This chapter should be read in conjunction with the detailed Practice Guidance, Safeguarding Children with Drug and Alcohol Using Parents.
In January 2023, a link was added in Further Information to NICE Quality Standard QS 204 Foetal Alcohol Spectrum Disorder.
Substance misuse refers to the problematic use of drugs (legal and illegal) and alcohol which can lead to social, psychological, physical and legal problems. Whilst they may have different treatment methodologies for the adults with these problems, they are considered together because the consequences for the child are similar.
One of the main difficulties in assessing the harm to children of living with parental substance misuse is that, in the majority of cases, substance misuse is associated with a range of other factors: such as, poverty and deprivation, poor physical and mental health, poor housing, domestic abuse, debt, offending and unemployment. Any or all of these factors are likely to have an impact on the parent and on the child. The relationship between these factors and substance misuse is complex and the substance misuse should not be addressed in isolation.
Substance misuse is often, but not always, associated with poor or inadequate parenting. Although a significant number of children of substance misusing parents receive good parenting, stability and have all their needs fully met. The impact of parental substance misuse can show itself in a number of ways. There may be physical neglect in that children are not kept clean, warm, or fed; emotional neglect through intoxication or the parent displaying little or no affection or nurture; and lack of care for the child's safety. The parents' behaviour is often characterised by unpredictability e.g. too much/not enough discipline, mood swings, being very affectionate or very distant. This leads to inconsistent parenting which can be confusing and damaging to the child.
Children may be introduced to drug and alcohol misuse at an early age by the behaviour of the parents and the availability of the substances within the home.
Substance Misuse and Domestic Abuse
There is no evidence that alcohol plays a direct causal role in domestic abuse, but evidence suggests a strong association between alcohol misuse and violence in the home. Furthermore victimisation has been shown to often lead to substance misuse problems. Like parental alcohol misuse, the impact of domestic abuse on children is often manifested in damage to family attachment, aggression or withdrawal; sleep problems, fear and a wish for safety. Therefore any assessment of parental substance misuse needs to routinely screen for domestic abuse and vice versa.
There are many different terms used to describe the combination of, and association between, substance misuse and mental illness with the most commonly used being 'dual diagnosis' and 'comorbidity'. Research shows that substance use, intoxication, harmful use, withdrawal and dependence may lead to or exacerbate psychiatric or psychological symptoms or syndromes. Conversely, psychological morbidity and psychiatric disorder may lead to substance use, harmful use and dependence. The most common associations for substance misuse are with depression, anxiety and schizophrenia, but eating, post traumatic stress, attention deficit, hyperactivity and memory disorders also occur. Alcohol problems, for example, are often seen with bipolar disorders, schizophrenia,and personality disorders. Therefore any assessment of parental substance misuse needs to routinely screen for mental health issues and vice versa.
Where there is concern that a parent is involved in substance misuse, the effect on the child needs to be considered, including:
- The child's physical safety when the parent is under the influence or withdrawing;
- Possible trauma to the child resulting from changes in the parent's mood or behaviour, including exposure to violence and lower tolerance levels in the parent;
- The impact of the parent's behaviour on the child's development including the emotional and psychological well-being, education and friendships;
- Possible neurodevelopmental consequences of substance misuse in pregnancy (e.g. Fetal alcohol syndrome that may contribute to developmental delays of intellectual disability);
- The impact on newborn babies who may experience 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;
- How safely the parent's alcohol and/or drugs and equipment are stored;
- Dangerously inadequate supervision and other inappropriate parenting practices;
- Intermittent and permanent separation;
- Inadequate accommodation and frequent changes in residence;
- Children being forced to take on a caring role and feeling they have the responsibility to solve their parent's, alcohol and drug problems;
- Children may feel negative emotions such as shame, guilt, fear, anger and embarrassment;
- Children may experience, or witness physical, verbal and sexual abuse and neglect;
- Unsafe sleeping practices.
Practitioners should also be aware that in some circumstances parental substance misuse, mental health issues and domestic violence may occur together, and that the impact of this 'trilogy of risk factors' on the welfare of a child should be comprehensively assessed.
Risk Factors Leading to Worse Outcomes for Children and Young People
General factors- high levels of disharmony, domestic abuse, physical, sexual or emotional abuse, inconsistent, ambivalent parenting, the absence of a stable adult figure, parental loss following separation or divorce, material deprivation and neglect, the family not seeking help. There may be a wide range of factors affecting the reluctance of parents to engage with services, including fear of judgement and prejudice, the lack of child friendly spaces when visiting agencies, financial or logistical barriers, and the lack of resources for services to visit clients at home.
Substance – Specific Factors
Both parents being substance misusers, substance misuse taking place in the home, greater severity of the problem.
Drug – Related Factors
Exposure to and awareness of criminal activity (e.g. drug dealing), presence of the child (although not necessarily in the same room) when the drugs are taken and witnessing someone inject.
The circumstances surrounding dependent, heavy or chaotic substance misuse may inhibit responsible childcare, for example, drug use may lead to poor physical health or to mental health problems, financial problems and a breakdown in family support networks.
There are many reasons why adults take drugs or drink alcohol. Parents may be aware that their behaviour has a negative impact on their child and try to protect their child from their substance misuse; however there is a risk in focusing on the adult's difficulty and in supporting their attempts to control their behaviour. The real impact on the child can be overlooked or seen as a secondary consideration.
To be healthy and to develop normally, children must have their basic needs met. If a parent is more concerned with funding their substance use or is under the influence of drugs or alcohol, they are unlikely to be able to achieve this consistently. A disorganised lifestyle is a frequent consequence of substance misuse. Parents may fail to shop, cook, wash, clean, pay bills, pick a child up from school or attend appointments etc. However, some substance misusing parents may successfully mask the problem by making sure their children get to school and appear well in public and show no evidence of a disorganised lifestyle.
Substance misuse and withdrawal may affect a parent's ability to engage with their child. It may also affect a parent's 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 – lost jobs, unsafe homes (littered with half empty bottles or discarded syringes), broken marriages, severed family ties and friendships, and disruption of efforts made by a local authority to help – are also likely to negatively affect a child.
Any professionals, carers, volunteers, families and 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?" and "What is the difference in parenting when the parent is either intoxicated, withdrawing or sober?"
Where any agency encounters a substance misuser who is pregnant and whose degree of substance misuse indicates that their parenting capacity is likely to be seriously impaired, they must make a referral to Children's Social Care Services.
The majority of chaotic pregnant substance misusing women will have been identified by maternity services and referred to the Substance Misuse Midwife and the Multi Agency Pregnancy Liaison Group (MAPLG). The aim of the group is to share information, establish the need to carry out assessments to determine the level of risk and safeguarding measures required, ensure the woman and family are offered the appropriate level of intervention and support at the earliest opportunity and develop a co-ordinated care plan.
Where a newborn baby is found to be withdrawing from substances at birth and there are possible safeguarding concerns and the child will be discharged home a, discharge planning meeting should take place. Please refer to Nottingham City Safeguarding Children Partnership Discharge Planning Meeting Guidelines.
Resilience and protective factors
The impact of a parent's substance misuse on children will vary from family to family, and children living with parental substance misuse will respond and cope differently. There are protective factors that have been shown to encourage resilience in situations of parental substance misuse. These include the presence of one stable (usually non-substance using) adult or a close bond with at least one adult carer (parent, sibling, grandparent) and a good support network beyond this. Reducing violence and conflict, continuing family cohesion and harmony in the face of the substance misuse, doing things together as a family, as well as parenting that is consistent, sensitive, warm but firm, are also protective factors. Schools also play a key role in building resilience; enjoying school, having teachers who are alert and aware of issues, engaging in a range of activities outside home and school, and having positive opportunities at times of life transition are all protective factors.
The referral may be made following a particular event which has brought the underlying issues of substance misuse into focus. For example, if there has been an assault on a child by a parent under the influence this would invoke the usual section 47 procedures.
A more difficult scenario is one where the threshold for emotional abuse or neglect has been reached despite the parent's best efforts to control their addiction. In these cases professionals may be reluctant to not give a further chance to parents, possibly fearing that using the child protection system may further push the parent over the edge in terms of their substance misuse.
There is a clear need to assess the impact of the behaviour on the child as well as the wider family context. Some adults counselling services may be reluctant to share information because of rules on confidentiality. However, the needs to safeguard children should be paramount and agencies with a history of the parent will have a valuable contribution to make.
Parents' own needs will need to be addressed and supported to access treatment services.
When a woman with a drug problem attends for antenatal care, she should be encouraged to contact the Substance Misuse Midwife for assessment and advice on the treatment options available to her.
Adfam - support to families affected by drugs and alcohol
Local support for families affected by drugs and alcohol: