Working with Parents who are Misusing Substances

Substance use may include experimental, recreational, chaotic and dependent use of alcohol and or drugs which may be acquired legally, illegally, be obtained with or without prescription and may be used singly or in any combination. Substance misuse is the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006).

Substance misuse affects different people in different ways depending on what is used, how it is taken, the physical/psychological state of the person and their circumstances. The impact on the individual may range from negligible to extremely serious. Any drug, including alcohol, has the potential to impact on an adult's ability to care for their children.

Substance misuse by parents/carers does not on its own automatically indicate that children are at risk of abuse or neglect. However, where substance misuse is causing physical, psychological, social, interpersonal, financial and or legal problems, the implications for children and families must be properly assessed. Parental substance misuse can impact on children of any age and the impact may be cumulative.

Practitioners working with parents / carers should remain aware that misuse of drugs and/or alcohol is strongly associated with harm to children, especially when combined with other features such as Domestic Abuse and/or mental health issues. Children who live with adults who misuse substances may require additional services to ensure that their needs are met, and it is essential that information is shared appropriately in order to aid the assessment of needs and risks.

Practitioners in Derby and Derbyshire working with families affected by parental substance misuse should use Guidelines for Gathering Information about the Needs of Children whose Parents have Drug / Alcohol Problems (Document Library, Assessment Tools).

Any assessment must consider the nature of the substance use, its effect on the parent's ability to look after and meet the child's needs and the subsequent impact on the child. Other risk factors such as Domestic Abuse and/or mental health issues must also be considered. The impact of parental substance misuse on an individual child will depend on numerous factors. Research identifies the potential impact across many aspects of health and development and some children will present as though all is well, others will act out their feelings.

In particular consideration should be given to the implications for a child of the following:

• Adults' focus on alcohol / drugs and activities related to this and the extent to which they prioritise the needs of the child;
• Inappropriate behaviour and a lack of boundaries;
• Poor home environment including unsafe storage of substances, injecting equipment or other paraphernalia;
• Increased irritability, emotional unavailability, irrational behaviour and reduced parental vigilance;
• Adverse impact on growth and development of an unborn baby / child;
• Impact of intoxication and withdrawal symptoms including mood disturbances;
• Co-sleeping whilst under the influence of substances.

Parental poor engagement, non-compliance with, or active resistance to, support plans should raise particular concerns about the wellbeing of children.

Engaging and working with parents who misuse substances may be particularly challenging. However, it is important to acknowledge that many parents recognise harmful effects on their children and that change is often motivated by these concerns.

All practitioners, including those from adult's services, should be aware of their responsibilities to safeguard children and this should be made clear in their work with adults. Practitioners should be able to provide information about the possible impact of parental substance misuse on children. This should be routinely explored with parents who should be supported to understand any concerns and to make changes to safeguard their children's welfare. All agencies, including adult treatment agencies and those providing antenatal care should carry out screening which identifies parental substance use and possible risks to children. All services should also consider any parents/carers in the household who do not misuse substances, and consider whether or not they are a protective factor in the household and if so, how they look after and meet the child's needs.

Adult service practitioners have a duty to ascertain whether the adult with whom they are working is a parent and whether there are children in the household or whether they are in a relationship with someone who has children. Adult services practitioners should always be alert to the impact of substance misuse on the child. All meetings regarding substance misusing parents including MAPPA, Integrated Offender Management and MARAC arrangements should include consideration of any needs or risk factors for the children concerned and any protective factors that are present. Where there are concerns about the welfare of the child, Children's Social Care must be given the opportunity to attend and contribute to such discussions.

Children's practitioners, who become aware that a parent is receiving services from a substance misuse agency, must make sure that they understand the nature of that contact. Services may include needle exchange, counselling, detoxification programmes, prescription for medication, Alcohol or Drug Rehabilitation Requirements as mandated by the courts or a combination of all.

There should be a discussion about the best way to establish services and support for the parent/s. Practitioners in children's and adults services must proactively work together using a Think Family approach to ensure there is a full understanding of the parents needs and the potential impact of this on their ability to care for their baby or child.

All agencies and practitioners should refer to the Derby City and Derbyshire Thresholds Document (see Documents Library, Guidance Documents) to identify the level of need and the appropriate assessment and interventions.

Where there are emerging needs, the family will require support and co-ordinated services through an early help assessment. See Providing Early Help Procedure.

Any assessment of the child's needs should involve the parent's substance misuse worker. Specific professional knowledge and skills must underpin the competence of an assessment of parental substance misuse.

It is essential that practitioners regularly review and communicate to other agencies if there is a change in the situation of the family and the impact that the parental substance misuse (and other issues if they are present) may have upon the child. Changes in substance use, including stabilisation or abstinence, should result in a re-assessment of the child's and family's needs, including the increased risk of psychosis when undergoing abstinence without support. Advice should be sought from the Designated Lead for Child Protection if necessary.

The Welfare of Unborn Children

Any concerns about a pregnant woman's substance misuse (or her partners/other person living in her household) should be raised with the Midwife and GP. It is important to assess the needs and give support to parents with substance misuse needs as early as possible. Close liaison between Midwifery services, Children's Social Care and Substance Misuse Services should ensure that Early Help or pre-birth assessments are undertaken whenever there is concern about the ability of a pregnant woman to care for her expected child (and jointly with her partner where applicable). See: Derby and Derbyshire Multi Agency Protocol for Pre-Birth Assessments and Interventions (Document Library, Protocols).

Young Carers

From an early age, children may assume the responsibility of looking after their parent. As Young Carers these children should be offered an Early Help Assessment to ensure their needs are identified and any services which are required. Young carers who are not coping and/or have needs which cannot be met by Early Help interventions, as they are complex or serious, should be referred to Children's Social Care.

Note: If practitioners identify that a child or children are living in a household where there is domestic abuse, parental/carer mental ill health and parental/carer substance misuse (drugs and/or alcohol), the interaction between these complex issues, and the cumulative harm they can cause, must be fully considered. These are indicators of increased risk to children and the likelihood of poor outcomes into adulthood, therefore effective assessment to clearly identify risk, strengths and resilience is required. Practitioners must ensure that all cases where cumulative harm is indicated are discussed with their line manager and/or designated safeguarding lead to ensure that appropriate support and interventions are identified. See the procedures for children in these specific circumstances: Domestic Abuse Procedure, and Working with Parents/Carers Who Have Mental Health Needs Procedure. These should be read in conjunction with the Derby City and Derbyshire Thresholds Document and Information Sharing Agreement and Guidance for Practitioners both of which can be found in the Documents Library, Guidance Documents.

If any practitioner or agency has any concerns about the capacity of the parent to meet the needs of their child, or where there are serious or complex needs or where there are Child Protection concerns, they should consult with their designated lead for Child Protection and make a referral to Children's Social Care. Concerns should be discussed with a parent unless it is judged that this action will jeopardise the child's safety.

See also Making a Referral to Social Care Procedure.

See also Guidelines for Gathering Information about the Needs of Children whose Parents have Drug / Alcohol Problems (Documents Library, Assessment Tools).

Following the referral to Children's Social Care, the service manager will analyse the available information and decide whether the matter requires assessment as:

• A Child in Need (Section 17);
• Or child suffering or likely to suffer Significant Harm (Section 47);
• Or neither.

Where there are concerns that a child may be or is likely to suffer Significant Harm Children's Social Care will convene a Strategy Discussion / Meeting involving health, police and other relevant agencies. See Child Protection Section 47 Enquiries Procedure, Strategy Discussions / Meetings.

In addition to considering whether or not the threshold for a Section 47 Enquiry has been met, a strategy discussion may also look at appropriate multi-agency interventions early in the process and seek to minimise risk.

Practitioners working with the parents should be involved in the strategy discussion / meeting.

The strategy discussion / meeting should consider:

• Ensuring that there is sufficient information about the parent's substance misuse and any other risk factors such as domestic abuse, on their ability to care for their child/ren and the impact on the child/ren;
• Whether specialist advice or assessment should be sought, who should undertake the investigation, where and how it will take place.

Given the potentially complex nature of Section 47 Enquiries it may be appropriate to hold additional strategy discussions to ensure that informed decisions are made. Expertise in both safeguarding children and substance misuse must be brought together to ensure that there is appropriate assessment and planning of services.

In addition to the information gathered and analysed within the Single Assessment, adult services should be requested to provide information in relation to:

• Patterns of substance use;
• Current and previous treatment / intervention and capacity to change and the timescale required for this;
• Their assessment on the impact of substance misuse on the ability of the adult to looks after and meet the child's needs;
• The parents' views about their substance misuse and the impact it has on them and their children;
• What support and services are needed, if any to enable the adults to effectively look after the child/ren.

Where there is no involvement of a specific drug or alcohol service, Children's Social Care should seek general advice if they have concerns about a parent's substance use. Parent's / carers should be encouraged to seek support / treatment for their substance related issues.

Practitioners who participate in the formal child protection process do so as a representative of their agency and not as an advocate or supporter for a parent. They will be involved in the decision-making process in which the welfare of the child remains paramount. They may be identified as important members of a Core Group which will develop and implement a Child Protection Plan for the child.

Parents are also entitled to be accompanied by a supporter or advocate at child protection conferences and in core groups.

Neonatal Withdrawal Symptoms can result from a variety of medications used during pregnancy not only when illicit substances are used. In the majority of cases this is identified as a risk factor during the pregnancy and a plan to monitor the baby appropriately will be put in place.

It is important to acknowledge that where the mother has engaged with drug treatment agencies and is prescribed substitute medication (Methadone or Buprenorphine) withdrawal symptoms in the baby do not necessarily demonstrate compliance and stability. Methadone and Buprenorphine themselves can cause neonatal withdrawal and therefore regular testing as part of a drug treatment programme will identify any illicit drug use in addition to prescribed medication and appropriate action can be taken.

Where a baby, is unexpectedly observed to be experiencing withdrawal symptoms, as diagnosed by a Paediatrician, the Midwifery Service and/or Nurses in the Neo Natal Unit should engage with the family. The mother should first be spoken to in order to gather relevant information including a history of any medication/illicit substances which may have been taken during the pregnancy. Where illicit substance use is confirmed or suspected a referral should be made to Children's Social Care. A multi-agency Pre-Discharge meeting should be held. Clear plans for on-going assessment, monitoring and support should be developed to ensure that the child's needs can be adequately met.

A baby affected by maternal alcohol use, during pregnancy, may suffer from Fetal Alcohol Spectrum Disorder, an umbrella term describing a range of effects that occur in an individual whose mother drank alcohol during pregnancy. Effects may include physical, mental, behavioural and/or learning disabilities with possible lifelong implications which may not be apparent in the immediate post-natal period. It is important that concerns about alcohol use and possible related effects are recorded to enable an informed assessment and appropriate level of services to be provided. See Derby City and Derbyshire Thresholds Document and Pre Birth Protocol (Documents Library, Guidance Documents).

Withdrawal from drugs and/or alcohol can significantly impair capacity to tolerate stress and anxiety and is likely to have an impact on the adult's ability to care for their child effectively.

Withdrawal from drugs and/or alcohol may be unplanned as a result of an inability to access either non prescribed or prescribed drugs or it could be planned. Withdrawals can often be managed through a planned detoxification programme in the community supported by local treatment services which can vary in length depending on the substances. Inpatient detoxifications usually include a stay of 2-3 weeks at an inpatient unit outside Derbyshire, or can be undertaken in a hospital setting if an individual is admitted for any reason and a detox is deemed to be necessary (most often for dependent alcohol use). Detoxification can be difficult and the family are likely to need additional support during this process. The child may also need support in their own right to understand what is happening.

The impact on the child of any planned or unplanned parental withdrawal from drugs and/or alcohol should always be considered. Practitioners preparing a parent/carer for detoxification must ensure that that appropriate childcare arrangements have been made and that any other agencies involved with the child are aware of the plan.

It is important to monitor both how the household is functioning and parental capacity post detox to ensure appropriate support is in place to maintain abstinence and prevent/manage triggers to relapse.

It is incorrect to assume that abstinence from drugs or alcohol will in itself lead to better childcare. Families who have had a chaotic lifestyle may need significant levels of support before they can effectively care for their children. Any changes in drug and/or alcohol use should trigger a re-assessment of the children's needs.