Chapter 52: Working with Families in which the Problematic Use of Drugs or Alcohol is an Issue |
Contents
- Introduction
- Equal Opportunities
- Information about Treatment
- Risk Assessment and Parental Drug or Alcohol Use
- Working with Parents whose Drug or Alcohol use Presents Substantial Risk for their Children
- Working with Pregnant Women whose use of Drugs or Alcohol causes Concern
- Procedure for Working with Pregnant Women whose Drug or Alcohol use is Problematic
- Consent, Confidentiality, Information Sharing and Child Protection
- Procedures for Making Referrals to Children and Learning Social Care
- Referral and Assessment Team Response to Referrals
- Collaboration and Case Management
- Supervision
Appendix 1 - Drug Testing of Adults
Appendix 2 - Checklist (to support assessment of need)
1. Introduction
These guidelines have been written for use by all statutory, non-statutory, independent, voluntary and GP services working in Luton with families in which the problematic use of drugs or alcohol is an issue and should be used alongside other LSCB procedures.
It must be acknowledged at the outset that the problematic use of drugs or alcohol by parents or carers does not, in itself, automatically indicate that their children are at risk of abuse or neglect.
However, at the same time, it is important that all workers involved with these families should recognise that they constitute a high-risk group.
Adults whose use of drugs and alcohol is problematic may face a wide range of associated problems, including accommodation and financial difficulties, difficult or destructive relationships, lack of effective social and support systems, poor health and issues relating to criminal activities. The impact of these stresses on any children involved may be of more importance than the impact of the drug or alcohol use itself.
It is vital that the problematic use of drugs or alcohol should be assessed in the context of family life and functioning. It should not merely be regarded as a problem of the parents in isolation or as a direct predictor of abuse or neglect.
Whenever there is concern about the welfare of a child and assessment and planning are taking place, it will be very important that consideration of any problematic use of alcohol or drugs by their parents or carers should be fully integrated into this process.
If it seems that the child is suffering or likely to suffer Significant Harm, assessment and planning will be conducted in accordance with established child protection procedures.
It is intended that these guidelines should help in ensuring that this work is conducted as effectively as possible, drawing on all relevant available sources of expertise.
The term 'problematic use of drugs or alcohol' is used throughout this document in preference to more familiar expressions such as 'drug use' or 'drug misuse'.
'Drug use' or 'misuse' can be applied to a wide spectrum of behaviours from occasional recreational use of cannabis through to the addictive use of Class A drugs.
It is felt that reference to 'problematic use', though sometimes a little clumsy, gives a more accurate picture of the target behaviours.
2. Equal Opportunities
It is intended that these guidelines be applicable in all situations, irrespective of race, gender, age, sexuality, class, culture, and disability.
It must be recognised that many stereotypes and assumptions exist concerning people who use drugs. It is essential that all workers making assessments should strive to ensure that their judgements are made on the basis of the observable evidence and are not influenced by prejudicial attitudes or suppositions on their part.
3. Information about Treatment
People with problematic use of alcohol and or drugs may have tried a range of different treatments and experienced a number of relapses.
Changing established habits can be complex and requires considerable motivation. However in the past access to treatment has been difficult and users, particularly women, may well have experienced poor provision and long waiting lists.
Many users fear losing their children and are reluctant to refer themselves for treatment.
Sometimes child protection investigations can motivate people to seek assistance and users should be supported in their plans.
Childcare staff are not expected to have detailed knowledge of the various interventions and treatments available and all alcohol and drug agencies will respond to telephone queries from social workers and attend multi-agency assessments if appropriate.
The Luton Drug and Alcohol Partnership provides a guide to services
The current adult services are as follows
Alcohol
ASC (Alcohol Services for the Community) provide day care, brief interventions, counselling and relapse prevention services. It aims to provide a safe supportive non-drinking environment to work through alcohol related problems.
Luton Drug and Alcohol Specialist Services assess problematic alcohol users for medical interventions including community and in patient detoxification. Patients receive key worker support from community psychiatric nurses.
Drugs
In the past eight years the availability of a range of treatment for problematic drug use has improved dramatically and there is now rapid access to substitute prescribing for heroin and complementary therapy and support to help users reduce their use of crack/cocaine.
Luton Drug and Alcohol Specialist Services provide community based prescribing with nurse support for those with problematic drug and or alcohol use and mental health issues.
The Luton Shared Care Drug Service provides GP care for crack and opiate users with key worker support. Advice is available about home detox and referral for inpatient detoxification.
Structured day care programme for opiate and crack use is available from CAN as well as a range of complementary therapies, counselling and motivational therapy.
Community care assessments for community or residential rehabilitation placements are completed by the community care social worker. Those who meet the critical and substantial criteria are eligible for consideration for funding.
Addaction in Luton provides advice and support to drug users and their families. Services include information on drugs and alcohol, needle exchange, complementary care and relapse prevention.
If the checklist in Section 4 below raises issues requiring clarification all agencies will be able to give advice and support childcare staff.
Services for Young People
The PUKE service run by ASC offers young people knowledge about alcohol and drugs and key worker support is available. Many young people are troubled by their parents drinking and PUKE will support young people with parents who are problematic users.
The Young People's Drug Service supports young people who have issues with drug use and need to reduce the risk to themselves and others. Support, counselling, diversionary activities, and appointments for medical assessments are available.
4. Risk Assessment and Parental Drug or Alcohol Use
This checklist at Appendix 2 should be completed with the parents/carers where possible. Third party information (for example, from neighbours or relatives) may also be sought to validate this information, though issues of confidentiality should always be addressed.
5. Working with Parents whose Drug or Alcohol use Presents Substantial Risk for their Children
Whilst significant drug or alcohol use by parents/carers does not automatically indicate that children in their care are likely to suffer abuse or neglect, it is likely to have some adverse effect on parenting. Agencies working with parents and carers should, therefore, remain alert to the fact that drug or alcohol use may significantly affect the quality of care offered to children. There is evidence to suggest that appropriate interventions aimed at improving the functioning of the family can reduce long-term harm to the children. However, parents/carers whose drug or alcohol use and lifestyles are chaotic may present a considerable challenge to inter-agency practice.
Despite close supervision on an inter-agency basis, it is not unusual for family functioning gradually to deteriorate over time, eventually reaching unacceptable levels, which require the removal of the children from their parents'/carers' care. What is sometimes lacking in this process of decline is a direct, albeit empathic, confrontation with the parents which brings home to them clearly and unequivocally the unacceptable nature of their current drug or alcohol use, the impact on their children and the inevitability that they will lose their children if the problems continue at their present level. This may create a helpful crisis for the parents and provide a creative basis for reconsidering their current lifestyle. The earlier this confrontation occurs in the intervention with more problematic cases, the greater the chance of minimising the damage which occurs to the parents' health and functioning and increase the well-being of the children. Where mental health issues are also present, effective liaison with the relevant services over the approach to be adopted is essential.
6. Working with Pregnant Women whose use of Drugs or Alcohol causes Concern
Pregnant women using drugs or alcohol to a problematic extent are likely to feel guilty about the harm which they may be causing to their babies and fearful of the judgement of others. When any agency comes into contact with such a woman, reassurance should be offered that all agencies are committed to working with her to assist with care for her baby, and that the baby will not automatically be removed from her care or be subject to a Child Protection Plan. The approach adopted should aim to maximise the likelihood of the woman's full cooperation with those services best able to promote the well-being of the expected child.
It should be ensured that a referral has been made to the relevant Hospital Trust for antenatal care and the relevant medical and midwifery staff should be provided with information about the extent and nature of drug and alcohol use, including relevant historical information. Suitable treatment options should be discussed. It is essential that such discussions involve staff with expertise in this field. Referral to and engagement with specialist drugs and alcohol services should be considered in each case. Where there is any concern about the likelihood of harm to the unborn child, a referral should be made to Children's Social Care, Referral and Assessment Team.
Options may include stabilisation, partial reduction, or complete withdrawal during pregnancy. Many women may wish to stop completely, but this may be undesirable for both medical and social reasons. Too rapid a withdrawal may harm the baby or cause a miscarriage or premature labour. The additional social and emotional stresses that accompany pregnancy may make it unrealistic to attempt total withdrawal at this time, particularly if the woman's partner is still using drugs or alcohol to any significant extent. There is a risk of relapse, which could be harmful to the child, and such a relapse may be concealed because of shame or fear of the consequences.
7. Procedure for Working with Pregnant Women whose Drug or Alcohol use is Problematic
Ensure that a booking is made for antenatal care.
A key midwife will be allocated and consideration will be given to referral to specialist drug or alcohol services. Where there are serious concerns about the health or future welfare of the expected child, consideration will be given to whether inter-agency planning should be initiated. This will normally be commenced by referral to the Referral and Assessment Team, if they are not already involved. The social worker, or key midwife if there is no Children & Learning Social Care involvement, will convene a Professionals' Planning Meeting.
Professionals' Planning Meeting
Purpose
- To confirm arrangements for assessment;
- To share information;
- To discuss drug or alcohol treatment planning;
- To identify immediate needs and to allocate tasks.
Membership
- Specialist drug alcohol services;
- Child care social worker;
- Key midwife;
- Obstetrician;
- Paediatrician;
- GP;
- Health visitor;
- Other key professionals.
Key midwife arranges parents' appointment with paediatrician
Parents' appointment with paediatrician
Purpose
- To discuss baby's treatment, breast-feeding, infection screening etc.;
- To visit neonatal unit.
Ongoing antenatal care, drug treatment and social work assessment, as required.
Pre-birth Planning Meeting/Child Protection Conference
4-8 weeks before EED. Convened by Children's Social Care if a Child Protection Conference, or by the key midwife.
Purpose:
- To share information and the findings of any assessment;
- To plan for the immediate care of the baby;
- To identify the required resources and assign tasks;
- Draw up inter-agency protection plan, as required;
- Review drug/alcohol treatment.
Membership:
- Those present at the Professionals' Planning Meeting, with the addition of the parents. If this meeting is to take the form of a Child Protection Conference, a wider attendance may be required, in accordance with the Child Protection Conferences Procedure.
Birth of baby
- Monitoring for withdrawal, if required (by Paediatrician and nursing staff);
- Assessment of care provided (by Paediatrician, nursing staff, midwifery staff and social worker, as appropriate).
Pre-discharge Planning Meeting/Child Protection Conference
Purpose
- To plan for the safe discharge of the baby;
- To establish any necessary follow-up;
- To establish arrangements for the review of the discharge plan;
- Draw up a longer-term inter-agency plan, as required;
- To decide on the need for future meetings.
Membership
- As at pre-birth meeting or conference with the addition of new staff who have been involved since the birth or will be involved following discharge (such as neonatal nursing staff and Health Visitor).
Timing
The timing of this meeting will need to be adjusted depending on the child's length of stay in hospital. If the child is in the hospital for an extended period it may be appropriate to hold a conference followed by a Core Group meeting prior to discharge.
Following discharge
- The child will be monitored and reviewed in accordance with arrangements established in the discharge plan;
- Should the plan not be adhered to, a further professionals' meeting or Child Protection Conference will be convened as required.
8. Consent, Confidentiality, Information Sharing and Child Protection
When working with people whose use of drugs or alcohol is problematic, the maintenance of confidentiality will often be of vital importance in engaging service users effectively. However, at the same time, research and experience have shown us that keeping children safe from harm requires professionals and others to share information about any risk of harm to which a child may be exposed. Those providing services to adults whose use of drugs or alcohol is problematic are faced with the challenge of balancing their duties to protect children from harm and their general duty of confidence towards their patients or service users.
This balance can be a difficult one to achieve but useful guidance is provided in the Information Sharing Protocol, Information Sharing: Practitioners' Guidance (DCSF 2008) and paragraphs 3.46-3.57 of Framework for Assessment of Children in Need and Their Families (Department of Health, 2000). In summary, this guidance suggests that 'in any potential conflict between the responsibilities of professionals towards children and towards other family members, the needs of the child must come first. Where there are concerns that a child is or may be at risk of suffering Significant Harm, the overriding principle must be to safeguard the child. In such cases, when it is considered that a child may be in danger or that a crime is being or has been committed, the duty of confidence can be overridden'.
Whenever 'there are concerns that a child may be suffering or is likely to suffer Significant Harm, it is essential that professionals and other people share information'. However, 'unless to do so would place the child or children at increased risk of Significant Harm, the nature of the child protection concerns should be explained to family members and children, where appropriate, and their consent to contact other agencies sought'. Since service users can never be guaranteed unqualified confidentiality where the welfare of children is concerned, it is important that all agencies working with vulnerable families should have clear and explicit policies about the sharing of personal information and that these policies should be explained to users of their services and to other agencies.
9. Procedures for Making Referrals to Children and Learning Social Care
Workers should remain alert to the possibility that child welfare concerns may arise when an adult family member has problems with drugs or alcohol. Should it seem to a professional working with any member of the family that there is a risk of a child suffering Significant Harm, referral must be made to the appropriate Referral and Assessment Team - see Recognising and Responding to Concerns about the Welfare of a Child Procedure. The intention to make a referral will normally be discussed with the family, unless this discussion may itself place a child at risk, for example where physical or sexual abuse is alleged. If it seems likely that a police investigation into a possible offence may follow the referral, advice should be sought from the Referral and Assessment Team about how and when the referral should be discussed with the family. The Referral and Assessment Team will, in turn, seek advice from the Police if necessary.
Referrals will normally be made by telephoning the local Referral and Assessment Team should a referral need to be made outside office hours, contact should be made with the Emergency Duty Team (see Local Contact Details). Anyone making a telephone referral must confirm the details in writing within 24 hours. In an emergency where there is the risk of immediate serious harm, the Police should be alerted by dialling 999.
The referral should provide the following information, as far as it is available:
- Cause for concern;
- The names of the child or children in question and dates of birth;
- The address of the child or children;
- The names of the parents and/or carers of the children;
- The school, nursery or day care facility that the children attend, if any;
- The family's General Practitioner;
- Any other professionals involved with the child or children or family e.g. Social Worker, Health Visitor, Probation Officer, Hospital etc;
- Other information including anything, which may be relevant as to how the investigation is to be conducted.
At the end of any discussion or dialogue about a child, the referrer (whether a professional or a member of the public or family) and the Referral and Assessment Team should be clear about who will be taking what action, or that no further action will be taken. The decision should be recorded by the Referral and Assessment Team, and by the referrer.
If there is any doubt about whether a referral may be appropriate, it is very important that advice should be sought. Many agencies will have in-house arrangements for the provision of child protection guidance via designated professionals and managers. Consultation is also offered by the Children's Social Care, Referral and Assessment Team.
10. Referral and Assessment Team Response to Referrals
All new referrals will be considered by the Referral and Assessment Team within 24 hours in accordance with Action to be taken following a referral to Children's Social Care Procedure. A view will be formed at this stage as to whether or not the referral falls within the scope of concern of Significant Harm and whether a Strategy Meeting or an Initial Assessment is required to make initial plans for an investigation. The Duty Social Worker will contact the referrer within 24 hours to advise her or him of the proposed action.
It need not always be regarded as necessary, or indeed realistic; to expect parents to stop using drugs or alcohol before they can be regarded as fit to care for their children. However, it will be important in every case to assess the overall effects of problematic use of drugs or alcohol on any children within the family.
Where the information available suggests that any child is placed at risk of Significant Harm, the procedures in Action to be taken where a Child is at risk of Significant Harm Procedure will be followed and an assessment will be conducted in accordance with these procedures. The checklist contained in Appendix 2 may be found useful as part of the assessment process.
11. Collaboration and Case Management
Effective inter-agency communication and multi-agency collaboration are of crucial importance in the management of ongoing work with families where there are dual concerns about problematic drug use and about child welfare. It must be recognised that successful collaboration between agencies can prove particularly difficult when the working principles, assumptions, and priorities underpinning their everyday work are radically different.
A mismatch of this type may often be found when specialists in child protection are asked to work with specialists in problematic drug and alcohol use. In these circumstances, it is important that those involved share their perspectives and perceptions openly and that they try to understand and respect the principles guiding other agencies.
When workers fail to discuss their differences but cling stolidly to the unspoken presumption that their perspective is right and that of their colleagues is wrong, joint work, which has nominally been agreed, may be subtly but substantially undermined.
When a child is subject to a Child Protection Plan, effective partnership working between child protection workers and specialists in problematic drug and alcohol use will be particularly important. Effective multi-agency working will be promoted by active participation in the Core Groups set up to implement and monitor child protection plans but may also require further bilateral planning and intervention.
Whenever joint working is felt appropriate, it is essential that the capabilities of the agencies involved in delivering the outcomes required are explored critically and that consideration is given to the need to seek expert assistance where the requisite kills are not available within the agencies currently engaged.
Experience has shown that unspoken assumptions may be made about the expertise and resources available within specialist agencies, which are not borne out in reality.
For example, child welfare specialists may assume that drug workers know all about drug use and will be able to deploy their knowledge to assess the impact of drug use on parenting. Drugs workers may assume that child welfare specialists are skilled in assessing the risk for children and families and that if the drug workers provide the facts, the child welfare workers will interpret them.
In reality is it quite possible the neither side can meet the expectations of the other. In such circumstances, the specialist agencies may be working closely together but important areas of need may be unmet because of the unwarranted assumptions being made by each agency about what the other is able to contribute.
Effective assessment in this field requires both an understanding of the social and physiological effects of drug use and the ability to identify the impact of these effects on parenting. Unfortunately, the ability to translate information from one sphere to another is currently relatively rare and it is essential that any potential skills gap in this respect be identified at an early stage.
It should be recognised that assessment in this field must be a continuous process not a one-off event. Should new information be received which may affect the judgement, which has been made about the impact of drug or alcohol use on parenting, this must be shared promptly with all the key agencies involved.
12. Supervision
Work in cases in which there are concerns about both problematic drug or alcohol use and child welfare are likely to prove particularly demanding because of their complexity. Additional concerns may include criminal behaviour, domestic abuse, exploitation by dealers and sexual exploitation. It is of great importance that a clear framework of supervision or professional consultation should support the workers involved.
Those offering supervision and consultation should pay particular attention to ensuring that the case is considered holistically and that a wide range of perspectives is taken into consideration.
For example, supervisors working with practitioners who specialise in work with problematic drug and alcohol use should ensure that child welfare concerns are always considered, that consultation with the Children's Social Care, Referral and Assessment Team takes place where required and that referrals are made whenever necessary.
Supervisors in the field of child welfare should always ensure that issues associated with problematic drug and alcohol use are fully understood and taken into account and that appropriate consultation or collaboration is initiated when required.
Appendix 1 - Drug Testing of Adults
A protocol for the undertaking of drugs tests has been agreed with the Primary Care Adult Shared Care Drug Service (SCDS) in Luton.
Circumstances where drug testing may be appropriate:
- As part of an Initial Assessment or Section 47 Enquiry (includes unborn babies);
- Change in family circumstances;
- Care Proceedings;
- Rehabilitation back home of children in care.
Drug testing referral process
- It is good practice to obtain written consent to drug testing from parents/carers or carers, if possible;
- The social worker contacts the Adult Shared Care Drug Service and discusses the referral with the Clinical Team lead prior to submitting the referral.
Client details required for referral to the Adult Shared Care Drug Service.
- Name;
- DOB;
- Telephone number;
- Address;
- Name of GP (if known);
- Contact details of referrer;
- Purpose of testing;
- Preferred start date;
- Frequency of testing;
- Details of specific drug & use.
Types of testing available:
- Urine Test - Clients can consent to having a sample taken on site under supervision. Detects use for 3-4 days prior to test except for cannabis;
- Saliva test - Only accurate for 36hrs after drug use;
- Hair testing - Traces drug use back for up to six months depending on the length of hair.
Appendix 2 - Checklist (to support assessment of need)
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