Home visits reduce risk of 'hidden harm' to children of drug treatment patients
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Home visits reduce risk of 'hidden harm' to children of drug treatment patients

In Australia a home-based child welfare intervention for methadone-maintained parents improved parenting and decreased parental indicators of potential child abuse or neglect while offering brief parenting education classes barely improved on usual care. This type of intervention offers one way to address current concerns about the children of dependent drug users.

FINDINGS The featured study1 recruited 64 methadone patients Most of the recruited parents were mothers, typically unemployed and in their late 20s and early 30s. On average they had been on methadone for over three years. caring full time for children aged from two to eight. At the start of the study, 40 scored above the level indicative of potential child abuse or neglect on a standard assessment questionnaire.

Patients were randomly allocated either to carry on with their usual care at the clinics (the control group) or additionally to one of two parenting interventions conducted by therapists from the research project. One consisted of just two sessions of conventional parenting skills training. The other was the specially devised Parents Under Pressure programme This aimed to help parents become aware of and regulate their emotional reactions, improve parenting skills, avoid relapse to substance misuse, and gain support from other people and from welfare and community services. Outside scheduled sessions therapists were available to (and often did) support patients by accompanying them to schools, social, legal and health services and in everyday activities such as shopping. involving ten home visits over three months lasting one to two hours plus practical assistance with community services and everyday activities. Day-before reminder calls and flexibility in response to the families' vulnerability to crises partly accounted it's thought for why just one of the patients allocated to it did not engage with the programme.

All but seven patients were reassessed after the three-month intervention period and/or again six months later. On all the measures of parenting, child welfare risk, and child behaviour, patients allocated to Parents Under Pressure had improved substantially, while generally the others had not. On the key measure of risk to the child, the control group had deteriorated, while those given limited parenting skills training had improved only slightly.

By the last follow-up, a third of the Parents Under Pressure patients no longer scored as child welfare risks, twice the proportion in the parenting skills group; none of the control group reached this level. However, another third remained potential risks. Though this was not an explicit objective, only the Parents Under Pressure patients had also been able to reduce their average doses of methadone.

IN CONTEXT Previously a pilot study from the same research team had tested the programme on nine methadone-maintained patients and recorded similar improvements,2 suggesting that the featured study was not a one-off. However, this does not guarantee that the results will be replicated elsewhere. Staff were particularly skilled The two therapists were experienced in working with families with complex needs and closely supervised by a researcher who devised the Parents Under Pressure programme, a degree of expertise and possibly too commitment which may be diluted in everyday practice. The team which devised the programme also researched it and provided the therapists; independent researchers tend to record less positive outcomes. and they and the researchers were likely to be highly committed to the programme.

Its seems likely too that patients not allocated to Parents Under Pressure were disappointed and that this affected outcomes, All the patients knew the options they might be randomised to, so were presumably willing to invest up to 20 hours of their time and to open their homes to the interventionists. Ten not allocated to the Parents Under Pressure programme quickly withdrew and were not included in the study, including seven from the control group. Whilst this compromised the randomisation procedure, it did so in a way which can be expected to have favoured the control group if the most motivated parents withdrew in disappointment. Drop out of patients once they were in the study could have had the opposite effect. Again this was greatest in the control group, fewer of whom attended the six-month follow-up. If more motivated parents had dropped out, this could account for the apparent worsening in the control group, especially since in some analyses drop-outs were assumed not to have improved since their last assessment. Conceivably, too, disappointment affected the outcomes of control patients who did attend for follow-up. However, this concern applies less to the brief intervention group, which also improved little. though sometimes in ways which might have disadvantaged the programme. Disappointment leading to excess drop-out in the control group may have been one of the reasons why just two of the patients originally allocated to Parents Under Pressure could not be followed up compared to 13 (about half) of the control group.

Except for methadone dose, all the measures were based on the parent's interview responses. The questionnaire assessing potential risk to the child was designed to cater for misleading responses, but validation of the improvements by (if available) the school, close family, or by direct observation, would have given greater confidence in the results. There is also the possibility that it was not just the Parents Under Pressure programme which was influential, but also/instead the degree of contact this entailed and where (ie, the home) this occurred.

Other evaluated attempts to improve the prospects for children living with parents who are problem drug users have been few and results patchy.3 4 A fairly close parallel (including home visits) to the featured study was undertaken at two US methadone clinics.5 Take-up of the parenting programme was excellent and parenting and child behaviour/attitudes improved, though the latter not consistently. Another US study at methadone clinics trialled psychotherapy groups aimed at improving parenting.6 Again engagement was good. Data from mothers and children indicated that the intervention had reduced the risk of child abuse or neglect but improvement was not seen on all the measures, in particular when the neighbourhood context was a limiting factor.

Methadone-maintained parents provided the impetus for the US-originated Strengthening Families Programme featuring parallel and then joint weekly groups of parents and children.7 Not explicitly a child protection intervention, nevertheless the improvements seen in parenting skills, children's social skills, and family relationships can be expected to have a protective impact.

UK research on parenting interventions in drug services is scarce and not directly relevant to the approach trialled in the study.8 9 10 There are, however, descriptions of similar interventions involving home visits which appear to embody the features commended by international research.11

Directly addressing parenting is not the only way to improve life for the children of substance using patients. Counselling couples to improve their relationship (and compliance with treatment for the partner in treatment) has spilled over to benefits for children.12 In so far as it stabilises the patient and brings them in to contact with social and welfare services, addiction treatment in itself improves the prospects for the children,13 though, as the featured study among others shows, there may still be elevated risks of neglect or abuse which can be further reduced by interventions targeting these risks.

Approaches found effective with parents in general may also prove effective with problem drug users. Promising results have been found with home-based interventions which involve all the family and 'coach' parenting skills rather than didactically educating, and provide case management services to link families to sources of support in the community.14

PRACTICE IMPLICATIONS Across the UK, national targets, service standards and policy statements have recently embodied the perspective that parenting and child welfare are core concerns for addiction treatment services,15 a contention featuring strongly in new Scottish16 17 and English18 drug strategies. Interventions like the one trialled in the study are one way It is important to distinguish the type of intervention in the featured study (a preventive applied across the board to all parent-patients) from the action which should be taken if an individual patient's child is assessed as at risk of serious harm. The main role of interventions such as those trialed is to reduce the numbers that deteriorate to this point. In individual child protection cases, service protocols and legal and ethical obligations will normally dictate the action to be taken, such as involving senior managers and child welfare authorities. Such cases may be revealed during the course of interventions like those in the featured study. This possibility should be provided for in staff training and guidelines and in the information given to patients invited to participate in interventions. services (and conceivably drug action teams or service consortia working across an area) can play their part in these agendas. With no blame implied and offering positive support, in the research they seem to have been welcomed by the patients.

There are an estimated 250,000 to 350,000 children of problem drug users in the UK.13 In a typical specialist drug treatment service in England, at least 1 in 8 patients and perhaps as many as half are potentially eligible for family interventions.20 Such work should not await the resolution of the parent's substance misuse problem; much can be done before this point to benefit the entire family, in the process (research suggests) also furthering the resolution of substance use problems.

The lessons of research to date seem to be that interventions need to be relatively intensive, well targeted at the risk/resilience factors affecting the child and the issues obstructing good parenting, that staff must be able to forge trusting relationships with adults wary of authority, yet retain the child's interests as paramount, and that they and the programme they are implementing must able to adapt to the contingencies affecting the family. Roles typically combine direct parenting support with a case management function, facilitating support from other welfare and community services and intervening when pressures threaten the family's progress.

The featured intervention embodies this learning, combining flexibility with manualisation. Studies have found most parents welcome this type of help and engage well with the programmes. Home-based interventions allow for children and other carers to be incorporated in the process, resolve the need for child care, permit assessment of home safety, provide for the learning and practice of new skills in the environment where they need to be applied,14 and are possibly more likely to be taken up by the parents.5

Many drug service workers feel ill-equipped for this work. Government advisers have pointed out that the first essential step is for treatment services to ask patients about their children.13 A recent official audit of English prescribing services found that half did not have assessment procedures which systematically enquired who else shared the home.19 Current NTA National Treatment Agency for Substance Misuse, special health authority charged with improving drug treatment in England. care planning guidance refers to the need for addiction treatment services to identify child protection issues. Additionally, patients should be questioned about their children in order to submit this data to national and regional monitoring systems, including those for drug using offenders.15 In the process, patients who might be offered family interventions will be identified.

How diligently such enquiries are made is unclear. Being able to offer concrete and supportive interventions such as those in the featured study makes asking about children both more acceptable to patient and worker and more worthwhile.

Thanks for their comments on this entry in draft to Daphne Obang, Methodist church Safeguarding Officer and former director of social services, and to Lorna Templeton of the University of Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY Dawe S. et al. Reducing potential for child abuse among methadone-maintained parents: results from a randomized controlled trial. Journal of Substance Abuse Treatment: 2007, 32, p. 381–390.

2 Dawe S. et al. Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme. Drug and Alcohol Review: 2003, 22(3), p. 299–307.

3 Barnard M. et al. The impact of parental problem drug use on children: what is the problem and what can be done to help? Addiction: 2004, 99, p. 552–559.

4 Suchmann N. et al. Parenting interventions for drug-dependent mothers and their young children: the case for an attachment-based approach. Family Relations: 2006, 55(2), p. 211–226.

5 Catalano R.F. et al. An experimental intervention with families of substance abusers: one-year follow-up of the focus on families project. Addiction: 1999, 94, p. 241–254.

6 Luthar S.S. et al. Relational psychotherapy mothers' group: a developmentally informed intervention for at-risk mothers. Development and Psychopathology: 2000, 12, p. 235–253.

7 Ashton M. Doing it together strengthens families and helps prevent substance use. Drug and Alcohol Findings: 2004, 10, p. 16–21.

8 Social Care Institute for Excellence (SCIE). Parenting capacity and substance misuse. SCIE, 2005.

9 Tunnard J. Parental drug misuse – a review of impact and intervention studies. Research in Practice, 2002.

10 Keen J. et al. Keeping families of heroin addicts together: results of 13 months' intake for community detoxification and rehabilitation at a family centre for drug users. Family Practice: 2000, 17(6), p. 484-489.

11 Harbin F. et al, eds. Substance misuse and child care: how to understand, assist and intervene when drugs affect parenting. Russell House, 2000.

12 Kelley M.L. et al. Couples-versus individual-based therapy for alcohol and drug abuse: effects on children's psychosocial functioning. Journal of Consulting and Clinical Psychology: 2002, 70(2), p. 417–427.

13 Advisory Council on the Misuse of Drugs. Hidden harm: responding to the needs of children of problem drug users. Home Office, 2003.

14 Donohue B. Coexisting child neglect and drug abuse in young mothers specific recommendations for treatment based on a review of the outcome literature. Behavior Modification: 2004, 28(2), p. 206–233.

15 Advisory Council on the Misuse of Drugs. Hidden harm. Three years on: realities, challenges and opportunities. Advisory Council on the Misuse of Drugs, 2006.

16 Scottish Government. The road to recovery: a new approach to tackling Scotland's drug problem. The Scottish Government, 2008.

17 Scottish Executive. Getting our priorities right: policy and practice guidelines for working with children and families affected by problem drug use. Scottish Executive, 2006.

18 HM Government. Drugs: protecting families and communities: the 2008 drug strategy. HM Government, 2008

19 Healthcare Commission and National Treatment Agency for Substance Misuse. Improving services for substance misuse: a joint review. Commission for Healthcare Audit and Inspection, 2006.

20 Jones A. et al. The drug treatment outcomes research study (DTORS) baseline report: appendices. Home Office, 2007.

Last revised 07 August 2008

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