Practice Guidance

Working with parental alcohol/drug use and its implications for Child Protection

Contents

  1. Introduction
  2. Recognition and Identification of Risk Factors
  3. Relapse Prevention
  4. Pregnancy and Drug Use
  5. Dual Diagnosis (Mental Health Issues and Substance Use)
  6. Inter-Agency Communication

Appendix 1
Appendix 2
Appendix 3
Appendix 4

1. Introduction

1.1 This practice guidance is based upon national guidance relating to work with drug using parents (SCODA 1997) and is applicable to staff from all agencies in order to identify indicators of substance use/misuse and to clarify the impact of this upon the care of the child/children.

1.2 It is designed to be utilised alongside the Department of Health Publication ‘Framework for the Assessment of Children in Need and their Families’ (2000) and promotes holistic assessment. The guidance is NOT prescriptive but attempts to offer some practical advice for all professionals and volunteers working with children, parents and carers. To assist practitioners in achieving this some suggested questions for consideration have been included, these are taken from the SCODA guidelines, and a copy of assessment questions is also included at the end of this guidance in Appendix 3.

1.3 This guidance reinforces that substance misuse by parents/carers should be seen in the context of family life and functioning.

Adults who misuse substances may be faced with multiple problems including:

  • Homelessness
  • Accommodation or financial problems
  • Difficult, destructive or violent relationships
  • Lack of effective social or support systems
  • Issues relating to criminal activities
  • Poor health

Assessment of the impact of these stresses on the child is as important as the substance misuse itself.

1.4 It is essential to share all concerns with senior staff/line managers who may be able to offer a different perspective or clarify concerns. Sharing information with other agencies may also help to clarify areas of concern and provide a fuller picture.

1.5 Within this document substance misuse is defined as:

"… use that is harmful, dependent use or use of substances as part of a wider spectrum of problematic or harmful behaviour" (Health Advisory Service, 1996)

1.6 Substance use/misuse (legal or illegal drug usage and/or alcohol consumption) by parents and/or carers does NOT on it’s own automatically indicate that children are at risk of abuse or neglect, although it is essential that workers recognise that this is a group for whom the potential associated risks are high. However, where there are concerns or suspicions that the child may be suffering, or at risk of suffering significant harm, referral must be made to children’s social care.

1.7 Whilst it is important for agencies offering services to parents/carers to be aware of the manner in which substance use/misuse can affect the quality of parenting offered to a child, it should also be recognised that in many cases such parents feel that they may be judged negatively and therefore avoid accessing appropriate agencies for advice and support.

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2. Recognition and Identification of Risk Factors

Parental Drug/Alcohol Use

2.1 A child may be considered to be at greater risk of harm where substance use is uncontrolled and chaotic, if the parent/carer alternates between states of severe intoxication and periods of withdrawal, especially if substances are mixed i.e. combinations of different drugs or alcohol combined with drugs.

2.2 Research indicates that the risk factors for the safety and welfare of the child may be heightened during periods of withdrawal – with parents/carers exhibiting a reduced responsiveness to the child’s needs and increased levels of anxiety relative to themselves as individuals.

2.3 Kearney et al (2000) state that the British crime survey in 2000 showed that 44% of domestic violence incidences involved people who had been drinking.

2.4 The consequences to the child of a carer experiencing physical or emotional changes due to the misuse of substances require assessment. Examples may include a parent or carer who may become unconscious or incapable whilst looking after the child, or they may fail to notice or pursue treatment for a child’s illness or accidental injuries or on occasions become violent.

2.5 The type, quantity and method of administration of drugs/alcohol are important but must be viewed in the context of the impact on the child.

2.6 In households where there are two adult carers and drug/alcohol use is organised to enable one carer to assume responsibility for child care when the other is intoxicated, or in households where there is a drug/alcohol free carer or supportive partner, or the parent makes arrangements for the care of the child, the actual effect on the child from the drug/alcohol misuse may be minimised with little intervention necessary. It is therefore important to separate drug/alcohol use and to be clear what, if any, constitutes a ‘risk’ to the child.

Consider:

  • Is there a drug/alcohol free parent/carer, supportive partner or relative? what part does this person play? could he/she be encouraged to do more?
  • Is the drug/alcohol use by the parent/carer experimental? recreational? chaotic? dependent? prescribed? is the parent's view of their use markedly different from agencies working with them? if a parent/carer is misusing alcohol do they have a pattern of binge drinking?
  • Does the parent/carer move between categories of drug/alcohol use at different times? does this also involve combining both drugs and alcohol? does this involve combining both illegal and prescribed medication? what happens to increase the amount they use i.e. triggers?
  • Is there a marked difference in the level of childcare at the times when the parent/carer is using drugs or alcohol and if so what differences are there?
  • What arrangements are there for the child's safety during drug/alcohol use?
  • If the parent is using prescribed medication check how long each prescription is for? is the prescribed medication stored safely? is the medication taken as prescribed?
  • Is there any evidence of a mental health problem alongside the drug/alcohol use? what is the relationship between the drug/alcohol use and mental health problem? does the drug/alcohol use cause these problems or have these problems led to the use?
  • Are there changed outcomes that can be negotiated e.g. reduction in consumption, change in drug use from injecting to oral use, reduction in frequency of injecting? move from buying drugs to receiving medication on prescription.
  • Pattern of substance usage over the past six months – increase in stability, decrease in stability?

Procurement of Drugs and Alcohol

2.7 There may be identifiable risks to a child in relation to the ways in which a parent/carer obtains substances. A parent/carer may take risks with the child's safety when procuring drugs or other substances. For example, a young child may be left alone whilst the parent/carer goes out to obtain drugs/alcohol, or the child may be taken to procure drugs/alcohol to places where they would be deemed to be at risk. Alternatively, a child may be used by a parent/carer to collect substances and may be tempted to try them.

2.8 In some cases, the family's accommodation may be used for selling drugs, prostitution or by other drug/alcohol users, to which the child may be exposed.

2.9 The issue of the cost of the substances being used, and how the money for them is obtained will need to be addressed. This should include whether appropriate finances are available and utilised for meeting the children’s basic needs and if the child is being involved in shoplifting or other illegal activities to raise money for drugs.

Consider:

  • Is the child left alone while the parents/carers are procuring drugs/alcohol?
  • Is the child being taken to places where there is risk? if so, what are the risks to the child?
  • How much are the drugs/alcohol costing? is this impacting upon the provision of the child’s basic needs – e.g. food, heating, bedding, etc?
  • Is the drug/alcohol use causing financial problems?
  • How is the money obtained? if through crime, how is this influencing the care of the child?
  • Is the home of the parent/carer being used to sell drugs?
  • Is the parent/carer allowing the home to be used by other drug/alcohol users? in what way? does this happen while the child is there?
  • Is the parent/carer aware of the legal implications associated with illegal substance misuse?
  • Is the substance usage financed through prostitution?
  • Are adequate provisions in place for childcare?
  • Are there potentially additional dangers to which the child is exposed due to wider lifestyle issues of parents and carers?

Health Risks (Drug and Alcohol Related)

2.10 In some situations there is clear evidence of health risks to children due to their parent’s/carer’s substance misuse, for example, used syringes on the floor, bottles of tablets accessible to children, methadone stored in the fridge etc. There is also evidence to suggest that where violence occurs as a result of either drug or alcohol usage there are acknowledged risks to children, both in terms of physical and emotional safety. Additionally, the welfare of children may be affected by the mental health issues of parents/carers whose lifestyles incorporate drugs and/or alcohol.

2.11 Part of any assessment should include questions about where drugs, alcohol and other substances are stored, and, if parents/carers are injecting drugs, how syringes are disposed of. Consideration should also be given to the parent’s/carer's awareness of health risks to themselves of their substance misuse. This could include whether they drive whilst under the influence of drugs, alcohol, or other substances.

2.12 Practitioners should be aware that a combination of violence, drug and alcohol usage, and mental health issues may increase risks to children. (Additional guidance is available in section 4 and also specific practice guidance relating to mental health issues and child protection is available.)

Consider:

  • If parents/carers are intravenous drug users, do they share injecting equipment?
  • Do they use a needle exchange scheme? how do they dispose of syringes? is the parent/carer aware of the health risks associated with injecting/using drugs?
  • If the parent/carer is on a substitute-prescribing programme, such as Methadone: is the parent/carer aware of the dangers of the child accessing this medication? are adequate precautions taken to ensure this does not happen? is the prescribed medication likely to impair their parenting/functioning? are they managing on their prescribed medication, or are they using street drugs as well? are they buying the substitute medication or being prescribed? are they using the medication as prescribed?
  • Is the child aware of where the drugs/medication are kept?
  • Is the parent/carer aware of/in touch with local specialist agencies that can advise on such issues as needle exchanges, substitute prescribing programmes, detox and rehabilitation facilities? if so, how regular is the contact? if not, are they aware of how to make contact with drug/alcohol agencies?
  • Is the parent/carer pregnant? if so, is the parent/carer aware of the risks to the unborn child?
  • Has the parent/carer been referred to a Substance Misuse Team (see Appendix 4) so their substance misuse can be monitored?

Perception Held by Parent/Carer of the Situation

2.13 The parent’s/carer’s perception of the situation is extremely important. If they are aware of the effects their substance misuse may be having on their children they are more likely to try and lessen the impact by stabilising or changing their use. Christensen (1987) states that interviews with children showed that they always knew about their parent’s drinking before their parents thought they did and the majority of the children said that they could remember it from as young as four or five years old. The importance of stability should be stressed rather than insisting parents/carers detox.

2.14 It must not be assumed that when/if a parent/carer becomes drug/alcohol free they will be a 'better' parent/carer.

Consider:

  • Does the parent/carer see the drug/alcohol use as harmful to:
    themselves? their child? their family life?
  • Does the parent/carer feel their substance misuse has any effect on their child? if so, what? do they recognise the emotional effects as well as the material ones?
  • Does the parent/carer place their own needs before the needs of their child? if so, in what way?
  • How does the parent/carer explain their drug/alcohol use to their child?
  • Do they feel anything would be different if they weren't using? are their ideas realistic? are they actively seeking help?
  • Is the parent/carer aware of the legislative and procedural context applying to their circumstances (e.g. child protection procedures, statutory powers)?
  • Are the parents aware of the worker's responsibility for the protection of children (i.e. the needs of the child are paramount and the resulting limits to confidentiality)?
  • What is the parent’s/carer’s capacity to work towards change? willingness?
  • Capability? form of support required? availability of support? what will prevent/stop work towards change?

Provision of Basic Needs

2.15 All types of abuse have been associated with drug misuse, with neglect being the commonest problem, toddlers being especially vulnerable (Alison, 2001 in Harbin and Murphy, 2001). It is important to know whether the childcare has changed for the better or worse from when the parent/carer was a non-user. It would be incorrect to assume that detoxification or ceasing of substance misuse would in itself lead to better childcare or a reduction of risk from abuse or neglect. This is not always the case and this expectation only serves to put the focus on the substance misuse rather than the parenting skills. An examination of the provision of basic necessities can allow some insight into how a child can be affected by parental/carer substance misuse.

2.16 Key questions to be addressed are whether the child's daily life revolves around the parent’s/carer’s substance misuse and to what extent the child is assuming inappropriate responsibilities. The needs of a child whose parents/carers misuse substances are no different than those of other children therefore questions concerning neglect, including whether there is adequate food, clothing, warmth and age-appropriate activities and opportunities need to be considered. School or nursery attendance and whether the child is reaching age-appropriate milestones should also be assessed.

2.17 Christensen (1997) states that parents stressed their children received hot food and clean clothes. The researchers identified that this was the parent’s checklist of being a good parent, and felt that in reality this does not mean that the child is receiving adequate care, as only the children’s physical needs are met. It is important to ensure that the child's emotional needs are not being compromised as a result of either the substance misuse or associated stress factors including poverty and poor accommodation.

2.18 It should also be established whether the child is being cared for by a large number of people while the parents/carers place their own needs before those of the child.

Consider:

  • Is there adequate food, clothing, bedding and warmth for the child?
  • Is the child attending school regularly and on time? is the child making reasonable educational progress?
  • Is the child engaged in age-appropriate activities?
  • Does the parents'/carer's drug/alcohol use disrupt daily routines? what is the effect of this?
  • What is the effect on the child of parental changes in mood or behaviour?
  • How are the child's emotional, general health and dental needs being met?
  • Is there any indication that any of the children are taking on a parenting role within the family (e.g. caring for parent, caring for siblings, excessive household responsibilities)?

Accommodation and Home Environment

2.19 The expense involved in drug and alcohol misuse can represent a considerable drain on the family's financial resources. This factor, alongside the chaotic and unstable lifestyle of some substance misusers, can affect the accommodation and home environment. It is therefore necessary to assess whether the accommodation is adequate for the child and whether the rent and bills for essential services are being paid. Stability for the child will be enhanced if the family remain in one locality, while frequent house moves may disrupt service provision of health and education for the child and impact upon their social development. The reason for frequent house moves needs to be explored. There may be issues of safety, social stigmatisation or lack of support networks to address. The presence of other adults in the household, whether they are substance misusers, and the extent of their involvement in the care of the child, also needs to be considered.

Consider:

  • Is the accommodation adequate for the child?
  • Is the parent/carer ensuring that the rent, mortgage and essential bills are paid?
  • Does the family remain in one area or move frequently? if the latter, why?
  • Are other drug/alcohol users sharing the accommodation? if they are, is there conflict? what impact does this have on the child? do they take responsibility for the child e.g. baby-sit?
  • Is the family heavily involved in a network of similar/problematic drug or alcohol users? what is the effect on them?
  • Does the child witness the taking of the drugs or alcohol? what is the effect on the child?
  • Are drugs/prescribed medication/injecting equipment/alcohol stored safely e.g. out of the reach of the child?
  • Could other aspects of the drug/alcohol use constitute a risk to the child (e.g. conflict with or between dealers, exposure to criminal activities related to drug/alcohol use, violence)?

Child's Developmental Profile

2.20 Research shows that the levels of behavioural problems, emotional difficulties and school related problems are higher in those children who have parents who are problem drinkers, than in other children (Tunnard, 2002). Assessment of a child’s development is an integral aspect of individuals being able to determine and qualify risk relating to a child. Some common indicators may be the child who is left alone in the playground, who doesn't know how to play, is bullied or is the bully. Children may also develop highly sophisticated fantasy worlds as either a way of dealing with living in a non-stimulating home environment where parents are too intoxicated to play, or the isolation they may face as other children are told by parents not to play with children whose parents are substance users.

2.21 How children approach problems is also indicative. Children who run away or have temper tantrums when confronted with something not immediately resolvable may also come from chaotic substance misusing families. Some children may also be using substances or have a sophisticated knowledge about them. There are also the 'parentified' children who over-care for the other children or are seemingly over-protective/over-sensitive. Such children may have high absentee rates when they have to look after parents or siblings, becoming 'at home' kids with roles including baby sitting, cooking, shopping, etc.

Consider:

  • Child's age and developmental stage
  • Is the child up-to-date with their health checks/immunisations?
  • Are there concerns about the way the child presents?
  • Is the child showing any signs of emotional distress through their behaviour? does the parent/carer recognise this?
  • Does the child have support networks: relatives/carers, friends, and school? (Research suggests that the availability of at least one consistently supportive influence in the child’s life will foster resilience.)
  • What is the child's understanding of the drug/alcohol misuse? (It is important that this is identified directly by the child/children not just adult parents/carers.)
  • Is the child assuming responsibility beyond their years, have they taken over a parenting role within the family?
  • Does the child know what is expected of them in terms of behaviour?
  • If the child is isolated how does the parent/carer deal with this?
  • What is the relationship between child and parent/carer, child and peers?
  • Does the child experience violence between parents or between parents and dealer etc.?
  • What model of behaviour is the child observing?
  • Does the child need specific drugs/alcohol education to reduce their own risk of substance misuse?

Family Social Network and Support Systems

2.22 Most adults who abuse drugs/alcohol are often in contact with their wider family network. It is important not to overlook the positive aspects of this when considering what childcare interventions are necessary. The relatives' awareness of the substance misuse although probable must not be assumed. Support when offered by relatives is not always without its own difficulties and therefore whether the parents are accepting of help from relatives needs to be explored. The adult’s social network may primarily involve other substance users who due to their own circumstances may have limited capacity to provide support. The family's responses to the involvement of professional or voluntary agencies will also need to be considered.

2.23 Previous contact with services may have proved difficult for them. It is important that substance-misusing parents/carers feel able to ask for advice and support when needed.

2.24 Questions to parents and children about their friends, asking what they do with them can help to identify isolated parents and children.

Consider:

  • Does the parent/carer and child associate primarily with families who are other drug/alcohol users? non-users? both?
  • Does the parent/carer have relatives who are aware of the drug/alcohol use? are they supportive? do they live nearby? do they collude with the substance misuse?
  • Will the parent/carer accept help from these relatives? has communication in the family become disrupted?
  • Is the parent/carer socially isolated? what is the effect of this on the child? is the child allowed to have friends visit the house?
  • Has the parent/carer ever been admitted to hospital or been in police custody/prison? if so what happened to the child?
  • Race and cultural needs of family.

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3. Relapse Prevention

3.1 If a parent has stopped using, or claims to have stopped using drugs or alcohol, there are a number of factors which should be explored as part of the assessment process.

Consider:

  • What substances were used? when did the drug use stop?
  • Are any other substances going to continue to be used?
  • Has the drug use stopped in conjunction with another person?
  • What is the reason for stopping using?
  • How was the drug use stopped (e.g. ‘cold turkey’, Methadone reduction, community detoxification, rehabilitation unit, long-term residential programme, unsupported)?
  • What has changed since the use has stopped, in adult’s life and children’s?
  • What methods are used to maintain a drug-free lifestyle?
  • When is the greatest risk of relapse?
  • What would be done if vulnerability to relapse was felt?
  • What positives are seen in a drug-free lifestyle for self/children?
  • What action would be taken if relapse occurred (who would you tell etc)?
  • Are you willing to provide urine samples to prove substance-free status?
  • Who would you work with to prevent relapse in the future?

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4. Pregnancy and Drug Use

4.1 Both drug users and non-drug users alike may experience ambivalent feelings about their pregnancy, especially if it is their first. While many women experience happiness and fulfilment some may also experience great anxiety and fear surrounding their change in role, their ability to parent and the changes a new baby may bring to existing relationships and children. Many drug using women may suffer low self-esteem, depression, anxiety and extreme guilt.

4.2 Drug taking women, especially those taking opiates, can have reduced fertility and irregular or absent periods. They erroneously believe that they cannot conceive and therefore do not use contraception. Pregnancy can often be a shock but may be the trigger for them to achieve abstinence. For others, the emotional turmoil may make it unrealistic to achieve abstinence.

4.3 Many women are reluctant to contact health care agencies or reveal their drug use, for fear of involvement from children’s social care or removal of children. Previous experience may also make it more difficult to make contact. There should be a pragmatic approach to appropriate individual management and control of drug use and subsequent stabilisation of lifestyle should be the objective (Hepburn, 1993).

4.4 In Leicestershire a multi-agency approach to pregnancy and drug use has been developed to improve outcomes for families and babies. The Obstetric Service at Leicester Royal Infirmary, in conjunction with the Community Drug Team, offers clinic time to substance using women and their families.

4.5 A small team of professionals are involved: an obstetrician, named midwife and specialist drug counsellor. Appointments are flexible and a drop-in facility is available within the clinic time (8.30am – 12 noon every Wednesday) or outside of clinic. The aim is to identify all women with a substance use history – past and present – including alcohol.

4.6 Access to advice, assessment and treatment is fast-tracked and they can be seen either in clinic, at home or at the Community Drug Team. Substance using partners are also offered priority for treatment. Women will only see three identified professionals (with occasional exceptions). Their care is planned and co-ordinated by the team. They take responsibility for liaison and consultation with community midwives, health visitors, GPs, social workers, post-natal wards, Neo Natal Unit (NNU) and theTransitional Care Unit (TCU).

4.7 Monthly review and planning meetings that involve a named social worker and staff from NNU/TCU enable progress to be shared, problems resolved and further planning to be addressed. This arena is ideal for monitoring child protection and children in need concerns. These issues are assessed continually with a woman (and her partner) and referrals are made as appropriate.

4.8 Child protection is an issue for many women and this is addressed with them as early in their care as appropriate. Factual information regarding assessment by the team, their involvement in decision-making and reassurance are given. Consent from the women is always sought from the women before a referral is made. Co-operation is encouraged. Review meeting decisions are discussed with the women (unless information is confidential). Strategy meetings are a way of addressing some child protection concerns.

4.9 Access to antenatal care and drug treatment that is non-judgemental, flexible, honest and sensitive to a woman’s needs is the primary aim of the service offered. Preparation for delivery and post-natal care is vitally important.

4.10 Some babies may experience withdrawal symptoms that may be related to the maternal opiate use. Women and their families are prepared for post-delivery intervention for their baby. This may include a period of monitoring and/or treatment for neo-natal abstinence syndrome. Introductory visits are arranged to NNU and TCU. Post-discharge care and monitoring is also planned, which may include the community midwife, health visitor, social worker and drug counsellor. Pre-discharge meetings can be of value.

4.11 The service offered is Leicestershire-wide, but some women may not wish to deliver at the Leicester Royal Infirmary. Strong links have been made with Leicester General Hospital and the Melton Community Unit. Liaison with Obstetric Services out of the county also occurs.

4.12 Women who are receiving prescribed treatment for their substance use often fear that this will not be continued during their stay in hospital. Staff record details in a woman’s hand-held and hospital notes. The hospital pharmacy liaise on a regular basis to ensure a smooth transition of prescribing into the hospital and back out into the community.

4.13 Some women may not have disclosed their substance use during pregnancy. This may only have become apparent during delivery or post-natally. Referral to the specialist drug counsellor is offered and appointments arranged during a woman’s hospital stay. Babies will be monitored in line with the hospital protocol and a referral made to children’s social care if appropriate.

4.14 Women who "fall out" of the system are tracked through other agencies, e.g. New Futures, and although they may not be in contact their care for delivery and post neo-natally can be planned. The Neo-Natal Unit will only offer follow-up appointments if they think it is necessary.

4.15 It is now increasingly recognised that drug use does not in itself cause poor parenting. Drug using parents tend to share a spectrum of characteristics, which predominate among children’s social care rather than being a direct correlation between drug use and child neglect or abuse. Drug use should not be the predominate reason for referral to children’s social care; an assessment of their lifestyle and parenting capacity should take place beforehand.

The Impact of Substance Use in Pregnancy:

4.16 Most women with substance using problems are of childbearing age . Pregnant substance users have an increased risk of:

  • Having a premature baby
  • Having a low birth-weight baby
  • Death of the baby before birth, or shortly after birth sudden infant death syndrome or ‘cot death’

4.17 Babies may experience withdrawal symptoms or exhibit signs of maternal drug use after birth. However, it is worth noting that:

  • Not all substance-using pregnant women disclose their substance use, and
  • Not all babies will show signs of withdrawal from substances

Consider:

  • How is the drug/alcohol use impacting on the child?
  • How is the safety of the child maintained during parental drug/alcohol use?
  • What support mechanisms do the family already have in place?
  • Are parents in touch with specialist services?
    have parents made appropriate provision for the baby’s birth (i.e. equipment, clothing, steriliser)?
  • Is the parent aware of the potential risks to their baby?

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5. Dual Diagnosis (Mental Health Issues and Substance Use)

Defining Dual Diagnosis

5.1 The term ‘dual diagnosis’ covers a broad range of mental health and substance misuse problems that an individual may experience concurrently. The nature and interaction between these two conditions is complex.

5.2 In some cases of a dual diagnosis, mental health problems follow on from substance misuse.

  • Acute psychiatric conditions can be adversely affected by certain substances e.g. psychosis following LSD or heavy amphetamine. In these cases the cessation of substance misuse usually leads to the cessation of the acute psychiatric episodes.
  • Withdrawal from some substances can lead to mental health problems e.g. anxiety and depression.

5.3 In other cases of dual diagnosis substance misuse follows mental health difficulties.

  • Self-medication to cope with the symptoms of health problems
  • Substance misuse worsening, exacerbating the course of pre-existing mental health problems
  • Intoxication and/or heavy substance dependency leading to mental health problems

Dual Diagnosis and Assessments: An Overview

5.4 In child protection cases it is important that the relationship between a parent’s/carer’s substance use, any mental health problems and actual impact upon the child’s development be thoroughly assessed. Both local substance misuse services and mental health services are available to assist in assessments, again using the Framework for Assessment of Children in Need and their Families (see Appendix 1).

5.5 In all cases it may be helpful to bear in mind that a significant proportion of people with severe mental health problems misuse substances as self-medication either episodically or continuously. Equally, many people who require help with substance misuse suffer from common mental health problems such as depression or anxiety. Many of these cases do not require specialist support or intervention for both mental health and substance misuse issues.

Prevalence

5.6 It is difficult to measure exact levels of substance misuse both in the general population and in those with mental health problems.

5.7 UK data from national surveys and local studies generally shows that:

  • Increased rates of substance misuse are found in individuals with mental health problems affecting around a third to a half of people with severe mental health problems
  • Alcohol misuse is the most common form of substance misuse by people with mental health problems
  • Where substance misuse occurs it often co-exists with alcohol misuse
  • Community mental health teams report that on average 8-15% of their clients have dual diagnosis problems, although higher rates may be found in inner cities
  • Homelessness is frequently associated with substance misuse and mental health problems
  • Prisons have a high prevalence of dual diagnosis cases

(Amended and based on Mental Health Policy Implementation Guide, Dual Diagnosis & Good Practice Guide, DoH)

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6. Inter-Agency Working Practice

Inter-Agency Communication

6.1 Role Clarity

When more than one agency/worker contributes to the assessment there must be:

  • Awareness of respective roles
  • Agreement about tasks
  • Work on a partnership basis
  • An identified co-ordinator
  • Clarity with parents

Confidentiality

6.2 Workers should ensure that, as with all child protection/child in need policies and practices the maintenance of confidentiality is adhered to, in accordance with the Data Protection Act, Human Rights Act, etc and other professional guidelines and Codes of Practice.

6.3 In accordance with good practice guidance, where appropriate, consent from the child’s parents/guardians should be sought prior to sharing information. However within a child protection framework certain levels of confidentiality may not apply as practitioners have a statutory obligation to share information if a child or children are considered to be at risk of significant harm.

Regular Communication

6.4 To achieve good working practice there is a requirement that all those working with the parent/carer and child at all stages of the assessment:

  • Are in regular contact with each other
  • Formulate work plans together
  • Share regular updates

6.5 The following issues should be given particular attention:

  • Are the parents/carers likely to co-operate with childcare support as well as drug/alcohol treatment?
  • Where families with drug/alcohol concerns move into the area there should be awareness of any previous work with the family.
  • People with dual diagnosis (drug/alcohol problem and mental illness) are recognised to be especially vulnerable and needy (obtain specialist support).
  • Drug/alcohol use, physical health, mental health, financial problems and breakdown of family networks may be interlinked. All need to be taken into consideration. Withdrawal from drugs can significantly impair capacity to tolerate stress and anxiety. Detoxing can be difficult, and a drug/alcohol using parent may require additional childcare support during this process. The child should receive support in their own right to help them deal with their feelings. The person with the drug/alcohol problem in the situation where the child is living may be someone other than the parent. This person may adversely affect the child's welfare.
  • Where the parent/carer or child has a physical disability or learning disability, additional consideration will be necessary.
  • When there are indications that a child is taking on a parenting role within the family consideration should be given to support that could be offered. i.e. Young Carers Project.
  • Parents seeking treatment is frequently seen as the solution to preventing continuing risk. However entering treatment for a variety of complex reasons can actually increase substance misuse temporarily and/or increase the risk to the child. For similar reasons, leaving treatment even when abstinent and fully motivated is not necessarily a positive factor when the care of the child is considered.
  • If a parent/carer says that they are in contact with a substance misuse agency it is important to clarify what this contact entails i.e. a visit to the needle exchange, counselling, receiving prescription for medication, or a combination of all.
  • Extended family may also need support. Information should be given about local Friends and Families groups.

If you did not know the parent was misusing drugs/alcohol would you still be concerned for the child?

Appendix 1

Alcohol Guidance

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Appendix 2 - Commonly Misused Substances

1.1 The effect of any substance on an individual will be influenced not only by the pharmacology of the substance, but the individual’s biological makeup, how they are feeling, who they are with and where they are. The information below briefly details common pharmacological effects and effects on the unborn baby.

Alcohol

1.2 Alcohol is a depressant drug. It begins to have an effect within 5 - 10 minutes and the effects can last for several hours depending on the amount and strength of the alcohol consumed, whether the person consuming has eaten, how heavy they are, how much they usually drink etc. Alcohol exaggerates the effects of other depressant drugs. The short-term effects can vary greatly from making users jolly and relaxed, to aggressive and violent. Tolerance to alcohol can develop as can physical dependence. Sudden withdrawal from very heavy alcohol use can produce a range of very unpleasant, and in some cases life-threatening, symptoms in the user.

1.3 The effects of alcohol on an unborn baby were first published in 1973. Infants born to alcoholic mothers may have the characteristic facial features of foetal alcohol. Growth retardation and mental retardation are universal features of this condition, the severity of which is directly proportional to the amount of alcohol consumed.

1.4 It has been reported that infants undergo acute withdrawal which usually occurs between 6 and 12 hours of age and shows the following clinical features: irritability, tremors, seizures, hyperacusis (abnormal acuteness of hearing), increased muscle tone and opisthotonus (spasm of the body where the head and heels are bent backwards and the body is bowed forward).

1.5 Pharmacological treatment is only required in severe cases or if seizures occur.

Amphetamines

1.6 Amphetamines have a stimulant effect on the central nervous system. They can produce feelings of exhilaration, confidence and energy. They can reduce the need to sleep and suppress the appetite. The effects generally will come on slowly after (about half an hour, depending on mode of administration) and can last for about 3 - 4 hours. Users can experience an inability to sleep, but can feel extremely tired once the effects of the drug have worn off. Tolerance can develop rapidly and regular use over a short period can lead to abrupt mood changes, aggression and in some cases psychosis. In most cases these effects will wear off once the drug has left the body.

1.7 Amphetamines can be taken orally, sniffed or injected.

1.8 There is still relatively little information available on the effects of amphetamines in the human neonate. There is however an increased risk of premature delivery and of placental abruption. Symptoms in babies exposed to amphetamines in the womb include: disturbed sleep (80%), tremors (71%), poor feeding (60%), vomiting (51%), hypertonia (increased rigidity of the muscles) (52%), high-pitched cry (40%), sneezing (45%), and frantic sucking (42%). Few long-term studies have been carried out, but those published confirm increased incidence of congenital brain anomalies plus short and long-term neurobehavioural problems.

Benzodiazepines

1.9 Benzodiazepines are minor tranquillisers prescribed for anxiety states. Illicit use is common in the UK. They essentially act to dampen brain activity so relieving feelings of anxiety, and in some cases inducing sleep. Some users experience drowsiness. Regular use of benzodiazepines over a period of more than a few weeks causes dependence and withdrawal symptoms that are often similar to the original feelings of anxiety for which they were prescribed. Tolerance can also build rapidly leading to the need for increased doses. Users are advised to slowly reduce the dose under medical supervision.

1.10 Illicit users of benzodiazepines are also likely to use other drugs and alcohol. The use of benzodiazepines with other depressant or sedative drugs (such as opiates or alcohol) can be particularly dangerous as each increases the other’s sedative effect. Benzodiazepines are generally swallowed as tablets or capsules. Some illicit users do inject the contents of tablets or capsules, which again is a particularly risky activity.

1.11 Effects on the unborn baby of this group of drugs have been widely studied and show no increase in congenital anomalies and, in particular, no increase in oro-facial clefts.

1.12 Babies born to heavy users are likely to be sedated and therefore be poor feeders. No known withdrawal symptoms have been reported and therefore pharmacological treatment is not indicated.

1.13 The long-term effects on infants have not been well reported.

Cocaine/Crack Cocaine

1.14 Cocaine and crack cocaine stimulate the central nervous system. Crack is a smokeable form of cocaine that can produce a very intense, but short-lived high, peaking after about 3 - 5 minutes and wearing off in 15 minutes. Cocaine hydrochloride powder is generally sniffed, the effects come on more slowly and wear off after about 40 minutes. Like amphetamine, cocaine (in either form) produces feelings of confidence and exhilaration. As the high is more short-lived than that with amphetamine, the dose needs to be repeated often. The intense high can be followed by feelings of anxiety, depression and with repeated use, irritability and paranoia. The user often feels that these negative feelings will only be alleviated through repeated use. Repeated use in a short period can lead to feelings of anxiety, particularly as cocaine increases the heart rate. Cocaine also suppresses the appetite and the need to sleep. Technically, cocaine is not physically addictive, however it can produce intense cravings in the user, which can manifest themselves in physical symptoms if use is discontinued.

1.15 There is a high incidence of pregnancy complications, including stillbirths, in users of crack and cocaine. Premature delivery is very common. The effects of cocaine and crack on unborn babies have been well documented. Studies suggest an association with congenital defects e.g. intestinal atresia (absence of passage through the gut), terminal (end of) limb defects, skull defects, congenital heart disease, structural cerebral anomalies, genitourinary anomalies and growth retardation.

1.16 Withdrawal symptoms include irritability, tremors, restlessness, abnormal cry, gastrointestinal (stomach and gut) disturbances, excessive mouthing, tachypnoea (increased breathing rate) and seizures. Long-term outcomes show neurobehavioral problems.

Ecstasy

1.17 Ecstasy is a stimulant, with slight hallucinogenic (perception altering) effects. Generally associated with dance culture, it can produce feelings of energy, confidence, empathy and friendliness. It is usually swallowed as tablets, but is occasionally sniffed. The effects generally last about 6 - 8 hours. Tolerance can build quickly, and repeated use often fails to produce the "loved up" feelings sought by the user. One of the main risks is overheating caused by excessive physical activity such as dancing. This can be countered by sipping about a pint of water an hour (excessive consumption of water can also be extremely dangerous and in some cases has been fatal). A further risk is that many other substances (e.g. ketamine, amphetamine) are often sold as ecstasy and often the user cannot be sure of what they are taking.

1.18 Ecstasy is a comparatively new drug and the long-term effects of use are not yet known. There is some emerging evidence that suggests that the drug is the cause of cerebral damage in adults who take it, but no human or animal studied has shown similar effect in the foetus. Little is known about the effects of ecstasy to either mother or baby in pregnancy.

Heroin/Methadone

1.19 Heroin is an opiate drug that is a powerful painkiller. Heroin is most effective when sniffed, smoked or injected. It depresses the central nervous system and brings about feelings of contentment and well-being. Many users describe feeling "wrapped in cotton wool"; this can make use especially attractive to those wishing to block out psychologically painful aspects of their lives. Higher doses of heroin can make the user drowsy. methadone is a synthetic opioid which has similar but less intense effects as heroin. It is often used in the treatment of heroin dependence to reduce withdrawal symptoms (though it is frequently used illicitly).

1.20 The major risks of heroin use are overdose, dependence, and the risks associated with injecting drug use. Overdose can occur with high doses of the drug and when heroin is used in combination with other depressant drugs. Tolerance to heroin can build quickly with frequent, repeated use and diminishes when use is stopped. Sometimes users overdose because they have not altered their dosage to match their tolerance after a break from using. Heroin produces physical dependency; withdrawal produces unpleasant physical symptoms, often likened to bad flu, which can last for a week or longer. Many users also experience feelings of psychological dependence.

1.21 The effects of narcotics on neonates exposed during pregnancy are well documented. The most commonly abused opiates are heroin and methadone but infants can be affected by codeine too.

1.22 The onset of symptoms varies with the drug being used, the quantity, frequency, duration of intrauterine exposure and the timing of the last dose prior to delivery.

1.23 Withdrawal from methadone tends to start later than withdrawal from heroin. However in both cases newborns usually appear normal at birth. Symptoms begin to appear during the first 24 - 48 hours although symptoms have been noted to start on days 5 - 10. Acute symptoms may last for several weeks with sub-acute symptoms persisting for months. While up to 90% of babies exposed to opiates in the womb develop symptoms, only around 80% require treatment. Infants exposed to methadone usually develop more severe symptoms and require treatment more often.

1.24 There is no correlation between blood levels of morphine in the mother or infant and severity of neonatal abstinence syndrome (NAS). However maternal blood levels of methadone are directly related to the severity of NAS.

1.25 The general effects of foetal exposure include growth retardation, weight loss during the neonatal period and prolonged hospital stays. More specific symptoms of NAS include:

  • central nervous system (brain) irritability, tremors, increased muscle tone, myoclonic (spasm of a muscle) jerks, seizures, sleep disturbances, yawning, excessive crying
  • respiratory distress: tachypnoea (raised breathing rate), nasal flaring, nasal stuffiness, sneezing
  • fever, sweating, mottling
  • gastrointestinal (stomach and gut): excessive sucking, poor sucking, excessive hunger, regurgitation, diarrhoea

Cannabis

1.26 Cannabis is a hallucinogen that comes in many forms; herbal cannabis, cannabis resin and, less commonly, oil. It is usually smoked, but can be eaten. Effects depend greatly on the amount and type and strength of cannabis used, the individual user and their environment. Common effects are reduced blood pressure, feelings of well being, increased appetite, heightened perception (to music or colours), sociability, giggliness, paranoia, dizziness, lack of awareness of time, poor short-term memory during use and sleepiness.

1.27 This is probably the most widely used illegal drug in the UK. The active drug readily crosses the placenta and accumulates in the foetus. Maternal cannabis use has not been extensively studied in pregnancy. There is no reported increase in obstetric complications following its use. There are a few case reports linking use during pregnancy with foetal alcohol-like syndrome whilst other studies have shown no effects at all.

Volatile Substances

1.28 Volatile substances include glues, aerosols and gasses. The vapours from these products are inhaled by the user and can produce feelings of euphoria, dizziness and lack of co-ordination. The effects are often compared to drunkenness caused by alcohol use. Volatile substance use can be extremely dangerous because of the way that vapours are inhaled (a number of deaths have been caused by the freezing of the larynx following butane being squirted into the mouth). There is little recorded evidence regarding the long-term risks of volatile substance abuse.

1.29 The effects on the unborn baby have not been reported, but this is largely due to the fact that women who use solvents tend to use a variety and may use other drugs and alcohol as well. Withdrawal is well documented in adult patients and there are studies confirming withdrawal in neonates exposed in the womb. Studies show that most babies have the characteristic odour. Typical abstinence symptoms are: excessive high-pitched cry, sleeplessness, tremors, hypertonia (increased rigidity of the muscles) and poor feeding. Withdrawal symptoms start between 24 - 48 hours of age and persist for about 5 days. 75% of babies develop withdrawal symptoms and require treatment.

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Appendix 3

Guidelines for professionals for assessing risk when working with substance using parents, (based on SCODA) (PDF document, 40kb)

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Appendix 4

Services For Parents

1.1‘Following assessment, children’s social care departments need to plan and provide for the child’s continued welfare. They need to look at ways of providing packages of care to meet the needs of the child and to support the family. The needs of the child and the needs of the parents should be separately identified, as they may be different.’ (SCODA guidelines, p23.)

1.2 It is important to work in partnership with parents when accessing appropriate services. In making agreements with parents, targets need to be achievable and realistic. Importantly, parents need to be fully aware of what is expected of them and what resources are available to support them.

1.3 Each service should have child protection policies and a policy about sharing information with other agencies. The National Drug Strategy developed Drug Action Teams. These teams have a significant role in co-ordinating services and ensuring co-operation between local authorities, health services, police, probation and non-statutory services working with drug users or with children of drug users.

1.4 When referring parents to services or working with parents who are already involved with services it is crucial to be clear about what role the services have and the nature of the support they are offering the parent.

1.5 There are specific services for Leicestershire, Leicester City and Rutland, which have a remit for working with drug and alcohol users:

  • Leicestershire Community Projects Trust (LCPT), 96 New Walk Leicester. 0116 2229522 Drug Advice Centre – offering assessment and casework to drug users, needle exchange, telephone help line, Community Care Assessments for drug users in Leicester City and Leicestershire
  • Base 12 – day services project for drug users, offering groupwork and social activities
  • Alcohol Advice Centre – offering assessment and casework to alcohol users and third parties who are affected by alcohol use, drop-in service, telephone help line, Community Care Assessments for alcohol users in Leicestershire
  • New Walk Community Project – day services project for alcohol users offering groupwork
  • New Directions Team – working with young people using drugs or alcohol (up to age 25 for alcohol users and 21 for drug users)
  • Auricular Acupuncture – is offered to users of the services, or on a drop-in basis
  • Motorvate – for young people at risk of offending
  • NHS Community Alcohol Team – Drury House, 50 Leicester Road, Narborough. 0116 2256350. Multi-disciplinary team offering assessment and casework to alcohol users in the Leicester City, Leicestershire and Rutland. Community Care Assessments for alcohol users in Leicester City. One-to-one counselling and support, psychological assessment and intervention, inpatient and community detoxification, hypnotherapy
  • NHS Community Drug Team – Paget House, 2 West Street, Leicester. 0116 2256400. Multi-disciplinary team offering assessment and casework to drug users in Leicester City, Leicestershire and Rutland. Young persons team to work with young drug users, substitute prescribing, worker providing support and intervention to pregnant drug users, inpatient detoxification, community care assessments for drug users in Leicester City
  • Turning Point – Loughborough 01509 611111. Working with drug and alcohol users in Loughborough and specific parts of Leicestershire – one-to-one advice and support, needle exchange, auricular acupuncture, young person workers

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