Chapter 4: Assessing Risks And Improving Outcomes
87. This chapter describes the key stages in both assessing and responding to any identified concerns about children and reviewing progress against outcomes. It reflects the GIRFEC practice model and also the principles of early intervention and recovery as well as the National Risk Assessment Framework for Children and Young People. The chapter is divided into 4 main sections. Specifically, it suggests:
- how services might assess risks and needs;
- how services should effectively plan care and provide supports for children and families - co-ordinated through the Child's Plan;
- delivery of services and interventions identified in the Child's Plan; and
- the importance of setting targets, describing outcomes in care plans and reviewing delivery of these.
88. This chapter reflects the GIRFEC practice model and also the principles of early intervention and recovery as described in the Opening Policy Framework Section. That section set out that, where a family has been identified as requiring further support (whether single agency or multi-agency co-ordinated), a fuller assessment should be undertaken to determine the nature of the support that will be required. A child's Named Person should ordinarily co-ordinate this assessment.
89. It also described that any initial assessment by the Named Person may then lead to a multi-agency assessment. Any assessment by the Named Person should also result in the development of a Child's Plan describing the actions to be taken, the key targets to be met, and by whom. A Lead Professional would usually be appointed at this stage to help co-ordinate the delivery of the actions included in the Child's Plan.
90. Generally - when assessing the wellbeing of any child and family - all services must look at the parent's substance use from the perspective of the child to understand the impact that this has on the child's life and development. Services should also consider each child in a household separately as their needs may differ significantly.
91. When assessing needs and risks, services working with children and families might find it useful to refer to the GIRFEC national practice model and risk assessment as contained in the National Risk Assessment Framework for Children and Young People.
92. Services should generally draw together information about:
- the child's age and stage of physical, social and emotional development;
- his or her educational needs;
- the child's health and any health care needs (e.g. hepatitis B vaccination);
- the child's safety while adults are using drugs and alcohol;
- the emotional impact on the child of frequent or unpredictable changes in adults' mood or behaviour, including the child's perception of parents' alcohol and/or drug use, and;
- the emotional impact on the child and family of a parent diagnosed with a blood-borne virus infection ( HIV, hepatitis B and hepatitis C). Equally the impact of changes in adult mood and health upon commencement of anti-viral therapy as part of a parent's treatment regime for a blood-borne virus;
- the extent to which parental alcohol and/or drug use disrupts normal daily routines; and
- unknown dangerous adults.
93. A more detailed checklist for gathering information about problematic alcohol and/or drug use and its impact on families is available at Appendix 3. This checklist has been developed to reflect the GIRFEC practice model with a specific focus on drug and/or alcohol related questions. Any service in touch with a family affected by parental alcohol and/or drug use can use this checklist, either in its entirety, or by selecting sections that are appropriate to their role.
94. Assessment cannot be seen as a one-off event - nor can it be separated from intervention. Concerns can reduce over time and can also increase. Equally, changes in a child or family's circumstances can strengthen or limit protective factors (see Chapter 1 for examples of these). Assessment needs to be a flexible and ongoing process. At any given time, it should take account of current circumstances but also previous experiences and needs to consider immediate impacts as well as longer-term outcomes for children.
95. A number of possible questions are provided for use by services to explore with families their needs, and also, to help identify risks to children. These questions also focus on those areas that the child and family themselves identify as difficulties and also strengths.
When assessing whether a child may need help services should consider the following questions:
- Are there any factors which make the child(ren) particularly vulnerable? For example, the child might be very young, or has other special needs such as physical illness, behavioural and emotional problems, psychological illness or learning disability(ies)? Are there any protective factors that may reduce the risks to the child?
- How does the child's health and development compare to that of other children of the same age in similar situations?
- Are children usually present at home visits, clinic or office appointments during normal school or nursery hours? If so, does the parent need help getting children to school?
- How much money does the family spend on alcohol/drug use? Is the income from all sources presently sufficient to feed, clothed and provide for children, in addition to obtaining the alcohol/drugs?
- Do the parents perceive any difficulties, and how willing are they to accept, help and work with professionals?
- What arrangements are there in place for the child(ren) when the parent goes to get illegal drugs or attends for supervised dispensing of prescription drug(s)?
- Is there evidence of neglect, injury or abuse, now, or in the past? What happened? What effect did/does that have on the child? Is it likely to recur? Is the concern the result of a single incident, a series of events, or the accumulation of concerns over a period of time?
- Do parent(s) think their child knows about their problematic alcohol or drug use? How do they know? What does the child/other family members think?
- Do the parent(s) maintain contact with services? Who will look after the child(ren) if the parent is arrested or is in custody?
Importance of relationships
96. Research shows that the child's voice can often be lost in assessment and decision-making.Children and young people can often find it difficult to articulate their views and their experiences of living with a drug and/or an alcohol using parent. The reasons for this can be: loyalty towards the parent, distrust of services, fear of the family being separated, or fear for their own, or their siblings' safety.
97. When involving children, effective communication is therefore essential. To achieve this, practitioners should develop a positive, supportive relationship with the child. 
98. Chapter 2 touched on the need to keep parents at the forefront of a co-ordinated response if services are to be effective in achieving overall recovery for the whole family. This is further evidenced by research  into the perceptions and experiences of parents involved with services. This research found that to achieve positive outcomes for families the following should be taken into full account:
- the quality of the relationship between the practitioner and parents is central to effective engagement and involvement of parents;
- the importance of sensitivity in order to build a trusting relationship;
- parents value honesty, reliability, good listening skills and practitioners who demonstrate empathy and warmth;
- explicit use of counselling approach (both generic and adapted to parents with learning difficulties) to develop empathy and increase the potential for more productive relations;
- explicit discussion with parents about their perceptions of how workers are using their professional power as a means of control or support - especially when working with resistance;
- comprehensive, strengths-based assessment - including family and social networks and methods such as family group conferences - can be effective especially where involving fathers and father-figures; and
- drawing, where necessary, on the expertise of key professionals that have worked with adults with learning disabilities, for example, to maximise their involvement and participation.
99. The National Parenting Strategy champions the importance of parenting, by strengthening the support on offer to parents and by making it easier for them to access this support.
It is good practice to work in partnership with parents and, where possible, parents should be included in any multi-agency meetings, in assessments and in developing care plans.
Achieving partnerships with parents and children in the planning and delivery of services to children requires the following:
Parents have sufficient information, both verbally and in writing, to make informed choices.
Parents are made aware of the help that is available.
Parents are aware of the consequences of any decisions they may take.
Parents are actively involved - where appropriate - in assessments, decision-making meetings, care reviews and conferences.
Parents and children are given help to express their views and wishes and to prepare written reports and statements for meetings where necessary.
Professionals and other workers listen to and take account of parents' and children's views.
There should be clear and accessible means for families to challenge decisions taken by professionals, and to make a complaint if necessary.
Administrative arrangements take account of the needs of parents and children; for example, the timing, location, environment and conduct of meetings should take account of their needs.
Care planning for children and families
100. The Getting it Right - Report on Angus Learning Partnership for Children Affected by Parental Substance Misuse (2011) emphasised the importance and value of simultaneously addressing the needs of the child and their parent(s) to achieve good outcomes for both.
101. The GIRFEC approach provides a series of common tools, language and planning processes that can improve the identification of the risks and needs in a child's life as part of a wider assessment of the child's development. In particular, and as mentioned above, any action to support a child should be co-ordinated through a single Child's Plan. Both the family and the services involved should be clear about the purpose of the Plan and what is expected of each family member and service to achieve recovery.
102. Assessments and any care planning need to include a realistic appraisal of the timescales for change for the entire family. This is because there will be occasions where the timescales for the parent's recovery may not match the needs of the child and contingency measures may need to be agreed by services. For example, this may involve consideration of respite or temporary care arrangements, or intensive supports being offered in the short term.
103. While effective drug and/or alcohol treatment is a positive outcome for the parent, recovery for the whole family will often include a number of interventions. These could include interventions designed to support children in their own right and/or to enhance parenting capacity and promote resilience. Support and treatment for the parent cannot, therefore, be seen in isolation from the wider family's needs. In effect, a family focus needs to be at the forefront of a co-ordinated multi-agency approach.
Delivering agreed interventions
104. Early identification of a need - and also timely interventions to support families and children - can prevent problems from escalating and becoming more complex, resource intensive and difficult to manage further downstream. To achieve this, regular and ongoing communications with involved services are essential here. For example, ongoing communication is the responsibility of all services to maintain and consideration should be given as to whether compulsory measures of supervision might be required to ensure compliance with identified interventions. Failure to keep appointments by families - or a proposal to withdraw a specific support service - should always be communicated to the Named Person and/or Lead Professional. Any decision to withdraw or significantly reduce methadone or benzodiazepines can impact negatively on parenting capacity and should also be communicated to the Named Person and/or Lead Professional.
105. When designing interventions services also need to take into account the following factors:
- In many instances, children may be responsible for providing practical support to their parents and/or siblings.
- In addition, or at times alternatively, this may take the form of emotional supports.
- Children should not be expected to take on similar levels of caring responsibilities as adults or be responsible for the intimate care and supervision of their parents and others.
- In assessing the family as a whole, and the types of supports that may be needed - consideration needs to be given to the levels of responsibility that are being taken on by a child, the levels of emotional support they have access to, and also the setting of boundaries within the family.
- All of these factors should be taken into account together with the levels of physical caring that are actually in place for the child.
106. Also, resistance, both from parents and children, can be a barrier to a child receiving support. The parent may not want to recognise the impact on the child and the child may unwittingly collude in that. Compulsory measures of supervision might be necessary to ensure compliance.
107. Particular consideration needs to be given by services here to identifying either critical - or particularly difficult - times for children and an awareness of what these may mean. Examples of these difficult times might include:
- a parent undergoing detoxification;
- discharge from adult services;
- a parent in hospital;
- a parent undergoing testing or anti-viral treatment for an identified blood-borne virus infection as part of their recovery from alcohol and/or drug use;
- in prison; or
- experiencing an episode of domestic violence.
108. Examples of strategies or techniques that may be used by services - working directly with children affected by parental problematic alcohol and/or drug use-might include:
- social support - this may involve group activities offering mutual support and exchange of experiences;
- information - on the substance use, potential consequences etc;
- skills training - how to deal with problems, social skills etc; and
- coping with emotional problems - helping the young person identify and discuss feelings.
What is important - practice points that help achieve change:
- engagement - how projects have built relationships;
- stickability - keeping with families looking at options and routes that will help them achieve change;
- practical steps - boundaries, routines, support and input to help improve family life;
- empowerment and self-determination are key facets in developing approaches.
Outcomes and review
"The definition of outcomes is the impact or end results of services on a person's life. Outcomes-focused services and support therefore aim to achieve the aspirations, goals and priorities identified by service users (and carers) - in contrast to services whose content and/or form of delivery are standardised or determined solely by those who deliver them."
(Glendinning et al, 2006)
109. Goals that are included in any care plan agreed by services should focus on tangible outcomes that the child, family and services can agree upon. An outcomes-focused approach should identify clear goals by which to measure improvement. Outcomes will vary and should be developed in partnership with parents and children to ensure these are realistic and measurable. This both helps the parent and child see progress but also is a way for services to measure change.
110. Language in relation to outcomes needs to be clear and understandable so that everyone knows what is being worked towards. Examples of some outcomes captured through the Lloyds TSB Partnership Drugs Initiative ( PDI) funding programme are described below:
- increased/consistent engagement with service;
- increased level of referral to, and engagement with, other services (including dentists, health checks);
- increased knowledge/awareness of impact of problematic alcohol or drug use on self and others;
- reduction/abstained from substance use;
- increased boundaries, structures, routines;
- increase in parenting/life skills;
- improved family relationships;
- increase in child's safety;
- increased coping mechanisms;
- increased confidence/self-esteem;
- increased participation in alternative activities;
- increased access to/participation in school, nursery, education, employment;
- increased positive engagement with community; and
- improved health and wellbeing.
111. It is helpful when considering desired overall outcomes for children and families for services to first set realistic shorter-term targets as well as longer-term goals. For example, a parent engaging with a service, or a child being removed from the Child Protection Register, to a longer-term goal, or core outcome, of an overall increase in the child's safety.
112. To ensure that any agreed Child's Plan and family supports remain effective, and on target, it will be necessary for relevant services to meet and review progress with the child (depending on age) and also the family. This will include evaluating the impact of the work done and any changes in the family's circumstances.
113. Consideration should also be given here to any targets that have not been achieved and to identify the reasons for this. This may result in changes to the Child's Plan and supports to include a more appropriate response or indicate that compulsory measures of supervision might now be necessary. Alternatively, it may be that a gap in resources is an obstacle and that further discussion between services is required. In some instances, the child and/or family's circumstances may have deteriorated and contingency plans will need to be considered.
Withdrawal of services
114. Services need to ensure that they do not withdraw support too early. Families can sometimes be left in a vulnerable position just as the situation appears to improve. Any planned withdrawal of a service should be communicated to the Named Person - and also the Lead Professional if one is in place. They will then consider whether the Child's Plan needs to be reviewed.
115. When a parent has stabilised and/or stopped their drug and/or alcohol use they must be given support to cope with everyday issues without resorting to substances as they may have in the past. This should be supported by a multi-agency approach wherever possible so that agencies can co-ordinate their activity and ensure good communication.
Assessing children and their families is not a one-off event. Individual services should always be alert to changes in families' circumstances and whether children appear to be well cared for and thriving.
Those professionals in regular contact with families should be alert to increases in stress, changes in parents' alcohol and/or drug useor other changes in their circumstances, and should consider any detrimental impacts on their ability to look after children. These changes may signal a need for more help or may indicate a need for consideration of compulsory measures of supervision.
Services should regularly re-assess and review their clients' family and wider living circumstances. For example, parents using alcohol or drug services should be asked routinely about how they are coping with parenting responsibilities and given the opportunity to talk about stresses or worries.
When visiting families at home, practitioners - including specialist alcohol or drugs workers - should always observe and record the conditions in which children are living.
If the worker feels able, they should discuss any worries about the safety or wellbeing of the children with the parents. If problems persist they should refer the child and family to the social work service for help and any protection needed.
If a specialist worker is uncertain about whether the care of - or conditions for - the child(ren) are adequate they should seek advice from a senior colleague with responsibility for child protection. If in doubt, they should seek help from a service with responsibility for protecting children's welfare - the social work service, the Reporter or the police.
Throughout their involvement with families in which parents have alcohol and/or drug useproblems, all services should continually consider:
- the extent to which parents may try to conceal their illegal drug taking/harmful drinking from services because they fear the negative consequences, and;
- how difficult parents may find it to change their alcohol and/or drug use and associated behaviours despite those negative consequences.
Services should acknowledge with parents that they recognise these factors and continually test the accuracy of information provided.
Parents may also find support and advice about their parenting, and possible risks to their children, difficult to accept. Professionals should be open about these difficulties and talk to parents about the importance of tackling problems early on.