Chapter 1: Describing the Challenge
15. This chapter describes the challenge facing services where families are affected by problematic alcohol or drug use, setting the context for the rest of the guidance document:
- a definition of 'problem substance use', focusing on drugs and alcohol;
- the scale of the problem in Scotland, particularly with respect to the number of children that may be affected;
- the types of impacts that problematic alcohol or drug use in the family can cause children and young people; and
- the counter-balancing factors that may help to build up a child's resilience.
What is problem substance use?
16. The Advisory Council on the Misuse of Drugs ( ACMD) defined 'problem drug use' in Hidden Harm (2003) as any drug use which has serious negative consequences of a physical, psychological, social and interpersonal, financial or legal nature for users and those around them. ACMD further described this drug use as normally heavy, with features of dependence, and typically involves the use of one or more of the following drugs:
- opiates (e.g. heroin and illicit methadone use);
- illicit use of benzodiazepines (e.g. diazepam); and
- stimulants (e.g. crack cocaine and amphetamines).
Problem drug use can also include the unauthorised use of over the counter drugs or prescribed medicines.
17. Alcohol is by far the most popular substance in Scotland. Sensible drinking guidelines for men and women are far lower than most people think. The recommended guideline is that women should not regularly drink more than 2-3 units per day and men should not regularly drink more than 3-4 units per day. Guidelines also recommend that everyone should have at least 2 alcohol free days per week, and should not binge drink ( HM Government 2007, Scottish Government 2009). Over the course of a week, women should not exceed 14 units and men should not exceed 21 units. Recommended guidance is different for women trying to conceive or who are already pregnant.
18. Three types of problem drinking are defined by the Scottish Intercollegiate Guidelines Network: 'hazardous drinking'; 'harmful drinking'; and 'alcohol dependence'.
- Hazardous drinking refers to the consumption above a level that may cause harm in the future, but does not currently appear to be causing harm. This is typically taken to mean between 21 and 50 units a week for men and 14 and 35 units for women. Hazardous drinking may also includes 'binge drinking', commonly defined as excessive consumption of alcohol on any one occasion involving 8 units or more for men, and 6 units or more for women, even though they may not exceed weekly limits.
- Harmful drinking is defined as a pattern of drinking that is currently causing evidence of damage to physical or mental health. Harmful drinking is usually taken to mean consumption at above 50 units per week for men and over 35 units for women.
19. Normally, a diagnosis of alcohol/drug dependence is made when three or more of the below criteria have been experienced or exhibited in the previous year. Relapse (or reinstatement of problem drinking or drug-taking after a period of abstinence) is also a common feature. The criteria included:
- a strong desire to take the substance;
- difficulties controlling its use;
- persisting in its use despite harmful consequences;
- a higher priority given to substance use than to other activities and obligations;
- increased tolerance to the substance; and
- a physical withdrawal state.
20. Practitioners should take into account the combined effect of the use of different substances at any one time - and over time - when considering an adult's ability to care for their child and parent effectively.
What is the scale of the problem in Scotland?
21. Recent trends show that drug use amongst those over 16 years as well as young people aged between 13 and 15 has decreased over recent years. There are an estimated 59,600 people (aged 15-64) with drug use problems in Scotland in 2009-10. This estimate comes from Estimating the National and Local Prevalence of Problem Drug Use 2009-10 ( ISD Scotland 2011), which showed that the estimated number of individuals using opiates and/or benzodiazepines in Scotland increased between 2006 and 2010: from an estimated 55,328 in 2006 - or 1.62% of the population aged 15-64 - to 59,600 individuals by 2010 - or 1.71% of the same population.
22. Evidence shows that alcohol use remains severe in Scotland with consumption and resultant harms at high levels. Alcohol sales data suggests that consumption is almost a quarter (23%) higher in Scotland than in England and Wales, and has increased by 11% since 1994. The Scottish Health Survey 2010 found that an estimated 49% of men and 38% of women exceeded the daily and/or weekly limit, and these are likely to be under-estimates.
Numbers of children affected by parental substance use
23. The Scottish Government currently estimates that around 40,000-60,000 children in Scotland may be affected by parental problematic drug use and that, of these, 10,000-20,000 may be living with that parent. 
24. Analysis from the Scottish Health Surveys ( SHeS) 2008-10 show that current estimates suggest that between 36,000 and 51,000 children are living with parents (or guardians) whose alcohol use is potentially problematic. 
25. Estimating the numbers of these vulnerable children is recognised as complex. There are clear challenges in collecting data about these children, largely because of stigma and secrecy surrounding problematic alcohol and/or drug use and the fear of repercussions. This means that substance-using adults may not present to services for treatments and dependent children may still remain hidden even when their parents do present.
26. In recent years, there has been a growing recognition in Scotland of the impact of problematic parental alcohol and/or drug use on children and young people's lives. Children's experiences - even within the same family - can be very different and they can display incredible strengths in managing difficult situations, as can their parents. Not all parents who use substances experience difficulties with family life, child care or parenting capacity. Equally, not all children exposed to substance use in the home are adversely affected in the short or longer term.
27. That said, the impacts of parental problematic alcohol and drug use can also have a very detrimental impact on the health and wellbeing of some children. Children can also be at increased risk of experiencing violence and maltreatment when living with parental problematic drug and/or alcohol use.
Examples of impacts
Pre-conception and pregnancy
28. There is guidance available on the use of alcohol and drugs for women who are pregnant, breastfeeding or trying to conceive. Guidance at these stages tends to highlight lower thresholds of adult problematic alcohol and/or drug use before services should consider these interventions to protect children.
29. Pre-conception and pregnancy are the earliest, and most critical, of these stages at which services can put in place effective interventions that will prevent long-term harm to children and families. For example, 'Improving Maternal and Infant Nutrition: A Framework for Action' states that "in addition to advice before pregnancy, during pregnancy women are advised to avoid alcohol completely." Drug use, at these critical stages, would be considered problematic, for example, where any woman reported regular use (i.e. more than once a week).
30. Women and their partners are often incentivised to improve their problematic drug and alcohol use when either trying to conceive or are about to become parents. Maternal alcohol and/or drug use can harm unborn babies in different ways at different times during pregnancy, increasing the risk of complications such as low birth weight, miscarriage, prematurity and stillbirth. Some babies are born dependent on alcohol and drugs and can develop withdrawal symptoms - known as Neonatal Abstinence Syndrome ( NAS).
31. Neonatal withdrawal symptoms vary in onset, duration and severity. Some babies can be very unwell for days or weeks and can require close observation and special medical and nursing care. NAS can also have an impact on attachment, parent-infant interactions, and the infant's longer-term growth and development.
Fetal Alcohol Spectrum Disorder
32. Alcohol consumption during pregnancy can affect the child's health and development in a number of ways. There is currently only limited evidence on the prevalence of Fetal Alcohol Spectrum Disorder ( FASD). However, it is known that a baby affected by maternal alcohol use during pregnancy can be born with FASD which describes the range of effects associated with a baby exposed to excessive alcohol in the womb.
33. FASD can resemble other conditions and is difficult to diagnose. As a result, the number of children in the UK with FASD is not accurately known but it is estimated that FASD occurs in as many as 1 in 100 live births.  Infants and children with FASD can be particularly challenging to care for as the condition is irreversible. Any effects are lifelong. Children with FASD display a variety of effects ranging from learning difficulties, having poor social and emotional development, hyperactivity and attention disorders, having difficulty understanding rules, cause and effect, receptive and expressive language, and problem solving and numeracy.
34. The advice from Scotland's Chief Medical Officer is that it is best to avoid alcohol completely during pregnancy as any alcohol drunk while pregnant will reach the baby and may cause harm. Women who are trying to conceive should also avoid drinking alcohol. There is no 'safe' time for drinking alcohol during pregnancy and no 'safe' amount.
35. Injecting drug use is associated with an increased risk of blood-borne virus infections e.g. HIV, hepatitis B and hepatitis C. HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). Hepatitis B and hepatitis C are viruses which affect the liver, people with long-term infection are at increased risk of serious liver disease and cancer.
36. Children can be at risk of blood-borne viruses through:
- mother-to-child transmission (during pregnancy, childbirth and breastfeeding);
- 'household contact' (i.e. living with adults or other children who are infected with blood-borne viruses where sharing of items such as razors and toothbrushes may take place, or blood-to-blood exposure is possible); and
- accidental injury involving used injecting equipment: e.g. a needle-stick injury.
37. Child neglect is a significant area of concern where problematic parental alcohol and/or drug use is a factor. Neglect is described in the National Child Protection Guidance for Scotland as:
"the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. It may involve a parent or carer failing to: provide adequate food, shelter and clothing, to protect a child from physical harm or danger, or, to ensure access to appropriate medical care or treatment. It may also include neglect of - or failure to respond to - a child's basic emotional needs."
38. Neglect continues to be a significant challenge for services in Scotland. As at 31 July 2012, 37% of all children on the Child Protection Register were registered because of physical neglect. There is considerable evidence that neglect is often linked with parental problematic alcohol and/or drug use. Notwithstanding this, there is limited evidence of the effectiveness of interventions to tackle neglect.  The evidence points to the need for early intervention approaches in order to make a significant difference.
Impact on different ages of children
Babies and infants
39. Babies are particularly vulnerable to the effects of physical and emotional neglect or injury. This can have damaging effects on their long-term development. The following examples illustrate possible harms to babies where parental problematic alcohol and/or drug use is a factor.
- Neglect can occur while the parent/carer is under the influence of substances, unaware of what is going on around him/her. Children may have their physical needs neglected, for example, they may be unfed or unwashed.
- Unhappiness, tension and irritability of parents under the influence of substances - coupled with a lack of commitment to parenting when preoccupied with substance use - may lead to poor parenting.
- Poor or inconsistent parenting may damage the attachment process between parent and child.
- Poor childcare, little stimulation or inconsistent and unpredictable parental behaviour may hinder the child's cognitive and emotional development.
- Lack of contact with other children, when attendance at nursery is irregular or erratic, may compound other problems in social and emotional development. Emotional difficulties should be addressed early to avoid more serious mental health issues from developing.
- Children can become withdrawn and isolated and develop an inability to form relationships.
- The financial demands of problematic alcohol and/or drug use may mean that the child's material environment is poor.
- They may be subjected to direct physical violence by parents, and learn inappropriate behaviour through witnessing domestic abuse.
Children of primary school age
At primary school age, children:
- may be at increased risk of injury, and show symptoms of extreme anxiety and fear of hostility;
- may develop poor self-esteem and blame themselves for their parents' problems;
- may be harmed by parental neglect or disinterest, especially with regards to how well they do at school;
- may feel embarrassment and shame; and
- may take on too much responsibility for themselves, their parents and younger siblings.
40. In addition to the impacts set out above, children coping with puberty without adequate parental support may be at increased risk of the following:
- greater risk of injury by parents as a result of becoming out of their parents control; and
- there is an increase of emotional disturbance and conduct disorders, including bullying.
41. Young people in families - where other family members misuse drugs and/or alcohol - may develop early problems with drugs and alcohol themselves.
"No-one tells me what's going on. I don't know what doctors are telling my mum and dad about what's wrong with them. I don't know what's going to happen to them".
Quarriers Carer Support Service (Moray)
Preventative and protective factors
42. Some of the impacts on children and families described above can be counter-balanced by other factors. Children and young people need support in dealing with what are often confused feelings and emotions towards their parents and families. They need strategies to help them cope with the various consequences of their parent's problematic alcohol and/or drug use. 
43. Resilience has been viewed as "normal development under difficult conditions".  Focusing on the positives and the strengths in a child's life is likely to help improve outcomes by building the protective network around the child and the self-protective potentials within the child.  At the same time, it is important to be alert to factors of adversity or vulnerability, which may potentially impact upon the child's wellbeing and the interaction of these factors with any identified resilience and protective aspects.
44. The second core component of the Risk Framework National Risk Framework to Support the Assessment of Children and Young People builds upon the Resilience/Vulnerability Matrix within the GIRFEC Practice Model. A set of Matrix Related Indicators have been developed here to support practitioners explore the key concepts of adversity/protective factors and vulnerability/resilience.