Alcohol - Health Committee Contents

Memorandum by the NSPCC (AL 14)


  The purpose of this evidence is to inform the Committee of the significant impact that alcohol misuse by parents or carers can have on the children and young people in their care.

  First, we provide a brief background to the NSPCC and the expertise that informs our submission. Secondly, we present factual information about the impact of parental alcohol misuse on children and young people. Thirdly, we consider a model of child and family support the NSPCC has provided in partnership with the Alcohol Recovery Project, in Camden, London since 2002. We conclude with a set of recommendations for action.

  We would be pleased to supplement this written evidence with oral evidence to the Committee. In addition, if members of the Committee would like to learn more about therapeutic support for children and families dealing with alcohol misuse we would be very pleased to host a visit to a suitable NSPCC project.


    (i) The National Society for the Prevention of Cruelty to Children (NSPCC) is the UK's leading charity specialising in child protection and the prevention of cruelty to children. The NSPCC exists to end cruelty to children through a range of activities which aim to prevent child abuse, help children at risk of abuse and help abused children to overcome the effects of abuse.

    (ii) We have a range of services throughout England, Wales and Northern Ireland. Their work includes:

(a) Providing telephone support for children and young people via ChildLine.

(b) Providing telephone support for adults concerned about the welfare of a child.

(c) Providing support for vulnerable children, young people and their families to help keep these children and young people safe and well cared for.

(d) Providing services for children and young people who need help to overcome the impact of abuse.

    (iii) The NSPCC broadly welcomes the Government's focus on alcohol use and its impact on children and young people. However, we are concerned that the dominant feature of this work is the threat that children and young people present to themselves and others by inappropriate patterns of drinking, as opposed to the threat posed to young and vulnerable children by alcohol misuse by their parents or carers.

    (iv) The NSPCC is concerned to highlight the considerable impact of alcohol on the safety and well-being of children and young people living with alcohol misusing parents or carers. We therefore welcome this Inquiry and the opportunity it presents to highlight this issue which has been neglected for too long and barely features in the national policy framework governing alcohol issues.

    (v) The evidence we present is based on our extensive experience of child protection and in particular the knowledge and understanding of our practitioners providing services to children and young people affected by parental alcohol misuse. We also draw upon the testimony of children and young people using our helpline service, ChildLine, and other services dedicated to children and families experiencing alcohol-related dysfunction.


Alcohol and maltreatment

  (i)  Child maltreatment is the outcome of a series of complex and inter-related factors of which parental alcohol misuse can be one. A significant proportion of child abuse involves parental alcohol misuse, and children and young people living in these circumstances are at increased risk of maltreatment. This does not mean that all children of alcohol misusing parents or carers will always, or even typically, experience maltreatment. However, a significant number of them will, and this is of particular concern to the NSPCC.

  (ii)  It is difficult to provide an exact figure for the numbers of children and young people who are living with parents or carers who misuse alcohol. Quantitative reports typically conflate drug misuse and alcohol misuse into a generic heading of "substance abuse". However, the Cabinet Office (2004) estimates that between 780,000 and 1.3 million children are affected by parental alcohol problems, a figure which broadly corroborates the estimate of 920,000 provided by Alcohol Concern (2000).

Recommendation 1

  Data collection and published data, for example as produced by the Office for National Statistics or the annual Child & Adolescent Mental Health Mapping exercise, should routinely disaggregate drug misuse from alcohol misuse where this is possible. Many parents and carers will use alcohol alongside other substances. This information should be clearly recorded. The gender of the misusing parent/carer and the nature of the substance abuse(s) of each should also be recorded. This would enable:

    — Appropriate research to be undertaken to uncover the forms of child maltreatment associated with alcohol abuse and whether these are significantly different to maltreatment associated with other forms of substance abuse.

    — Whether there is a distinctly gendered element to different forms of substance abuse and associated forms of child maltreatment. This would be helpful for identifying primary causal factors and, therefore, the most effective forms of support and intervention.

  (iii)  In the year ending March 2008, ChildLine received more than 80 calls each week (a total of 4,176 calls) from children and young people where alcohol misuse by a "significant other" was the substantive reason for the call. We cite some anonymised ChildLine case examples below to illustrate the impact of parental alcohol misuse on children.

  (iv)  Alcohol misuse has a significant impact on the life and family experiences of children and young people, for example:

    (a) Conflict and particularly exposure to domestic violence, is commonly associated with alcohol misuse. Gilchrist et al (2003) found alcohol to be a feature in 62% of prosecuted cases of domestic violence, while 48% of offenders were alcohol dependent.

    "Dad drinks a lot and gets drunk at weekends. My step-mum's pregnant, and he pushes her about when he's drunk. I keep telling her to leave him, but she always goes back and I'm worried about her children. Mum says he used to push her around too".

    (ChildLine call 2007-08).

    (b) Physical abuse and neglect are often associated with parental drinking (Forrester et al, 2006).

    "She [mum] gets violent with my little sister as well. She always goes out, and leaves me and my sister alone, when she gets back she smashes up the house, and takes it out on my little sister when she's done nothing wrong. I've been to school with bruises and when they ask I have to lie and pretend I've done it myself".

    (ChildLine call 2007-08).

    (c) Relationships between children and their parents and carers or peers are likely to be affected. Children and young people typically feel ashamed and embarrassed by the behaviour of a drinking parent (Tunnard, 2002).

    (d) Parenting capacity may be compromised as a result of alcohol misuse, resulting in emotional unavailability, variable or volatile behaviour (Cleaver et al, 1999), and in some cases behaviour that is abusive or neglectful.

    "I can't live with mum as she does drugs and goes drinking every night ... dad hit [my] sister once but she called the police and he never hit her again ... dad hardly food shops ..."

    (ChildLine call 2007-2008).

    (e) Role reversal is a common feature in families affected by alcohol misuse, where children will accept responsibility for the care and well-being not only of siblings, but of the alcohol misusing parent(s) (Tunnard, 2002).

    "... didn't go to school today ... had to look after the kids again |"

    (ChildLine call, 2007-08)

    (f) Poverty: Limited family funds, if diverted into buying alcohol, can result in real deprivation and/or pressure on individuals within the family. A failure to pay household bills, the mortgage or rent, can, over time, have a dramatic and detrimental effect on a family's security and relationships (Tunnard, 2002, Forrester et al, 2006).

  (v)  The experiences of children living in a family environment where alcohol misuse is a significant factor are wide-ranging and unpredictable. What is known is that children of alcohol misusing parents "|have higher levels of behavioural difficulty, school-related problems and emotional disturbance than children of non-problem drinking parents, and higher levels of dysfunction than children whose parents have other mental or physical problems". (Alcohol Concern, 2009)

  (vi)  The outcomes for these children are equally diverse, and include in particular: anti-social behaviour; emotional problems; poor educational engagement and difficulty in developing or sustaining trusting relationships (ibid). Parental alcoholism is also a major predictor of alcohol use in adolescents. The children of alcohol misusing parents or carers are at greater risk of alcoholism than the children of non-abusing parents or carers (Chassin et al, 1999)

  (vii)  Parental misuse of drugs or alcohol is a common issue for child care social workers. In a qualitative examination of social work case files, Forrester et al (2006) found parental substance misuse emerged as a major feature in 34% of cases. These cases tended to be associated with more severe levels of concern, for example, they accounted for 62% of children subject to care proceedings and 40% of those placed on the child protection register. The study also highlights "the central importance of alcohol misuse", for while drug misuse receives more attention than alcohol misuse, by researchers and the media, Forrester et al's sample found more cases involving alcohol misuse overall. In addition, those cases involving alcohol found a higher incidence of violence and were less likely to involve a substance misuse professional. "It is therefore clear that alcohol misuse is a central issue for social workers".

  (viii)  In the main, the children tended to be younger and part of a family where both parents were substance misusers, or to come from single parent families where the lone parent was a substance misuser (Forrester et al, 2006). Families were typically chaotic; characterised by violence, relationship breakdowns, housing difficulties and unemployment. The concerns surrounding children's welfare were predominantly associated with neglect (ibid).

  (ix)  Notwithstanding the above, referrals from health visitors and general practitioners were the exception rather than the rule (ibid) suggesting that substance misuse issues are either not being identified or not being referred by community health professionals. Primary health care professionals play a crucial role in the early identification of alcohol misuse, and in the development of multi-agency assessment and support. The government's plans to expand the health visiting workforce are warmly welcomed. However, it is important that this expansion is not confined to targeted interventions such as Family Nurse Partnerships. The universal service traditionally supplied by health visitors and widely welcomed by families is a resource in which the NSPCC would wish to see significant investment and growth.

Recommendation 2

  We recommend increased investment in the home visiting universal health visiting service, in addition to government plans to expand Family Nurse Partnerships and to ensure the availability of a health visitor at children's centres.

Recommendation 3

  We also recommend that qualitative research should be undertaken to establish why community health professionals are not identifying and/or referring parents/carers with problems associated with substance, and particularly alcohol, abuse.

  (x)  Forrester et al (2006) identify the legal status of alcohol and its prominent role within society as being a possible partial explanation for the challenges that arise when working in this area. They conclude this may be the reason why the inter-agency framework works less well in relation to alcohol misuse than to other substances.

  (xi)  The National Service Framework for Children Young People & Maternity Services (NSF) (2004) is clear that the children of substance and alcohol misusing parents/carers are likely to need particular support.

Recommendation 4

  The abovementioned research might usefully be extended to include an examination of why the inter-agency framework works less well in relation to alcohol misuse than to other substances. This would inform the development of appropriate practice and procedures in a multi-agency environment.

  xi.  Finally, Forrester et al continue that social workers are ill-prepared for work with substance-misusing parents and lack appropriate training. This is compounded by the lack of involvement of substance misuse professionals in care plans.

Recommendation 5

  All professionals working with children and families should be required to undertake appropriate multi-agency training concerning the impact of parental/carer drug and alcohol misuse on the children for in their care.

  (xii)  Anecdotal evidence from the NSPPCs services indicates a high level of substance misuse in cases of serious or fatal child abuse, and this is verified by studies into fatal child abuse which record the persistence of "substance abuse" as a risk factor: 60% of cases (Wilczynski, 1995); 57% (DCSF, 2008)i. Further interrogation shows a complex picture of co-morbidities, without any clear indication of a primary causal factor. For example: 66% of cases show incidence of domestic abuse and 55% of cases show incidence of mental health disorders. What is clear is that substance misuse, though rarely a causal factor when taken in isolation, is a high risk factor when associated with either or both domestic abuse and/or a mental health disorder (DCSF, 2008).

Recommendation 6

  Detailed scoping for further research into co-morbidities should be undertaken as a matter of urgency. This should, in particular, consider how, where multiple factors are present, the primary cause might be identified, as this will shape the support offered to parents, carers and families.

  (xiii)  The link between alcohol misuse and non-fatal child abuse is also clear. Robinson & Hassle's study in Camden & Islington (2000) found that alcohol played a part in around 25% of known cases of child abuse and that domestic violence, drug misuse and alcohol misuse were found to be the highest contributory factors within the family unit affecting the welfare of the child. Of particular concern, particularly given the frequency with which it occurred, was the fact that substance misuse was not included in assessment (Robinson & Hassle, 2000). These findings bear out the current experiences of NSPCC teams working with substance misuse, including alcohol misuse, where adult and children's services do not typically plan jointly for children in need and children who are subject to a child protection plan.

Recommendation 7

  The Department of Health and the Department for Children, Schools & Families should develop a stronger policy focus on the impact of parental alcohol misuse on children.

Recommendation 8

  The Department of Health and the Department for Children, Schools and Families should develop joint guidance for all professionals working with children and families reinforcing the need to:

    —  Ensure that assessments explicitly include and record an assessment of need and risk in connection with alcohol and/or substance abuse.

    —  That this assessment should record alcohol misuse as a separate factor to other forms of drug abuse.

    —  That the gender of the substance/alcohol abusing parent/carer should be routinely recorded.

    —  That an appropriate record is made of plans for support, intervention and review.

Recommendation 9

  This information should be aggregated within Local Authority Children's Services Department and used to inform Primary Care Trust (PCT) Joint Strategic Needs Assessments (JSNAs) and Local Authority Children & Young Persons' Plans (CYPPs).

Recommendation 10

  The Department of Health and the Department for Children, Schools and Families should consider the development of a joint performance indicator concerning the identification of parental/carer alcohol misuse, the rate of referral and the impact of treatment in terms of the effect it has on family stability.

  In addition, women experiencing domestic violence are 15 times more likely to misuse alcohol than the general female population and this affects their parenting capacity (Stark et al, 1996; Stephens et al, 2000; Humphreys et al, 2003)

  Other research suggests that children are more likely to suffer physical abuse if the father is the drinker, and neglect if the mother is the drinker (Cleaver et al., 1999).

Recommendation 11

  Further research should be commissioned to establish to what extent abuse associated with alcohol misuse is gendered. This will inform the nature of intervention and support provided.

  xv.  Alcohol misuse is typically conflated into a generic figure for "substance misuse". This is not helpful for developing social policy on alcohol-related harm and arguably serves to mask some of its negative effects. Alcohol is qualitatively different from other substances included in the term "substance misuse" in that it is a legal substance, is widely and easily available, relatively cheap and widely socially embraced across class, gender and many cultures (more so, arguably, than abstinence). It is the ease of access to alcohol, and the relative acceptability of its use, that inadvertently conceals the extent and severity of its impact on family life.

Recommendation 12

  Substance abuse data should be disaggregated into component parts showing "alcohol misuse" and other substance misuse. This would:

    —  Provide a clear source of quantitative evidence to inform practice and policy in this area.

    —  Provide commissioners with high-quality information concerning the sorts of specialist services required.

  xvi.  Routine assessment of parental alcohol use is widely undertaken, and should form a part of all ante-natal presentations (RCOG, 2006). This should include enquiries concerning alcohol use by partners.

  xvii.  Similarly, routine assessment of parental alcohol misuse should form a part of all post-natal enquiries and this should include enquiries concerning alcohol use by partners.

Recommendation 13

  Alcohol (mis)use should form a routine and consistent element of post-natal assessment by health visitors and/or general practitioners.


    "Children and young people and families receive high quality services which are coordinated around their individual and family needs and take account of their views".

    (National Service Framework for Children's & Maternity Services, 2004, Core Standard 3)

    "The stresses of parenthood can precipitate or exacerbate parents' difficulties. In some cases, children may be at risk of harm as a result of their parents' problems; substance or alcohol misuse, in particular, can lead to a chaotic lifestyle".

    (National Service Framework for Children's & Maternity Services, 2004, p.79, para 9.2)

  The Family Alcohol Service (FAS) started in May 2002, as a partnership project between the NSPCC and the Alcohol Recovery Project (ARP), to provide therapeutic and family support services to families in Camden and Islington where there are parental alcohol problems.

    (i) It is one of a number of NSPCC projects providing support services to children and families experiencing parental alcohol problems. Such services are relatively rare.

    (ii) The project aims to bridge the gap between services to adults and services to children by offering support to the whole family through one service, using a solution-focused approach which emphasises the values and strengths of family members, looking at their motivation to change their behaviour to concentrate on the needs of their children.

    "Despite the evidence that many families and children are badly affected [by alcohol misuse], recognition of their experiences, alongside service provision for these families, has been limited. Traditionally services have focused on the needs of problem drinkers |" (Velleman et al, 2003)

    (iii) Following a short assessment period, FAS offers a range of services, suited to the needs of each family. This may include family sessions, individual work with the drinking parent and the non-drinking partner, couple sessions, as well as individual play therapy sessions with children affected by their parents' alcohol problems.

    "I come here when Mummy is not well and it's nice to have someone to talk to".

    "It's great to come to this place—you can talk about difficult stuff".

    Feedback from service users: NSPCC Family Alcohol Service

    (iv) The aim is to increase children's resilience and ability to cope with their situation, as well as helping parents+ recognise the impact their drinking has on their children and make positive changes to benefit them.

    "FAS listens to me when I talk about the things I do well for my family, not just the bad things".

    "Alcohol misuse affects all the family—the work you do with the whole family makes sense".

    Feedback from service users: NSPCC Family Alcohol Service

    (v) FAS work with families for about six to nine months on average in an intensive way, often seeing more than one family member for individual sessions. Referrals mostly come from Social Services but the project also works with other alcohol agencies as well as health services. Self-referrals are also encouraged and often these are more motivated to attend and make positive changes.

    (vi) An evaluation of the first 12 months of this project was published in 2003. It found, amongst other things that:

    — The FAS engaged with 74 families including 120 children in the first year of service.

    — Many of the children were on the child protection register, the subject of care proceedings, living with other family members or in care.

    — Family members were "enthusiastic in their praise for the service. Both referrers and FAS staff have reported significant success in engaging difficult-to-treat families in the change process".

    — Children became less anxious and more able to express and resolve negative feelings about their home circumstances. School attendance and achievement improved.

    — Most importantly: the aspiration of the FAS was to be seen as an example of good practice. The evaluation found that "| FAS has made a good start on becoming just that, demonstrating some inspiring and innovative work in an extremely difficult area of practice".

  Safe, Sensible, Social: The next steps in the National Alcohol Strategy (HM Govt, 2007) acknowledges the risks parental alcohol misuse presents for children and young people, but does not include any recommendations in this context.

Recommendation 14

  We recommend that the Department of Health and the Department for Children, Schools & Families develop a stronger joint focus on the issue of parental alcohol misuse and its impact on children and young people.

Recommendation 15

  We further recommend that consideration is given to the provision of more family-focused therapeutic work with alcohol misusing parents/carers and their children, such as that outlined above and in line with the requirements of the Department of Health, National Service Framework for Children's & Maternity Services, Core Standard 3.


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March 2009

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