6.1 Children Living in Households where there is substance misuse: Guidance

Substance misuse is the problematic use of alcohol and/or drugs. While there are different treatment methodologies for adults with these problems, they are considered together because the consequences for the child are quite similar.

Substance misuse usually refers to someone who inappropriately uses or is dependent on illicit drugs, alcohol, prescription drugs or solvents; and their use of these is associated with having a harmful effect on the individual, their family or the community. However, professionals should be mindful that a single use of alcohol and/or drugs can have consequences which are equally as devastating as long-term use.

Many substance-misusing adults also suffer from mental health problems. This may be referred to as 'co-existing conditions’. However, mental health problems may go undiagnosed because substance or alcohol use is masking the symptoms, or because they render a proper diagnosis not possible.

Domestic abuse, parental mental illness, and drug and alcohol misuse have been identified in serious case reviews and domestic homicide reviews as significant factors in families where children have died or been seriously harmed. Where all three issues are present, they are often described as the ‘toxic trio’.

Throughout this document reference is made to parents or carers who misuse substances. Professional should also be alert to situations where other adults or siblings within a household who may be misusing substances. This may put other children at risk, in particular where the adult or older sibling is left in charge or takes on a significant caring role for younger children.

Children’s physical, emotional, social, intellectual and developmental needs can be adversely affected because of their parent’s (or carer’s) misuse of substances. These effects may be through acts of omission or commission, which then have an impact on the child’s welfare and protection.

Substance misuse can consume a great deal of time, money and emotional energy, which will unavoidably impact on capacity to parent a child. It also puts the child at an increased risk of neglect and emotional, physical or sexual abuse, either by the parent or because the child becomes more vulnerable to abuse by others.

The circumstances surrounding dependent, heavy or chaotic substance misuse may inhibit responsible childcare. For example, substance misuse may lead to poor physical health or to mental health problems, financial problems and a breakdown in family support networks. Substance misuse may also impact on the ability of a parent or carer to assess and manage risks to their children, including the risk of harm.

Children may be introduced to drug and alcohol misuse at an early age by the behaviour of the parent and the availability of the substances within the home.

Parents who misuse substances may be good enough parents who do not abuse or neglect their children, and it is important not to generalise or make assumptions about the impact on a child of parental substance misuse. However, it is important that the implications for the child are properly assessed, having full regard to the parent’s ability to maintain consistent and adequate care. Equal regard should be given to each and every child's level of dependence, vulnerability and any special needs.

Services for children and adults will need to work together to tackle the problems caused by substance misuse in families in order to safeguard children and promote their well-being. Support and intervention should be holistic and consider the needs of all family members.

Where there is concern that a parent is involved in substance misuse, the impact on the child needs to be considered, including:

• the child’s physical safety when the parent is under the influence of drugs and/or alcohol
• chronic neglect, which children can suffer from before birth and throughout childhood
• possible trauma to the child resulting from changes in the parent’s mood or behaviour, including exposure to violence and lower tolerance levels
• the impact of the parent’s behaviour on the child’s development, including their emotional and psychological well-being, education and friendships
• the impact on new born babies who may experience foetal alcohol syndrome (which can have lifelong effects) or other drug withdrawal symptoms.
• the extent to which the parent’s substance misuse disrupts the child’s normal daily routines and prejudices the child’s physical and emotional development
• the impact on the child of being in a household where illegal activity is taking place, particularly if the home is used for drug dealing or other activities that can be related to drug dealing, including sex work or parties
• children being particularly vulnerable when parents are withdrawing from drugs
• dangerously inadequate supervision and other inappropriate parenting practices
• there being reduced money available to the household to meet basic needs, e.g. inadequate food, heating and clothing, problems with paying rent (that may lead to household instability and the family moving from one temporary home to another)
• children being forced to take on a caring role and feeling they have the responsibility to solve their parent’s alcohol/drug problems
• children being exposed 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 and alcohol (e.g. methadone stored in a fridge or in an infant feeding bottle)
• children being exposed to contaminated needles, syringes or other drug paraphernalia
• parents becoming involved in criminal activities, and children being at risk of separation (e.g. parents receiving custodial sentences)
• parental ill health or death, or parents needing to attend inpatient hospital treatment or rehabilitation programmes
• children being socially isolated (e.g. impact on friendships) and at risk of increased social exclusion (e.g. living in a substance-misusing community)
• children being passengers in a car whilst a substance misusing parent (or carer) is driving
• the risk of impaired growth and development, or problems with behaviour and/or mental/physical health, including alcohol/substance misuse and self-harming behaviour.

This section outlines a number of potential indicators which may be present. However, it is important not to generalise or make assumptions about the impact on a child of parental substance misuse. Only a full assessment will identify the level of risk.

If a parent (or carer) is concerned with funding an addiction, or is under the influence of drugs or alcohol, this may impact their ability meet their child’s basic needs. Whilst some users are high-functioning even with significant addiction, a disorganised lifestyle is a frequent consequence of substance misuse. Parents may fail to shop, cook, wash, clean, pay bills, attend appointments, etc.

Substance misuse may affect a parent’s ability to engage with their child and their ability to control their emotions. Severe mood swings and angry outbursts may confuse and frighten a child, hindering healthy development and control of their own emotions. Such parents may even become dependent on their own child for support. This can put stress on a child and mean they miss out on the experiences of a normal childhood.

Other consequences of substance misuse can (but do not always) include lost jobs, unsafe homes, broken marriages, severed family ties and friendships, and disruption of efforts made by a local authority to help. Where these exist, they are also likely to negatively affect a child.

Any professionals, carers, volunteers, family or friends who are in contact with a child in a substance-misusing environment must ask themselves: ‘What is it like for a child in this environment?’.

Professionals who are concerned about the children of parents (or carers) who misuse substances should follow the BSCP's Neglect Guidance. Professionals should use risk assessment to assess the extent to which substance misuse is likely to be impacting on the unborn child or on the ability of the adults to safely parent their child/children. In line with the Continuum of Need Incorporating Threshold Guidance, consideration should be given to making a referral to Children’s Social Care using the Multi-Agency Referral Form (MARF).

Where a referral is deemed by Children’s Social Care to meet the threshold for level 3, appropriate action will be taken to assign this to the most appropriate agency to lead a coordinated, multi-agency, Early Help response to meet the needs of the whole family. Early Help in Buckinghamshire is now provided by the Family Support Service.

Where the child/children are deemed to be suffering, or are at risk of suffering, significant harm (level 4), statutory safeguarding processes will be followed, led by Children’s Social Care. Relevant agencies will be involved in the initial assessment and strategy meeting, which will determine the most appropriate course of action.

Substance misuse in pregnancy can have serious effects on the health and development of the child before and after birth. Not every woman who uses substances will need additional support or a referral to specialist services. Many other factors affect pregnancy outcomes, including poverty, poor housing, poor maternal health and nutrition, domestic abuse and mental health. Assessment must be used to understand the impact of, and risks associated with, parental substance misuse and this must take account of other factors such as these.

Women who experience problems with substances 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, and be fearful of being judged and stigmatised. It is vital that women who use misuse substances have informed consent, receive support in their pregnancy, are promptly referred to treatment services where needed, and,  crucially after the birth, are supported to enable the baby to remain with them if it is safe and appropriate.

The Department of Health recommends that women should avoid alcohol altogether during pregnancy. NHS Guidance reflects that experts remain unsure exactly how much, if any, alcohol is completely safe to drink when pregnant and so recommends that the safest approach is not to drink any. No alcohol means no risk of alcohol harm.

If a woman does drink during pregnancy, alcohol passes freely through the placenta and so can affect the growing baby right the way through until birth. A baby’s liver is one of the last organs to develop and does not mature until the latter stages of pregnancy. The unborn baby cannot process alcohol as efficiently as the mother and the alcohol can seriously affect their development.

Alcohol consumption is associated with infertility, miscarriage and still birth. Drinking, particularly during the first three months of pregnancy, increases the risk of premature birth and low birth weight.

The adverse effects of alcohol consumption on the developing foetus represent a spectrum of physical, behavioural and neurocognitive impairments and the risks are greater the more alcohol is consumed. The term Foetal Alcohol Syndrome (FAS) is used to describe the problems a baby has as a result of exposure to alcohol in the womb. Some children may develop mild symptoms, while others may be severely affected. Problems associated with FAS include:

• poor growth while in the womb and after birth so the baby may be shorter/smaller than average, have a small head and jaw and may have deformed limbs
• cerebral palsy
• learning disorders including problems with thinking, speech, social skills and/or memory
• mood, attention or behavioural problems
• problems with the liver, kidneys, heart of other organs
• hearing and sight problems
• epilepsy
• a weak immune system.

Drug use during pregnancy is associated with increased risk of miscarriage and pre-term labour, low birth weight babies 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. The condition is potentially life-threatening, especially for the foetus). Babies may be born with withdrawal symptoms (neonatal abstinence syndrome) where drugs have been taken regularly during pregnancy.

Although full information is not available on all of the longer term effects of drug use during pregnancy, different drugs are associated with a range of potential impacts including different types of behavioural and learning difficulties. As with alcohol misuse, the impact on some babies may be mild, but others may be seriously affected.

Professionals providing care for pregnant women should ask sensitively, but routinely, about all substance use, prescribed and non-prescribed, legal and illegal, including alcohol. If it emerges that a woman may have a problem with drugs or alcohol, she (and her partner) should be encouraged to attend substance misuse services or specialist maternity services, and staff should offer to make the referral. Professionals asking questions of a pregnant woman should also factor in presentation and known history, as well as the information provided, as usage of substances may be minimised.

It is important not to make generalisations and to consider the nature, type and frequency of the substance misuse, and the stage of pregnancy. Where appropriate, services should arrange a multi-disciplinary meeting to review the extent of the woman’s substance use, including type of drugs, level, frequency, pattern and method of administration, and consider any risks to the unborn child from current or previous use. Such discussions should include relevant drug treatment agencies that will be able to contribute to decision making around the appropriate course of action, even where the parents are not currently engaged in drug treatment programmes.

If Children’s Social Services are not involved, the obstetrician, midwife or GP should ask the mother to consent to liaise with them. If the woman does not consent, staff should consider whether the extent of substance misuse is likely to pose risk of significant harm to her unborn baby. Consent is not required if the unborn baby is considered to be at risk of significant harm.

If significant harm seems likely and/or the mother continues to misuse substances, or is unwilling to engage with the substance misuse services, a referral to Children’s Social Care must be made (also see the Pre-birth procedure).

It is important not to delay making a referral to Children’s Social Care in order to:

• ensure that maternity services can provide appropriate antenatal services and liaise with drug and/or alcohol treatment agencies
• allow sufficient time to make adequate plans for the baby’s protection
• allow sufficient time for a full and informed assessment
• avoid initial approaches to parents in the last stages of pregnancy, at what is already an emotionally charged time
• enable parents to have more time to contribute their own ideas and solutions to concerns, and increase the likelihood of a positive outcome to assessments
• enable the early provision of support services so as to facilitate optimum home circumstances prior to the birth
• identify significant family members who might be able to provide support, and consider the use of a family group conference to facilitate this.

The midwife should ensure appropriate screening is undertaken in line with local procedures, and test results should be available in hospital notes.

If it is known that a baby is going to be born with neonatal abstinence syndrome or evidence of drug toxicity, pre-birth planning will have taken place (see Pre-birth procedure) and there should be a Child in Need Plan or a Child Protection Plan in place.

If a baby is born suffering from withdrawal symptoms or Foetal Alcohol Syndrome, and this is unexpected, the midwife must refer the baby to Children’s Social Care immediately. In these cases, the baby has suffered significant harm and normal child protection procedures apply (see Neglect Guidance).

Unless the baby is already the subject of a Child Protection Plan, a strategy discussion should be held with the CAIU, medical professionals and any other relevant professionals.

This discussion will need to decide and plan:

• the assessments to be initiated, including whether or not to initiate a Section 47 enquiry
• whether it is safe for the baby to be discharged/remain at home
• health and Children’s Social Care plans to provide support and monitor progress
• arrangements for notification of discharge from hospital.

Children’s Social Care should be informed by hospital staff as early as possible prior to discharge.

It is important that services working with adults recognise the potential risks of adult substance misuse to children.

Where safeguarding concerns are identified, all professionals should follow the advice set out in What to do if you have a Concern. Information should be shared in line with this procedure and the Buckinghamshire Multi-Agency Information Sharing Code of Practice. Effective and timely information sharing will help ensure relevant professionals are able to assess risks to an unborn baby, child or young person, and ensure appropriate action is taken.

Substance misuse professionals must identify those adults who are parents, or who have regular care-giving access to children, and share the information with Children’s Social Care as early as possible.

Children’s Social Care, substance misuse services and other relevant agencies must undertake a multi-agency assessment including specialist substance misuse and other assessments, to determine whether or not parents with substance misuse problems can care adequately for their child/children. Such assessments should include whether they are willing and able to lower or cease their substance misuse, and what support they need to achieve this.

Meetings in adult services regarding drug or alcohol misusing parents must include consideration of any needs of, or risks to, children concerned. Children’s Social Care must be given the opportunity to contribute to such discussions.

All care programme meetings for adults who are parents must include ongoing assessment of the needs or risk factors for the child/children concerned.

Children’s Social Care should be invited to and contribute to such meetings if appropriate.

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