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5.14 Drug Misusing Parents/Carers

RELATED NATIONAL GUIDANCE

Hidden Harm - Responding to the Needs of Children of Problem Drug Users, Advisory Council on the Misuse of Drugs (ACMD)

Chapter 1: Assessing need and providing help, Working Together to Safeguard Children 2015

Foetal Alcohol Syndrome, FAS Aware UK 

RELATED LOCAL GUIDANCE

Safeguarding Children Living with Substance Using Parents/Carers (Blackburn with Darwen) - to follow

Blackburn with Darwen Triage Assessment Tool

Blackburn with Darwen Screening and Referral for Triage Form Substance Misuse

RELATED CHAPTERS

Drug Misusing Parents/Carers Procedure

Information Sharing and Confidentiality Procedure

AMENDMENT

In November 2013, this chapter was updated in line with Working Together 2013.


Contents

  The Impact on Children and Families
  Eight Golden Rules
  Confidentiality and Information Sharing
  Assessments
    Initial Screening Assessment
    Checklist
    Children in the Family - Provision of Good Basic Care
    Describing Parental Substance Use
    Accommodation and Home Environment
    Procurement of Drugs
    Health Risks
    If the Parent(s) Inject:
    Family and Social Supports
    Parent's Perception of the Situation
    Child Centred Assessment
    Key Areas that could be Explored
    Analysis: Making Sense of the Information
  Pregnancy and Neo-Natal Care


The Impact on Children and Families

  1. A child's growth and development depends on a variety of interacting social and biological factors, which can be broadly grouped into three categories: conception and pregnancy, parenting, and the wider family and environment.
  2. Hidden Harm - Responding to the Needs of Children of Problem Drug Users (ACMD 2003) outlines the way in which problem drug use can impact on the development of children in affected families.
  3. Throughout their lives children may need the services of various professionals. Positive interventions at different stages of their growth and development can contribute to children and young people reaching their full potential. Effective collaboration, good joint working and a sharp focus on the family as a whole are essential if children of substance misusing parents are to receive appropriate care and support.
  4. It is recognised that there may be barriers to agencies working together; however, these must be addressed to ensure that all agencies act together appropriately and at the right time in accordance with the needs of children and young people. All agencies have a part to play in helping to identify problems at an early stage. Basic information should be gathered about the family and household circumstances of those who misuse substances.


Eight Golden Rules

  • Problem substance users normally want to be good parents;
  • Problem substance users should be treated in the same way as other parents whose personal difficulties interfere with their ability to provide good parenting;
  • Base your judgements on evidence, not optimism;
  • There will be many aspects of the child's life that are nothing to do with drugs or alcohol and may be equally or more important;
  • Recognise that the parents are likely to be anxious. They may be worried that they could lose their children. Children, especially older ones, may also share similar anxieties;
  • Do not assume that abstinence will always improve parenting skills;
  • The family situation will not remain static, assessment should be revisited at least every six months or when ever new concerns arise; whichever is sooner;
  • Understand what is the child's experience of living with substance misusing parents; speak to them alone or with an advocate.


Confidentiality and Information Sharing

  1. See Information Sharing and Confidentiality Procedure. As in all situations of actual or possible harm to children the right to share information overrides the individual's right to confidentiality.


Assessments

  1. When assessing the well-being of a family, agencies must look at the parents' drug and/or alcohol use from the perspective of the child to understand the impact this has on the child's life and development. Each child should be considered on an individual basis. It is important to consider that parents often do not stop using drugs or alcohol when they have children although it can often be a strong motivator for change.

Initial Screening Assessment

  1. All agencies which engage with adults with substance use, in any capacity, must ask the following questions:
    • Are you a parent?
    • How many dependent children are you responsible for?
    • If the adult is under the influence of a substance or if the adult is in custody or receiving medical attention, ask where are the children currently?
  2. Agencies supporting adults who are problem substance users should in addition obtain the following information in their initial screening assessment:
    • The child(ren's) age and gender;
    • Who is their primary carer?
    • Which school or nursery do they attend, if aged two years or over?
    • Who else is living in the household?
    • Are there support agencies in touch with the family who are supporting the children (identify the child's Health Visitor, GP, School Nurse, Children's Centre, Drugs worker and, where involved, Social Worker). Is there is a Lead Professional?
    • How do parent(s) views the impact of their substance use on their child?
    • Can the extended family and / or friends can help?
    • Are there any other agencies voluntary or statutory available to help?
    • Is the parent/s willing to accept help?
    • Is there a risk of losing their accommodation?
    • Has a Common Assessment Framework (CAF) been completed? If answer is no, do you now need to commence a CAF?
  3. This information may be obtained through the course of normal agency work over a period of time or in one session specifically designed to do so, depending on the agency's remit and normal working practices. It is recognised that consultation with other agencies may be necessary to complete this assessment (Social Work, Health, Education, Housing, Voluntary Sector agencies.) Where there are immediate child safety issues these should be referred on to Children's Social Care or the Police.
  4. During work with substance users who are parents; agencies should be alert to stresses arising from the substance use, which are likely to impact on children. Professionals should advise and discuss with parents the harmful impact of their continued substance misuse on their children.
  5. When assessing parental substance misuse the following two models give an overview of the process. Examples of specific questions and areas for consideration and expansion are also detailed. To ensure good multi-agency working and information sharing, this assessment must be entered onto a CAF in line with local guidance

Click here to view the Assessment Framework Triangle Model

Click here to view Assessment Process Model

Checklist

  1. All Staff should be able to answer the following questions:
    • Are children usually present at home visits, clinic or office appointments during normal school or nursery hours?
    • What reason has been given for the child being absent from school?
    • Is the child attending school/nursery regularly?
    • Is the child punctual for school/nursery?
    • Do parents think that their child knows about their drug use?
      • How do they know?
    • What arrangements have been made for the children when the parent goes to get illegal drugs or attends for supervised dispensing of prescription drugs?
    • How much money does the family spend on drug use? What % of the weekly income does this come to?
      • Is the income from sources presently sufficient to feed, clothe and provide for children in addition to obtaining substances?
    • Who will look after the children if the parent is arrested or is unable to care for them?
    • What arrangements are made for storing any drugs or prescription medication?
  2. When deciding whether a child may need help, agencies should consider the following questions:
    • Are there any factors which make the children particularly vulnerable, e.g. very young child, other special needs such as physical illness, behavioural and emotional problems, psychological illness or learning difficulty, threatened or actual loss of accommodation?
      • Consider the needs of the unborn child.
    • Are there any protective factors that may reduce risk to the child? (It may be necessary to consult with specialist children's service workers to determine this.)
    • How does the child's health and development compare to that of other children of the same age and in similar situations?
    • What kind of help do you think the child needs?
    • Do the parents perceive any difficulties and how willing are they to accept help and work with professionals?
    • What do you think might happen to the child? What would make it more or less likely?
    • Is there suspicion of neglect, injury or abuse, now or in the past? What happened? What effect did/does that have on the child? Is it likely to recur?
    • Is the concern the result of a single incident, a series of incidents or a culmination of concerns over a period of time?
    • What does the child think? What do other family members think? How do you know?

Children in the Family - Provision of Good Basic Care

  • How many children are in this family?
  • What are their names and ages (wherever possible, include dates of birth)?
  • Are there any children living outside the family home and, if so, where? Why, and with whom?
  • Do the parents see any of the children as being particularly demanding?
  • Are there any other special circumstances such as illness, disability which need to be considered?

For each child:

  • Is there adequate food, clothing and warmth for the child? Are height and weight normal for the child's age and stage of development?
  • Is the child receiving appropriate nutrition and exercise?
  • Is the child's health and development consistent with their age and stage of development? Has the child received necessary immunisations? Is the child registered with a GP and a dentist? Do the parents seek health care for the child appropriately?
  • Does the child attend nursery or school regularly? If not, why not? Is s/he achieving appropriate academic attainment?
  • Does the child present any behavioural or emotional problems? Does the parent manage the child's distress or challenging behaviour appropriately?
  • Who normally looks after the child?
  • Is the child engaged in age-appropriate activities?
  • Are there any indications that any of the children are taking on a parenting role within the family (e.g. caring for other children, excessive household responsibilities, etc)?
  • Is the care for the child consistent and reliable? Are the child's emotional needs being adequately met?
  • Is there a risk of repeated separation for example because of periods of imprisonment (e.g. short custodial sentences for fine default)?
  • How does the child relate to unfamiliar adults?
  • Are there non-substance using adults in the family readily accessible to the child who can provide appropriate care and support when necessary?
  • Does the child know about his/her parents substance use?
  • Is there evidence of drug/alcohol use by the child?

Describing Parental Substance Use

  1. Identify sources of information, including conflicting reports, give consideration to negative impact on the child:
    • Specify drug of choice and how this is used, e.g. method, frequency quantity.
    • Is the drug use by parent:
      • Experimental - i.e. only used on a few occasions may be number of different drugs.
      • Recreational - i.e. not using every day may be at weekends only on pay day or on nights out. (Some agencies are getting away from using this term, gives a feel of safety.)
      • Chaotic - i.e. usually variety of substances and in varying amounts frequent periods of intoxication and withdrawal.
      • Dependent - i.e. using substance or substances every day. Experiences withdrawal when not using however may be controlled and not chaotic use (see Definitions section 10).
    • Identify whether the drug used is illicit or prescribed and whether use is regularly supplemented / 'topping up'
    • Does the user move between these types of drug use at different times?
    • Does the parent misuse alcohol?
    • What patterns of drinking does the parent have?
    • Is the parent a binge drinker with periods of sobriety? Are there patterns to their bingeing? i.e. weekends or at times of stress.
    • Is the parent a daily heavy drinker?
    • Does the parent use alcohol concurrently with other drugs?
    • How reliable is current information about the parent's drug use?
    • Is there a drug-free parent/non-problematic drinker, supportive partner or relative?
    • Is the quality of parenting or childcare different when a parent is using drugs and when not using?
    • Does the parent have any mental health problems alongside substance use? If so, how are mental health problems affected by the parent's substance use? Are mental health problems directly related to substance use?
    • Is there any history of self harm?
    • Is there any history of sexual abuse?
    • Is there any history of domestic abuse?
    • Are there known learning difficulties?

Accommodation and Home Environment

  • Is the family's living accommodation suitable for children? Is it adequately equipped and furnished? Are there appropriate sleeping arrangements for each child, for example does each child have a bed or cot, with sufficient bedding?
  • Are rent and bills paid? Does the family have any arrears or significant debts?
  • Is there any evidence of fuel poverty?
  • How long have the family lived in their current home/current area? Does the family move frequently? If so, why? Are there problems with neighbours, landlords or dealers?
  • Is the household at risk of losing their accommodation? If yes, what action has been taken by the landlord?
  • Do other drug users / problem drinkers share or use the accommodation? If so, are relationships with them harmonious, or is there conflict?
  • Is the family living in a drug-using / heavy drinking community?
  • If parents are using drugs, do children witness the taking of the drugs, or other substances?
  • Have the parent/s ever overdosed intentionally or accidentally?
  • Have any of the children witnessed their parents or other users having "overdosed"?
  • Are children exposed to intoxicated behaviour/group drinking?
  • Could other aspects of drug use constitute a risk to children (e.g. conflict with or between dealers, exposure to criminal activities related to drug use)?

Procurement of Drugs

  • Where are the children when their parents are procuring drugs or getting supervised methadone? Are they left alone? Are they taken to unsuitable places where they might be at risk such as street meeting places, flats, needle exchanges, adult clinics?
  • How much do the parents spend on drugs (per day? per week?) How is the money obtained?
  • Is this causing financial problems?
  • Do the parents sell drugs in the family home?
  • Are the parents allowing their premises to be used by other drug users?
  • Is/are the child/ren involved in the procurement of drugs?

Health Risks

  • Where in the household do parents store drugs / alcohol?
  • What precautions do parents take to prevent their children getting hold of their drug / alcohol? Are these adequate?
  • Do the children know where the drugs / alcohol are kept?
  • Does the child/ren witness the parent/s taking their medication either at home or at the pharmacy? (Risk of young children copying their parents.)
  • What do parent/s know about the risks of children ingesting methadone and other harmful substances?
  • Do parents know what to do if a child has or they suspect has consumed methadone or other drugs?
  • Do parents know what to do if a child has consumed a large amount of alcohol?
  • Are they in touch with local agencies that can advise on issues such as needle exchanges, substitute prescribing programmes, detoxification and rehabilitation facilities? If they are in touch with agencies, how regular is the contact?
  • Is there a risk of HIV, Hepatitis B or Hepatitis C infection?
    • Blood-borne viruses (e.g. HIV, hepatitis B and C) are not in themselves issues for child protection and there is no evidence that child protection issues arise disproportionately in families affected by these viruses. Workers should seek specialist advice if issues about blood-borne viruses arise in the course of their work.
  • Are parents aware of increased risk of cot death if baby is co-sleeping when parents are using substances including prescribed or illicit drugs and alcohol (NB This also applies if sleeping on sofa or chair etc)?

If the Parent(s) Inject:

  • Where is the injecting equipment kept? In the family home? Are works kept securely?
  • Is injecting equipment shared?
  • Is a needle exchange scheme used?
  • How are syringes disposed of?
  • What do parent/s know about the health risks of injecting or using drugs?
  • If pregnant, are they aware of screening tests for blood borne viruses and appropriate immunisations?

Family and Social Supports

  • Do the parents primarily associate with other substance users, non-substance users or both?
  • Are relatives aware of parent(s) problem alcohol/drug use? Are they supportive of the parent(s) and/or/child(ren)?
  • Will parents accept help from relatives, friends or professional agencies?
  • Is social isolation a problem for the family?
  • How does the community perceive the family? Do neighbours know about the parents drug use? Are neighbours supportive or hostile?
  • Have you considered the support of the Senior Parenting Practitioner (NB post primarily linked to Anti Social Behaviour (ASB) and referrals accepted where there are ASB concerns as well as other issues i.e. drugs/alcohol/mental health/domestic abuse) or family support services?

Parent's Perception of the Situation

  • What do parents think of the impact of the substance misuse on their children?
  • Is there evidence that the parents place their own needs and procurement of alcohol or drugs before the care and welfare of their children?
  • Do the parents know what responsibilities and power agencies have to support and protect children at risk?

Child Centred Assessment

  1. In working with and assessing the needs of children with drug or alcohol using parents, the work that is undertaken with them should aim to establish what it feels like for the child(ren) to live in that household and to establish whether the child(ren) need information and/or support in dealing with the issues that impact upon and affect them.
  2. In doing so, the worker should approach the child(ren) in a way which is appropriate to their age and development which enables the child to tell a story without putting them on the spot and forcing them to "tell tales." The worker should attempt to establish the child's level of awareness and understanding about substance misuse and the willingness of the child to provide information or answer questions. It is also important for the worker to try and establish what support the child(ren) needs and who might be an acceptable source for that help e.g. a friend or friend's parent, family member, concerned other and so on.

Key Areas that could be Explored:

  • What they do on a daily basis;
  • Whether or not they feel safe;
  • Where do they turn for help, protection and comfort;
  • What it is like when their parents are under the influence of drugs and/or alcohol;
  • What it is like when they are not;
  • What fears, hopes and anxieties they have about their parents' behaviour;
  • What they would most like to change;
  • What they would most like to stay the same;
  • Is there violence in the home;
  • Does anything else happen that frightens them;
  • Extent of caring responsibilities they might assume because of parental drug/alcohol use;
  • The extent to which developmental milestones are being met;
  • Are they being bullied at school?

Analysis: Making Sense of the Information

  1. This is the most important part of the assessment process as a poor analysis of the information that has been collated will invariably lead to poor decision making and care planning. In making sense of the information that has been gathered, where that information should take the worker is framed in terms of the following questions:
    • Is the parents' drug or alcohol use significantly affecting parenting capacity?
    • Is the parents' drug or alcohol use and associated behaviour significantly impacting upon the child's health and safety, social, emotional and educational development?
    • What are the resources and strengths in this family and how might they impact on the care of the child?
    • What is the parents' understanding and attitude on the need for change?
    • What change might be acceptable and attainable?
    • What types of professional intervention will help reduce the harm to the children?
      • Consider the use of universal provision as the preferred option as this is often less stigmatising for the children.
    • Where, on the continuum of early help, children in need, children in need of protection, does this particular family sit?
  2. Outlined below are some suggestions which may assist the analysis component of the assessment:
    • A chronology of significant events;
    • Who else is involved and why - a synthesis of current information, observations and any other assessments;
    • The views and perspectives of all interested parties, including children, parents, family, neighbours and members of the community and other professionals/agencies;
    • Checks to test the reliability of information/evidence and its sources;
    • Identify any other factors that may influence the assessment e.g. values of individual worker; parental attitudes and level of co-operation and honesty;
    • Evidence based judgements underpinned by research and theory relating to drug and/or alcohol use, child welfare and parenting;
    • Identify and utilise pooled knowledge, skills, resources and support networks.
  • Completion of the Grade Care Profile if neglect is the issue.


Pregnancy and Neo-Natal Care

Introduction

  1. Pregnancy may act as a catalyst for change presenting a 'window of opportunity'. Drug users may not use general health services until late into pregnancy and this increases the health risks for both the mother and child. Individualised care will be provided for substance using women, in line with polices and guidelines of the unit at which the women selects to access maternity care.
  2. Attracting and maintaining women in drug treatment services is vital (Hepburn 1993) as follow-up studies demonstrate that the long-term outcome in women who enter a methadone treatment programme during pregnancy is better in terms of their pregnancy, childbirth and infant development, irrespective of continuing illicit drug use (Finnegan,1991). Women attending treatment services usually have better antenatal care and better general health than drug using women not in treatment, even if they are still using illicit drugs (Batey & Weissel 1993). Therefore Drug and Alcohol Services will prioritise all pregnant women with drug and or alcohol problems to allow for the earliest engagement possible.
  3. Engagement of a drug and or alcohol using partner in treatment is an important aspect of enabling the pregnant women to achieve progress at the earliest possible stage.

Management of Antenatal Care

  1. The key aims of management are to attract the women into health care treatment services, provide antenatal care and stabilize or reduce drug use to the lowest possible dose. Professionals should advise and discuss with parents the harmful impact of their continued substance misuse on their children and this should be recorded.
  2. It is important that no agency worker advises a pregnant woman to stop using drugs or alcohol without first referring the matter to the midwifery service or discussion with the key worker in addiction services. The immediate withdrawal of such drugs or alcohol could result in premature birth or miscarriage.
  3. Good co-ordination and information sharing between relevant parties is imperative. In Lancashire, please see the Multi-Agency Pre-Birth Protocol for more information.
  4. In Blackburn with Darwen: Given the possibility of early delivery, it is recommended that a meeting is held between 24 weeks - 32 weeks gestation to ensure that care and support is appropriate to the needs of the woman the baby and her immediate family and that plans are in place for the family post-delivery. This should reduce the need for emergency child protection proceedings at birth. The parents should be informed about all meetings and supported and encouraged to attend. 
  5. Where agencies or individuals anticipate that the unborn baby may be at risk of Significant Harm, a referral to Children's Social Care must be made as soon as the concerns are identified. See Making a Referral to Children's Social Care Procedure for more information.

Effects of Substances on the Foetus and Baby

  1. It is important for clinicians to note that some of the effects of different drugs used during pregnancy are broadly similar and are largely non-drug specific. Intra-uterine growth retardation and pre-term deliveries contribute to increased rates of low birth-weight and increased prenatal mortality rate. These outcomes are multi-factorial and are also affected by factors associated with socio-economic deprivation, including smoking (Kaltenbach &Finnegan 1997).
  2. Higher rates of early pregnancy loss and third-trimester placental abruption appear to be major complications of maternal cocaine use. Increased rates of stillbirth, neonatal death and sudden infant death syndrome are found. Heroin has been shown to have a direct effect on foetal growth and an association with pre-term delivery. It has also been shown to result in a higher rate of small-for-date babies, even when allowing for other compounding factors and the expression of neonatal abstinence syndrome (NAS). There is shown to be a significant correlation between methadone dose and NAS.

Maternal Health Problems

  1. There are a number of health problems in pregnancy, which need to be discussed with the woman and reviewed throughout the pregnancy. These include general nutrition, risks of anaemia, dental hygiene and complications from chronic infection related to injection practice. These all contribute to the increased rate of obstetric complications and premature delivery found in drug using women. Drug using women are at high risk of antenatal and postnatal mental health problems.

Management of Labour

  1. Each Hospital Trust has its own procedures for the management of labour.

Neonatal Withdrawal

  1. Many babies will not need paediatric interventions, but it is important to have access to skilled neonatal paediatric care. However, all babies of substance using mothers will be subject to a withdrawal scoring sheet, which some women might interpret as intervention.
  2. Signs of withdrawal from opiates are vague and multiple and tend to occur 24-72 hours after delivery. They include a spectrum of symptoms such as a high-pitched cry, rapid breathing, hungry but ineffective sucking, and excessive wakefulness. At the other end of the spectrum symptoms include hypertonicity and convulsions but these are not common. Neonatal withdrawal can be delayed for up to 7-10 days if the woman is taking methadone in conjunction with benzodiazepines. Benzodiazepine use causes more prolonged symptoms, including respiratory problems and respiratory depression.

Postnatal Management

  1. Breastfeeding should be encouraged, even if the mother continues to use drugs, except where she uses a very high dose of benzodiazepines, crack/cocaine. Specialist advice should be sought if she is HIV positive. Methadone treatment is not a contraindication to breastfeeding.
  2. Health professionals should note that the care of the pregnant drug user and the safe delivery of the baby is just the start of care. Continuing support, which may need to include parenting advice and skills training, may be desirable both pre-and post-discharge if the ideal outcome of maintaining mother and child together is to be achieved.

Discharge Planning

  1. To ensure that care and support continues on discharge a planning meeting should be considered and arranged on an individual basis if required. Prior to discharge all information should be reviewed and plans documented in the case notes, with liaison on discharge to relevant agencies. Relevant agencies will be notified of the discharge plan and the midwifery services will contact Substance Misuse Services to ensure continuation of prescribed medication. Details of the discharge plan should be entered onto the CAF.

Prescribing Drugs for Pregnant Drug Users

  1. Substitute prescribing can occur at any time in pregnancy and is lower risk than continuing illicit use. It has the advantage of allowing engagement and therefore identification of both health and social needs as well as offering the opportunity for brief interventions and advice to improve outcomes. (Note specialist advice must always be sought.)
  2. Expectant mothers who are drinking dependently should be referred as a matter of priority to a Drug and Alcohol Service and not be advised to stop without supervision due to the risk of withdrawal.

End