Risk and Resilience: The Impact of Substance Misusing Parents on children

1. Risk and Resilience: The Impact of Substance Misusing Parents on children LSCB/ LSAB Annual Conference, 25th September 2013 Professor Richard Velleman Emeritus Professor of Mental Health Research, University of Bath

2. Risk & Resilience for children in substance misusing families • Problematic alcohol, and drug use in parents and the effects on their children • Intergenerational Transmission (of substance misuse, and other –ve outcomes) • Prevention, treatment and support for these families

3. Risk & Resilience for children in substance misusing families 1. Problematic alcohol and drug use in parents How big is this problem? The figures we have equate to almost 4 million people in the 16-65 age group in the UK being dependent on alcohol and/or drugs. Assuming (conservatively) that every substance misuser will negatively affect at least two close family members, this suggests about eight million family members (spouse, children, parents, siblings) in the UK are living with the negative consequences of someone else’s drug or alcohol misuse. Best estimate is that 4 - 5 million UK children (out of 13.2 million – 34%) are affected.

4. Risk & Resilience for children in substance misusing families What is known about the effects on families? Lots of families have lives which are very negatively affected by substance misuse, all across the world – we have studied this in the UK, in Mexico, in Australia in the aboriginal outback, in Italy, but others have looked at this also, and the conclusion is the same: Family members (especially children, but also spouses and parents) are often very badly affected by having someone with a serious drug or alcohol problem living in their midst.

5. Risk & Resilience for children in substance misusing families There is a solid evidence base for the impact of substance misuse on families generally, and on children in particular, both as children and when adults. There are a very large number of studies that demonstrate negative effects on children whilst they are still young and in early adolescence (again, reviewed a number of times, see the references I have left with the organisers as a separate file).

6. Risk & Resilience for children in substance misusing families All this work has led to the following conclusions: People who develop a serious problem with their use of alcohol or drugs can and often do behave in ways that have a significantly negative impact • on family life in general, • and on other individual members of the family.

7. Risk & Resilience for children in substance misusing families In terms of the impact on family life in general: substance misuse can impact negatively on a range of family systems and processes, including • family rituals, • roles within the family, • family routines, • communication structures and systems, • family social life, • and family finances.

8. Risk & Resilience for children in substance misusing families And, as well as on these family systems, it can also often impact negatively on other individuals within the family: problems such as • domestic and other types of violence, • child abuse, • individuals driving whilst intoxicated, • or disappearing for days on end, • or embarrassing family members, • or spending all the money so that there is nothing left for the family are all typical of the types of behaviour which people have described as stressful and with which they have to cope.

9. Risk & Resilience for children in substance misusing families The results of these and other uncertainties are that family members commonly develop problems in their own right, often manifested in high levels of physical and psychological symptoms. These things are often worse for the children. Many of these children experience negative childhoods, including • violence, abuse and living with fear; • inconsistency from one or both parents; • having to adopt responsible or parenting roles at an early age (more)

10. Risk & Resilience for children in substance misusing families • having to deal with denial, distortion and secrecy; • having problems related to attachment, separation and loss; • disturbed family functioning, conflict and breakdown; • role reversal and role confusion, both related to their parents, and themselves.

11. Risk & Resilience for children in substance misusing families Many of these children subsequently demonstrate negative effects of these experiences: these problems include • higher levels of behavioural disturbance, • anti-social behaviour (conduct disorder), • emotional difficulties, • school problems, • ‘precocious maturity’, • and a more difficult transition from childhood through adolescence, than children who have not had this upbringing.

12. Risk & Resilience for children in substance misusing families Other recent work has also shown that children affected by parental substance misuse are more likely to reach the attention of social services than are children affected by other issues, and when they do so, are more likely to experience problems in the interaction between their parents and social services than occurs with other types of problem.

13. Risk & Resilience for children in substance misusing families There are longer-term impacts on these children: • more likely themselves to develop problems with substances, • often linked to earlier onset of use, • and therefore at greater risk of developing problems in other areas of life as adults. Family factors predominate: family dysfunction and disharmony in their family of origin seems most responsible for problems for these children, both when they are children, and later as adults, as opposed to problems caused by the drinking itself.

14. Risk & Resilience for children in substance misusing families HOWEVER, there is growing evidence that not all children are adversely affected, either as children or adults; some children are resilient and do not develop significant problems. This has important implications for prevention and intervention, and I shall return to this in a minute.

15. Risk & Resilience for children in substance misusing families 2. Intergenerational Transmission http://www.communities.gov.uk/communities/troubledfamilies/ • Known for years that alc & drug probs ‘run in families’ (refs to all of this are in the separate file) • But lots of bad research led to a too strong, deterministic model ….. • That led to ‘risk over-prediction’ • But better research has still shown that there ARE (some) inter-generational continuities • An example from my own research: R&R ….

16. Risk & Resilience for children in substance misusing families 250 Young people, 16-35 2 groups – with, and without, seriously problem drinking parent We did not obtain confirmation of the idea of problem drinking being passed on from generation to generation. There were very few differences between the two groups in terms of their drinking and drug-taking. • whether they had ever used alcohol or any other drug, • whether use had ever been a problem, • whether they were still using, • how much used, how often used – in all these areas of drinking and drug-taking, there were no differences between our two groups.

17. Risk & Resilience for children in substance misusing families Some differences did emerge relating to drinking and drug-taking. • The offspring group started using at a younger age (and this was the case with alcohol, cannabis, and other illicit drugs); • They were somewhat more likely to either be using alcohol in a 'risky' fashion currently, or to have previously had problems with their alcohol use; • and they were somewhat more likely to be using in a 'risky' fashion in more than one area of substance use - alcohol, cannabis, other illicit drugs, prescribed drugs, smoking, and home medicines. SO – there IS a risk, but it is not as strong as previously thought.

18. Risk & Resilience for children in substance misusing families What is the evidence that there is inter-generational transfer of OTHER poor outcomes? Very similar results here as well. In our R&R research, we also looked at both childhood adjustment, and adulthood adjustment. Childhood adjustment – generally, very poor. Massive differences between our two groups on virtually all of our measures – family problems relating to family rituals, roles, routines, communication, social life, and finances, family disharmony, violence, aggression, arguments, relationships with parents, childhood problems, friendship problems etc

19. Risk & Resilience for children in substance misusing families But Adulthood adjustment – generally, no differences! No real differences emerged between our two groups in terms of areas such as • self-esteem, • life-satisfaction, • problems with anxiety and depression, • problems with delinquency and deviance, etc. (Some people in both groups DID have problems – the difference was in attribution!) So again, we looked more closely, and again we DID find some differences:

20. Risk & Resilience for children in substance misusing families • we found that some of our sample also had an increased risk of a more negative adulthood adjustment - some were likely to be more depressed, more anxious, have relationship difficulties, leave home early, and generally be more dissatisfied with their lives.  So, we had a situation where most of our offspring group seemed to be OK as young adults, although some did seem to be damaged. • The big question, then, was what made the ones with the worse outcome worse?

21. Risk & Resilience for children in substance misusing families What we found relates to RESILIENCE (a topic I have written about and talked about lots over the last few years). What we know is that some children are resilient: some children who grow up in a family where one or both parents misuse alcohol or drugs do NOT develop serious problems, either as children and especially as adults.

22. Risk & Resilience for children in substance misusing families So what leads to resilience? Two things: • fewer risk factors (things which INCREASE negative impact), and • more protective factors (which protect FROM those risk factors). What are Risk Factors for these children: Interestingly - NOT drinking or drug-taking, or even drunkenness or intoxication. Instead, they are the family problems which arise because of this intoxication.

23. Risk & Resilience for children in substance misusing families We know that the major negative impact comes from: • family disharmony, and within this, from • family violence, • parental conflict, • parental separation and loss, • and inconsistent and ambivalent parenting.

24. Risk & Resilience for children in substance misusing families What are the Protective Factors?. They are (again) Family factors, and Individual/Community ones Family protective factors: • Harmony (absence of violence, rows, disharmony) • presence of a stable adult figure • close positive bond with one+ adult, caring role • affection, good support network wider family [More!]

25. Risk & Resilience for children in substance misusing families • Spending significant time together as a family (family meals), • Characteristics and positive care style of parents (a balance between ‘care’ and control’. ‘Care’ includes parental support, warmth, nurturance, attachment, acceptance, cohesion, and love; ‘Control’ includes parental discipline, punishment, supervision, and monitoring – eg ESPAD); • Utilisation of rules and consequences, and experiencing strong parental supervision or monitoring of behaviour related to those rules, • Parental modelling of the behaviours expected of or wished for from their children, • The child having family responsibilities, • Family observing traditions and rituals (cultural, religious, familial).

26. Risk & Resilience for children in substance misusing families Individual/community protective factors include: • Having a hobby or a creative talent or engagement in outside activities or interests (such as sport, singing, dancing, writing, drama, painting, etc) – anything that can provide an experience of success, and/or approbation from others for the child’s efforts, • Successful school experience, • Strong bonds with local community / community involvement, • Self-monitoring skills and self-control, • Religion or faith in God. • A sense of humour, • Intellectual capacity, • Easy temperament and disposition,

27. Risk & Resilience for children in substance misusing families Why are these protective factors?? Because ALL of them - • both the ones relating to positive family functioning, • and those relating to external support and outside interests, work because they can produce attachment and security as opposed to unpredictability, insecurity, exclusion and isolation; • Attachment and Security are the key elements that lead to resilience.

28. Risk & Resilience for children in substance misusing families To summarise what we know about Intergenerational Transmission: The risks are not as bad as some people suppose or make out – lots of children are resilient. It is NOT a foregone conclusion that children brought up in these environments are doomed to carry on in the same way. The ones who are resilient seem to have fewer risk factors and/or more protective factors in their environments, which allow them to grow up feeling more secure and more attached to others.

29. Risk & Resilience for children in substance misusing families These factors relate to • someone offering the child warmth and affection over a significant period, • and to the child doing at least something which provides a sense of achievement or worth.

30. Risk & Resilience for children in substance misusing families So, onto my third area – Prevention, Treatment & Support: How might we break the links so that kids who are not receiving a protected upbringing become more resilient? Answer: we provide interventions which create these protective factors, either from the parent or parents; or from others! • It is not the case that people and family systems and structures are immovable objects. • And there are an increasing number of interventions that are being developed and used which help families and individuals in those families change.

31. Risk & Resilience for children in substance misusing families So, what do good interventions do, to help families change and children become more resilient? • First, they work on the RISK factors. All the main areas which lead to major negative impact are prime areas for intervention with families where one parent drinks or uses drugs problematically, even if the drinking or drug-taking itself is not amenable to change. Good interventions work on the risk factors mentioned: • –        family disharmony, and within this, on • –        family violence, • –        parental conflict, • –        parental separation and loss, • –        and inconsistent and ambivalent parenting

32. Risk & Resilience for children in substance misusing families Second, good interventions work on the PROTECTIVE factors: if we understand some of the elements which make up resilience in children, again we can work with families to develop these characteristics. So good interventions work with • the other parent, enabling them to provide a stable environment and give the time and attention which so many children require; • the parental relationship, enabling parents to retain their cohesive relationship and present a united and caring front to the children; • the family relationship, ensuring that family relationships, family affection, and family activities and positive family rituals are maintained;

33. Risk & Resilience for children in substance misusing families • Good interventions work with other adult figures outside of the nuclear family, ensuring that there is at least someone who can provide the necessary stabilising influence; • Good interventions work with these adult figures (either inside or outside of the family), to encourage the child to develop those aspects of their lives which will give them a sense of success, achievement, mastery, competence – all things which enable a young person to develop the self esteem and self confidence necessary to enable them to become resilient.

34. Risk & Resilience for children in substance misusing families And good interventions work with the child him- or her-self, • helping the child to remove him- or her-self from the disruptive behaviour of the problem parent or parents; • helping the child to disengage from the disruptive elements of family life and engage with stabilising others outside the family, • or with stabilising activities (school, clubs, sports, culture, religion) within which the child can develop a sense of self and self-esteem.

35. Risk & Resilience for children in substance misusing families So there are many protective factors, • Both ones relating to positive family functioning, • and ones relating to external support and outside interests, As well as having fewer or less intense risk factors [eg violence]). These all lead to resilience, because they can produce attachment and security as opposed to unpredictability, insecurity, exclusion and isolation; • Attachment and Security are the key elements that lead to resilience.

36. Risk & Resilience for children in substance misusing families Interestingly, similar factors exist related to helping other young people, who DON’T have parents with alc or drug problems, to also be resilient. Many of these relate to the family: • Parental modelling of appropriate alcohol use; Monitoring and Supervision; Responsive and supportive parenting; Having clear, consistent and enforced rules, and clear expectations about alcohol and use; Higher family cohesion, levels of family bonding and family cooperation; and Satisfactory child-parent relationships and children wanting to emulate parents .

37. Risk & Resilience for children in substance misusing families So, all of these things mean that there are lots of things that people can do to help • reduce the risks to these children, • and to increase the probability of children being resilient. And most of these are unrelated to substance misuse. There is much more about this in a paper Lorna Templeton and I produced a few years ago which is in the reference list : Velleman, R. & Templeton, L. (2007) Understanding and modifying the impact of parental substance misuse on children. Advances in Psychiatric Treatment, 13, 79-89.

38. Risk & Resilience for children in substance misusing families Treatment & Support This is not just theory: services exist which do these things. There are not that many: but some services and some interventions have been developed to assist these children who are having to cope with a relative’s (usually a parent’s) drinking or drug taking, • either in dealing with their current distress • or in trying to prevent future problems. And some services exist to promote resilience in the general population as well. Some examples in the UK are:

39. Risk & Resilience for children in substance misusing families STARS Option 2 Strengthening Families FAS Breaking the Cycle M-PACT Young Addaction Plus Preventure Base Camp – Turning Point GBG – Good Behaviour Game Blackpool Substance Misuse Family Intervention Project Family Drug & Alcohol Courts and increasingly, more.

40. Risk & Resilience for children in substance misusing families OK – but do they work?? Findings? • Lots of research in the USA shows they DO work. In the UK, all research and evaluation do far provides indications, not conclusive evidence (small samples, insufficient length of time, evaluation of pilots etc) • BUT - all indications are positive. • Strengthening Families – best evaluated, over some years, in USA and elsewhere – strongly positive findings. Major impacts on substance use and problems, and on other problem behaviours.

41. Risk & Resilience for children in substance misusing families Findings (Cont) • Good Behaviour Game: undertaken when children are aged 6-8, evaluated 14 years later, when the children are 19-21. • Major impacts on substance use and problems, anti-social behaviour & delinquency, risky sexual behaviour, etc • Preventure: major reduced rates of starting using and misusing alcohol, other drugs, and +ve effects on truancy, panic attacks and depression. • Our work, evaluating many of the others (FAS, M-PACT, Base Camp, BtC, YAP, etc) …

42. Risk & Resilience for children in substance misusing families Some extracts: Young Addaction Plus: • young people:82% had attempted to reduce their engagement in harmful behaviours; 96% had attempted to reduce or avoid their involvement in crime; 91% were making important changes in their lives in an attempt to secure stable housing, and 78% were attempting to engage in activities such as accessing education or taking up sports or hobbies. • families, 80% improved their ability to cope more effectively; 78% were successfully taking steps to address problematic family functioning, and 85% of families were beginning to re-establish their relationship with the young person. Breaking The Cycle • 88% showed a reduction in: substance use, and in harmful behaviours; and an improvement in social and parenting skills; and that they were more successfully prioritising the wellbeing of their children ….

43. Risk & Resilience for children in substance misusing families Breaking The Cycle (cont) Clients who have been involved with Breaking the Cycle for some time felt that: • They had a clear future; They had goals they were working towards; They felt that change was possible and sustainable Overall, 83% of clients achieved some level of progress in working towards their treatment goals; 81% of parents stabilised, reduced or stopped highly problematic substance use that was impacting negatively on their and their family’s lives 82% of parents reduced their involvement in harmful behaviours including involvement in unresolved disputes, domestic violence and engagement in crime 84% of parents acknowledged the benefits of engaging in a meaningful occupation 87% of mothers and/or fathers increased their efforts to prioritise their children’s healthy development.

44. Risk & Resilience for children in substance misusing families Option 2 significantly reduced the time children spent in care, and was significantly cheaper, saving thousands of pounds per child. M-PACT programme empowered families to make positive changes. • The biggest change was in what the families communicated about, and how they communicated – the group and family work allowed them to learn to listen to each other and accept different feelings and points of view, leading to an enhanced understanding of each other, the addiction and its impact. • Being supported to set realistic and relevant goals was also valued.

45. Risk & Resilience for children in substance misusing families Conclusion • Children are often badly affected by being brought up with a parent with a drug or alcohol problem. • One effect can be that these children in turn go on to have serious problems with substances themselves , or to have other poor outcomes (ie SOME inter-generational transfer). • We break these links by developing resilience in children, by working with them and their families.

46. Risk & Resilience for children in substance misusing families 4. Interventions which use these methods are insufficiently evaluated as yet, but all of the indications are very positive. So - I cannot emphasise enough the fact that there are a huge number of ways of intervening with children, parents, and family members, even if the drinker or drug misuser is unwilling to address their alcohol or drug consumption; and of intervening more generally with parents and families to try to develop resilience in their children.

47. Risk & Resilience for children in substance misusing families It is important is that we professionals are not left feeling powerless to help these families and children, and I hope I have shown that there is lots we can do with children, and their families • by focusing on reducing risk factors, • and building up resilience ones.

48. Risk & Resilience for children in substance misusing families So, let me by conclude by stating that • These families and children clearly do need our help, • they have a right to expect it, • and there are (many) things we can do; • so it is all of our responsibilities to ensure that this help is provided.  Thank you.