Substance misuse causes considerable harm and is presently an immense global issue of public concern. It is a wide-ranging problem, damaging individuals, families and entire communities. In general, substance misuse is not only growing considerably within the United Kingdom, but also worldwide. Simultaneously, the number of children involved in the vicious circle of drug taking and problem drinking by their parents is also increasing. Although governments, policy makers and practitioners are recognizing the problem and taking steps towards tackling the effects of substance abuse within families; the issue in general seems far from being solved.
Alcohol is legally available and easily accessible throughout England. It is positively associated with socialising, relaxing and celebrating. Although problems linked to excessive alcohol consumption are widespread and well established, it seems that alcohol misuse is somehow more socially accepted and does not have the same stigma as using drugs. Consequently, the issue of alcohol abuse, especially in families with children, often remains undiscovered, and the negative impact and effects of the excessive drinking behaviour of parents on children remain under-recognized and neglected. Estimates by the Prime Minister’s Strategy Unit (2004) are that between 780,000 and 1,3 million children in England are (in)directly affected by an alcohol problem of at least one parent – in other words: 1 in 11 children live in a household where alcohol misuse is present.
While alcohol and the negative consequences associated with its uncontrolled use have been around and well documented for centuries, the drug industry has only been developing and growing rapidly over the last few years. Concordant with the Advisory Council on the Misuse of Drugs (2003) up to 300,000 children – or 3% of all children under 16 – currently belong to a family where one or two of their parents struggle with a dangerous drug issue.
Parental substance misuse is also not unheard of in social services caseloads with one quarter to one third of families known to social services as being involved with misusing drugs or alcohol (Cleaver et al., 1999; Kearney et al., 2003). Many of these children do at least temporarily not live with their addicted parents.
Putting these figures together, more than 10% of all children in England are exposed to suffer under the effects of their parental drug or alcohol misuse and it is extremely likely that these numbers will continue to grow over the following years. It seems also reasonable to believe that the official figures of affected children may be under-estimating the true scale of the problem as it is extremely difficult to calculate how many families have to cope with some form or the other of substance abuse (Templeton, 2006). First, not all drug and alcohol services take proper care to establish whether or not their clients are also parents and second, not all clients are willing to provide information about the existence of own children. Third, some institutions do not disclose figures, collect data properly or tend to under-report; and fourth, nobody knows how many substance misuser are not seeking treatment and, therefore do not appear on any official statistics (Keen et al., 2001; ACMD, 2003). Consequently, missing data and a clear underestimate of the total number of affected children by parental substance misuse seem obvious.
Substance abuse can include negative physical (such as health risks and neglect), psychological (such as attachment disorders and depression) as well as social (such as poverty and crime) influences on both parents and their children (Kroll et al., 2000). Parental alcohol and drug abuse can affect children’s health and development in the long term from as early as conception and often into adulthood, leading to varying forms of strong, adverse and complex consequences (Turning Point, 2006). Additionally, all conceivable types of child maltreatment have repeatedly been associated and clarified in various studies with parental substance abuse – including negligence (as the most common type of abuse), sexual, emotional and physical abuse (Cleaver et al., 1999; Alison, 2000; Forrester et al., 2006). The impact of alcohol and/or drugs may also significantly affect the parent’s capacity of adequate parenting (Alison, 2000). The negative impact of a dependency on the substance misuser himself can lead to chaotic lifestyles, complicating and preventing parents to support and care for their own children, meeting their basic needs and providing a safe and encouraging home environment (Keen et al., 2001; Home Office, 2008).
With the knowledge that parental misuse of certain substances can have a seriously negative impact on children’s physical, psychological and emotional health and development, it is essential that these children potentially at risk are identified as early as possible in order to arrange for appropriate protection and safeguard their welfare (Nottingham City, 2004). This is the responsibility of all professionals in different ranges of services; they all must be able to identify and treat substance misuse related problems by adults, and also focus on the problems of affected children (Keen and Alison, 2001). Therefore, increasingly more research is being done, policy initiatives started and family-supporting services and projects have developed rapidly (Templeton et al., 2006). Although considerable progress has been made in recognizing and tackling the problem of substance abuse and the issue has won much public awareness in the last years, sadly, the death of children through the hands of their parents recalls that the system still fails to safeguard children at risk.
Professionals face a variety of often complex issues and struggle with working unimpeded. The most common problems are a lack of understanding, gaining access to the substance misuser and their children, resilience, dilemmas about confidentiality and information sharing, inter-agency tensions, assessment, lack of training and the ability to focus on both, adults’ and children’s needs (Kroll and Taylor, 2000; Taylor and Kroll, 2004). Without a doubt, changes and new approaches are needed, and through joint assessment, better information sharing and inter-agency cooperation, the focus should be on effective intervention and treatment for the substance misuser as well as of the so far often “invisible” and neglected children (Kroll and Talyor, 2000; Head of Safeguarding Children, 2008).
The first section of this essay describes effects and causes associated with parental substance abuse. It highlights the impact of drug and alcohol misuse on the foetus during pregnancy and later on the child from newborn to adulthood, as well as resilience and protective factors for affected children. Part two focuses on professionals: their responsibilities regarding children’s safeguarding and the challenges they face when confronted with substance misuse. The third section covers the legal framework of safeguarding children and other related political measures. The fourth section examines the progress made so far by looking at different projects, interventions implemented and recent developments. In contrast, section five gives an insight into reality, pointing out some of the most obvious problems and recent incidents. It touches thoroughly discussed issues such as information sharing, inter-agency cooperation and training. The last section considers aims and goals, their implementation and suggests recommendations for a more effective strategy in the future.
Throughout this article substance misuse/abuse refers to the use – either dependant use or associated with adverse effects – of prescribed (such as tranquilizers, sleeping pills, pain-killers, depressants) and illicit (such as opioids, cocaine, ecstasy, cannabis) drugs as well as alcohol (Newcastle Child Protection, 2002) with critical social, interpersonal, financial, physical and psychological negative effects for both the users and those around them (ACMD, 2003).
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SUBSTANCE MISUSE AND EFFECTS ON PARENTS AND THEIR CHILDREN
“There is reasonable basis in research to suggest that a child whose parent is misusing substances is at increased risk. Substance misuse can demand a significant proportion of a parent’s time, money and energy, which will unavoidably reduce resources available to the child. Substance misuse may also put the child at an increased risk of neglect and emotional, physical or sexual abuse, either by the parent or because the child becomes more vulnerable to abuse by others” (Lewis, 1997)
Parental substance abuse does not necessarily mean that children are at risk of harm or “in need” or receive poor parenting – in some cases they would not even be affected in a negative way (Newcastle Child Protection, 2002). However, only a few children will not have to deal with multiple, mounting and varying negative consequences and survive such a complex issue entirely unscathed. While a concrete pattern of effects can never be clearly determined due to the complexity of the issue, many of the children may be permanently affected in an adverse manner, either emotionally, physically, socially, intellectually or developmentally (ACPC, 2004). Problems include a variety of health and developmental issues, ineffective parenting, criminal activity, poverty, chaotic lifestyles and educational attainment, and have long been underestimated and an abandoned research field (Keen and Alison, 2001; HM Government, 2008).
The Children Act (1989, s17 (10)) defines a child in need as “unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority; his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or he is disabled”. In this context harm means “ill-treatment (sexual abuse and forms of ill-treatment which are not physical) or impairment of health (physical or mental health) or development (physical, intellectual, emotional, social or behavioural development)” (The Children Act 1989, s31 (9)).
Among hundreds of other prescribable substances, alcohol and opiates should be reduced or avoided at all during pregnancy. Although it is not possible to evaluate all the effects of drugs and alcohol to a full extend on a fetus, it is known that it can be damaging at any time during pregnancy (from conception onwards up to birth, with the first 3 months being particularly vulnerable), causing a variety of health and development problems.
Babies whose mothers were dependant on opiates or alcohol during their pregnancy are more likely to be smaller, of lower birth weight, premature and at higher risk of the sudden infant death (ACMD, 2003). Additionally the addicted mothers’ affected health and her possibly poor nutrition (high levels of sugar, not enough calcium, proteins, fruits and vegetables) often have an additional negative impact on the fetus’ physical and psychical development and the baby’s health.
If an unborn is exposed to maternal alcohol abuse, this cannot only lead to the familiar serious impairments related to substance abuse mentioned before, but also to a remarkably common developmental problem known as Foetal Alcohol Syndrome. Foetal Alcohol Syndrome includes a series of potential effects on children such as learning disabilities, heart defects, lower body weight, decreased height, facial deformities, vision and hearing difficulties, ADD (Attention Deficit Disorder), ADHD (Attention Deficit Disorder with Hyperactivity), conduct disorder and inappropriate behaviour (Dore et al., 1995).
Expecting women sharing injection equipment or working as prostitutes to finance their drug use, live with the constant threat of being infected with HIV or hepatitis B; for children born to drug dependent mothers who are infected with HIV, hepatitis C or hepatitis B, there is also a remarkably elevated risk to be also infected during pregnancy, birth or while being breastfed (ACMD, 2003).
Heavy and prolonged maternal substance abuse, both opiates and alcohol, will very likely expose the child to the Neonatal Abstinence Syndrome, which is a term for a range of problems a newborn may encounter when withdrawing from exposure to narcotics. Typical symptoms include high-pitched and excessively long periods of crying, shivering, sneezing, sweating and temperature, vomiting and diarrhea, feeding difficulties, disturbed sleeping patterns, convulsions,, irritability and hyperactivity, high sensitivity to touch, wild sucking, rapid breathing and cardiac action (Marcory and Harbin, 2000).
Despite the chance that appropriate antenatal care from the beginning would increase the possibility of a healthy and normal pregnancy and satisfactory development of the fetus, mothers involved with substance dependence often do not seek antenatal care, particularly due to their fear of being stigmatized. (Newcastle Child Protection, 2002).
As a baby grows older, the likelihood of experiencing some negative consequences due to its parents’ substance abuse is not diminished in any way and the impact will vary considerably, depending on several factors such as the child’s age and stage of development.
The establishment of a decent, confident and secure relationship to at least one caregiver in the early months has widely been recognized as the foundation of a child’s normal development. However, children of substance misusing parents often experience parental unavailability, inconsistent care and conflictual relationships (ACMD, 2003). A habit often lets a parent focus more on acquiring and using his drugs or alcohol rather than its children’s needs. Intoxication and coping with withdrawals symptoms lead to limited time, attention and emotional unavailability (Kroll and Taylor, 2000).
Further, children of drug and alcohol abusers often have to experience an enforced temporary or permanent separation or loss of a parent due to abandonment, hospitalization, imprisonment, treatment, removal or other emergencies (ACMD, 2003). All these points contribute to life-long complicated and insecure attachment.
The above-specified problems commonly also affect the nature and quality of parenting, which in turn often naturally results in further difficulties in a child’s development (ACMD, 2003). Research proves that many substance abusing parents lack exemplary models for parenting as they have received poor parenting and maltreatment themselves (Keen and Alison, 2001).
As dependence on a substance becomes central, parents are more likely to neglect their children which bears various risks and dangers them, regardless of their age group. Children may be inadequately supervised or left alone at home, exposed to preventable accidents and/or injuries (Kroll and Taylor, 2000). But not only children are at risk of accidents, also drugged or drunken adults are exposed to a higher level of self-induced incidents such as falls, forgetting food on the hob or falling asleep with still glowing cigarettes. Parents with an addiction repeatedly also tend to be unable to fulfill their children’s own basic needs so daily hygiene, a balanced diet and general health may suffer as well as stability, routines (such as bedtimes, getting up and out for school) and boundaries (Alison, 2000).
Further health risks may be provoked not taking children’s routine health appointments or problems seriously enough or careless disposal and therefore easy access to drugs, bottles, syringes and needles (Kroll and Taylor, 2000; Alison, 2000). There is also notable danger for children that have observed their parents using substances, copying them (ACMD, 2003).
“Girl, 2, dies drinking her mother’s methadone” (2002)
“Boy, 2, died after taking parents’ methadone” (2006)
“Boy, 14, dies after drinking methadone at his aunt’s flat” (2008)
Another consequence of parental unavailability is that children are often left alone with daily adult/parental responsibilities such as caring for their younger siblings, meeting their parents needs, managing finances and household chores (Kroll, 2004). Such additional and inadequate responsibilities may in turn result in the loss of social opportunities and poor academic performance of child- some research gives evidence that children miss school (regularly) by being kept at home due to caring responsibilities and left with little time to socialize.
Social isolation becomes more severe as the child grows older and starts to be careful about exposing family life to outsiders and lives in a circle of denial and secrecy due to shame and fear (ACMD, 2003).
Misusing drugs or alcohol does not only contribute to negligence but often goes hand and hand with other forms of child abuse and violence at home. The possibility of abuse and child maltreatment is enforced by the likelihood that children may be exposed to a number of possible dangerous strangers or inappropriate carers within their own home (Newcastle Child Protection, 2002). Research also reveals a lower tolerance level and moderate loss of temper associated with substance abuse, causing aggressive behaviour and resulting in violence to appear frequently (Kroll, 2004).
Emotional neglect and abuse is also an issue within a parental substance misusing environment. Children often either feel rejected and unloved by their parents as they concentrate and spend considerably more time on their destructive habit than with them, or embarrassed and often also guilty (Kroll, 2004). Maintaining an addiction is a financial burden, not only making it difficult to complete household costs, but also regularly leading to criminal activity to buy drugs or alcohol.
Children of addicted parents are also more likely to be exposed to early criminal conduct and/or its consequences – not infrequently because they have been with a parent while they had been committing a crime (ACMD, 2003). Although parents try and tend to hide their habit from their children, children sooner or later discover it and typically have to deal with it by themselves which usually adds to a variety of already existent behavioural problems due to the mentioned consequences of parental substance abuse – children tend to be more aggressive, feel upset or anxious and show anti-social behaviour (ACMD, 2003).
Negative parental examples and role models such as drug taking, alcohol abuse, crime, poor living conditions and inappropriate behaviour inevitably can lead a child to view their parents’ actions as being normal and approved so that substance abuse and outrageous conduct by themselves becomes more likely as they enter into their teens and adulthood (ACMD, 2003).
Research into child resilience has shown that key protective factors can have an enormous impact on preventing children from being damaged by parental substance misuse. The field of factors includes having a parent not misusing substances, a strong bond with a caring adult and support from extended family (Templeton and Velleman, 2007). Further to mention are a violence-free home, sufficient financial resources and an upstanding support system as well as educational success and involvement in different activities (19?). Working towards personal goals and dreams, taking education or career opportunities or even leaving the parental home are also common strategies to deal with experiencing substance abuse at home (Templeton and Velleman, 2007).
Parents generally are aware of the negative consequences and influence on their children, and they often experience a range of impacts as a result of their weakness which moreover will have follow-on affects for their children, for example in their parenting capacity. Many of them have experienced difficult childhoods and were poorly parented themselves – in this cases drugs or alcohol are often used to deal with a range of traumas and tension associated (Alison, 2000).
PROFESSIONALS
It is the reliability and function of all genres of professionals and agencies – including general practitioners, health visitors, doctors, midwifes, pediatricians, mental health services, family support services, treatment institutions, social services, police, educational settings and voluntary sectors – to safeguard and protect children. Safeguarding is equal to keep children safe from harm and abuse – both deliberate abuse as well as accidents, bullying and crime – and to promote their well-being and development in a healthy and safe environment (HM Government, 2006). Everyone having contact with children must be aware that it is not acceptable to remain sidelined if a child is in need or risk of harm (Lord Laming, 2003). However, it is noteworthy that each professional recognizes and accepts the limitations of his own roles and values the essential share of others (Keen and Alison, 2001) – otherwise everyone’s duty and the mission “to put a child’s welfare first” soon gets lost and remains no one’s responsibility (Inter-Agency Guidelines, (2008).
Challenges
When encountering parental substance abuse, all professionals face a series of dilemmas, conflicts and tensions in their work with children and adults. They often simply feel unprepared and lack the expertise, skills and training to focus and work effectively with adults and children to the same purpose, and even if they do have the proper training, professionals often just do not see their role in engaging with children or substance misusing parents (Templeton and Velleman, 2007). Professionals interviewed by Taylor and Kroll (2004) stated one after another that they lack training which covers child safeguarding and protection processes and feel inexperienced to work with children of drug and alcohol users, children in need or risk of harm. Additionally, there seems to be a common confusion among different agencies regarding their individual roles and therefore allocation of clear responsibilities. A large part of these issues lay in the individual and independent development of substance misuse services and child welfare approaches over the last years. While adult treatment services place the substance abusers first and often do not involve existing children, the primary purpose of child protection agencies are solely the children, generally not taking into account parents’ needs (Colby and Murrell, 1998 in Taylor and Kroll, 2004). But agencies working with children must also take into account the situation and the problems of the respective parents, being aware of the impact parents’ behaviour have on children. At the same time, services for adults must not ignore existing children, so a great cooperation between agencies and services is needed (Templeton and Velleman, 2007). Professionals and agencies have to deal with parents who may bot be easy to engage with, who may not want to cooperate with them, are reluctant to open up, tell the truth or prepare to change (Nottingham City ACPC, 2004). Therefore it can be a challenge to obtain, establish and maintain trusting relationships with either the parents or the effected children (Inter-Agency Guidelines, 2008). On the other hand, families with a drug and/or alcohol problem fear a range of consequences and rejection by opening themselves to professionals, which usually keeps them in a twist of silence and secrecy, thus preventing them access to support and help for themselves or their children (Nottingham City ACPC, 2004). Parents are often reluctant to approach services and seek treatment, have problems to confide in others and reveal their drug and/or alcohol problem as they particularly fear that any disclosure could lead to losing their children and that their family might be treated differently, stigmatized or denied by others (Nottingham City ACPC, 2004). Although confidentiality is a key principle for such agencies, no organization can guarantee it and in some cases, professionals have to share information, especially when a child’s welfare is at risk (The Stella Project, 2002).
SAFEGUARDING AND LEGAL FRAMEWORK
As mentioned earlier in this article, agencies, services and professionals in touch with children or/and adults who are parents have a variety of responsibilities to safeguard children, assess their needs and promote their welfare. In the United Kingdom, considerable legislative framework exists for this purpose, with the Children Act 1989 and the United Nations Convention on the Rights of the Child as the elementary and reforming pieces of child law. In general, the Children Act (1989) focuses on improving children’s lives and demands comprehensive services to all children as well as tailored ones for those with additional needs. It also clarifies that if a local authority “has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote that child’s welfare” (The Children Act 1989, s47 (1)). The Children Act also provides the legal grounds for the five Every Child Matters (2003) outcomes in law – be healthy, stay safe, enjoy and achieve, make a positive contribution, achieve economic well-being.
Later the Children Act (2004) implemented a requirement for local authorities and a range of agencies engaging with substance abusing parents to rank first the welfare and safety of their children. Local authorities and agencies are made responsible to determine if a child is in need and/or risk and then to take appropriate steps to protect him from (further) significant harm (ACMD, 2003). Further The Children Act (2004) focuses on co-operation to improve and secure the well-being of children. Early awareness and intervention is critical to reduce the numbers of child protection cases but assessment is an immensely complex process. When assessing the welfare of a child, practitioners must work sensitively and child-centred, analysing the parental substance misuse from the child’s position to better understand the impact upon his development and life (Lord Laming, 2003).
For a more standardized, coordinated, early and practical way to assess children’s individual needs, the Common Assessment Framework (CAF) was designed and forms part of the Every Child Matters (Lord Lamming, 2003). The Department of Health also provides the Framework for the Assessment of Children in Need and their Families, which is based on a more ecological approach. Further, all local authorities are required to have an Area Child Protection Committee to organize and supervise child protection measures. When determining that a child is at risk of significant harm, child protection procedures should immediately be initiated to ensure that the necessary referral is made to the social services (ACMD, 2003).
It is crucial that assessment is ongoing and changes are carefully monitored – when a parent is in treatment or free from drugs or alcohol dependence it does not necessarily mean that children do not longer suffer from any adverse consequences (Nottingham City ACPC, 2004). Further, if no concerns regarding the well-being of a child are established, professionals should remain in connection with the family and carefully observe them as harmless situations often quickly change into an unpredictable environment for the child (Newcastle Child Protection, 2002).
PROGRESS
Over the last years, there has been a wide range of Government initiatives, programmes, strategies and policies aimed at tackling (parental) substance misuse. The Updated Drug Strategy for England 2002, Models of Care for Alcohol Misusers, the Green Paper on Children at Risk, Extended Schools, the Children’s National Service Framework, Sure Start and Early Excellence Centres, mentioned above, are only some examples of key initiatives (ACMD, 2003; The Stella Project, 2002):
The Updated Drug Strategy for England in general specifies a variety of actions undertaken by the Government to tackle drug use and restrict the access to Class A (heroin, cocaine) drugs. Further it acknowledges that there is not enough attention given to children of drug dependent adults and thus more focus on helping them as well as addicted mothers is needed.
The Models of Care for Alcohol Misusers first effort is to identify, work towards and minimize negative consequences of alcohol abuse on children. In particular, this strategy also addresses abuse and domestic violence as the main associated problems with alcohol dependence.
The Green Paper on Children at Risk is a strategy addressing a series of key recommendations of the Laming Report and aiming to implement policies to improve the life chances of children.
The concept behind the Extended Schools project, initiated by the Department for Education and Skills, is that schools could create stronger relationships parents and children, motivate their pupils and so raise standards by offering a wider service such as adult education, health services and childcare.
The Children’s National Service Framework main goal is to reduce inequalities in health and social services as well as upgrading the overall standard of such services. The scheme specifically concentrates on the needs of children of drug and alcohol abusers.
Sure Start provides different services and support of all kind to all families in more disadvantaged areas and in cases of parental substance misuse, the Sure Start team will seek advice, refer to and work closely with the relevant practitioners and agencies. Early Excellence Centres were established to raise children’s welfare and development by working coordinated with other community agencies and offering advice, support, childcare, health services and early learning.
With a comprehensive legislative framework already established in the United Kingdom and several initiatives and programmes running, it does not seem especially needed to modify existing legislations or implement new ones or start more projects to protect children effectively. Nevertheless, those already existing must be fully understood and applied by practitioners in all areas, and everyone must clearly understand his responsibilities and those of the others (Lord Lamming, 2003).
However, the death of the children Baby P and Victoria Climbie are tragic examples of the failings in the child protection system.
Despite considerable commitment and progress made so far, challenges remain in the protection of children and their safeguarding as well as in the daily reality of practitioners. The issues mainly surround training, adequate levels of staffing, improvement of data systems and information sharing and better coordination and cooperation problematically (Lord Lamming, 2003).
REALITY
The exact number of minors suffering under parental substance abuse known to social services is not clearly determined. In 1999, Cleaver et al. estimated that around 25 to 60 percent of all children in child protection proceedings were living with a parent having a drug or alcohol problem. A more recent study of 290 child custody cases in four different London boroughs revealed that 34% (100 families) where affected by substance abuse, resulting in more than 50% of all children in care proceedings and over a third of all children on the child protection files being subjects of parental substance abuse (Forrester and Harwin, 2006). Both researchers also found that most affected children were under the age of five years.
Information sharing
Although the government set clear guidelines on sharing information with the publication of “Information sharing: Guidance for practitioners and managers” in 2008, breaching confidentiality, information sharing and data protection still remain some o
