Not addicted but still having an impact: children living with parents who misuse drugs and alcohol

Guest post by Dr Ruth McGovern, Institute of Health & Society, Newcastle University

There is growing political interest in the misuse of alcohol and drugs by parents and its impact upon children. The newly published Drug Strategy 2017 highlights drug and alcohol dependent parents as a priority group with an estimated 360,000 children living with parents who are dependent upon alcohol or heroin.

As a registered social worker, I have often identified ‘dependent parental substance misuse’ as a risk factor in many ‘child in need’ assessments conducted by Children’s Services. Around half of all child protection cases, recurring care proceedings (repeat children removed and placed into local authority care) and serious case reviews (enquiries following child death or serious injury where neglect or abuse is known or suspected) involve parents who misuse substances. However, the impact of parental substance misuse is not limited to addicts. The number of children living with parents who misuse but aren’t dependent upon alcohol and drugs is likely to be substantially more than the number of children living with those who are addicts. As such, greater harm in the population as a whole is likely to be experienced by these children.

I have been part of a group of academics and clinicians who have recently concluded a rapid evidence review funded by Public Health England (PHE). The review found evidence that parents who misuse, but aren’t dependent on substances, can have a significant impact on the physical, psychological and social health of their child. For instance, in early childhood we found that children of mothers misusing alcohol [1] were twice as likely to suffer a long bone fracture and five times as likely to be accidentally poisoned, than children whose mothers do not drink heavily. Children of mothers misusing alcohol or drugs are also more likely to require outpatient care or to be hospitalised due to injury or illness, and for longer. The impact of substance misuse by parents continues into adolescence, with our review showing an increased likelihood of antisocial, defiant and violent behaviour in late adolescence as well as substance misuse by the child. However, many of these children and families are not identified as being affected by the substance misuse of a parent and subsequently do not receive the help they need in the form of an intervention.

Therefore, our review also examined the evidence for effective interventions to help reduce the numbers of parents misusing alcohol and drugs. Family-level interventions, particularly those that offer intensive case management, or those which provide parents with a clear motivation (such as those linked to care proceedings) show promise in reducing the problem. Unfortunately, there was little research examining the effectiveness of interventions for parents misusing but not dependent on alcohol and drugs.

PAReNTS study logo

To respond to this evidence gap, we designed the PAReNTS study (Promoting Alcohol Reduction in Non Treatment Seeking parents). Within this study we are examining the feasibility and acceptability of alcohol screening (using the AUDIT-C questionnaire [2]) and brief interventions with parents involved in early help and statutory children’s social care services. The brief intervention is an adapted version of the ‘How much is too much?’ programme for parents [3] which combines advice and behaviour change activities and is delivered by both social care practitioners and the local alcohol service. Whilst alcohol brief interventions have been found to be effective in adults who misuse alcohol, little is known about the effectiveness of such interventions for parents with additional and complex needs. This presents unique challenges, for instance, parents may be concerned about the stigma of being labelled as having an alcohol problem, particularly if this could be used as a reason to remove their child from their care. There is clearly a need for a sensitive approach. In future blog posts, I hope to update you on the progress we make with the PAReNTS study and whether it is feasible to deliver early interventions with alcohol misusing parents to improve the wellbeing of children, who are often overlooked in public health.

References:

1. Below the age of 10 years, much of the evidence focuses on mothers with alcohol misuse problems as most caregiving is carried out by mothers during early years. 
2. The AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence): https://www.integration.samhsa.gov/images/res/tool_auditc.pdf. 
3. This programme was highlighted by the National Institute for Health and Clinical Excellence alcohol prevention guidance (PH24): https://www.nice.org.uk/guidance/ph24.

Image credits:

• First image: Copyright: Alcohol Concern April 2008. Taken from the report 'Keeping it in the Family Growing up with parents who misuse alcohol'. ISBN number 1 869814 92 4: https://www.alcoholconcern.org.uk/Handlers/Download.ashx?IDMF=399c1dd7-1cb3-407d-a093-b3d486ac034d

Food as a job, life and research: the many meanings of what we eat

Posted by Amelia Lake, dietitian and public health nutritionist & Fuse Lecturer in Knowledge Exchange in Public Health, Durham University

Food is my job. As an academic dietitian and public health nutritionist I spend my time questioning why people eat what they eat, and thinking about what we can do to change behaviours. As a mum, I also spend a lot of time at home wondering why a 4-year-old and a 17-month-old eat what they eat!

Its nutrition and hydration week, which aims to highlight, promote and celebrate improvements in the provision of nutrition and hydration locally, nationally and globally. So this is an excellent opportunity to explore the many roles of food in public health.

Top shelf material

Food is life. We need nutrition and hydration for life and to maintain health.

Food is a thread that moves through every aspect of our life from the everyday to the special occasion.

I read somewhere that the origin of culture was when raw ingredients were cooked. The importance of this event was not so much in how food was prepared but in the organisation of individuals around meals and meal times.

Food has shifted populations and started wars; think of the thirst for sugar, tea and coffee (also known as the ‘hot drinks revolution of the eighteenth century’) and the impact that had on various countries and their populations.

Food is our culture and identity; it is an intrinsic description of who we are and where we come from. For example, I am a complex mixture of Persian dishes, Indonesian dishes and some Northern Irish wheaten bread and Tayto crisps.

Food is our comfort. That dish your mother made, it’s a warm familiar blanket; it evokes memories, both good and bad. It is a way in which we show others that we care for them and are thinking of them.

The party bag horde - a focal point for arguments

Food is a focal point for arguments: “No you can’t have any more sweets from the party bag…” A conversation every parent has at one point or another.

Our social media feeds provide us with ‘food porn’, hands that whizz up magical results in seconds. Additionally, social media and the press provide us with self-styled food and nutrition 'experts' presenting us with spiralised courgette and clean eating advice.

Food continues to dominate our life and the public health agenda on a global scale.

The World Health Organization’s global targets for 2025 to improve maternal, infant and young child nutrition tackle a range of issues from obesity to stunting and wasting.

In this country we are familiar with the concept of our obesogenic environment; an environment in which calories are easily accessible and available and with little opportunity to expend that energy. In an attempt to tackle the obesity problem in this country our government will follow Mexico and introduce a sugar levy.

Despite the issues of over-nutrition and the seemingly endless opportunity to buy food, food poverty is a term we have become more familiar with. Despite it sounding like it belongs to another era, it’s a very real issue for a significant proportion of our population. Oxfam estimates that 500,000 people in the UK are now reliant on food parcels. Foodbanks provide nutrition to those who struggle to feed themselves and their families and have sadly experienced rapid growth in recent years, especially in the UK.

How can research help to address these global and local problems?

Free fruit with every purchase

Within Fuse ‘food’ runs through a number of research themes, from behaviour change to healthy ageing. As part of the national School for Public Health Research, a team of Fuse researchers has evaluated a food training programme run by Redcar and Cleveland Council. To promote the findings from this research we decided to create a short film and this week were filming in a small sandwich shop in the market town of Guisborough, where you were offered a free piece of fruit with every purchase. This small business owner’s focus is food. She provides food to customers every lunch time. This owner had attended the training course run by the Council and decided to make a difference by providing more healthy food.

This is an important step, supported by research. On this nutrition and hydration week, I am sure you will agree that there is still much to be done on this important and vast topic across many disciplines and on a global scale.

Sublime and ridiculous: the glamorous life of a public health researcher

Guest post by Rebekah McNaughton, Research Associate in Public Health and Lecturer in Research Methods at Teesside University 

They say that variety is the spice of life and that is certainly true in my line of work. When I started my career as a public health researcher I understood that a great deal of my time would be spent reading other people’s research, doing fieldwork and writing numerous reports. That has certainly been true of the last 10 years of my career. What I didn't expect was the huge variety that I would come to love.

Doing fieldwork is by far my favourite aspect of the job. I'm naturally quite inquisitive and I'm really lucky to get paid to do something I enjoy- being nosey! So far, I have worked on projects with children and young people, parents, teachers, public health professionals and patients. You name it: I've probably worked with them. And, to be honest, it has ranged from the sublime to the ridiculous…

Crowd control: Some research participants refused to be quiet for the focus group

Yes, I've done focus groups in schools and community venues. I've sat on people’s sofas having a cup of tea and a biscuit. I've been challenged by young people determined to embarrass me whilst talking about sex and relationships education. All of this I expected as part of the ‘routine’.

What I didn't expect, however, was trying my hardest to concentrate on asking ‘the right questions’ whilst the washing machine was screaming in the background on the extended spin cycle. Or being mauled by a rather ‘licky’ dog and trying to make sense of the tape afterwards. I didn't expect to need crowd control skills when trying to carry out work with 24 new mums and their 28 babies and toddlers, all wriggling on the floor and not one of them being courteously quiet for the tape. However, today took the biscuit. I went to talk to two health visitors, at their place of work. Nothing out of the ordinary, or so I thought. In need of some privacy, I was led into a tiny windowless room (a cupboard), a cupboard lined with patient notes and not enough room to swing a cat. The three of us huddled around a mop and bucket, like women dancing around their handbags in a club circa 1989, whilst I held out the voice recorder. At the same time I was trying desperately not to drop it in the murky water swimming at the bottom of the bucket. Oh, the glamorous life I lead…

Would I change it? Absolutely not! No two projects are the same. Meeting participants is by far the best aspect of my job; it brings obstacles and challenges but most of all it makes my job a lot of fun!

Photo attribution: www.flickr.com, Anthony J, 'Six pack', The results of the 'final project' in our childbirth class, (Left to right: Sienna, Maguire, Sophia, Ethan, Claire and Noah)

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The Troubled families Programme: what's health got to do with it?

Guest post by Stephen Crossley, PhD student in the School of Applied Social Sciences at Durham University

A couple of weeks ago, the expansion of the Troubled Families Programme was formally announced during the Queen’s Speech. This formality came two years after the government itself announced their plans to expand it, around 10 months after they announced further details such as the criteria to be called a ‘troubled family’ under Phase 2 of the programme, and around six months after some local authorities started working with ‘troubled families’ as part of the expanded programme.

Another troubled family?

There have been numerous criticisms of different elements of the Troubled Families Programme since the programme was announced in the wake of the riots in England in 2011, with David Cameron promising to ‘turn around’ the lives of the most troubled and troublesome families in England by the end of the Parliament that finished in May 2015. Ruth Levitas and Jonathan Portes highlighted that the figure of 120,000 ‘troubled families’ used by the government (characterised as ‘neighbours from hell’ in the prime Minister’s launch speech), actually referred to research published four years earlier on families thought to be experiencing multiple disadvantages such as maternal mental health, poverty, material deprivation, poor quality or overcrowded housing. Levitas argued it was a discursive strategy which succeeded in feeding vindictive attitudes towards the poor.

A report carrying a series of interviews with families, written by Louise Casey, the senior civil servant in charge of the programme, was criticised for its lack of ethical process and the government admitted it was a ‘dipstick’ process which didn’t meet the government criteria for research and therefore didn’t require ethical approval. My own investigations revealed that a ‘survey’ used by Casey to highlight the need for ‘radical reform’ didn’t actually exist. In a series of speeches during 2013, Casey told audiences of a survey which showed that, in one deprived area in the North East, not one out of 3000 children had attended a dentist for a routine check-up, but that 300 had presented at A&E for emergency dental care. The survey was, in fact, an anecdote shared during a meeting about a different government programme, which Casey never thought to check before sharing with audiences, preferring instead to tell them it ‘encapsulates the problem’ of ‘troubled families’ in a single example. Casey also told the 2013 RCGP conference that these 120,000 families ‘dominated NHS budgets. That’s the long and the short of it’, which isn’t exactly true either.

To date, however, health has played a relatively minor part in the Troubled Families Programme (TFP) and health issues were not mentioned in either the criteria for families in Phase 1, or the outcomes expected in order for their lives to be considered ‘turned around’. But this is starting to change. The government published a report in July 2014 entitled: ‘Understanding Troubled Families’ which included information on the characteristics of families entering the programme in its early stages (my brief (Mis)understanding Troubled Families is available here). The data showed that the majority of the families being worked with under the banner of the TFP were not particularly anti-social, weren’t serial offenders and most of the children were in education, albeit not all of the time. In fact, the only characteristics that could be applied to a majority of families included in the report were that they were white, they lived in social housing, they had an adult on out-of-work benefits (although we don’t know why) and they had a family member with a serious health issue or a disability. In short, and if any personal characteristic can adequately explain unemployment, these families were probably more likely to be out of work because of health, disability or caring issues than because of any intergenerational culture of worklessness.

In the expanded second phase of the programme, ‘parents and children with a range of health problems’ is included as one of the six criteria for families, who have to hit two of the criteria to be labelled ‘troubled’. Other criteria include ‘children who need help’ and ‘children who have not been attending school regularly’. These vague criteria are open to interpretation and councils will be encouraged to go out and find ‘troubled families’ in order to ‘turn them around’ (or make ‘significant and sustained progress’ in phase 2) and claim the cash bonus, via the Payment By Results process, for doing so. A health bulletin on ‘troubled families’ was also published when the new criteria were announced, highlighting the health related issues some ‘troubled families’ faced, and a ‘leadership statement’ followed shortly after, accompanied by information on skills and training and interim guidance on data sharing amongst partner agencies. With health visitors and school nurses now under the remit of local authorities in England, it is likely that many will become involved with the TFP.

All of these developments should concern health professionals. The TFP assumes that the answer to the families problems lie firmly within the four walls of the family home, with a strong rhetorical focus on ‘getting in through the front door’ and working with the family ‘from the inside out’. In short, there is no room in the narrative for wider determinants of people’s circumstances. Its alleged success has never been proven. There is scant evidence to justify such an approach and it is unlikely that having a determined, non-specialist key worker will make much difference to many of the health problems ‘troubled families’ experience. The programme is a good example of what David Hunter and Jenny Popay and others have called ‘lifestyle drift’, where the focus of interventions drifts towards attempting to change individual behaviour, despite the wealth of evidence pointing to other solutions. But this ‘responsibilization’ strategy is also a punitive, stigmatising discourse which is targeting some of the poorest and most vulnerable families in England, telling them that they are the architects of their own misfortune and that they just need to try harder and follow a routine. A simultaneously fascinating and alarming article in the BMJ recently, exploring the role of psychology in government workfare programmes highlights that this approach is not a unique aspect of the government’s welfare ‘reforms’. Health professionals should tread carefully.

Stephen Crossley's first peer-reviewed article on ‘troubled families’ can be found here.

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Have we been had?

Guest post by Jean Adams, Centre for Diet and Activity Research (CEDAR)

Parents don’t like sweets at supermarket checkouts. The ‘guilt lane’, as it’s been called, seems designed to attract children in a place where they are a captive audience – you can’t just move away from the checkout when you have a trolley full of shopping that you need to pay for.

This consumer concern is what seems to have prompted many supermarkets to impose total, or partial, bans on checkout confectionary.

It was certainly a healthy dose of parental curiosity that prompted our recent study on food at checkouts in non-food stores. The lead author was in Primark with her pre-schoolers, noticed a LOT of sweets by the till, and started to wonder how pervasive a phenomenon this was.

We felt food at checkouts in non-food stores was a worthwhile thing to study for two reasons. Firstly, these are places where we assumed most people aren’t naturally thinking about food. Buying confectionary at a supermarket is, perhaps, appropriate. But at a clothes shop? Presumably most people don’t go into Primark to buy some energy-dense, nutrient-poor snacks. So any purchases they do make are unplanned and prompted entirely by the display, rather than, say, hunger. Secondly, a lot of campaigning attention has been devoted to #junkfreecheckouts in supermarkets. To some good effect. But if the problem has just shifted to other types of shops, then any war is not yet won.

So we enlisted the help of two medical students, who were keen to get some hands-on experience of public health research, and did a survey of all the non-food stores in the MetroCentre - which has the dubious accolade of being the second largest shopping centre in the UK (I’m sure it was the largest in Europe at some point).

Of 205 non-food stores in the MetroCentre, 32 of them, or 16%, had food within arm’s reach of the checkout queuing area. All these stores stocked less healthy checkout food, although about half of them also had foods that were not specifically identified as less healthy. This was mostly bottled water or chewing gum – so not exactly healthful! Overall more than four-fifths of checkout food was less healthy and would not be allowed to be advertised on children’s TV in the UK.

As well as making life easier for the parents of young children, there may well be health benefits of #junkfreecheckouts. Around the world, most checkout food really is ‘junk’ – soft drinks, and foods high in energy and salt, and low in vitamins and minerals. Checkout food may prompt impulse purchases and purchasing requests from children, which parents find hard to resist.

But, importantly, I’m not aware of any research that shows that people who see more checkout junk food eat more junk food, or that removing checkout junk food leads to changes in what people buy or eat. This is one of those absence of evidence, rather than evidence of absence situations – we just don’t know what effect checkout confectionary has on what kids eat.

There was an interesting discussion on the Food Programme recently suggesting that sales of confectionary from UK supermarkets were steady, or rising, despite many stores removing it from checkouts. Checkouts aren’t the only way to prompt impulse purchases in supermarkets. Prominent, end-aisle displays, and price promotions seem to be keeping sweets sales buoyant. At least for now.

This wasn’t what we meant: a prominent confectionary display opposite a #junkfreecheckout at my local supermarket (that pizza wasn’t mine!)

Which makes me wonder…have we been had? Have supermarkets taken confectionary off tills because it makes them look responsible and ‘part of the solution’, knowing full well it will have no effect on sales? And what might the consequences of that be for public health? Well, no change on the diet front. But what if supermarkets voluntarily choosing to remove checkout junk food, means that it also closes down a conversation on unhealthy food environments? Could the supermarkets keep referring to this non-change as a way of trumpeting how importantly they take health, and silencing any requests for further, serious, meaningful change?

I find this a bit scary. Some well-intentioned public health campaigning might have made things worse? I don’t know that it has. Maybe it hasn’t. Probably it hasn’t? Hopefully it hasn’t. Probably it’s just made no difference. At the very least, it makes life a bit easier for stressed out parents trying to get the shopping done and their kids to eat a healthy diet?

No time to run: is role overload contributing to physical inactivity in parents?

Posted by Caroline Dodd-Reynolds

Last night during a Twitter exchange, it somehow came about that I would write a #fuseblog on barriers to physical activity and a healthy diet in working mums. Interestingly, my one-year-old daughter had just gone nicely to bed at this point and so my husband and I treated ourselves to a healthy(ish) home-cooked dinner, albeit at 9pm. Normal service was resumed however at 12.30am when we were woken by the sound of the one-year-old vigorously banging on her cot and shouting, ‘Is DARK!’ (yes, it’s the middle of the night). So here I am typing this blog with two hours of sleep under my belt. Primarily this is why I no longer do very much exercise-based physical activity, or indeed eat as healthily as I used to. I am sure there are many who can relate to this sleep-deprived existence. Certainly the transition to parenthood can be an experience of life-changing proportion. For me, the transition back to work after months of no sleep and complete displacement from my previous identity was interesting.

There is guilt at leaving my little one at nursery and then there is the race through the day so that I can leave early enough for us to have an hour of (potentially active) play before bedtime. There is guilt at not being able to attend the evening functions at work, the interesting lectures that I know would be pure luxury to immerse myself in. There is pressure to succeed at work, not so much to prove that I can be both a parent and an academic, but more that if I don’t, then there is little point in having endured the guilt. And what of physical activity? Well, please see my previous points as to why this takes a seat so far back that I can barely see it.

The Chief Medical officers recommend 2hr 30min moderate-vigorous physical activity (MVPA) per week for adults; an individual is classed as inactive if achieving less than 30min moderate physical activity per week. Time spent engaged in MVPA declines with age and in 2012, 67% of men and 55% of women aged 16 years and over were meeting recommendations. These data were self-reported and objective monitoring methods suggest these figures are inflated. Guidelines for reducing sedentary behaviour are less clear but should involve avoiding prolonged periods of sitting. I am a full-time Lecturer in Physical Activity and Nutrition and so the irony of spending hours (sitting) writing lectures on the perils of sedentary behaviour and energy-dense snacks, is not lost on me. I did a quick PubMed search including physical activity and working mums as key terms and found a lonely but slightly reassuring 10 articles.

One article describes succinctly and astutely the fact that much is known about motherhood as a transitional influence on the physical activity habits of new parents, but actually very little about those new parents (or indeed any parents) who work. Emily Mailey and her colleagues, from the Dept of Kinesiology at Kansas State University, talk about ‘role overload’ and how this is associated with negative health outcomes such as elevated stress, depression and anxiety. I am starting to feel better here. The 25 mothers and fathers who participated in focus groups for this study reported barriers such as ‘scheduling constraints’ which I think many working parents may identify with – for me it is the Outlook calendar that keeps me on track and I know that if I schedule 30min into it on a Tuesday, I do have time to nip out for a run and I am more productive for it. But then what if someone requests a meeting or tutorial? Interestingly, ‘prioritising’ is noted as a facilitator. One mother comments that she had to get up at 5am to fit her physical activity into her day. Indeed this is a thought that often crosses my mind. Another, is that working parents may well comprise a special population in terms of physical (in)activity habits and sedentary behaviour; when I was on maternity leave I was certainly more active than I am now.

Anyway, I’m writing this on a Friday (thank goodness for the weekend). I really must clean the bathroom tomorrow, and the car needs a good wash, these will get my activity counts up, great. Oh but then there is that paper I need to write, and next week’s lecture I have yet to prepare. I know realistically what I will be doing this weekend – and it may not comprise any minutes of MVPA, nor help my preparation for next week at work, but I know it is the finest choice and that my little girl will laugh out loud with delight when she sees the animals on the farm.

Feeling slightly more awake after some strong coffee, I have just read this blog back and am sad that it sounds rather negative. It isn’t meant to, but it has made me think a little more about how I spend my days (and the potential to ask for a standing desk at work). And in case you were wondering, I would not swap my little girl for any amount of physical activity. Mailey and co. talk about being a role model and being active with your children. In a good week with no illness, sleepless nights or marking, we probably do manage to achieve this to an extent. And my little girl is happy, active and eats a healthy but balanced diet (vegetables and chocolate included) so perhaps we are doing things right after all?