Safeguarding Children Affected by Problematic Drug and Alcohol Use (Parental and Child use)

1. Introduction

Drug and alcohol use by parents or carers does not inevitably lead to poor outcomes for children, but each aspect of their lives may be affected. "Hidden Harm" (Advisory Council on the Misuse of Drugs 2003) highlighted both the scale and seriousness of the problem. Findings were as follows:

Hidden Harm Findings:

• There are an estimated 250,000-350,000 children of problem drug users in the UK;
• Parental drug use can and does cause serious harm to children from conception to adulthood;
• Reducing such harm needs to be a major objective of policy and practice;
• Effective treatment of the parent has significant benefits for the child;
• Integrated services can take many practical steps to safeguard children and promote their welfare;
• The number of children affected is only likely to decrease when numbers of problem users decrease;
• Lack of knowledge and skills in working with drug issues is a barrier to effective working.

Drug and alcohol use may be just one of a series of interrelated factors within a family, such as poverty or depression, so that disentangling exactly what causes poor outcomes for the child can be difficult (Forrester and Hawkins 2004). The SCIE Research Briefing 06: Parenting Capacity and Substance Misuse points out that studies have often failed to evaluate the impact of substance use on parenting capacity relative to other aspects of disadvantage (Social Care Institute of Excellence 2004). However, the research indicates that, whatever the primary cause of a parent's difficulties in caring adequately for their child, drug and alcohol use is likely to add to those difficulties.

It is acknowledged that not all individuals using drugs and alcohol have problems with parenting: understanding drug and alcohol use, the behaviours of the parents and the impact of this on the child requires careful assessment to unpick the interrelated factors within a family and the environment the child lives within. This policy offers guidance and a framework for achieving this. The procedures within this document also refer to use of Legal highs' which are substances which produce similar effects to illegal drugs (such as cocaine, cannabis and ecstasy) but that are not controlled under the Misuse of Drugs Act. Despite not being illegal they still have the potential for harm.

National Treatment Agency

In December 2010, the National Treatment Agency produced a document that issued supporting information around the development of local protocols between Children and Family Services, Local Safeguarding Children's Partnerships and Drug/Drug and Alcohol Partnerships with recommendations that this should be agreed by all key partners. This document has been key in producing and implementing this policy.

1.1 Quick Reference Guide

1.2 Acknowledgements

The following documents were used to help develop these guidelines. Particular thanks are given to the organisations that produced the source materials.

• Advisory Council for the Misuse of Drugs (2003) Hidden Harm – Responding to the Needs of Problem Drug Users;
• Working Together to Safeguard Children;
• Department of Health and Social Care National Treatment Agency for Substance Misuse (2010) Joint Guidance on Development of Local Protocols between Drug and Alcohol Treatment Services and Local Safeguarding and Family Services.

1.3 Policy Statement

The purpose of this policy is to offer guidance for all staff working with children and families in understanding:

• The impact of drug and alcohol use on parenting capacity;
• The risks to children of parental drug and alcohol use;
• The risks of child drug and alcohol use.

This policy also guides practitioners on what action they should take to:

• Identify children at risk;
• Assess parenting capacity;
• Assess risk to children;
• Make appropriate multi-agency referrals and work effectively to safeguard and promote the wellbeing of children.

This policy has been created by a multi-agency group in line with the following National Treatment Agencies 2010 recommendations:

• Strengthening the relationship between drug and alcohol service and children and family services;
• Identification, assessment and referral of drug and alcohol using parents;
• Identification, assessment and referral of children who need to be safeguarded;
• Referrals thresholds and pathways into children and family services;
• Referrals and thresholds and pathways into drug and alcohol treatment services;
• Effective joint working arrangements, including sharing of information and data;
• Staff competencies and training.

2. Child Drug and Alcohol Use; Considerations and 'Early Help' when Working Directly with Children who are Using Drugs or Alcohol

Providing early help is more effective in promoting the welfare of children than reacting later. Early help means providing support as soon as a problem emerges, at any point in a child's life, from the foundation years through to the teenage years.

Effective early help relies upon local agencies working together to:

• Identify children and families who would benefit from early help;

• Undertake an assessment of the need for early help; and

• Provide targeted early help services to address the assessed needs of a child and their family which focuses on activity to significantly improve the outcomes for the child. Local authorities, under Section 10 of the Children Act 2004, have a responsibility to promote inter-agency cooperation to improve the welfare of children.

Professionals should, in particular, be alert to the potential need for early help for a child who:

• Is disabled and has specific additional needs;
• Has Special Educational Needs;
• Is a young carer;
• Is showing signs of engaging in anti-social or criminal behaviour;
• Is in a family circumstance presenting challenges for the child, such as problematic drug and alcohol use, adult mental health, domestic abuse; and/or is showing early signs of abuse and/or neglect;
• If you are concerned that there is an element of coercison or exploitation being used against the child outside of the family home then a Child Exploitation Screening Tool should be completed. The worker should also explore if parental capacity to protect children is reduced due their own problematic substance and or alcohol misuse.

2.1 Effective Assessment of the Need for Early Help

Local agencies should work together to put processes in place for the effective assessment of the needs of individual children who may benefit from early help services.

Children and families may need support from a wide range of local agencies. Where a child and family would benefit from coordinated support from more than one agency (e.g. education, health, housing, police) there should be an inter-agency assessment. These early help assessments, such as the use of the Team Around the Child (TAC) or a Early Help Assessment (EHA), should identify what help the child and family require to prevent needs escalating to a point where intervention would be needed via a statutory assessment under the Children Act 1989.

For an early help assessment to be effective:

• The assessment should be undertaken with the agreement of the child and their parents or carers. It should involve the child and family as well as all the professionals who are working with them;
• A teacher, GP, health visitor, early years' worker or other professional should be able to discuss concerns they may have about a child and family with a social worker in the local authority. Local authority children's social care should set out the process for how this will happen; and
• If parents and/or the child do not consent to an early help assessment, then the lead professional should make a judgement as to whether, without help, the needs of the child will escalate. If so, a referral into local authority children's social care may be necessary.

If at any time it is considered that the child may be a Child In Need as defined in the Children Act 1989, or that the child has suffered significant harm or is likely to do so, a referral should be made immediately to local authority children's social care. This referral can be made by any professional.

3. Information Sharing

Agencies, when beginning work with any service user, should inform the service users as a matter of course about their policy on information sharing and confidentiality and explain the kinds of situations where they may need to share information. Agencies should give some indication of why, and with whom they may need to share information. They should ask for the service user's consent to sharing necessary information in advance. This will save time, misunderstanding and potential conflict later. Concerns that a child may be suffering Significant Harm, or is likely to, will always override a practitioner or agency requirement to keep information confidential. Practitioners have a responsibility to act to make sure that a child whose safety or welfare may be a risk is protected from harm, sharing information appropriately. Further information is available via Protocol on Sharing Information in Order to Safeguard and Promote the Welfare of Children.

4. Identification and Assessment

Children can be adversely affected by parental drug and / or alcohol use in many ways and the potential for suffering significant harm as a result should not be underestimated. Although not all children whose parents abuse drugs and / or alcohol will be adversely affected. Please refer to Appendix 1: Indicators for Children at Risk of Problematic Parental Drug and Alcohol Use for early indicators of potential harm.

4.1 Screening Tools

Agencies might use different screening tools to identify the risk.

Please refer to Appendix 2: Developing Assessment for an example of a screening tool for use with parents with problematic drug and alcohol use.

Please refer to Appendix 3: Assessment for Pregnant Clients for an example of a screening tool for use with children using drugs and alcohol.

Note: Children (including all children up to their 18th Birthday) may be referred to Horizon within Lincolnshire. Horizon may continue to work with that child until they are 21 if required. However, any identification of drug use in adults (18 plus) would be referred into one of the two available adult drug and alcohol services.

4.2 Assessment

Agencies identifying concerns will need to assess the initial level of concern and which aspects of the child's development are being affected. This assessment should focus on the impact upon the child rather than the adult's drug and/or alcohol use.

Please refer to Appendix 4: Parental Drug and Alcohol Checklist for guidance on what to prepare for an assessment.

5. Support for Young People who have Parents with Problematic Drug and Alcohol Use

5.1 Acting on Concerns about Children

There will be circumstances where you do not think the child is at risk of suffering or likelihood of suffering significant harm but feel that their health or development may be at risk if they do not receive additional help from one or more services. Interagency work should start as soon as there are concerns about a child's welfare, not just when there is a 'Child Protection' concern.

5.2 Identifying Additional Needs

The TAC process has been designed to help practitioners assess needs at an early stage and then work with the child / young person, their family and other practitioners and agencies to meet these needs. As such, it is designed for use when:

• You are worried about how well a child / young person is progressing;
• You might be worried about their health, development, welfare, behaviour, progress in learning or any other aspect of their wellbeing;
• A child / young person or their parent / carer raises a concern with you;
• The child's or young person's needs are unclear, or broader than your service can address i.e. multi agency;
• The child or young person would benefit from an assessment to help a practitioner understand their needs better;
• For information and support on how to access the TAC process please visit Lincolnshire Children, Team Around the Child website.

5.3 Children in Need

If multi-agency work with the child and family does not result in a plan which is meeting the needs of the child a referral should be made to Children's Social Care via the Customer Service Centre (01522 782 111 or 01522 782 333 out of hours) who have a duty to consider whether a Children's Social Care Assessment is required. You can make referrals to Social Care for 'children in need' in the same way you would for 'children in need of protection' (i.e. a telephone referral followed up with a written referral). Once an assessment has been undertaken this may result in the child being made subject to a 'child in need' plan under Section 17 of the Children's Act 1989.

Child and Family Progress Plans are implemented and monitored in a similar way to Child Protection Plans. An initial meeting is held followed by a review meeting at regular intervals thereafter to monitor the implementation of the plan. In some circumstances the child may move between the 'child in need' 'Team Around the Child' and 'child protection' process as the level of risk and the needs of the child change.

5.4 Children in Need of Protection

If you think a child may be suffering, or at risk of, suffering significant harm, you must refer the child to Children's Social Care via the Customer Service Centre (01522 782 111 or 01522 782 333 out of hours) or call the Police. Unless the child is at immediate risk of harm a referral to social care is likely to be the more appropriate route. A referral can be made by telephone and you may be asked to follow up a telephone referral in writing.

If you think the child may already be subject to a child protection plan you can ring and ask them to check their records by carrying out a 'child protection enquiry' through the safeguarding unit on 01522 554 061.

Any professional who has had contact with the child or family, however minimal, is expected to contribute to the child protection process including attending child protection conferences and submitting a report.

5.5 Young Carers

In some circumstances the child / young person may be providing a caring role for one or more parents. Young carers are not necessarily children in need, but should always have their needs thoroughly assessed; as a carer, they should have the same rights as other carers as outlined in Standard 6 of the National Service Framework. All carers, including young carers, should be advised of the carers register and any available information and resources.

Carers First work in partnership with Lincolnshire County Council to provide support to young carers aged up to 25 years. A young carer is anyone under the age of 18 whose life is in some way restricted because of the need to take responsibility for the care of someone who is ill, has a disability, has a mental health condition, or is affected by substance misuse.

Spurgeons "Lincolnshire Young Carers Count" telephone: 01522 553275 or email: youngcarers@lincolnshire.gov.uk.

Adult carers can contact Carers Frist on 01522 782224 or by emailing: hello@carersfirst.org.uk.

6. Support for Parents with Problematic Drug and Alcohol Use

6.1 Treatment Services

The best source of information about the drug and alcohol treatment services in Lincolnshire is through their websites. Contact with the drug or alcohol treatment services can be made by any agencies, families and friends or clients themselves. There is also a service available (for those aged under 18) in Lincolnshire that will provide specific help with any problems the young person may be having around drugs and alcohol.

6.2 Support Websites and Helplines

There are many useful websites with information and support available around drugs and alcohol:

• Oasis (Lincoln based support for carers/families);
• NHS Choices (alcohol);
• NHS Choices (drugs);
• NHS (Change for Life);
• Talk to Frank;
• Families (Drug and Alcohol Support);
• Alcoholics Anonymous;
• Alcohol Change;
• Beating Addictions;
• Drink Aware;
• Drug Scope (Archived via DrugWise);
• Drugs Line;
• Why Not Find Out.

Other Telephone Helpline are also available, for example:

• Narcotics Anonymous - 0300 999 1212 - www.ukna.org;
• Alcoholics Anonymous - 0845 769 7555;
• Drinkline - 0800 917 8282;
• FRANK - 0800 776 600;
• Families Anonymous - 0845 120 0660.

7. Support for Pregnant Drug and Alcohol Users

7.1 Antenatal Assessment and Care

Please also refer to the Pre Birth Protocol for a pathway to assist with the decision making process when undertaking pre-birth assessments.

Where appropriate drug/alcohol agencies and other agencies should offer and carry out a pregnancy test with the consent of the woman. If the woman is pregnant she should be encouraged to inform her GP as soon as possible and/or referred to Maternity Services. Please refer to Appendix 5: Problematic Parental Drug and Alcohol Use Including Young Parents for factors to be considered when working with pregnant women who also use drugs and alcohol.

A multi-agency meeting may be called at any point during the course of the pregnancy to coordinate the care plan. Within Maternity Services and drug/alcohol services a senior staff member should be identified to take responsibility for co-ordinating good practice in the care of pregnant drug/alcohol users and/or drug/alcohol users with dependent children. Regular meetings should be held between Maternity Services, Children's Services, drug/alcohol agencies and Primary Care to discuss further improvements to existing service provision.

7.2 Planning Meetings

A planning meeting for the expectant mother may be called at any time by any agency to update and coordinate the multi-agency care plan. Please refer to the pre-birth protocol link above for specific details of what should happen and when including when to refer to children's services. It is important to note that the birth of the baby may create further problems, particularly if there is an unstable relationship or financial or housing difficulties.

A decision on whether a Pre-Birth Child Protection Conference is required can also be made at this meeting. Children's Services, the GP, health visitor, staff from the maternity and neonatal services and drug/alcohol agencies, with the prospective parent or parents/family may be invited.

7.3 Prescribing during Pregnancy

Some patients want to give up using drugs/alcohol when they become pregnant. However, this does not always happen. It is important to be flexible and respond quickly to changing use. All treatment options should be client led and therefore discussed with the woman (and her partner) and where possible their views should be taken into account.

Appropriate drug/alcohol treatment will depend on the amount and types of drugs/alcohol used, as well as the patient's motivation, current situation and past history. The care plan should aim to reduce risks to both parent and unborn child. Prescribing substitute or maintenance drugs should be carried out in conjunction with the drug/alcohol agency and Obstetrics Team. The National Institute for Health and Care Excellence (NICE) guidance allows, in certain circumstances, Nicotine Replacement Therapy to be prescribed.

7.4 Labour

Prescribed substitute medication (e.g. methadone) should be given in addition to routine pain relief. A medical alcohol detoxification regime may need to be considered on admission for dependant drinkers.

7.5 After the Birth

The mother and baby should be admitted to the postnatal ward together. Neonatal admission will only occur if prematurity or a medical condition merits it.

Encourage attachment and bonding – encourage positive parenting, swaddling and comforting the baby. Observe for signs of withdrawal. It is highly unusual for a baby to have withdrawal at birth. These symptoms may start soon after the birth, peak at four days and disappear by two weeks Benzodiazapines and methadone withdrawal symptoms may present later.

Breast-feeding should be encouraged, as with any mother, so long as the drug and/or alcohol use is stable and the baby is weaned slowly. The actual amount of drug that is passed into baby is low and, in general, the advantages of breast-feeding far outweigh the disadvantages.

Women who use crack cocaine or large quantities of Benzodiazapines may be advised not to breastfeed. Hepatitis B and Hepatitis C infection poses no additional risk to baby. Women who are HIV positive are advised not to breast feed due to the risk of transmission.

If a mother discloses her drug use during labour or post birth her midwife and/or the local Alcohol and Drug Team should be contacted immediately to discuss treatment options for mother so that she is more likely to stay on the ward. Observations of withdrawal are same as any baby. A multi-agency group should make an assessment of her home circumstances and support networks as soon as possible.

Continue with any care plans in relation to the child (e.g. child protection or children in need).

8. Professional Disagreements and Escalation

If at any stage of this process differing opinions arise professionals should initiate the Professional Resolution and Escalation Protocol.

9. Working with Families who are Difficult to Engage

Some children may be living in families that are considered resistant to change. A knowledge review on effective practice to protect children living in such families, undertaken by C4EO, has identified practices which can enable practitioners to engage with these types of families and improve outcomes for children. See C4EO website.

Further guidance is also available within the LSCP Core-interagency:

Procedures for working with hostile, non-compliant clients and those who use disguised compliance within the context of safeguarding children. See Recognising Disguised Compliance & Disengagement Among Families: Practice Guidance.

Attending drug and alcohol services and adhering to drug screening/breathalysing tests should not be considered engaging with treatment if this is the only part of their treatment programme they adhere to.

10. Training and Resources

If you wish to access further training around the issues contained within this policy around drug and alcohol use and children's safeguarding then the Safeguarding Children e-Academy is an innovative solution to enhance the learning process for those individuals and organisations who work with children.

Drugs and alcohol training, tools and information to help professionals and practitioners deliver effective family support provided by Adfam can also be reached through the following link to the training section of their website:

• Training and Development, Adfam.

11. Further Information

GOV.UK, Guidance: Foetal Alcohol Spectrum Disorder: Health Needs Assessment

GOV.UK, Guidance: Parents with Alcohol and Drug Problems – Adult Treatment and Children and Family Services

GOV.UK, Guidance: Parents with Alcohol and Drug Problems: Support Resources

NICE Quality Standard QS 204 Foetal Alcohol Spectrum Disorder

Appendix 1: Indicators for Children at Risk of Problematic Parental Drug and Alcohol Use

• Emotional difficulties e.g. crying for no apparent reason, inexplicable feelings of anger;
• Attachment issues and behavioural difficulties e.g. bullying;
• Being left home alone or with inappropriate carers;
• Developmental delay;
• Presenting as not being used to a routine e.g. irregular attendance at nursery or school;
• Neglect and other forms of abuse, high levels of accidents in the home, possibly due to poor parental supervision;
• Family dislocation e.g. moving schools, relationship conflict, domestic abuse;
• For children with disabilities there can be increased risks to their safety and inconsistent approach to the management of the child's medication;
• School problems e.g. truancy, levels of attainment dropping, difficulty in concentrating;
• Offending behaviour;
• Early use of drugs and alcohol – minimisation of the risks associated with or a very strong dislike of drugs and alcohol;
• Feelings of gloom, worthlessness, isolation, shame and hopelessness, poor self-esteem, disempowerment;
• Unwillingness to expose family life outside scrutiny, social isolation, not taking friends home;
• Tendency to keep secrets;
• Role reversal and confusion e.g. protecting others, acting as a mediator and/or confidant, taking on an adult role;
• Extreme anxiety and fear, fear of hostility, violence.

Appendix 2: Developing Assessment

When deciding the appropriate response to the concerns there will be a need to evaluate the seriousness of the information available. In order to do this, it may be helpful to:

• Speak to the parents about the concerns and obtain their views about the situation and what services/support they think they need;
• Speak to other colleagues including in other agencies who know the child and their parents;
• Use a diary to monitor patterns of behaviour or concerns over time;
• Check your agency records and produce a chronology;
• Ask the parents whether they are currently/have recently engaged with drug and alcohol treatment services;
• Speak to your line manager or a professional with responsibility for child protection/safeguarding children;
• Seek consent of involving extended family members where appropriate;
• Consider triggering a Team Around the Child (TAC).

Workers can then utilise their skills to further explore issues, examine discrepancies or positively reinforce behaviours. Example questions which can be asked or included in assessments:

• Do you have any concerns about your children at the moment?
• Tell me about the relationships within the family. Who provides you with support?
• What would need to change in order for you to be the parent you want to be?
• Do you think your drug and alcohol use has any effect on your children?
• Being a parent is stressful at the best of times, what extra support do you think you and your family might need?

Appendix 3: Assessment for Pregnant Clients

All pregnant women should be asked about their use of prescribed and non prescribed drugs, both legal and illegal, as part of routine enquiries about general health during pregnancy. Time should be allowed for the exploration of the patient's and the professional's concerns about the risks for both the mother and the child. This needs to be done sensitively so that the woman is not deterred from seeking help, even if she continues to use. However, practitioners should ensure that the woman and her partner are aware of the impact of the following behaviours:

• The use of tobacco, street drugs, alcohol and some over the counter drugs, including the adverse effects of some medicines;
• Chaotic drug/alcohol use; e.g. polydrug use, erratic dosage precipitating withdrawals or intoxication;
• Ask the client whether she is currently/has recently engaged with drug and alcohol treatment services;
• Injecting and sharing of drug using paraphernalia;
• Unprotected sexual activity.

If the woman's partner also uses drugs/alcohol, they should be encouraged to access treatment as this increases the chances that the patient will be able to control her drug/alcohol use during pregnancy. Pregnant women and their partners who smoke cigarettes should be identified and specialist smoking cessation offered as early as possible. Where appropriate an amended version of this document should be provided and explained to patients and their partners. Drug/Alcohol Workers, Maternity Staff and other practitioners working with pregnant women, children and their families should consider the following as a part of the on-going assessment process:

• Which drugs/alcohol are being used;
• Current amounts of drug/alcohol use;
• Patterns of use;
• Route of administration (injecting or smoking);
• Other risk behaviour related to the drug/alcohol use;
• Stage of pregnancy;
• The woman's support networks;
• The needs of unborn child;
• Whether the women has other children; their living situation; and their main carer/guardian;
• Concerns about woman's partner using drugs or alcohol;
• Concerns about Domestic Abuse.

Appendix 4: Parental Drug and Alcohol Checklist

Click here to view Appendix 4: Parental Drug and Alcohol Checklist.

Appendix 5: Problematic Parental Drug and Alcohol Use Including Young Parents

Click here to view Appendix 5: Problematic Parental Drug and Alcohol Use Including Young Parents.

Appendix 6: Children Drug and Alcohol Use Flowchart

Click here to view Appendix 7: Children Drug and Alcohol Use Flowchart.