1. Introduction 

1.1 Population description and drug use 

·         It has been estimated that there are between 250,000 and 350,000 children of problem drug users in the UK, 2-3% of all under 16 year olds. Problematic users were defined as those exhibiting serious negative everyday consequences resulting from their drug use, and were identified from the regional drug misuse databases (Advisory Committee on the Misuse of Drugs (ACMD), 2003). Six percent of men, and 29% of women accessing drug treatment services in England and Wales with children at home, either lived alone or with strangers (Meier et al., 2004). The more severe the drug use disorder, the more likely it was that a parent would be separated from their children.

·         Parental drug use can impact upon household stability; child health, safety, and neglect (including access to illicit drugs); reception into care system; changes in the quality of parent-child relationships (when there is an interaction with socio-economic deprivation); and increase social stigmatisation (ACMD, 2003).

·         The timing of any teratogenic insults (production of structural malformations in foetal development) in relation to fetal development is critical in determining the type and extent of damage produced. Women who are dependent upon drugs may not cease use even when they become pregnant. Drug exposed newborns may exhibit reductions in birth weight and head circumference (an indirect measure of brain size), and be at increased risk from structural malformations. Exposure to drugs during pregnancy may lead to long lasting cognitive change in the newborn, who may show abnormalities in learning, and other behavioural changes, including sensory modalities. Offspring of opiate dependent mothers show withdrawal syndromes, although this has not yet been demonstrated with cocaine.

·         Additional effects on the child include an increased risk of problematic behaviour; poor school performance; difficulty in developing peer relationships; anxiety about the health and safety of the parent.

·         Drug use per se may not be an aetiological factor, but interacts with socio-economic deprivation, environment stressors, and poor mental health.

·         Whilst family drug use did not directly lead to an increase in prevalence in younger aged children, it influenced the choice of the child’s peer group (Bahr et al., 1993). This in turn influenced the child’s drug using behaviours. In contrast, other studies in USA teenagers suggested that parental choice of drugs determines that of their child (Johnson et al., 1991).

·         Older children may act as carers/guardians for younger siblings, with all attendant problems. In some cases this may lead to resentment (ACMD, 2003). 

1.2 Approaches  

·         Like other types of prevention intervention, few have been subject to rigorous evaluation. There is evidence from the USA, however, that it is possible to recruit and retain children and parents over long periods of time.

·         Although most programmes have originated in the USA, experiences of residential, home-visiting, non-residential programmes and playgroup-based clinics have led to an outline of issues and dilemmas faced by this population. These include balancing trust and acceptance with intervention when problems are identified, harmonising accessibility and flexibility with the provision of child-focused activities and adult education, finding a location that is both suitable and affordable, appropriately supporting staff, collaborating with other services and securing adequate funding, including for ongoing evaluation and monitoring (Banwell et al., 2002).

·         Only marginal improvements have been observed in studies of the effects of community health nurse visits, although some mothers are more likely to enter treatment if visited by positive role models (e.g. other mothers experienced in similar life events) (Black et al., 1994; Ernst et al., 1999).

·         Playgroup based clinics (e.g. based on health, welfare, and advocacy) assist children in developing skills, and allows parents to share information and to play with their children. In existing programmes no demands are usually made regarding drug use, but support is available to those who request it (Denton et al., 2000).

·         Greater successes at residential schemes for drug using parents have been attributed to low attrition rates, and greater positive intervention perceptions by staff. 

1.3 Gaps and inconsistencies in the available literature 

·         Data on dependent children are not included in the NDTMS minimum set.

·         Not all parents who have drug problems have childcare difficulties. Stable households may experience disruption during periods of chaotic or escalating drug use.

·         Children and extended families are rarely the focus of interventions.

·         Planned pregnancy and contraception.

·         Maternal drug use during gestation period.

·         Focus on mothers to the exclusion of fathers.

1.4 Implications and recommendations derived from the literature 

·         Holistic family approaches, including integration of courses on parenting skills may improve the quality of self-esteem and parent-child interactions.

·         Implementing and managing such programmes likely to be difficult and resource intensive.

·         Examination of social expectations/disapproval upon child welfare.

·         Examination of non-pharmacological risk factors for description of impact upon children.

·         Safety at home should be discussed with drug using parents, particularly concerning injection equipment and drug storage.

2. Intervention focus 

2.1   Programmes targeted towards children of problematic drugs users (Bauld et al., 2004; for summary see DH Fact Sheet 3, Drug prevention with the Children of Drug Using Parents (attached)) 

• What the intervention did?

The Children and Young People’s Project (CAYPP) was based in Liverpool at two adult drug treatment centres. It was a weekly run voluntary initiative that offered a range of activities including diversionary pursuits and issues based work, including drugs and alcohol, violence and aggression, mental health, bereavement, ‘keeping safe’, confidence, and self esteem.  

• Who it was targeted at?

Drug and alcohol workers at the two agencies referred families to the project, and specifically targeted children and young people who:

·         Had parents in treatment

·         Children of drug using parents, considered to be ‘children in need’ according to Section 17 of the Children’s Act 1989.

·         Were aged between 7 and 16

·         Had some awareness of parental substance use 

• How evaluated?

·         Qualitative fieldwork using a framework approach whereby at least two researchers reviewed transcripts and identified key themes, allowing for the indexing and charting of data.

·         Eighteen interviews were conducted with project workers and managers; drugs workers; steering group members; parents; children.

• Measures of success or failure?

There was a lack of baseline data; therefore project outcomes rely on self-reported perceptions of project’s impact.

Children and young people

·         Amongst young people, drug and alcohol use was spoken about in an open manner

·         The project lessened the children’s sense of isolation by helping them to develop a solid peer support network

·                     Children’s level of confidence increased

·                     There was a positive shift in some children’s behaviour

·         Some suggestion that project assisted older participants to engage with other agencies

Parents

§         Increased communication between parent and child

§         General openness within families in talking about substance use

§         Increased motivation in undertaking activities together 

2.2 An intensive family focussed intervention for children of methadone treated parents (Catalano et al., 1999) 

• What the intervention did? 

·         Examined whether intensive family-focused interventions with methadone treated parents could reduce both parents' drug use and prevent children's initiation of drug use.

·         The experimental intervention supplemented methadone treatment with 33 sessions of family training combined with 9 month of home-based case management

·         Programme addressed risk factors for relapse and risk and protective factors for drug use among children

·         Training involved structured cognitive affective behavioural skills curriculum developed especially for the project, incorporating motivation, discussion, guided practice, independent practice, and generalisation. Skills training for parents developed in relapse prevention and coping, anger management, child development, holding family meetings, setting clear expectations. Parents also taught how to teach their children refusal and problem solving skills and strategies for succeeding in school.

·         Some skills training sessions involved children in order to allow parents to practice new skills in a controlled environment.

·         Home based case management helped parents and children generalise and maintain the skills learned in group training. This followed a standard manual, and began 1 month before parent training, and lasting a total of 9 months.

• Who it was targeted at?

• Methadone treated parents and their children (aged 3-14 years old).

• Parents had to be in treatment for a minimum of 90 days prior to the study, and have their children living with them at least 50% of the time

• How evaluated? 

·         144 methadone-treated parents were assigned randomly into intervention and control conditions and assessed at baseline, post-test, and 6 and 12 months following the intervention.

·         Their children (N = 178) were assessed at baseline, and 6 and 12 month follow-up points.

·         Parent measures included relapse and problem-solving skills, self-report measures of family management practices, deviant peer networks, domestic conflict, and drug use.

·         Child measures included self-report measures of rules, family attachment, parental involvement, school attachment and misbehaviour, negative peers, substance use, and delinquency.

·         Outcomes measured using a mixture of structured interviews and questionnaires.

• Measures of success or failure? 

• One year after the family skills training, results indicated significant positive changes among parents, especially in the areas of parent skills, parent drug use, deviant peers, and family management.

• Few changes were noted in children's behaviour or attitudes. Positive effects were reported in younger children, who were observed to have greater family involvement with their parents at the 6 month follow up.

• Programmes such as this may be an important adjunct to treatment programs, helping to strengthen parental driven family bonding and to reduce parents' drug use. 

2.3    A family drugs service based in Huddersfield, West Yorkshire (Brailsford, 2004) 

This intervention, which was established in late 2003, aims to provide a holistic approach to children and families affected by substance misuse. Services are targeted towards children aged between 5 and 13 whose parents were substance users. The following aims, outcomes, and indicators have been proposed:

 2.4   School based universal prevention in areas of high prevalence of parental drug use (Dore et al., 2003) 

From the abstract: 

Despite widespread recognition of the risks that parental drug use pose to children, few resources are available to help such children. Using a developmental intervention approach, the authors designed and tested a model curriculum for use with groups of latency-aged children in schools located in communities where drug use is pervasive. In implementing this curriculum with 206 3rd-4th grade inner-city children, the authors documented the need that children affected by family drug use have for workable strategies and skills for coping with aversive environments. The responsiveness of group participants to structure, predictability, and affirmation in the groups was remarkable. Measurable changes occurred in classroom behavior and feelings of self-worth. Obstacles to implementing and testing such an intervention are discussed. 

2.5   Review of programmes for the children of illicit drug-using parents (Banwell et al., 2002). Available upon request, provides a brief summary of various projects, mainly in the USA and Australia. Too little information is provided to make a judgment of the qualities of the reviewed studies, but the paper summarises some main approaches, which may be of use. Available upon request.

From the abstract: 

Concern about the health and general well-being of children whose parents use illicit drugs has contributed to an increased interest in intervention programmes, but the number of such services is still limited. We review published papers about residential, home-visiting and nonresidential programmes and use these and our experience in studying playgroup-based clinics to outline issues and dilemmas they face. These include balancing trust and acceptance with intervention when problems are identified, harmonizing accessibility and flexibility with the provision of child-focused activities and adult education, finding a location that is both suitable and affordable, appropriately supporting staff, collaborating with other services and securing adequate funding, including for ongoing evaluation and monitoring 

References 

Advisory Committee on the Misuse of Drugs (2003) Hidden Harm: Responding to the needs of children of problem drug users. 

Bahr SJ, Hawks RD, Wang G (2003) Family and religious influence on adolescent substance abuse. Youth and Society 24:4 443-465. 

Banwell C, Denton B, Bammer G (2002) Programmes for the children of illicit drug-using parents: Issues and dilemmas. Drug and Alcohol Review 21 (4): 381-386 

Black MM, Nair P, Kight C, Wachtel R, Roby P, Schuler M (1994) Parenting and early development among children of drug abusing women: effects of home intervention. Pediatrics 94:440-448. 

Catalano RF, Gainey RR, Fleming CB, Haggerty KP, Johnson NO (1999) Addiction 94: 241-254 

Denton B, Banwell C, Bammer G (2000) A welcome place: a health service for drug using parents and their children nine years on. Canberra, National Centre for Epidemiology and Population Health, Australian National University. 

Dore MM, Nelson ZL, Kaufmann E (1999) "Friends in need": Designing and implementing a psychoeducational group for school children from drug-involved families. "Friends in need": Designing and implementing a psychoeducational group for school children from drug-involved families. Social Work 44: 179-190

Ernst C, Grant T, Streissguth A (1999) Intervention with high-risk alcohol and drug-abusing women: II. Three year findings from the Seattle model of paraprofessional advocacy. Journal of Community Psychology 27:19-38.

Johnson V, Pandina RJ (1991) Effects of the family environment on adolescent substance use, delinquency, and coping styles. American Journal of Alcohol and Drug Abuse 17:1 71-88.

Meier PS, Donmall MC, McElduff P (2004) Characteristics of drug users who do or do not have care of their children. Addiction 99:955-961.