How substance abuse affects parenting

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					How substance abuse affects parenting
Author: Judith Edwards, Early Intervention Program
Originally published/presented: Lecture for the NSW Institute of Psychiatry,

   •   1.0 Introduction
   •   2.0 Summary
   •   3.0 The magnitude of the problem
   •   3.1 Characteristics of mothers with substance use issues
   •   3.2 Characteristics of addicted/withdrawing infants
   •   4.0 Parenting issues
   •   4.1 Risk factors
   •   4.2 Neglect
   •   5.0 The developmental needs of infants
   •   5.1 One to four months of age
   •   5.2 Four to six months of age
   •   5.3 Later months
   •   6.0 Extra considerations in assessing infant risk in families with
       substance abuse issues
   •   7.0 Responses to a needs assessment
   •   8.0 Case work
   •   8.1 The parent-infant relationship
   •   8.2 Parent issues
   •   8.3 Fears and stigmatisation
   •   8.4 Multiple agencies
   •   9.0 Conclusion - The challenges in this work


The aim of this paper is to look at how substance use issues in parents can
effect the development of their infants. This will be done by:

   •   Discussing the characteristics of drug and/or alcohol dependent
   •   Discussing the characteristics of drug and/or alcohol affected babies
   •   Thinking about how substance use in parents might effect infants
   •   Discussing what extra things a child focussed intervention might be
       looking at when assessing risk of a young child in families with
       substance use issues
   •   Contemplating the challenges in the work.


The time around the birth of a child, while challenging for all families, also
provides a window of opportunity where most parents are highly motivated to
make positive changes for the sake of their child.

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Experience in The Benevolent Society's Early Intervention Programs is that
parents with substance use issues usually start out just as highly motivated to
make things better for their children.

They therefore need the same developmental information and support from
which all new parents benefit. However, they face additional problems around
parenting which need specialised interventions to adequately address the
developmental needs of their children.

Experience in the Early Intervention programs has also shown that for many
parents with substance use issues the time around birth is indeed a window of
opportunity for change.

This can mean that with adequate support they may begin to address the
issues which have contributed to their substance abuse and be able to make
real changes in their own and therefore their children's lives. For this to be
able to happen there is a need for skilled, sensitive interventions, which grow
from an understanding of all the issues relating to these parents as well as
their children.

The magnitude of the problem

From 1984 to 1994 there was a fourfold increase in the number of people on
methadone maintenance programs in Australia (Walsh, 1994), and most
observers believe there is in excess of 250,000 heroin users in Australia
(Crosbie, 1997). These figures do not of course include those who abuse
other illicit or prescribed drugs and alcohol, but they serve to show that
substance use is part of our community.

It is difficult to estimate the number of women who give birth each year with a
substance use issue, as most women report that they try not to disclose this
when they are admitted to give birth.

Again we only have figures from the various services for substance users in
pregnancy attached to the various hospitals, but this again gives a sense of
the extent of the problem:

   •   Drugs in pregnancy Service, RPAH, 60 women used the service in
       1996 (now unfunded)
   •   Drugs in pregnancy Service, Westmead, 77 women used the service in
       1996 (now unfunded)
   •   Drugs in pregnancy Service, Liverpool Hospital, 46 women used the
       service in 1996 and 60 in 1997 and 56 in 1998
   •   Chemical Use in Pregnancy Service, RHW, 90 women used the
       service in 1996, 93 in 1997 and 114 in 199.

Characteristics of mothers with substance use issues

The following are characteristics of mothers with substance abuse:
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   •   Pregnant addicts present for antenatal health care consistently later
       than other women. This seems to be in part due to women attributing
       amenorrhoea, nausea etc to normal drug use symptoms. Social stigma
       and denial have also been identified as contributing to this.
   •   Women report that they don't tell staff of maternity hospitals about their
       substance use issues, to avoid stigmatisation. If women do disclose
       their substance use issues they report it is because of the fear of
       physical complications in delivery, both for themselves and their infant
   •   Women drug users tend to have partners who are part of the drug
       scene themselves, either users and/or suppliers
   •   Women with substance use issues present with anxiety and sense of
       powerlessness. They also have lower self esteem and lower self
   •   Other psychopathology often found includes mood disorders, and
       phobic disorders.
   •   Women often talk about the guilt and shame of possibly hurting the
       foetus because of drug use
   •   Pregnant women drug users expend most of their energy in obtaining
       and using drugs so that thoughts of the baby they are carrying are
       pushed into the background with the result that the ability to grasp the
       reality of the child seems to be far more tenuous than it is in non drug
       using mothers
   •   This group is at high risk of depression and difficulty with motherhood
       due to the increased likelihood of: - difficult births - high degree of
       medical intervention - separation of mother and child in the first days
       after birth - breast feeding often not advisable (although mothers on
       less than 50mg of methadone can breast feed) - poverty - social
       isolation - an absence of supportive relationship - own history of being
       poorly parented - feelings of incompetence and failure (particularly
       when infant is withdrawing)

Characteristics of addicted/withdrawing infants

Babies born to drug dependent women bring with them their own extra issues
that make them more difficult to manage. As well, they have higher rates of
sudden infant death syndrome, infection, developmental delays, speech
pathologies and behavioural disorders related to problems in their nervous
system, such as hypersensitivity to environmental stimuli.

Narcotic withdrawal soon after birth leads to babies being less responsive,
less cuddly and less alert. Two main behaviour patterns are seen in the early
weeks of the narcotic addicted infant. The first pattern involves sleep
disturbances and the second involves tireless almost frantic sucking
behaviour. These behaviours are challenging to anybody, let alone parents
who are also dealing with their own substance use issues at the same time.

Parents report feelings of confusion and incompetence when they can't
console or comfort their babies. While overfeeding in response to the infant's
mixed signals, can lead to colic and other tummy upsets and a worsening of
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the baby's symptoms which places even more stress on the parent infant

There is also a less obvious withdrawal syndrome that presents as abnormal
sleep patterns. This is easily attributed to other causes and may be missed
altogether, although it is likely to persist for quite a long time and cause
severe stress for both parents and child.

Even if these extra complications do not occur, the extra stresses that
accompany the arrival of any new baby, can easily become unmanageable in
families already coping with the stresses of a lifestyle which includes
substance use.

Particular issues relating to infant withdrawal include:

   •   Infant's symptoms can range in severity from almost imperceptible to
       convulsions, vomiting and a continuous high pitched cry
   •   In public hospital nurseries a scoring system that allocates different
       points to different symptoms and severity of symptoms is used to
       determine whether the baby is admitted to the neonatal nursery for
       observation or to the neonatal intensive care unit
   •   Babies may be given phenobarbitone for symptoms of withdrawal. This
       is often commenced in hospital and then gradually withdrawn after
       discharge home.

Parenting issues

As is well known, the first few months of parenting are difficult for all parents.
Without appropriate support, this particular group of parents often begin to self
medicate again to get through.

Studies on parenting skills and attitudes of families where parents have drug
and alcohol issues consistently agree that while this group of parents have
significant emotional investment in the welfare of their children they
demonstrate a more intrusive and threatening style of parenting.

This parenting style is known to lead to attachment disorders, and, while
recognising the relationship between attachment and later behaviour is not a
strictly linear one, this outcome is of some consequence particularly in this
group of children who are likely to be already suffering developmental deficits.
Since it is generally agreed that poor attachment represents a developmental
context that makes later difficulties more likely to occur in children.

Risk factors

Parental substance abuse was one of the earliest identified risk factors for
child abuse and neglect, but as Tomison noted in a National Child Protection
Clearing House discussion paper on child maltreatment and substance abuse,
"while there is clearly a substantial associative relationship between
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substance abuse and child maltreatment as a whole, researchers have yet to
fully determine the extent of the relationship between child maltreatment and
substance abuse" (p2, 1996).


In the early intervention programs, neglect, both physical and emotional, has
been observed to be the main risk factor for children in families where parents
have substance use issues.

This neglect has come to be thought about in these programs as stemming
from the parent's inability to make a space to think about their child's needs.
This inability is caused, in part, by the same issues as non substance abusing
families eg: parents' own history of abuse, socio- cultural stresses etc., but is
exacerbated by issues specific to substance abuse such as:

   •   The often chaotic lifestyles and social instability where any routine is
       around picking up drugs not the needs of an infant
   •   Physical symptoms of hanging out or the blunting of feelings while
       using which means that parents are emotionally unavailable to their
       infants for much of the time.

This group of parents is repeatedly observed to have trouble balancing the
needs of their infants with their drug use. Without appropriate support, the
pattern that has been observed in the early intervention programs is one of an
initial, relatively successful compromise between the two, followed by a
gradual escalation of drug use as the stress builds up, accompanied by
lessening ability to meet the developmental needs of the baby.

The developmental needs of infants

In normal development, babies learn about the world from their interaction
with their main carers. When parents are attuned to their baby they reflect and
extend on what the baby may be feeling.

Parents with substance use issues however, often have inconsistencies and
incongruence in the parental response such that the infants' expectations of
themselves and others, which develop in the context of those earliest
relationships, become distorted.

To consider the effect on infant development of substance using parents it is
useful to review some of the basic requirements of infants to enable them to
meet their developmental challenges in the first twelve months. Sroufe's Self
Regulation model is useful for looking at this.

According to this model the newborn baby's developmental issues are around
motor and state control. To facilitate this parents need to be able to tune in to
their child and respond in a synchronous way while helping the child deal with
environmental stimulus. As discussed above, there are often extra issues
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around this if a baby is withdrawing and difficulties are exacerbated if parents
are hanging out for drugs or have blunted affect due to substance use.

One to four months of age

Between the ages of one and four months babies need regular routines
including periods of deep sleep and quiet alertness. Mothers with substance
issues and without other support find it extremely difficult to provide a regular
routine for their baby or assist their child to manage their states.

Four to six months of age

Between four and six months infants are meant to be learning to manage
tension, babies at this stage become easily frustrated and often want to be
carried around a lot. Mothers who are dealing with their own tensions around
substance use are usually unable to facilitate this stage finding it most

Later months

In the later months, establishing an effective attachment relationship becomes
most important. Mothers need to be able to tolerate clinging behaviour while
supporting the search for independence. This is a time when night waking and
difficulty with settling becomes apparent again and again parents with their
own stress around substance use are less able to tolerate the behaviour or
facilitate their child's development.

Extra considerations in assessing infant risk in families with
substance abuse issues

There are some additional conditions in assessing infant risk in families with
substance abuse issues:

   •   Is there a supportive person, who is not involved in drug or other
       substance use, monitoring the child?
   •   Is there a deterioration in the care of the child when the parent is
   •   Is the environment adequate (instability of accommodation, ability to
       pay bills, enough food, warmth, adequate clothing)?
   •   Are children adequately cared for while parents are picking up drugs
       and/or affected by substances?
   •   Are parents aware of risks to their infant associated with their drug
       taking (passive smoking, contact with members of the drug culture)?
   •   Is there a positive social network (or does it revolve around using and
       the drug culture)?
   •   Are the parents willing to accept help?
   •   Do parents place their own needs for substances ahead of their child's

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Responses to a needs assessment

In October 1997, the Early Intervention programs completed a Needs
Assessment Report of families with young children where parents had
substance use issues.

Responses in the Needs Assessment survey, of both parents with drug and/or
alcohol issues and professionals currently involved with them showed that
intervention with this group of families needs to involve at least three things:

   1. Helping parents understand the effect of drug use on their ability to
   2. Supporting parents to adequately meet the developmental needs of
      their children in the context of parental issues of substance use.
   3. Investigating the consequences for children of being raised in a family
      where parent/s have substance use issues.

Case work

While some literature deals with the effects on young children of growing up in
a family where parents are dealing with drug and alcohol issues, little is
written about the kinds of support or interventions from which these families
might benefit.

Most studies agree that many substance using parents have experienced
abuse in their own childhood and drug/alcohol use may be a way of masking
the effects of this.

In the early intervention programs substance use is often seen as, in part, self
medicating against fears of the effects of recollections of abusive childhood
experiences. These factors mean that work with these families needs to be
able to offer the opportunity to work on parents' own childhood issues when

When this can happen parents are able to make changes which mean they
become more consistent in their responses, and more emotionally connected
to their infant. (Of course this intervention is only positive when a parent has
indicated their readiness to be involved in this way).

The parent-infant relationship

Since an infant's development, including attachment behaviours, proceeds
regardless of the quality of the parent-infant relationship work in these families
encourages and supports parents to interact as positively as possible with
their infant.

In home visits case workers help parents tune in to their infant by, for
example, pointing out what their infant seems to be finding pleasurable or not

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pleasurable. The case worker also discusses with parents the meanings of
different infant behaviours, thereby helping them to decide on appropriate

By explaining sleep patterns and perhaps demonstrating wrapping
techniques, workers support parents in assisting their infants to regulate sleep
as well as help parents to feel more competent. If parents agree, interactions
may be videoed and discussed later to help parents think more about what is
happening between them and their infant.

Much of the worker's time is spent helping parents set up as predictable an
environment as possible for the infant, so routines are planned, regular sleep
patterns and meal times are encouraged and external supports are brought in,
when necessary, to support this.

Parent issues

The experience in the early intervention programs that many parents in this
client group have their own issues around abandonment and rejection means
that many of the normal behaviours of withdrawing infants can lead to real
difficulties in the parent infant relationship.

Acknowledging and explaining the causes of this behaviour in their infants as
well as talking about the feelings this behaviour produces in parents has been
found to have positive outcomes both in terms of the child's development and
parental confidence and involvement.

Fears and stigmatisation

Current clients in the early intervention programs as well as parents surveyed
in the 'needs assessment' conducted out of these programs, repeatedly refer
to their feelings of stigmatisation and fear of losing their child to 'the welfare'.

This means that they find it very difficult to access normal community services
such as early childhood nurses, playgroups, childcare, Department of Housing
etc., for fear of the reaction to their drug use and possible notification.

As well they are often estranged from their usual support systems. A home
visiting service is often the only way to support these families and issues of
engagement and developing trusting worker client relationships are
paramount. Issues of confidentiality and referral to statutory departments must
be discussed from the beginning of contact.

Multiple agencies

There are often many agencies involved with these families, (for example one
early intervention client family had contact with; drug and alcohol counsellors
for both parents. probation officers for both parents, foster care workers,

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speech therapist, paediatrician, Department of Community Services and a
community centre where a parent is doing community service).

However, families report that the information which they receive from these
agencies feels fragmented. Home visiting services like the early intervention
programs are not only more likely to be accepted into the family, but are also
able to get a more holistic picture of what is happening for a family. This
enables workers to help parents think through their child's needs for health
care, social contact with other children etc while also assessing parental
ability to meet these needs.

Workers in the program are able to transport and support families in their
contacts with other agencies which means that they are not only experienced
by the parents as being helpful but that they are more able to be sure the
needs of the child are being met.

Conclusion - The challenges in this work

The challenges in this work are similar to those in all infant parent work:

   •   Keeping the child at forefront of mind in midst of parental chaos and
   •   Continuing to try to see things from the infant's perspective when the
       child is actually nonverbal and therefore requires more of a worker to
       understand what is happening for them
   •   Antenatally, helping parents think about the baby, help it become real
       in their mind
   •   Non judgemental attitudes
   •   Dealing with underlying psychological issues so that they don't get
       projected onto the infant and in this group, so that relapse into drug use
       might be prevented.

For further information

Contact: Executive Strategy Unit
 Phone: 61 2 9339 8038
   Fax: 61 2 9360 2319

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