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1.4.12 Substance Misuse: Guidance for Social Workers and Substance Use Screening Tool (SUST)

RELATED READING

This chapter should be read in conjunction with Hillingdon SUST - Substance Use Screening Tool.


Contents

  1. Introduction
  2. Significance of Substance Misuse
  3. Policy and Protocols
  4. Definitions
  5. Expectations of Social Work Staff
  6. Child Protection Cases
  7. Looked After Children/Young People

    Appendix 1: Classification of Illegal Substances


1. Introduction

Purpose and Focus of Guidance

This guidance is intended to assist Children and Families staff to implement the agreed policy intentions of Hillingdon's Drug Action Team (DAT), of which Social Services is a key member.

The focus of this guidance is those:

  • Children/young people who are `Looked After'; and
  • Children whose names are on the child protection register and who have parents/carers with substance misuse problems;
  • Children and young people who are assessed as being in need.

The remainder of this document provides for practitioners:

  • An overview of why substance use/misuse is of significance to child protection/child care work;
  • An indication of the local context insofar as it was revealed by the work completed by CAE;
  • The collective policies (i.e. values, principles and intentions);
  • The inter-agency protocol agreed between members of Hillingdon's DAT (i.e. binding multi-agency agreement specifying respective roles and responsibilities);
  • Definitions of substance misuse to be applied by staff;
  • A summary of the actions expected of staff at specified times in undertaking work associated with child protection or child care planning.


2. Significance of Substance Misuse

National

Levels of drug and alcohol use by young people in the UK are amongst the highest in Europe and for some; leisure and use of drugs and alcohol may be synonymous according to Boys et al 2000.

A key Government objective with respect to drugs is to reduce the use of Class A drugs and the frequent use of any illicit drugs amongst all young people under 25 years of age, and especially by the most vulnerable groups.

Hidden Harm (Advisory Council on the Misuse of Drugs 2003) indicates that 200,000 ­ 300,000 children in England and Wales have one or both parents with serious drug problems, excluding alcohol i.e. approx. 2-3% of children under 16.

The inquiry highlighted that parental problem drug use can and often does compromise children's health and development from conception onwards. Adverse consequences are typically multiple and cumulative and may include early substance misuse for the child her/himself.

The risk of harm to the child may be reduced by effective treatment and support for the parents and other factors, including regular attendance at a supportive school.

`Taking care with drugs: responding to substance misuse among looked after children' (DH / Drugscope 2002) reports on research which suggests that for looked after children:

  • Their substance taking is greater and starts younger than for young people in the general population (Ward 1998);
  • They are at increased risk of abusing `solvents' (Worley 2001);
  • Those who are excluded from school and are offending report the greatest level of substance taking (Melrose and Brodie 2000);
  • Alcohol and solvents are the substances most likely to be abused by looked after young people (Worley 2001).

Addaction's users survey 2004 (see addaction website) showed 20% of respondents looked after in childhood, with drug use starting at an early age (13 years). This was first perceived as problematic at 17 with help sought much later, typically 27 years.

In the light of the above survey, it is then important that local policy and practices aim to reduce delay in recognition of substance misuse problems and consequently in seeking help and support.

Local

The results of a snapshot survey administered by CAE during May 2004 (concerning the 518 children who had LAC reviews held between 01.11.03 and 30.04.04) suggested, with respect to Hillingdon's looked after population:

  • 5.2% of looked after children had substance misuse problems recognised by the child, or carers or professional (27 children);
  • The substance misuse problems identified were cannabis (12 children), tobacco (7 children), drug combinations (6 children) and alcohol (2 children);
  • A further child was suspected, but not acknowledged as having an alcohol problem;
  • 15 children (3%) have parents who misuse substances and this was a major factor in their looked after status.

The results of that same exercise with respect to children whose names were on the child protection register in December 2003 indicated that 27% (32 of 120 children) had parents/carers with substance misuse problems.

No aggregated information was available with regard to children placed out- borough or about the misuse of substances by children whose names are on the register.

Anecdotal evidence suggested that substance misuse was probably far less prevalent amongst those unaccompanied asylum seeking children (many of whom have been placed outside of the borough) than amongst local peers.

The results of the above work need to be treated with considerable caution because there:

  • Was difficulty in obtaining accurate information without recourse to individual files;
  • May have been significant variation in the recognition of substance misuse problems, depending on knowledge, training and personally held value systems of individual chairs of conferences and reviews.

Nonetheless, the results offer the best available description of the current local context within which local agencies need to formulate policy and practice responses.


3. Policies and Protocols

The policies and protocol agreed by DAT recognise that:

  • All professional practice must be consistent with relevant legislation e.g. Family Law Reform Act 1969, Children Act 1989, Data Protection Act 1998, Human Rights Act 1998, Crime and Disorder Act 1998 as well as Common Law with respect to consent to treatment, confidentiality and information sharing;
  • Each agency has its own primary role and priorities;
  • Shared policies and an agreed protocol represent an attempt to define and promote practice, consistent with individual agency needs which serve to support the achievement of government's expectation of the professional network.

The expectations described below are additional to any described in the London Child Protection Procedures for children `suspected to be suffering or likely to be suffering significant harm' i.e. the threshold for initiating enquiries under s.47 Children Act 1989.

Policy Agreed by all DAT Agencies

All relevant agencies are committed to the following:

  • In addressing relevant events and circumstances, the interests of the individual child will be the first, though not the exclusive consideration;
  • The welfare of the individual child will be best served through early identification of substance misuse and provision of co-ordinated multi- agency support;
  • Each agency will develop an incident management procedure relevant to its own setting/s to make expectations of individual staff clear;
  • Information exchange will (subject to any explicit legal or policy constraint or decision about an individual) be maximised in an attempt to achieve synergy of effort across all relevant agencies;
  • Decisions about confidentiality must include consideration of risks to both the individual child involved in the substance misuse and potential harm to others in the community;
  • Agencies will commit to a programme of multi and single agency training (mandatory for those staff/carers identified as relevant) intended to provide sufficient knowledge, confidence trust and willingness amongst their staff to implement this policy and its associated protocol;
  • Each agency will routinely screen all young people identified as vulnerable for their substance related needs, using the Hillingdon multi agency substance use screening tool (SUST). Staff should then initiate tier 1, tier 2, or tier 3 follow up intervention, based upon the needs indicated by the screening score;
  • The translation of these organisational commitments into local professional practice will be monitored and formally reviewed by the DAT 12 months after relevant agencies confirm to the DAT, that procedures to enact these intentions are in place.

Protocols

All agencies

So as to maximise consistency and add value to the work of individual agencies, the following commitments apply to all agencies.

In dealing with an individual child/young person about whom there is concern relating to suspected or proven substance misuse, the following issues (in addition to any arising from the primary role of the agency concerned) will be considered by all agencies:

  • Is it likely that another agency will be able to offer helpful information and/or advice/ treatment or support?
  • What are the child/young person's wishes/feelings?
  • Whose consent may be required to seek such information?
  • Do the circumstances justify not seeking such consent and/or overriding a refusal of young person or a parent who has parental responsibility?
  • Is there a possible professional duty to report an incident or concern to another agency?

Children and Families

Reflecting legal obligations and expectations of the DH / DFES and Hillingdon Council with respect to looked after and children in need, Children and Families will also ensure that:

  • An exploration about substance use should take place with all children who are assessed and the Hillingdon SUST - Substance Use Screening Tool is used during the Assessment of all young people over the age of 12 where there are concerns that substances are being used;
  • The substance use screening tool is used every 6 months with all Looked After Children 12 years and over or younger if substance related concerns exist;
  • Statutory reviews of Looked After children and health assessments must explore issues related to substance use and ensure that the SUST has been applied;
  • A referral for tier 3 services (specialist team) is made if/when such a need is recognised and agreed by the young person;
  • In liaison with education services and Healthy Hillingdon, looked after children and those whose names are on the child protection register receive tier 1 educational input and that alternative provision is offered where this has been missed;
  • The immediate caregiver has been provided with sufficient training about recognition of concern, clear advice about incident;
  • Management and the requirement to record and report all relevant information to the case accountable social worker;
  • (In the case of looked after children) that the personal education and personal health plans do, or will reflect any suspected or identified need arising from young person's substance misuse;
  • The parent or other person with parental responsibility has been effectively involved (unless to do so is agreed by a supervisor/manager likely to increase any risk of significant harm);
  • The police have been informed without delay of any suspected or alleged crime;
  • Workers from drug and alcohol services been invited to any relevant strategy meetings and child protection conferences (in accordance with London Child Protection procedures)
  • Substance misuse is added to the monthly review monitoring forms completed by chairs of looked after children reviews and child protection conferences and during the formulation and review of pathway plans for care leavers;
  • A multi-agency support strategy is implemented for those children agreed to require it.


4. Definitions

Substance Misuse Amongst Children and Young People

For the purposes of application in practice by all agencies, the definition of substance misuse will be:

  • Consumption or supply by a child/young person of all Class A, B and C drugs (see Appendix 1: Classification of Illegal Substances); and/or
  • Consumption of tobacco and/or alcohol and/or volatile substances to a degree believed likely to adversely impact on her/his or others' health, quality of life or future life chances.

Substance Misuse Amongst Parents/Carers

With respect to parents/carers, the threshold for defining `misuse' is `consumption of any substance which has been found by a court or been professionally assessed to impact upon that individual's parenting to the extent that the child may suffer `significant harm'.

Four Tier Model of Provision of Substance Misuse Services

The Health Advisory Service introduced the following 4 tier model which has been used in the organisation of Hillingdon's services and which should inform and facilitate staffs' categorisation of need and formulation of responses and referrals:

  • Tier 1: Universal Drugs and Alcohol Education and prevention: basic drugs facts and advice, information about sources of help and referral to more specialist services. Key providers include; primary and secondary schools, youth and community group leaders;
  • Tier 2: Targeted Drugs and Alcohol Education and prevention: specific, targeted substance related education and prevention advice, information and associated interventions, including skills development and harm minimisation, health advice and generic emotional support. Key providers include generic youth oriented service providers with a sound knowledge of drugs and skills in working with young peoples problems, including GP's youth workers, Connexions, children and family social workers;
  • Tier 3: Specialist Substance Misuse Treatment and Care: Young peoples specialist drug and alcohol treatment and care, complex casework rqui4ring multi disciplinary team work, substitute prescribing etc. Key providers include specialist youth dedicated substance misuse treatment services, CAMHS, specialist foster carers, residential staff, YOT's Social Workers;
  • Tier 4: Intensive/In patient Substance Misuse Treatment: Specialist intensive treatment interventions for young drug and alcohol miss-users with complex needs (de-tux, rehab, dual diagnosis) Key providers include specialist youth dedicated substance misuse treatment services CAMHS, specialist foster carers, intensive after care.


5. Expectations of Social Work Staff

General

Staff to whom this guidance is circulated should familiarise themselves with its contents and may wish also to consult the report from which it was developed `Substance Misuse: Vulnerable Children and Young People ­ Proposals for Adoption by Hillingdon DAT' 02.12.04.

The definitions of substance misuse provided above should be taken as the benchmark for evaluation of individuals/family needs.

Practice consistent with agreed policy

So as to ensure sufficient knowledge and confidence, staff should also take advantage of the training opportunities being provided in 2005.

Whilst professional judgement will always be required and each case considered on its merits, staff are expected to practice in a way which is consistent with the policy commitments made by members of the DAT and reproduced above.

For example, decisions about confidentiality must include consideration of risks to both the individual child involved in the substance misuse and potential harm to others in the home / unit or community. See SCODA Policy guidance for drug interventions regarding young peoples competence to ask for and consent to treatment without the knowledge of parents or carers.

Any decision to depart from the expectations laid out in the agreed policies and protocols would need to be authorised by a manager and be recorded within relevant file/s.

Staff should also actively encourage carers with whom they have placed a child/young person to attend relevant training and development opportunities.

A proportion of children/young people living at home as well as those being looked after will be without schooling.

Where the above situation lasts more than about a week, social workers should consider what measures might reasonably be taken to address (in addition to lost academic opportunities) the need for education/support to minimise risks from substance misuse.

Assessments

Consistent with the policy aim of early identification, all assessments should address the possibility of substance use and misuse by the parent/carer or the child her/himself.

Where misuse is explicitly suspected, clear from the situation, or when an individual acknowledges it, the SUST tool (available in each relevant location) should be employed.

In formulating assessments, reference should be made to the agreed protocol, and the likely benefit of information-sharing across agencies (with, or when justified, without consent) to ensure a co-ordinated response.

Given the rapidly changing circumstances of young people in need and in the care system, such assessments of need will often need to be repeated routinely as well as in response to specific incidents.

Use of supervision

Both in work associated with s.47 enquiries, implementing child protection plans and in direct work with looked after children, social work staff are likely to be faced with significant dilemmas and the need to complete important risk assessments.

In addition to any general guidance offered by this document, full use must be made of formal supervision and a clear record made of decisions reached therein.

Sorted staff can be consulted for professional advice.


6. Child Protection Cases

The policies, protocols and guidance in this document represent Hillingdon's response to these expectations.

Both the immediate and longer term risks associated with parental/carer misuse of alcohol, drugs etc need to be recognised and distinguished in work associated with s.47 enquiries and the implementation of child protection plans.

It is especially important that the cumulative affects of alcohol/drugs misuse are recognised when ongoing attempts are being made to support a child within her/his own family.

Social workers should also bear in mind there is evidence that the probability of substance misuse by the children of adult misusers is raised beyond what it might otherwise be.

Reports to conferences

Conference reports should reflect what is known or suspected about parental substance misuse and/or substance misuse by children/young people.

The SUST tool offers the means of quantifying and assessing substance use or misuse profile of each young person.

Conference Chairpersons already monitor the extent and nature of substance misuse amongst parents/carers and will expect social workers to be able to report upon what they have established in their work with, or enquiries about a family.


7. Looked After Children/Young People

Given the additional vulnerability of those looked after, and results of Addaction's research indicating individuals may be unable/unwilling to recognise the problem until some years later, it is critical to be alert to the possibility of substance misuse, even when its existence or significance is minimised by individuals and/or their family.

General

Staff should be aware of the need for substance related education, information and advice for all looked after children/young people, as well as the need to ensure adequate screening to identify more individual needs.

National Minimum standards for children's homes introduced in 2002 represent explicit expectations of:

  • Advice and support (standard 12.4);
  • Written guidance on health promotion including alcohol, smoking and other substances (standard 12.5);
  • Staffs' active discouragement of smoking, consuming alcohol, solvent and illegal substance abuse (standard 12.6).

Case accountable social workers should work in collaboration with residential staff to achieve these aims.

The Substance Use Screening Tool SUST should be applied to all Looked After young people aged 12 and over on admission to care and at six monthly intervals, or sooner if required. It will normally be incorporated into ongoing assessments e.g. Assessment and Action records. (note the age of 12 is a minimum requirement, depending upon the young person it may be appropriate to apply to children as young as 8 years if substance use is suspected or known about.

A&A records

Full use should be made of the A&A Records as practical instruments for regular exploration and recording of educational and health needs, including those arising from substance misuse.

It may often be more appropriate for the social worker to arrange that a foster carer or residential worker who has a positive relationship with the individual jointly complete the record.

Health assessments ­ in borough

Social workers should also actively encourage children/young people and their carers to make full use of the routine formal health assessments, currently undertaken for locally placed children/young people by a school nurse and ratified by Hillingdon Clinical Commissioning Groups (CCG’s) medical adviser before its submission to the case accountable social worker for inclusion in the file.

The form used by the nurse for recording this health-related information is currently being amended to better reflect the detail offered by the SUST tool.

In the case of teenagers, a significant proportion of whom decline the offer of annual health assessments, social workers should consider in supervision, the extent to which such a refusal should be accepted at face value, any grounds for particular concerns e.g. serious substance misuse and the possible need to negotiate a referral to a specialist source of assessment or support e.g. `SORTED.'

The summary section of the relevant age-related A&A Record should be presented at statutory reviews, where the Chairperson will be:

  • Noting the information relating to substance misuse with respect to its significance to the individual; and
  • Aggregating it to build up an ongoing profile of the needs of Hillingdon's looked after population.

Whilst anecdotal evidence suggest that the prevalence of substance misuse amongst unaccompanied asylum seeking children may be lower than indigenous Hillingdon children, the possibility should still be considered and (where necessary) an interpreter engaged to assist in the exploration of the issue and in the formulation of any required responses.

Health assessments - out borough

For those children/young people placed out borough, the format of routine health assessments will differ according to the Clinical Commissioning Groups (CCG’s) area in which they are placed.

Social workers will need to identify (via Hillingdon Clinical Commissioning Groups (CCG’s) and/or the current carer) the source of such assessments and ensure sufficient information is sought and recorded with respect to substance misuse.

A disproportionate number of unaccompanied asylum seeking children (UASC) are currently placed out-borough and the disadvantage described immediately above is compounded by a likely absence or insufficiency of medical records as well as by inadequate command of the English language.

For those young people, social workers should ensure by means of direct liaison with relevant local services and/or via the carer that any specific need arising from substance misuse are not overlooked.

Health action points

Care Plans and (in the case of eligible, relevant and formerly relevant young people) Pathway Plans should be modified to reflect the health assessment action points emerging from health assessments.

The achievement of agreed actions should be formally reported upon at subsequent statutory reviews.

Incident management

It is critical that all relevant information about a child/young person, including any known or suspected substance misuse is passed on to a substitute carer (in a foster home or residential unit).

Where the misuse of alcohol, drugs or other substances is thought likely to result in acute crises, a risk assessment and strategy for incident management must be discussed, recorded and agreed (preferably in collaboration with the child/young person).

Monitoring returns

In March 2004, information was supplied to the Government Office for London (GOL) by Hillingdon's Clinical Commissioning Groups (CCG’s) and included best available estimates of the numbers of:

  • Vulnerable young people;
  • Those assessed as needing targeted prevention;
  • Those receiving targeted prevention;
  • Young people assessed as needing a drug specific intervention;
  • Those receiving a drug specific intervention.

Looking ahead, social workers should be aware that in addition to their monitoring of individual needs, the Government Office for London has defined some `key performance indicators (KPI) which seek to collate and evaluate the following:

  • Number of looked after children receiving drug education, including harm reduction, as a % of all such children (YP KPI 2a);
  • Number of looked after children receiving early intervention as a percentage of all those looked after (Tier 2) YP KPI 3c).

From April 2005 Children and Families will probably be required to report direct to GOL (though the precise definitions may be amended before that date).

In consequence, staff should anticipate being asked at reviews which of their clients has had substance use screening and which have `received drug education (including harm reduction)' and which have received early intervention'.


Appendix 1: Classification of Illegal Substances

The Misuse of Drugs Act 1971 as amended

  Class A Class B Class C
Principal Drugs included Opium Heroin/methadone Cocaine/Crack LSD Ecstasy Magic mushrooms (processed) Class B drugs prepared for injection Amphétamines Barbiturates Codéine Mild amphetamines Anabolic steroids Benzodiazepines (minor tranquillisers e.g. temazepam, diazepam) Some stimulant, anti-depressant and anti-obesity medicines Cannabis resin Cannabis oil (derived from herbal cannabis) Cannabis herb
Maximum penalties for possession 7 years and/or a fine 5 years and/or a fine 2 years and/or a fine
Maximum penalties for trafficking, supply or production Life imprisonment and a fine 14 years and/or a fine 5 years and/or a fine
  • The government is proposing to increase the maximum penalty for trafficking/ supply/ production of all Class C drugs to 14 years;
  • GHB (gamma-hydroxy butyrate) is under consideration to be added to the Misuse of Drugs Act as a Class C drug;
  • Magic mushrooms are currently not illegal to possess or eat in their fresh raw state, but it is an offence to make a preparation from them such as heat, or freeze dry them or cook them. In which case they are then classified as a Class A drug and carry the maximum penalty for possession;
  • The above table refers to some commonly available drugs. It is not a complete list of controlled drugs.

End