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Forrester D., Holland S., Williams A. et al.
Cardiff University and University of Bedfordshire, 2012.
In Wales Option 2 works intensively over a few weeks with substance using parents whose children are at serious risk – serious enough for imminent care proceedings. This second evaluation confirmed that the cost-saving service helps keep children with their families without inadvertently harming the children.
Summary This report presents findings from a study funded by Alcohol Research UK into outcomes and experiences of families referred to the Option 2 service in Cardiff. The study was carried out between 2009 and 2011.
Option 2 is funded by the Welsh Assembly as a crisis intervention service for families of parents with drug or alcohol problems. Aims are to safeguard children at serious risk of harm and to improve family functioning, reducing the need for children to taken from their families and placed in the care of child welfare services. Intervention is short (four to six weeks) but intensive (workers available 24 hours a day). Among other therapeutic and practical interventions, workers use motivational interviewing and solution-focused counselling styles.
An initial evaluation found the service produced significant cost savings by reducing the need for children to be taken in to care, but these findings are difficult to interpret; care tends to improve child welfare, so a service which reduces the use of care may have a negative impact on some children.
It was therefore important to know the impact Option 2 has on child welfare – along with parental substance use and family functioning, outcomes investigated by the featured study. It took advantage of the fact that Option 2 does not have a waiting list. If a referral is received when the service is full, details are taken, but the family will generally not receive the service, providing a natural comparison group against which to benchmark the service’s impact.
Of the 75 families approached to join the research, only just over a third did so, generally because at follow-up on average 5.6 years after referral they could not be contacted because they appeared to have moved. In response, the researchers recruited families more recently in receipt of Option 2 services. This and the inability to individually match Option 2 and comparison cases compromised the study’s ability to be sure of comparing like with like, while small numbers of families generally also made it impossible to adjust outcomes for any differences. Comparable data to that collected at follow-up was not available at referral to Option 2, so the quantitative comparisons were based on the degree to which scores assessed after the intervention had changed by the follow-up point.
In the end outcomes were compared for 15 Option 2 families (52 children) and 12 comparison group families (32 children); in all but a few cases, only the female parent participated in the research. Families had very serious problems related to parental alcohol (16 families) and/or drug use (12 families), in turn related to very high levels of concern about risks to children, including children being assaulted, born withdrawing from drugs, experiencing severe neglect, or witnessing violence in the home. Commonly children were being considered for care or being placed on the child protection register. These concerns arose in complex contexts of multiple other problems, including most prominently inter-generational abuse, low maternal self-esteem, and high levels of violence and poverty. Despite their problems, the families were in general not seeking help and felt reluctant to receive it, most prominently due to concerns over losing their children.
There were some substantial differences between the groups. Illicit drug use was a problem for 72% of Option 2 families but for only 23% of comparison families, whose problems mainly related to alcohol. More Option 2 children had been referred (73% v. 58%) in order to try to avoid care proceedings.
Over the average 5.6 years follow-up families had received inputs from a wide range of agencies. Parents particularly valued services which were available when needed, provided long-term support, and where professionals were caring and committed. Such services seemed to maximise the likelihood of parents addressing their alcohol and drug problems.
At follow-up most parents had considerably reduced their drug and alcohol use. Despite this, overall the families were still in severe difficulty; many parents scored as stressed and at risk of psychological problems, many families experienced discord, and a high proportion of the children had emotional and behavioural problems. This evidence was supported by in-depth interview accounts of family difficulties and often the inter-generational transmission of problems.
However, families who had received the Option 2 service seemed to do considerably better than those who had not. In particular:
• parents were far more likely to have reduced their alcohol or drug misuse (94% v. 58%);
• fewer parents were stressed and at risk of psychological problems (44% v. 85%);
• families had more solidarity and cohesion;
• children were less likely to enter care (8% v. 44%) and none were permanently in care (compared to 38%); and
• the same was true when considered in terms of families whose children were taken in to care – 13% with Option 2 v. 50% without chart.
Despite more avoiding care, Option 2 children’s welfare did not significantly differ. It appeared that children who had received the Option 2 service were retained in their family homes, without this resulting in poorer outcomes. These findings were based on interviews with 21 of the 54 children still under 18 at follow-up assessing their emotional and behavioural health.
Quantitative results were supplemented by in-depth interviews with parents. On the basis of these accounts, all but one of the families were grouped into those who reported ongoing problems (9), those where improvements had been recent or partial (7), and those where obvious and sustained improvements were reported since referral to Option 2 (10). Actually having received Option 2 services was strongly associated with better outcomes; 70% with sustained improvements had received the service, compared to 57% with mixed fortunes and 33% with ongoing problems.
Overall, parents reported that Option 2 had been extremely positive for them:
• it was there when they needed it;
• workers were caring and seemed to understand their problems;
• the focus on recognising and building strengths was helpful;
• workers managed to help families make achievable plans for change and support them to carry out changes;
bull; workers were helpful in negotiating with other agencies and professionals.
Their main criticism was that the service was not available for long enough, or that they would have liked to be able to be re-referred when later they had problems.
Care needs to be taken in drawing overly firm conclusions given small numbers, the challenges experienced in recruitment, and in some respects the lack of comparability of the comparison group. However, findings are in line with those from an initial evaluation with data on care entry from a far larger sample. Taken together, these studies seem to make it safe to conclude that Option 2 significantly reduces the need for children to enter care by improving parent and family functioning. It appears to be an effective way of engaging parents with serious drug and alcohol problems, helping them significantly reduce their drug or alcohol use, and improving family wellbeing. There was no indication that Option 2 was inadvertently harming children by keeping them with their families.
Option 2 is one of the best evaluated services to prevent children entering care in the UK. Its success is likely to generate large cost savings for local authorities and other social care, health and criminal justice agencies. The service should be more widely implemented and adapted to local needs. New services should be carefully evaluated to ensure they at least match the initial services in their quality and results.
The findings do however make a case for longer-term support for such families and a more comprehensive and long-term intervention to address the often continuing and severe problems of the children both after Option 2 and after normal procedures.
commentary The parents of well over a million children in Britain have a drug or alcohol use problem. Across the UK, national targets, service standards and policy statements have embodied the perspective that their welfare is a core concern for services in contact with problem drug users, a contention featuring strongly in current Scottish and English drug strategies.
The potential for child protection interventions to do serious harm as well as create major benefits makes evaluation vital. In particular, the researchers cautioned that children are not necessarily best served by being kept out of care, yet in the earlier Option 2 evaluation, care entry was all they could measure. The featured study offers some reassurance (though based on interviews with a minority of the children) that reducing entry in to and time in care was not at the expense of child welfare.
Unable to randomly allocate, the featured study took the next best option of recruiting families referred to the service, but unable to be seen. In theory this could approximate random allocation because it might be pure chance whether a family was referred when the service was full. In practice, more than chance seems to have been at play. The previous study of Option 2 discovered that “social workers ... tend to discuss cases informally before making referrals.” A similar process could have led in the featured study to the more serious child protection cases and those involving users of illegal drugs featuring more strongly among parents of families not just referred to Option 2, but accepted in to the service.
How that might have affected the outcomes is suggested by a parent quoted in the featured report, shocked to realise after engaging with Option 2 that, “Oh my god, they are on the verge of taking my kids!” More Option 2 parents faced this prospect than did those in the comparison group, affording Option 2 workers greater leverage and parents greater motivation. The flip side is that despite more Option 2 parents entering the service facing imminent loss of their children, many fewer ended up having their children taken in to care chart above right. An evaluation of a similar service in Middlesbrough found that it too prevented the need for permanent placement of children in care and reduced time in temporary placements.
The Welsh Assembly Government has implemented services along the same lines across Wales organised jointly by local authorities and local health boards, initially concentrating on families where there is parental substance misuse and concerns about child welfare. By regulation teams providing the services must consist of at least five professionals and there must be a social worker, nurse and health visitor, perhaps an attempt to address the need to maintain quality noted in the featured report. An evaluation concluded that the schemes “appeared to improve short-term outcomes for a good number of families”, though, staff felt, less so for a few families with “very chaotic lives and serious multiple issues”.
Such services attempt to help families already at the brink of losing care of their children. Before that point there is a strong case for offering parenting and child welfare interventions to all problem substance users in contact with services. Because these offer positive support without implying parental failure, they often have a good uptake and can reduce the numbers who reach the point reached by the families in the featured study. British researchers who have specialised in substance misuse in families have offered recommendations based on a review of the international literature.
Thanks for their comments on this entry in draft to research author Donald Forrester of the University of Bedfordshire in England, and Niall Casserly of the Rhondda Cynon Taff and Merthyr Tydfil Integrated Family Support Team in Wales. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 31 July 2014. First uploaded 22 July 2014
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STUDY 2008 Final report on the evaluation of 'Option 2'