GETTING OUR PRIORITIES RIGHT (GOPR)

Chapter 1

DESCRIBING THE CHALLENGE

This first chapter describes the challenge and provides a snapshot of substance use in Scotland. It also summarises some of the general and specific effects of parental problem alcohol and/or drug use on the well-being of children and their families and at key stages.

This chapter is divided into two main sections:

• Describing the challenge - including describing how many children are affected by their parent's problem alcohol and/or drug use.
• Examples of Impacts - on all stages of children's lives and on the family and also describes factors that may help to minimise these impacts.

For practitioners' ease of reference, the key messages from this First Chapter are summarised below.

SUMMARY MESSAGES FROM CHAPTER ONE - DESCRIBING THE CHALLENGE

Describing the Challenge

Substance use is associated with a large variety of drugs from all major groups, illegal, prescribed and legal. Its effects on families can vary greatly.

For the purpose of this guidance we generally refer to problem alcohol and/or drug use as the stage when the use of drugs or alcohol is having a harmful effect on a person's life.

Pregnancy and pre-conception stages are the earliest - and most critical stages - at which services can put in place effective interventions that will prevent long-term harms to children and families.

Early identification of concerns should indicate what interventions are required to protect children.

Examples of Impacts

No safe level of alcohol use during pregnancy has been established. Ideally services should be looking for early signs where children might be at risk.

Guidance at these stages tends to highlight lower thresholds of adult substance use before services should consider these interventions to protect children.

When considering an adult's ability to care for their child and parent effectively, services should take account of the combined effects of the use of different substances at any one time - and over time.

Services should take account of this when considering interventions to protect vulnerable babies and prevent longer-term harms.

Infants and children with Fetal Alcohol Spectrum Disorder - which may result from mothers drinking during pregnancy - can be particularly challenging to care for.

This condition has potential lifelong consequences.

In light of these severe impacts, it is vitally important that services work effectively at the critical pre-conception and pregnancy stages to advise women about sexual health planning, the consequences of drinking alcohol before and while pregnant and otherwise using substances.

In doing so they should follow the advice given by Scotland's Chief Medical Officer.

Services should take account of the effects of problem alcohol and/or drug use on all family members.

Having done so, they should put in place effective, strength focused supports that promote children's resilience to the harms caused by damaging substance use.

DESCRIBING THE CHALLENGE

WHAT ARE WE TALKING ABOUT

29. The Introduction to this Guidance set out that its purpose is to provide updated good practice for use by all services working with vulnerable children and families where problem alcohol and/or drug use is a factor.

30. It is perhaps helpful to first set out what is meant here by problem alcohol and/or drug use. There are various definitions that can be useful in understanding the impact of problem drug and/or alcohol use on an individual and others. The main categories are described below.

DEFINITIONS OF PROBLEM DRUG USE

31. The Advisory Council on the Misuse of Drugs (ACMD) defined 'problem drug use' in Hidden Harm (2003) as any drug use which has serious negative consequences of a physical, psychological, social and interpersonal, financial or legal nature for users and those around them.

32. ACDM further described this drug use as normally heavy, with features of dependence, and typically involves the use of one or more of the following drugs:

• opiates (e.g. heroin and illicit methadone use);
• illicit use of benzodiazepines (e.g. diazepam); and
• stimulants (e.g. crack cocaine and amphetamines).

33. Problem drug use can also include the unauthorised use of over the counter drugs or prescribed medicines.

DEFINITIONS OF PROBLEM ALCOHOL USE

34. Alcohol is by far the most popular substance in Scotland. Sensible drinking guidelines for men and women are far lower than most people think. The recommended guideline is that women should not regularly drink more than 2-3 units per day and that men should not regularly drink more than 3-4 units per day. Guidelines also recommend that everyone should have at least two alcohol free days per week, and should not binge drink (HM Government 2007, Scottish Government 2009a).

35. Over the course of a week, women should not exceed 14 units and men should not exceed 21 units. Recommended guidance is different for women trying to conceive or who are already pregnant.

36. Three types of problem drinking are defined by the World Health Organisation's International Classification of Diseases, 10th Revision (ICD-10): 'hazardous drinking'; 'harmful drinking'; and 'alcohol dependence'.

• Hazardous drinking refers to the consumption above a level that may cause harm in the future, but is not currently causing clear evidence of harm. This is typically taken to mean between 21 and 50 units a week for men and 14 and 35 units for women. Hazardous drinking may also includes 'binge drinking', commonly defined as excessive consumption of alcohol on any one occasion involving 8 units or more for men, and 6 units or more for women, even though they may not exceed weekly limits.
• Harmful drinking is defined in ICD-10 as a pattern of drinking that is currently causing evidence of damage to physical or mental health. Harmful drinking is usually taken to mean consumption at above 50 units per week for men and over 35 units for women.
• ICD-10 defines alcohol dependence as a cluster of physiological, behavioural, and cognitive phenomena in which the use of alcohol/drugs takes on a much higher priority for a given individual than other behaviours that previously had greater value. It typically includes:
  • a strong desire to take the substance;
  • difficulties controlling its use;
  • persisting in its use despite harmful consequences;
  • a higher priority given to substance use than to other activities and obligations;
  • increased tolerance to the substance; and
  • a physical withdrawal state.

37. Normally, a diagnosis of alcohol/drug dependence is made when three or more of the above criteria have been experienced or exhibited in the previous year. Relapse (or reinstatement of problem drinking or drug-taking after a period of abstinence) is also a common feature here.

PROBLEM ALCOHOL AND DRUG USE DURING PREGNANCY

38. There is guidance available on the use of alcohol and drugs for women who are pregnant, breastfeeding or trying to conceive. Guidance at these stages tends to highlight lower thresholds of adult problem alcohol and/or drug use before services should consider these interventions to protect children.

39. Pre-conception and pregnancy are the earliest, and most critical, of these stages at which services can put in place effective interventions that will prevent long-terms hams to children and families. ('Improving Maternal and Infant Nutrition: A Framework for Action' http://www.scotland.gov.uk/Publications/2011/01/13095228/188 - p.90 states that 'In addition to advice before pregnancy, during pregnancy women are advised to avoid alcohol completely.')

40. Drug use, at these critical stages, would be considered problematic, for example, where any woman reported regular use (i.e. more than once a week).

POLYDRUG USE

41. This term applies where individuals use more than one type of substance in a problematic way, or who are dependent on more than one type of substance e.g. alcohol dependent as well as opiate dependent (Department of Health 2007).

42. Practitioners should take into account the combined effect of the use of different substances at any one time - and over time - when considering an adult's ability to care for their child and parent effectively.

43. In general terms, problem alcohol and/or drug use may be evident where it has become apparent that substance use has become the person's central preoccupation to the exclusion of significant personal relationships. For the purpose of this guidance we refer generally to problem alcohol and/or drug as the stage when the use of drugs or alcohol is having a harmful effect on a person's life.

WHO WE ARE TALKING ABOUT

RECENT EVIDENCE OF ALCOHOL AND DRUG USE IN SCOTLAND

44. Informed policy making and planning at local and national levels should be based on an assessment - where possible - of the extent of the problem. In this case, this means the extent of drug and alcohol use in Scotland and also the numbers of children that might be adversely affected. These are described below.

DRUGS PREVALENCE

45. Recent trends show that, although drug use amongst the general adult population (16 years and over) and young people (13 and 15 year olds) has decreased over recent years, there are still an estimated 59,600 people (aged 15-64) with drug use problems in Scotland in 2009-10.

46. This estimate comes from the publication, Estimating the National and Local Prevalence of Problem Drug use 2009-10 (ISD Scotland 2011) and showed that the estimated number of individuals using opiates and/or benzodiazepines in Scotland increased between 2006 and 2009-10.

47. In 2006, there were an estimated 55,328 individuals using opiates and/or benzodiazepines in Scotland - or 1.62% of the population aged 15-64. In 2009-10 these figures had increased to 59,600 individuals or 1.71% of the same population.

48. Significant progress has been seen in access to treatment as a result of significant service redesign being implemented. For example, between October-December 2011, 85% of the 11,006 people who started their first treatment for drug or alcohol use had waited three weeks or less since their referral. Of these, 50% had waited one week or less. By March 2013, this figure is expected to be 90% which is in line with the national HEAT (A11) Drug and Alcohol Treatment Waiting Times Target.

49. The achievement of this target will work towards engaging problem drug and/or alcohol individuals with appropriate treatment services at an earlier stage. This is likely to achieve a higher rate of successful outcomes for the client, their children, family and the wider community. Information about drug and alcohol treatment waiting times is published on a quarterly basis and can be viewed at:
www.drugmisuse.isdscotland.org/wtpilot/waiting.htm.

ALCOHOL PREVALENCE

50. On the alcohol side, evidence shows that alcohol use remains severe in Scotland. Consumption and resultant harms are at high levels. Alcohol sales data suggests that consumption is almost a quarter (23%) higher in Scotland than in England and Wales, and has increased by 11% since 1994.

51. The recent Scottish Health Survey 2010 found that an estimated 49% of men and 38% of women exceed the daily and/or weekly limit and these are likely to be under-estimates. Indeed, sales data suggests that enough alcohol is sold in Scotland for every adult to exceed sensible weekly guidelines each and every week since at least 2000.

52. The findings of a recent report (Untold Damage: Children's accounts of living with harmful parental drinking) also suggest that in the UK a disproportionately large number of calls received by Childline from children concerned about a significant other's drinking come from Scotland.

53. The Scottish Government has invested in, and continues to, prioritise early intervention approaches. This includes by delivering Alcohol Brief Interventions (ABIs) for people drinking at hazardous and harmful levels. This is because there is strong evidence that these interventions are cost-effective in helping to prevent more serious problems from developing.

NUMBERS OF CHILDREN AFFECTED BY PARENTAL SUBSTANCE USE

54. The Scottish Government currently estimates that around 40-60,000 children in Scotland may be affected by parental problem drug use and that, of these, 10-20,000 may be living with that parent.

55. Analysis from the Scottish Health Surveys (SHeS) 2008-10 show that current estimates suggest that between 36,000 and 51,000 children are living with parents (or guardians) whose alcohol use is potentially problematic.

56. Estimating the numbers of these vulnerable children is recognised as complex. There are clear challenges in collecting data about these children. This is largely because of issues of stigma and secrecy surrounding problem alcohol and/or drug use and also the fear of repercussions. This means that substance using adults may not present to services for treatments and dependent children may still remain hidden even when they do present.

57. This can particularly be the case with children affected by problem parental alcohol use. These children are often less quickly identified by children's services than those in families with problem drug use (Forrester and Harwin 2008). This can result in an increased chance of harms to these children and also of them being left at risk.

58. The focus here has to be on ensuring that, once individuals, children and families are identified:

• they can access services promptly as these are needed;
• services communicate with children and families in a way that is non-stigmatising;
• services should be recovery-focused; and also
• services help the children and their families to improve their lives and that any progress can be evidenced.

IMPACTS ON CHILDREN AND FAMILIES

59. Together with an assessment of the extent of the problem, informed policy making and planning at local and national levels should also be based on an understanding of the consequences or impacts.

60. Some possible impacts on children of parental alcohol and/or drug use - and at key stages - are described below together with some of the factors that can help to reduce these.

GENERAL

61. In recent years, there has been a growing recognition in Scotland of the impact of problem parental alcohol and/or drug use on children and young people's lives. Children's experiences - even within the same family - can be very different and they can display incredible strengths in managing difficult situations, as can their parents.

62. Also, the Introduction to this Guidance stressed that not all parents who use substances experience difficulties with family life, child care or parenting capacity. Equally, not all children exposed to substance use in the home are adversely affected in the short or longer term.

63. That said, the impacts of parental problem alcohol and drug use can also have a very detrimental impact on the health and well-being of some children. Children can also be at increased risk of experiencing violence and maltreatment when living with parental problem drug and alcohol use. In children's calls to ChildLine, for example, high levels of physical abuse have been reported by children living with parental problem alcohol use in particular.

64. Child neglect is also a significant area of concern where problem parental alcohol and/or drug use is a factor. Neglect is described in the National Child Protection Guidance for Scotland 2010 as follows:

"Neglect is the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. It may involve a parent or carer failing to: provide adequate food, shelter and clothing, to protect a child from physical harm or danger, or, to ensure access to appropriate medical care or treatment. It may also include neglect of - or failure to respond to - a child's basic emotional needs." (Scottish Government 2010)

65. A study of kinship care in Scotland commissioned by the Social Work Inspection Agency found that two thirds of children were no longer living with parents due to problem alcohol and/or drug use and for reasons of neglect.

66. Neglect continues to be a significant challenge for services in Scotland. As at 31 July 2011, 43% of all children on child protection registers were registered because of physical neglect. There is considerable evidence that neglect is often linked with parental problem alcohol and/or drug use. Notwithstanding this, there is limited evidence of the effectiveness of interventions to tackle neglect. The evidence that there is, points to the need for early intervention approaches in order to make a significant difference.

SOME SPECIFIC EXAMPLES OF IMPACTS

PRE-CONCEPTION AND PREGNANCY

67. Women and their partners are often incentivised to improve their problem drug and alcohol use when either trying to conceive or are about to become parents. Services, working together effectively at these stages can help them to achieve this. These stages may be termed the earliest of interventions. Many factors affect the outcomes of pregnancy and the health and well-being of mothers and babies. Substance use is only one factor.

68. Maternal alcohol and/or drug use can harm unborn babies in different ways at different times during pregnancy, increasing the risk of complications such as low birth weight, miscarriage, prematurity and stillbirth. Some babies are born dependent on alcohol and drugs and can develop withdrawal symptoms - known as Neonatal Abstinence Syndrome (NAS).

69. Neonatal withdrawal symptoms vary in onset, duration and severity. Some babies can be very unwell for days or weeks and can require close observation and special medical and nursing care.

70. NAS can also have an impact on attachment, parent-infant interactions, and the infant's longer-term growth and development.

FETAL ALCOHOL SPECTRUM DISORDER (FASD)

71. There is currently only limited evidence of the overall extent or prevalence of Fetal Alcohol Spectrum Disorder (FASD). However, it is known that a baby affected by maternal alcohol use during pregnancy can be born with FASD which describes the range of effects associated with a baby exposed to alcohol in the womb.

72. FASD can resemble other conditions and is difficult to diagnose. As a result, the number of children in the UK with FASD is not accurately known but it is estimated that FASD occurs in as many as 1 in 100 live births. Infants and children with FASD can be particularly challenging to care for as the condition is irreversible. Any effects are lifelong.

73. For these reasons it is vitally important that services work effectively at the critical pre-conception and pregnancy stages to advise women about the consequences of drinking alcohol at these stages. In doing so they should take account of advice from Scotland's Chief Medical Officer.

74. It is best to avoid alcohol completely during pregnancy as any alcohol you drink while pregnant will reach your baby and may cause harm. Women who are trying to conceive should also avoid drinking alcohol. There is no 'safe' time for drinking alcohol during your pregnancy and there is no 'safe' amount. We do know that the risk of damage increases the more you drink. Drinking no alcohol during your pregnancy is the best and safest choice.

75. Children with FASD display a variety of effects ranging from learning difficulties, having poor social and emotional development, hyperactivity and attention disorders, having difficulty understanding rules, cause and effect, receptive and expressive language, and problem solving and numeracy. These children will not follow general patterns of learning or be able to re-apply rules and principles learnt from one situation to another.

BLOOD BORNE VIRUSES

76. Injecting drug use is associated with an increased risk of blood borne virus infections i.e. HIV, hepatitis B and hepatitis C. HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). Hepatitis B and hepatitis C are viruses which affect the liver, people with long term infection are at increased risk of serious liver disease and cancer.

77. Children can be at risk of blood borne viruses through:

• Mother-to-child transmission (during pregnancy, childbirth and breastfeeding).
• 'Household contact' (i.e. living with adults or other children who are infected with blood borne viruses where sharing of items such as razors and toothbrushes may take place, or blood to blood exposure is possible).
• Accidental injury involving used injecting equipment e.g. a needle-stick injury.

78. Children and families affected by blood borne viruses often require additional help and support in order to help them cope with the diagnosis, treatment, illness and stigma (CHIVA 2010).

INFANCY AND PRE-SCHOOL YEARS

79. Babies are particularly vulnerable to the effects of physical and emotional neglect or injury. This can have damaging effects on their long-term development. The following examples illustrate possible harms to babies where parental problem alcohol and/or drug use is a factor:

• Neglect can occur while the parent/carer is under the influence of substances, unaware of what is going on around him/her.
• Unhappiness, tension and irritability parents under the influence of substances - coupled with a lack of commitment to parenting when preoccupied with substance use - may lead to inappropriate responses to the child.
• Poor or inconsistent parenting may damage the attachment process.
• Poor childcare, little stimulation or inconsistent and unpredictable parental behaviour may hinder the child's cognitive or emotional development.
• Lack of contact with other children, when attendance at nursery is irregular or erratic, may compound early deficits in social and emotional development.
• Generally children can become withdrawn and isolated and develop an inability to form relationships.
• Emotional difficulties should be ameliorated early to avoid more serious mental health issues from developing.
• The financial demands of problem alcohol and/or drug use may mean that the child's material environment is poor.
• Physical or emotional rejection may prevent children from developing a positive sense of identity and self-esteem.
• Children may have their physical needs neglected, for example they may be unfed or unwashed.
• They may be subjected to direct physical violence by parents, and learn inappropriate behaviour through witnessing domestic abuse.
• When parents' behaviour is unpredictable and frightening, children may display emotional symptoms similar to those of post-traumatic stress disorder.

PRIMARY SCHOOL YEARS

80. At primary school age, children:

• May be at increased risk of injury, and show symptoms of extreme anxiety and fear of hostility.
• May develop poor self-esteem and blame themselves for their parents' problems.
• May be affected negatively by parental neglect or disinterest negatively, especially with regards to academic attainment and attendance.
• Experience distress and disrupt education and friendship patterns as a result of unplanned separation. Parents' behaviour can make children feel embarrassment and shame, and as a consequence they curtail friendships.
• May take on too much responsibility for themselves, their parents and younger siblings. These children are young carers although they may not identify themselves as such.

SECONDARY SCHOOL YEARS

81. Children coping with puberty without adequate parental support may be at increased risk of the following.

• They may become increasingly beyond parental control and run a greater risk of injury by parents.
• There is an increased of emotional disturbance and conduct disorders, including bullying.
• They may be increasingly embarrassed and anxious about how to compensate for physical neglect.

82. If a children's family problems affect concentration:

• They may be prone to being bullied themselves.
• Their attainment in school may not match ability.
• They may struggle to attend school due to meeting the needs of their parents and siblings.
• Children looking after their parents or siblings (i.e. young carers) are particularly disadvantaged and experience significant disruption to their education.
• They may fear family break-up, or reject their family altogether. They are often wary of exposing family life to outside scrutiny, so friendships are restricted, and they become isolated with no one to turn to.

83. Young people in families - where other family members misuse drugs and/or alcohol - may develop early problems with drugs and alcohol themselves.

QUOTES

Quarriers Carer Support Service (Moray)

"No-one tells me what's going on. I don't know what doctors are telling my mum and dad about what's wrong with them. I don't know what's going to happen to them".

PREVENTATIVE AND PROTECTIVE FACTORS

84. Some of the impacts on children and families described in the previous part of this Chapter might be minimised by other factors. Children and young people need support in dealing with what are often confused feelings and emotions towards their parents and families. They need strategies to help them cope with the various consequences of their parent's problem alcohol and/or drug use.

85. Resilience is a process of interaction between the individual and the life around them. Therefore it is potentially open to influence. We may be able to link the resilience of children and the recovery of the parents. Shared characters may be:

• Planning.
• Self-esteem and confidence.
• Self-efficacy.
• The ability to deal with change.
• Choices that can be made.
• Previous experiences of success and achievement.

86. However resilience may not always be positive. We need to guard against the view that resilience in children will protect. It may do, along with other protective factors, but it may also mask the 'hidden' needs of such resilient children.

87. Effective interventions tend to target the whole family. These can include focused supports for children, focused supports for adults and then bringing these together to achieve a 'whole family' approach.

88. Examples of types of supports might include:

• Practical support e.g. help to establish household routines; e.g. morning and evening support.
• Family therapy.
• Children's skills training.
• Cognitive and behavioural parenting skills training.
• Couple therapy.

89. These work to promote resilience and increase together with reducing substance use and related substance harms.

90. These types of interventions can also increase other protective factors which - where in place - can improve a child's overall circumstances. Examples of protective factors include:

• sufficient income and good physical standards in the home;
• a consistent and caring adult, who will provide for the child's needs and give emotional support;
• regular monitoring and help from health and social work professionals, including respite care and accommodation;
• an alternative, safe residence for mothers and children subject to violence and the threat of violence; regular attendance at nursery or school;
• sympathetic and vigilant teachers; and
• belonging to organised out-of-school activities, including homework clubs.

91. It is important that services take account of the effects of problem adult alcohol and/or drug use (and any wider related issues - see Chapter 2 and Related Issues section) on all members of a family. Having done so, they should put in place effective supports that promote children's resilience and repair harms caused by damaging substance use.

92. For practitioner's reference - examples of some types of effective family interventions that have been used where substance misuse is a factor were described in literature review undertaken by the Scottish Child Care and Protection Network (SCCPN) which can be viewed at
www.sccpn.stir.ac.uk/documents/MitchellBurgess2009PSMResearchReview.pdf