Parental Alcohol Misuse And Children

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POSTNOTENumber 570 Feb 2018Parental Alcohol Misuse andChildrenOverviewMultiple studies on parental alcohol misuseshow it has significant negative effects onchildren’s physical and mental well-being. Sucheffects can be experienced over the short- andlong-term, and can continue throughout life.This POSTnote outlines what is known aboutthe prevalence of PAM in the UK, and reviewsevidence about its effects. It also describesservices available for affected children.BackgroundDuring childhood, parental alcohol misuse (PAM) can affectchildren’s everyday routines and mental and physical wellbeing. Children can also experience direct physiologicaleffects from pre-natal exposure to alcohol. However thereare no systematic national data on children affected byparental drinking or clear guidelines on the level of drinkingat which parenting capacity is impaired.Existing Government guidance focuses on minimising healthrisks for the drinker and recommends men and women over18 years drink fewer than 14 units per week, and spreaddrinking over three or more days.1 A unit of alcohol isequivalent to a half-pint of ordinary strength (3-4% ABV)beer a small glass of wine, or a standard measure of spirits.2Alcohol misuse generally refers to drinking at harmful ordependent levels (see Box 1).The level of drinking at which parenting is impaired isunclear. Most evidence focuses on the effects, on children,of parents drinking at or above harmful or dependent levels.This POSTnote therefore uses the term PAM to refer to Parental alcohol misuse (PAM) refers to aspectrum of problem drinking by those withparental responsibility for children. It is unclear how many children across theUK this affects. Most studies focus on the effects of parents’harmful and dependent drinking on children,including educational and behaviouraleffects and impacts on physical and mentalhealth. Services for families affected by PAM canbe provided by local authorities or charitiesand vary geographically. It is not clear howmany of these services are targetedspecifically at children. Effective interventions focus on factorsknown to protect children from the effects ofPAM, as well as providing services for thewhole family and improving parenting skills.harmful or dependent drinking by any adult with parentalresponsibility, including biological parents, step-parents, andfoster carers. This POSTnote outlines what is known aboutthe number of children affected by PAM in the UK andreviews evidence about its effects. It describes the servicesavailable for children affected by PAM and effectiveinterventions. Less research focuses on the effects of lowlevels of parental alcohol consumption on children, but ishighlighted where available.3,4Scale of PAM in the UKEstimates of the total number of children affected by PAMvary widely according to sources and definitions used (Box2). These figures are likely to be underestimates as they aretaken from survey data and respondents generally underreport alcohol consumption.5 Uncertainty about whatconstitutes ‘problematic drinking’, associated stigma, andfear of having children removed by social services maydelay drinkers and their families in seeking help.6,7 Inaddition, most figures are based on either the number ofadults with children who are seeking treatment for alcoholdependence or the number of children known to socialThe Parliamentary Office of Science and Technology, Westminster, London SW1A 0AA; Tel: 020 7219 2840; email: post@parliament.uk www.parliament.uk/post

POSTNOTE 570 Feb 2018 Parental Alcohol Misuse and Childrenservices due to problems that may include PAM. There maybe more children whose parents are not in treatment or whoare not known to social services, and who do not receivesupport themselves.8Box 1. Defining Alcohol MisuseGuidance on alcohol consumption focuses predominantly onminimising health risks for those who drink. There are two mainapproaches to categorising health risks from alcohol consumption. Unit-based approach. Health risks from alcohol consumptionare calculated on the number of units of alcohol consumed perweek. For example, Public Health England outline three levels ofrisk: lower risk (drinking fewer than 14 units per week);increasing-risk (regularly consuming between 14 and 35 units aweek for women, and between 14 and 50 units for men); andhigher risk (regularly consuming over 35 units a week forwomen, and above 50 units a week for men).9 The Governmentdefines binge drinking as exceeding 6 units (for women) or 8units (for men) on a single drinking occasion.10 Questionnaire-based approach. The World HealthOrganisation’s Alcohol Use Disorder Identification Test is ascreening tool often used to detect problem drinking.11 Itidentifies three levels of potentially problematic drinking basedon answers to a series of 10 questions: hazardous drinking(drinking that increases the risk of harm to the drinker or others);harmful drinking (drinking causing physical or mental healthproblems directly related to alcohol); and alcohol dependence(drinking above harmful levels, typically with a strong desire toconsume alcohol and difficulties in controlling its use).Policy on children affected by PAMResponsibility for children affected by PAM spans a numberof national Government departments, (including those withresponsibility for health, education, and communities andlocal government), as well as local authorities, as it caninclude adult treatment services, children’s social careservices, and public health.12The Government’s 2012 Alcohol Strategy made no mentionof children affected by PAM.13 Subsequent guidancepublished by Public Health England (PHE) in 2013 and theDepartment for Education in 2015 recognised the need tosupport children affected by PAM.14,15 The 2015–2020Troubled Families programme, administered by the Ministryof Housing, Communities and Local Government, workswith families affected by substance misuse (drugs and/oralcohol), among other complex problems.16 Evaluationfindings for this programme are expected in Autumn 2018.In 2016 the Chief Medical Officer published new guidelineson health risks from drinking, which included advice ondrinking during pregnancy.1 The 2017 Drug Strategyrecognises that many approaches to address drug misuse,also apply to tackling alcohol misuse.17 In the same year,the then Health Minister Nicola Blackwood committed toimproving the information, support and, if necessary,treatment, to reduce the harms of alcohol misuse.18The Scottish Government’s alcohol strategy includes theaim to support families affected by PAM, including improvingthe identification of those affected, sharing of informationamongst agencies, and building the capacity and availabilityof support services.19 The Welsh Government’s strategyPage 2also includes the aim to support and protect families, andspecialist Integrated Family Support Services work withfamilies affected by PAM.20 In Northern Ireland, addressingthe effects of PAM is a key priority in the New StrategicDirection for Alcohol and Drugs, including commissioningtherapeutic services for children affected.21Effects of PAMThe effects of PAM depend on the level of parental drinking,whether both parents misuse alcohol, the child’s age, andthe presence of other factors such as domestic violence.22Studies in this area suffer from a number of weaknesses. PAM is associated with other issues such as maritalconflict and deprivation, which are themselves linked tonegative outcomes for children.23,24 Such issues mayexacerbate the negative impact of PAM on children.25 Itis difficult to determine whether negative outcomesexperienced by children are caused by PAM, or bythese other associated factors. There is little standardisation in the definitions of PAM,hampering comparability between studies. There are gaps in the data. Few studies examine theeffects of parental drinking in the general population,rather than those involved in specialist treatmentservices or child protection cases. Gaps also exist forspecific groups of children, including those fromminority ethnic groups.8,24This section first examines existing evidence of the effectsof drinking during pregnancy on children’s physical healthand cognitive outcomes. It then considers the effects ofPAM during childhood on social relations, mental andphysical health, educational outcomes, experience ofneglect, and future alcohol use.Maternal drinking during pregnancyDetermining the effects of drinking during pregnancy isdifficult due to the influence of other factors such as diet.26Government guidelines now recommend that the safestapproach for pregnant, breastfeeding, or women who areplanning a pregnancy, is not to drink alcohol at all.1,27Low levels of drinking during pregnancyThere is a lack of consensus on the effects of drinking smallamounts of alcohol during pregnancy. UK cohort studies,which follow the same group of people from birth onwards,have found no effect of drinking at low levels (no more than1-2 units per week or per occasion) on child educational andbehavioural outcomes after accounting for socioeconomicand other factors (such as level of educational attainmentand whether the pregnancy was planned).28,29 Studies usingdifferent methods, have found drinking at low-moderatelevels (between 1-6 units per week) is linked to smalldecreases in child IQ, educational attainment andbehavioural scores compared to not drinking at all duringpregnancy.30,31,32 The strongest evidence is for an increasedrisk of pre-term birth and low birthweight for mothers thatdrink more than one unit a week.33

POSTNOTE 570 Feb 2018 Parental Alcohol Misuse and ChildrenBox 2. Estimates of Prevalence of PAM and Children AffectedUK-wide data An estimated 41% of pregnant women in the UK drink duringpregnancy, placing the UK in the top five European countries interms of alcohol use during pregnancy.34 Heavy drinking during pregnancy, generally above ‘binge’ levels,can lead to foetal alcohol spectrum disorders (FASD), includingfoetal alcohol syndrome (FAS).35 NHS data from 2014-15 showsthere were 276 diagnoses of FAS in England, 2 in Wales, and nodiagnoses in Scotland or Northern Ireland.36 These figures are likely to underestimate prevalence as theclinical features of FASD are not well-defined. For example, arecent review estimated that in 2012, 32 children were born withFASD for every 1,000 number of live births in the UK.37 Anotherreview estimated the prevalence of FAS among the generalpopulation in the UK to be 61 per 10,000 people.38 Differencesbetween these reviews and NHS statistics suggests that theremay be a number of children affected by FASD that are notdiagnosed and therefore not receiving support.Data from national survey data for England Public Health England are producing new estimates of thenumber of children affected by PAM.17 This will update statisticsfrom a 2009 report,39 which were based on 2004 data and isexpected in April 2018. Analysis of data from two large surveys from 2014 estimatedbetween 189,000 and 208,000 children live with an alcoholdependent adult, of which 14,000 live with two alcoholdependent adults.40 Data from Public Health England and the Office for NationalStatistics suggest that in 2016, 15,500 children in England livedwith an adult receiving treatment for alcohol dependence.41Data from national survey data for Scotland Estimates from the 2008-10 Scottish Health Surveys suggestbetween 36,000 and 51,000 children live with parents orguardians whose alcohol use is potentially problematic.42Data from national survey data for Wales Data from a number of national surveys in 2016 shows therewere nearly 5,000 ‘children in need’ registered with localauthority children’s services due to parental substance misuse(including both alcohol and drug use).43 ‘Children in need’include those who are likely to have their health significantlyimpaired or are unlikely to maintain a reasonable standard ofhealth and development without the provision of local authoritychildren’s services.Data from national survey data for Northern Ireland Data from a 2013 national survey reported that 65% of 1,987respondents with dependent children had exceededrecommended daily limits (3-4 units for men and 2-3 for women)in the week before the survey. Responses to clinical interviewquestions (used internationally as an assessment instrument foridentifying problems with alcohol) indicated that 9% of surveyrespondents with dependent children were problem drinkers.44Differences in definitions and measures between surveys mean thestatistics above are not directly comparable, but give a broad pictureof the issue across the UK.Foetal Alcohol Spectrum Disorders (FASD)Alcohol can affect foetal development and can cause birthdefects or complications during pregnancy.9 The term ‘foetalalcohol spectrum disorder (FASD)’ refers to a group ofconditions that can occur in a person whose motherconsumed alcohol during pregnancy. Children affected byFASD often have learning difficulties; mood, attention orbehavioural problems; poor physical growth; and distinctivePage 3facial features.9 They are also at high risk of mental healthissues, problems at school, and involvement in crime.35Parental drinking during childhoodSocial relations and everyday lifePAM can disrupt everyday routines and lead to inconsistentand unpredictable parenting.25 Research with children livingwith alcohol-dependent parents has found that many reportfeeling socially isolated, and are reluctant to seek help dueto feelings of stigma, shame and guilt about not wanting tobetray parents.8,45,46,47 Calls to helplines reveal the chronicworry and fear experienced by children living withPAM.8,48,49 Children may have to care for the affected parentor younger siblings.46 This can negatively impact schoolattendance and homework.50 Recent research found thatnon-dependent parental drinking can also affect children.For example, 18% of children reported feeling embarrassedby seeing their parent drunk, while 15% reported disruptedbedtime routines as a result of their parents’ drinking. 3Physical and mental health impactsPAM is associated with impacts on children’s mental andphysical health. Reviews of studies identify increased risk ofobesity, eating disorders, and attention deficit hyperactivitydisorder, as well as of hospital admissions and injuries. 50,51Neglect and abuseA 2011 study found 61% of care applications in Englandinvolved misuse of alcohol and/or drugs.9,52 Between 201114, PAM was implicated in 37% of cases involving the deathor serious injury of a child through neglect or abuse inEngland.53 Children involved in child protection casesinvolving PAM have poorer welfare outcomes than those incases where alcohol is not a factor, and such cases place aconsiderable burden on social services.54,55Attitudes to alcohol and future alcohol useParents’ alcohol use is linked to adolescent alcohol use,56though some studies suggest peer alcohol use may be amore important influence.4,9,57,58,59,60 Many parents believethat introducing adolescents to alcohol is an important partof ‘growing up’, and may be beneficial.61,62 There is mixedevidence about the effects of parents providing adolescentswith alcohol. Some studies suggest it reduces risky drinking,such as bingeing,63 but other studies find it is associatedwith earlier initiation into alcohol use and heavier drinking byadolescents.64,65 Government guidelines recommendchildren do not drink at all under the age of 15, andthereafter only under parental supervision.66Services for children affected by PAMThe services that are available vary throughout the countryas each local authority has different needs. A freedom ofinformation request by the All-Party Parliamentary Group(APPG) for the Children of Alcoholics (COA) to localauthorities in England found that less than half of the 126respondents had a specific strategy to support childrenaffected by PAM.67 This compares to 2015, when threequarters of the 138 responding local authorities did not have

POSTNOTE 570 Feb 2018 Parental Alcohol Misuse and Childrena strategy to support children affected by PAM.12 Servicesfor children may also be commissioned as part of adultalcohol treatment services. However, these can only supportchildren whose parents are already in treatment and aretherefore likely to reach only a limited number of childrenaffected by PAM.68A report by the charity Adfam suggested that dedicatedfamily services are rare and often provided by grassrootsorganisations with local expertise and support networks,rather than local authorities. These organisations may nothave the capacity to meet modern commissioningrequirements and secure funding.68 Charities providingservices for children affected by PAM include the NationalAssociation for the Children of Alcoholics (Nacoa), theNSPCC, and Addaction.Effective interventionsThere have been few high-quality evaluations of servicesspecifically targeting children affected by PAM in the UK(Box 3).69 Research suggests three effective aspects.Protective factors and resilienceMany children experiencing PAM go on to become welladjusted adults despite stressful childhood experiences. 25,70Research has identified a number of protective factors thathelp children to be resilient and have positive outcomes.These include individual characteristics such as having highself-esteem and being optimistic, as well as other factors,such as maintaining normal routines like family meals. 51,70,71Family-focused servicesFamily-focused services have been shown to improveoutcomes for the alcohol misuser as well as children, and tobe cost effective.8,72,73 Data from a cohort study andinterviews with children found that services focusing on thewhole family, rather than just the child or parent, wereeffective in achieving long-lasting change.74,75Research with children themselves has found that childrenwant services that focus on them as individuals, rather thandefining them by their parents’ problems.48,76 Group supportis beneficial in reducing feelings of isolation and blame.8Young people appear to favour services that combine spacefor them to engage in ‘normal’ activities alongside moretherapeutic services such as counselling.77Up to half of children cared for by a family member, usuallya grandparent (commonly referred to as kinship care), haveexperienced PAM. This group faces challenges includingsocial isolation and stigma, and may require specialistservices.78 A pilot programme run by Mentor UK in Scotlandhelped kinship care families to form peer support groups.Initial evaluation has shown that the groups foster familycohesion and self-esteem among children.79Parenting skillsInterventions which target both parenting practices andsubstance misuse aim to improve family functioning andPage 4reduce family conflict in order to protect children. Therehave been few well-evaluated studies in the UK, but initialfindings suggest this approach improves familycommunication, cohesion, and child well-being.80Box 3. Evaluated Interventions in the UKEvaluations of services that specifically target children affected byPAM are generally small, short-term and often lack a comparisongroup to allow the benefits for children to be specifically linked to theintervention.8 Interventions that have been evaluated include: Family Drug and Alcohol Courts (FDAC) target families involvedin care proceedings where substance misuse is a factor.Families have regular meetings with a judge trained inmotivational interviewing, and have access to peer supportworkers. Compared to similar cases heard in traditional courtsFDAC have been shown to be better at helping families keeptogether, improve adherence to treatment and prevent furtherneglect or abuse. They are also more cost-effective.72,73 The Option 2 Programme is a short-term intensive interventionfor families in Wales with serious child protection concernsrelated to parental alcohol or drug misuse. Families are assigneda case worker

Children Multiple studies on parental alcohol misuse show it has significant negative effects on children’s physical and mental well-being. Such effects can be experienced over the short- and long-term, and can continue throughout life. This POSTnote outlines what is known about the prevalence of PAM in the UK, and reviews evidence about its effects. It also describes services available for .

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