Hair strand testing can be reliable for assessing drug use over periods of time  however caution is needed for alcohol hair strand testing which is less reliable. While alcohol hair strand tests can detect periods of ‘heavy’ drinking, they should not be used to establish abstinence or low level/moderate consumption. Therefore any biological tests used (urine, breathalyser, hair strand, blood tests) provide a broader picture when combined and also should always be considered alongside collective knowledge / third party reports. They are only one aspect of a full range of factors to be used in assessment.


9. Additional Local Information

For more specific local procedures relating to each LSCB's Drug and Alcohol Service:

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