CAUTION: This is the text underlying the published version of the same bulletin entry. It may not incorporate late revisions and corrections. Neither the text nor the citations were finalised for publication so may be inconsistently presented and sometimes take the form of notes rather than polished text. It is offered as a source of additional information and citations but should not be relied on, especially when it departs from the published version available at:
http://findings.org.uk/count/downloads/download.php?file=bulletins/PUP.nug
For further information or to comment on this draft contact editor@findings.org.uk.
© Drug and Alcohol Findings 2008. Permission is given to distribute this document unamended electronically or on paper or to incorporate passages in other documents as long as the source and copyright owner are acknowledged including the web address http://findings.org.uk.

Bulletin 7 August 2008
Home visits reduce risk of ‘hidden harm’ to children of drug treatment patients
In Australia a home-based child welfare intervention for methadone-maintained parents improved parenting and decreased the risks of child abuse or neglect. In contrast, offering brief parenting education classes barely improved on usual care. This type of intervention offers one way to address current concerns about the children of dependent drug users.
Findings 
The featured study recruited 64 patients at two methadone clinics who were caring full time for children aged from two to eight. Most parents were mothers, typically unemployed and in their late 20s and early 30s. On average they had been on methadone for over three years. At the start of the study, 40 scored above the level indicative of potential child abuse or neglect on a standard assessment questionnaire.
Patients were randomly allocated either to carry on with their usual care at the clinics (the control group) or additionally to one of two parenting interventions conducted by therapists from the research project. One consisted of just two sessions of conventional parenting skills training. The other was the specially devised Parents Under Pressure programme, involving ten home visits over three months lasting one to two hours. It aimed to help parents become aware of and regulate their emotional reactions (also an important element in other programmes), improve parenting skills, avoid relapse to substance misuse, and gain support from other people and from welfare and community services. Outside scheduled sessions therapists were available to (and often did) support patients by accompanying them to schools, social, legal and health services and in everyday activities such as shopping. Day-before reminder calls and flexibility in response to the families’ vulnerability to crises partly accounted it’s thought for why just one of the patients allocated to it failed to engage with the programme. 
All but seven patients were reassessed after the three-month intervention period and/or again six months later. On all the measures of parenting, child welfare risk, and child behaviour, patients allocated to Parents Under Pressure had improved substantially, while generally the others had not. On the key measure of risk to the child, the control group had deteriorated, while those given limited parenting skills training had improved, but only slightly. 
The upshot was that by the last follow-up, a third of the Parents Under Pressure patients no longer scored as child welfare risks, twice the proportion in the parenting skills group. None of the control group reached this level. Though this was not an explicit objective, only the Parents Under Pressure patients had also been able to reduce their average dose of methadone. However, even among these patients improvement was incomplete; in a third of cases children remained potentially at risk.
In Context 
About the study
Previously a pilot study from the same research team had tested the programme on nine methadone-maintained patients and recorded similar improvements, suggesting that the featured study was not a one-off. This does not, however, mean that these results will be replicated elsewhere. The two therapists in the featured study were experienced in working with families with complex needs and closely supervised by a researcher who devised the Parents Under Pressure programme, a degree of expertise and possibly too commitment which may be diluted in everyday practice. The team which devised the programme also researched it and provided the therapists; independent researchers tend to record less positive outcomes.
It’s possible too that patients not allocated to Parents Under Pressure were disappointed and that this affected outcomes in ways which would not be seen outside the context of a randomised study. All the patients knew the options they might be randomised to, so were presumably willing to invest up to 20 hours of their time and to open their homes to the interventionists. Ten not allocated to the Parents Under Pressure programme quickly withdrew and were not included in the study, including seven from the control group. Whilst this compromised the randomisation procedure, it did so in a way which can be expected to have favoured the control group if the most motivated parents withdrew in disappointment.
Drop out of patients once they were in the study could have had the opposite effect. Again this was greatest in the control group, fewer of whom attended the six-month follow-up. If more motivated parents had dropped out, this could account for the apparent worsening in the control group, especially since in some analyses drop-outs were assumed not to have improved since their last assessment. Conceivably, too, disappointment affected the outcomes of control patients who did attend for follow-up. However, this concern applies less to the brief intervention group, which also improved little.
Whatever the reason, these losses meant that just two of the patients originally allocated to Parents Under Pressure were not followed up compared to 13 (about half) from the control group.
Except for methadone dose, all the measures were based on the parent’s interview responses. The questionnaire assessing potential risk to the child was designed to cater for misleading responses, but validation of the improvements by (if available) the school, close family, or by direct observation, would have given greater confidence in the results. 
All three options to which patients were allocated differed not just in content but in the amount of contact with the study’s therapists, and one involved home visits. This leaves open the possibility that it was not just the Parents Under Pressure programme which was influential but as well or instead the degree of contact and where this occurred. 
About other studies
Evaluated attempts to improve the prospects for children of a similar age living with parents who are problem drug users have been few and results patchy. 
UK research on parenting interventions in drug services is scarce and not directly relevant to the approach trialed in the study.   There are, however, descriptions of similar interventions involving home visits which appear to embody the features commended by international research.
A fairly close parallel to the featured study was undertaken at two US methadone clinics with patients whose children were aged from three to 14 years. Clinic-based family training groups combined with nine months of home‑based case management led to substantial reductions in illicit drug use and improved parenting practices and family harmony. Disappointingly, when the children’s behaviours and attitudes were directly assessed, changes few and inconsistent, though in terms of drug use and delinquency, these favoured families offered the intervention. The willingness of the parents to improve family life was apparent in the take-up of the programme (78% of the patients who were eligible) and the fact that the home visits element was engaged in by three-quarters of participating families. 
In another US study, psychotherapy groups aimed at improving parenting were trialed with methadone-maintained mothers of children under 16 years of age. All but a few randomly allocated to the 24-week intervention completed it. Data from mothers and children indicated that the intervention reduced the risk of child abuse or neglect, and data from the mothers that it improved parenting and reduced illegal drug use, though the limiting effect of the neighbourhoods the families lived in and their lack of social support seemed apparent in the lack of improvement on some measures.
Methadone-maintained parents provided the impetus for the US-originated Strengthening Families Programme. A more complex intervention than the one tested in the featured study, this involves parallel weekly groups of parents and children followed by a session where the families come together to practice and consolidate their learning. Not explicitly a child protection intervention, nevertheless the improvements seen in parenting skills, children’s social skills, and family relationships can be expected to have a protective impact. 
Directly addressing parenting is not the only way to improve life for the children of substance using patients. Counselling couples to improve their relationship (and compliance with treatment for the partner in treatment) has spilled over to benefits for children which exceeded those from individual therapy. This approach may attract male patients more readily than parenting interventions, but is applicable only when partners are together, and has so far been trialed when only one is in trouble with their substance use. 
In so far as it stabilises the patient and brings them in to contact with social and welfare services, addiction treatment in itself improves the prospects for the children, though, as the featured study among others shows, there may still be elevated risks of neglect or abuse which can be further reduced by interventions targeting these risks. 
Approaches found effective with parents in general may also prove effective with problem drug users. Promising results have been found with home-based interventions which involve all the family and ‘coach’ parenting skills rather than didactically educating, and provide case management services to link families to sources of support in the community.
Practice Implications 
Across the UK, national targets, service standards and policy statements have recently embodied the perspective that child welfare is part of the core business of addiction treatment services, a contention featuring strongly in English and Scottish drug strategies effective from 2008. The English strategy promises to prevent harm to children by intervening early, prioritising parents’ access to treatment where children are at risk, and by providing intensive parenting guidance and access to services such as housing, employment support and education. In Scotland, too, the strategy aims to strengthen the focus of adult substance misuse services on the needs of children and families.  Interventions like those trialed in the study are one way services (and conceivably drug action teams or service consortia working across an area) can play their part in these agendas. With no blame implied and offering positive support, in the research they seem to have been welcomed by the patients both in terms of starting and completing the programme.
It is important to distinguish the type of intervention in the featured study (a preventive applied across the board to all parent-patients) from the action which should be taken if an individual patient’s child is assessed as at risk of serious harm. The main role of interventions such as those trialed is to reduce the numbers that deteriorate to this point. In individual child protection cases, service protocols and legal and ethical obligations will normally dictate the action to be taken, such as involving senior managers and child welfare authorities. Such cases may be revealed during the course of interventions like those in the featured study. This possibility should be provided for in staff training and guidelines and in the information given to patients invited to participate in interventions.
In 2003 the UK’s Advisory Council on the Misuse of Drugs estimated that there were between 250,000 and 350,000 children of problem drug users in the UK. Since 2006 the Drug Treatment Outcomes Research Study has sampled 1796 adults starting treatment for drug problems across England. Half had children aged under 16 and 1 in 8 had children living with them, an indication that in a typical specialist service at least 1 in 8 patients and perhaps as many as half are potentially eligible for family interventions. Such work should not await the resolution of the parent’s substance misuse problem; much can be done before this point to benefit the entire family, in the process (research suggests) also furthering the resolution of substance use problems. 
The lessons of research to date seem to be that interventions need to be relatively intensive and well targeted at the issues obstructing good parenting. Staff must be able to forge trusting relationships with adults wary of authority, to the point where they are repeatedly welcomed in to the home, be able to adapt to the contingencies affecting the family as they arise, yet retain the child’s interests as paramount. Roles typically combine direct parenting support with a case management function, facilitating support from other welfare and community services and intervening when third-party pressures threaten the family’s progress. 
Many drug service workers feel ill-equipped for this work. The argument has been made that the core attributes and skills deployed with their patients and clients are also core for family work. Ideally though this core would be built on through specific training and supervisory support to give workers not just extra information and skills, but also the confidence to intervene in this professionally and emotionally risky area.
Government advisers have pointed out that the first essential step is for treatment services to ask patients about their children. When in 2005/06 the Healthcare Commission and the National Treatment Agency for Substance Misuse (NTA) investigated prescribing services in England, they found that half did not have assessment procedures which systematically enquired who else shared the home. Current NTA care planning guidance refers to the need for addiction treatment services to identify child protection issues. Additionally, patients should be questioned about their children in order to submit this data to national and regional monitoring systems, including those for drug using offenders. In the process, patients who might be offered family interventions will be identified. 
How diligently such enquiries are made is unclear. Being able to offer concrete and supportive interventions such as those in the featured study makes asking about children both more acceptable to patient and worker and more worthwhile. Home-based interventions allow an efficient incorporation of children in the treatment process, resolve the need for child care, permit assessment of home safety, provide for the learning and practice of new skills in the environment where they need to be applied, and are possibly more likely to be taken up by the parents.