1.11 Children of Parents / Carers who Use Substances Problematically

1. Definitions

Substance misuse may include experimental, recreational, poly-drug, chaotic and dependent use of alcohol and / or drugs. Problematic substance use occurs when the substance use is unsafe (for the person using substances or for someone else).  Medication that is prescribed can also be used problematically

Parental problematic drug (prescribed and/or non prescribed) or alcohol use parental use of drugs / substances (prescribed and / or non prescribed) or alcohol becomes relevant to child protection when substance use impacts on the safety of, or care provided to, a child/ren.

2. Recognition

In families, problematic substance use (prescribed and / or non prescribed) – including alcohol use – is strongly associated with Significant Harm to children. The risk of harm to children may increase where there are other stressors in the family such as domestic abuse, parental mental illness, financial worries and other forms of disadvantage.

The risk to child/ren may arise from:

• substance use, including alcohol,affecting their parent/s’ practical caring skills: perceptions, attention to basic physical needs and supervision which may place the child in danger (e.g.  a young child unsupervised inside or outside of the home);
• substance use, including alcohol, affecting parents’ emotional care of children e.g. emotional regulation or availability, quality of attachment to the child, separation from the child,  judgement in relationships with the child and adults around the child;
• parents experiencing mental states or behaviour that puts children at risk of injury, psychological distress e.g. absence of consistent emotional and physical availability (emotional abuse), inappropriate sexual behaviour (sexual abuse), physically aggressive behaviour (physical abuse), or neglect (e.g. lack of  stability and routine, lack of medical treatment or irregular school attendance);
• children are also vulnerable when parents are withdrawing from drugs and / or alcohol; parents in ‘withdrawal’ from substances (stopping substance use in a planned or unplanned way) are likely to be less consistent, less emotionally available and may be physically unwell. Children’s needs may not be prioritised and children’s vulnerability may be increased;
• the risk is also greater where there is evidence of parental (and/or other adults in the home) mental ill health, domestic abuse and when both parents are using substances problematically.
• 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 unsuitable friends, customers or dealers;
• normalising substance use and offending behaviour, including children being introduced to using substances themselves;
• unsafe storage of injecting equipment, drugs (prescribed and non prescribed) and alcohol e.g. methadone stored in a fridge or in a child or infant bottle, tablets are accessible to children, a child has been exposed to  needles and syringes;
• children having caring responsibilities inappropriate to their years placed upon them (see Safeguarding Young Carers chapter);
• parents becoming involved in criminal activities, and children at possible risk of separation (e.g. parents receiving custodial sentences or other disruption of family life);
• children experiencing loss and bereavement associated with parental ill health and death;
• parents 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.  feeling unable to bring friends home from school or to the area in which they live);
• children may be in danger if they are a passenger in a car whilst a drug / alcohol misusing carer is driving.
• recovery is not a linear process for either parent or child/ren. Children may experience changes, even positive changes as ‘unsafe’ because any changes can feel that they destabilise the status quo the child has learned to cope with.

Children whose parent/s are using substances problematically ( including alcohol, prescribed and non prescribed medication) may suffer impaired growth and development or problems in terms of behaviour and / or mental/physical health, including alcohol / substance misuse and self-harming behaviour. They may be more likely to experience poverty and deprivation, trauma and impact of intersectionality throughout the lifespan.

Any professionals, carers, volunteers, families and friends who are in contact with a child  experiencing parental drug or alcohol use must ask themselves “What is it like for a child in this environment? Is the drug and alcohol use problematic / unsafe?”.

3. Importance of Working in Partnership

Working in partnership across agencies and services is vital for an effective assessment of risk and to ensure the safety of child/ren.

Professional staff in drug and alcohol services must exchange information with child care social workers, health visitors, school nurses and midwives to be able to assess risks for the unborn baby and child (see Information Sharing and Confidentiality section).

Care programme meetings regarding drug or alcohol using parents must include consideration of any needs or risk factors for the children concerned. Children’s Social Care must be given the opportunity and should contribute to such discussions.

Strategy Discussions and Child Protection Conferences must include workers from any drug and alcohol service involved with the family in question.

4. Maternal Substance Misuse and Drug Exposure in Pregnancy

Maternal substance misuse (particularly alcohol use) in pregnancy can have serious effects on the health and development of the baby before and after birth. Many factors affect pregnancy outcomes, including poverty, poor housing, poor maternal health and nutrition, domestic abuse and mental health. Assessing the impact of parental substance misuse must take account of such factors. Pregnant women (and their partners) must be encouraged to seek early antenatal care and treatment to minimise the risks to themselves and their unborn child.

Pregnancy and breastfeeding – seek up to date advice including specialist advice around impact of specific substances.

Where any agency encounters  a person who is using substances  who is pregnant or is pregnant and has a partner whose degree of problematic substance misuse indicates that their parenting capacity is likely to be seriously impaired, they must make a referral to Children’s Social Care – see Making a Referral chapter.

To consider sharing any information around parental substance use in pregnancy with maternity services (midwifery, specialist services, hospital teams), to support good quality pregnancy care including safeguarding birth plans and to help understand the clinical needs of the baby following delivery.

5. Newborn Babies and Children

Children born after substance misuse or prenatal drug exposure may be affected by one or more of the following symptoms;

• brain damage;
• balance problems;
• behavioural problems;
• cognitive delays;
• congenital syndromes;
• difficulty sleeping;
• feeding problems;
• Foetal Alcohol Spectrum Disorder (see Section 6);
• irritability;
• language delays;
• learning disabilities;
• low birth weight;
• premature birth

Newborn babies may experience withdrawal symptoms (e.g. high pitched crying and difficulties feeding), which may interfere with the parent / child bonding process with increased risk of experiencing a lack of basic health care, poor stimulation and be at risk of accidental injury. Parents and babies are likely to need additional support including clinical intervention.

Where a newly born child is found to need treatment to withdraw from substances at or after birth, an assessment and a pre-discharge discussion should take place and consideration should be given to making a referral to Children’s social care in line with the Making a Referral chapter before the child is discharged home.

6. Foetal Alcohol Spectrum Disorder (FASDs)

To aid correct diagnosis of FASD concerns re parental alcohol use in pregnancy should be shared and recorded in order that it is accessible in the child’s notes. FASD shares identifiers with Neurodiversity e.g. ADHD, Autism but is permanent and unchanging brain damage which benefits from specific understanding and treatment).

Foetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. These effects can include physical problems and problems with behaviour and learning. Often, a person with an FASD has a mix of these problems.

FASDs refer to a collection of diagnoses that represent the range of neuro-developmental effects that can happen to a person whose mother drank alcohol during pregnancy. These conditions can affect each person in different ways, and can range from foetal alcohol syndrome to mild to severe foetal alcohol spectrum difficulties.

A person with an FASD might have:

• poor coordination;
• hyperactive behaviour;
• difficulty with attention;
• poor memory and processing skills;
• executive functioning difficulties;
• difficulty in school (especially with maths);
• learning disabilities, speech and language delays;
• intellectual disability or low IQ;
• poor reasoning and judgment skills;
• Sleep and sucking problems as a baby;
• Vision or hearing problems;
• Poor understanding of social rules;
• Superficially may appear bright and chatty;
• Difficulty following complex instructions/ abstract language;
• Difficulties with attention & concentration;
• Difficulties with planning and organising time;
• Performance can fluctuate from day to day.

6.1 Physical effects

Not all children with FASDs will have typical physical presentation. Some may have all the listed physical presentations, and some may have some or none of these. It is outdated for diagnosis to rely on diagnosis physical features, reported concerns about maternal alcohol use in pregnancy are a better indicator for FASD diagnosis.

Physical effects can include distinctive facial features, such as small eyes, an exceptionally thin upper lip, a short, upturned nose, and a smooth skin surface between the nose and upper lip (the philtrum). Deformities of joints, limbs and fingers.

Advice and support:

• What is FASD – National FASD;
• Fetal Alcohol Spectrum Disorder (FASD) – Amaze Sussex;
• About Fetal Alcohol Spectrum Disorders (FASDs)
• NICE Quality Standards to Improve the Diagnosis, Assessment and Prevention of FASD.

7. Protection and Action to be Taken

Where there are concerns by practitioners involved with a family about a child living  with parental substance use, or in a home where other members of the household are using substances , an assessment of the parent’s capacity to meet the child’s needs and protect them from harm should take place. This should consider  the impact on the child of experiencing parental substance use/other adults in the home using substances and  parents’ capacity to mitigate any risks identified. A referral to Children’s social care should be made- Making a Referral chapter.

Parents should also be offered information and encouragement to access support and clinical assessment (GP, CGL, Oasis etc) as well as other community support (12 Step, Kennedy Street, Cascade etc).