Key Learning: Alcohol’s Hidden Harm:
a three year Cohort Study, July 2012
This report is based on an evaluation of five services intended to help children whose parents/carers misuse alcohol. The report is intended to help those developing or seeking to improve alcohol hidden harm services to understand both the process of establishing a service and the models of intervention that make a difference to children and their families. The full report is available by request from Comic Relief.
Crucial to the establishment of effective services were:
- Reflective practice;
- External clinical supervision;
- Evidence and experience based intervention style, delivered by well qualified staff and strongly supported volunteers;
- Ability to engage clients;
- Strong partnerships with adult alcohol services and universal services especially schools
- Resilient communities.
Services should include elements focused on:
- Developing children’s social capital by increasing parenting skills / ability to communicate;
- Developing children’s social capital by extending their networks of support;
- Ensuring that children ‘Have things to do, places to go’.
Effective services were also:
- focussed on the whole family, offering support for family members whether they were problem drinkers or not and providing parents/carers with therapeutic support as well as training, skills and resources to improve their parenting.
- flexible enough to adapt to the emerging issues and needs of clients once they had started to engage including which family members they worked with, the location of the work, and if other agencies were involved.
- longer than 5-6 months, with the opportunity to extend that duration, or return for further support according to client needs.
- Therapeutic, using techniques such as motivational interviewing, play therapies, and/or or one to one or couples’ counselling.
- able to raise awareness of the effects of alcohol hidden harm among universal services most likely to come into contact with children on a day-to-day basis. Schools and primary school staff in particular, can play a vital role in identifying parental alcohol abuse.
Services are also most effective if they were:
- Based on evidence and experience
- Well led and managed with the leadership’s vision clear to staff and volunteers
- Embedded within a resilient community. The most effective interventions were child centred, meaning they:
- Developed children’s social capital.
- Extended children’s networks of support outside the immediate family
- Ensured children had “things to do, places to go”.
- Focussed on the child’s safety, and their ability to communicate outside the home.
- Developed resilience.
- Were therapeutic and did not just focus on giving children a break and leisure activities.
At Comic Relief, we do three things. We raise much needed cash, we allocate that cash to projects both here at home, and in the world’s poorest countries, and we raise awareness of issues we feel strongly about. This is one of a series of reports we’ve commissioned that aim to derive learning from the work we fund and the various sectors we work within, in order to inform our thinking and promote debate. We’re also committed to using the report’s findings in practical ways, where possible, and sharing them with other relevant stakeholders.
The findings reported here result from an evaluation of five alcohol hidden harm services funded from 2009/2012 and have also been translated into a toolkit for funders and organisations seeking to emulate this work and to develop their own responses to the harm caused by parental alcohol misuse. This report was commissioned by Comic Relief and written by external evaluators Jenny McWhirter and Esme Madill. The views expressed within it are the author’s and not necessarily those of Comic Relief.
Background and Methodology
Around 1.3 million children and young people in the UK (or 10% of the total) are at risk because of parental drinking. Around one third of domestic violence incidents are linked to alcohol and alcohol misuse by parents is identified as a factor in over 50 per cent of child protection cases. Significantly, the children of problem drinkers have more problems than children of non-problem drinkers. Under- achieving at school, emotional and psychological problems, and anti-social behaviour are some of the difficulties that such young people can develop. At age 15 young people who have a parent with an alcohol problem have a higher risk of psychiatric disorder. Heavy drinkers themselves are more likely to have had a parent with an alcohol problem than the population in general.
Despite this relatively large population at risk from the Hidden Harm of alcohol the impact of parental alcohol misuse on children and young people had received relatively little attention from national policy makers, compared with the harm associated with illegal drugs. Thus children and parents who misuse alcohol may be in touch with a number of different services, but none specifically addressing the needs of the child affected by parental alcohol misuse.
In 2008 Comic Relief invited organisations to bid for funds to establish services specifically addressing the needs of children whose parents misuse of alcohol place them at risk of harm. Five projects received funding for three years and were evaluated over the life of the grant for this report. The key aim for these services was to help children and young people to develop resilience, ‘a universal capacity that allows a person, group or community to prevent, minimize or overcome the damaging effects of adversity’. Among the intended outcomes for the work were improved parenting skills, better relationships and communication with children, all of which contribute to resilience.
The services were evaluated through an in-depth case study approach which included a review of routine data and interim reports sent to Comic Relief, and a series of interviews, questionnaires and other child-appropriate methods. Lead practitioners and managers were interviewed biannually throughout the three year period considered. Senior managers, volunteers, trainees and key partners were also interviewed, as were child service users, who also had the opportunity to attend focus groups. Tools were developed to measure strengths and weakness of relationships with other organisations relevant to their service, the development of supportive relationships between the beginning and end of interventions, social capital for children and an outcome questionnaire for both adults and children was used to measure changes in children’s social functioning, resilience, emotional wellbeing, parenting and concerns. Demographic information was also collected to assist in the analysis. Where possible, findings were triangulated by comparison with data from more than one participant or method. Participation by clients was voluntary and the findings reported here therefore reflect the views of those able and willing to engage with the evaluation process.
The evaluation found that for some services children reported parents being more supportive and helpful, that they socialised more and felt less isolated because they realised that their problems were experienced by others.
Services were best able to promote factors important in building resilience among their clients by being child centred and whole family orientated. Their flexible and non-judgemental approach to service users meant that they could more successfully engage with problem drinkers and other family members with caring responsibility for the children, some of whom had chaotic lives and whose families had difficulty getting help or staying in contact with services previously.
Some services offered support for children in the form of group activities and mentoring. Group work can help children feel less isolated as they meet others who have shared their experiences, and well run youth groups can engage children for months, improving their support from both peers and adults. Children valued having someone to talk to about their feelings outside of their family, and this also encouraged them to talk more freely with their families and with other professionals.
As well as ensuring that children both have things to do and places to go, successful approaches were therapeutic, for children and adults. Priorities were the child’s safety, their self esteem and their ability to communicate their experiences to others outside the home.These, along with the feeling of support, are key features for building a child’s resilience. Therapeutic techniques such as motivational interviewing, play therapy, or one-to-one and couples’ counselling were used successfully by some of the services. There was also some evidence that one-to-one work can enable young people to learn more specific skills, such as anger management.
Where services offered support for parenting skills they were able to help parents improve their communication with their children. Parents reported fewer concerns about their children’s behaviour and emotional wellbeing and spent more time together doing fun activities. Overall whole family approaches led to more sustainable changes than services which worked only with children.
Effective interventions were longer than 5-6 months, according to client needs. Adult clients valued the opportunity to return for further support and advice at a later stage.
Overall, families attribute positive outcomes to the quick response to referral, to a lack of judgement about the parents’ drinking, and to the range of approaches available to support them and their children.
Projects with decisive leadership, consistent management and administrative support were most effective and provided staff with the support they required to deliver high quality services. Services which demonstrated strong leadership and management were able to anticipate problems and were resilient when faced with challenges arising from a lack of community resilience, changes to funding or changes for partner agencies. Services were more effective when based in communities experiencing less deprivation and with a greater level of social and economic resilience.
The importance of effective staff recruitment, training and support cannot be over emphasised. Those staff working with vulnerable families with regular clinical supervision allowed them the space to reflect on the impact of their interventions under expert guidance. Support and training was especially important for volunteers and sessional staff, as was appropriate supervision within a well-structured working environment. Skilled practitioners delivering flexible therapeutic services enabled families to make positive changes which impacted on outcomes for children and young people. This was the case even when the external environment or intervention models were not ideal.
Effective services took steps to evaluate their work and were based around learning and evidence of what works.
Despite the difficulties involved in establishing new or reliable partnerships, investment in this aspect of service development, particularly with adult alcohol treatment providers early on, led to increased referrals and joint provision of services. In all cases this took longer than expected, and funders should allow for this.
Agencies that held these strong partnerships based on previous work helping substance misusers found it easier to develop Hidden Harm services than those new to this area. Making sustainable changes in the lives of socially and economically excluded families living in areas of severe economic decline is very difficult. Partnerships will need to address the lack of social, cultural and employment opportunities, while interventions focused on reducing drinking will need to address the lack of replacement activities in towns with high unemployment and limited support services.
Universal services, especially schools and children’s centres contributed to a reduction in alcohol hidden harm by providing a location where children feel at ease within a setting they already know. Primary schools are particularly important partners. By helping teachers to understand Hidden Harm they provided more effective support and appropriate referrals, and helped children by making the school a safe environment away from the sometimes chaotic or unpredictable environment at home. Where the local statutory and voluntary services worked together there was more effective referral and support for families.
Alcohol Hidden Harm services should focus on the needs of the child, be viewed as a long term investment in the whole family, include a therapeutic element, for a minimum of six months. Non judgemental parenting support is critical, and should be built into interventions seeking to reduce alcohol Hidden Harm. Work with children can take place in groups and on a one-to-one basis, and should always focus on building a child’s resilience. Evaluation should be built in from the start.
Good leadership is essential, and both line management structures and the leadership’s vision should be clear to both staff and volunteers. Project leaders need to make sure that all staff are properly trained and managed, and that all staff working with families with complex needs have clinical supervision. Project leaders should also consider the benefits that volunteers and sessional staff can bring to a project as long as they are properly trained and supported, and are provided with a sense of the value they bring to the agency. Partnerships are also critical to the success of the project but take time and energy to nurture and sustain, particularly in difficult funding environments. Adult alcohol services, schools and children’s centres are critical partners in addressing the Hidden Harm of alcohol and need to be involved from the start. Partner agencies should aim to develop common referral mechanisms and recording procedures, so that service users can move seamlessly through a network of support, where the service is not aimed at the whole family, Funders should assess the strength of both the applicants and their partners before awarding funding, if possible through telephone interviews. If partnerships are poor then a year of development funding should be considered, rather than entrenching deprivation in areas without strong agencies.
Brief interventions are best avoided without strong evidence of their efficacy. Projects should be monitored for the first year, and projects may well need funding and training in order to be able to carry out further evaluation themselves. Learning from past projects should be shared, through consultancy support where necessary, and for any larger projects the leaders should attend project management training where the funder can clarify expectations.
External evaluators should use routine internal reports and those developed for funders as much as possible, in order to avoid overburdening practitioners. Evaluators should try to develop strong working partnerships with those being evaluated so they can act as a critical friend, and offer support so that they and their partners can integrate evaluation into their own work.
There is a need for services which aim to prevent the harm caused by parental alcohol misuse. Such services should seek to address the needs of children by working with the whole family, whether this includes the adult drinker or not.
These services require strong leadership and management and should work in partnership with adult services and universal services, particularly schools. Services should include elements which improve communication between parents/carers and children and which enable children to build networks of support with other adults in the community. Therapeutic services and those offering youth groups and therapeutic group activities reduce children’s feelings of isolation and can help develop their resilience.