Summary note – this response is structured as follows.

1.       Introductory remarks about factors related to health inequalities influencing substance use.

2.       Specific prevention initiatives that have the potential to address health inequalities and substance use in certain groups. 

3.       Barriers to service access. It is not possible to make generalisations as there is no one size fits all approach addressing specific needs. However, this section highlights key features and barriers/solutions with respect to particular populations who are at a disadvantage from health inequalities. Frequently, these problems manifest across population groups, and so those identified may be relevant for other groups. 

1. Introduction

There are a large number of risk factors, some of relevance to health inequalities, which have been identified as promoting experimental substance use:

Laws and norms favourable towards drug use; Availability of drugs; Extreme economic deprivation; Neighbourhood disorganisation; Physiological characteristics; Early and persistent behavioural problems; Family history of drug use; Poor family management practices; Family conflict; Low bonding to family; Academic failure; Lack of commitment to school; Early peer rejection; Social influences to use drugs; Alienation and rebelliousness; Attitudes favourable to drug use; Early initiation of drug use

However, it is not possible to decide on one indicator that links all the others from the available evidence. All play a part, and there is a multitude of interplaying permutations.

There are a wide range of individual and environmentally determined factors statistically associated with drug use, and a great number of interactional permutations. The main factors can be classed as intrapersonal, micro-environmental, and macro-environmental. All of these may potentially reinforce inequalities in health. The following section highlights some of the existing research in this area. However, it is important to note that statistical associations are far from deterministic.

1. Parental education: there is some association between parental education and adolescent substance misuse, but this association is far from simple and the use of cigarettes, alcohol, and cannabis ranges from being significantly negative to being significantly positive, furthermore there is little association between the education of both parents and adolescent substance misuse.

2. Family structure: a large body of research has found that adolescents who reside with both biological parents are less likely to be substance misusers. While this research generally finds all types of substance misuse to be more prevalent among adolescents who live with a single parent, the evidence regarding the effect of living with one biological parent and a stepparent is less conclusive and there are often differences between studies on standardised measures of family structure which makes synthesis of data difficult. Moreover, single parent homes are sometimes associated with a variety of problem behaviours and contextual factors.

3. Economic situation: in most industrialised countries, lower economic and occupational status is associated with more smoking and alcohol use among adults, but similar to parental education, the economic status of the family has generally not been found to be associated with adolescent substance misuse. In the USA for example, substance misuse is more prevalent in affluent towns and neighbourhoods, whilst in England substance use is positively associated with neighbourhood deprivation.

4. Parental control: research on the effects of parenting styles has frequently distinguished between parental support, monitoring, and rule-setting. In general, strong parental support and monitoring has been found to be associated with less substance use among European youth. In contrast, studies of parental rule-setting have either found no such association, net of other factors, or a positive association. Generally, the two extremes of over protective and unsupportive , as well as poorly defined and combative parental relationships can be associated with drug use.

5. Truancy: research in a variety of countries has rather consistently found adolescent substance misuse to be associated with higher levels of truancy and other measures of school performance. Furthermore, individual students are more likely to initiate substance use in schools where truancy is high and student commitment to school is low. For example, some UK studies have shown that pupils excluded from conventional school education were four times more likely to have used illicit drugs, and five times more likely to be current drug users than pupils who have not been excluded. Truants are thought to be twice as likely to be users of cannabis or solvents, and three times as likely to report use of ‘harder’ drugs.

6. Sibling substance use: Substance use by siblings has been argued to be amongst the strongest predictors of adolescent substance use. Having an elder sibling who uses a particular substance was associated with more use in the younger individual.

7. Personality and Psychology: experimentation and use of illicit drugs need not indicate developmental or personality problems and may occur independently of these, and without adverse individual effects. However, studies have shown substance use disorder comorbidity in over half of psychiatric patients, and the literature emphasises drug use as a response to developmental problems. This risk factor overload has lead to a greater emphasis on multi-factor approaches in which the aggregate number of risk factors and their interplay is highlighted. A move towards exploring personality factors in the context of problem behaviours has been encouraged.

8. Age at initiation: studies have emphasised that initiation into substance use at an earlier age increases the likelihood of drug experimentation and problematic use, e.g. 19% of those that used cannabis before the age of 15 later developed drug use problems; twice as many as those who began their drug use at the age of 19. However, age of initiation may be no more than an indicator of other risk factors predictive of drug use, in which case there may be situations in which delaying age of onset may have little impact in reducing the risk of problem drug use. One longitudinal study for example in a cohort of 18 year olds found that a substantial part of the difference in drug use at a later age attributed to age of onset was accounted for by other individual and situational factors such as social disadvantage and greater exposure to peers who had used drugs.

Table 1 Risk and Protective Factors: While some factors may be categorical (e.g. early onset of illicit drug use), many are dimensional, with relative levels of risk and protection.

Section 2.

2.1 Data from the USA, suggests that family-based interventions have the potential to address substance use, especially in environments where health inequalities may exist.

·         “Interventions designed for the family target risk and protective factors specific to the family context as well as interactions between the family and other contexts that may involve the child or have an impact on the child. Research has identified a number of family-level risk and protective factors associated with initiation of drug use. Specifically, studies show that the presence of substance abuse disorders among parents or other family members poses both genetic and social risks for children (Bry 1994; Dumka et al. 1995; Johnson and Montgomery 1989; Merikangas, Dierker, and Fenton, this volume; Van Hasselt et al. 1993). Other family risk factors include parental or sibling use of alcohol, tobacco, and other drugs; positive family attitudes toward and acceptance of substance use; lack of attachment to parents at any developmental stage; sexual or physical abuse; economic instability; and poor family management (Hawkins et al. 1992, 1985). Protective factors in the family include consistent and contingent discipline; a strong parent-child bond; high levels of supervision and monitoring; and parental warmth, affection, and emotional support (Ge et al. 1996; Hawkins et al. 1992). Dishion and colleagues (1988) have demonstrated the importance of the family as an intervention context by showing, in longitudinal and cross-sectional analyses of prevention interventions, that enhancing parenting behaviors that have been shown to be protective can have a positive influence on the child. Specifically, they demonstrated that skill in parental monitoring can be taught and that this skill is a viable method of preventing early-onset drug use in children. Additionally, research indicates that protective family factors can moderate the effects of risk factors. Specifically, Brook and colleagues (1990) found that the risk of associating with peers who use drugs was offset by protective family factors such as parent conventionality, maternal adjustment, and strong parent-child attachment. Their research stresses the importance of the ongoing role of the family in the socialization of children well into the adolescent years. Family prevention interventions have successfully used behavioral, affective, and cognitive approaches to target a variety of family behaviors. Among them are parent-child interaction strategies, communication skills, child management practices, and family management skills (Bry, Catalano, Kumpfer, Lochman, and Szapocznik, this volume). A major factor that distinguishes family-based prevention interventions with positive outcomes from other parenting programs is that, similar to successful school-based programming, they concentrate on skill development rather than on simply educating parents about appropriate parenting practices. Effective programs use interactive teaching strategies to present skills to parents and their children, allow for practices and feedback, assign homework, and then help family members refine skills that work and modify those that do not. Another factor that contributes to the success of family interventions is who participates. Family interventions may focus on the parents or child separately or on the family as a whole. Among the most innovative and effective are those interventions that include parents and children in individual and group training sessions. In these interventions, work is done individually with the parents and the children and then the entire family is brought together to practice the skills and strategies learned in the individual sessions. This approach may be complicated if parents divorce and remarry. For example, Collins and Shanahan found it necessary to collect data from three families (the original nuclear and two stepfamilies) to gain a full picture of the whole family for one child.”

• “Although the number of research-based family prevention interventions is increasing, there are still relatively few that have been subjected to rigorous efficacy studies and even fewer that have subsequently been replicated with diverse populations under less controlled conditions. However, this is rapidly changing, and many advances are being made. Currently there are universal, selective, and indicated family-based programs in the field (Catalano, Kosterman, Haggerty, Hawkins, and Spoth, this volume; Institute of Medicine 1994; Kumpfer, this volume). Some programs that originally targeted one population have been modified for others. For example, the Strengthening Families Program was originally designed as an indicated intervention for parents on methadone maintenance (Kumpfer, this volume). It has now been adapted for universal audiences (Spoth, this volume) and for use in a variety of cultural and physical contexts.”

Both taken from Drug Abuse Prevention Through Family Intervention. NIDA Research Monograph, Number 177

2.2 Scientific Findings From Family Prevention Intervention Research

Brenna H, Bry, Richard F. Catalano, Karol L. Kumpfer, John E. Lochman, and José Szapocznik (citation as above)

• The critical role of family factors is acknowledged in virtually every psychological theory of substance abuse (Brook et al. 1990; Bry 1983; Catalano and Hawkins 1996; Dembo et al. 1979; Dishion et al. 1988; Elliott et al. 1989; Hawkins et al. 1992; Jessor 1993; Kandel and Davies 1992; Kaplan and Johnson 1992; Kellam et al. 1983; Kumpfer 1987; Newcomb and Bentler 1989; Oetting and Lynch 1993; Wills et al. 1992). Nevertheless, only recently have research findings about family protective and risk factors been applied in prevention intervention research.

• Protective Family Factors -  Family factors that appear to inhibit substance abuse can be categorized into five broad characteristics or activities that take place both in the home and outside the home. Protective factors within the home include close, mutually reinforcing parent-child relationships (Brook 1993; Brook et al. 1984, 1990; Catalano et al. 1993; Dishion et al. 1988; Werner and Smith 1992). Positive discipline methods on the part of parents are also protective against substance abuse (Blocket al. 1988; Catalano et al. 1993; Dishion et al. 1988; Kellam et al. 1983). Protective factors outside the home include monitoring and supervision of children’s activities and relationships (Catalano et al. 1992; Chilcoat et al. 1995; Dishion et al. 1988; Ensminger 1990; Fletcher et al. 1995; Richardson et al. 1989; Smart and Gray 1979). Family involvement with and advocacy for the children outside of the home, such as at church and in school, also prove to be protective against substance abuse (Brunswick et al. 1992; Kandel and Davies 1992; Krohn and Thornberry 1993). Finally, parents’ taking initiative and seeking information and support for the benefit of their children is protective (Crockenberg 1981; Nye et al. 1995; Rhodes et al. 1992, 1994; Stack 1974). These protective factors appear to reduce adolescent substance abuse by establishing a parent-child relationship, from birth, within which parents exert strong positive influence by knowing what their children do day to day, by providing ample praise for their appropriate behaviors, and by constantly introducing them to and actively supporting their engagement in a variety of pleasurable alternatives to substance abuse.

• Family Risk Factors - On the other hand, there are other family factors that clearly increase the probability that a child will abuse substances. Parental rejection and neglect heighten the risk of substance abuse (Block et al. 1988; Shedler and Block 1990). Physical abuse, sexual victimization, and other exposure to violence greatly increase the probability of substance abuse (Briere 1988; Briere and Zaidi 1989; Burnam et al. 1988; Clayton 1992; Dembo et al. 1989, 1992; Miller et al. 1987; Polusny and Follette 1995; Rohsenow et al. 1988; Zierler et al. 1991). Finally, substance abuse by parents and siblings greatly increases the chance that children will abuse substances (Andrews et al. 1993; Brook et al. 1991; Dishion et al. 1988; Merikangas et al. 1992; Sher et al. 1991). In sum, these family risk factors seem to increase substance abuse by producing children with memories of rejection, pain, humiliation, and interpersonal conflict, while depriving them of the protective factors of interpersonal warmth, supervision, and positive guidance in effective life functioning. The unpleasantness in these children’s lives increases the reinforcing value of substance use, while the missing protective factors leave the children without viable, alternative methods to gain pleasure or relief from pain.

2.3 Drug Education Prevention Information Service (DEPIS)

• The Drug Education Prevention Information Service (DEPIS) has produced a background paper which looks at drug education materials for children and young people with Autism

             www.drugscope.org.uk/uploads/ projects/documents/Autism.pdf 

2.4 Further relevant information derived from and academic literature search

1. Simpson MK (1998) Just say 'no'? Alcohol and people with learning difficulties. Disability and Society 13:541-555

This paper critically analysed the scant literature which exists on the role of alcohol in the lives of people with learning difficulties. Though the research evidence is largely insecure, it does seem relatively clear that people with learning difficulties drink considerably less and abstain in higher numbers than the general population. In spite of this, the literature is predominantly characterised by a focus on the potential dangers of excessive alcohol consumption. In contrast, the possibility that a great many people with learning difficulties may have their access to alcohol debarred is not considered to be a problem requiring attention. It is argued that this is based on a failure to appreciate the cultural significance of alcohol for most people, and that the discourse on learning difficulties is being underpinned by a concern with physical, but not cultural access.

2. Karacostas DD, Fisher GL (1993) Chemical dependency in students with and without learning disabilities. Journal of learning disabilities. 26:491-495

This work aimed to determine if students with learning disabilities (LD) demonstrated a higher frequency of substance dependency than students without learning disabilities (NLD). A total of 191 adolescents with LD (101 males and 90 females) were given the Substance Abuse Subtle Screening Inventory (SASSI). The sample consisted of 88 students with LD and 103 NLD students between the ages of 12 and 18. The SASSI is an objectively scored self-report inventory that accurately classifies adolescents as chemically dependent (CD) or not chemically dependent (NCD). A significantly higher proportion of students with LD than NLD students were classified as CD. Of the 30 students who were classified as CD, 70% were students with LD. Discriminant analysis (a technique designed to classify cases into the values of a categorical dependent, usually a dichotomy, i.e. absence or presence of a condition) indicated that the presence or absence of a learning disability was a better predictor of classification of CD or NCD than gender, ethnicity, age, socioeconomic status, or family composition.

However, the relationship may be more complex than the above article suggests. This next study suggests that in children with specific conditions, i.e. ADHD, learning disabilities in earlier childhood do not predict later substance misuse, but that this is more closely related to high IQ and good school performance

3. Molina BSG, Pelham, WE (2001) Substance use, substance abuse, and LD among adolescents with a childhood history of ADHD. Journal of Learning Disabilities 34:333-334

This study examined a clinic-referred sample of 109 children with attention-deficit/hyperactivity disorder (ADHD) and followed them into adolescence in order to ascertain alcohol and other drug use and abuse. Learning disability (reading or maths) in childhood was examined as a predictor of adolescent substance use and substance use disorder for alcohol and cannabis. No statistically significant group differences for children with LD versus those without LD emerged even after using different methods to compute LD. IQ/achievement discrepancy scores were similarly not predictive of later use or abuse. However, children with ADHD who had higher IQs and higher levels of academic achievement in childhood were more likely to try cigarettes, to smoke daily, and to have their first drink of alcohol or first cigarette at an early age. Children with ADHD who had higher reading achievement scores were less likely to have later alcohol use disorder. Although these findings are necessarily preliminary, due to the small number of children interviewed, the pattern of results suggests that level of cognitive functioning-rather than discrepancy between IQ and achievement-is important for the prediction of later substance use and abuse, at least in this clinic-referred sample of children with ADHD.

2.5.1 Children of drug using parents

·         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).

2.5.2 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.

2.5.3 Intervention focus

2.5.3.1 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

• 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

2.5.3.2 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.

2.5.3.3    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: