Report Abuse Report Abuse

1.5.3 Children of Drug and Alcohol Misusing Parents

AMENDMENT

This chapter was amended in February 2014. Section 2, Recognition and Identification of Risk Factors, Procurement of Drugs or Alcohol has been revised to include reference to safe storage.


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 Working Practice and Communication


1. Introduction

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

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 updated in 2006, which 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.

Hidden Harm - 'Responding to the needs of children of problem drug users' a report by the advisory council on the misuse of drugs (2003) delivered 6 key messages from their enquiry.

  • They estimate there are between 250,000 and 350,000 children of problem drug users in the UK - about 1 for every problem drug user;
  • Parental drug use can and does cause serious harm to children at every age from conception to adulthood;
  • Reducing the harm to children from parental drug use should become main objective policy and practice;
  • Effective treatment of the parent can have major benefits for the child;
  • By working together services can make practical steps to improve the health and wellbeing of affected children;
  • The number of affected children is only likely to decrease when the number of problem drug users decreases.

The report goes on to make 48 recommendations aimed at improving data collection, understanding the impact of parental drug use on children, listening to children, improving treatment provision and social care intervention, improving maternity primary care, children's services and service's delivered to female offenders. Link: Gov.uk website.

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 family, social or support systems;
  • Issues relating to criminal activities;
  • Poor health;
  • Poor environment.

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

It is essential to share all concerns with senior practitioners/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. Documentation of concerns and risk is vital.

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).

Concerns about a child or young person

Substance use/misuse (legal or illegal drug usage and/or alcohol consumption) by parents and/or carers does NOT on its own automatically indicate that children are at risk of abuse or neglect, although it is essential that practitioners 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 likely to suffer significant harm, a referral must be made to Children Social Care Services (All professionals must confirm verbal and telephone referrals in writing within 24 hours of being made).

In cases where a child/ren is not thought to be suffering, or likely to suffer significant harm, a Early Help Assessment should be carried out by a professional working with the family, and relevant action taken accordingly (Please see Early Help Assessment Procedure for more information).


2. Recognition and Identification of Risk Factors

Parental Drug/Alcohol Use

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 drug and alcohol combined with drugs.

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.

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.

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.

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.

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/ascertain

  • 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 or prescribed?
  • Are the parents working with any other agencies and who are they?
  • 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 patterns 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? What triggers any changes in use?
  • 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 all the prescribed medications stored safely and have you checked?
  • Is the medication taken as prescribed? Is the medication consumed in the pharmacy?
  • 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 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 - increase in stability, decrease in stability?

Procurement of Drugs and Alcohol

There may be identifiable risks to a child in relation to the ways in which a parent /carer obtains substances.

Consider the following:

  • 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? (Current illicit prices should be checked with other drug treatment services) 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? If a parent is sex working consideration needs to be given to the risks that a pimp may pose to the adult and to 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 supportive family members available to help care for the child?

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 usages 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.

Part of any assessment should include questions about where drugs, alcohol and other substances are stored, and, if parents/carers are injecting drugs, how drug using paraphernalia, needles, syringes, filters, spoons and pipes, are stored and 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.

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 Referral, Investigation and Assessment and also specific practice guidance relating to Adult Mental Health and Child Protection Guidance mental health issues and child protection is available).

Consider:

  • If parents/carers are intravenous drug users, do they share injecting equipment?
  • Does the parent/carer know how to respond to an overdose situation?
  • Do older children know how to respond to an overdose situation?
  • Do they use a needle exchange scheme?
  • How do they dispose of drug using paraphernalia?
  • Is the parent/carer aware of the health risks associated with injecting/using drugs?
  • 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?
  • 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? This includes safe storage at home and also if they need to use it outside the home;
  • 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 pregnant? If so, is the parent/carer aware of the risks to the unborn child?
  • Has the parent/carer been referred to a Community Drug Team for treatment?

Perception Held by Parent/Carer of the Situation

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 achieve abstinence.

It must not be assumed that when/if a parent/carer becomes drug/alcohol free they will be a 'better' parent/carer, as children can become confused when a parent/carer becomes drug free as their behaviour towards them can change. Abstinence/stability can be a 'risky' time for children who begin to experience the parent putting in boundaries and routines.

Consider:

  • Does the parent/carer see the drug/alcohol use as harmful to: themselves, their child and 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?
  • 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 there somebody else that can?
  • 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)? It is good practice for this to be discussed at the first meeting;
  • What is the parent's/carer's capacity to work towards change, willingness and motivation to work towards change?
  • Capability, form of support required, availability of support?
  • What will prevent/stop work towards change and provision of basic needs?

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.

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. Are their health needs being addressed?

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.

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:

  • Are 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)? Consider support via a young carer's organisation.

Accommodation and Home Environment

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, including whether they are substance misusers and the extent of their involvement in the care of the child, also need to be considered.

Consider:

  • Is the accommodation adequate for the child, bearing in mind the child's development needs?
  • 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 and what risks do they pose?
  • Is there any conflict and what impact does this have on the child? If they are, is there conflict?
  • What impact does this have on the child?
  • Do they take responsibility for the child?
  • Is the family heavily involved in a network of similar/problematic drug or alcohol users?
  • What is the effect on them?
  • 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)? Social Workers need to check police intelligence and reliability of this information.

Child's Developmental Profile

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.

Some children may be using substances or have a detailed knowledge about them. Some children may adopt a caring role either for younger siblings or their parents and taking responsibility for household tasks. This may lead to higher than average absentee rates from school.

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 can be a protective factor but the quality of that detachment needs to be assessed);
  • 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);
  • Does the child know what is expected of them and are they exhibiting behavioural issues?
  • If the child is isolated from extended family and friends 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/experiencing from parents and other carers and are there any other reasonable role models?
  • Does the child need specific drugs/alcohol education to reduce their own risk of substance misuse (and can support be found for this)?

Family Social Network and Support Systems

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. Often family members are not aware of the substance use. 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.

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.

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 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?
  • What has been tried to support the family already?
  • 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.


3. Relapse Prevention

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

Consider:

  • A 'lapse', one off use;
  • Relapse - a resumption of old behaviours and thought processes;
  • What substances were used?
  • When did the drug use cease?
  • Are any other substances going to continue to be used?
  • Has the drug use ceased in conjunction with another person, what if they start again?
  • What is the reason for cessation of use?
  • How did the drug use cease (e.g. abrupt withdrawal, Methadone reduction, community detoxification, inpatient detoxification, rehabilitation unit, long-term residential programme, unsupported)?
  • What has changed since the use has ceased, in the adult's life and children's life?
  • What strategies are used to sustain a drug-free lifestyle?
  • What support is available?
  • When is the greatest risk of relapse/lapse?
  • What would be done if vulnerability to relapse/lapse was felt?
  • What positives and negatives are seen in a drug-free lifestyle for the adult/children?
  • What action would be taken if relapse/lapse occurred (who would you tell etc)?
  • Are you willing to provide urine samples or swab tests to prove substance-free status?
  • Who would you work with to prevent relapse/lapse in the future?


4. Pregnancy and Drug Use

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.

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 seek to achieve abstinence or maintenance on prescribed medication. For others, the emotional turmoil and complex social problems e.g. domestic violence, insecure housing may make it unrealistic to achieve abstinence but they may be able to make significant reductions in their use thus reducing risk. Treatment should be tailored to realistic achievable goals.

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).

In Leicestershire a multi-agency approach to pregnancy and substance use (including alcohol) 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. UHL employs a Specialist Substance Misuse Midwife that works across drug and alcohol treatment (and including women receiving treatment in a criminal justice setting) and obstetric care.

Access to advice, assessment and treatment is offered and they can be seen either in clinic, at home, at the GP's surgery or at Community Teams; supported by a robust risk assessment. Substance using partners are also offered treatment. Their care is planned and co-ordinated by the professionals that are involved. They take responsibility for liaison and consultation with community midwives, health visitors, GPs, social workers, post-natal wards, Neo Natal Unit (NNU) and a multi-disciplinary team review takes place to enable progress to be shared, problems resolved and further planning to be addressed. This arena is ideal for monitoring safeguarding concerns. These issues are assessed continually with a woman (and her partner) and referrals to Children's Social Care Services or other agencies are made as appropriate.

Safeguarding 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 safeguarding concerns.

Following referral to Children Social Care a decision will be made whether a pre-birth assessment will be necessary. The outcome may be a family support package or Section 47 Enquiries may be instigated. For more information see Referrals to Children’s Social Care Procedure.

Access to antenatal and postnatal 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.

Some babies may experience withdrawal symptoms related to the maternal opiate use. Advice and information are provided to the family regarding neonatal abstinence syndrome, foetal alcohol syndrome, foetal alcohol effects and the use of crack, benzodiazepines and smoking in pregnancy. Postnatal care will include a period of monitoring on the postnatal ward for a minimum of 3 days to assess for any neonatal abstinence syndrome; it is also an opportunity to assess attachment, basic care delivered to the baby and for advice and information to be given to the parents, foetal alcohol syndrome and foetal alcohol effects. This may include a period of monitoring and/or treatment for neo-natal abstinence syndrome. 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.  For more information see Initial Child Protection Conferences Procedure.

The service offered is Leicestershire-wide, but some women may not wish to deliver at Leicester hospitals. Strong links have been made with obstetric units outside of Leicestershire e.g. Nottingham, Nuneaton, Peterborough.

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. There is an agreed prescribing protocol in place.

Some women may not have disclosed their substance use during pregnancy. This may only have become apparent during delivery or postnatally. Referral to the appropriate service 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 and young people's services if appropriate.

Women who "fall out" of the system or do not access treatment are tracked through other agencies, e.g. New Futures (a street agency for working prostitutes), and although they may not be in contact their care for delivery and post neo-natally can be planned.

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'.

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 pregnancy?
  • How is the safety of the baby maintained during parental drug/alcohol use?
  • What support mechanisms do the family already have in place?
  • Are they in touch with antenatal care and if not ascertaining the reason why?
  • Is the parent aware of the potential risks to their baby?
  • What preparations have been made for the new baby?


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

5.1 Dual Diagnosis and Assessments: An Overview

The term dual diagnosis has been applied to a number of different groups of people with two co-existing conditions such as personality disorder and mental health problems and learning disability and mental disorder. However, the term is also used to refer to a group of people who have co-existing problems of mental disorder and substance misuse. (Royal college of Psychiatrists (2002) which the individual may experience concurrently. The nature and interaction between these two conditions is complex.

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, cocaine, crack and cannabis use. In these cases the cessation of substance misuse may lead to the cessation of the acute psychiatric episodes;
  • Withdrawal from some substances can lead to mental health problems e.g. anxiety and depression.

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

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

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 is 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. Care planning approach can be utilised for clients with complex mental health problems to be assessed, treated and reviewed in an effective way.

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. Individuals with a personality disorder would be included within this group. 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.

5.2 Prevalence

It is difficult to measure exact levels of substance misuse both in the general population and in those with mental health problems. It is thought to be around 50% (DOH 2006).

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 followed by cannabis;
  • 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 2002 2006 Bradley Report 2009)


6. Inter-Agency Working Practice and Communication

6.1 Taking action when there are concerns about a child or young person

In cases where a child/ren is not thought to be suffering, or likely to suffer significant harm, a Early Help Assessment should be carried out by a professional working with the family, and relevant action taken accordingly (Please see Early Help Assessment Procedure for more information).

If there are concerns that a child or young person is suffering, or likely to suffer significant harm, the professional should make a referral to Children's Social Care Services. See Referrals to Children’s Social Care Procedure.

6.2 Role Clarity

When more than one agency/worker contributes to Early Help Assessment there must be:

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

6.3 Confidentiality

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.

6.4 Regular Communication

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 suffering, or likely to suffer Significant Harm.

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.

The following issues should be given particular attention:

  • Are the parents/carers likely to co-operate with family support as well as drug/alcohol intervention and how will this cooperation be measured?
  • 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, conflict and anxiety;
  • Detoxing can be difficult, and a drug/alcohol using parent may require additional childcare support during this process. Children can experience post-detoxification confusion as there is a change in the parental behaviour towards them, including change of boundaries and routines and discipline. The child should receive support in their own right to help them deal with their feelings, if available. 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. Is this a Private Fostering arrangement (adoption and fostering 2002)?
  • Where the parent/carer or child has a physical disability or learning disability, additional consideration will be necessary e.g. exploitation by other users;
  • 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?

References

Commonly misused substances: Drugscope

Guidelines for professionals assessing risks when working with substance using parents: Link: Gov.uk website

Services for parents: Link: Gov.uk website

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