Evaluation of the Children of Alcohol Dependent Parents programme innovation fund: full report

Q: 7. Next steps

The Children of Alcohol Dependent Parents programme is moving into its second phase, for which OHID is developing a strategy for implementing learning from the programme locally and across government. This includes looking at ways to: roll out key learning to new areas maintain and enhance provision in existing areas expand support to include families affected by parental drug misuse Through the £533 million drug strategy funding allocated to improving the treatment and recovery system in England, local authorities are now able to invest in interventions to improve their local treatment systems, which will be selected from a ‘menu of interventions’. Several interventions on the menu can be applied to children and families work. By local authorities investing their funding from the strategy in a unique programme of children and families work, it will: help to give children the very best start in life break intergenerational cycles of negative behaviours level up a range of health and social related inequalities save costs across the local health, social, education and criminal justice systems In addition, if local areas invest in such a programme, it will support them to meet many of the aims within the drug strategy. OHID is working with local authorities to encourage and support them to establish a new programme and enhance work in existing IF areas.

Question 1

1.  Introduction

Accepted Answer

This report presents the findings from evaluation activities carried out as part of the national evaluation of the Children of Alcohol Dependent Parents (CADeP) innovation fund (IF) programme across 9 local areas (spanning 13 local authorities) in England. The programme was evaluated by the Tavistock Institute of Human Relations (TIHR) in partnership with IFF Research between mid-October 2018 and March 2022.

This chapter starts by setting out the policy context, with reference to evidence of the issue and impacts of parental alcohol misuse (PAM), as well as parental conflict and recent policy responses to this.

The next section then presents an overview of the CADeP IF project and its main aims and objectives, before outlining the overall evaluation methodology for the national evaluation of the project and its links with the local evaluations. It also discusses some of the limitations of this evaluation.

The last section of this introduction (‘1.4 Report overview’) provides an overview of the rest of the report to signpost the reader to the different chapters and what they will cover.

1.1 Background

Alcohol misuse is a significant cause of premature mortality and morbidity in the UK. It contributes either wholly or partially to 200 health conditions that often require hospital admission due to acute alcohol intoxication or to the toxic effect of alcohol misuse over time. Aside from its effects on the individual, alcohol misuse also has a wider social impact, particularly on children and families.

It is estimated that there are around 120,552 alcohol dependent adults living with children in England, based on data from 2018 to 2019. Of these, around 21% were in treatment in 2020, indicating an unmet treatment need of 79%. Meanwhile, a considerable number of children are living with parents in households affected by alcohol and substance misuse. According to the Children’s Commissioner for England’s data on childhood vulnerability, there were 478,000 children living with an alcohol or drug dependent parent in 2019 to 2020. This is a rate of 40 children per 1,000 parents.

The substantial number of children living in households affected by drug and alcohol misuse is reflected in social service statistics. [Parental substance misuse features in up to two-thirds of childcare applications in which social services have concerns over the welfare of children. However, children affected by alcohol misuse are often classed as ‘in need’ rather than ‘at risk’. A lack of pre- and post-qualification training for social workers around substance misuse issues has been seen as potentially contributing to the underestimation of the risk to children where alcohol is present.

Another difficulty in estimating the size of the problem is the fact that children themselves may respond differently when parents are misusing alcohol, which makes the identification of children affected by parental alcohol use difficult without additional training. Girls are more likely to seek help, while boys more often come to the attention of services through their presenting behaviour – for example, through youth offending services, negative behaviour at school or non-attendance. Research remains very patchy with regard to the impact for specific groups, such as:

black, Asian and ethnic minority groups
children of prisoners
children cared for by others
children affected by foetal alcohol spectrum disorder (FASD)
the young homeless

This problem is compounded by the fact that policy responsibility for children affected by parental alcohol dependency spans several government departments, including health, education, communities and local government. At a local level, it spans adult treatment services, children’s social care services and public health. Primary responsibility for commissioning alcohol services in England was transferred to local authorities from primary care trusts in 2013 to 2014^{[footnote 1]}. While this shift was received positively by many in the sector, concerns have been raised that the breadth of responsibility and limited resources within public health departments may dilute expertise. Additionally, as they are managed locally, there are significant differences between areas across England in how many alcohol dependent people receive treatment.

1.1.1 The Impact of parental alcohol dependency on children

PAM has a multifaceted impact on children, which is complicated by that fact that it often co-exists with other problems. Affected families can experience a range of related issues, including:

physical and mental illness
parental conflict
domestic abuse
substance misuse

Regarding domestic abuse, a review of research on the link between alcohol misuse and violent behaviour indicated that violence can occur both in the context of intoxication itself, or during withdrawal from alcohol use. Furthermore, alcohol dependency can sit within the broader context of a general pattern of abusive behaviour. It can also negatively affect parental capacity, a factor in child maltreatment and neglect^{[footnote 2]}. Parental substance use was recorded in 39% of serious case reviews between 2014 and 2017, which are carried out when a child has died or has been seriously harmed. In 2019 to 2020, it was also reported that parental alcohol misuse was a factor in 16% of child-in-need (CIN) cases.

Nevertheless, the relationship between alcohol misuse and its impact on children is complex, and it is not directly related to either the overall level of consumption or styles of drinking. Lower levels of consumption may still be harmful, but not come to the attention of services.

The multidimensional effects of PAM create a complex combination of needs for the children involved. There are a number of studies demonstrating the impact that PAM can have on children. Attention to parental drinking has increased in recent years following several MPs campaigning to raise awareness of the issue. In 2018, the Parliamentary Office of Science and Technology summarised the harm of PAM as being linked to:

inconsistent and unpredictable parenting and social isolation, stigma, shame and guilt for children
negative impacts on children’s mental and physical health, including increased risk of obesity, eating disorders and attention deficit hyperactivity disorder, as well as hospital admissions and injuries
abuse and neglect
problematic drinking in adolescence and adulthood

1.1.2 The relationship between alcohol misuse and parental conflict

In line with the Early Intervention Foundation’s definition, parental conflict is understood as “conflicts that occur between parents/carers that are frequent, intense and poorly resolved”. Parental conflict is not domestic abuse, because there is not an imbalance of power and neither parent seeks to control the other or is fearful of the other. But similarly it can have negative impacts on children’s welfare.

While the effects of domestic abuse on children are better understood, new research is showing that parental conflict is also harmful to their wellbeing.

Some parental conflict is normal. However, where conflict is frequent, intense and poorly resolved, children are placed at a considerably higher risk of multiple adverse outcomes. These include anxiety, depression, conduct problems, academic failure, substance misuse, criminal behaviour, homelessness, self-harming behaviours and suicidality^{[footnote 3]}^{[footnote 4]}^{[footnote 5]}.

There is a growing interest in investigating the relationship between alcohol misuse and parental conflict at the level of policy and practice. The emerging evidence consistently points to a relationship between the two. Some longitudinal studies support the view that this association is causal – in other words, that alcohol misuse increases the incidence of parental conflict. That said, there is little evidence regarding how substance misuse does this (in other words, directly or indirectly through its contribution to other stressors). There is also evidence from a small number of studies for a reverse causal association: that parental conflict can result in the onset of alcohol and other types of substance misuse.

The majority of research into volatile relationships and PAM focuses on domestic abuse, particularly in the context of adverse childhood experiences (ACEs) and the so-called ‘toxic trio’ (an interaction of domestic abuse, parental substance abuse and parental mental health issues within the household)^{[footnote 6]}. Although the term is becoming increasingly contested, research has found that the ‘toxic trio’ interact with each other leading to a ‘toxic effect’, creating increased risks of significant harm to children.

Less is known about parental conflict and alcohol dependency in terms of the effects on children. Nonetheless, the evidence that does exist suggests that children affected by both parental substance misuse and conflict have complex needs, especially regarding mental health and wellbeing. There is some qualitative evidence that this increased risk is incurred due to the child’s heightened exposure to conflict (due to parental substance misuse). There is stronger, but mixed, evidence (in the same report) that the increased risk to the child is incurred through the combined impact of parental conflict and substance misuse on parenting practices and family functioning.

While the nature of the negative outcomes for these children is the same as for those in families experiencing either parental substance misuse or conflict alone, the same evidence as referenced above has also shown that children affected by both issues are more likely to display externalising and internalising behavioural problems.

Examples of externalising behaviours (directed towards the external environment or taking the form of outward behaviour) include:

aggression
conduct problems or disorders
violence
antisocial behaviour problems

Meanwhile, internalising behaviours (directed inwards, acting as a method of coping with stress through negative feelings directed towards the self) can include:

anxiety
depression
self-harming behaviours such as substance misuse

In terms of addressing parental conflict and PAM, a small, yet growing, body of research supports approaches that address parental conflict as part of alcohol treatment. For example, behavioural couples therapy (BCT) is recommended by the National Institute for Health and Care Excellence (NICE) for treating issues including alcohol dependency. Evidence also shows that, compared with individual-based interventions, participation in BCT by married or cohabiting drug and alcohol-misusing patients results in greater reductions in substance use, higher levels of relationship satisfaction, greater reductions in partner violence and more favourable cost outcomes^{[footnote 7]}.

Tackling both alcohol misuse and parental conflict together can also be beneficial for the children involved. For example, BCT has been shown to improve children’s functioning more than individual-based or couple psychoeducation and can lead to reductions in the number of children of substance-dependent parents with clinically significant psychosocial impairment^{[footnote 7]}.

1.1.3 The policy landscape and service provision

Treatment for alcohol dependence – if delivered according to best practice – has been shown to be effective and cost-efficient. However, only about 1 in 5 adults who could benefit from treatment actually receive it.

Some measures have been taken in recent years to address gaps in policy and service provision. For example, the absence of PAM in the 2012 alcohol strategy was rectified by subsequent guidance from Public Health England (PHE) on Developing local substance misuse safeguarding protocols (published in 2011 and updated in 2013) and the [Department of Education’s Working together to safeguard children statutory guidance (published 2013, and updated in 2015 and 2018).

The former highlights the importance of focusing on children’s welfare in situations of parental alcohol misuse, recommending a more co-ordinated, collaborative approach to support in this regard. The latter acknowledges that children may be at greater risk of harm or require additional help in families where the adults misuse drugs or alcohol, subsequently recommending that support is integrated into early help (Tier 2) support plans.

In 2016, the Chief Medical Officer published new guidelines on health risks from drinking, including advice on drinking during pregnancy. Meanwhile, the 2017 drug strategy recognises that approaches to tackling drug misuse also apply to alcohol misuse. Recommendations in this drug strategy, which were partially based on the findings from the Dame Carol Black independent review of drugs, are likely to benefit both those affected by alcohol and drugs.

At a local level, however, services remain highly varied. There are longstanding discrepancies between local authorities in how many alcohol dependent people are treated. Since 2013 to 2014, each local authority in England has been responsible for making sure their own community has access to alcohol and drug services. Local authorities generally do not directly provide the services themselves. Instead, they manage the process by ‘buying’ the services from another organisation, a process generally known as ‘commissioning’ or ‘procurement’.

The location of such services is varied. Some are commissioned as part of adult alcohol treatment services, but these services can only support children whose parents are already in treatment. Dedicated family services in this area are rarer and often provided by the voluntary sector rather than local authorities. Services are also provided by both national charities and smaller grassroots organisations, but most lack secure funding and the capacity to meet modern commissioning requirements.

Moreover, many local authorities have recently faced significant funding cuts, which has placed substantial pressure on services. This has had a particularly prominent impact on treatment possibilities for alcohol users, as services have often had less focus on their specific needs and new barriers to accessing appropriate services have emerged^{[footnote 8]}. This is also true for children of alcohol dependent parents. Fewer than half the local authorities responding to a survey undertaken as part of the Parliamentary Review in 2018 indicated that they had a specific strategy in place to support children affected by PAM. However, the number with a strategy had doubled since the previous survey in 2015.

The 2018 Parliamentary Review and other reviews of evidence have pointed to a lack of good-quality evaluation and research into the effectiveness of services. Nevertheless, the research that is available shows that early intervention in a parent’s alcohol misuse brings opportunities to address the effects it has on children. Effective joint working between children’s services and alcohol services, combined with effective identification and interventions, have also been shown to minimise the longer-term impact of PAM on a child’s future health and wellbeing.

Overall, research has indicated 3 aspects of intervention that are particularly effective:

protective factors and resilience – related to individual factors and maintaining normal routines
‘whole-family’ focused services – although children themselves want services that focus on them as individuals rather than defining them by their parent’s problems
parenting skills

A notable example of recent research carried out on the current drug misuse and treatment landscape in the UK is the Dame Carol Black review, the final part of which was published in 2021. This was a major independent review into drug prevention, treatment and recovery that was commissioned by the government. While it was not specifically focused on alcohol misuse, the gaps it highlighted in service provision are relevant for both substance and alcohol misuse. Among other recommendations, the report called for the following:

better co-ordinated support for drug users, with accountability at both the level of the local authority and national government
increased funding for alcohol and drug treatment and recovery services, particularly in terms of training a suitably qualified workforce, which has diminished following years of chronic underfunding
joint commissioning plans that include mental health, housing and employment support, as well as treatment and recovery services for drug use
investment in an innovation fund to test out which marketing and behavioural interventions could work in the UK

Part 2 of Dame Carol Black’s report also mentioned that tailored support is needed for parental substance misuse, adding that:

Families with parental drug misuse need specific support which must be co-ordinated at a local level. There is promising emerging evidence of the outcomes of programmes such as the Children of Alcohol Dependent Parents (CADeP) programme. This support should be expanded to drug misuse and, depending on results, rolled out across England.

A recent programme that has been rolled out in the UK alongside the CADeP IF is the Reducing Parental Conflict (RPC) programme, funded and managed by the Department for Work and Pensions (DWP), with a focus on disadvantaged families. This aims to promote children’s mental health and longer-term outcomes by supporting parents experiencing levels of conflict harmful to children. The RPC programme is also working to facilitate the integration of support to reduce parental conflict in local services for families.

1.2 Aims and objectives of the innovation fund

The CADeP IF initially provided up to £4.5 million for 9 local areas, across 13 authorities, to support them in innovating and improving systems and practices to enhance the identification of, and outcomes for, children of alcohol dependent parents (ADPs) and their families between 2018 to 2019 and 2020 to 2021. These 9 projects also aimed to address parental conflict in the families identified by these interventions.

The IF was part of a wider package of financial support that also included:

£380,000 to fund a helpline for children run by the National Association for Children of Alcoholics. This money was to grow capacity for the helpline and support the organisation to extend its reach
£1 million for voluntary sector organisations to build capacity nationally to better identify and support children of alcohol dependent parents, and to tackle conflict within families through voluntary, charitable and other not-for-profit organisations

The implementation and outcomes of these 2 additional interventions were beyond the scope of this evaluation, which only focused on the IF project implementation and outcomes.

Funding for the CADeP programme came from the Department of Health and Social Care (DHSC) and DWP, given the complementarity of the aims of the project relating to ADPs and parental conflict. The Office for Health Improvement and Disparities (OHID – formerly PHE) was responsible for managing the fund.

The IF was subsequently extended until the end of March 2022 through £700,000 of DWP funding to mitigate the impact of the coronavirus (COVID-19) pandemic, and £500,000 of DHSC funding to help create a legacy for the programme that reflects the progress made over the last 4 years.

The CADeP IF programme aimed to finance 9 areas to implement innovative, evidence-informed interventions to improve outcomes for children whose parents are dependent on alcohol. It aimed to identify sustainable models of service delivery that can be widely replicated and rolled out across the country. Successful bidders were asked to commit to ambitious plans that would lead to:

reductions in unmet treatment need for ADPs and an increase in successful completions of those who were in treatment
an increased access to adult and children’s mental health (with improving access to psychological therapies (IAPT) and community mental health support for families where there is an assessed need for these services
an increase in referrals to and from children’s social services, the Supporting Families programme (formerly, the Troubled Families programme) and early help services for children of dependent drinkers (and an increase in access to targeted support)
better identification of children taking inappropriate care responsibilities and increased uptake in targeted interventions to support those families
a reduction in cases where looked-after children of ADPs are taken back into care and/or spend time on the child protection register
an increase in the number of adults participating in interventions to reduce parental conflict alongside, or as part of, traditional treatment

Areas with high prevalence of children of ADPs were particularly encouraged to bid. All needed to demonstrate joint working between adult alcohol treatment services and children’s services, along with wider services provided by voluntary sector organisations and charities, mental health services, Troubled Families programmes and schools.

At the same time, areas that had been selected for DWP’s RPC programme were out of scope for this funding. This was to ensure a fair allocation of funding from government initiatives in this area and avoid the potential for creating uncertainty about the impact from different interventions.

Project bids also had to demonstrate that:

they were sustainable: the proposals needed to show how changes brought about as a result of the funding would be continued after the time period of grant payments
they provided value for money: and that they could be assessed using SMART (specific, measurable, achievable, realistic and timely) criteria
they were committed to evaluation and dissemination of learning: all projects needed to commission and report on their own local evaluations and work with the national programme evaluators commissioned by the DHSC
they were informed by service user and carer consultation: the proposals needed to provide evidence that, where appropriate, they had been informed and supported through service user and parent or carer consultation

Bids from 70 areas were received by the funding application deadline (17 July 2018). PHE, working with a national panel, prioritised the bids, interviewed shortlisted projects and recommended applicants to the Parliamentary Under-Secretary of State for Public Health and Primary Care for final approval. The grant was awarded under section 31 of the Local Government Act 2003 and was subsequently monitored in accordance with the Cabinet Office Minimum Standards.

The final list of funded areas included (in alphabetical order):

Brighton and Hove City Council
Haringey Council
Knowsley Council
North Tyneside Local Authority
Portsmouth City Council
Rochdale Metropolitan Borough Council (including also Bolton, Bury, Salford and Trafford)
St Helens Council
Swindon Borough Council
West Sussex County Council

1.3 Evaluation methodology

The national evaluation of the CADeP IF project aimed to explore the effectiveness of the programme in supporting changes to systems, and interventions aimed at families affected by alcohol dependency and parental conflict, while at the same time facilitating ongoing learning of key stakeholders in DHSC, DWP and OHID as well as in the 9 local areas. A subsidiary aim was also to support the areas in conducting their own local evaluations to determine the impact of their projects.

The evaluation was formed around the following research questions (RQs), which informed the evaluation design:

RQ1: how did the innovation fund lead to improvements in the timely identification of parents and children of ADPs?
RQ2: how has the programme contributed to improvements and innovation in the local system for supporting parents and children of ADPs?
RQ3: what impact have the interventions supported by the programme had on the children and families identified?
RQ4: what knowledge can be drawn from this for future policy and practice?

These questions were answered using the following methods:

Baseline analysis (October 2018 to June 2019)

The first stage of the project involved:

an in-depth analysis of all project applications to identify the context, activities and expected outcomes for each of the areas
exploratory calls with each of the areas to determine the project management structures locally, plans for the local evaluations, and an initial exploration of the planned project activities and their expected outcomes
analysis of national drug treatment monitoring system (NDTMS) summary data between 1 April 2017 and 31 March 2018 to provide contextual information on the number and types of parents accessing treatments in the project areas and relevant treatment outcomes

Establish theory of change and evaluation frameworks (February to May 2019)

The next step was to conduct visits to each of the 9 areas to conduct theory of change (TOC) workshops with between 5 and 25 stakeholders in each area. This involved:

drafting and agreeing project TOCs with each of the projects
conducting calls with project leads and local evaluators to clarify their evaluation plans, including the use of validated scales to measure the impact of interventions – with a particular emphasis on the use of particular tools to assess the impact on parental conflict among project participants

Telephone survey of project areas (November 2019 to January 2020)

Just over a year after the start of the project, interviews were undertaken with 27 key stakeholders across the 9 areas with key strategic planning and implementation responsibility.

The interviews focused on exploring progress made in relation to 3 key themes:

improving identification
combining work on parental conflict with work on addressing alcohol dependency in parents
achieving sustainable improvements to local systems and processes

Case study interviews (June to July 2021)

Case study interviews were conducted in each of the 9 areas, focusing on the implementation and impact of the CADeP IF project funding in each area. This involved interviews with up to 10 key stakeholders per area, including:

project leads
commissioners
local evaluators
operational staff implementing the interventions
other local stakeholders such as schools, midwives, social workers, police and housing services

Sustainability interviews (November 2021 to January 2022)

Interviews were conducted with project leads and commissioners in each of the areas to explore:

how the additional funding for projects until the end of March 2022 was being spent
what concrete steps had been put in place to sustain changes and new ways of working brought about as part of the funding
what the overall legacy of the project has been

Production of case study vignettes (January to February 2022)

Additional funding provided by DHSC was used to develop illustrative vignettes (a vignette is a short case study exemplar of a particular project or practice) of innovative practice implemented in each of the 9 local areas.

This was done by drawing on data from the local evaluations and conducting 2 to 3 interviews in each area with operational staff involved in implementing such interventions – these are used to illustrate the findings in chapters ‘4. Delivering support to children and families’ and ‘5. Improving outcomes of children, parents and families’ of this report below.

Analysis of local evaluation reports and NDTMS data (March 2022)

The last step was to draw out key information from the 9 local evaluation reports relating to the implementation, impacts and outcomes of the 9 projects, and to summarise these in this report. This was supplemented by the analysis of NDTMS data to identify any trends in the number of families accessing treatment in the project areas.

Running alongside all these evaluation methodologies was a programme of 6-monthly learning events organised and facilitated by the Tavistock research team with OHID. These events aimed to allow local areas to share and discuss key themes related to their implementation of the IF projects and to learn from each other. Six such learning events took place between March 2019 and January 2022 (see ‘Appendix A’ for more details).

The main limitation of this methodology was that the national evaluation only had limited opportunities and resources to conduct research in the 9 areas to explore the impact and effectiveness of what the projects had achieved as this was the remit of the local evaluations. Instead, our focus was on engaging with the 9 projects to answer RQs 1 and 2 (and therefore RQ4), and to support the project areas themselves in collecting strong and robust data to answer RQ3.

For this, we were dependent on the design and quality of the local evaluations, which were commissioned by the local areas and were not directly within our control. This meant that tools used locally were often not as robust as possible (for example, not using validated scales to measure the impact of services) and that the methods of analysis used were sometimes limited (see chapter ‘5. Improving outcomes of children, parents and families’ below).

Another limitation beyond the control of either the national or local evaluations was the impact of COVID-19 and the lockdown on participant numbers and particular interventions. This meant that, as explained in chapter 5, sample sizes were in some cases much lower than originally intended, which reduced the strength of the conclusions reached.

1.4 Report overview

Chapter ‘2. The implementation of the CADeP IF project’ starts by describing the implementation of the IF projects in the 9 areas, including the local context at the start of the programme, what they wanted to achieve, and a broad outline of what they did with the funding. The following chapters then present the main results of the evaluation in relation to RQs 1, 2 and 3.

Chapter ‘3. Earlier identification of children, parents and families’ focuses on RQ1, and what the 9 projects did to try and improve the identification and referral of children, parents and families affected by parental conflict and alcohol dependency, including workforce training, improved data-sharing, governance and helping different services to work together more closely. It is mainly based on interviews we have conducted with the projects, but also draws on evidence from the local evaluations.

Chapter ‘4. Delivering support to children and families’ gives an overview of what the projects did to improve or enhance the support provided to children, parents and families affected by parental conflict and alcohol dependency, through individual support for parents and children as well as whole-family support (RQ2). It also explores the challenges in conducting this work and draws out key lessons learned. It is based on interviews we have conducted with the projects and the local evaluations, and illustrates particular examples with some of the 9 case study vignettes.

Chapter ‘5. Improving outcomes of children, parents and families’ focuses on answering RQ3 – on what difference the provision delivered as part of the IF project made to children, parents and families, and also what they liked or disliked about the approaches adopted. It combines both qualitative and quantitative evidence, and draws mainly on the local evaluations and an analysis of the most up-to-date NDTMS data. Once again, particular outcomes are illustrated with some of the case study vignettes.

Chapter ‘6. Conclusions and reflections’ provides a summary of the findings for each of the 4 research questions, including recommendations for future policy and practice, and ends with some reflections based on our evaluation of this project.

Finally, chapter ‘7. Postscript’ provides a postscript describing the next steps in the development of the CADeP programme, building on the findings from this evaluation.

Question 2

2.  The implementation of the CADeP IF project

Accepted Answer

This chapter presents the context in the 9 areas at the start of the programme and what was done with the IF funding to address some of the issues identified.

The first section presents the results of the analysis of NDTMS data to show the situation before the start of the project, while section 2.2 provides an overview of some of the system strengths and weaknesses in the 9 areas at the start of the project. Finally, section 2.3 gives an overview of the 9 projects and what each of them focused on, drawing out some of the common themes.

2.1 Local contexts in the 9 areas at the start of the programme

Analysis of NDTMS data shows that during 2017 to 2018, before the CADeP IF project funding was introduced, a total of 8,446 adults were in community treatment for alcohol use (including alcohol and non-opiate drug use) in the 9 areas. Among those 8,446 clients in treatment in the IF areas, just over two-thirds (68%) started a new treatment journey in 2017 to 2018. Of these, 17% were parents living with their own children and 26% were parents not living with their children.

Table 1: number of clients in the 9 IF areas and England by parental status (2017 to 2018)

Parental status	All clients in treatment IF Areas N (%)	All clients in treatment National N (%)	New treatment journeys IF Areas N (%)	New treatment journeys National N (%)
Parent living with own children	1469 (17%)	17,930 (19%)	997 (17%)	12,067 (19%)
Other child contact living with children	246 (3%)	4,321 (5%)	178 (3%)	2,734 (4%)
Parent not living with children	2,244 (27%)	25,277 (27%)	1,474 (26%)	16,782 (26%)
Not a parent or no child contact	4,471 (53%)	46,977 (49%)	3,080 (54%)	31,691 (50%)
Incomplete data	16 (0%)	520 (1%)	14 (0%)	396 (1%)
Total	8,446 (100%)	95,025 (100%)	5,743 (100%)	63,670 (100%)

Source: NDTMS 2017 to 2018 data. N = number of clients. Note: national figures exclude the numbers of the 9 IF areas.

As can be seen in table 2, the number of clients in treatment ranged from 239 in Portsmouth to over 3,000 in Rochdale Metropolitan Borough Council (MBC, which combines 5 local authorities). It shows that the highest proportion of parents (over 57% – including those living with and not with their children) was in Knowsley, while in Brighton and Hove the proportion of parents was around one-third (32%) of all clients.

For convenience, the term ‘parents’ will be used in the following sections to refer to this group of clients unless otherwise indicated.

Table 2: number of parents in treatment during the year 2017 to 2018 in the 9 IF areas

IF area	Parents living with own children (%)	Parents not living with own children (%)	Parents with other child contact - living with children (%)	Total number clients (including parents and non-parents) (%)
Brighton and Hove	122 (13%)	175 (19%)	10 (1%)	924 (100%)
Haringey	83 (12%)	185 (26%)	19 (3%)	699 (100%)
Knowsley	90 (22%)	147 (35%)	0 (0%)	418 (100%)
North Tyneside	75 (13%)	146 (26%)	0 (0%)	568 (100%)
Portsmouth	34 (14%)	84 (35%)	10 (4%)	239 (100%)
Rochdale (MBC)	643 (19%)	940 (28%)	162 (5%)	3,380 (100%)
St Helens	118 (21%)	177 (31%)	15 (3%)	575 (100%)
Swindon	55 (17%)	85 (27%)	0 (0%)	316 (100%)
West Sussex	249 (19%)	305 (23%)	30 (2%)	1,331 (100%)

Source: NDTMS 2017 to 2018 data. Data is based on all clients.

Overall, there were 3,063 children within the IF areas living with adults who were in treatment during 2017 to 2018, according to NDTMS data of all clients during 2017 to 2018. The number of children living with adults in treatment ranged from 84 in Portsmouth to nearly 1,500 in Rochdale (see table 3).

Table 3: number of children with parents in treatment in 2017 to 2018 in the 9 IF areas and England

IF area	All clients in treatment	New treatment journeys
Brighton and Hove	211	148
Haringey	184	108
Knowsley	134	82
North Tyneside	125	59
Portsmouth	84	69
Rochdale (MBC)	1,491	1,152
St Helens	231	155
Swindon	105	43
West Sussex	498	327
IF areas combined	3,063	2,143
National	39,709	26,214

Source: NDTMS 2017 to 2018 data. Data is based on all clients; national figures exclude the numbers of the 9 IF areas.

The majority of parents in treatment in 2017 to 2018 across the 9 areas were male (61%) – which was very close to the national average (60%). The only exception was Knowsley, where a slightly higher proportion of parents receiving treatment (51%) were female. In contrast, in Haringey, only 31% of parents in treatment were female.

Figure 1: age distribution of parents across the 9 IF areas in treatment in 2017 to 2018

Source: NDTMS 2017 to 2018 data. Number of clients = 3,950. Data is based on all clients in treatment with alcohol problems with a parental status of ‘living with child’ or ‘parent not living with children’.

As can be seen in figure 1, around two-thirds of parents in treatment were aged between 30 and 49 years, while only 5% were 60 years old or older (which is very similar to the national picture). The age profile in each of the 9 areas was fairly similar. The area with the youngest client group was Swindon – 88% were aged below 50. In contrast, in Haringey 67% were younger than 50 years.

Nearly half of the parents in the IF areas (46%) indicated that they had mental health needs identified at the same time as starting treatment for alcohol dependency in 2017 to 2018. Again, there was considerable variation across authorities – in North Tyneside, for example, 86% of parents said they had no mental health treatment need, whereas the proportion with a mental health treatment need was more than half in Rochdale, Portsmouth, Brighton and Hove, Knowsley, and St Helens.

As can be seen in table 4, of the 46% parents with identified mental health needs, more than half (55%) were receiving support from their GP, while 21% were not receiving any form of treatment.

Table 4: treatment of parents starting treatment across 9 IF areas (2017 to 2018)

Treatment type	Percentage (%)
Primary care mental health treatment	55
Community or mental health services	21
No treatment received	21
Other mental health treatment	3

Source: NDTMS 2017 to 2018 data. Number of clients = 1,216. Data is based on new treatment journeys in 2017 to 2018 and on parents with an identified mental health need (excluding no treatment needed and missing data); the category ‘other mental health treatment’ combines ‘receiving any NICE-recommended psychosocial or pharmacological intervention provided for the treatment of a mental health problem in drug or alcohol services’ and ‘engaged with IAPT’.

As shown in figure 2, 17% of parents were registered at or above Tier 2 on the social care scale. Tier 2 refers to early help, Tier 3 covers ‘children in need’ and Tier 4 includes children who are in the care system and those with a child protection plan. The proportion of parents registered at or above Tier 2 across the IF projects was the same proportion as across the whole of England in 2017 to 2018, according to NDTMS data based on new treatment journeys.

Figure 2: social care tier status of parents starting treatment across all 9 IF areas (2017 to 2018)

Source: NDTMS 2017 to 2018 data. Number of clients = 2,626. Data is based on new treatment journeys in 2017 to 2018.

When entering treatment, across the 9 areas, 52% of parents reported monthly average alcohol units consumed of less than 400, and 17% of 800 or more, which was very close to the national average (54% and 17% respectively) in 2017 to 2018, according to NDTMS data. This was fairly similar across the 9 areas – although the proportion consuming 800 or more units per month ranged from 6% in Brighton and Hove to 24% in Knowsley.

Overall, the majority of parents entered treatment through self-referral or referrals from family or friends (see figure 3). In Knowsley, Haringey and St Helens, more than one-third of referrals came through health and social care, while in Swindon, around one-quarter of referrals came through the criminal justice system.

Figure 3: referral source of parents entering treatment in the 9 IF areas (2017 to 2018)

Source: NDTMS 2017 to 2018 data. Number of clients = 2,649. Data is based on new treatment journeys in 2017 to 2018.

Figure 4 shows that parents’ duration in treatment ranged widely – from under one month up to just under 4 years – although around half had been in treatment for a period of between one and 6 months in 2017 to 2018.

Figure 4: treatment duration of parents in treatment across the 9 IF areas (2017 to 2018)

Source: NDTMS 2017 to 2018 data. Number of clients = 3,952. Data is based on all parents in treatment the 9 areas.

Figure 5 shows that, across the 9 areas, 60% of clients completed their treatment in 2017 to 2018 – this included 39% who completed it ‘alcohol/drug free’. In contrast, more than one-third dropped out or did not complete their treatment for other reasons, which is very similar to the national average.

Figure 5: treatment completion rates for parents exiting treatment across the 9 IF areas (2017 to 2018)

Source: NDTMS 2017 to 2018 data. Number of clients = 2,508. Data is based on clients who exited in 2017 to 2018.

2.2 System strengths and weaknesses in the local areas

Analysis of the IF applications and results of the TOC workshops in the 9 areas identified a mixture of existing system strengths and challenges present at the start of the project – with project activities designed to address the latter while building on the former.

With the exception of Rochdale, all areas identified a lack of skills or confidence among frontline staff in identifying ADPs and/or parental conflict, and hence gaps in identifying and engaging such families as an issue they were hoping to address. Five of the 9 areas also lacked coherent or systematic approaches to alcohol dependency and/or parental conflict, and identified this along with effective collaboration across services as contextual challenges.

Brighton and Hove, for example, listed the following issues, among many others, in their TOC:

lack of confidence among professionals in addressing the issue with parents
fear of resistance or lack of time to build trusting relationships
lack of robust mechanisms to identify ADPs, especially fathers
lack of systemic response to alcohol dependence and family conflict
lack of common language and approach among services

Other issues identified included:

gaps or weaknesses in treatments available for alcohol dependency or parental conflict
significant cuts or funding issues related to this service area
a lack of capacity among frontline staff
a lack of buy-in or commitment among some service staff to address these issues

Portsmouth provided another good illustration of these issues, with the following system-level challenges identified in its TOC:

frontline staff in relevant services with low awareness about alcohol dependency and low confidence to address the issue
alcohol not seen as a serious issue by some professionals
services do not fully know the level of need in the city
social workers stretched or with little spare capacity
adult substance misuse services not well integrated with children’s services
previous relevant services lost due to local authority cuts
a shift in the skills base of substance misuse practitioners in recent years (loss of experienced staff and cuts)

The project in Rochdale sought to address a particular issue that was distinct from the other 8 areas, which included challenges associated with supporting ADPs and their families while in prison, and supporting the transition to community and family life after release. Systemic issues identified in Rochdale included:

absence of holistic support for transition from prison
substance misuse work in prisons often focuses on drugs rather than alcohol
lack of awareness and understanding about intergenerational cycles of adversity and links to alcohol misuse

All areas also indicated that there was a high level of unmet need among ADPs in their areas. Other key issues included cultural acceptability of alcohol and various barriers to accessing support, including lack of awareness, physical and practical barriers or reluctance to seek help.

With regard to children and young people, all areas agreed that there were significant negative outcomes for children of ADPs, while around half specifically mentioned a high level of unmet need or a high level of hidden need. Two areas also identified young people’s reluctance to access support as a key challenge in their TOC.

While the localities identified many different problems and challenges that they hoped their project would help to address, they were also able to outline existing strengths or assets that they hoped to build on. These included:

existing links with relevant services or frontline staff
existing successful treatments for alcohol dependency in the area with high completion rates
the treatment service being well-regarded among the public or other services
access to other relevant project funding and support, including the RPC programme training
commitment to the aims of the CADeP IF project among senior local authority staff and/or frontline service staff

2.3 CADeP IF projects details

This section provides an overview of the 9 projects, including:

what their key focus was
who carried out their local evaluations (some areas commissioned universities to carry out the evaluations, while others relied on local authority staff to do this)
what the funding was used for

Brighton and Hove City Council: Back on Track (BOT) project

Key focus: to foster a partnership approach involving different services to provide a holistic whole-family approach that bridges the gap between adults’ and children’s services

Local evaluator: School of Psychology, University of Sussex

Key elements of this BOT project:

enhanced support for adults by the alcohol treatment service
enhanced support for children and young people, including young carers, who are affected by their parent’s alcohol use
training for staff working with families in schools, advice services and other voluntary and community settings
a public health campaign accompanying this work to raise awareness of the scale of the issue in Brighton and Hove, and where people can go for help

Haringey Council: Insightful Families project

Key focus: a permanent and sustainable system-wide improvement in awareness and prioritisation of the needs of families with alcohol issues and parental conflict

Local evaluator: Haringey Council, public health analyst

Key elements of the Insightful Families project:

upskill professionals and community groups across Haringey to spot the early warning signs of alcohol misuse and parental conflict
train members of Haringey’s children and family’s workforce in using specific tools to aid discussions with family members about alcohol and their emotional and social needs, and to motivate families to access the specialist Insightful Families service
provide whole-family support interventions by a team of trained specialist workers from the alcohol treatment service provider across Haringey

Knowsley Council: Connecting Families programme

Key focus: to provide early intervention for families in need through the delivery and co-ordination of a number of interventions delivered by different services

Local evaluator: Public Health Institute, Liverpool John Moores University

Key elements of this Connecting Families programme:

upskill the wider workforce through the training on alcohol brief interventions for professionals
increase capacity for the alcohol treatment service to provide support to more parents and their children in alcohol treatment
engage young people with caring responsibilities for ADPs
set up a peer support group for community members affected by alcohol and substance misuse
develop a referral pathway and support for victims of domestic abuse or parental conflict, where alcohol was a factor in a police call-out
identify children and families at risk or experiencing harm through a new ‘hidden harm’ post

North Tyneside local authority: the Bottled Up (BU) project

Key focus: to implement an enhanced pathway to improve outcomes for children and families by increasing the identification of parents misusing alcohol and their children, and providing evidence-based interventions and support

Local evaluator: Population Health Sciences Institute, Newcastle University

Key elements of the BU project:

employ an adult alcohol worker to support parents who misuse alcohol at hazardous, harmful and dependent levels
employ a children and adolescent mental health support (CAMHS) worker to support children of alcohol-misusing parents regarding their emotional and mental health needs
employ a young carers worker to support young people undertaking caring responsibilities due to a parent misusing alcohol
deliver community reinforcement approach and family training (CRAFT) for adults caring for, or affected by, the drug and alcohol misuse of a family member where there are children and/or a young person in the family

Portsmouth City Council: the Family Support Project (FSP)

Key focus: to improve the lives of families impacted by PAM in Portsmouth by increasing the identification and referral of families and providing whole-family support to them

Local evaluator: National Institute for Health and Care Research Applied Research Collaboration (NIHR ARC) Wessex, University of Southampton

Key elements of this FSP:

upskill the workforce to improve identification and referrals
build a more consistent and coherent service response to ADPs through the co-location of key staff, and improved partnership and multi-agency working between the children, adult and alcohol treatment services
increase capacity of the alcohol treatment service through the recruitment of key staff to provide a case management approach to families
use a ‘family hub’ setting to deliver a family intervention that applies parental conflict and family therapy-type approaches that together lead to better family lives for families impacted by PAM

Greater Manchester (Rochdale, Bolton, Bury, Salford and Trafford): Early Break Holding Families Plus (HFP) project

Key focus: to identify and provide better and earlier help to ADPs, prior and subsequent to release from prison, their children and wider family around them, to enable improved transitions between custody and community life, reduce family conflict and improve child outcomes

Local evaluator: Manchester Metropolitan University

Key elements of this HFP project :

adapt the Holding Families programme, which provides whole-family support for children and family members affected by parental substance misuse, to support parents who are transitioning from prison into the community
recruit and train a dedicated team of staff in the Holding Families approach and enable them to work with individuals and the whole family pre- and post-release
organise family events through the programme with the voice of the child being a central part of this process
connect families with, and refer them onto, other existing and relevant services

St Helens Council: Building Bridges (BB) project

Key focus: to work in partnership with the children services’ multi-agency safeguarding hub (MASH) and other services to better identify those in need, and build abstinence resilience and improved family dynamics among families where alcohol and parental conflict has been identified as an issue through effective evidence-based interventions

Local evaluator: Public Health Institute, Liverpool John Moores University

Key elements of this BB project:

deliver a training package to increase professionals’ knowledge around the consequences and impact of alcohol and parental conflict on families, and increase their confidence in having conversations with clients and patients around alcohol use
employ an early intervention co-ordinator to carry out outreach work and programme delivery, and provide specialist advice to professionals and one-to-one support with families at children’s centres
develop 2 complex case worker roles to manage more complex cases, mitigate risk and improve outcomes for the families, and create and maintain crucial relationships with statutory sector partners
develop family recovery champion role to incorporate invaluable lived experience to the team
deliver evidence-based interventions to families
increase capacity to deliver a number of evidence-based interventions to families, depending on their specific needs, through 3 key programmes (First Steps, Confident Families and M-PACT)

Swindon Borough Council: Swindon RESTORE project

Key focus: to create a multi-agency virtual team to improve the identification and support provided to families affected by alcohol use and parental conflict.

Local evaluator: Public Health Swindon

Key elements of the RESTORE project:

deliver a parenting programme in schools to upskill teachers in identifying children of ADPs and facilitating universal family support
deliver a year-long project designed to promote peer mentoring and bonding activities with targeted families in the borough
appointment of specialist alcohol family support workers to identify children living with ADPs and refer them for assessment, support and use of a restorative conferencing model
employ a specialist alcohol worker in the alcohol treatment service to make links with other services and provide in-depth support to ADPs
provide therapeutic group counselling for children and young people living with ADPs
fund a local charity to increase capacity to provide support to families around relationship-building and resolution of family conflict

West Sussex County Council: Growing Families project

Key focus: to enhance existing services to identify and provide better and earlier help to pregnant mothers, parents and children by recruiting and training existing service staff, implementing integrated service pathways, and delivering evidence-based interventions to parents and children

Local evaluator: West Sussex Public Health and Social Research Unit

Key elements of the Growing Families project:

improve early identification of alcohol use during pregnancy and the first year of a child’s life through the development of a referral pathway to the substance misuse service, and a workforce training event on the effects of parental alcohol use and relationship conflict
introduce a new service that was developed by the local substance misuse service to provide early support for ADPs and people drinking any amount of alcohol during pregnancy (including their partners)
increase capacity to provide a therapeutic service for children and young people of alcohol dependent parents or carers countywide
deliver a summer campaign to disseminate reliable information and guidance about parental alcohol use using an existing online platform used by expectant parents

The information summarised above shows that, while the areas used the IF in different ways to respond to particular contextual issues locally and to fund different services, there were some common themes across the areas. The overall approach was one of boosting aspects of the current system in each locality with ways of working with ADPs, while introducing interventions focused on identifying and addressing particular issues faced by children, parents or families.

As described in more detail in chapter ‘4. Delivering support to children and families’, some areas adopted a model in which one service provided support to the whole family, while others chose to use different providers to deliver such support. A particular focus of most projects was also to put resources into workforce development and inter-agency collaboration, aimed at improved identification and awareness of needs, and strengthening the capacity to work holistically with families, particularly those below Tier 3 (including early help and universal support).

Throughout this report, we refer to the 4 tiers of assessment of needs used by children’s social care in England. These are described below:

Tier 1 universal: children with no additional needs whose health and developmental needs can be met by universal services
Tier 2 early help: children with additional needs that can be met through the provision of early help
Tier 3 targeted help: children with complex multiple needs who need statutory and specialist services. A referral to children’s social care is required. Children in Tier 3 are often referred to as ‘children in need (CIN)’
Tier 4 specialist: children in acute need who require immediate referral to children’s social care and/or the police. Statutory interventions (for example, care orders) happen at this point, and children in Tier 4 are often referred to as looked-after children (LAC)

One of the key issues in many areas was that, while support for children and families at the highest levels of need (typically at tiers 3 and 4) was well-structured, the identification and referral for support below such statutory intervention was less well organised and often missed opportunities for early identification.

This was often the result of inadequate co-operation and collaboration between adult and children’s services in identifying families affected by PAM, particularly at tier 2. The subsequent absence of support could result in escalation of need.

Question 3

3.  Earlier identification of children, parents and families

Accepted Answer

This chapter explores:

how the IF projects strove to improve the identification and referral of children and families
the challenges they encountered
how challenges were overcome

We begin by presenting the main system challenges the projects endeavoured to address. It is worth noting that some of the challenges faced by particular areas were shared with us in confidence. For this reason, such issues are often only described in a general sense without identifying particular IF projects.

The following sections then explore the key enablers of success identified in the national and local evaluations to overcome these challenges, including:

strategic buy-in at all levels of service planning and delivery
effective communication and collaboration between services
effective systems to identify and refer families for support
increased practitioner awareness, skills and confidence

The last section (‘3.5 Increased practitioner awareness, skills and confidence’) provides lessons learned from the IF projects’ activities aimed at attempting system change in the identification and referral of children and families.

3.1 System challenges

In chapter ‘2. The implementation of the CADeP IF project’ above, we outlined the main system challenges in the 9 areas resulting in relatively low levels of identification and referral of children and ADPs for support both locally and nationally. In most cases, these reflected the absence of multi-agency approaches through which children and adult services collaborate to identify and support families holistically.

Siloed working and poor inter-agency communication have contributed to the failure of adult services to recognise alcohol dependent adults as parents. Equally, universal services and early help have been less able to identify and respond to alcohol dependency and parental conflict among the parents of troubled children. This has resulted in failures to detect the hidden harm among children of ADPs before issues escalate to the point where they require statutory intervention.

Examples of this were illustrated well at the start of the project – for instance, on the Brighton and Hove CADeP IF application:

Our existing services are not responding effectively to the hidden impact on children of parental alcohol dependency, or the conflict that dependency causes within families. They tend to respond to the individual child’s or adult’s presenting need rather than take a more family systemic and relationship approach that is confident in getting below a hidden issue.

Similarly, in its CADeP IF application, the Haringey project recognised the absence of a:

coherent system-wide approach to helping children, their parents and their protective networks, with additional support from a specialist team.

Prior to the start of the project, Haringey’s alcohol and substance misuse treatment service provided a smaller amount of whole family work and parenting programmes. It also received few referrals of ADPs from children’s social care and early help teams.

In Knowsley, ADPs’ levels of need were known to be very severe, but often universal services for children, such as health and schools, lacked the skills and confidence to identify and refer families for support.

Similarly, prior to the IF project in Portsmouth, frontline workers in regular contact with children were often unaware of parental alcohol misuse. This was compounded by the normalisation of alcohol use and staff lack of confidence in asking questions about possible dependency or parental conflict. Parental fears of social service involvement, combined with a lack of effective identification systems and relevant expertise among family workers, further contributed to the problem remaining hidden, as highlighted by the early help team on the Portsmouth evaluation report:

On our assessment form there is no question about alcohol. As you get to know a person, you might find that the parents have underlying issues as well. If it wasn’t for the young person telling me, I wouldn’t know. Parents want to keep it quiet. Sometimes we ask the question if we feel it might be an issue, but not routinely.

3.2 Strategic buy-in at all levels of service planning and delivery

The evaluation has shown that the most progress in improving systems of identification and referral was made in those areas that had senior level buy-in from the start of the project. This was often a product of a history of established strategic and commissioning partnerships, especially between children’s social care and public health.

In St Helens, for example, public health was already part of an integrated people’s service department that included adult and children’s social care before the CADeP IF began. This department was committed to fostering greater integration of different services, which facilitated the project aims in the area. A stakeholder interviewee stated:

At the outset, [the public health commissioner] brokered high-level negotiations with the head of children’s services and got their approval.

Responsibility for the implementation of the project was passed down to provider middle management with oversight of progress at senior and strategic levels. This approach led the project, and its partnerships, to “blossom, beyond initial expectations, in volume, equal partnerships, mutual respect and relationships between individual workers”, as one of the stakeholders reported in an interview.

As described in more detail in section ‘3.3 Effective communication and collaboration’ below, it allowed for a stronger integration of children’s social care and the local treatment provider. This led to the identification and referral of families affected by alcohol dependency and/or parental conflict.

A stakeholder commented:

This is an example of how strategic integration translates to delivery; we see it in other projects as well.

For example, by forging inter-agency integration, the managers and staff of the St Helen’s IF project have succeeded in placing the service they manage at centre stage, and making it a valued partner within the local network of relevant statutory and voluntary services.

Similarly, North Tyneside built a multi-agency partnership with children’s and adult services as part of a steering group that had regular meetings during the first 12 months of the project. The group agreed on the vision and wrote the bid together, which meant that:

Everyone was on board from the start. North Tyneside is a small borough, so we were already used to working together but not as closely as with [the IF] Bottled Up [project]. This meant that the collaborative culture was already there.

Such buy-in from the top allowed the project to develop new ways of identifying families where parental conflict, or PAM, including binge drinking, was an issue. It was achieved by working more closely with the MASH and referring families to a multi-agency team for support. This created the operational challenge of requiring practitioners seconded to the project to adapt to new ways of engaging and working with families. An example was visiting families in the community rather than sending out letters asking them to attend the treatment centre. Initial difficulties were experienced by some staff in adapting to such a changed role. This demonstrated that achieving sustainable system change is dependent on both senior buy-in and commitment at all levels of implementation and delivery.

The benefits of senior buy-in are critical in enabling system change by facilitating, for example, system-wide acknowledgement of the links between alcohol dependency, parental conflict and the emotional wellbeing of children. Consequently, there was some recognition, in the words of one stakeholder, that:

[Parental conflict] is now being led from the top (…) and [it is viewed] as an integral part of the work with the whole family. The discussions now go from the point of assessment to the referral form itself, helping to train the wider workforce to identify it, too, because it’s so important to what they do. It’s now integrated at every level. Right from the outset, they are alerted to parental conflict within families.

Another area found that the lack of emphasis on parental conflict was due to a focus on physical aspects of safeguarding and capacity issues within particular parts of the service. A stakeholder interviewee commented:

So, the emotional impact of parental alcohol dependency or use is often neglected. If that was more accepted in parts of the service, like the ‘front door’, then things like parental conflict work would have more traction. An added issue, though, is that even if these things are recognised, there is often a lack of capacity to deliver services.

The ‘front door’ is the arrangement that local authorities have in place to respond to an initial contact from a professional or member of the public who is concerned about a child.

Finally, the Rochdale IF project was led by a third-sector organisation, and was focused on identifying and supporting the children of alcohol and substance-misusing parents in prison. It brokered a more bottom-up approach to liaison and relationship building with different agencies across the whole adult and children’s system. The aim was to provide child-centred support at ground level to families experiencing intergenerational trauma.

However, this work was constrained by the siloed nature of the existing funding system of support available to parents and children, which hampered efforts to provide whole family engagement and support.

As written in the Rochdale local evaluation report:

The systems are so difficult to navigate, and the services within them are so under pressure, [there] is almost the look of relief on the professional’s face when they realise that they can signpost them somewhere else. (…) We need to take responsibility for that, and we need to change our systems, and just give permission across a wider agenda for [the] needs of families to be met.

3.3 Effective communication and collaboration

The previous section has shown that, while strategic leadership was a key enabler of system change in most of the IF areas, effective collaboration was also needed at an operational level to improve the identification and referral of children and ADPs for support. The evaluation demonstrates that this was particularly effective where the additional funding was used to enable the co-location or close co-operation of adult and children’s services staff.

St Helens, for example, adopted a much more proactive approach to identification as a result of the funding received. As this alcohol treatment provider stated in an interview, before the start of the project:

People would normally find their way here. We wouldn’t actively go out and look for alcohol dependent parents. Instead, we would rely on self-presentation by the parents themselves, or referral from social care and other agencies. Certainly, we just didn’t have the capacity [to be more proactive].

St Helens children’s services operates a ‘front door’ MASH. It provides an integrated approach and multi-agency point of assessing the needs of children and families referred for support. This includes referrals from the police, schools, the Supporting Families programme and other frontline services. It is designed to facilitate information-sharing and decision-making on a multi-agency basis often, though not always, through co-locating staff from other agencies.

The town’s alcohol treatment provider, which hosted St Helens IF project, had a member of their team based in the front door service. This meant that they were able to screen referrals, and provide specialist advice and support for specific cases. They were also able to provide training and support for other professionals working in the service (including neglect training, parental conflict training and substance misuse training). During lockdown, this work had to be done remotely through Microsoft Teams meetings, but this still worked well as it was based on established relationships and ways of working.

Adopting this proactive approach meant that families where alcohol dependency or parental conflict were identified as an issue could be referred to the IF project for further support, particularly when the level of need was below Tier 3. This way the project also created a pathway to support for families at Tiers 3 and 4, which often resulted in a ‘step down’ to Tier 2. This enabled the project to significantly increase the number of parents identified for whole-family support provided at Tier 2 and to prevent escalation to higher levels of support.

Working alongside children’s social care staff and contributing to wider activities, such as participating in the MASH strategic board, raised awareness among practitioners of the valuable contribution the alcohol treatment provider could make. A children’s services staff member stated that:

We relate very closely with [the provider] … got a close relationship with them and the workers there. Whatever we need from them, they’re always willing to provide it. Often, they will refer clients over to us and vice versa.

The screening process carried out as part of the MASH was also increasingly used to identify parental conflict issues. The alcohol treatment provider supported this through appointing a dedicated worker in the service to assist with such cases, so that families in which parental conflict was identified as an issue could be referred to this specialist for engagement and support.

North Tyneside also funded a role within the project to be based in early help as part of the MASH. This enabled her to work closely with other staff involved in the screening process and to identify children affected by parental conflict or PAM. The project also helped change the system of recording need.

Consequently, families referred to the MASH are now coded, for example, as ‘Parental Conflict’ or ‘Bottled Up’ on their case notes to help identify potential referrals for further support as part of the IF project. This was done to ensure that they were connected to the right IF interventions. In some cases, families received multiple interventions, where necessary.

A stakeholder highlighted this in an interview:

Picking up families through the MASH has meant that early referrals are made to Bottled Up rather than families being referred directly to other agencies in higher tiers, such as social workers. Bottled Up enables the team to get in there early on to avoid further problems and keep families together.

Areas without such a close integration between adult and children’s services found it harder to achieve successful system change in this way.

The Knowsley Connecting Families programme was designed to provide early intervention for families in need through the delivery and co-ordination of several interventions targeted at parents, children and other family members affected by alcohol dependency. However, while the Knowsley local evaluation report was able to demonstrate positive impacts, it also highlighted a continued lack of co-ordination and communication by the early help team between services across the system. To overcome this, some of the CADeP IF funding was used towards the end of the project to recruit a ‘hidden harm’ worker to make better links between the alcohol treatment provider and early help.

3.4 Effective systems to identify and refer families for support

Closer working relationships between adult and children’s services staff were also facilitated in some of the other areas. This included trying to establish more effective systems to identify and refer families for support between services.

Swindon, for example, originally intended to use IF funding to establish a ‘virtual hub’, which would, as stated in the local evaluation report:

… bring professionals from a range of partner agencies together on a regular basis … with each element of the team responding to specific areas of need and then linking together in a virtual team to ensure a co-ordinated, family-based response.

This was meant to bring adult and children’s services together to work more closely in addressing parental conflict or alcohol dependency. But, while there was ‘signposting’ to other services, there were no effective referral mechanisms to ensure that families signposted to other services actually accessed them. As highlighted by a stakeholder interviewed, this meant that while:

… children’s services are doing really good things, and [there is] some really innovative practice, there is [also] an element of disconnection from adult services, including the substance misuse service; so, there is signposting rather than referrals, which means that there is no seamless transition between services.

Several areas tried to address this challenge by establishing new mechanisms or systems to ensure that families referred were encouraged to access the whole-family offer provided by one or several agencies as part of the project (see chapter ‘4. Delivering support to children and families’ below for more details on the different types of such whole-family support provided by projects). This was seen as particularly important for families referred by early help for non-statutory support at Tier 2.

In West Sussex, for example, many referrals of pre- and neo-natal parents to the alcohol treatment provider were made by other agencies, including midwifery, antenatal and perinatal mental health services, children’s services, public health, and internally when the client, or their partner, became pregnant. When women booked their first appointment with the midwife, for example, both the woman and her partner (if present) were asked questions about their medical and social history, as well as any previous alcohol or substance misuse. The completed questionnaires were sent to the Head of Safeguarding to assess the level of risk and need. She then signposted them to the IF Growing Families programme delivered by the alcohol dependency treatment provider for further support. In addition, she organised safeguarding meetings every month with the alcohol treatment provider to discuss all the families assessed in this way.

The safeguarding midwife commented:

We have good communications and try and work in a multi-disciplinary way (…) We have safeguarding meetings every month where these families will be discussed. Growing Families send someone, and that’s really useful because they can sometimes identify if they’ve missed a referral, or that a family has not accepted a referral… They’re very accessible.

Haringey, on the other hand, had established a new system for early help teams across the borough to carry out assessments of families referred for support where alcohol was flagged up as an issue. As part of the new system, the early help teams are alerted by their team managers through the case management system to carry out an initial brief assessment when they meet the family using the alcohol use disorders identification test consumption (AUDIT C) form. This is an alcohol use screening test used by health professionals as a tool to assess a service user’s level of risk to alcohol harm. The AUDIT C scores range from 0 to 40 with lower scores indicating less severe problems with alcohol.

One of the stakeholders noted:

They have now added a pop-up message when alcohol is flagged so that people are told to finish the AUDIT C – this wasn’t there before. Managers look at all the cases and see that alcohol is flagged – so they open it as an ‘occasion’ to start the AUDIT C process. They then allocate it and, because the AUDIT C process is started, the worker has to finish it.

In addition, the IF was used to fund and allocate specialist staff to each locality to attend 3-way meetings with the parents and early help staff to introduce the service provided by the IF project and explain what it would involve. This was seen to be a good way to ensure that referrals for such non-statutory support below Tier 3 was more likely to be accessed by families:

Because it’s voluntary, some clients are keen for support while others are resistant. It can take a while to ensure uptake of support, which involves relationship building and 3-way meetings. They try to highlight the attractive parts of the programme – for example, school holiday activities – so families struggling with what to do can link in and build trust with the service.

Both St Helens and North Tyneside used a different, less resource-intensive approach to engage families identified and referred to their services for support. This involved early help seeking consent from them to be contacted by IF project workers.

This was crucial in North Tyneside, as the whole-family support was provided by 3 services (CAMHS, the alcohol treatment provider, and a third-sector organisation supporting young carers – see chapter ‘4. Delivering support to children and families’). The consent form signed at the start of engagement allowed all 3 services to access the early help case management system to view and record any additional information about the families. The team could then visit them in their own homes or other community settings to engage them in the project. This meant that, from the families’ perspective, the IF Bottled Up project was perceived as one service provided by 3 different workers.

This was highlighted by an interview with one of the stakeholders:

Clients perceive Bottled Up as one service – so do not see themselves as referred to another service when support is offered by another partner. So, for example, when the adult worker is on holiday, the family can still access support from other Bottled Up project workers, by talking, for example, to the children’s worker – as they are all seen as part of ‘family support’.

A similar system was used in St Helens – but only for the alcohol treatment provider involved in the screening of referrals in the MASH (see section ‘3.3 Effective communication and collaboration’ above). Once a family (at Tier 2) was identified as needing such support from the IF project, the social worker would ask them to agree to be contacted by the alcohol treatment provider by phone to engage them in the service.

Email correspondence with the St Helens treatment provider stated:

This has worked really well and essentially has stopped cases from being escalated beyond level 2. So, the focus is being shifted from the social worker asking about engaging, and this not happening, to them asking: “Will you be okay with [treatment provider] contacting you?” and we then have more success with engaging them. Essentially, the aim is to move away from consenting for referrals and towards clients agreeing to having conversations with agencies, which may sound small, but has really positive implications.

3.5 Increased practitioner awareness, skills and confidence

All areas used workforce development to increase the identification and referral of children and families affected by PAM, and generally had 2 main objectives and target groups. First, it was targeted at children’s service staff working mainly in early help or children’s social care to improve their ability to identify and refer children and their parents or carers who would benefit from support to overcome issues related to alcohol dependency or parental conflict. This was particularly relevant in those areas that did not adopt a co-location approach as described in section ‘3.3 Effective communication and collaboration’ above – but was also used in areas such as St Helens to increase the confidence and knowledge of those working in the MASH to improve their knowledge of the problems facing such families.

The training provided through the IF projects typically included:

how to start conversations with parents about alcohol dependence and parental conflict that could encourage them to take up offers of help and support
tools for assessing parental alcohol dependence, including the use of new recording or referral systems introduced as part of the project (see previous section ‘3.4 Effective systems to identify and refer families for support’)
knowledge of the patterns, behaviours and impact of alcohol dependence and parental conflict
information on the resources and services available locally – including the CADeP IF project

From the evidence we reviewed, and those we spoke to, the benefits of such workforce training can be summarised as:

increased awareness and practical knowledge of patterns of alcohol use and the impact of PAM on parents, children and families
increased awareness of the relationship between alcohol misuse and parental conflict, and between alcohol misuse and domestic abuse
improved capacity, competence and confidence in recognising and responding to PAM and its impact on children
increased knowledge and awareness of treatment and other relevant local services, and how to refer or signpost families for support

Overall, the local evaluations showed that most of the training was well received and experienced as relevant, but its impact was sometimes lessened by other commitments, which meant that some staff felt unable to commit fully to implementing the training as well. There were also several examples of the way staff turnover led to loss of knowledge and reduced the impact of the training. Added to this, embedding the learning in practice was not always achieved if practitioners did not have ongoing support in integrating it with their work.

In Haringey, the original plan was for the IF project to train 40 members of the children and families’ workforce, although eventually it was expanded to all members. They were trained in the use of 2 tools. This included the AUDIT C, and the Information and Brief Advice^{[footnote 9]} intervention, which provides tools for discussions with family members about alcohol use and their social and emotional needs.

In addition, they provided training that delivered a clear understanding of the relationship between alcohol and parental conflict. Haringey used an ‘embedders’ model as part of its training offer – this relied on the idea of training senior staff or ‘champions’ of the approach within services, and for these staff to roll out the training and ways of working to others.

A stakeholder interviewed reported that:

Staff confidence has increased, as well as their ability to start conversations with families that they wouldn’t have felt or been able to do before. The embedded trainer aspect really helped with this.

The training, coupled with other systems implemented in this area (see section ‘3.4 Effective systems to identify and refer families for support’ above), led to almost 20 appropriate referrals of families from children’s social care and early help staff in just a quarter – this was said to be more referrals than they would normally receive in a year by this route. However, there was still the capacity for more as there was clear evidence that some staff, despite completing the AUDIT C, did not refer families on for support. Also, there was evidence of high levels of staff turnover even among those identified as ‘embedders’.

A stakeholder interviewed commented:

We ended up doing this [training] 3 times. The first time we found out they had had a massive staff turnover – we realised that, if it changes at the top (in other words, a new service head comes in), then everything else changes. The new head brings in the people they have worked with before, so there is a whole middle management shift.

This suggested that such training needed to be offered on an ongoing basis to maintain and sustain new ways of working.

Much of the training delivered as part of the IF project was targeted at a variety of professionals in the general workforce with regular contact with parents, families and children. This training was most often intended to increase the general level of awareness of the signs of alcohol dependency and parental conflict, and their impact on children. Coupled with this, such system-wide training introduced participants to the local agencies and frameworks for identifying and supporting PAM parents and their children, with the aim of increased identification and referrals. In some cases, there was also the hope that some staff would be able to provide low-level support themselves without the need to refer for specialist support.

The Knowsley alcohol and substance misuse treatment team, for example, provided brief interventions training to 270 professionals from the local workforce as part of the project. Those receiving the training represented a wide variety of professions and organisations, including health visitors, adult and children’s social workers, domestic abuse support staff, mental health workers, housing officers, food banks, pharmacists, GPs, children’s centres, schools, community services, probation, police and the fire service. The training aimed t:

upskill professionals
increase their knowledge around alcohol, the consequences and impact of alcohol dependency
increase their confidence in having conversations with clients and patients around alcohol use

The Knowsley local evaluation found that:

Most stakeholders were very confident in signposting families to additional support for alcohol dependency. However, confidence levels varied in identifying the impact of parental alcohol use, and in delivering support to parents and their children.

Other projects delivering such training to frontline staff reported similar results. In particular, while it often raised their awareness of the issues and their confidence to identify needs, most still felt unwilling to provide support to parents and instead preferred to refer them on to specialist services.

In response to limited capacity to attend training among some frontline staff, including teachers and social workers, some areas had also developed much shorter ‘bite-sized’ training modules that could be delivered in around an hour to cover key issues of concern. This was seen as an important resource to address high levels of staff turnover among such staff.

Several areas also made use of training opportunities made available by DWP’s RPC programme to raise awareness of how to identify and understand the impact of parental conflict in families among frontline staff or services providing whole-family support. For example, in North Tyneside a staff member trained in working with parental conflict cascaded training to other project staff. In this way, working with parental conflict was grafted onto current workforce awareness, pathways and ways of working.

In West Sussex, the social services early help team ran an event called Growing Resilient Families in February 2020 to facilitate the work of the IF project and with a particular focus on increasing awareness of the impact of parental conflict. Eighty-nine professionals attended, representing a mix of different organisations, including:

NHS staff (such as maternity services and nursing)
early help
social care services
mental health services
substance misuse services
the voluntary sector
education

The local evaluation carried out a feedback survey at the end of the event and a follow-up survey 6 months later. The feedback from the event was very positive in terms of increased knowledge about reducing parental conflict. Respondents felt it had boosted their confidence to ask questions about it more often, as reported in the West Sussex local evaluation report:

I will ask how the relationship is with the couple rather than just asking if the woman is safe at home, which implies DV [domestic violence] only.

Respondents at follow-up also reported that the event had increased their confidence in discussing parental alcohol use and conflict with families, and signposting to relevant services. However, some participants also noted that other work priorities could limit their ability to implement their learning, while others said that it was easy to forget what they had been taught 6 months later.

As stated in the West Sussex local evaluation report:

The sad truth is that time and work restrictions often swamp us and making changes to how we do things can fall by the wayside. I think a reminder of the key elements of such events with practical suggestions of things organisations can do would really help here.

Further details are also provided in chapter ‘4. Delivering support to children and families’ (section ‘4.2.1 Enhancing whole-family work’) of how work on reducing parental conflict has been embedded in the delivery of support to families in several areas.

The COVID-19 pandemic and resulting lockdowns had an impact on both the ability of areas to deliver training to frontline staff, as well as the opportunities of some of those who were trained to apply their learning.

Several areas addressed the first of these 2 issues by moving training online or producing materials for services to access and re-use in future. The advantage of online delivery was that it could reach larger audiences without the need for travel or site bookings, but it reduced opportunities for interaction at such events.

3.6 Lessons learned

Overall, the main lessons learned from attempts at improving the identification and referral of children and families as part of the CADeP IF project include the following:

Buy in and commitment at all levels is essential for system change

Implementing and sustaining effective systems and approaches to identify and refer families affected by alcohol dependency and parental conflict relies on the buy-in and commitment at all levels of adult and children’s services.

While senior staff are required to set the overall strategic direction of such work, it should be implemented by people at an operational level who recognise the value and importance of taking the time to identify and refer families for support to minimise the negative impact on children.

Active pathways, and encouragement, at Tier 2 avoids escalation and reduces negative impact on children

Access to support, referrals or signposting families for support at Tier 2 is not enough to substantially increase participation rates in whole-family support services delivered by treatment providers and other third-sector organisations.

Instead, services making referrals need to implement effective ways of ensuring that families identified at Tier 2 (and above) can be enabled and encouraged to access support. This can avoid escalation and reduce the negative impact on children. In addition, it is essential to work with delivery partners as part of the referral process or gain consent for them to engage families directly.

Awareness of attitudes to alcohol among practitioners improves practice

When providing training to practitioners, it is important to include an exploration of their own attitudes towards alcohol and how these are likely to shape their response to its use among parents, along with the perceived impact on their children. Otherwise, it is possible that they might normalise alcohol use in their conversations, consequently minimising its negative effects on the family and any children involved.

Local authorities should consider making relevant training on the impact of alcohol dependency and parental conflict a requirement for early help and children’s social care staff, rather than an optional extra, given the known impact of these issues on children’s outcomes.

Continuously improving the impact of training and development

Local authorities also need to consider introducing mechanisms for evaluating and continuously improving the impact of training and development that is focused on increasing understanding of alcohol dependency and parental conflict at all levels of services.

Practitioner clarity on parental conflict, domestic abuse and their differences

Practitioners responsible for assessing the needs of families need sufficient knowledge and understanding of the differences between parental conflict and domestic abuse to identify the most suitable types of support for families. They also need to be aware of how parental conflict can cause other family issues, such as alcohol misuse and mental health issues, as well as vice versa.

Use secondment to embed learning

Adult and children’s services need to use experienced practitioners, or staff seconded from elsewhere, to help practitioners embed learning from training on alcohol dependency and parental conflict in their practice.

This is particularly relevant in terms of addressing staff turnover and other work commitments, which sometimes make it difficult for practitioners to participate in training.

Question 4

4.  Delivering support to children and families

Accepted Answer

This chapter describes:

how the 9 project areas used the CADeP IF to improve or enhance support provided to families affected by parental conflict and/or alcohol dependency
some of the challenges faced in doing so
the extent to which any changes made as a result of the project are likely to be maintained once the funding ends

The chapter ends with an overview of some of the lessons learned from delivering services to families as part of the project.

4.1 Types of support the areas delivered

Overall, the projects can be broadly divided between:

the one service delivery model: where whole-family support was delivered by one provider
the several service model: where whole-family support was delivered by several different services or providers

An example of the former was St Helens, which used the funding to increase capacity of its alcohol and substance misuse treatment provider to deliver more evidence-informed services to families, building on improved referral pathways (see section ‘3. Earlier identification of children, parents and families’ above).

Similarly, Rochdale provided whole-family support through a third-sector organisation by adapting an existing programme model to support parents who were transitioning from prison into the community. This was done by working with the whole family around the child or children within a structured outcome model.

Haringey also delivered whole-family support through its alcohol treatment provider, offering an 11-week parenting programme to parents and children that incorporated different activities, along with individual and group support. As shown in these examples, the funding was often used to adapt the provision of support to families affected by alcohol misuse by one provider – often a third-sector organisation. The funding was used to:

appoint additional staff
extend capacity
revise the service delivery model
add new services to their offer

In contrast, some of the other areas focused on providing whole-family support through several providers – in most cases, with each service delivering support to either the parents, children or others affected by parental alcohol misuse. A good example of this approach was Brighton and Hove, where 3 different services in the authority provided support to parents, children living with ADPs, and young carers respectively. In some cases, this included adapting the service offer, but in others the funding was mainly used to increase capacity or deliver it in a more flexible or expansive way (see section ‘4.2 The difference the IF made to the delivery of services’ below).

Similarly, North Tyneside used the funding to deliver whole-family support to parents, children and young carers through staff from 3 different providers in a community setting. As for the one service delivery model, the IF was used to either employ additional staff, extend capacity of an existing service, or revise or add new services to their offer.

It is worth noting that some areas adopted a hybrid approach that fell between these 2 contrasting models. Swindon, for example, can be broadly categorised as having followed the several service model – however, this included one third-sector organisation that provided whole-family support, while others targeted parents and children specifically and exclusively.

4.2 The difference the IF made to the delivery of services

The main changes in the support offered by the 9 IF projects can be categorised as relating to:

increased capacity to work with parents affected by alcohol dependency and/or parental conflict and their families
increased capacity to provide support to children and young people affected by parental alcohol dependency and/or parental conflict
the delivery of new services to provide support to others affected by parental alcohol dependency and/or parental conflict, including kinship carers, the wider family or friends

These are each explored in the sections below.

4.2.1 Enhancing whole-family work

Areas enhanced or refocused their whole-family work by:

changing their approach to working with the family
adapting the timing or location of delivery
co-ordinating the delivery of support with other services or agencies
integrating approaches to reduce parental conflict into their work

One of the ways in which the IF enabled an enhanced approach to whole-family working was to provide more capacity to do the work in a more flexible or in-depth way. This was done either by employing more staff or by reducing the caseload of existing staff members, which encouraged participation and enabled services to spend more time responding to the needs of families. Such a situation was often contrasted with ‘business-as-usual’ service provision, where the usual workload of staff in alcohol and substance misuse treatment services means that they often neither have the time nor flexibility to respond in such a way.

A good example of such a changed approach can be found in the Portsmouth whole-family support project – as illustrated in ‘Box 1: Portsmouth whole-family support project’ below. It shows that the IF allowed the alcohol treatment provider staff more time and flexibility to provide extended support to parents, thereby building trust to engage others in the family to access support as well.

All of the families received a flexible intervention according to their needs, which was primarily based on acceptance and commitment therapy (ACT) but with integrated elements of restorative practice, systemic family work, and relationship work for couples. ACT builds on cognitive behavioural therapy (CBT) and dialectical behaviour therapy (DBT), but also draws on other approaches such as mindfulness and emotion regulation to help people to overcome challenging thoughts and distortions.

Thirteen couples completed some parental conflict work as part of the intervention, but only 3 of them had a structured intervention based on Up2U’s creating healthy relationships intervention.

Box 1: Portsmouth whole-family support project

The project was run by the Society of Saint James (SSJ) and aimed to reduce the impact of parental alcohol misuse on families. This involved providing individualised whole-family support to both co-habiting and not co-habiting parents, children, other dependents over the age of 18, and extended family members to address alcohol and substance misuse and parental conflict. It adopted a holistic approach based on ACT, but also drew on other modalities, including talking therapies, responsive interventions and Up2U healthy relationships training.

SSJ staff thought that, as a third-sector organisation, they were able to reach families reluctant to engage with statutory children’s social care services or the main substance misuse hub before their problems escalated to require statutory intervention. This included some parents from occupations that included nurses or social workers.

A senior family worker stated:

We noticed we were hitting this layer of people who wouldn’t necessarily turn up to the main substance misuse hub.

Families accessing the service really appreciated the flexibility and non-judgemental approach used by the Whole Family Support project. This included sometimes delivering the support in people’s own homes, which meant they did not have to receive support in a daunting environment.

One parent commented:

It was more comfortable because it was in my own surroundings. It was easier, I guess, to talk rather than in any sterile, strange environment. That helped, massively.

Another important factor was that time was available to support the whole family for extended periods of time, often lasting more than 6 months, to really engage all family members, build trust and persuade parents to let their children receive help. Providing tailored support to the whole family:

helped to reduce parental conflict
made parents more aware of the impact their drinking had on their children
provided adults with ways to support and manage their own emotions

One parent said:

Had it not been the way that they work (…) that holistic focusing on the family as a whole (…), there’s no way our relationship would’ve survived.

The children benefitted from a range of interventions, including activities to:

help them explore their own feelings
understand their parents’ drinking
make a safety plan
identify someone to rely on

One of the children commented:

… We now have someone to rely on, that helps us with what’s happening, and before we didn’t really have anyone, because we didn’t really know what to do with the problems.

There were several examples in which the support had reduced parental drinking and had helped to create a happier home environment for the whole family. One parent stated:

I think there’s a lot more laughter in the house. My youngest, who I think it has affected more (…), she just turned round and said, ‘It’s really nice to have my mummy back.’

Sources: interviews with SSJ senior family worker and family support worker, and Portsmouth local evaluation report.

Such an approach – encouraging others to seek help by initially supporting one family member – was referred to by Haringey as the ‘ripple effect’ (also see box ‘7. Haringey Insightful Families project’ in section ‘5.2.1 Quantitative evidence’ below). A stakeholder commented:

A child affected by parental alcohol use might start work with the hidden harm worker and this encourages the parent to access alcohol treatment.

Project staff in North Tyneside also documented the way the additional funding for their project had allowed them to deliver more preventative services to families with problematic alcohol use to avoid an escalation of need:

This project goes back to 10 to 20 years ago, when practitioners had very small caseloads and could do intensive work with both adults and children, working to keep families together. Now underfunded and overstretched alcohol services have caseloads of 75+ clients, so they can’t work from a whole-family approach. (…) Bottled Up enables the team to get in there early on to avoid further problems and keep families together.

Increased capacity to deliver services to families or parents also allowed them to be more responsive and flexible in the support they provided, rather than adopting a ‘one size fits all’ approach.

In West Sussex, for example, the alcohol treatment provider offered tailored interventions for each client depending on their need. This varied from one-to-one sessions and home visits to joint sessions for couples and group sessions. Pregnant mothers referred for support particularly appreciated one-to-one work, as many were put off by the stigma of attending groups, as reported in the West Sussex local evaluation report:

What they’ve liked is that they haven’t had to go to groups all the time, [and] they’ve found it very beneficial to have one-to-one contact and discussions. They are more likely to sign up to these sessions over groups … Even if it’s work over the phone; it’s a big selling point.

St Helens used the IF funding to enhance the services provided by their existing alcohol and substance misuse treatment service. This involved employing staff with particular expertise to expand their work with families affected by alcohol dependency, including a Family Recovery Champion to incorporate invaluable lived experience into the team. This role provided families with the opportunity to speak with someone who had similar experiences to them and a personal understanding of the issues they were facing. Their offer to families was also expanded by offering 3 evidence-informed programmes to families for different levels of need and intensity, including:

The First Steps programme

A brief intervention and advice programme that provides 6 sessions over a 6-week period. It focuses on reducing the impact of alcohol use on families and is underpinned by systemic theory. The programme provides a range of resources, tools and a digital app, and facilitates access to mutual aid groups and apps.

The Confident Families programme

A 12-week parenting programme for parents who are misusing alcohol. The programme uses transactional analysis to help:

improve communication and behaviour
create positive role models
build parenting skills
enhance parents understanding of children’s developmental needs
identify the impact of neglect
explore consistent parenting and safe supervision
develop positive coping strategies and positive ways of managing challenging behaviour

The Moving Parents and Children Together (M-PACT) programme

This is a 12-week whole-family support programme that was developed by Action on Addiction. It was designed to work with children and families with multiple complex needs who are affected by substance use. The programme uses a psychosocial and educational approach, and has been running within a wide range of organisations across the UK since 2006.

In addition, St Helens also used additional funding received between October 2021 and March 2022 (see section ‘1.2 Aims and objectives of the innovation fund’) to fund a RPC co-ordinator role with a particular remit to work with families experiencing parental conflict.

The IF also allowed services in several areas to provide support in other, more flexible ways with regard to the time and location of support.

North Tyneside, in particular, delivered most of the support to parents and young people in community settings. The project lead stated:

The project decided to not take the support into a partner’s traditional building; instead, we worked with an ethos of going to the family rather than them coming to the service.

This meant that, for example, young people usually received support in their school on a one-to-one basis, while parents were often visited in their family home. This flexibility was valued by clients and was seen as encouraging better participation in treatment.

As shown in ‘Box 1: Portsmouth whole-family support project’ above, Portsmouth also found that such flexibility of being able to “bring the service to the client” rather than expecting them to attend the alcohol treatment provider kept many parents more engaged. One reason for this is that some parents are reluctant to attend the alcohol and substance misuse treatment service because of the stigma associated with such venues.

This experience was also mirrored by project staff in Brighton and Hove, as shown in the Brighton and Hove local evaluation report:

I’ve had a bit more flexibility to do home visits or do some outreach, and that’s gone really well because where I’ve been able to say, ‘Well, look, if you can’t come here, I can come to you’; it’s kept that parent engaged.

Some services also provided support to parents online or over the phone, particularly during the COVID-19 pandemic. North Tyneside found that this meant that they could still provide support during lockdown, and it also extended their reach and capacity to work with more families. While there was some initial reluctance among clients to access help in this way, it had become more ‘normalised’ by the end of lockdown. It was hoped that providing telephone support would enable the service to help more people going forward to deal with an increase in alcohol misuse in the area as a result of the pandemic.

St Helens also offered flexibility in the timing of support as a way to encourage more participation from families. This included delivering M-PACT programme sessions during the evening, making them accessible for children to attend after school and their parents after work. Another advantage of this was that the rest of the alcohol and substance misuse treatment service was closed at this time – which reduced the stigma associated with attending such a venue. The alcohol treatment provider also offered a taxi service, using its own minibus to transport a number of families to and from the M-PACT group (as reported in the St Helens local evaluation report).

Chapter ‘3. Earlier identification of children, parents and families’ above has already described the way several areas enabled services to work together more closely to identify and refer families and children for help. In some cases, the project also encouraged much greater collaboration between services in delivering support.

This was particularly the case in some of the areas adopting the several service model, most notably so in North Tyneside, where 3 services (CAMHS, the alcohol and substance misuse treatment service, and the Young Carers service) developed a multi-agency partnership as part of the project. Such close collaboration meant that families referred to the Bottled Up project were more likely to experience it as one service. This encouraged frictionless referral between partners and, as a result, fewer drop-outs when families were referred for support with another partner agency.

Co-ordination of support was also evident in other areas – even where services were not working as closely together as in North Tyneside. As the vignette in ‘Box 2: Brighton and Hove Back on Track (BOT) project’ below shows, a real strength of the BOT project in Brighton and Hove was the way it enabled services working with one family member to signpost them to a named person on the project. This was also often supported by closer collaboration when discussing the support provided by different services working with the same family.

Box 2: Brighton and Hove Back on Track (BOT) project

This vignette explores the way the BOT project provided support to one family in a holistic way. Parental conflict had instigated various issues, including problematic drinking by both parents, and a child-protection plan had been put in place by social services.

The OASIS family practitioner provided support to the mother over a 6-month period as a result of a referral from social care. She was initially quite reluctant to receive help, displaying real nervousness and shame, and often cancelled appointments, blaming it on difficulties to balance work and child-caring responsibilities. She commented:

I thought, ‘Well, that’s that then, my kids are going to get taken off me and that’s it.’

The family practitioner was able to overcome this by visiting her in her own home and using a supportive, non-judgemental approach, due to the lower caseload she had while working on BOT. The practitioner stated:

She didn’t have to fit into a stretched, overworked system – I could bring an offer to her that worked around her needs.

The support enabled the mother to recognise the damage of her alcohol use on her children and that it also stopped her from addressing other issues. She reduced her drinking and took up a new hobby, running, which gave her access to a new friendship group and improved her wellbeing. She disclosed:

Just admitting to somebody and really feeling there was no judgement there of what I’ve done. I could say it and feel really bad, warts and all.

The ru-ok? young people’s and family practitioner provided support to the son (aged 10 years old) after he was referred to the BOT project by his school nurse. He was worried about his parents’ drinking and wanted to know more about the effects of alcohol. The young people’s and family practitioner used an active planning tool called the ‘egg and triangle’ based on the adolescent mentalisation-based integrative treatment (AMBIT) approach to explore his concerns and set goals to help him feel safe. She met with him on a weekly basis over almost 12 months. In a thank you card to her, pictured below, he wrote:

You have helped me to get through a very hard time in my life and I would probably be very sad still, if it weren’t for what you’ve taught me to think about life and not worry about what is in my brain.

Image showing thank you card from a 10-year-old child.

A real strength of the project was the ability of those working on it to signpost families to another person rather than to ‘a different service’ to provide support. The family practitioner reported that:

There was a real emphasis on making accessing services as easy as possible for families and breaking down some of the barriers of doing so.

This meant that a senior young people’s psychotherapist working for Young OASIS also provided 8 sessions of therapeutic support to his younger sister (aged 8 years old). As it started during the pandemic, it had to be done online via Zoom. The psychotherapist used creative activities like painting and story dice to enable the girl to express her feelings and fears. She talked about her parents’ separation and how she experienced anger in the past between her mum and dad when they used to shout at home.

Support to the family ended after the child-protection plan was removed – over one year later, the case remains closed and no more safeguarding issues have been raised.

Sources: interviews with OASIS family practitioner, Young OASIS senior young people’s psychotherapist, and ru-ok? adolescent service manager and supervisor of young people’s and family practitioner; Brighton and Hove local evaluation report.

Another significant change in the provision of whole-family support evidenced by the IF project relates to the way several areas integrated addressing parental conflict into the delivery of services to families.

A good example of this is Haringey, where both the language and approaches to reducing parental conflict were integrated into the Insightful Families project delivered by the alcohol treatment provider. This started right from the referral process (see chapter ‘ 3. Earlier identification of children, parents and families’ above), where initial discussions and the referral form itself encouraged children’s services staff to be alerted to parental conflict in families. This was then addressed as part of the work with families by alcohol and substance misuse treatment staff working on the project:

We talk about parental conflict confidently and it is core within the Insightful Families project, and we’re now starting to talk to wider substance misuse services about it and train them about it and how to address conflict in families.

Haringey developed their own tools, which are now used to support children as part of hidden harm work. When they work with the parent, they explore with them how their own experience of parental conflict when they were young is impacting their parental behaviour now. The Haringey project lead stated:

Everyone can relate to parental conflict – a bit like alcohol dependency – and they can see themselves in the harm done. It is so normalised, so people learn a lot from it. Everyone recognises it. It helps people change behaviours and learn what is healthy and what isn’t.

Similarly, West Sussex has integrated a greater awareness of parental conflict into service delivery with all their alcohol and substance misuse treatment service clients, no matter their substance misuse issue, with a focus on pregnant clients and those with very young children. Before the project started, there was no emphasis on parental conflict, especially with regard to the language being used, as reported in an interview with the alcohol treatment provider:

The support might have been on offer to some extent, but the phrasing and the understanding of it as a separate issue was not there.

Now they look for the early warning signs that their involvement both in the CADeP IF project and the wider RPC programme has engendered.

In North Tyneside, parental conflict had not been as successfully integrated into their work with parents as in some of the other areas. However, CAMHS workers supporting young people as part of the project were said to have benefitted from it – enabling better identification of parental conflict and starting conversations with families supported as part of the project about it. Project staff reported that:

Before the project, if a young person was referred to CAMHS with suicidal thoughts, parental conflict would not have been high on their radar, but now it’s at the forefront of their minds.

Some areas had also trialled the use of standalone, evidence-based parental conflict interventions to support families affected by alcohol dependency. As described in detail above, St Helens delivered 3 such interventions within its alcohol and substance misuse treatment service, including M-PACT, to integrate a holistic behavioural change model looking at all aspects of parental conflict, including reducing the impact on children.

Haringey, Swindon, Portsmouth, and Brighton and Hove also offered interventions aimed at a small number of parents or couples only, but – as discussed in more detail in section ‘4.3 Challenges in delivering services (and how they were overcome)’ below – these were generally not as successful as projects where parental conflict was integrated into family support models in a more holistic way.

4.2.2 Work with children and young people

The previous section provided many examples of whole-family work with young people and children. A very good example of this was the different interventions delivered by St Helens, which focused on reducing the impact of alcohol use on the whole family. In the words of one alcohol and substance misuse treatment staff member:

The funding has enabled Change, Grow, Live (CGL) to become an adult service that has a child focus.

Similarly, the HFP project developed in Rochdale by Early Break delivered their whole-family service with the voice of the child being a central part of this process. Early Break works with children and families of alcohol and substance-dependent parents in prison. They provide a relationship-based, child-centred programme for restoring and strengthening positive family relationships in the face of intergenerational conflict, trauma, domestic abuse, and alcohol and substance misuse. HFP focuses on the relational aspects of family breakdown that social services often has less time or resources to address, with their primary focus on safeguarding and child protection.

Family events took place through the programme, ensuring the child was kept at the centre of the work and giving them a voice. The way in which the voice of the child was embedded in such whole-family work in Rochdale is illustrated in the following vignette (all names used in these vignettes are pseudonyms to maintain the anonymity of participants).

Box 3: Rochdale Holding Families Plus (HFP)

HFP met Jasmine, a 34-year-old mother of 3, while she was serving a 7-week sentence in Styal Prison. Jasmine’s family had experienced extensive and repeated alcohol and drugs misuse, domestic abuse and associated traumas over 3 generations.

Jasmine was estranged from her son Carl (aged 19), her daughter Lucy (aged 9) and her mother Maggie. Carl was facing his own battles with substance misuse and Lucy, a victim of sexual abuse and neglect, was being cared for by Maggie through a special guardianship order. Jasmine injected amphetamines and binged on spirits weekly. The acquisitive crimes she committed to support her dependency led to her imprisonment.

While Jasmine was in Styal Prison, Maggie felt anger and resentment toward her daughter and had cut off contact with her. She had lost her own son to substance misuse and feared losing her daughter. Because she did not want to see her grandchildren following the same path, Maggie gave up work to look after Lucy and was determined to protect her. But she found parenting difficult and had a deep mistrust of social services. Lucy was refusing to go to school.

HFP supported Lucy and shared her voice with family members to help them better understand the impact of their behaviour on her. Consequently, they encouraged Maggie to communicate with Lucy in an age-appropriate way and put basic boundaries in place. They also helped Maggie to navigate the education and social care systems, while supporting her at safeguarding meetings with social services. HFP met with Lucy and collaborated with her school in gaining a better understanding of Lucy’s mental and emotional health and how to support her. This helped build both Lucy’s and Maggie’s trust in the school and led to her resuming attendance.

Meanwhile, Jasmine left Styal and was placed in accommodation. She remained alcohol-free but lapsed briefly into amphetamine use. She started a new relationship with Bill and soon became pregnant. Bill was unemployed and a cannabis user and HFP supported him in seeking employment. HFP’s mental health worker helped Jasmine deal with her return from prison and her renewed amphetamine use. This led her to re-engage with the drug treatment services.

HFP continued to support Jasmine, who was caring for baby Alice. She was in a supportive relationship while continuing with treatment for drug use. For these reasons, she was able to keep her baby while remaining under supervision and was subject to regular checks from social services. Meanwhile, HFP enabled Maggie to confront her own anger and recognise Jasmine’s willingness to change. Eventually, with everyone’s agreement, Maggie and Lucy met Jasmine and, through these restorative family meetings, their relationships began to improve.

Carl (Jasmine’s estranged 19-year-old son) also started meeting with HFP’s mental health worker. She helped him understand his ACEs and supported him with anxiety management, emotional regulation and relationship building. Carl was also persuaded to engage with substance misuse services. Eventually, HFP arranged for him to meet Jasmine and slowly his relationships with the rest of the family were restored.

Twelve months ago, HFP closed the case because the clients all felt on track as a family unit. Lucy and Alice are currently living with Jasmine and her partner. Lucy is no longer on a Special Guardianship order and is being supported to stay with the family and attend school. She said:

I was shocked at first at the fact she had gone to prison, but my mum’s sorted it out now and she’s a completely different person.

Jasmine’s relationships with Carl and Maggie are restored. Carl no longer uses crack cocaine or commits crime, and both he and Bill have jobs as a result of the support received through HFP.

Artwork showing a rainbow featuring positive affirmations and a child and mother, drawn by a child whose family was supported by HFP.

Sources: interview with Early Break operations manager; Rochdale local evaluation report; HFP costed case study, July 2021.

In other cases, the IF funding was also used to expand capacity of statutory or third-sector organisations, or to help them introduce new or revised services specifically targeted at children and young people living with ADPs. This included, for example:

ru-ok? in Brighton and Hove adapting its normal focus on children and young people with alcohol and/or substance misuse issues to include those living with parents who are misusing substances
Vibe in Knowsley developing a new offer for young people that is more focused on alcohol dependency and parental conflict issues called Vibe Connect. This was based on an existing project called ‘Me Time’ that supports young people who require support and have a caring role with a family member or, if they are vulnerable due to family substance misuse issues, have experienced domestic abuse and/or have a parent or carer suffering from mental health issues
STEP Swindon adapting an existing programme of group therapeutic support for children and young people with mental health and wellbeing issues (for example, self-harm) to focus just on those living with ADPs. These groups are aimed at providing them with a platform for discussion, creative outlets and ways to manage the issues they face

West Sussex, in contrast, expanded an existing service previously piloted in 2 areas to the whole county to provide therapeutic support to children of ADPs. The aims of this programme included ensuring the effective identification of children and young people whose parents are alcohol dependent, and supporting them to improve outcomes in their health and wellbeing.

The programme was in very high demand in the area and achieved a large number of referrals – a total of 254 individuals over the study period. Of these, a total of 214 children and young people received treatment (including at least 2 or more sessions). As the vignette below in ‘Box 4: West Sussex: Change, Grow Live’s (CGL’s) therapeutic service for children’ shows, it also achieved many positive outcomes, including establishing good practice in supporting the post-therapeutic transition of participants. The team achieved this by working closely with schools and teachers to ensure that children had ongoing support after the sessions had finished. With the client’s permission, they tried to identify someone in the school the young person could talk with and other ways teachers could help to relay their information and suggestions, thus improving any challenges they faced.

Box 4: West Sussex: Change, Grow Live’s (CGL’s) therapeutic service for children

The Children and Young People’s Therapeutic Service was one of the key branches of support delivered in West Sussex. Having previously been piloted in 2 parts of the county, the IF funding enabled CGL to expand the service to the whole county in December 2018. The key aim of the therapeutic service was to support children and young people aged 4 to 18 years old who were affected by parent or carer alcohol dependency, thus improving their health and wellbeing.

Having piloted the service, CGL knew there was a county-wide need for specialist support for children with alcohol dependent parents. The young persons and families service commented:

We had this model that we knew worked… and we’d had referrals coming in. We knew there was a need, and we’d started to get some outcomes.

There are few such services catering specifically to children in West Sussex. While some counselling services exist for young people aged 13 and above, there is no counselling or play therapy for younger children. The therapeutic service addressed this gap in local service provision. It offered support to children in schools involving activities and conversations about what was happening at home and how they felt about it.

One particularly successful aspect of the service was the impact that supporting the child had on the whole family. By bringing children into discussions about parental alcohol dependency, they were able to work through difficult emotions while the therapist also supported parents to communicate more openly with them at home. In one example, an 8-year-old girl knew that her mother had disappeared but had not been told she had relapsed and been taken to a detox clinic. The children and young persons therapeutic service lead noted her confusion:

She wanted to know what happened but didn’t feel able to ask anyone. I asked her if she wanted me to speak to her dad to find out and she agreed. I explained to dad that she wanted to be included in conversations about her mum. So, dad said he would be more honest with her about her mum’s drinking.

Following the therapist’s advice, the father started using a ‘worry monster’ activity for his daughter to share worries with him.

Analysis of questionnaires completed by children who finished therapy showed that there were small yet statistically significant improvements in their life satisfaction and wellbeing scores. The quantitative results are echoed in feedback from professionals, families and children, who highlighted the positive impact these sessions had on the children’s emotional wellbeing.

One of the children wrote:

It has helped me like myself, and helped me deal with situations that I wouldn’t have been able to deal with before.

A parent reported:

He is happy and content again.

A teacher noted:

She always came back to class in a happier mood and was more content, which helped her have a positive Friday and end to each week.

Image of a collage made in a child’s first session with the therapist, featuring colourful hearts and smiling fruit and vegetables.

Sources: interviews with CGL children and young persons therapeutic service lead and young persons and families service manager; young person’s case study (age 8; Q3, 2021); West Sussex local evaluation report.

North Tyneside also increased its capacity to support children and young people by funding a CAMHS worker, as part of the project, to identify and support those living with parents with alcohol issues, often below the level of alcohol dependency. Providing support to young people in the community, and particularly in schools, was a new way of working for them – previously they would have only seen them in therapeutic settings. It targeted young people who would previously not have met the CAMHS specialist criteria.

A headteacher in a local school explained that, before the project, they had very little access to such support as they would not have had the resources to pay specialist counsellors:

You’re struggling to get help from any direction in schools… young people’s mental health services are stretched to the limit, and there’s a ridiculous waiting list.

Box 5: CAMHS work in the Bottled Up project, North Tyneside

The North Tyneside Bottled Up project was a multi-agency programme that involved the CAMHS service, the Young Carers service, the North Tyneside Recovery Partnership and others.

The CAMHS worker addressed a service gap by offering support to children and young people aged 5 to 19 who did not meet formal CAMHS referral criteria. She met with children of alcohol dependent parents in locations of their choice to support them with their emotional and mental wellbeing. She stated:

This is a bespoke service for young people who are struggling with having a carer or a parent or somebody close to them that [has] issues with substances, and that being validated, supported and recognised.

Providing highly flexible support, the CAMHS children and young persons worker used a variety of methods to engage children and young people. These included bespoke activities and crafts for children, or meeting young people for a walk along the seafront or a chat during their lunch break at work. She reported:

A lot of them did like the fact that it was really flexible support that fitted around their lives – especially as they often had quite chaotic things going on. I would often ask them what their interests were, and one was really into Minecraft, so we made cardboard Minecraft swords while we were talking.

The practitioner also helped clients to deal with the stigma and taboo surrounding the issues they were facing:

Alcohol misuse is a very secretive thing within families. Young people are told, ‘Don’t talk about this, don’t say anything.’ You have to really invest and spend some time and show them that they can trust you and you’re there for them.

Collaboration between different professionals across the Bottled Up project enabled a whole-family approach. If the parent rejected help, the CAMHS worker could support the young person and build a relationship with the family that way. Such an approach often encouraged parents to engage with the adult worker and vice versa, allowing the project to work with parents and children in a holistic way.

This included one family who lived in a more affluent area. As reported by the CAMHS children and young persons worker:

Mum was very reluctant for the young person to have any support because there was some worry about what that might look like and: ‘Would people know?’ But the adult worker (…) built up that relationship with Mum [and] explained what my role might be. Eventually Mum agreed for me to meet up with the young person, and that worked really well. We would meet up outside the home (…) because she was very worried about people knowing why I was there.

Overall, the flexibility of the project improved access for clients with often chaotic home lives, while its ability to support young people in a timely manner helped to prevent escalation into mental health services at a later point.

Sources: interviews with former CAMHS children and young persons worker and senior CAMHS practitioner; North Tyneside local evaluation report.

CAMHS said a key project aim for them was to identify vulnerable families where the parents had had issues with alcohol, but the children were not known to children’s services and so their issues were often hidden. This included children with less obvious safeguarding – for example, low levels of attendance or attainment at school. Some of them may have had a referral into early help, but previously it would not have led to any intervention.

In an interview, the CAMHS provider noted:

But then, a year or 2 later, they would be re-referred because things had escalated and they were self-harming and so on. Bottled Up prevents this from happening.

So, the service was intended to prevent further escalation of the need for such children and families.

4.2.3 Work with others

Finally, 4 of the 9 projects used the CADeP IF to provide support to others affected by parental alcohol dependency, including wider family members, kinship carers and friends. This was done through peer support networks to encourage those with experience or a history of alcohol or other substance misuse to provide a network of support to others.

A good example of this is provided by Knowsley (see ‘Box 6: Knowsley Family Matters Zoom project’ below), which funded a local charity to train community volunteers to engage those affected by addiction to attend community groups and benefit from peer-to-peer support to enhance a whole-family approach to recovery (all names used in these vignettes are pseudonyms to maintain the anonymity of participants).

Box 6: Knowsley Family Matters Zoom project

The Family Zoom Project was a peer-to-peer programme set up by Emerging Futures (EF) – a national charity that supports families affected by addiction and homelessness. This was done by training community volunteers using the ‘family coaching’ connection, awareness, nurture (CAN) and asset-based community development (ABCD) models. The aim was to enable them to engage those affected by addiction to attend community groups and benefit from peer-to-peer support to enhance a whole-family approach to recovery.

The project managed to identify and train 22 volunteers from April 2019 onwards, of which 10 became actively involved in reaching out to others across 5 community hotspots in Knowsley. Two of these were particularly engaged and were employed by Emerging Families on permitted earnings contracts. Even though the onset of COVID-19 made it much harder to identify affected families, they were able to set up several Zoom or WhatsApp groups that met weekly, involving around 17 affected family members.

The EF managing director commented:

The essence of family coaching is bringing people together and we could not do that [during COVID-19] – so delivery had to move online. But the fundamental principles of helping another in a group – that magic can still happen by Zoom.

Referrals into the groups came from the alcohol treatment service as well as various local community organisations with strong local roots. The volunteers also provided a lot of one-to-one family coaching to encourage others to attend the group sessions.

One of those who attended such a group was Chloe, whose husband suffered from depression, and had received support for his cocaine and alcohol addiction. Chloe reported that, through attending the Family Matters Zoom meetings, she had “at last been listened to about the issues that thankfully are now disappearing”. Chloe’s partner was now drug-free and family life had improved significantly.

After the funding for EF through the IF ended in March 2021, delivery of the Family Zoom Project was handed over to the alcohol treatment provider and the recovery family worker ran the group for one hour each week, with the help of Chloe. The delivery approach was adjusted slightly. This included, for example, inviting speakers from mutual aid meetings (such as Alcoholics Anonymous, Narcotics Anonymous or Al-Anon) to the group. Numbers participating declined during lockdown, but the recovery family worker hoped to reinvigorate it in the next few months through her new role as group leader at CGL, as she saw the importance of such peer support.

The recovery family worker commented:

Commissioners need to understand that this is a family issue. You can get someone sober, but if their whole family isn’t supported – they go back into a family that hasn’t been treated to know what they’re dealing with.

Sources: interviews with EF managing director, EF enterprise and community manager, CGL recovery family worker and CGL quality, audit, governance and performance lead; EF quarterly reports; Knowsley local evaluation report.

4.3 Challenges in delivering services (and how they were overcome)

This section presents the main challenges projects faced in delivering services to families as part of the CADeP IF projects, and ways they tried to overcome them. Overall, these related to:

challenges encountered as a result of the COVID-19 pandemic and lockdown
lack of continuity among staff or providers
lack of joined-up working between services
issues in the integration of parental conflict into services
lack of referrals into services

4.3.1 Challenges associated with COVID-19

Perhaps unsurprisingly, COVID-19 was often cited as the key challenge for many of the projects delivering services for young people and families. In several cases, this meant that particular interventions or elements of services had to be put on hold or significantly modified.

This was particularly the case for those relying on face-to-face work involving groups of participants, such as M-PACT in St Helens and Knowsley. The latter was only able to involve one group of 10 families in this intervention, of which 6 completed it successfully, before the start of the pandemic.

St Helens also had to pause delivery of M-PACT for a 12-month period during the pandemic. However, in collaboration with Action on Addiction (who created this intervention), they set up a hybrid version of the service, involving a mixture of online and face-to-face sessions, to allow them to continue delivering it during COVID-19. This meant that they were able to engage a total of 36 families, including around 63 children and 37 adults, between 2019 and 2021 – exceeding their initial target of 16 families set at the start of the project (as reported in the St Helens local evaluation report).

West Sussex faced a similar challenge for both their therapeutic work with children and the family work with parents. Delivering the therapeutic intervention remotely was particularly difficult as the majority of participants were primary-aged children. They tried to address this issue by sending postcards home to students and doing regular welfare checks with their parents. They also started doing online counselling with the older students.

They were able to get back into schools after summer 2020 and work with all the children. One key learning point was that some of the older students were happy to continue to receive remote support even after the end of lockdown. This was helpful as it reduced the amount of travel across the county needed by the therapists. However, the majority of students still preferred face-to-face support.

Parental support was also delivered remotely (online or by phone) by West Sussex during COVID-19, and this also presented some challenges for the family workers. In particular, they found it difficult to build rapport and relationships with clients they had never met in person over the phone. According to the West Sussex local evaluation report:

You miss out on some of the visual cues you can get from face-to-face work.

This was seen to be a particular challenge when dealing with parental conflict.

Swindon had similar issues in delivering the Safe Families project (see ‘Box 8: Swindon Safe Families project’ below), which aimed to support families whose isolation led to alcohol misuse and parental conflict from September 2020 onwards. Lockdowns limited the number of referrals into the service and the ability of volunteers to visit families, but they tried to overcome this by delivering some of the work remotely. Check-in phone calls with parents and children were used to try and maintain direct contact, and to combat the downsides of online support compared with face-to-face work. At home, resources and activities were set up (around relationships, anger, stress and so on), and they tried to make these accessible to young people, delivering packs to doorsteps where necessary. They also supported families at Christmas with hampers, food parcels and gifts.

4.3.2 Lack of continuity among staff or providers

The implementation of the projects and delivery of services were also negatively affected in several areas by a lack of continuity among the staff or providers involved.

This was a particular issue in one area, where a re-commissioning process of a new alcohol treatment provider occurred after the start of the IF project in 2018. Brighton and Hove had aimed to make improvements to the formal identification of parental conflict and other parenting issues as part of their initial assessment process when parents presented for treatment.

Meetings were set up so that the assessment could be reviewed by a set of parents, the children, a treatment worker, a data analyst and young carers. Recommendations were communicated back to the steering group for review and, at that point on 1 April 2020, the alcohol and substance misuse treatment provider was changed, meaning that all of the work carried out was lost as a result.

A stakeholder interviewed stated:

The new provider had their own ways of doing things, so all that work that had been done kind of ended up unfortunately not materialising.

This was cited to be one reason why the integration of parental conflict into the support provided to ADPs as part of the alcohol and substance misuse treatment service had not progressed as quickly as expected.

As discussed in section ‘4.4.1 Re-commissioning substance misuse services’ below, several areas have addressed this issue by requiring providers to continue the delivery of such services as part of the re-commissioning process.

Staff turnover among those co-ordinating and delivering the project was also cited as a key challenge in several areas. This included several project co-ordinators or commissioners finding other jobs – which meant that project memory and momentum was lost.

North Tyneside encountered a particular issue of losing key delivery staff. This was a challenge for them as their project adopted the several service model – delivering support to parents, young people and young carers by different providers. Two of 3 staff funded by the project left just before the end of December 2021 and the project had to wait for the 2 services (CAMHS and Young Carers) to recruit replacement staff before they could continue to deliver the full whole-family service.

A stakeholder from the project stated in an interview:

When you have 3 or 4 partner agencies involved but you’re recruiting to one project, you’re not in control of your own staff and workforce … If it had just been a local authority project, we could have pulled in people from elsewhere, but here we have to work with partners and their recruitment constraints and recruitment timetables. So, it is a lot more challenging.

4.3.3 Lack of joined-up working between services

Another challenge associated with the several service model in particular was that the provision of support for families was sometimes not as well co-ordinated as it could have been.

As discussed in chapter ‘3. Earlier identification of children, parents and families’ above, one of the challenges facing most of the projects was for adult and children’s services to share data and information on families effectively with each other. This problem was often exacerbated when support to different family members was delivered by various agencies.

Knowsley, for example, found that this meant that, in some cases, there was a lack of awareness in the system of whether agencies were working with members of the same family or not, preventing a more joined-up whole-family approach. In the words of one of the stakeholders:

Although the service offers had really good outcomes, when we mapped the families that were in receipt of them, they weren’t the same families. So, they were all in different pathways – receiving good services and achieving good outcomes – but it wasn’t that a family would get a CGL worker and then the child would go to Vibe and then as a family they’d receive M-PACT.

They tried to address this towards the end of the project by appointing a hidden harm worker to forge a closer relationship between early help and the alcohol and substance misuse treatment service, with the family at the heart of it.

4.3.4 Issues in the integration of parental conflict into services

While, overall, most of the 9 areas felt that they had made good progress in integrating parental conflict into the whole-family support they provided, some progressed more slowly. This was sometimes due to weaker links with the wider RPC programme in some areas, or particular issues associated with the relevant training.

One area, for example, told us confidentially that at the start of the project it was “hard to mention the words ‘parental conflict’ in early help”. After the appointment of a new senior leader in early help more recently, this had changed, and they had been able to work on better integration of parental conflict into the delivery of the project.

Another area told us, once again in confidence, that at the start of the project, the IF and RPC programmes had initially been kept quite separate and only since January 2021 had there been more of a recognition within the authority of a need to bring these more closely together. Progress in integrating parental conflict into the delivery of whole-family support had, as a result of this, been understandably slower in such authorities.

As noted in section ‘4.2.1 Enhancing whole-family work’ above, some areas had also trialled the use of standalone parental conflict interventions to support ADPs.

Haringey, for example, had offered a 16-week BCT programme to some ADPs referred to the IF Insightful Families project for support. Similarly, Brighton and Hove had piloted the use of the 18-week Parents as Partners intervention online with 6 couples between January and July 2021. Following on from this, they also wanted to offer some face-to-face support with up to 3 couples.

However, demand for such interventions was said to be low among parents accessing support and it was difficult to get sufficient numbers of referrals. In Haringey, for example (as reported in the Haringey local evaluation report):

Feedback from participants was that the full parental conflict counselling programme took 4 months, and this was viewed as too long. It was also felt that, as the parental conflict counselling sessions commenced after the Insightful Families parenting programme ended, that the timing of this offer was wrong, and the preference was for parental conflict work to be fully incorporated within the parenting programme.

This meant that work on parental conflict was instead integrated into the whole-family support programme delivered by the alcohol treatment provider as part of the IF project, initially through a group session focusing on this topic. The response to this was overwhelmingly positive. In fact, service users requested additional focus to be placed on parental conflict, resulting in 2 more group sessions being dedicated to exploring this topic.

In Brighton and Hove, there was also a lack of interest in the offer for standalone parental conflict interventions targeted at couples (although RPC provision can also be targeted at single or separated parents). One issue was that many of the parents that the alcohol treatment provider was working with were single parents, while some of the couples it was offered to did not see ‘communication’ or ‘parental conflict’ as the key issues they wanted to address.

The project also tried to get referrals through the children’s services ‘front door’ – but there was again often reluctance among staff to focus on parental conflict when there were so many issues, such as around neglect, for example, that they saw as bigger priorities to address first.

One stakeholder commented in an interview:

In a system in which we were more alert to the impact of alcohol, then these attendant offers around things like parental relationships I think would have more purchase. I still think that, on a fundamental level, we do not think of alcohol use as dangerous and urgent a situation in families as we do around substance misuse, or where there are very obvious signs of neglect and safeguarding issues in terms of parenting and abuse. So, it still feels like the junior partner to me. And we’re still making the case! That’s why the key message for us [coming out of the project] is: ‘You have to assume this isn’t okay for the child’.

However, the alcohol treatment provider thought that such standalone interventions may be more successful if they are targeted at families with lower levels of need, where the problematic alcohol consumption is linked or even caused by parental conflict or other related family issues.

4.3.5 Lack of referrals into services

Lack of referrals was not just an issue for standalone parental conflict interventions, but also affected some other services delivered as part of the IF projects (see previous chapter ‘3. Earlier identification of children, parents and families’).

This was often exacerbated during COVID-19 when lockdown meant that schools were closed and were less able to refer young people for support. In Brighton and Hove, for example, referrals into a provider delivering support to children mainly came from schools before the start of the pandemic through very active promotion of the service, including meeting with teachers, school nurses and others. This meant that they were able to identify children who were often not ‘on the radar of children’s services’ but were negatively affected by their parents’ alcohol consumption (see ‘Box 2: Brighton and Hove Back on Track (BOT) project’).

The number of referrals dropped significantly after the start of the pandemic and the service was more dependent on receiving referrals from social workers. However, this meant that the service was supporting lower numbers of children and mainly those at Tiers 3 and 4 of social care. One provider stated in an interview:

I am worried about the young people that we’re not getting from school.

The project had tried to address this by working more closely with the children’s services front door to identify families and children at Tier 2, as well as training delivered to a local police officer, but numbers of referrals remained lower during lockdown.

West Sussex also initially had problems with getting enough referrals of parents into their alcohol and substance misuse treatment service, which was focused on providing whole-family work to pregnant mothers or parents of very young children. However, outreach work and training provided for staff working in antenatal and perinatal care services, as well as midwives and health visitors, significantly increased the number of referrals into the service. While this meant that they managed to engage many mothers in the service, they found it much harder to reach fathers.

A stakeholder reported in an interview:

We haven’t been able to see partners, which has been a massive issue. Antenatal care has been women only … they’re just coming back now, but we know from reports coming through from the police and social services that alcohol use and domestic abuse has really escalated. We’ve had women booking in who’ve said they were drinking to excess … this will have impact on the referrals we get [post pandemic].

4.4 Sustaining changes

Interviews conducted towards the end of 2021 explored projects’ plans for sustaining the work developed as a result of the CADeP IF funding (see section ‘1.3 Evaluation methodology’ above).

One of the key findings from this research is that all areas were committed to building on the success of, and learning from, this programme and hoped to continue activities in some way or another. The main ways they hoped to sustain the project work were through:

re-commissioning the treatment provider to include whole-family work as part of its basic remit
continuing to fund posts or services created as part of the project
building on the learning made and any resources developed as part of the project to continue to support families

4.4.1 Re-commissioning substance misuse services

One of the main ways in which projects hoped to continue delivering their approach to whole-family support was by including a requirement for such an approach in future re-commissioning of their alcohol and substance misuse services. Indeed, 6 of the 9 areas had either just gone through such a re-commissioning process or were just about to do so in the next 12 to 18 months.

North Tyneside, for example, said that, as a result of their experiences of the IF project, their re-commissioning plans required any future alcohol and substance misuse treatment service to appoint an adult worker to provide support to families in a community setting – as was done for the CADeP IF project – and to adopt other learning from this. This included, for example, not to operate the normal ‘3 strikes and you’re out’ punitive system for non-attendance, but to include a much more proactive way of working.

A stakeholder stated in an interview:

Providing more preventative work to include families with problematic drinking where it is not necessarily alcohol dependency, but still of concern.

Similarly, Portsmouth was, at the time of interview, in the middle of the re-tendering process for its whole alcohol and substance misuse treatment service. It has since then re-commissioned the same provider for this service and will mainstream the approaches developed as part of the IF project over the next 4 to 10 years, depending on contract extensions. This will involve working in partnership with social care and other partners to promote positive approaches to parenting.

Building on the learning from the project, the provider will use a team of 2 family support workers, offering up to 18-week interventions for 50 families a year based on its whole-family case management model. This will include a focus on parental conflict in those families where it is seen as a key factor of parents’ alcohol and other substance misuse. The provider will also be required to support all children living with a parent who has substance misuse or alcohol dependency issues – not restricted to children at particular tiers of social care services. The CADeP IF project was said to have achieved buy-in to the value of such an approach at the strategic level both within public health and children’s services.

Haringey had already recently re-commissioned its own treatment service and had required the successful bidder to show that they would adopt a whole-family approach and that parental conflict would also be integrated into their work with families. Their existing provider bid for the contract and was successful, as they were able to build on the work done as part of the IF project.

Similarly, St Helens has recently re-commissioned the same provider to deliver the local substance misuse service for up to an additional 7 years. This contract award included substantive funding for 3 additional staff to support provision of a quality family substance misuse service, with 2 additional social workers and an additional recovery co-ordinator. It also involves the delivery of a new 12-week parental conflict programme.

However, even though several areas reported that they hoped that such re-commissioned services would be able to continue to deliver services to ADPs and their families, several were concerned that, without additional funding, they would not be able to do so with as much flexibility and in as much depth as over the last 3 years. As one area told us, in confidence:

Really bluntly, drug and alcohol services need more funding. There have been non-stop cuts to funding over the past 5 years. The impact of these cuts means that, 2 years ago, the caseload for a worker was 50 people, and now it’s 90 people. This is too much, particularly as the workers are being asked to work more holistically on top of having to manage crisis situations such as those with suicidal tendencies or in domestic violence situations. So, your ability to support the whole family is limited. It’s not from a lack of wanting, not from a lack of caring – it’s just literally a matter of capacity.

Several interviewees shared such a sentiment and hoped that heightened awareness of the issues facing families as a result of the Dame Carol Black review would increase funding for such services.

West Sussex stood out as the only area that had been able to secure ongoing baseline funding without any reduction before the end of the CADeP IF project. In fact, they had actually increased their funding for the therapeutic work with children. They believed that the evidence of the benefits to children and families demonstrated by the project and local evaluation had helped to convince the authority to continue to fund these services. They hoped to mainstream them as part of their 2023 re-commissioning plans.

4.4.2 Continuing to fund posts or services created as part of the project

Other areas also said that their experience of the benefits of the work done as part of the IF had convinced services in their area to continue to fund posts or services created or modified as part of the project.

CAMHS in North Tyneside, for example, had recruited a full-time worker to carry on with the Bottled Up community approach going forward using their own budget.

Similarly, Brighton and Hove had integrated the family practitioner role into their alcohol treatment service because the role was seen as working so well, supporting their offer and enabling them to work with more parents (rather than just ‘adults’). However, as a result of the end of the funding, their caseload size had increased again so they had less time to spend on whole-family work. Similarly, the young people’s service in Brighton and Hove that grew significantly as a result of the funding had shrunk back in size to what it was before the project.

Continued funding of posts or services created as part of the IF project was often said to be harder for third-sector organisations or charities unless they could draw on other resources, or where it had just topped up existing funding. The Young Carers charity in Brighton and Hove, for example, had already secured funding from other sources to continue their role in supporting young people with caring responsibility for ADPs delivered as part of the project. In contrast, a charity that had set up and run a peer support network in Haringey was probably unlikely to do so once the IF funding ended, as one stakeholder reported in an interview:

I am not sure if they will continue to develop this way of working in the new contract, as it is harder to sustain without the additional funding. So, it is a concern not having the outside agency looking over our shoulder and asking: ‘What about the significant others?’

This was also a concern for the HFP project in Rochdale, as sustaining this service depended on applying for small pots of money to continue with and develop the interventions and learning generated by the project. Interviewees expressed their frustration at:

… siloed commissioning that cannot accommodate the breadth of work envisaged by HFP, especially in relation to intergenerational and trauma-based work with families affected by substance misuse, conflict, and risk-taking behaviours.

4.4.3 Building on the learning made as part of the project

Finally, all the projects said that staff within the various services involved in the project had benefitted from developing greater awareness and skills related to working with families affected by alcohol dependency and parental conflict. In addition, they could draw on materials and training resources developed as part of the CADeP IF project to ensure that such awareness and skills were not lost due to staff turnover in such services – as was shown to be an issue even during the project.

In Knowsley, for example, the legacy of the project was said to include the brief intervention training, which is now part of the ongoing training offer by the alcohol treatment provider. Staff are also now trained in the delivery of the M-PACT intervention (which had to stop due to COVID-19). Similarly, Brighton and Hove hoped to continue using their bite-sized training offer (see previous section ‘3.5 Increased practitioner awareness, skills and confidence’), which can be delivered to different services to raise awareness of the impact of alcohol dependency and parental conflict on children.

Overall, most areas said that activities carried out as a result of the IF had raised awareness of the issues among staff across services and had started a learning journey towards supporting families more effectively in future. A stakeholder from the North Tyneside project commented that:

We feel like there is still loads to develop and learn from the families. So, it is like we are at the start of phase 2 rather than that we have got a project where we know that we have cracked it.

4.5 Lessons learned

Overall, the main lessons learned from delivering support to families as part of the CADeP IF project include the following:

Third-sector organisations

Families with alcohol dependency or problematic drinking behaviours are often more willing to engage with third-sector organisations that provide a more flexible and strengths-based approach (that focuses on individuals’ strengths, such as personal strengths or social and community networks, and not on their deficits or issues they face).

In contrast, they can sometimes be afraid to access support from statutory services as they are afraid that this could lead to involvement of social services in their family and escalation to CIN or child protection plans.

Community settings

Families are more likely to engage in services if they are provided in community settings, including schools or people’s own homes. Requiring them to attend substance misuse treatment centres can be off-putting, given the stigma attached to addiction and not wanting to be seen attending such a place by others locally.

Flexibility in the timing, location and mode of service delivery can together encourage families to attend who otherwise might drop out due to other commitments or their reluctance to engage.

Impact of parental conflict

The integration of an awareness of the impact of parental conflict was very much welcomed by services delivering support to parents, children and families.

Overall, this was seen as being most effective and welcomed by participants when activities were integrated into the service as an element within a more holistic offer to tackle the combined effects and causes of alcohol dependency and parental conflict, rather than delivered as standalone parental conflict interventions.

Importance of trauma-informed learning

A key learning point for many projects was the importance of trauma-informed working. Such an approach is needed in light of the fact that many ADPs have experienced multiple forms of trauma throughout their life. This is often intergenerational, meaning that their own children are at risk of experiencing mental and trauma-related harm.

Remote working

Remote-working approaches offer opportunities for expanding capacity of services but are not suitable for all types of clients. The COVID-19 pandemic raised many issues for projects, but several of the areas found ways of providing support remotely or using hybrid approaches.

Some teenagers and parents with less severe needs sometimes preferred accessing services in this way. Providing support in this way also relies on staff being confident in using online technologies to engage with families and finding tools that are best suited to such approaches.

Moving forward, such remote working can in certain circumstances increase the capacity of services. However, in other cases it will not be suitable for particular types of provision, and face-to-face support should be provided whenever possible.

Whole-family support work is resource intensive

Doing whole-family support work is resource intensive, and often requires the support of specialist staff and services that can address the needs of parents, children and wider family members.

Without additional funding, many services are likely to find it hard to maintain the level of support provided as part of the IF project, where extra resources were dedicated to particular staff to work in a particular way.

Question 5

5.  Improving outcomes of children, parents and families

Accepted Answer

This chapter presents the evidence from the 9 local evaluations of the impact and outcomes of the CADeP IF project activities, as described in the previous chapter on children and parents identified and referred for support (‘4. Delivering support to children and families’). It also draws on the analysis of NDTMS data over the last 4 years, for the 9 areas and nationally, to explore any evidence of the impact of the programme on participation rates.

The chapter is structured as follows:

‘5.1 The difference project activities made to children’ outlines the main impacts of project activities on children, based on quantitative and qualitative evidence collected by the local evaluations
‘5.2 The difference that project activities made to parents or carers’ does the same for parents
‘5.3 The difference the CADeP IF projects made to participation rates’ presents our analysis of NDTMS data to assess whether CADeP IF projects may have had an impact on participation rates of ADPs
‘5.4 Lessons learned’ ends with an overview of some of the lessons learned from exploring the impacts and outcomes of delivering activities across the 9 areas

5.1 The difference project activities made to children

5.1.1 Quantitative evidence of the impact on children

Most of the evidence of the impact on children collected as part of the local evaluations is qualitative, although there was some quantitative evidence, as shown in table 5 below.

Table 5: quantitative evidence on outcomes for children and young people

Area	Activity	Scale	Domain	Sample
West Sussex	CYP therapy	CGL scale	Wellbeing	111
West Sussex	CYP therapy	SLSS	Life satisfaction	52
St Helens	M-PACT	SCWBS	Wellbeing	64
Haringey	Whole-family support	My Star	Health and wellbeing	19

The strongest evidence of impact of activities on young people relates to the provision of the therapeutic service in West Sussex (see ‘Box 4: West Sussex: Change, Grow Live’s (CGL’s) therapeutic service for children’) and M-PACT in St Helens, both of which were also supplemented by qualitative data. Portsmouth and Knowsley also collected quantitative evidence to assess the impact of their support on young people, but very small sample sizes due to the COVID-19 pandemic meant that they were not able to detect statistically significant outcomes.

The section below reports statistically significant differences between baseline and follow-up assessments of the corresponding scales. If a result is statistically significant, it is unlikely to be explained solely by chance or random factors. The probability value (or p value) tells you the statistical significance of a finding. In most studies, a p value of 0.05 or less is considered statistically significant, but this threshold can also be set higher or lower. Where possible, effect sizes are reported in addition to p values. Effect sizes are standardised measures of the magnitude of change over time, which can be interpreted according to conventions as small, medium, large or very large.

Young people living with ADPs who were referred for therapeutic support in West Sussex completed 2 scales at the start, mid-point and end of treatment. This included the following 2 scales:

The SLSS was only used by the project from 2019 onwards, so pre- and post-treatment responses were only collected from 52 young people (compared with 111 for the CGL scale).

The West Sussex local evaluation identified statistically significant differences over time for both scales, with significantly higher average scores (representing higher levels of wellbeing and life satisfaction) at completion compared with entry- and mid-point review. More specifically, analysis of the SLSS showed an increase from an average mean score of 3.85 to 4.15 by the end of treatment (p<0.05). This suggests a small but significant improvement in life satisfaction among children supported by the service.

It is worth noting though that the data from West Sussex excluded around 10% of referrals who declined or disengaged from the service before treatment end. Also, there was no control or comparison group to determine if the changes measured were purely due to the therapeutic service or may have occurred as a result of other interventions or changes. However, according to the West Sussex learning evaluation report, the findings were supported by the views of:

professionals, families and children, who commented consistently about improved emotional wellbeing due to therapy.

Of the 86 children and young people who participated in the therapeutic intervention between January 2020 and March 2021, 62 completed feedback forms with space to provide open text responses as well as closed questions, such as ‘Do you think our time together helped you?’. While 92% of participants said ‘Yes’ (84%) or ‘A little bit’ (8%) to this question, explanations of how it had helped included the following (taken from the West Sussex learning evaluation report):

It was nice speaking to someone who doesn’t know me and speaking to someone who can give me different perspectives… I was able to get things off my chest and I wasn’t bottling things up anymore.

… It has helped me like myself and helped me deal with situations that I wouldn’t have been able to deal with before.

Interviews with 32 parents or carers and 27 professionals (such as teachers, special educational needs co-ordinators, pastoral or safeguarding leads and link workers) provided further evidence of the positive impact of the therapeutic intervention. As one professional commented (in the West Sussex learning evaluation report):

[The] student felt supported and cared for. He knew he had a safe person he could confide in and who understood the home issues.

Similarly, a parent or carer noted that:

It has really helped him understand his feelings with the situation and he has really benefitted from it. He is happy and content again.

St Helens provided quantitative evidence of the impact of the M-PACT whole-family support intervention on children and young people (as well as adults – see section ‘5.2 The difference that project activities made to parents or carers’ below). This was done using the Stirling Children’s Wellbeing Scale (SCWBS).

The Stirling Children’s Wellbeing Scale (SCWBS) (PDF, 428KB) is a 12-item scale split into 2 sub-scales of ‘positive emotional state’ and ‘positive outlook’. It was designed to provide a holistic measure of emotional and psychological wellbeing in children aged 8 to 15 years. Example scale items include: ‘I can find lots of fun things to do’, ‘I feel that I am good at some things’ and ‘I think lots of people care about me’. The minimum score for the SCWBS scale is 12 and the maximum 60, with higher scores representing higher levels of wellbeing.

Previous studies carried out when developing the scale found a mean score of 43.51 and 44.0 among school children in Scotland. Compared with this, the average score was 31.0 for the 64 children completing the scale at the start of M-PACT in St Helens, denoting a much lower level of wellbeing than among the average population. This rose to 48.0 by the end of the intervention, indicating a significant increase in wellbeing (p<.001). The effect size of 1.69, which is here the standardised mean difference (in other words, Cohen’s d) indicates a very large increase in wellbeing (see table 6 below). Both sub-scales (‘positive emotional state’ and ‘positive outlook’) also yielded a statistically significant increase in the level of wellbeing from pre- to post-assessment (p<.001).

Table 6: impact of M-PACT on children and young people using the SCWBS (St Helens)

Scale	Number of children	Baseline mean (SD)	Follow-up mean (SD)	Significance	Effect size
Subscale: Positive outlook	64	16.2 (4.53)	24.2 (3.70)	p<0.001	d=1.48
Subscale: Positive emotional state	64	14.8 (4.81)	23.8 (3.72)	p<0.001	d=1.69
Total scale	64	31.0 (8.71)	48.0 (7.04)	p<0.001	d=1.69

Source: St Helens local evaluation report and own analysis. Note: SD = standard deviation; p = probability value; d measures effect size.

Once again, there was no comparison or control group of young people who did not take part in the M-PACT intervention – but qualitative interviews with 21 children (and 11 parents or carers) conducted as part of the local evaluation provided supportive evidence of the positive effect of M-PACT. Thus, for example, 2 young people reported (as detailed in the St Helens learning evaluation report):

When you walk through the door, it’s like a lot of weight’s gone off your shoulders because there’s people in here who have been put through what you have …

M-PACT brings families together and helps them build a better connection. Family is stronger together with CGL.

Similarly, a parent said that, since taking part in M-PACT, her son’s behaviour and attendance at school had improved considerably (as stated in the St Helens learning evaluation report):

They was getting excluded from school and then I’ve come here and got clean… they was being naughty in school and I’ve gone today and I’ve got an amazing report.

Quantitative data collected in Haringey also provides evidence of the impact of whole-family support on young people’s health and wellbeing (see table 8). This project used the My Star tool with children at the beginning and end of accessing support as part of the IF Insightful Families project.

The My Star tool was developed as a way of capturing the voice of the child, their needs and their perspective on the changes they are experiencing. It was also used to check that the changes made by parents are enabling their children to thrive. It focuses on 8 domains, such as physical health, relationships, feelings and behaviour, and self-esteem.

Even though only 19 young people completed the scale during the project, it resulted in a significant overall change (p<0.05) in health and wellbeing. The size of this effect can be interpreted as medium (see table 7).

Table 7: impact of Insightful Families on children and young people using My Star (Haringey)

Domains	Average – initial	Average – follow-up	Significance	Effect size
Being safe	4.2	4.6	p<0.05	d=0.50
Confidence and self-esteem	3.8	4.2	p<0.05	d=0.60
Education and learning	3.8	4.4	p<0.05	d=0.58
Feelings and behaviour	3.3	4.1	p<0.01	d=0.80
Friends	4.1	4.5	NS	d=0.38
Physical health	3.9	4.4	NS	d=0.47
Relationships	3.8	4.2	NS	d=0.32
Where you live	3.5	4.1	NS	d=0.42
Average	3.8	4.3	p<0.05	d=0.50

Source: Haringey local evaluation report and own analysis. Note: NS = not statistically significant; p = probability value; d measures effect size.

While there were positive mean changes across all domains, the changes were only statistically significant for those relating to children’s emotional wellbeing, mental health and education. In contrast, they were not significant for those domains less likely to be directly affected by young people’s involvement in the intervention, including friends, physical health and where they live.

5.1.2 Qualitative evidence of the impact on children and young people

All the other areas also provided qualitative evidence of the impact of whole-family support or individual interventions on young people. What stood out was that they liked the following:

Not being judged by project workers

A young person in the Knowsley learning evaluation report said:

You can be anything you want and you’ll be supported and not judged by whatever you choose.

Making contact with other young people in similar situations

A young person in the Swindon learning evaluation report said:

I have learned that I am not alone and that there are people who are happy to support me.

A young person in the Swindon learning evaluation report said:

I could open up about how I was feeling, it was very chilled and helped me to feel more in control of things in my life.

Engaging in creative activities as a way of expressing their emotions

A young person in the Brighton and Hove learning evaluation report said:

Also did some drawings a lot and that painting of just like how you feel, and I really enjoyed that as well. It helps a lot because, like, you’re kind of like taking the feelings and putting it on paper. Like getting all the bad ones out.

Finding a safe space:

A young person in the Knowsley learning evaluation report said:

I like getting out of the house and just being a kid and not having to worry.

The evaluations provided very little evidence of things young people disliked about the programmes – although, as expected, there were some negative comments relating to lack of support during COVID-19 or having to access support remotely.

Thus, some participants in Rochdale said that they would have preferred face-to-face sessions with their worker, and one young person said they would have liked more family meetings, but, due to COVID-19, the prison could not facilitate access to these during the pandemic. In West Sussex, one young person said they actually preferred talking with their therapist remotely during lockdown, as detailed in the West Sussex local evaluation report, but would have liked a more private space in their home to do so:

I wish though that I have a private space to talk. I liked it that it wasn’t face to face and on the phone, but I wish I had somewhere more private to talk.

Otherwise, young people were most likely to complain about the support ending or not being able to access the support for longer.

Impacts and outcomes documented by the qualitative interviews with children and their parents or carers included:

Learning new coping strategies

A parent in the Portsmouth local evaluation report said:

She’ll walk away for a minute, walk around the block, and come back, to diffuse the situation… she said to me, ‘Mum, I do the finger thing that [family worker name] told me [about].’ I said, ‘I do that, I do it under the table.’ Even I know my son uses it, which is really good.

Increasing their understanding of their parents’ alcohol dependence

A young person in the Brighton local evaluation report said:

When [practitioner] explained more about what happens with alcohol and what it does and why my [parent] was angry, that helped. [Practitioner] explained how [alcohol] doesn’t make people feel good when there’s too much; it makes them feel worse but they can’t decide to stop there.

Improving their overall wellbeing

A young person in the Brighton local evaluation report said:

I noticed that I was, like, much more happier and, like, I was going out with my friends a lot. Like, I wasn’t like, dull or anything. I was just, like, really bright. Yeah, I think so. My mum would say to me, like, for a couple days after the meeting with [practitioner], ‘You seem really bright today’.

Improving their relationship with their parent(s)

A project staff member in the Rochdale local evaluation report said:

[S/he] shared that the relationship with Mum got stronger due to the programme as the communication became better and Mum developed parenting skills that supported the young person to be the child in the relationship.

5.2 The difference that project activities made to parents or carers

5.2.1 Quantitative evidence

Several areas used different scales to measure the impact of accessing whole-family or individual support on parents. The strongest evidence with the largest sample sizes was provided by St Helens and Haringey – as shown in table 8 below.

Knowsley also used a validated scale to measure the impact of M-PACT. However, the sample size was very small so results are not reported.

Table 8: scales used to assess impact of CADeP IF project activities on parents

Area	Activity	Scale	Domain	Sample
St Helens	M-PACT / Confident Families	PHQ-9	Mental health – depression	84
St Helens	M-PACT / Confident Families	GAD-7	Mental health – anxiety	83
Haringey	Whole-family support	Family Star Plus	Parenting and wellbeing	101
Haringey	Whole-family support	Parental conflict scale	Relationship quality	50
North Tyneside	Parental support	SWEMWBS	Wellbeing	21
North Tyneside	Parental support	EQ-5D-5L	Quality of life	21
Portsmouth	Whole-family support	VLQ	Values	20
Portsmouth	Whole-family support	RCQ	Readiness to change	14

St Helens assessed the impact of their support for parents, including both the M-PACT and the Confident Families programme (see previous section ‘4.2.1 Enhancing whole-family work’), using 2 scales at the start and end of their engagement:

The Patient Health Questionnaire 9 (PHQ-9)

PHQ-9 is a validated self-completion questionnaire used to assess health, and screen and monitor the severity of depression. It asks people how bothered they have felt over the last 2 weeks about a list of 9 things such as:

feeling down, depressed or hopeless
feeling tired or having little energy
moving or speaking so slowly that other people could have noticed

Individuals are asked to rate whether they felt this way on a scale between ‘Not at all’ (score 0) and a maximum of ‘Nearly every day’ (score 3), resulting in a total possible score of 27. A total score of:

0 to 4 indicates no depression
5 to 9 indicates mild depression
10 to 14 indicates moderate depression
15 to 19 indicates moderately severe depression
20 and above indicates severe depression

The Generalised Anxiety Disorder Assessment (GAD-7)

GAD-7 is a validated self-completion questionnaire used to assess health, and screen and monitor the severity of anxiety. It is scored like the PHQ-9 and asks how bothered respondents have felt about 7 items, including, for example:

feeling nervous, anxious or on edge
not being able to stop or control worrying
worrying too much about different things

A total score of:

0 to 5 indicates mild anxiety
6 to 10 indicates moderate anxiety
11 to 15 indicates moderately severe anxiety
15 to 21 indicates severe anxiety

The analysis identified statistically significant differences over time for both scales (p<.001), with reduced levels of depression measured by the PHQ-9 scale (from an average score of 17.7 equivalent to ‘moderately severe depression’ down to 3.5 ‘no depression’) and anxiety as measured by the GAD-7 (from an average score of 15.2 equivalent to ‘severe anxiety’ at treatment start, down to 3.3 ‘minimal anxiety’ by their end of engagement). As shown in table 9, both effect sizes can be interpreted as very large according to conventions.

Table 9: impact of M-PACT project on parents using the PHQ-9 and GAD-7 in St Helens

Scale	Number of parents	Baseline mean (SD)	Follow-up mean (SD)	Significance	Effect size
PHQ-9	84	17.7 (6.83)	3.5 (4.16)	p<0.001	d=1.90
GAD-7	83	15.2 (5.38)	3.3 (4.27)	p<0.001	d=1.78

Source: St Helens local evaluation report and own analysis. Note: SD = standard deviation; p is probability value; d measures effect size.

As for all other measures used in this project, there was no control or comparison group – however, the measured changes are very large and are therefore unlikely to have come about if parents had not participated.

Qualitative interviews with 13 parents who engaged in the Confident Families and 11 who participated in the M-PACT interventions provided further evidence of how the project had helped to bring about such positive outcomes. One parent, for example, reported in the St Helens learning evaluation report:

Honest to God, I’d come into CGL literally on the floor. I’d be dead angry; I’d have resentment towards everybody and everyone. I’d be kicking off at my key worker at CGL; you know it was all their fault. Kicking off at social services and if anybody said something I’d react to it and think it’s all about me. Whereas now I’m learning and I’m still learning every day…this is the longest I’ve ever been clean. I’m coming up to my 3 months and that’s massive for me.

Participants valued having a CGL key worker who provided one-to-one support in person or by telephone for any bespoke needs they had. Others said that it was the non-judgemental and supportive approach that helped them remain with the service.

The local evaluation also calculated the benefit-cost ratio of the support provided to families in St Helens using a case study methodology developed by PHE. This tool aimed to estimate the economic costs that have been avoided as a result of the intervention and was specifically recommended for use with projects funded through the CADeP IF. The analysis suggested that, for some families, the project resulted in significant cost savings for the local authority, as a result of reduced spending on children’s social care services.

Haringey also collected quantitative evidence of the impact of whole-family support on parents. This was done using the Family Star Plus and one item of a questionnaire (based on a scale shared with projects by DWP) to assess the relationship quality of parents still in a relationship and for those no longer in a relationship but with shared parental responsibilities.

The Family Star Plus is a diagnostic and evaluative tool used to assess parenting and health outcomes across 10 domain areas that align with the UK government’s Supporting Families initiative. The domains are:

physical health
your wellbeing
meeting emotional needs
keeping your children safe
social networks
education and learning
boundaries and behaviour
family routine
home and money
progress to work

All ADPs were asked to complete a Family Star Plus tool at the beginning of working with the Insightful Families programme and at the end of their engagement.

As can be seen in table 10 below, there was a statistically significant change (p<0.01) across all domains for parents participating in the Insightful Families project – and on average when combining all scores. This suggests that the project had a beneficial effect on their parenting and health outcomes. More specifically, the largest effect sizes were identified for those domains likely to be most directly affected by the support, including ‘wellbeing’, ‘meeting emotional needs’ and ‘family routine’.

Table 10: impact of Insight Families on parents using Family Star Plus (Haringey)

Domains	Average – initial	Average – follow-up	Significance	Effect size
Boundaries and behaviour	5.7	6.6	p<0.01	d=0.71
Education and training	5.9	6.5	p<0.01	d=0.42
Family routine	5.5	6.6	p<0.01	d=0.84
Home and money	6.0	6.6	p<0.01	d=0.65
Keeping your children safe	5.3	6.3	p<0.01	d=0.79
Meeting emotional needs	5.2	6.4	p<0.01	d=0.93
Physical health	6.0	6.8	p<0.01	d=0.66
Progress to work	5.4	6.0	p<0.01	d=0.43
Social networks	5.5	6.4	p<0.01	d=0.68
Your wellbeing	5.3	6.5	p<0.01	d=0.92
Average	5.6	6.5	p<0.01	d=0.70

Source: Haringey local evaluation report and own analysis. Note: number of clients = 101; p = probability value; d measures effect size.

In addition, parents who participated in the Haringey whole-family support programme delivered by Humankind as well as the standalone 16-week BCT programme also completed one item of a scale, asking parents to rate their relationship with their spouse, partner or ex-partner on a scale of 0 to 10 – completed by 24 parents still in a relationship and 26 of those no longer in a relationship.

Table 11 shows that, for both groups, there was a significant improvement in relationship quality (p<0.001) from when they started on the programme until the end of their engagement. It is worth noting, however, that this analysis is only based on one item of a scale – and it was used both with parents who had just participated in the whole-family groups as well as a small number of couples who also received behavioural therapy. This means that these results provide some partial evidence that, overall, the support provided by Haringey had a beneficial effect on parental relationships.

Table 11: impact of Insightful Families project on relationship quality using the parental relationship questionnaire item (Haringey)

Parent group	Number of parents	Baseline mean (SD)	Follow-up mean (SD)	Significance	Effect size
Parents currently in a relationship	24	4.89 (1.9)	6.58 (1.7)	p<0.001	d=1.99
Parents who are no longer in a relationship	26	4.27 (1.8)	6.08 (1.7)	p<0.001	d=1.83
All parents	50	4.6 (1.9)	6.3 (1.7)	p<0.001	d=1.77

Source: Haringey local evaluation report and own analysis. Note: SD = standard deviation; mean and SDs are estimates based on statistics of the groups ‘parents currently in a relationship’ and ‘parents who no longer in a relationship’, test statistics were calculated using these estimates; p = probability value; d measures effect size.

A workshop conducted by Haringey staff explored how the Insightful Families project had helped to impact positively on parents involved in the interventions and successfully reduced parental conflict. Key findings from this workshop, as detailed in the Haringey learning evaluation report, were that it had:

normalised parental conflict as conflict is a normal part of any relationship and it’s important to openly discuss it. It is when the conflict is ‘unhelpful’ that change is needed
embedded parental conflict work within the entire service provision. By taking this step, it allowed conversations to start that would not have occurred previously
provided ‘lightbulb moments’ – Insightful Families staff spoke about how ADPs initially did not realise that parental conflict was having an effect on their children and how ‘lightbulb moments’ arose once the ADPs did realise it could be negatively affecting their children

‘Box 7: Haringey Insightful Families project’ below illustrates how the integration of work on parental conflict into whole-family work as part of the Insightful Families project impacted positively on families, leading to a de-escalation of conflict.

Box 7: Haringey Insightful Families project

The Insightful Families programme was delivered in Haringey using a whole-family approach. This was based on the understanding that, since excessive alcohol use affects all family members but in different ways, it is necessary to work with the entire family to ensure that the needs of each family member are addressed.

The ‘ripple effect’ concept played an important role in Haringey’s approach to whole-family work. It is based on their first-hand experience that successfully supporting one family member often encourages other members to seek help. For example, a child affected by parental alcohol misuse might start work with the hidden harm worker, and this encourages the parent to access alcohol treatment.

A Humankind area manager commented:

We’ve known in the field for a long time that family work is really important, as usually the whole family is affected by substance misuse, not just the user themselves. Thus, family members benefit from doing the recovery journey in parallel. Too often, the help we can offer is only for the substance misuser – this project really allowed us to think about the child at the heart of that work.

By integrating a whole-family approach, Insightful Families envisioned both practical and cultural changes to the provision of services in Haringey.

A senior public health commissioner stated:

Funding for a family programme allowed us to really break down the silos of working we had created, where an alcohol service sees a male who has children as an ‘adult male’, not as a ‘parent’. [Meanwhile], hidden harm workers work with children but not the whole family, and affected friends and families are offered very little.

Changing this isolated dynamic proved to be one the project’s key achievements. It improved collaboration and communication both between services and families themselves. In practice, this involved providing each family member with individual support, such as parenting programmes for the adults and hidden harm workers for the children, while also bringing the family together through co-produced activities. Families appreciated this joined-up approach.

One parent stated:

Insightful Families saw our family as a whole unit and wanted to support everyone in the family, which felt different to social services.

Photo of horticultural activities completed as part of family activity sessions.

The whole-family approach was also key to embedding parental conflict support in work tackling alcohol dependency. Incorporating discussions about significant others into conversations with adults regarding their alcohol dependency helped them think about the effects it was having on other family members. This was described by practitioners as the ‘lightbulb moment’: the moment when parents realise that their dependency is a source of conflict at home and is having an impact on their children. One parent described it as follows:

Insightful Families helped me to think about how my behaviour impacted on the children and the whole family. For example, whilst I was still drinking, [my daughter] was taking on the role of carer at home to support us.

The success of the Insightful Families’ whole-family approach can also be seen in the increased numbers of both children and adults accessing support. Between 2019 and 2021, the number of alcohol dependent parents supported increased from 43 to 178 (exceeding the target of 120 set at the start of the project). The number of children receiving support also rose from 24 to 169 (just shy of the target of 170). Meanwhile, feedback collected from service users speaks to the positive impact on family cohesion and wellbeing.

In one case, a family whose children were taken away by social services were ultimately reunited due to the whole-family work they had been doing with Insightful Families, as a senior public health commissioner reported:

The parents… made it clear that having the Insightful Families team around them when their children were taken away gave them the strength, the time and the skills to get through the process and get their children back… And then the children had their own relationship with the hidden harm workers… It shows that, because we were working with everybody, that family came back together.

Sources: interviews with senior public health commissioner at Haringey Council and area manager – London and south at Humankind; Haringey local evaluation report.

Quantitative evidence on the impact of support to parents was also collected by Portsmouth and North Tyneside (see table 8 above), albeit involving smaller samples of participants. Portsmouth used the Valued Living Questionnaire.

The Valued Living Questionnaire (VLQ) was used as a diagnostic and evaluative tool to get participants to reflect on the discrepancy between what they value and how they live their life. Similar to the Family Star Plus, it consists of 10 domains, such as:

parenting
work (paid and unpaid)
partner or intimate relations
learning and education
other family relationships

Analysis of 20 completed forms at the start and end of the intervention showed an overall improvement in means scores from baseline to the end of engagement (p<0.05). The use of the VLQ was also valued by parents as a way of helping them realise how their alcohol dependency and associated behaviour was at odds with their desire to care for their children. As one participant explained in the Portsmouth local evaluation report:

She’d asked me what was important… I had to give her a number, like how high it was, important. Obviously, my kids were 10. Then she came down to my health, and I said: ‘No, I don’t care about my health.’ Then she made me think of it another way. She went: ‘But you care about your kids…’ I was like: ‘Yes.’ She went: ‘So if you’re not looking after yourself, and you’re going to make yourself ill to the point where you may not be here, that’s not good for your kids’, and she made me completely switch it around. Now, obviously, I’ve started thinking about my health a little bit more. Not much more, but it’s still enough to keep me going and keep me here for my kids.

In North Tyneside, 21 out of 85 adults who received direct support from the treatment provider as part of the Bottled Up project completed the Short Warwick–Edinburgh Mental Wellbeing Scale (SWEMWBS) and EQ-5D-5L scales to measure the impact of participation on their wellbeing and health-related quality of life respectively.

SWEMWBS is a 7-item scale measuring mental wellbeing. Higher scores indicate higher levels of wellbeing with scores ranging from 7 to 35. Mean scores for SWEMWBS significantly increased from 21.7 at baseline to 26.12 at follow-up (p<.001) as shown in table 12. The mean score at follow-up was significantly higher than the average population wellbeing of 23.6 according to a health survey for England in 2011.

The EQ-5D-5L scale is a standardised measure of health status developed by the EuroQol Group. It consists of 5 dimensions (mobility, self-care, usual activities, pain or discomfort and anxiety or depression) rated at 5 levels, ranging from:

no problems
slight problems
moderate problems
severe problems
extreme problems

It also includes the EuroQol visual analogue scale (EQVAS), which records patients health from 0 to 100, with 100 representing perfect self-rated health.

As shown in table 12, the EQ-5D-5L index value combining all 5 dimensions on a scale of 0 to 1 increased from 0.76 at baseline to 0.81 at follow-up, although this was not statistically significant. A significant change (p<0.05) was, however, recorded for the ‘anxiety or depression’ dimension after receiving support from the treatment provider.

Similarly, the parents’ self-rated health, EQ-5D-EQVAS, increased significantly from 71.9 to 82.0 at follow up (p<0.05). This is similar to the average score for women (82) and men (83) recorded as part of a population survey across the UK.

Table 12: impact of support on wellbeing and health-related quality of life using SWEMWBS and EQ-5D-5L scales (North Tyneside)

Scale	Number of adults	Baseline mean (SD)	Follow-up mean (SD)	Significance
SWEMWBS	21	21.7 (4.52)	26.1 (3.93)	p<0.001
EQ-5D-5L index value	21	0.76 (0.15)	0.81 (0.15)	NS
EQ-5D-5L EQVAS	21	71.9 (19.07)	82.0 (10.58)	p<0.05

Source: North Tyneside local evaluation report and own analysis. Note: SD = standard deviation; p = probability value; NS = not statistically significant.

Several areas also reported the results of the assessment of parents’ alcohol consumption and its impact on their health and social functioning using the AUDIT C and treatment outcomes profile (TOP) instruments. However, in many cases, numbers of responses were quite low (relative to total number of participants), there was high drop-out over time and no details were provided in the local evaluation reports of how such outcomes compared with other clients accessing alcohol treatment services locally. Hence, it was often difficult to judge the robustness and strength of such findings from using these tools.

For example, West Sussex local evaluation report reported on the results of the use of the TOP with 42 parents or pregnant mothers accessing the Growing Families project. It found a statistically significant decrease in the average number of alcohol units consumed in a day from initial assessment to case closure (14.1 average units a day compared with 2.4 units a day at closure; p<0.001). However, some clients accessing the service did not complete the forms as they did not meet the threshold for substance misuse services at referrals, while in other cases it also included the partner of someone referred for support with 0 units of alcohol consumed each day at baseline.

Similarly, North Tyneside reported a significant decrease in AUDIT C scores for 21 ADPs participating in the programme – from 19.3 at initial assessment stage to 11.9 at follow-up (p<.001). This change can be interpreted as large (Cohen’s d=1.26). However, once again this was based on only a small sample of parents participating in the programme and excluded those who did not complete their treatment.

5.2.2 Qualitative evidence of impact on parents or carers

Qualitative interviews with parents conducted in most of the 9 areas showed that what parents particularly liked about the interventions included the following:

The non-judgemental nature of the support provided, often by third-sector organisations

This support was often contrasted with their contact with statutory agencies, which they experienced as more punitive and judgemental.

As reported in the Knowsley local evaluation report:

When I was speaking to [worker], she didn’t make me feel like, ‘Oh she’s had her kids taken off her’, it wasn’t like that, so for her to actually listen and let me offload without pre-judging you or having preconceived ideas about you, that’s the part of the service I have enjoyed the most.

And in the Brighton and Hove local evaluation report:

Just admitting to somebody and really feeling there was no judgement there of what I’ve done. I could say it and feel really bad, warts and all. Just having that really honest conversation with somebody who wasn’t part of my family and saying it out loud without any guidance.

The provision of holistic support

This support focused not just on the ADP but also on the needs and experiences of other family members to reduce family and parental conflict, and reduce the negative impact on children.

As detailed in the Portsmouth local evaluation report:

Had it not been the way that they work, had it not been that again, that holistic focusing on the family as a whole and the impact that it has and keeping that in mind, there’s no way our relationship would’ve survived.

And in the Knowsley local evaluation report:

I was telling everyone: ‘I’ve not even affected my kids, they don’t know’. And we did a thing and they wrote on it: ‘Me mum thought it was a secret but we all knew’, and I was like: ‘Oh my God’.

Place-based support

This place-based support offered support in people’s own home or in more child-friendly, community-based settings. This was experienced as less threatening and stigmatising, and more accessible.

As detailed in the Portsmouth local evaluation report:

The recovery place was more for my drinking and more for me; this is more family-based, so it’s more kid-friendly, which is so important.

Flexibility provided by project workers

This flexibility provided by project workers in terms of setting up appointments and engaging with participants, including working around clients’ work schedules, childcare and schooling.

Participants also liked the flexibility with regard to project length, where support was not time limited so that relationships with the whole family could be developed and trust could be established – this helped to explore and address the reasons underlying the alcohol misuse and dependence, and the causes of parental conflict.

Such flexibility is further illustrated by one of the whole-family services delivered by a third-sector organisation in Swindon, resulting in considerable benefits for families involved (see ‘Box 8: Swindon Safe Families project’ below).

Box 8: Swindon Safe Families project

Swindon Safe Families (SSF) is a Christian charity that started working on the RESTORE project in September 2020 to support families whose isolation led to alcohol misuse by at least one family member and/or parental conflict.

It consisted of 2 work streams: a befriending service and a family hosting service, which were both run by volunteers and co-ordinated by SSF staff. The work was based on the understanding that, for a lot of families, isolation and lack of supportive networks can often lead to problematic coping mechanisms such as alcohol misuse.

SSF staff and volunteers contributed their success to the flexibility in the focus of their work, which extended beyond just working on the alcohol consumption itself to also include addressing other surrounding factors. The Family Friends service involved trained volunteers befriending family members and offering a wide range of support. An SSF support manager stated:

Sometimes it’s as simple as getting a cup of tea, going to the gym together or doing something with the kids, so the parents can have time together and re-connect. It’s not always about alcohol; it’s about getting the person out of the house to have a break from the pressures of family life.

The volunteers also supported family members in accessing further statutory and charity-based support for problematic alcohol use to help overcome addiction and other issues. This included being with them during the self-referral process or providing childcare during appointment times to remove barriers to accessing such support.

The project has recently supported one parent facing complex challenges, including alcohol dependency, mental health issues and parental conflict. This has included:

having open, trauma-informed conversations about addiction
help with babysitting to spend some quality time with his partner
guiding him to access services to address his alcohol dependency

The parent commented:

You haven’t just signposted me, but you’ve taken me there and that means so much more!

Families were said to be attracted to this service as it was delivered by a third-sector organisation with which they could choose to engage. The SSF support manager stated:

We are not compulsory, we are never part of a child protection plan; it’s something that you have to want and, if you don’t, there are no repercussions.

By the end of January 2022, SSF volunteers had worked with 37 families, including 80 children, as part of the RESTORE project. Of these, 77% of families did not see an escalation in need within children’s services. In addition, 83% of parents reported maintaining or improving their confidence and positive parenting techniques, while 87% of parents stated that their overall family relationships and personal wellbeing had improved or been maintained through the support from SSF.

Sources: interviews with programme director for Safe Families, and SSF support manager and team lead; Swindon local evaluation report.

Meeting other parents or families

Meeting other parents or families facing similar issues to share concerns made them feel less isolated, as detailed in the Knowsley local evaluation report:

I think it helps meeting other families as well – other people who are in the same situation – because often you think you’re the only one. And when you can identify with other people who are going through the same thing, it makes you realise that you’re not on your own and that other families suffer the same – you know, other children suffer the same.

The only evidence in the reports of things parents or carers did not like about the support they received related to having to get help remotely during COVID-19. It is worth noting that such a lack of negative feedback overall could also reflect the fact that most of those interviewed had completed their treatment successfully, which means that they were more likely to provide positive feedback.

As with young people (see section ‘5.1 The difference project activities made to children’ above), parents’ feedback on receiving support remotely was mixed. Most felt that they would have preferred more face-to-face contact and that, for example, having to access meetings via Zoom or by telephone impacted negatively on their engagement.

Others, on the other hand, said that such remote meetings were easier to access. For instance, St Helens local evaluation report stated that it allowed them to:

log into the groups on a daily basis, and this may not have happened if the meetings were held face to face.

Indeed, in several cases, it was the only way for support or engagement to continue during lockdown (see, for example, ‘Box 6: Knowsley Family Matters Zoom project’ on how Knowsley used Zoom to allow a peer support group to continue meeting during this period). As reported in chapter ‘4. Delivering support to children and families’, some areas also found that providing remote support extended their reach and capacity to work with more families and, while there was some initial reluctance among clients to access help in this way, it had become more ‘normalised’ by the end of lockdown.

Qualitative interviews with parents reported in the local evaluations provide many examples of the positive outcomes of whole-family support delivered by the CADeP IF projects. This included the way such work impacted them in the following 3 ways:

Helped them to realise the impact their dependency had on their children

St Helens local evaluation report stated:

I didn’t see drink as an issue and had a domestic with my partner where things got very out of hand…I admitted to my social worker that I had a drink problem. I already knew about CGL. I self-referred and then was put on the courses and I’m gaining great insight learning the ripple effect of what effect it’s having on the kids.

Knowsley local evaluation report stated:

So, I think this has been really important because I realised how much of an impact my alcoholism was having on my children. I thought they’d come out pretty unscathed, I thought my daughter was full of bravado. She put a very funny front on and it was only through coming to these sessions, when we had to bring something that resembled addiction, that she broke down and I actually realised how much I had impacted her life. So that’s something that I’ve got out of it personally is that realisation and I think the kids have been able to offload as well.

Such a realisation was often key to galvanising them to commit to treatment and overcome their addiction or alcohol misuse.

Portsmouth local evaluation report stated:

Obviously, the drinking thing has come down [reduced from 40 to 50 daily to 9 to 10 daily on the AUDIT C scale]. That’s obviously hugely helped and, I guess, I’ve woken up and said: ‘Oh yes, this is what it feels like to function’. My brain is working and small things aren’t a problem.

Helped to address parental conflict in their relationships

Portsmouth local evaluation report stated:

We wouldn’t have survived, our relationship, our marriage wouldn’t have survived” – speaking to her husband, she said, ‘We can have a conversation and you’ll listen and you will take on board things that are said to you, whereas before you just wouldn’t, it would be, there would be no point’.

Had wider positive impacts, including greater life satisfaction and wellbeing

Brighton and Hove local evaluation report stated:

My mental health is so much better. I know how to deal with things. I’m a present mum. I’m there for my children, not just physically but emotionally and mentally now.

The impact whole-family support can have on ADPs is well illustrated in the following vignette, which demonstrates the effect of the M-PACT intervention in St Helens on one particular parent and her family (all names used in this vignette are pseudonyms to maintain the anonymity of participants):

Box 9: St Helens Building Bridges project – Carrie’s story

Building Bridges (BB) was delivered by the alcohol and substance misuses service CGL in St Helens. BB links services and agencies in the area to provide a whole-family approach to recovery from alcohol dependence and substance misuse. At its core is the Moving Parents and Children Together programme (M-PACT). It lasts 12 weeks and is for children and families with multiple complex needs who are affected by substance use.

This is the story of Carrie who got her life, and family, back through BB after more than 20 years of alcohol dependency.

Carrie was described as lively, strong and resourceful. She was “always looking for something” from the age of 7, when she had began with Tipp-Ex and glue. Her mum kicked her out of the family home at 15 and many chaotic years followed. Carrie has experienced abusive relationships as well as caring ones. She made several attempts to end her alcohol dependency through detox and begin recovery. At one point, she was drinking 2 litres of vodka a day. She was hospitalised during a psychotic episode and has been close to death more than once. She has 4 children and was determined to care for them. Her 2 sons are now adults, and her 2 younger girls live with her.

Carrie first came to CGL in 2017 for treatment but, despite detox and a harm reduction plan, she lapsed back into dependency. She returned in 2019, by which time BB had extended family support for alcohol dependent parents. M-PACT places enormous value on capturing, and hearing, the voice and experience of the child in these sessions. Carrie’s case worker stated:

It’s a safe environment. Children are enthusiastic because they have a voice and see the parents getting better. It’s about re-construction, it’s not just alcohol or relationships; it’s the whole picture.

People need to be abstinent at the start of the programme. Her CGL case worker strongly encouraged Carrie to take part, building on his own experience of addiction: “I’m in recovery myself so I understand how it works.”

Carrie was hesitant to open up at first but, when she wrote a letter to her addiction and recognised the positive life-changing possibilities, she committed to seeing it through. Her daughters also took part. They were subdued initially but, as their confidence grew, they spoke openly and honestly and made friends with other children in the programme. The family team also collaborated with the girls’ school on how to support them. Through the BB programme Carrie’s case worker sees:

children becoming children and not absorbed by their worries about their parents. When the parents see this, that’s when the magic happens.

Carrie confirms that learning about the impact on her children was an eye-opener for her.

Carrie is now in full recovery, working as a family team volunteer at BB and running peer-to-peer groups. She hopes to apply for a permanent job with the project. Rebuilding her family with the help of BB meant that Carrie’s daughters are no longer categorised as CIN by social services. For Carrie, the experience has been transformative:

In the past, recovery groups were just for the person with the addiction, but M-PACT involved our children and the whole family. I’ve now got my family back and a bright future for us all to look forward to.

Image showing the words of a parent who took part in the Building Bridges project: “I fall, I rise, I make mistakes, I learn; I get hurt, I bounce back; I’m not perfect, I’m human; I have confidence, I have faith; I will continue putting one foot in front of the other.”

Sources: interviews with family team complex case worker, and programme participant and volunteer with CGL St Helens; St Helens local evaluation report.

5.3 The difference the CADeP IF projects made to participation rates

Analysis of the NDTMS data for the 8 projects aiming to increase the number of parents and children accessing support (this excludes Rochdale, which, as discussed in section ‘2.3 CADeP IF projects details’, did not include this as a target) provides some evidence of a positive impact on participation rates – although this could have been caused by other external factors. In particular, they could have been influenced by other funding received by local areas at the same time as the IF.

Figures 6 and 7 provide an overview of the number of parents starting treatment for alcohol only and alcohol and non-opiates in the IF project areas compared with national figures, excluding the 8 IF projects. This shows a general upward trend, both in the 8 IF areas and nationally, between 2017 to 2018 (before the CADeP IF project started) up to 2019 to 2020. This is followed by a sharp decline in 2020 to 2021, likely to be caused by the COVID-19 pandemic.

However, the percentage increase in the numbers between 2017 to 2018 and 2019 to 2020 is greater in the CADeP IF areas than nationally. More specifically, in the 8 areas, the number of parents increased by 42%, while nationally it was just 6% over this period. It is worth noting that the figures for 2016 to 2017 are only provided for context – to show that numbers accessing treatment were fairly constant before 2018 and the introduction of the IF programme.

Figure 6: change in number of parents accessing treatment for problems with alcohol across the 8 IF projects (excluding Rochdale) between 2016 to 2017 and 2020 to 2021

Source: NDTMS data for new treatment journeys.

Figure 7: change in number of parents accessing treatment for problems with alcohol in England between 2016 to 2017 and 2020 to 2021

Source: NDTMS data for new treatment journeys. National figures exclude the 8 IF projects.

Table 13 below provides a more detailed breakdown of these changes in the 8 CADeP IF areas, with reference to the different types of adults accessing support. This includes:

parents living with their own children
parents not living with their children
adults living with children that are not their own

It shows a steady increase in the proportion of parents living with their own children, from 16% of adults accessing treatment in 2016 to 2017 and 2017 to 2018, up to 22% in 2020 to 2021.

In contrast, the proportion of ‘parents not living with their children’ remained relatively constant over this time period, but with a sudden very large dip in 2020 to 2021. It is difficult to ascertain the reason for this change in 2020 to 2021, but it is likely to be linked with COVID-19 in some way, as a similar trend was recorded nationally.

It is interesting to note, however, that the proportion of parents living with their own children accessing treatment actually went up even in 2020 to 2021 in the CADeP IF areas. This would suggest that the projects may have continued to have an impact on this group of parents even during the pandemic, and supports the success of the improved referral routes for most areas described in chapter 3.

One possible explanation for this is that it reflects a reduction in fathers not living with their children accessing support – possibly as a result of more limited access to services due to lockdown. This is reflected in the fact that the proportion of men entering treatment fell noticeably in both the CADeP IF areas (from around 59% to 54%) and nationally in 2020 to 2021 (from 61% to 57%).

Table 13: number of clients with alcohol problems starting treatment in the 8 IF areas (excluding Rochdale) by parental status between 2016 to 2017 and 2020 to 2021

Parental status	2016 to 2017 (%)	2017 to 2018 (%)	2018 to 2019 (%)	2019 to 2020 (%)	2020 to 2021 (%)
Parent living with own children	532 (16%)	536 (16%)	733 (19%)	772 (20%)	852 (22%)
Other child contact – living with children	52 (2%)	43 (1%)	112 (3%)	137 (3%)	25 (1%)
Parent not living with children	874 (27%)	813 (25%)	1079 (28%)	1055 (27%)	706 (18%)
Not a parent and/or no child contact	1772 (55%)	1854 (57%)	1896 (50%)	1949 (50%)	2337 (60%)
Incomplete data	11 (0%)	7 (0%)	0 (0%)	6 (0%)	0 (0%)
Total	3241 (100%)	3253 (100%)	3820 (100%)	3919 (100%)	3920 (100%)

Source: NDTMS data for new treatment journeys.

The change recorded for parents from 2017 to 2018 onwards is also mirrored in the number of children of ADPs whose parents accessed treatment (it is worth noting that this does not reflect the number of children receiving support, but the number of children whose parents received support) as shown in tables 14a and 14b.

It shows an increase over time between 2017 to 2018 and 2020 to 2021 in the 8 CADeP IF areas as well as nationally, although the proportional change is significantly greater in the former than in the latter. Once again, this suggests that the IF projects were able to increase the number of parents and children being supported by services locally – particularly given the whole-family support provided by many of them, which included children and young people.

Table 14a: number of children whose parents accessed treatment between 2016 to 2017 and 2020 to 2021

IF area	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Brighton and Hove	126	148	197	184	180
Haringey	135	108	90	90	102
Knowsley	97	82	203	183	174
North Tyneside	104	59	77	122	149
Portsmouth	66	69	54	159	105
St Helens	183	155	220	217	333
Swindon	60	43	118	79	92
West Sussex	209	327	490	573	530
IF projects	980	991	1449	1607	1665
National	28110	27366	29306	29379	31184

Table 14b: percentage change in number of children whose parents accessed treatment between 2016 to 2017 and 2020 to 2021 in IF projects vs nationally

Area	2016 to 2017 and 2017 to 2018	2017 to 2018 and 2018 to 2019	2018 to 2019 and 2019 to 2020	2019 to 2020 to 2020 to 2021
IF projects	1%	46%	11%	4%
National	−3%	7%	0%	6%

Source: NDTMS data for new treatment journeys. Note: national figures exclude the 8 IF projects.

Analysis of the data did not identify any other noticeable trends in the project areas compared with the national data – although there were some common trends. For example, there was an increased proportion of parents identified with mental health needs and an increase in the proportion of parents with child protection plans in place at treatment entry in the CADeP IF areas, as well as nationally. There was no noticeable improvement in treatment outcomes in the project areas.

5.4 Lessons learned

Overall, the main lessons learned relating to achieving positive outcomes for children and parents accessing support include the following points:

The local evaluations provide good evidence of the positive impact that support for children of ADPs can bring about, including on their wellbeing and life satisfaction

Such support can take different forms, including one-to-one therapeutic interventions as well as whole-family support provided to parents and children, which can include both formal and informal activities. All such activities were found to lead to positive outcomes for children.

There is clearly a shortage and growing demand for support for children and young people

This is likely to increase even further as a result of the COVID-19 pandemic, which has been shown to have exacerbated levels of alcohol dependence and misuse among some families. There is a need, therefore, to consider how best to fill this gap.

Young people living with ADPs particularly value support that provides them with a safe space to explore their feelings with a therapist

This support may, for example, be through creative activities or with other young people with similar experiences. Interacting with others in a group setting can help them to feel less alone, and provide them with a supportive environment to express and explore their emotions and traumatic experiences.

Both parents and children living with ADPs value support that is non-judgemental

Such an approach encourages them to open up about their experiences and helps ADPs to understand the impact their drinking has had on their children. Additionally, children are likely to feel more able to express their fears to their parents.

Flexibility of support is important

Parents value the support of dedicated staff or key workers who have the time and flexibility to provide individual support tailored to their needs, and work, childcare and schooling schedules.

Parents are also more likely to stay engaged and achieve successful outcomes if the support provided is flexible both in terms of location and length, so that relationships with the whole family can be developed and trust can be established.

It is important to address reasons underlying alcohol dependence

Positive outcomes are also more likely to be achieved when treatments explore and address the reasons underlying the alcohol dependence, such as:

parental conflict
mental health issues
financial stressors
other potential challenges

Question 6

6.  Conclusions and reflections

Accepted Answer

This chapter presents the main conclusions of this evaluation in relation to each of the 4 research questions underlying this study (see section ‘1.3 Evaluation methodology’). It also offers some reflections on:

the overall CADeP IF programme
its implementation over the last 3 years
the future direction of policy in this area

As a reminder, the 4 research questions are:

RQ1: how did the innovation fund lead to improvements in the timely identification of parents and children of ADPs?
RQ2: how has the programme contributed to improvements and innovation in the local system for supporting parents and children of ADPs?
RQ3: what impact have the interventions supported by the programme had on the children and families identified?
RQ4: what knowledge can be drawn from this for future policy and practice?

6.1 How the innovation fund led to improvements in the timely identification of parents and children of ADPs

The evaluation has shown that this was achieved through the ways outlined below:

Effective strategic leadership to facilitate closer collaboration and communication between adult and children’s services teams and other services

Effective system leadership is needed to make and sustain changes in the identification of children and families affected by parental alcohol misuse and parental conflict.

In the CADeP IF projects, this was achieved in some areas through the active participation of senior leaders from across relevant services through regular steering group meetings, and in helping to identify and overcome particular practical challenges throughout project implementation. Of particular importance for this project was the buy-in from, and strong links between, strategic leads within local authorities, public health, adult substance misuse treatment providers and children’s social care.

It also required system leadership at a more operational level among those responsible for planning, implementing and sustaining changes. It worked less well where senior leaders did not share a common vision or were unable to overcome resistance to change in parts of the system because, for example, of varying priorities, practical problems or capacity issues across services.

System leadership facilitated closer collaboration and communication between adult and children’s services teams and other local services or providers

The IF encouraged improvements in systems of identification and referral that went beyond simple signposting to include closer collaboration in encouraging and enabling families to access support below the threshold of statutory intervention. This helped to avoid problem escalation, while also reducing the negative impact of parental alcohol misuse on children.

The evaluation demonstrated that this worked particularly well where the IF funding was used to enable the co-location or close collaboration of adult and children’s service staff to identify families most likely to benefit from support. This also raised awareness of the support other services could provide and encouraged providers to learn from each other about, for example, how to identify the signs of parental conflict or alcohol dependency, or how to start conversations about it.

Active collaboration also relied on putting in place data-sharing agreements between services so that practitioners could not only access and share data on families, but also contact them directly to engage them in support.

Workforce development targeted at children’s services staff and substance misuse practitioners

Workforce training targeted at children’s services staff and frontline workers was a significant factor driving system change in the identification and referral of children and families

The CADeP IF projects did this by increasing knowledge and awareness of the impact of parental alcohol misuse and parental conflict, generating the confidence to start conversations with ADPs, and introducing tools that could help in the assessment of need. Where successful, they made practitioners more aware of what others in the system do, and how it could fit in with their own work and responsibilities.

Such training was particularly effective where staff were chosen to embed the learning in their services, or opportunities were provided to refresh learning outcomes. The impact of workforce development interventions was weakened, though, by factors such as:

staff turnover
other priorities
capacity issues
in some cases, the weak integration of learning with practice

These could be overcome by achieving buy-in at every level of management and practice to ensure that the training was more likely to be taken up and embedded.

6.2 How the programme contributed to improvements and innovation in the local system for supporting parents and children of ADPs

The evaluation has shown that the programme has done this in the following ways:

Hiring new staff to reduce the caseload of treatment providers, giving them the opportunity to engage and support families in more flexible ways

The CADeP IF made a particularly valuable contribution when used to:

enhance capacity
reduce the caseload of provider staff
give staff the time to engage and support families in more flexible ways

Parents really valued the support of dedicated staff or key workers with the time and flexibility to provide individual support tailored to their needs, and work, childcare and schooling schedules.

They were also more likely to stay engaged and achieve successful outcomes if the support provided was flexible, both in terms of location and length. This allowed services to develop relationships and trust with the whole family.

It was also seen as important to encourage families to stay engaged and complete their treatment, or to persuade other family members to access support through the so-called ‘ripple effect’.

Expanding capacity or introducing new services specifically targeted at children and young people

CADeP IF funding was used in some projects to expand capacity of providers or introduce new services specifically targeted at children and young people.

This was recognised as filling a large gap in demand in the 9 areas, given long waiting lists or lack of provision for similar types of support for children and young people locally. Such provision was particularly effective where projects placed the voice of the child at the centre of the intervention. This was achieved through the use of various tools and approaches to shape service provision with the needs, experiences, feelings and views of young people.

Young people living with ADPs particularly valued support that provides a safe space to explore their feelings with a therapist, for example through creative activities, or with other young people with similar experiences. Interacting with others in a group setting can help them to feel less alone, and provide them with a supportive environment to express and explore their emotions and traumatic experiences.

Integrating parental conflict work into the support provided to parents, children and families

Providers used the IF funding to integrate work on parental conflict into their support for parents, children and families.

Some areas delivered some standalone parental conflict interventions to couples struggling with alcohol dependence. However, such work was generally seen as more effective when it was provided as an element of a more holistic whole-family support offer.

Increasing capacity for the delivery of more whole-family interventions

The IF project has influenced re-commissioning plans of alcohol and substance misuse services in several areas to include a much stronger focus on whole-family support.

Six of the 9 areas had either recently gone through such a re-commissioning process or were about to do so in the next 12 to 18 months. All reported that the lessons learned from implementing the project had shaped their future plans. This success is also testament to the local strategic-level recognition of the projects’ achievements and potential.

Some concern was expressed, however, that, where re-commissioning funding is below the level provided by the IF, the holistic support offered to children of ADPs and their families might not have the same depth and flexibility.

The COVID-19 pandemic encouraged projects to develop new ways of working, including providing support remotely or using hybrid approaches. The pandemic raised many issues for projects, as it often led to reduced numbers of referrals and not being able to deliver some services that relied on face-to-face contact. However, several areas delivered services funded by the IF remotely. Some groups, particularly teenagers and parents with less severe needs, sometimes preferred accessing services in this way.

Moving forward, such remote working may, in certain circumstances, increase the capacity of services. However, in other cases it will not be suitable for particular types of provision, and face-to-face support is likely to continue to be needed to assist families with more severe and complex needs.

6.3 The impact the interventions supported by the programme had on the children and families identified

The evaluation has shown the following:

Increased treatment participation rates

There was a larger percentage increase in the number of parents and children accessing treatment in the project areas compared with areas not receiving such funding.

Analysis of the NDTMS data for the 8 projects aiming to increase the number of parents and children accessing support (excluding Rochdale, which did not include this as a target) showed a noticeable increase in the number of parents accessing treatment between 2017 to 2018 and 2020 to 2021.

More specifically, in the 8 areas, the number of parents increased by 42% between 2017 to 2018 and 2019 to 2020, while nationally it was just 6% over this period. This was followed by a sharp decline in 2020 to 2021, likely to be caused by the COVID-19 pandemic. It is worth noting, though, that the measured change up until the start of the pandemic could have also been caused by other external factors, including other funding aimed at increasing participation rates provided to these areas.

The improved levels of participation of parents in the IF project areas from 2017 to 2018 onwards are also reflected in an increase in the number of children of ADPs who accessed treatment over that time period compared with national data.

Positive impact on parents accessing treatment

Whole-family support delivered as part of the project had a significant positive effect on parental wellbeing, life satisfaction and relationship quality

The M-PACT programme delivered by St Helens resulted in statistically significant reduced levels of depression and anxiety over time. Similarly, whole-family support in Haringey led to statistically significant improvements in parenting, relationship quality and self-reported health outcomes. These findings were supported by qualitative evidence, which highlighted the way parents valued the way whole-family support often enabled them to realise the impact their drinking had on their children.

In addition, parents reported that the support helped them to address parental conflict and relationship issues, while experiencing improved life satisfaction and general wellbeing as a result of changes in their drinking behaviour. The evaluation also suggested that such positive outcomes are more likely to be achieved if treatment does not focus solely on the use of alcohol, but explores and addresses the reasons underlying their alcohol dependence, including parental conflict, in a more holistic way.

Positive impact of whole-family support and therapeutic interventions in young people

Whole-family support and therapeutic interventions had a positive impact on young people, and also often improved their wellbeing and life satisfaction.

A therapeutic service in West Sussex for children and young people aged 4 to 18 years affected by parent or carer alcohol dependency resulted in small but statistically significant improvements in their life satisfaction and wellbeing. Similarly, the M-PACT programme in St Helens led to a significant increase in wellbeing among young people and a large effect size.

Qualitative interviews supported these findings and showed that individual or group interventions:

helped to teach young people new coping strategies
increased their understanding of their parents’ alcohol dependence and their relationship with them
often improved their wellbeing

6.4 The knowledge that can be drawn from this study for future policy and practice

The evaluation of the CADeP IF project has highlighted several messages of relevance to the future development of policy and practice in the support provided to children and families. These are set out below with reference to those co-ordinating delivery of such support, providers responsible for delivering it, and the government.

6.4.1 Recommendations for those co-ordinating delivery of support

Champion effective strategic system leadership and promote collaboration at all levels between children’s services, treatment providers and other relevant local agencies

Staff across children’s services, alcohol treatment providers and other relevant local agencies need to be encouraged to work together to bring about the best outcomes for families affected by alcohol dependency.

Ensure a more seamless transition when referring families between services

This includes finding effective ways to share data between providers so that all have access to the same information and assessments of families’ needs do not need to be duplicated.

This supports the earlier identification of alcohol dependent adults as parents, and children of ADPs in need of support, to avoid escalation of need.

Include a strong focus on supporting children and families affected by parental substance misuse and work on reducing parental conflict in re-commissioning plans of substance misuse services

In recognition of the positive impact the approach had in the IF projects, several of the local authorities included a requirement to include whole-family working and a focus on children affected by alcohol dependence in their re-commissioning plans.

Embed or enhance workforce development plans into service provision that focus on increasing knowledge and awareness of parental alcohol misuse and parental conflict.

This should be targeted at frontline children’s services staff, substance misuse practitioners and wider agencies that have contact with these families. This would give frontline staff the confidence to start conversations with ADPs and the tools to assess need, provide support and make referrals. Workforce development would make a significant contribution to the increased, and earlier, identification and referral of children and families.

6.4.2 Recommendations for those delivering support

Place the voice of the child at the centre of service development

This is needed to ensure that provision is sensitive to their needs and preferences, and that support is delivered to children and young people in a non-judgemental way and adopts strength-based approaches.

Design services that are specifically targeted at children and young people affected by parental alcohol misuse

They should be provided with age-appropriate support that provides them with a safe space to explore their feelings – for example, through creative activities, with other young people with similar experiences, or through therapeutic interventions.

Embed whole-family interventions into service delivery

Working with the whole family helps to overcome family conflict and ensures that parents are aware of the impact of their behaviour on their children.

Provide support to families in community settings

Requiring families to attend substance misuse treatment centres can often be off-putting, given the stigma attached to addiction and not wanting to be seen to attend such a place by others locally.

Improve awareness in frontline staff of the impact of parental conflict and how it is different from domestic abuse

They also need to be aware of how parental conflict can contribute to, or be enabled by, parental alcohol misuse and poor mental health.

Improved awareness equips staff to combine support on parental conflict with other challenges parents and families might face, while ensuring that no parents are referred to parental conflict support where domestic abuse is a feature of the parental relationship.

Take every opportunity to give treatment provider staff the opportunity to engage and support families in more flexible ways

Flexibility in the timing, location and mode of services can encourage families to attend who might otherwise drop out or be reluctant to engage.

6.4.3 Recommendations for the government

Provide ongoing funding to deliver services

The evaluation has shown that delivering whole-family support work and therapeutic support for children is effective but also very resource intensive, and often requires the support of specialist staff and services that can address the needs of parents, children and wider family members.

Evidence provided by CADeP projects demonstrates convincingly that earlier whole-family interventions can either avoid expensive higher-tier support or enable families to step down from it.

Overcome the often-siloed funding for children and adults’ services

The CADeP IF project has made a positive step in the right direction by funding the development of new approaches that combine a focus on alcohol dependency and parental conflict with the needs of children, parents and others affected by parental alcohol misuse.

However, more needs to be done to ensure that providers can access more long-term funding sources to continue such work in an effective and sustainable way.

Work across government to embed the learning from this programme into other relevant government programmes

This is to support a reduction in siloed working at all levels of the system.

6.5 Reflections

This section provides some final reflections on the IF programme based on our evaluation and our ongoing involvement in the learning events. These are structured in response to a series of questions arising from the project and suggestions from members of the project steering group.

6.5.1 Transferable learning from the programme

The CADeP IF project has provided many examples of good and seemingly effective practice to identify and support children and families – as illustrated in the 9 case study vignettes presented previously in chapters ‘4. Delivering support to children and families’ and ‘5. Improving outcomes of children, parents and families’ of this report.

Some of these were developed in response to the funding, but others built on existing interventions and expanded their capacity or incorporated new elements into them. Overall, though, they provide good examples of interventions or approaches that could be adapted in different settings.

At the same time, it is worth noting that most were developed in specific contexts and drew on the leadership, skills and knowledge of particular individuals in the areas. Some were also implemented on the basis of additional funding provided by the CADeP IF project, which enabled them to provide, for example, more flexible or intensive support than without it.

Indeed, some areas reported that they were unlikely to be able to sustain some of the approaches adopted without such continued funding. This means that, while much of the learning could, in theory, be transferred to other areas, this would depend on the availability of such important contextual factors that are needed for them to succeed in other settings.

6.5.2 Evidence on what works and how this situation could be improved on in future

Chapter ‘5. Improving outcomes of children, parents and families’ has shown that, for several interventions targeted at children and families, there was good quantitative and qualitative evidence of impact, although sample sizes were often relatively small and no control or comparison groups were used.

However, providing such evidence was never the explicit intention of the programme or evaluation. The CADeP IF commissioners could have chosen some effective and well evidenced interventions and rolled them out across the 9 areas to discover more about what works. Instead, they offered resources to the 9 areas that could make a strong case for generating systemic changes to universal problems within their own unique localities.

This creative approach to innovation has generated rich learning from the endeavours of the 9 projects. Stronger evidence of what works could be developed in future by trialling some of the interventions, such as the therapeutic intervention for young people in West Sussex or different forms of whole-family support delivered in some of the other areas, using experimental or quasi-experimental designs.

6.5.3 The mechanism of the CADeP IF for promoting change

Overall, the CADeP IF project has proved to be a very effective mechanism for promoting change in the areas. One of its key strengths was the length of funding provided, which was extended to over 3 years as a result of the COVID-19 pandemic to allow projects ample opportunity to implement and refine changes in their systems for identifying and supporting families and children. This was also facilitated by the regular learning events, which allowed projects to share ideas with each other and learn new ways to overcome particular challenges locally.

One issue that hindered progress in some areas was over-ambition in the changes or interventions they hoped to implement, and which sometimes fell short of their plans. At the same time, the length of the project and the approach adopted within it allowed them the flexibility to amend their plans and use the funding to focus on the most successful aspects of their projects or to fill particular gaps identified. This was particularly crucial given the impact of COVID-19 on project delivery in almost all 9 areas.

Question 7

7.  Next steps

Accepted Answer

The Children of Alcohol Dependent Parents programme is moving into its second phase, for which OHID is developing a strategy for implementing learning from the programme locally and across government. This includes looking at ways to:

roll out key learning to new areas
maintain and enhance provision in existing areas
expand support to include families affected by parental drug misuse

Through the £533 million drug strategy funding allocated to improving the treatment and recovery system in England, local authorities are now able to invest in interventions to improve their local treatment systems, which will be selected from a ‘menu of interventions’. Several interventions on the menu can be applied to children and families work.

By local authorities investing their funding from the strategy in a unique programme of children and families work, it will:

help to give children the very best start in life
break intergenerational cycles of negative behaviours
level up a range of health and social related inequalities
save costs across the local health, social, education and criminal justice systems

In addition, if local areas invest in such a programme, it will support them to meet many of the aims within the drug strategy.

OHID is working with local authorities to encourage and support them to establish a new programme and enhance work in existing IF areas.

Question 8

Appendix A: details of 6 learning events

Accepted Answer

Six learning events took place between March 2019 and January 2022, including:

March 2019: this was a whole-day learning event held in London to launch the project, attended by several ministers. The 9 IF areas presented the aims and objectives of their projects, while the Tavistock team gave an overview of our approach to the national evaluation and ways of working with the 9 areas and local evaluators. This included details of the launch of an online learning platform (Basecamp) to engage with project leads and evaluators, initiate discussions, raise questions and share relevant resources.
October 2019: this was another whole-day interactive learning event in Manchester. It provided opportunities for projects to meet in a mixture of small groups and plenary sessions to discuss their successes and challenges to date and approaches to evaluating their interventions.
May 2020: this was the first online learning event after the start of the pandemic and focused on identifying initial impacts (‘quick wins’) of the work done so far and how projects were responding to delivering support during lockdown.
November 2020: this online event focused on working with projects to reflect on the use of evaluation evidence collected so far to demonstrate the impact of their projects. This resulted in a presentation to senior government officials in December 2020 by all 9 projects.
June 2021: this online event, co-hosted with DWP, focused on approaches to integrate reducing parental conflict support into the work done by projects with ADPs and their families.
January 2022: this last online learning event was used to share and celebrate particular project successes and to reflect on how to sustain changes and learning going forward.

Question 9

Appendix B: local evaluations

Accepted Answer

There were local evaluations commissioned by the local areas involved in this CADeP IF programme, and independent of this national evaluation carried out by Tavistock Institute of Human Relations. See the published local evaluations below.

West Sussex

Growing Families Project: Supporting Children and Young People of Alcohol Dependent Parents/Carers - Local Evaluation 2022

Portsmouth

Whole Family Support Project: Supporting families living with alcohol misuse in Portsmouth: an evaluation of the Family Support Project (scroll down to ‘Resources for Professionals’). An addendum to the report is available on the same page.

North Tyneside

Bottled up project: Final Report: Bottled Up: Identifying and supporting children and families to reduce alcohol harm (scroll down to ‘Related documents’)

Brighton and Hove

Back on track project: Local evaluation of Brighton & Hove ‘Back on Track’

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Ferguson, KM. ‘Exploring the psychosocial and behavioral adjustment outcomes of multi-type abuse among homeless young adults.’ Social Work Research 2009: volume 33, issue 4, pages 219-230. ↩
Timpson H and others. ‘Evaluation of the Innovation Fund St Helens Building Bridges Project: Final Report.’ 2021. ↩
Fals-Stewart W, O’Farrell TJ and Birchler GR. ‘Behavioral Couples Therapy for Substance Abuse: Rationale, Methods, and Findings.’ Science & Practice Perspectives 2004: volume 2, issue 2, pages 30-41. ↩ ↩²
Public Health England. ‘Substance misuse treatment for adults: statistics 2017 to 2018.’, NDTMS, 1 April 2017 to 31 March 2018. ↩
The Alcohol Identification and Brief Advice project (Alcohol IBA) helps professionals to identify those individuals whose drinking might impact their health, now or in the future, and to deliver simple, structured advice aimed at reducing this risk. ↩

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1. Introduction