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Harwin J., Alrouh B., Ryan M. et al.
Lancaster University, 2016
Five-year follow-up of London families finds better outcomes among those in the Family Drug and Alcohol Court than ordinary care proceedings.
Summary The Family Drug and Alcohol Court is an innovative approach to care proceedings in cases where parental drug use or drinking is a key feature. It aims to improve outcomes for children by helping parents to change behaviours that put their children at risk of harm (eg, problematic substance use, referred to as ‘substance misuse’), by reuniting families in a way that is safer and more sustainable, or by enabling swifter placement with permanent alternative carers where families cannot be reunited.
A five-year follow-up of a London Family Drug and Alcohol Court for women with substance use problems and their children.
This alternative approach to ordinary care proceedings produced better outcomes relating to substance use, family reunification, and family stability.
Parents viewed the process as fair, respectful, and empowering, which contrasted with ordinary proceedings where parents felt they had no voice and did not understand the process.
The Family Drug and Alcohol Court differs from ordinary care proceedings, [described by the Family Rights Group here], in a number of ways:
• Judges stay with a case from first to final hearing.
• There is a fortnightly court review without lawyers where the judge can monitor progress, and speak directly to families and social workers, keep parents engaged and motivated, and explore ways of resolving problems.
• There is a specialist, multi-disciplinary team, which provides a broad service for both the families (including assessment, planning, and links to other services) and the courts (advising the court on the prospects of parents overcoming their substance misuse).
These facets are part of the court’s overall problem-solving and collaborative approach.
The aim of the featured evaluation was to establish the long-term outcomes of the Family Drug and Alcohol Court (the first court of its kind in England) after proceedings had ended. This included identifying whether positive outcomes captured in a previous evaluation (2014) were still evident, whether these earlier findings would be supported with a greater number of cases, and if there was any difference in outcomes at the end of the follow-up between families not reunited at the end of the proceedings in the Family Drug and Alcohol Court group versus the comparison group. The focus was on mothers and children because of the difficulties the researchers encountered in obtaining consistent informationThe 2014 evaluation reported that information about fathers was very unreliable and this was particularly problematic when following up cases once proceedings had ended. about fathers from local authority files.
This evaluation analyses data from a larger number50 new Family Drug and Alcohol Court cases were added. The number of comparison cases could not be increased for this study as the local authorities involved had identified all the relevant cases that they considered met the Family Drug and Alcohol Court eligibility criteria at the point when care proceedings started. of Family Drug and Alcohol Court cases than the 2014 evaluation, and reports for a longer follow-up period – up to five years after the end of proceedings. It included all cases entering the Family Drug and Alcohol Court in three local authorities between January 2008 and August 2012 (140 cases involving 201 children), and all cases in ordinary care proceedings from another three local authorities between April 2008 and August 2012 (100 cases involving 149 children). In both groups, the cases were put forward because substance misuse was a key factor in initiating the care proceedings. [All cases were heard at the Inner London Family Proceedings Court.] Data was collected about mothers and their children at three points in time: the start of proceedings; the end of proceedings; and at the end of the follow-up (which was up to five years; cases that concluded more recently had a shorter follow-up period).
Some cases were identified as unsuitable for Family Drug and Alcohol Court, and excluded from both groups. This happened when:
• The parent was experiencing psychosis.
• There was “serious domestic violence posing a major risk to child safety, or a history of severe domestic or severe other violence where help had been offered in the past and not accepted”.
• A “history of severe physical or sexual abuse of the children”.
The study found new evidence that the Family Drug and Alcohol Court produces better outcomes for mothers and children in both the short and the longer term.
Substance misuse cessation
This was defined in the evaluation as abstinence from alcohol or illegal drugs [in line with their treatment plan], or being stabilised on an agreed treatment programme (such as methadone) and not taking any non-prescribed or illegal street drugs.
In the short-term, there were higher rates of cessation by the end of care proceedings among mothers in the Family Drug and Alcohol Court than the comparison group (46% vs. 30%). There was also evidence of a longer term ‘Family Drug and Alcohol Court effect’ that enabled some mothers to maintain positive change after care proceedings and the court intervention had come to an end. Among those who were reunited with their children, a significantly higher proportion of Family Drug and Alcohol Court mothers were estimated to have sustained cessation over the five-year follow-up than mothers in the comparison group (58% vs. 24%).
A higher proportion of Family Drug and Alcohol Court than comparison families were reunited or continued to live together at the end of proceedings (37% vs. 25%), and a higher proportion of Family Drug and Alcohol Court than comparison children returned to mothers who were no longer misusing (35% vs. 21%). However, in both groups more children were placed in alternative care (than were not) because mothers had not been able to overcome their substance misuse difficulties by the end of the proceedings.
A similar percentage of Family Drug and Alcohol Court and comparison children were living in permanent placements by the end of the proceedings (77% vs. 74%) – including children who returned to live with their mothers as well as those placed in alternative care.
Whilst Family Drug and Alcohol Court families had better outcomes overall, many families in both groups continued to be vulnerable and encounter difficulties after the intervention had come to an end. The first two years were the most risky.
For signs of (in)stability, the researchers looked in particular at the occurrence of three key events during the three-year follow-up periodIt was only possible to follow up mothers on this measure for three years because thereafter the information became too sparse to report on.: substance misuse; a permanent placement change for children; or return to court. Based on this measure, a significantly higher proportion of Family Drug and Alcohol Court than comparison mothers (51% vs. 22%) who had been reunited with their children were estimated to have experienced no disruption to family stability at the three-year follow-up.
Other events considered included domestic violence, mental health issues, a subsequent baby, neglect and abuse, a permanent placement, and emotional and behaviour problems among children. Over the five-year follow-up period around a quarter of all reunified mothers were estimated to have experienced domestic violence or mental health issues; approximately one fifth of Family Drug and Alcohol Court and comparison mothers gave birth to subsequent children; and around one fifth of Family Drug and Alcohol Court and over one third of comparison children experienced neglect.
The findings suggest that the Family Drug and Alcohol Court was more successful than ordinary services in helping parents to sustain substance misuse recovery, minimising risk, and keeping families together. However, qualitative evidence collected from case files in relation to ‘life events’ highlight the continued challenges faced by families in both groups. The insight that the two years after proceedings was the period of maximum risk suggests that support in these first two years is important, and could for many parents be a useful way of preventing problems from accumulating and getting a hold.
As the case characteristics of the two groups were well matched, it is reasonable to infer that participation in the Family Drug and Alcohol Court was the main determinant of the better Family Drug and Alcohol Court outcomes at the end of proceedings. As well as access to intensive treatment through the court, a significantly higher proportion of Family Drug and Alcohol Court families received substance use and family support services during the care proceedings than comparison families, according to the 2014 report. This was due to the work of the Family Drug and Alcohol Court team in coordinating services and the approach taken to keep families engaged.
The services were highly valued by the parents who appreciated easy access to the team, ongoing support, insight, and practical help. Just as important as receipt of services was the parents’ view that the process was fair, respectful and empowering. The unique role of the judge as both mediator and problem-solver was highly appreciated. Parents with experience of ordinary care proceedings repeatedly emphasised that “in ordinary proceedings they felt they had no voice and did not understand the process”.
The encouraging results in relation to family reunification could have financial implications, with some likely longer term savings to courts, the Legal Services Commission, children’s social care, and adult services and health services, as outlined in the recent report from the Centre for Justice Innovation.
The report makes the following recommendations:
• Extend the availability of Family Drug and Alcohol Courts, and preserve them in the long-term.
• Local health and adult social services to contribute to the funding required for the specialist Family Drug and Alcohol Court teams.
• To enhance the prospects of lasting and safe reunification, in higher-risk cases, more multidisciplinary support should be made available to mothers and their children in the first two years after reunification.
commentary The findings suggest that we can be optimistic about the Family Drug and Alcohol Court – it was found to be more successful than ordinary proceedings in minimising risk, keeping families together and helping parents to sustain substance use recovery over the five-year follow-up period. But, as the authors said, it is “not a panacea”. Indeed many families from both groups continued to be vulnerable and encounter difficulties, highlighting the enormous challenges faced by this cohort, and the professionals trying to help, even with the mechanisms of the specialist court.
many parents experienced the ‘toxic trio’ of substance misuse, mental health difficulties and domestic violence
Their earlier evaluation noted that none of the cases were ‘easy’: “The parental profiles reinforced the picture found in other studies of the many difficulties parents experience in addition to substance misuse, especially the so-called ‘toxic trio’ of substance misuse, mental health difficulties and domestic violence.”
Although parental substance use was the focal point of the cases in the featured evaluation, mental health issues (37% Family Drug and Alcohol Court cases and 40% ordinary proceedings) and domestic violence (71% and 64%) were very prevalent. In fact, according to a sister studyThe study also involved observations of 46 hearings in 10 Family Drug and Alcohol Courts, and interviews with 12 Family Drug and Alcohol Court judges. involving observations of court hearings and interviews with judges, domestic violence and/or parental mental health difficulties were sometimes deemed the more pressing problems.
A previous analysis revealed that the likelihood of substance misuse cessation and subsequent reunification in the Family Drug and Alcohol Court was lower among people experiencing domestic violence, using crack cocaine, and/or with a history of more than five years’ contact with children’s services; while length of substance use history, older children, or the mental health profile of the mother was not found to be predictive or successful outcome in either group.
An Effectiveness Bank hot topic has delved into the challenges and opportunities of working with people with overlapping or coexisting mental health and substance use issues. One of the main issues that emerged was the preoccupation in the literature and in practice about understanding which comes first, the substance use issue or mental health issue – which is chicken, and which is egg? And following on from this, which agency should take the lead? What might initially sound pragmatic has actually helped to foster a climate of fragmented services. This problem is circumvented in the Family Drug and Alcohol Court as it brings relevant professionals around the table at the same time to understand the holistic needs of the parent and family. This includes services for substance use (community and residential), mental health (GPs, psychiatric hospitals, and community psychiatric nurses), parenting (Strengthening Families, Strengthening Communities or the Webster Stratton Incredible Years), housing, and domestic violence.
Family drug and alcohol courts were first implemented in the United States in the 1990s, and migrated to the UK in 2008. Here two juvenile court judges who have presided over courts in the US from the beginning describe how they came about:
“… It took us a rather long time to realize that our children’s services agencies and we as judges did not have the expertise to assess for substance abuse, design treatment plans, or monitor treatment effectively. We knew that the parents were unlikely to be able to assess their own needs because in most cases they resist acknowledging the extent of their addiction. Thus, it was a logical step for us to reach out to the substance abuse treatment community and invite them into our courts to create a process in which they would advise us about our clients’ substance abuse treatment needs and then provide that treatment.”
London was the home of the original UK Family Drug and Alcohol Court pilot (analysed here and in the Effectiveness Bank). The courts are now present in four London boroughs (Camden, Islington, Lambeth, and Southwark), along with Milton Keynes and Buckinghamshire, East Sussex, Coventry, West Yorkshire (Leeds, Bradford, Kirklees, Calderdale and Wakefield), South West Peninsula (Plymouth, Torbay and parts of Devon), Kent and Medway, Gloucestershire, and Southampton. Though the National Unit for Family Drug and Alcohol Courts aims to extend the benefits of the court to more children and families and more areas, it seems not all local authorities are yet convinced by the model. A paper published by the Department for Education in 2016 reported that some local authorities had “considered using [the Family Drug and Alcohol Court] but were not actively pursuing it” – the main reason being the “lack of interest from the judiciary.”
“There is no appetite [for the Family Drug and Alcohol Court …]. Even if you took away drugs and alcohol issues there are too many underlying factors in family circumstances that would lead to it not working”.
One local authority cited their alternative involvement with Strengthening Families, a model discussed in this Effectiveness Bank analysis, which they found to offer good support. Another had received Innovation Programme funding to appoint three workers to build specialist expertise in domestic violence, drugs and alcohol and mental health issues. And two local authorities were delivering the Cafcass Plus model, where family court advisers work with local authorities with the aim of diverting cases from care proceedings.
Substance use is a key factor in a large proportion of applications to the court, underscoring the need for interventions which are sensitive and responsive to this. A 2012 studyBased on a sample of cases (247 cases involving 401 children) received from 83 Local Authorities between 11th-30th November 2011., for example, found that substance use was a contributing factor in around two-thirds (61%) in England. Unlike the judge quoted above, many judges have found the non-adversarial and problem-solving approach of the Family Drug and Alcohol Court precisely what is needed to address the multiple, overlapping challenges families face.
This evaluation, and the ones preceding it, focussed on families going through care proceedings between 2008 and 2012. Since then a number of changes have come into effect. Perhaps most pertinent to the Family Drug and Alcohol Court was the introduction a 26-week time limitWith discretion to the court to extend cases by up to 8 weeks at a time if deemed necessary. for completing care and supervision cases (under the Children and Families Act 2014). The implications of this were raised in the 2014 report, including professionals’ concerns about the “extent to which this will help or hinder attempts to improve outcomes for children affected by parental substance misuse” – that it will, in theory, “reduce the time available to test parents’ motivation and ability to control their problematic drinking or drug use, through a therapeutic intervention overseen by the court.”
To view reports from the feasibility study, and evaluations in 2011 and 2014, click here. To hear parents and professionals explaining the Family Drug and Alcohol Court, click here. And for a more general perspective, read this Focus on the Families Effectiveness Bank hot topic about interventions with families affected by substance use.
For any questions on the larger body of research from Professor Harwin and colleagues, see this dedicated website or make contact directly using firstname.lastname@example.org.
Last revised 05 March 2017. First uploaded 03 February 2017
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HOT TOPIC 2017 Focus on the families
STUDY 2008 Final report on the evaluation of ‘Option 2’