Children of Alcohol and Substance Misusing Parents and Carers

In 2003, the Advisory Council for the Misuse of Drugs (ACMD) published Hidden Harm, a report on the impact of parental drug use on children. The key messages of the report were:

• There are significant numbers of children affected by parental substance and alcohol use in the UK;
• Parental problem drug use causes serious harm to children of all ages;
• Reducing this harm to children should be a main objective of policy and practice;
• Effective treatment for the parent/carer can have significant benefits for children;
• Services should work together to take practical steps to protect the health and well-being of affected children;
• The number of children affected is unlikely to decrease until the number of problem drug users decreases.

Drug and alcohol misuse is a factor in a significant number of children in need and child protection cases. Research suggests that in child protection cases, alcohol is a factor in at least 33% of cases, and in care proceedings, drug and alcohol misuse is a factor in up to 70% of cases (Harwin and Forrester, 2003). The Biannual Analysis of Child Protection Database Notifications 2007-2009 (DfE 2013) reviewed 268 cases. Of these, 60 (22.4%) cited parental drug misuse and 58 (21.6%) cited parental alcohol misuse. It is highly likely these figures are an underestimate of the actual frequency of occurrence and parental substance misuse is likely to affect an even greater proportion of children in less obvious or acute ways.

More recently in 2012, the Children's Commissioner for England published Silent Voices, a report on the impact of parental alcohol misuse on children. The key messages of this report were that:

• The misuse of alcohol by parents negatively affects the lives and harms the wellbeing of more children than does the misuse of illegal drugs;
• Too often, parental alcohol misuse is not taken as seriously, in spite of alcohol being addictive, easier to obtain, and legal;
• The effects of parents' alcohol misuse on children may be hidden for years, whilst children try both to cope with the impact on them, and manage the consequences for their families;
• Policies and strategies should take into account the impact on children who may be affected by a range of levels of parental alcohol consumption and not just dependent drinkers.

Not all families affected by drug and/or alcohol use will experience difficulties, and the reality is that parenting problems rarely occur in isolation; those families who experience challenges in one area of their life have an increased chance of experiencing similar levels of difficulty in other areas (Social Exclusion Task Force 2008). The effects of these difficulties are complex and interlinked, resulting in an elevation of family vulnerability. One of the main challenges in assessing risk and/or harm to children is the presence of these factors, and their interconnection with substance use and subsequent effect on parenting are cumulative. The more factors present, the higher the risk of negative outcomes (Velleman and Templeton 2007). Negative outcomes are not inevitable however severe disadvantage will occur in a proportion of families.

For example, substance misuse, mental health problems and domestic violence (Co-occurring Issues, formerly known as Toxic Trio) are commonly associated with child protection involvement and are described as “key risk factors” for harm and abuse to children. There is substantial research documenting the association between these parental problems and poor outcomes for children. 

N.I.C.E Definition of substance misuse (2007)

“Intoxication by or regular excessive consumption of and/or dependence on psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances)”.

NICE Definitions of alcohol misuse (2010)

• “Increasing risk drinking is defined as regularly consuming between 22 and 50 units per week (adult men) or between 15 and 35 units per week (adult women). Also known as 'hazardous drinking', a pattern of drinking that increases the risk of health and social harms to the individual or to those around them”;
• “Higher risk drinking is defined as regularly consuming over 50 units per week (adult men) or over 35 units per week (adult women). Also known as 'harmful drinking', a pattern of drinking that is highly likely to be causing health and social harms to the individual or those around them”;
• “Alcohol dependence is defined as a cluster of behavioural, cognitive and physiological factors that typically includes a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking despite harmful consequences. They will also give alcohol a higher priority that other activities and obligations”;
• “Binge drinking is a pattern of alcohol consumption characterised by drinking to get drunk or drinking large quantities of alcohol on a single occasion. In terms of units, for men it is defined as drinking more than 8 units of alcohol in a single session and for women, drinking more than 6 units in a single session”.

The children of such parents are entitled to help, support and protection within their own families wherever possible.

Drug and/or alcohol using parents are entitled to expect that they will be treated in just the same way as other parents whose personal circumstances lead them to seek help. Parents and carers need to be encouraged to seek help, support, and treatment to address their drug and/or alcohol use and to reduce the harm it causes to them, their children, family, and society. Assessments must focus on the needs of children and their parents' and carers' ability to provide for them. Each family should be assessed individually, without prejudice, and offered appropriate support and service provision - with safeguarding / child protection referrals made where necessary.

Overview

Early Help is crucial for children and families affected by alcohol and other substances, inter-agency communication and co-ordination is essential for safeguarding and protecting children from harm, and consultation between staff from specialist drug and/or alcohol, child health and child protection services should occur as part of routine practice.

Parents and carers can and do use alcohol or other substances and still prioritise the safety and welfare of their children. However it is essential that staff recognise that this is a higher risk group. Alcohol and/or substance use is a cause for concern when it adversely affects the quality of care that a child receives and consequently poses a risk to their health and development, or has the potential to do so.

Adults who misuse alcohol or other substances may also be faced with multiple needs including homelessness or financial issues, co-dependent, controlling or abusive relationships, lack of effective social and support systems, poor health and consequences to criminal activity. Assessment of the impact of these stressors on the child is important, reinforcing that parents and carers should be seen in the context of family life and functioning, not purely as an indicator or predictor of harm and abuse to children.

Issues of trust, fear of perceived consequences or conflict of interest, may lead parents and carers to under report the extent of their alcohol or substance use and its impact on their lives. Learning from Serious Case Reviews suggests that professionals may experience optimistic bias when reviewing family progress, and lack professional curiosity in thoroughly exploring or predicting how continuing alcohol or substance use will impact on the children. Findings within SCRs also include an over-reliance by professionals on self-reporting. Parents may simply lack awareness of the impact of their alcohol or substance use and associated lifestyle consequences on their children, or they may present as compliant and provide an over-optimistic or distorted picture of distance travelled.

The profile and incidence of problem substance use is subject to constant change.

The Advisory Council on the Misuse of Drugs (ACMD) has identified three key characteristics of parental problem substance use - the high level of poly-drug use, the prevalence of intravenous use, and the existence of other factors affecting parenting capacity (poverty, social exclusion, mental health problems, and environment). The report [1] also identified that high levels or dependent substance use often results in chaotic and unpredictable behaviour, which can be as damaging as the substance use itself.

The harms to children from parental alcohol misuse are wide ranging and may include: physical effects such as harm to the developing foetus, neglect, emotional, sexual and physical abuse, complex psychological and social problems. Varying levels of consumption and patterns of drinking e.g. binge-drinking (not just dependent drinkers) can affect children and it cannot be assumed that higher levels of consumption equates to greater harm (Office of the Children's Commissioner, 2012).

Alcohol Concern has identified [2] that the misuse of alcohol can be associated with significant harm to children, even more so when combined with co-existing issues such as domestic violence and abuse, other substance use as well as parental mental ill health. The risk to children may arise from:

• Adverse impact of growth and development of an unborn child resulting in birth defects, lifelong learning disabilities and neurological disorders;
• Falling asleep with a baby in a bed, chair or sofa leading to overlay;
• Use of the family resources to finance the parents/carers' drinking habits, characterised by inadequate food, heat and clothing for the children;
• Exposing children to unsuitable care givers or visitors or total lack of supervision;
• Children's absenteeism from school, other school related issues or health appointments;
• Children taking on the role of carer either for other siblings or the Parent/carer(s);
• Effects of alcohol which may lead to uninhibited behaviours e.g. inappropriate display of sexual and/or aggressive behaviour and reduced parental vigilance;
• Unsafe storage of alcohol thus giving children ease of access or 'permissive parenting' where children are allowed or encouraged to drink.

In addition, alcohol can be a factor in family problems related to social exclusion. Also, heavy drinking is a common factor in family break-up, and marriages where one or both partners are misusing alcohol are twice as likely to end in divorce as marriages where alcohol problems are absent [3].

Clearly it is impossible to know just how many adults misuse substances and how many children are affected. Any figures are likely to be under-estimates, particularly if gleaned only from numbers accessing treatment. However, high levels of poly-substance use remain a dominating feature and it is important to note that the profile of drug use is dynamic, particularly in the light of substances that can be bought online, including New Psychoactive Substances (NPS) as well as performance and image enhancing drugs (PIEDs) such as anabolic steroids. It is important therefore to focus on the impact of the substance on parenting capacity.

According to the Home Office survey for 2011/2012 cannabis was the most commonly used drug (6.9% of adults), followed by powder cocaine (2.2%), the use of which has risen in the long term. Alcohol concern (2010) highlights that “drinking habits have changed significantly”. Though the unit cost of Alcohol has increased relatively it is more affordable and available than previously, particularly when buying wholesale or from supermarkets with alcohol consumption having more than doubled over the past 50 years. 1 in 4 adults are regularly drinking above lower risk guidelines. Patterns of drinking have changed with the relative increase of the unit cost of alcohol in pubs and clubs pushing more people to drink at home and pre-loading before going out. Thousands more children now grow up in homes where alcohol is misused by one or both parents. Current estimates suggest 30% of children in the UK live with at least one adult binge drinker, 22% live with a hazardous drinker, 2.5% live with a harmful drinker and 6% live with a dependent drinker (Manning et al, 2006). This equates to 3.3 million children affected - 2.6 million children in the UK living with a parent/carer who drinking at increasing or higher risk levels (this includes binge drinking and regular drinking) and a further 705,000 are living with a parent/carer who is alcohol dependent.

Another prevalent factor is the complex relationship between alcohol and domestic abuse and the increased risks for children. Perpetrators of domestic abuse may choose to use alcohol as a socially acceptable excuse to minimise, deny or blame their behaviour and avoid being held responsible for their actions. Alcohol consumption has been found to be associated with increased frequency and severity of physical violence but does not reflect the wider picture of controlling, coercive and threatening behaviour. Perpetrators may also actively encourage or coerce a partner to use alcohol to increase control over them or shift responsibility away from them to humiliate and degrade their partner as a parent. Victims may also use alcohol as a coping mechanism and pejorative attitudes from professionals can further traumatise a person through secondary victimisation. Therefore as there is no direct causal link, it is important for practice to be informed by the true nature of the relationship between alcohol and domestic abuse so avoid misleading assumptions that reducing or stopping drinking will mean relationships, domestic abuse and outcomes for children will automatically improve (Humphreys, 2005; Galvani & Humphreys, 2007).

^{[1] Hidden Harm – Responding to the needs of children of problem drug users; ACMD 2003
[2] Child Protection issues for professionals working with parents/carers who misuse alcohol; Alcohol Concern 2006
[3] Velleman, R. (1993) 'Alcohol and the family', London, Institute of Alcohol Studies}

The ability of a parent to successfully care for the needs of their child will vary depending upon their level of substance or alcohol use, influencing a parent's mood and potentially resulting in inconsistent parenting as a consequence of dramatic swings between disorder and periods of relative stability. Parents may use a variety of authoritarian, controlling, permissive and neglectful parenting styles.

Parent-child role reversal is a characteristic often seen in substance using households. All children help their parents; however for children of substance or alcohol using parents, this behaviour may develop into an increased dependence on the child. Some children may take on the role of primary carer, developing feelings of responsibility for parental wellbeing, whilst others may experience feelings of confusion, leading to boundaries between parent and child becoming increasingly blurred (Kroll et al 2009).

Whilst a parent accessing treatment should be viewed by professionals as a positive step for the family, practitioners will also need to consider how this may affect children. Withdrawing from psychologically or physically addictive substances can have severe adverse effects including; increased anxiety, irritability, insominia, depression, vomiting and symptoms of paranoia (NSW Department of Community Services, 2004). Further impacting on the capacity of the parent to effectively care for their child. Symptoms of intoxication and withdrawal may mean that parents find it difficult to perform household tasks and maintain routines such as preparing meals, providing clean clothes, appropriate supervision of children and responding to their child's emotional needs. (Dawe, Harnett & Frye, 2008). The lack of effective parental supervision can leave children vulnerable in the community, and at risk of grooming and exploitation. Financial difficulties and debt may also present as parents may ignore buying household essentials such as food and clothes or paying bills in order to pay for drugs or alcohol.

The extent to which parenting capacity is sustained or diminished, and to which children are at risk of harm and abuse is influenced by the presence of protective factors such as: good physical standards in the home, the child attends nursery, day care or school regularly, the family has sufficient income to cover household necessities.

When working with a parent who is coping with multiple and complex issues, practitioners are likely to have to support them with multiple needs. Practitioners should be mindful that referrals to a multitude of agencies and professionals in an attempt to tackle all needs simultaneously can be overwhelming for the family, particularly where there are existing social functioning and manageability issues. An effective intervention strategy offering coordinated support is necessary and must be planned and purposeful, based on comprehensive assessment which includes the families' views and wishes and is staged to meet the family's needs and capacities over time. The role of the lead professional is crucial to ensuring the success of the strategy.

Harm and abuse associated with parental substance or alcohol use is cumulative and can have long lasting consequences. Practitioners should be aware that there are a number of risks associated with parental substance or alcohol use which can have the potential to cause direct harm to children, including:

• Neglect of parental responsibilities, leading to physical, emotional or psychological harm;
• Experiencing or witnessing neglect or abuse – physical, verbal or sexual;
• Experiencing or witnessing domestic violence;
• Exposure to unsuitable care givers or visitors;
• Unsafe storage of substances e.g. methadone (used in the treatment of opioid dependency);
• Adopting parenting responsibilities;
• Transmission of blood borne viruses and incomplete immunisations;
• Lack of household stability;
• Use of family resources to finance substance misuse, resulting in lack of basic necessities or household utilities.

A child's growth and development depends on a variety of inter-relating social and biological factors, which can be broadly grouped into three categories - conception and pregnancy, parenting, and the wider family and environment. Hidden Harm and Silent Voices outline the way in which alcohol and drug use can impact on the development of children in affected families.

Assessments provide an opportunity to deliver harm reduction interventions for parents which should be grounded in the notion that drug and alcohol use per se does not necessarily affect parenting adversely; however the behaviours associated with it may have a detrimental effect on the welfare of children. By reducing the impact of parental alcohol or substance use on children, risks to them can be ameliorated. If they can be considered a resource a non-using partner, sibling, or grand-parent may be considered a protective factor and it is good practice to consider their support needs in any assessment.

Where possible assessments should be conducted jointly, and practitioners will use their own assessment tools, but will use information gathered from shared assessments as the foundation to their work. If assessments can be carried out simultaneously there are benefits to the family and for the quality of the assessment.

An holistic assessment should consider:

• Early identification of the most vulnerable families and/or cases where children are suffering, or are likely to suffer, significant harm, leading to timely offer of proportionate intervention early help or family support;
• Both current and future needs;
• The individual needs of all family members (including those of young carers);
• Ideally children and parents should be seen both together and separately, wherever possible;
• Assessment of adolescents, who may have specific unmet needs, such as being young carers, but may also be vulnerable to grooming and exploitation in the absence of effective parental supervision;
• Assessment of eligibility criteria for services taking account of the complex and varied needs of the whole family;
• Observations of any prevailing mental health needs for either parent, carer or child and any other adult member of the household;
• Details of supervision and contact arrangements for the children and any care giver;
• Assessment of any equality, diversity and inclusion needs. Interpreters, advocates and other methods of communication should be considered where a need is identified;
• Observation of the family together, particularly where children are not able to express their views or wishes through age or disability;
• Where a practitioner does not see the children, and where appropriate they should ask specific questions to gather as much information about the children, including questions around school attendance, attainment and general health.

Analysis: making sense of the information

This is an important part of the assessment process as poor analysis of the information that has been collated will invariably lead to poor decision making, care planning and poor outcomes for the family. 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' alcohol or substance use significantly affecting parenting capacity?
• Is the parents' alcohol or substance use and associated behaviours 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' conceptual understanding, attitude and motivation on the need for change?
• What change might be realistic and attainable?
• What interventions will help reduce the risk of harm to children?
• Where, on the continuum of children in need/children in need of protection, does this particular family sit?

Outlined below are some suggestions which may assist the analysis component of the assessment:

• A family genogram;
• A chronology of significant events;
• A record of family composition. A synthesis of current information, observations and any other provider assessments;
• The views and perspective of all interested parties, including children, parents, family, neighbours and members of the community and other professionals/agencies;
• Triangulation of assessment information and its sources; professionals can be over reliant on parent's self-reporting and may develop an optimistic bias of progress;
• Identify any other factors that may influence the assessment e.g. values of individual worker; parental attitudes and level of co-operation and transparency;
• Value based judgements underpinned by evidence, research and theory relating to alcohol or substance use, child welfare and parenting;
• Completion of the Graded Care Profile or equivalent assessment tool for neglect used in your area.

Substance misuse in pregnancy is associated with increased risks. Pregnancy provides an excellent opportunity for healthcare professionals to provide education and care within a harm reduction framework. Treatment and care goals must be realistic and tailored to the needs of the individual woman. Healthcare professionals caring for such individuals have a responsibility to support the woman throughout her pregnancy and beyond, and to create a positive pregnancy experience. They should provide encouragement to women to seek antenatal care and treatment for their drug use, provide information regarding blood-borne viruses, and agree a comprehensive care plan to meet the needs of the woman and her baby and ensure communication exists between the multi-disciplinary team at an early stage to manage concerns and safeguarding issues.

Women who experience problems with substances (and who often face other pressures) don't always realise that they are pregnant until later in the pregnancy (their periods may have stopped and they may have believed they couldn't get pregnant). They may present and book late to maternity services, be fearful of being judged and stigmatised. It is vital that women who use substances have provided informed consent, receive support in their pregnancy, a prompt referral to treatment services where needed, and, crucially after the birth, are supported to enable the baby to remain with them whenever it is safe and appropriate.

The Department of Health recommends that women should avoid alcohol altogether during pregnancy because alcohol passes freely through the placenta so can affect the growing foetus right the way through until birth. While guidance is provided for women who wish to drink during pregnancy, to not drink more than 1 or 2 units once or twice a week, this is to 'minimise the risk of harm' rather than eliminate the risk of harm. Therefore, no consumption of alcohol = no risk of associated alcohol harm. When alcohol does cause harm, the effects may not be limited to Foetal Alcohol Spectrum Disorder (FASD) alone, alcohol consumption is associated with infertility, miscarriage and stillbirth. The adverse effects of alcohol consumption on the developing foetus represent a spectrum of physical, behavioural and neurocognitive impairments. The range of disorders associated with FASD varies in severity and clinical outcomes depending on the level, pattern, and when the mother consumes alcohol.

Any women with suspected alcohol dependence should always get specialist advice before stopping completely or reducing suddenly as it can be dangerous to do this too quickly and without proper support. Sudden and severe alcohol withdrawal can vary from mild problems, such as sleeping badly and feeling shaky and anxious, to much more serious, sometimes life-threatening problems such as seizures or delirium tremens (DTs). Therefore it is crucial that specialist advice is sought and received and the amount of alcohol consumed is reduced gradually and safely.

Substance use is associated with increased risk of miscarriage and pre-term labour, low birth weight and stillbirths.

Stimulants (e.g. crack) can cause an increased risk of placental abruption, (The placenta normally separates from the wall of the uterus after the baby has been born. In placental abruption, part or all of the placenta separates from the uterus before the baby has been delivered. This condition is potentially life-threatening both to mother and child).

Not every woman who uses substances will need additional support or a referral to specialist services. If you are unsure and need advice contact your local specialist midwifery service or the midwifery safeguarding team.

New-born babies may experience neo-natal abstinence syndrome (Kocherlakota 2014) (e.g. high pitched crying and difficulties feeding), this may interfere with the parent / child attachment process. Babies may also experience a lack of basic health care, poor stimulation and be at risk of accidental injury (including overlay) and poor parental supervision.

The Adfam research 'Medications in Drug Treatment; Tackling the risks to children 2015' examined cases where children have died or come to harm from ingesting Opioid Substitute Treatment (OST) medicines prescribed to help people overcome opiate addiction. The report identified 17 Serious Case Reviews involving the ingestion of OST drugs by children in the last five years, plus potentially more incidents that don't reach that level of inquiry. The information presented in this report highlights that not only are such events not isolated, but that they have happened with quite depressing regularity. OST is an extremely valuable tool in the treatment of drug dependency and has an evidence base supporting its part in our treatment system. The overwhelming majority of the people who need and use OST do so safely. However, we also must recognise that the drugs used, especially methadone, are toxic, powerful and present a clear danger to children when stored or used incorrectly by their parents and carers (Medications in Drug Treatment; Tackling the risks to children Adfam 2015).

Other risks to child(ren) may arise from:

• Substance misuse affecting their parent/carers' practical caring skills: perceptions, attention to basic physical needs and supervision which may place the child in danger (e.g. child leaving the home unsupervised);
• Substance misuse may also affect control of emotion, judgement and quality of attachment to, or separation from, the child;
• Parents/carers experiencing mental states or behaviour that put children at risk of injury, psychological distress (e.g. absence of attuned or consistent parenting, emotional and physical availability, inappropriate sexual and / or aggressive behaviour, or neglect (e.g. limited stability and routine, lack of medical treatment or irregular school attendance);
• Children are particularly vulnerable when parents and carers are withdrawing from drugs or alcohol;
• The risk is also greater where there is evidence of mental ill health, domestic violence and abuse and when both parents/carers are misusing substances (co-occurring issues);
• There being reduced money available to the household to meet basic needs (e.g. inadequate food, heat and clothing, problems with paying rent that may lead to household instability and mobility of the family from one temporary home to another);
• Exposing children to associated lifestyle risks that may include drug using peers or acquaintances, or exposure to drug use and associated paraphernalia;
• Normalising substance use and offending behaviour, including children being introduced to using substances themselves;
• Unsafe storage of injecting equipment, drugs and alcohol (e.g. methadone stored in a fridge or in an infant feeding bottle). Where a child has been exposed to contaminated needles and syringes. Most drug and alcohol services give advice and lockable boxes for medication to be stored safely;
• Children having caring responsibilities inappropriate to their years placed upon them;
• Parents/carers becoming involved in criminal activities, and children at possible risk of separation (e.g. parents/carers receiving custodial sentences);
• Children experiencing loss and bereavement associated with parental ill health and death, parents/carers attending inpatient hospital treatment and rehab programmes;
• Children being socially isolated (e.g. impact on friendships), and at risk of increased social exclusion (e.g. living in a drug using community);
• Children may be in danger if they are a passenger in a car whilst an alcohol or substance misusing carer is driving.

Children whose parent and carers are misusing substances may suffer impaired growth and development, challenging behaviours, mental and physical health issues which may include using alcohol or substances themselves and self-harming behaviour.

Some groups of children may be particularly vulnerable:

• Where there is life-threatening substance use;
• Where substance use related behaviours may impact on children (e.g. such as acquiring illicit drugs whilst accompanied by children);
• Where substance use impacts on the quality of the parenting/care;
• Unborn children;
• Children 5 years and under, especially children 0-24 months;
• Children with chronic illness;
• Children with disabilities or special educational needs;
• Young people missing from home or education;
• Young Carers;
• Where Co-occurring Issues are present (substance use, domestic violence, mental ill health);
• When a young person is injecting substances;
• Where there is poor parental physical health;
• Children who live with an adult at risk;
• Children in families where a child has been previously removed.

Alcohol/substance misuse professionals must identify those adults who are parents and carers (including defacto parents), or who have regular care giving access to children, and routinely share the information with key professionals in universal services as early as possible (e.g. midwife, health visitor or school nurse). Routine communication with universal services is an essential part of good interagency working, safeguarding practice and promoting early help. There is also evidence that when service users are disengaging from alcohol/substance misuse treatment there may be an increased risk to children.

It is therefore imperative that routine information sharing takes place between all agencies involved with the family, when alcohol/drug services are engaging and disengaging with parents, carers or adults in regular contact with children. Where there are no identified risks, specific details need not be shared other than that the service is involved (or is no longer involved) with the family. Best practice, even where there are no concerns from the point of view of alcohol/substance misuse services, would be to ensure universal services are contacted as other involved partner agencies may wish to discuss with adult keyworkers any emerging risk.

Early identification of parental alcohol/drug use by frontline staff working with children and families will also greatly assist in providing support for children. Some areas promote the use of drug and alcohol screening questionnaires for frontline staff to incorporate into their assessments with parents/carers to support early identification and intervention.

LA children's social care, alcohol/substance misuse services and other agency services must undertake a multi-disciplinary assessment using the Early Help Assessment / Assessment Framework including specialist alcohol/substance misuse and other assessments, to determine whether or not parents/carers with alcohol/substance misuse problems can care adequately for their child(ren). Such assessment should include whether they are willing and able to lower or cease their alcohol/substance misuse, and what support they need to achieve this.

Professionals in all agencies must recognise that their duty to safeguard and promote the welfare of children.

All care programme meetings for adults who are a parent/carer must include ongoing assessment of the needs or risk factors for the child(ren) concerned. LA children's social care should be invited to such meetings if appropriate and contribute.

Strategy meetings / discussions, child protection conferences and core group meetings, must include professionals from any drug and alcohol service involved with the subject child and their family.

Local Safeguarding Children Partnerships are responsible for taking full account of the challenges and complexities of work in this area by ensuring that inter-disciplinary / agency protocols and training are in place for the coordination of assessment and support and for close collaboration between all local children's and adult's services.

Dispute resolution; professional disagreement between agencies should be resolved in line with local dispute resolution processes and within the child's timeframe.

The need to share information to ensure the safety of children will always override any confidentiality agreement with a parent, child or other operational considerations.

Fears about sharing information or jeopardising or therapeutic with a parent or carer cannot be allowed to stand in the way of the need to safeguard and promote the welfare of children at risk of harm and abuse. Any professional involved with the family should not assume that someone else will pass on information that may be critical in keeping a child safe.

All staff must become familiar and work with Local Safeguarding Children's Partnership (LSCP), local statutory frameworks and protocols for sharing information with Children's Social Care, Multi-Agency Safeguarding Hubs (MASH), Local Authority Designated Officers (LADO) and the Police, where appropriate.

Professionals are often over reliant on objective testing being a reliable proxy indicator of the safety of a child. Although objective testing can be a useful indicator of risk, any test results should be viewed contextually and include presentation, behaviour, motivation to engage, and social functioning etc. A 'negative' test result does not necessarily mean that any risk to a child had been reduced.

Whilst tests can help in the assessment of parental alcohol/substance use, it is necessary to understand that they are only one tool and should not be used in isolation. Selecting a method for testing the presence of alcohol or substances will depend on what testing aims to establish, as well as over what length of time and, If necessary, provides a legally defensible chain of custody. An over-reliance on and an increased frequency of testing is not always helpful. Urine tests are not always observed, and can therefore be tampered with, they can only show the presence of substances used in the previous days and cannot show accurate levels of usage. Breathalysers again, can only show very recent alcohol use, with ankle bracelets offering the only 'continuous' testing method to demonstrate prolonged abstinence from alcohol and 'sober' days. Hair strand testing can be reliable for assessing drug use over periods of time, however caution is needed for alcohol hair strand testing which is less reliable. Whilst alcohol hair strand tests can detect periods of 'heavy' drinking, they should not be used to establish abstinence or low level/moderate consumption. Therefore any biological tests used (urine, breathalyser, hair strand, blood tests) provide a broader picture when combined, and considered alongside wider assessment and information gathered from other agencies. They are only one aspect of a full range of factors and tools to be used in assessment.

All agencies should have a framework in place that includes regular supervision, and reflective practice discussion. Supervision should consider and record any unmet learning needs and plan for continued professional development. Practice should be reviewed and challenged constructively and core training requirements commensurate with level and role of the practitioner should be clear and should be routinely refreshed.

Learning loops should be present in governance structures to ensure all staff are kept up to date with best practice and that learning from Child Safeguarding Practice Reviews and qualitative audit processes is distilled and disseminated.

The take up of LSCP training should be encouraged to promote knowledge of local pathways, frameworks and thresholds for intervention.

For more specific local procedures relating to each LSCP's Drug and Alcohol Service:

• Bolton;
• Bury;
• Manchester;
• Oldham - to follow;
• Rochdale - to follow;
• Salford - to follow;
• Stockport;
• Tameside - to follow;
• Trafford;
• Wigan - to follow.

Adfam - support to families affected by drugs and alcohol

The National Association for Children of Alcoholics

Dual Diagnosis - A Good Practice Handbook

NHS Choices Care Programme Approach

Hidden Harm - Responding to the Needs of Children of Problem Drug Users

NSPCC Learning from Serious Case Reviews

Think Child, Think Parent, Think Family

Guidance - Foetal Alcohol Spectrum Disorder: Health Needs Assessment

Guidance: Parents with Alcohol and Drug Problems – Adult Treatment and Children and Family Services

NICE Quality Standard QS 204 Foetal Alcohol Spectrum Disorder