A window of opportunity for children growing up with parental substance-use problems

Do our service systems encourage children growing up with substance-using parents to report their situations and get support? This is a highly relevant question for countries and systems attempting to help people and families struggling with substance-use problems.

Two articles have raised concerns about children growing up with parental substance use in this issue of NAD (Tamutienė & Jogaitė, 2019; Tedgård, Råstam, & Wirtberg, 2019). One of the articles describes a qualitative study of children growing up with parental substance-use problems, selected from a population of “social risk families” from the statutory child welfare system in Lithuania. That study focused on how easy it is for children to report their experiences, and produced the following findings:

Affected children are in a tough situation psychosocially.

Fear makes it difficult for children to disclose their experiences at home.

The informal support network is very limited for many children.

Friends with similar experiences are highly significant, but affected children also fear telling friends due to being unsure of how they will react.

Schools often know about the situation but do not try to help.

The involved social workers focus on the drinker or substance user, rather than on the affected children.

Studies related to Nordic welfare-state contexts and treatment settings have found similar situations, with those children growing up with parental substance-use problems struggling in everyday life and lacking informal and professional support networks to address their needs (Itäpuisto, 2014; Ruud et al., 2015; Wangensteen, Bramness, & Halsa, 2018; Werner & Malterud, 2016).

There is increasing awareness about children growing up with parental substance-use problems. In the Nordic context, different policy initiatives have been introduced in recent years in attempts to improve this situation. The Swedish, Finnish and Norwegian governments now require all health professionals to support the children of parents with all types of illnesses, including problems with addiction and alcohol and other drugs (AOD) (Skogøy et al., 2018). The regulations deriving from the 2010 law in Norway require all health professionals to register children in the patient’s health record and assess the needs of these children and their families. This also involves having conversations with the parent about their children’s needs and offering help to the family by providing them with information and having conversations with the children. Furthermore, health professionals need to encourage parents to cooperate with other services in establishing the necessary support (Skogøy et al., 2018).

So has this change to the law made a difference for children growing up with parental substance-use problems? Ruud et al. (2015) examined whether these changes have led to an increase in family-oriented practices across five health regions in Norway. Several findings from that multi-centre study are in the process of being published, but some results are already available. Skogøy et al. (2018) concluded that the number of children registered in their parent’s health records has increased since the law change. Furthermore, health professionals scored highly for their knowledge and confidence in working with families and children, but at the same time reported moderate levels of family support and made few referrals. The health professionals also reported quite low rates of conversations with children of patients, with the average ranging from between zero and one over the past two months.

The increasing awareness is manifesting some positive changes, but the results from both Lithuania and the Nordic countries indicate that the services currently being provided to children are not sufficiently integrated. It is tempting to refer to the terms used by Hacking (1999): “making up people” or “making up kinds”. He used these terms to describe the process in which certain categories and ideas are inhabited in a social setting. There have been some policy improvements within the institutional matrix of AOD services in the Nordic context, including a stronger statutory obligation to register and follow up children. Children are emerging as a “kind” in AOD services. However, research indicates that working with children and families does not constitute a common practice of the relevant institutions, with the needs of children and families not being sufficiently addressed or “made up” in the way services are provided.

One of my former informants, a clinical director at an AOD treatment institution in Norway, described the situation in the following ways: “affected children have not been seen, because of the idea that AOD treatments can be reduced down to parts” and “service providers tend to reduce their understanding so that they can focus on their core mission”. It is particularly interesting that even when social workers are allocated to work with families, like in the Lithuanian study, the professionals focus primarily on the drinker or the substance user. The thought-provoking paradox is that the disclosure of parental substance misuse does not directly imply the disclosure of alcohol-related harm to children or that they will receive appropriate help (Tamutienė & Jogaitė, 2019). Moreover, similar conclusions can be drawn from the context of AOD treatment in Norway, with the scope of treatment narrowing down to the individual (Selbekk & Sagvaag, 2016).

I would like to quote one of the male informants in the study of Wangensteen et al. (2018), who is now 21 years old but has a background of living with parental substance-use problems:

People talk about the problem, but not of the consequences of the problem. I am one of the consequences of the problem. They keep talking about my mother: “Your mum is on drugs, your mum is off drugs, your mum is in treatment, your mum is in the process…”. I do understand their approach, but we never talked much about me.

In my view the consequences of the problem in this sense are also a part of the problem. So the question is whether we can widen our institutional understanding and better integrate children and families within the core mission of dealing with addiction and substance-use problems. Addiction and substance-use problems are more than what happens inside the brain and body of individual persons, since they also involve social and relational processes acted out in close relationships, support networks, communities and society that have to be taken into consideration.

It can be very difficult for children to disclose family “secrets” such as parental substance-use problems; the barriers are high and so working on lowering them is crucial. However, this commentary has focused on cases where parental substance use is reported and there is a connection between a family and the service system, either in the context of specialised care or local health and social services. These encounters represent a unique opportunity to reach out to children in these families, providing support to the children in their own right and as part of families. There is potential in utilising this window of opportunity to a much greater degree than currently – we know too much about the potentially harmful situations that children live in to look the other way.