Informing a strategic plan for children of parents who use substances within a defined community Catherine Comiskey and Karen Galligan Date 24h /10/2017 Authors declare no conflict of interests.

Introduction There is no current methodological approach or estimates on the hidden numbers of children with a parent who uses substances within a defined community region. There is concern for these children, and with the lack of effective interventions. In addition, those children who manage life under the supervision of a parent who uses drugs and alcohol should receive coordinated support from appropriate services available based on their individual needs.

Aims and Objectives To provide a literature review of the most effective interventions that may match the needs of children, parents and families in the region. To provide a brief estimate of the prevalence of children impacted by parental substance (including alcohol) misuse. To provide a consultation with a) service providers, b) family members and c) people who use services to assess their views. To deliver a comprehensive methodological framework and report, which will inform the development and implementation of a defined community strategic plan

Study Methodology A systematic search of the literature Benchmark multiplier method to estimate prevalence using existing data sources A consultation survey of service providers on risk, protective factors and enablers Semi-structured interviews on needs with key service providers Semi structured interviews on needs with people who attend services for substance use (see Galligan and Comiskey session 4) Focus groups on needs with family members (see Galligan and Comiskey session 4)

Data analysed Detailed review of existing data from the region on drug and alcohol use and treatment (including regional results from the EMCDDA general population survey and Treatment Demand Indicator (TDI)) Detailed audit of local services data Consultation survey with 16 different services in the region Findings from 7 service provider interviews 7 x 45 minutes Findings from 16 parent interviews 16 x 45 minutes Findings from 7 family members in 2 focus groups each for one hour Approximately 400 pages of transcribed text from 19.25 hours of audio interviews

Key Findings

Results – prevalence of adults using illegal drugs - Benchmark Data from the 2011 census was combined with the prevalence rates on any illegal drug use in the past year from the EMCDDA/NACDA 2010-11 general population survey. Combining these data sources provided estimates of numbers of persons aged 15-64 years using illegal drugs in the region in the last year. Details of the numbers for each county in the region were provided.

Results – Adult to child multiplier from local services audit Data from a recent study on the numbers of children among adults attending services, Galligan and Comiskey (2016) found that for every unique client identified in the local services, there was just under one child, with an exact ratio of 1 client to 0.88 children, (Galligan and Comiskey, 2016).

Results: Prevalence of children with parents who used any illegal substance last year Applying the benchmark multiplier method, provided an estimate of 16,868 children at potential risk of being impacted by illicit drug use. Using the Census 2011 data for children under the age of 18 in the region, this represented 13% of children at risk of being impacted by illicit drug use.

Prevalence of children with parents who received treatment for substance uses From the TDI 2014 data for the region and applying the method gave a minimum estimate of 2558 or 1.98% of children potentially impacted by parental substance use In summary these numbers show that a minimum of 2% (n=2,907) children were estimated to have a parent receiving treatment for substance use and a maximum of 13% children (n=16,868) were estimated to have a parent who used an illegal drug in the last year in the region.

Prevalence of children with parents who use alcohol Also, available however are prevalence data for people who scored scores of alcohol dependency on the EMCDDA/NACDA survey. It was found that 7% of 18-64 year olds indicated higher dependency on alcohol defined by three positive RASP scores. Using the benchmark multiplier approach again found that that as many as 18,809 children may have a parent with alcohol dependency in the region. T his would imply that 14.5% of children may have a parent who is alcohol dependent.

Results Service Provider Interviews- Risks

Service Provider Interviews- Protectors

Service Provider Interviews- Enablers

Service Provider Interviews- Other items

Conclusions and next steps Findings from the literature review, the prevalence study, the parent, grandparent and service provider interviews and surveys were used to inform a draft strategic plan. Three over arching goals were targeted at the level of the child, the parent and supporting family and the service provider and system. In a large community workshop key stakeholders reviewed these goals, set priorities and finalised the strategic plan.

Figure 1 : Strategic themes for the region Children Increase protections that lessen the impact of hidden harms to children in the region Parents and Families Improve parent effectiveness and family supports within challenging circumstances Services and Systems Increase collaboration across services and improve communication and information

In Conclusion: Strategy Implementation Comiskey and Sheehan (2017) reiterate that implementation is a process rather than an event and that there are distinct phases of implementation. A number of models point to four stages. In the Active Implementation Framework (Fixsen et al. 2005) and these are : exploration; installation; initial implementation; full implementation.

Thank you Catherine.Comiskey@tcd.ie Twitter @ComiskeyCath

TWELVE STEP METHODOLOGICAL FRAMEWORK FOR HIDDEN HARM ESTIMATION Expert advisory group meet to agree details of the process. A draft audit form for recording and counting unique adults across services is presented and agreed. Step 2 Each local service within the agreed defined boundary and reference time frame completes the approved audit form Step 3 Anonymous audit forms are returned to the study team, duplicates are removed. Benchmark one, and the enumeration of adults known to use illegal drugs or alcohol and known to services is completed. This benchmark provides a minimum estimate of adult prevalence for the region. Step 4 The number of children known to services among these adults is counted after the duplicated adults are removed. Estimate one on the minimum number of the number of children is provided. Step 5 The ratio of known adults to known children is computed, and expressed in terms of numbers of children per one adult, the child to adult multiplier is derived. Step 6 The EMCDDA guided or similar, national general population survey on prevalence is accessed for data at the local level on any illegal drug use in the last year. Prevalence rates are applied to the local census data. An estimate of the prevalence of illegal drug use among adults is computed. Benchmark two is derived and defined as the number of adults using any illegal drug. Step 7 The child to adult multiplier is applied to benchmark two. Estimate two, on the number of children to adults in the general population using any illegal drug in the last year is derived. Step 8 The EMCDDA guided or similar, national general population survey on prevalence is accessed for data at the local level on dependent alcohol use in the last year. Prevalence rates are applied to the local census data. An estimate of the prevalence of dependence alcohol use among adults is computed. Benchmark three is derived and defined as the number of adults with dependent alcohol use. Step 9 The child to adult multiplier is applied to benchmark three. Estimate three, on the number of children to adults in the general population with dependent alcohol use is derived. Step 10 Local service providers are consulted on needs of children, parents and services in the region. Step 11 Estimates of prevalence are validated by the expert advisor group and results on needs are discussed and agreed. Step 12 An implementation and dissemination plan are devised and executed with the expert advisory group.

Figure 2: Strategic priorities for the region Children Priority 2: Pilot and roll out a targeted intervention for the most vulnerable children, that addresses child resilience, psychological and mental well-being including trauma, stress, anxiety, burden and fear. Priority 4: Pilot and roll out a targeted intervention for the most vulnerable children that addresses enabling school attendance and performance. Parents and Families Priority 1 :Pilot and roll out a targeted fully supported interventions for parents on effective parenting including anger management and dealing with domestic violence, coping skills and crime. Priority 6: Pilot and roll out a targeted support interventions for parents and supporting family members on raising awareness of services and liaising with social and other services for the care of children Services and Systems Priority 3: Provide clear information for families and services on how decisions are made in relation to children, their welfare, protection and care in the context of agreed thresholds. Ensure consistency and equity across services and systems on the information provided. Priority 5: Expand and increase interagency working by expanding and implementing key service level agreements within the interagency working protocol.