Picking up the pieces

A father coming down from taking crack cocaine cannot stand the
crying of his infant son. He shakes him in anger, causing permanent
brain damage. A mother out shopping becomes angry with her
six-year-old daughter. The mother is drunk and starts hitting her
child, nearly killing her. An eight-year-old girl always comes to
school late, dirty and dressed in summer clothes in winter. When
teachers try to talk to the mother she smells strongly of
alcohol.

These are all real children and real events. They all involved
parents who misused alcohol or drugs. And all were referred to
social services departments.

Social services departments have a responsibility to investigate
and prevent abuse of children. They also have a wider remit to
provide services for children “in need”. While many parents with a
drink or drug problem are able to care adequately for their
children, substantial numbers have difficulties in doing so.

Social services deal with many of these families yet there has been
little research on the incidence of parental substance misuse, its
effect on child welfare, and social services departments’ handling
of cases. The study described here (unpublished), funded by the
Nuffield Foundation, tackles these questions. It is the first
large-scale British study of social work cases involving parental
substance misuse and provides a detailed profile of all parental
substance misuse cases dealt with by social services in four London
local authorities. It explores the impact on children and
interventions by social services.

What did we find? Perhaps the most striking finding was the sheer
extent of the drugs and alcohol problem among parents. It affected
more than one-third of all cases dealt with by social services over
a year. And the more serious the child welfare concerns, the higher
the proportion of parental substance misuse: 40 per cent of
children on the child protection register and 62 per cent of those
subject to care proceedings involved substance misuse. Care orders
have a profound impact on children and their families but care
proceedings also make major demands on social workers’ time and are
immensely costly. So parental substance misuse is not only common
and damaging – it is also particularly costly in terms of time and
money.

Alcohol, crack cocaine and heroin predominated but alcohol misuse
was most frequent of all. It accounted for 41 of the 100 families
dealt with over the year and was combined with drug misuse in 27
other families. By contrast drug misuse alone was found in 32
families – still of course, a high proportion. But this pattern
varied markedly, with alcohol-related misuse predominant in outer
London and drugs in the inner city. As the overall proportions were
identical, it is clear that substance misuse is a common issue for
social workers in areas with contrasting socio-demographic
profiles.

Worryingly, cases of crack cocaine appear to have shot up,
overtaking heroin misuse. In 1994 our earlier research in similar
areas found heroin was 10 times as common as crack cocaine in
social work caseloads. Just three years ago the gap had narrowed
considerably but heroin rates were still four times higher. By
2000-1 cocaine had overtaken heroin. What is more, this high
incidence was found in all four authorities. Our study is
London-based but there is evidence that crack misuse is increasing
in other areas of the UK. If this trend continues it bodes ill for
children’s welfare. We found crack cocaine was associated with
babies coming into care. The cases were also particularly difficult
to work with and social workers frequently faced threats of or
actual assault. Yet up to now research findings and practice
experience have been primarily based on heroin, and to a lesser
extent amphetamine misuse.

The extent of crack cocaine in our sample may overshadow other
trends that are every bit as worrying, if less arresting. The
substance that caused the most harm to children – and appeared to
cause the most professional difficulties – was undoubtedly alcohol.
These cases were rarely referred before harm had taken place to the
child. Of the 13 children who ended up in hospital with serious
injuries, nine involved alcohol misuse and the most behaviourally
disturbed children all had parents who misused alcohol.

By contrast, parental drug misuse triggered a very rapid response
not only by social services, but by the health sector too. Newborn
babies, who predominated in cases of drug misuse, were made the
subject of strong protection plans sometimes resulting in the child
being removed and placed for adoption. And even when the plan was
for children to return to parents, more resources were put in,
assessments were inter-disciplinary and planning was more likely to
be clear and decisive.

Specialist substance misuse workers were also frequently involved
and their input was highly valued by social workers. This was not
so with alcohol misuse. The very low levels of identification of
problem drinking before birth, and the complete lack of referrals
from health visitors, who are ideally placed to identify problems
at an early stage, suggested that systems to detect and hopefully
prevent harm to children worked poorly in relation to alcohol
misuse.

So why should alcohol misuse be so under-recognised? Society’s
tolerance of alcohol compared with drugs seems an obvious cause.
This may explain why the inter-agency framework seemed to work less
well in relation to alcohol abuse than to drugs. Other causes were
specific to social work.

Our study highlights an urgent need to improve substance misuse
training radically. The little training received by most staff
focused only on drugs, while basic training was often confined to
an isolated lecture. With the introduction of a new social work
degree, now would be a good time to give substance misuse a higher
profile. In the new social work qualification mental illness and
learning difficulties must be covered, but not substance
misuse.

However, the messages from our study extend beyond social work. To
reach social services, the problem has to be severe. What safety
net is there to help the much larger number of children in need
because of parental substance misuse?

In July Prime Minister Tony Blair announced a government study into
the problems associated with alcohol misuse. Our study suggests
that the government needs to launch initiatives at several levels.
Public information and education – used so effectively in
drink-driving campaigns but never tried for child care – are needed
to raise awareness of the risks to children. Improved inter-agency
working and training for all professionals would allow better early
identification.

Better targeting is an urgent priority. Traditionally, substance
misuse services have targeted men but much more needs to be done to
help women – a staggering 83 per cent of the families in our study
were affected by maternal substance misuse. To increase the
participation of mothers, services need to offer outreach home
visits and care for children during appointments.

To prevent harm to children from parental substance misuse at a
time when drinking and drug taking is increasing is a formidable
task. It cannot wait.

Donald Forrester is lecturer in social work, Goldsmiths
College, University of London and Judith Harwin is professor of
social work, Brunel University.

For further details concerning the study please contact
D.Forrester@gold.ac.uk