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One of our hot topic essays on important issues which sometimes generate heated debate. How to protect the children of problem substance users can hardly be a more emotive and – since a US-inspired project came to Britain offering to pay drug users to be sterilised – contentious issue. Despite the issue’s profile, truly informative studies are few.
How to protect the children of problem substance users can hardly be a more emotive and – since a US-inspired project came to Britain offering to pay drug users to be sterilised – contentious issue. Bending to the UK context, the project reluctantly decided not to pay for sterilisation but only for problem drinkers and drugtakers to use long-term birth control. The project’s radical policies highlighted what is certainly a huge and pressing problem affecting well over a million children in Britain whose parents have a drug or alcohol problem.
Across the UK, national targets, service standards and policy statements have embodied the perspective that child welfare is a core concern for services in contact with problem drug users, a contention featuring strongly in the latest Scottish and English drug strategies. In England it formed a specific workstream of the National Treatment Agency for Substance Misuse (now absorbed in to Public Health England), which has produced guidance on how authorities responsible for drug and alcohol services can work more closely with children and family services. In 2010 Scotland produced new child protection guidance which among others, more fully addressed the issue of children affected by parental substance misuse. That was followed in 2013 by updated guidance specific to substance use, intended for all child and adult service practitioners working with vulnerable children and families affected by problematic parental alcohol and/or drug use.
Establishing what works for those at risk among children of drinkers and drugtakers is difficult because it would be unethical to deliberately deny services in order to determine whether they really do help. However, the potential for interventions to do serious harm as well as create major benefits makes evaluation vital. Evaluations of specialist British services in Wales (1 2) and Middlesbrough found they prevented the need for permanent placement of children in care and reduced time in temporary placements. Importantly, the later of the two Welsh studies was able to directly confirm that reducing entry in to and time in care was not at the expense of the children’s welfare. There was no indication that the service inadvertently harmed children by helping keep them with their families.
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 concern over child welfare. Regulations stipulate that 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 highlighted by researchers. An evaluation concluded that at the first three sites, the new 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”. There was evidence directly from the families that their lives and those of the children had improved, but with no comparison group it is unclear whether the interventions were the cause of the improvements.
Another approach developed in the USA extends the drug court model to family courts. Drug courts attempt make court proceedings non-adversarial and more oriented to therapeutic procedures and treatment interventions. The family versions aim to enhance the effectiveness of child welfare agencies by promoting engagement in substance use treatment, motivating parents to address their reliance on substance use, and coordinating the services needed to stabilise families.
The first family drug and alcohol court in Britain was piloted at an inner London family court initially for three years to the end of 2010. Researchers concluded that more parents seen by these specialist courts than by comparison courts had controlled their substance misuse by the end of proceedings and been reunited with their children. They were also engaged in more substance misuse services over a longer period. Evidence of cost savings were noted in relation to court hearings, out-of-home placements, and fewer contested proceedings. Parents and staff felt this was a better approach than ordinary care proceedings.
A later report from the same study with a longer follow-up of more families reinforced the earlier findings. More family drug and alcohol court parents had stopped misusing substances and dealt with other problems, and more mothers had been reunited with their children, but this 36% v 24% gap was not statistically significant.
Similar courts have now opened in Gloucestershire and Milton Keynes and as reported early in 2015, more were due to open in 2015/16 in areas including East Sussex, Kent and Medway, Plymouth, Torbay and Exeter, and West Yorkshire, funded by the Department for Education. Despite this significant expansion, as in London, these courts will sit once a week and hear relatively few cases.
From the USA the first large-scale outcome study of a family drug court compared the progress (as revealed by court and administrative records) of mothers and children processed through three such courts with those processed through normal channels either in the same areas or in similar areas without a family drug court. Findings favoured the family drug courts. Mothers processed through these courts were more likely to be unified with their children, who spent less time in out-of-home placements. More drug court mothers entered substance use treatment and they did so more rapidly, stayed longer and were more likely to complete the programme. However, the relative benefits arising from the family drug courts were at best a minor influence on child custody outcomes, and the study could not be sure that all relevant differences between the two sets of families had been accounted for.
With possible implications too for non-court interventions, one way to improve family drug court outcomes was the subject of a randomised trial in the USA. It tested a programme developed for family drug court counsellors which involved the mother’s family and other significant figures in their lives. Compared to a more typical case management role, it led to more mothers retaining their parental rights and greater improvements in substance use, health, family functioning, and risk of child abuse.
The services discussed above 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 treatment and harm reduction or other services. Because these offer positive support without implying parental failure, they often have a good uptake and can reduce the numbers who reach crisis point. But when the child is already deeply in trouble with drugs and/or crime, placing them in an alternative, long-term and more settled family environment can be better for them than continuing to try to make a dysfunctional substance-abusing family work.
What seems the most widespread of such programmes was developed by the charity Action on Addiction based on a US model reviewed by Drug and Alcohol Findings. Though it has developed way beyond these roots, its origins were in an attempt to help drug using parents do the best for their primary-school age children. Its originator planned to achieve this by “improving parent child relationships ... We try to change the family dynamics, to create a more democratic family where they actually have family meetings, talk together, and plan activities together.”
The basic format involves weekly sessions last two to three hours. For about an hour parallel groups of children and parents from four to 14 families develop their understandings and skills led by parent and child trainers. In a second hour parents and children come together as individual family units to practice this learning. The remaining time is spent in logistics, meals, and enjoyable family activities. Though the research and its reporting did not meet rigorous standards, there was evidence of substantial improvements in parenting skills, children’s social skills, and family relationships. Parents became less depressed and their drug use diminished. Their children became less aggressive, better behaved at home, said their relationships with other children had improved, and were more able to express themselves. Older children reduced their use of tobacco, drugs and alcohol.
Action on Addiction calls their version ‘M-PACT’ – Moving Parents and Children Together. The programme supports children aged 8–17 who are experiencing the effects of parental substance misuse. Its ‘whole family’ approach works with parents and children from up to eight families at any one time over up to 10 sessions. Implementations accredited by Action on Addiction are taking place in 30 services or areas in England.
Pilot programmes run in 2006 and 2007 were evaluated based on interviews with programme facilitators and with young people and parents in the month following the end of the programme. The results offered “a powerful demonstration of the benefits of a holistic approach to substance misuse.” A later and larger evaluation was based on similar interviews with 37 children, 36 adults and over 30 group facilitators from 13 M-PACT programmes in England. Most families’ accounts indicated they had benefited in a range of ways: by meeting others who were experiencing similar problems, through greater understanding about addiction and its impact on children and families, and by improving communication within the family. In many families there seemed more openness and honesty, stronger relationships, more time spent together as families, fewer arguments, and less conflict.
Based on five programmes in England assessed in 2013, an attempt was made to estimate the costs per family and to value the resultant benefits to society. The respective figures were £802 in costs, or £1852 including training and license fees, versus £2213 in benefits over the first year, largely due to improved school attendance and adults moving into employment. These benefits were based on the post-programme assessments of families made by M-PACT practitioners rather an through an independent and anonymous research process and, as with the other studies, there was no control set of families not offered the programme against whom its benefits could be benchmarked. Instead 25% of the observed benefits were discounted as improvements which might have happened even without M-PACT.
M-PACT is not the only family and child programme to have been mounted by drug and alcohol services and to have been evaluated, though no evaluation to date has been able to rigorously measure and attribute outcomes to the interventions. M-PACT’s evaluators have explored the common themes across this programme and two others based on interviews with 23 youngsters aged 10–17 whose families had been in the programmes. Themes were that they had benefited through meeting other people and having an opportunity to talk and share experiences, learning about addiction, and better understanding and controlling their emotions. They felt their families had as a result become safer, healthier and more cohesive.
The same research team has adapted for children an intervention they developed for the adult relatives of problem substance users. Interviews with teenagers in Northern Ireland whose families had engaged with the programme suggested there had been benefits similar to those seen with M-PACT.
Funded by the charity Comic Relief, five drug and alcohol services in England have implemented programmes addressing the needs of children at potential risk due to their parents’ drinking. An evaluation concluded that such services should work with the whole family, whether this includes the adult drinker or not. This work was not easy – it required careful staff recruitment and adequate training and support, strong leadership and management, and partnership with adult services and universal services, particularly schools. The evaluators recommended services should include elements to improve communication between parents/carers and children and which enable children to build networks of support with other adults. Therapeutic services and those offering youth groups and therapeutic group activities were found to reduce children’s feelings of isolation and help develop resilience. One output of the project was a ‘toolkit’ to support managers, commissioners and practitioners involved in designing, assessing or improving such services.
Australian guidelines on how drug and alcohol treatment services can become ‘family sensitive’ support the Comic Relief evaluation’s emphasis on staff and organisational strengths. The guidance quotes a review which says “the importance of having an organisational commitment to the development of family-focused interventions cannot be understated.”
Residential treatment offers an opportunity to safely learn and practice parenting skills, one taken by a US centre which randomly allocated new mothers to a brief but rigorous attachment-based parenting programme. This involved a trained parenting coach working in the residential centre with mother and child together for 10 sessions, aided by reviews of video-recorded mother-child interactions. The result was more supportive parenting conmpared to mothers not allocated to the programme.
In focusing on interventions specifically to protect children we should not lose sight of the important fact that successfully treating substance use problems in itself can benefit families including the children, and perhaps particularly so when the substance use treatment is itself based on a family or couples intervention (1 2 3). It is one reason why it might be counterproductive to deter adults from seeking or accepting treatment for their substance use problems for fear they will lose their children.
Despite the issue’s profile, truly informative studies are few. Run this hot topic search to see the full list.
Last revised 10 May 2017. First uploaded 01 July 2010
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STUDY 2008 Final report on the evaluation of ‘Option 2’
HOT TOPIC 2017 Focus on the families