Relation to the impact of substance misuse on young people and on parenting capacity. |
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A useful definition of substance misuse, for the purposes of this paper, is provided by the Advisory Council on the Misuse of Drugs as the “social, psychological, physical and legal problems related to intoxication and/or regular excessive consumption and/or dependence as a consequence of the taking of drugs or other chemical substances (excluding tobacco)” (ACMD, 1982). Government strategy and service provision for young people involved in, or vulnerable to, substance misuse will be examined with particular reference to recent findings and initiatives. It seems apparent from the literature that services for people with alcohol and drug problems and those concerned with the welfare and protection of children have tended historically to operate in quite separate domains with little cross-collaboration and co-working. Problematic substance misuse and its impact on parenting have generated a number of challenges for service providers in terms of meeting the needs of children and families more appropriately and effectively. These issues will be critically appraised with reference to recent research findings, initiatives and recommendations.
 The research and practice literature on substance misuse has historically tended to fall into two separate categories of problem alcohol use and illicit drug misuse, each with its own distinct theoretical base in terms of causation and treatment programmes. Problem drug use has been defined by the Standing Conference on Drug Abuse (1997) in terms of the negative social, relationship, financial, physical, psychological and legal effects of usage on families. Alcohol misuse, in contrast, appears to defy simple definitions in terms of measures of weekly amounts consumed since, as Cleaver et al (1999) point out, relatively light drinking can be problematic if it is consumed all at once, latterly termed ‘binge’ drinking. However, in recent years, commentators have observed an increased blurring of boundaries, with the greater use of alcohol by young people, increased availability of illicit drugs and many service users combining the use of alcohol with other drugs (Waller and Rumball, 2004). Waller and Rumball (2004) describe how substance misuse can lead to significant social and psychological impairment in terms of “failure to fulfil major role obligations at work, school or home” through “substance-related absences; suspensions or expulsions from school; neglect of children or household”(p.8). The government, under its banner of “protecting communities”, declared its aim to adopt a more holistic approach, situating problems of substance-misuse within the context of local community development and regeneration initiatives (DH, 1999). The formation of local strategic partnerships was advocated, to encourage close collaboration between local groups, charities, other relevant agencies and local government bodies and health authorities in order to address local drugs problems more effectively. The declared aim, thus, was to establish “a range of consistent, integrated and comprehensive approaches appropriate to local needs”, that they should “target alcohol, tobacco and solvents as well as illicit drugs” and that “they should recognise the importance of including effective monitoring and evaluation components” (DH, 1999). The National Treatment Agency for Substance Misuse have noted that historically, children and young people in particular have been ill-served by service provision which has been poorly co-ordinated and delivered, characterised by “isolated interventions being provided to children who are highly vulnerable with complex needs”(2005, p.7). The government’s earlier stated aim for a more holistic, integrated approach to service provision has been further encapsulated within its joint strategy to establish firm links between the guidance documents ‘Every Child Matters’ (DfES, 2003; DfES, 2004) and the national drug strategy for young people (DfES, 2005). One key principle of this new strategy is to ensure that the needs of vulnerable children and young people are central to provision, placing greater emphasis on prevention and targeting early intervention at those most at risk. Within this remit, for example, all young offenders will be screened for substance misuse and, after assessment, they will be provided with “access to early intervention and treatment services within 10 working days” (NTA, 2005, p.5). The NTA document refers to the HAS (2001) four-tiered framework of provision to “deal with complex and often multiple needs of the child or young person and not just the particular substance problems” (2005, p.11). The development of joint assessment processes and multi-agency collaborative partnerships, between different services offered through the voluntary sector, outreach teams, youth offending teams, child and adolescent mental health services, health, education and social services, are also highlighted. This latest government guidance stresses the need for all those who work with children to recognise their role in addressing substance misuse among children and young people (DfES, 2005). The need for basic knowledge and understanding within core competencies through appropriate training programmes, building on the work already being undertaken with local drug action teams, is also highlighted. This new strategy is undoubtedly ambitious and will be evaluated and monitored in the coming years. The adverse impact of substance misuse on parenting capacity has been documented and addressed in a number of ways. For example, statistically, studies of social work intervention in child protection cases, conducted by a number of researchers, have shown significant associations with parental problem alcohol or drug use. Cleaver et al (1999) cite studies by Gibbons et al (1995) and the NSPCC (1997) which show that 20% of families presenting at the referral stage were found to have a history of drug or alcohol problems. Brisby et al (1997) found that heavy drinking or intoxication featured in some 60% of cases reaching the child protection conference stage in their research based in Wales. Cleaver et al (1999) also record that parental problem drinking is associated with child abuse. While paternal problem drinking was significantly linked with physical abuse, as reported by children, maternal problem drinking was more often associated with child neglect (Cleaver et al, 1999). The NSPCC recorded that “one third of calls reporting neglect include a parent abusing drugs or alcohol. This was most often the mother. Alcohol was mentioned in two of three of those cases”(Cleaver et al, 1999, p.35). Cleaver et al (1999) highlight the lack of systematic research into the links between problem drinking or drug use and the different forms of child abuse and the need for further investigation into these issues. In the arena of child protection work, key legislation, such as the Children Act 1989, cited the child’s welfare as paramount, with all those working in statutory child care services having an explicit remit to protect children’s interests. Another express principle was that children deemed to be at risk of serious harm or ‘in need’ were to remain with their natural parents wherever possible. These principles, together with a new emphasis on working in partnership with parents and other involved agencies, through the 1991 Working Together guidelines, may have improved relations between service providers and substance misusing parents. However, in practice, it seems that, as Waller and Rumball (2004) note, a number of tensions with this new approach became apparent. For example, some professional workers became obliged to focus upon protecting the needs of children even where their primary organisational and therapeutic centre of activity was with the needs of adults. Workers in drug and alcohol services became more acutely aware of their need for skills to assess children’s needs and their clients’ parenting capacity. The assessment and support of adults often presenting with a history of problematic substance misuse and poor parenting demands a high level of worker skill and commitment. Furthermore, historically there has been a strong tendency for social workers and the courts to focus heavily on physical tests for illicit substance use, through the use of urine samples, for example, as evidence in assessments of parenting ability. It was observed that often “care planning meetings may repeatedly require the mother or partner to overcome their substance use as though the parenting difficulty will then be solved” and that “unrealistic targets may be set for detoxification or rehabilitation” (Waller and Rumball, 2004, p.337). Waller and Rumball further suggest that such an approach may well have served to compound substance misuse problems particularly for women since there may be an increased risk that such women may conceal their use of substances or a pregnancy. In any assessment of parenting capacity, issues other than the physical evidence of substance use are also relevant, such as the effects of particular substances on parents’ ability to care for their children. Waller and Rumball (2004) and Cleaver et al (1999) point out the well-documented associations, for example, between chronic parental alcohol and stimulant use and a higher risk of physical harm to their children, the links between sedative substances, including opiate use, and physical neglect and the evidence that all substance misuse is linked to risk of the emotional neglect of children. Other social issues for workers to consider include the nature of some mothers’ relationships with partners and friends who may also have problematic substance use and how these might detract from the adequate care of their children. Substance-related social behaviours, household violence and financial problems are all, it seems, implicated when parenting capacity is being thoroughly assessed. As Waller and Rumball assert, there may have been an over-emphasis on the ‘hard evidence’ of urine testing in child protection procedures when substance use “could more appropriately be managed by enabling the parent to recognise the limits of their abilities and the priorities for their children” (2004, 338). More recent government guidance, such as that produced by the Department of Health (1999), urges the development of more co-operative and constructive relationships between agencies and services concerned with both the protection of children and support for vulnerable adults. Some commentators, such as Bean (2000), have charted how perceptions of drug use, and ways to tackle it, have changed over the years. The contemporary view some thirty years ago saw an emphasis on drug-use, notably excluding alcohol and nicotine, as an illness requiring long-term medication with treatment exclusively being provided through the health service. Later, with the increasing fears around HIV and AIDS, needle-sharing became an important concern and users were receiving more direct help in the form of needle exchanges and offered drugs to replace the need to inject. More latterly, the use of illicit drugs has become perceived increasingly within the context of criminal and anti-social behaviour (Bean, 2000). Political debate on illicit substance use, particularly the use of drugs, has focused upon changing behaviour generating a number of initiatives to tackle dependency and the social antecedents of drug use. Alongside this, renewed calls have been made to relax certain penalties for drug possession, with stronger sanctions against those dealing in and trafficking drugs. The UK government’s ten-year strategy “Tackling Drugs to Build a Better Britain” was introduced in 1998, pledging to help young people resist drug misuse, protect communities from drug-related criminal and anti-social behaviour, provide treatment for people with drug problems and curtail the availability of illegal substances (Home Office, 1998). It is notable that this document, together with subsequent governmental guidance, makes only a passing reference to assessing children’s needs and providing services to safeguard their welfare within the context of parental substance misuse. In short, it seems that drug-misuse by parents, and associated links with parenting capacity, was not being directly addressed at governmental level (Home Office, 1998; 2002). In recent years, in the light of the concerns surrounding parental substance misuse, there appears to have been an upsurge of government funding for research and evaluation projects at local level. One influential project was an independent study conducted by Bates et al (2000) examining the attitudes, values and practices of some of the main agencies working with substance misusing parents and their children. More than 50 in-depth interviews were conducted with staff members in key agencies, such as the Drug Dependency Clinic, Health Visitors and the Social Services Directorate in Liverpool, together with “drug-using parents whose children have been the subject of case conference proceedings” (Bates et al, 2000, p.8). Bates et al (2000) elicited responses from a semi-structured questionnaire covering subjects such as training and qualifications, experience with drug-using families, child protection procedures and the referral process, attitudes about substance-using parents and inter-agency working. Interviews with parents focused on issues including drug-taking history, family background, relationships and child care experiences and involvement with social workers and other professionals. Data analysis generated some issues common to all three agencies. Each staff group acknowledged their own skills specific to their own field of work, as would be expected, but few staff members across all groups were trained in terms of the three issues of substance-misuse, child protection and parenting ability in relation to each other. The social workers, for instance, felt “ill-equipped and lacking in confidence in working with parents who use drugs” and the Health Visitors had “no specific training in drug issues” (Bates et al, 2000, p.48). The Drug Dependency workers thought that their specialist knowledge equipped them better for assessing the potential risks to children of different types of parental drug use. These workers were also viewed by the parents as the most knowledgeable in terms of their drug-using. Lack of clarity about different roles and inter-agency difficulties were highlighted by staff in all the agencies as a key concern. The social workers, for example, raised the issue of “lack of knowledge of roles between professionals, which in turn leads to a lack of trust and honesty in sharing information” (Bates et al, 2000, p.48). The Health Visitors flagged up their experience of poor co-operation between agencies. They also saw the drugs workers as too ‘adult-centred’, social services departments as crisis-oriented and ill-equipped to offer preventative work with families and GPs as often uncommunicative and generally unaware of child protection issues (Bates et al, 2000). Parents perceived many professionals as judgemental about their lifestyles and often disapproving of their standards of child care. They also felt that professionals tended to over-react, often assuming that their use of drugs automatically meant that they were inadequate parents. The researchers, although valuing the parents’ views, acknowledged that parents may present themselves to researchers more favourably than may be justified by the reality of professionals’ experiences of working with them. Conversely, of course, the professionals’ views also may have not accurately reflected reality. It is interesting to note that elsewhere in the study, the social workers’ views did not match the parents’ perceptions. As the authors state “the majority of social workers do not see parental drug use per se as a problem in itself and that individual assessment is the key to effective interventions” (Bates et al, 2000, p.48). This study does seem to contain elements of bias and value judgement. The authors clearly adopt a sympathetic stance towards parental substance use and, consequently, tend to minimise the potential hazards that the activity may present to both parents and children. For example, they choose not to record in the summary of their findings some key points made by the social workers, stating that “the issues raised by this sample of very experienced social workers largely speak for themselves and require little elaboration” (Bates et al, 2000, p.48). Concerns expressed by social workers in the research by Bates et al (2000) included the view that “drug agencies tend to put their clients’ interests before those of the clients’ children” (p.33) and that “child safety is our main reason for involvement but we can only do this with the co-operation of parents” (p.47). Bates and colleagues argue for a “more creative, accessible and integrated approach” (2000, p.79) to drug misuse and child protection in general. They call for the eradication of negative attitudes from professional workers which they see as serving only to alienate substance-misusing parents. Key recommendations flagged up were the need for training on an inter-professional basis to combine knowledge of all three issues of substance-misuse, parenting and child abuse; the rejection of a policy which automatically registers children as ‘at risk’ solely on the basis of their parents use of substances; and, an urgent improvement in inter-professional understanding and co-operation. The recommendations from this study have been echoed in other similar studies, such as that conducted in Lambeth by White and colleagues (2002). White et al, focusing on substance-using women who were pregnant and/or had children under 5 years of age, flagged up the lack of consistent methods for identifying and quantifying women substance misusers and their children.. They also highlighted the common fear of many of these women that their children would be taken away and that this was a major reason for avoiding antenatal care (White et al, 2002, p.47). The contentious issue, raised in the previous study, of weighing up the needs of children against those of the parents, also featured in the research by White et al (2002). The tension between establishing a trusting and co-operative relationship with mothers whilst having appropriate regard for the risks of harm to their children appears to present an ongoing dilemma for all those working in this arena. A later study by Hayden (2004) has examined parental substance misuse and child care social work in an English city social work department to determine both the extent of this phenomena and responses to it within the child protection arena. Previous research, by Kearney et al (2000) for example, has suggested that substance misuse is both under-recognised and underestimated in social work caseloads. Hayden’s research discovered that substance misuse was a factor requiring greater consideration within child care assessments and as an issue to be targeted in the development of preventative responses to child welfare concerns. Hayden also cites studies by Tunnard (2002) which suggest that there are more British studies on parental drug misuse in comparison to alcohol misuse “despite estimates of much greater numbers of children living in families affected by the latter substance”(2004, p.19). Local Drug Action Teams apparently offer some good training programmes in the drugs field but training in alcohol misuse issues is sparse (Hayden, 2004). Hayden (2004) highlights a number of problems with the Assessment Framework model for working with children and families (DH, 2000). Her research found that some families explicitly refused support and were unwilling to work with social workers where there were identified child care concerns. Also, many social workers were ill-equipped to know how to support parents, compounded by fears for their own safety. For the parents who used substances, a major concern was the lack of trust and understanding between themselves and professional workers which seriously hampered their ability to get the help they needed. Indicators for better future practice tend to mirror those flagged up in the earlier studies cited above. One key issue, cited by the social workers in particular, is the way in which services are configured, notably the fact that specialist substance misuse service provision does not generally incorporate child welfare issues. Murphy (2001), cited by Hayden (2004), reiterates the finding that future responses to difficulties in families where substance misuse is a feature must be tackled through a holistic inter-agency, inter-system approach. Hayden sums up the challenge for professionals thus “structured risk assessment procedures are viewed as no substitute for well-trained staff who are taught how to recognise substance misuse before it becomes all too evident; they then know how to intervene appropriately” (2004, p.20). Kroll (2004) urges for the need to bring the child’s perspective of living with substance misuse into the entire assessment process. She points out that it cannot be assumed that all parents who use alcohol or drugs mistreat their children. However, as many researchers, such as Brooks and Rice (1997), Klee et al (1998) and Howe et al (1999), have found, parental substance misuse can adversely affect family dynamics and relationships, attachment and social and psychological functioning and also significantly increase the risk of familial violence (Kroll, 2004). Kroll, too, argues that workers need to increase their knowledge base, but also to develop their skills of observation and communication with children and cultivate ability to “enter the world of substance-misusing families” (2004, p.138) in order to gain insight into what it is like to be there, both for parents and children. Kroll essentially advocates a family systems perspective within the child care social work arena, asserting that “effective assessment and intervention rest on an understanding of the dynamics of denial and resistance, as well as the impact of attachment to the substance and its effect on parent/child relationships” (2004, p.138). This approach clearly demands a degree of in-depth training and commitment on the part of service providers which has implications for funding and resource allocation. In conclusion, then, it seems that substance misuse and the adverse impact it can have on children, young people and parenting capacity has only recently begun to receive a higher profile. There has been an increasing amount of government guidance, especially in the last five years or so, which has directly addressed these issues through a commitment to a more holistic and integrated approach than hitherto has been the case. The key messages to emerge from the research, government strategy and practice seem to be the need to improve inter-agency and inter-system communication, trust and the sharing of knowledge and skills coupled with building better relationships with both parents and children in order to respond to their needs more appropriately and effectively. Ultimately, prevention of substance misuse is likely to be greatly enhanced in a universal way by public policies which aim to promote stable families, neighbourhoods and communities. As Waller and Rumball suggest “Government policies that effectively tackle poverty, social exclusion and inequality will also help prevent substance use problems and dependence” (Waller and Rumball, 2004, p.47).
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