How do drug and alcohol misuse, mental health problems and domestic violence affect parenting?

Substance misuse, mental health problems and domestic violence are commonly associated with child protection involvement and are described as "key risk factors" for child abuse and neglect. There is substantial research documenting the association between these parental problems and poor outcomes for children. Children are particularly vulnerable to cumulative harm in families with multiple and complex problems in which the unremitting daily impact of multiple adverse circumstance and events has a profound and exponential impact on children, and diminishes their sense of safety and wellbeing (Bromfield & Miller, 2007). Despite the strong association between these parental problems and child protection, there is limited guidance for practitioners that sets out exactly how these problems affect parenting. The focus of this section is to identify the adverse effects of parental mental health problems, substance misuse and domestic violence on individuals, their parenting behaviours and the consequent immediate risks to children.

This paper does not investigate the subsequent long-term effects of abuse and neglect on children. For more information on the long-term effects of abuse and neglect for adult survivors, see Lamont (2010).

It is important to note that the severity and longevity of the effects of parental substance misuse, mental health problems and domestic violence on children depend upon the nature, extent and severity of the problem and manner in which it affects the individual. Not all children whose parents experience mental health problems, substance misuse or domestic violence will experience poor outcomes. For example, in a meta-analysis of 118 studies, Kitzmann, Gaylord, Holt, and Kenny (2003) found that 37% of children who had witnessed domestic violence had comparable or better outcomes than children from otherwise similar backgrounds who had not witnessed domestic violence. The extent to which parenting capacity is sustained or diminished and children are at risk of abuse or neglect is also influenced by the presence of protective factors. Responses within families are diverse; some children are able to experience supportive and nurturing environments despite the presence of parental problems. This section draws on research about mental health problems, substance misuse and domestic violence to unpack how these problems can affect individuals, their capacity to parent and, in turn, their child's risk of experiencing abuse or neglect.

How can parental substance misuse affect parenting?

Individual impacts

• There are many different types of licit and illicit substances. The substances most commonly involved in parenting concerns are alcohol, opiates (heroin, cocaine), amphetamines (ecstasy, speed), psychoactive drugs (marijuana) and the overuse of prescription drugs.
• Substance use affects the brain, impairing the senses (e.g., blurred vision, impaired hearing), perception (e.g., reaction time, balance), motor skills (e.g., impaired coordination, shaking), speech and judgement (e.g., reason, caution, self-restraint, inhibitions). Depending upon the nature of the substance, it may act on the brain as an accelerant (e.g., methamphetamine) or a depressant (e.g., alcohol). Some substances can induce violence (e.g., alcohol) or paranoia (e.g., "ice") in some users. Substance misuse may result in extreme lethargy, tiredness, lack of consciousness or "passing out", coma and death.
• Withdrawing from addictive drugs can also have severe adverse affects such as increased anxiety, irritability, sleeplessness, depression, vomiting and paranoia (NSW Department of Community Services, 2004).
• There are serious long-term health effects for chronic substance misuse (e.g., cancer, liver failure, heart disease), which may themselves impair functioning (Commonwealth of Australia, 2007; NSW Department of Community Services, 2004).
• Maintaining a substance addiction may include involvement in drug dealing (as a buyer or supplier) or criminal behaviour such as shoplifting, burglary or prostitution as individuals attempt to finance their drug habit.

Impacts on parenting behaviour

• Symptoms of intoxication and withdrawal may mean that parents find it difficult to maintain household tasks and routines such as preparing meals, ensuring the child's clothes are clean, supervising children, maintaining regular routines for school attendance and responding to their children's emotional needs (Dawe, Harnett, & Frye, 2008).
• Financial difficulties may arise as parents may ignore buying household essentials such as food, clothes and bills in order to pay for drugs (Dawe et al., 2007).
• Substance misuse influences a parent's mood and can cause inconsistent parenting as a result of fluctuating mood swings, which may result in parents on some occasions using controlling, authoritarian and punitive parenting and, at other times, permissive and neglectful parenting styles (Dawe et al., 2007). Parents themselves have reported yelling more often, being inattentive, being more self-focused, using reactive or authoritarian parenting, creating an atmosphere of secrecy and allowing the child to take on a parenting-type role when affected by substance misuse (Odyssey House Victoria, 2004).

Risks to children

• There is a high risk of neglect for children whose parents misuse substances. For example, poor supervision may lead to children's needs not being met (having regular healthy meals, clothes being washed, attending school, emotional attention and nurturing) (Dawe et al., 2007).
• Children are at risk of physical and emotional abuse if a parent's response to intoxication or withdrawal symptoms is violent, reactive or punitive (Dawe et al., 2007). They may also be at risk of sexual abuse by a parent if the parent has a predisposition to abuse due to loss of inhibition (Dawe et al., 2007). Children are also at risk of sexual abuse from extra-familial perpetrators, especially when the child is at risk of supervisory neglect. Exposure to drug use, drug overdose, drug dealing and other criminal activity is also possible (Dawe et al., 2007).
• Children may develop pervasive fears: of fights and violence (to parent or themselves); of discovery of family secret and the parent being incarcerated or the child being removed; or for parents' wellbeing and safety. The added emotional stress can harm the development of children's brains and impair cognitive and sensory growth (Perry, 2001). Therefore children are at risk of poor developmental outcomes. Fears may trap children into a position where they cannot discuss their parent's drug problems or ask for help from their parents, their peers, other family members, family support networks or professionals (Dawe et al., 2007; Odyssey House Victoria, 2004).
• Even before birth, babies in the womb experience the adverse effects of poor diet, drugs and alcohol use, or violence perpetrated on their mother. Maternal stress experienced during pregnancy can cause physiological stress responses in the foetus, which affect the amount of oxygen and nutrition received by the unborn child (Rice, Jones, & Thapar, 2007). Other peri-natal complications may include withdrawal symptoms and premature births (Kroll & Taylor, 2003; Tunnard, 2002).

How can domestic violence affect parenting?

It is vital to consider violence between intimate partners in the context of parenting, as research shows that violence between intimate partners is more likely to occur between couples with children, often commencing during pregnancy (Taft, 2002). Violence between intimate partners is overwhelmingly a gendered issue with the vast majority of incidents involving a female victim and male perpetrator (Australian Bureau of Statistics, 2005). While acknowledging that there are other patterns of violence (Australian Bureau of Statistics, 2005), in this paper we address the issues presented by this dominant pattern of men's violence towards women. This is evident in the way in which parenting impacts are delineated below for mothers as victims and fathers as perpetrators of intimate partner violence.

Individual impacts

• Physical assaults may result in a range of injuries (e.g., bruising, scratches, cuts, burns, bone fractures). Long-term physical assault may result in reduced mobility, long-term adverse health effects, disability, miscarriage and sexual and reproductive health problems. A Victorian study showed that domestic violence is "responsible for more ill-health and premature death in Victorian women under the age of 45 than any other of the well-known risk factors, including high blood pressure, obesity and smoking" (VicHealth, 2004, p.8).
• There is a well-established relationship between the experience of intimate partner violence and mental health problems (e.g., depression, anxiety, trauma, self-harming and suicide) (Campbell, 2002; Golding, 1999; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; VicHealth, 2004). Although not as strong, there is also an association between the experience of domestic violence and substance misuse (Golding, 1999; see previous and following sections for discussions of substance misuse and mental health problems).
• Domestic violence includes sexual assault by an intimate partner (Heenan, 2005). In a national survey of Australian women, 12% reported experiencing sexual violence perpetrated by a current or former partner. Of women who were sexually assaulted by their partner, 73% were also physically assaulted (Mouzos & Makkai, 2004).
• Domestic violence is linked with homelessness and housing instability for victims fleeing violent partners. Data from the Supported Accommodation Assistance Program (SAAP) for 2007-08 show that the main reason females with children sought support was domestic or family violence (50%) (Australian Bureau of Statistics, 2006). Around 100,000 Australians are homeless, including 7,483 homeless families (10,608 parents and 16,182 children). Of this homeless population, 12% are children under 12 years (most accompanied by a parent) and a further 21% are aged 12-18 years (these children are mainly on their own) (Australian Bureau of Statistics, 2006).
• At its most extreme, domestic violence can result in death. In Australia, approximately 20-25% of all homicides were perpetrated by spouses (Mulroney, 2003).

Characteristics of perpetrators

• Perpetrators of domestic violence have been shown to display the following characteristics towards their partners:
  • control;
  • entitlement;
  • selfishness and self-centredness;
  • superiority;
  • possessiveness;
  • confusion between love and abuse (e.g., claiming they would not become violent with their partner if they did not love the partner so much);
  • manipulation;
  • externalisation of responsibility;
  • denial;
  • minimisation; and
  • victim blaming (Bancroft & Silverman, 2002).
• Service providers are cautioned to avoid making assessments about violent men's propensity for future violence based on self-reports. Men who are violent towards their partners may make strong anti-violence statements while continuing their violent behaviour (Bancroft & Silverman, 2002). In terms of adverse effects, perpetrators of domestic violence may experience homelessness, housing instability, relationship breakdown, separation from their children, loss of contact with their children and disintegration of father–child relationships, criminal charges, prosecution, and incarceration as a result of their violent behaviour.

Impacts on parenting behaviour

Mothering

• Mothers who have experienced domestic violence are frequently held responsible for "failing to protect" their children (Holt, Buckley, & Whelan, 2008) but research shows that the majority of mothers make considerable efforts to protect their children (Mullender et al., 2002). Women may actually choose to remain with violent partners as they consider it too dangerous to leave. With evidence that violence frequently continues and may actually increase after separation (Holt et al., 2008) such fears cannot be discounted. These findings suggest that a blaming approach with mothers is unlikely to be helpful.
• Effects of violence (e.g., pain, distress, anger, irritability, fear, reduced mobility, hospitalisation) may affect a mother's parenting capacity, as may mental illness or substance misuse problems that emerge as a consequence of domestic violence (see previous and following sections). Domestic violence may result in mothers being emotionally distant, unavailable or unable to meet their children's needs (Holt et al., 2008).
  

  I didn't have the same patience with the children when he was there, because I think I was frightened he was going to lose his temper. (Mother in Mullender et al., 2002)

• In their attempts to prevent or manage men's violence, and as a result of living in fear, mothers have reported prioritising their partner's needs over those of their children and denying their children normal childhood experiences (Humphreys, Houghton, & Ellis, 2008; Holt et al., 2008, p. 801). "I was so hooked into placating him that I emotionally neglected the kids" (mother in Mullender et al., 2002).
• Evidence suggests that violence can damage the mother–child relationship. Belittling, undermining, insulting and hitting women in front of their children may affect children's respect for their mother's authority (Bancroft & Silverman, 2002; Humphreys, 2007), and her ability to exercise authority and control over her children (Holt et al., 2008).
• It is worth noting that some research suggests that the effects of domestic violence on mothering may not be permanent. A study in the United States found that women who had experienced intimate partner violence in the past but were no longer victims had significantly better scores on a self-reported measure of parenting skills than women who were currently experiencing violence from an intimate partner. There was no significant difference between women who had experienced intimate partner violence in the past and women who had never experienced intimate partner violence (Casanueva, Martin, Runyan, Barth, & Bradley, 2008). On a similar theme, children who had escaped domestic violence with their mothers predominantly felt that their fathers were to blame and reported wanting to stay with and support their mums (Mullender et al., 2002).

Fathering

• There is limited research regarding the effects of domestic violence on father–child relationships or on men's capacity to father. The fathering practices of men who are violent towards their intimate partners will vary along a continuum of abusive to optimal parenting. It has been argued that men who perpetrate family violence cannot be fully responsible parents, as exposing children to domestic violence is in itself abusive (Bancroft & Silverman, 2002).
• Based on their clinical experience Bancroft and Silverman (2002) identified common parenting characteristics of men who were violent towards their spouses. The characteristics, which are further validated from other empirical evidence, suggest that men who were violent towards their spouses were more likely to:
  • have developmentally inappropriate behavioural expectations of children (Fox & Benson, 2004);
  • generally be under-involved with their children and less physically affectionate but, at times (and unpredictably), to be powerfully present in the child's life, interacting with energy and humour, and spending money freely;
  • be authoritarian and rigid when involved in the disciplining of children, and self-report being more likely to use physical punishment and to "smack hard" (Fox & Benson, 2004);
  • be self-centred and put their own wants above the needs of their children, or even believe that children exist to meet their fathers' needs (Fox & Benson, 2004; Mullender et al., 2002);
  • behave in a manner that suggests they are resentful for their children being the centre of attention (Humphreys et al., 2008; Radford & Hester, 2006);
  • undermine (in addition to being violent towards her) their children's mother by overruling her parenting decisions, ridiculing, belittling and insulting her in children's presence or to children, and telling children that their mother is a bad or unsafe parent (Humphreys, 2007; Holt et al., 2008; Radford & Hester, 2006);
  • be manipulative with their children: for example, creating confusion about which family members are responsible for violence and encouraging children to blame themselves or their mother (Radford & Hester, 2006); and
  • make statements and express emotions regarding their love and pride for their children and desire to be involved in their children's life, despite the confusing reality of their under-involvement (Rothman, Mandel, & Silverman, 2007).
• Children's reports of the damage or disintegration of the father–child relationship as a result of domestic violence focus on betrayal of trust, loss of respect, seeing their father as a source of fear and terror, loss of love, and hatred for their father (Mullender et al., 2002). "We do not see my dad now and don't want to see him. I am happy about not seeing him" (8-year-old girl in Mullender et al., 2002).

Risks to children

• The term "witnessing" domestic violence may imply that children are passive observers who see or hear the violence between the adults in their home but research shows that children experience domestic violence rather than being passive onlookers.
• In a US study, mothers reported that:
  • 37% of children were accidentally hurt during domestic violence;
  • 26% of children were intentionally hurt during domestic violence;
  • 49% of mothers were hurt protecting children;
  • 47% of perpetrators used the child as pawn to hurt mothers;
  • 39% of perpetrators hurt mothers as punishment for children's acts;
  • and 23% of perpetrators blamed mothers for perpetrator's own excessive punishment of children (Fox & Benson, 2004).
• Children are sometimes hurt as a part of the torture and abuse of their mothers. They may be held hostage or threatened. Children may also be forced to watch or perpetrate the abuse of their mother, other siblings or pets (Humphreys et al., 2008; Radford & Hester, 2006).
• The psychological effects of witnessing verbal, physical and sexual assaults perpetrated upon the mother, combined with the effects of living with a father who is frightening, inconsistent, intolerant, and unable to put children's needs first are abusive.
• The toxic stress and complex trauma caused by living in a perpetual state of alert can damage the developing brain and have profound long-term psychological effects (Perry, 2001).
• Children living with domestic violence display physical, developmental, psychological and behavioural effects, as well as the impact of trauma and developmental regression. Compared to those who don't witness abuse, children who do have been shown to have significantly poorer outcomes on 21 childhood psycho-social, developmental and behavioural dimensions. Behavioural problems include acting out, violence and aggression towards others. Outcomes for child witnesses were similar to those where children were also directly physically abused (Kitzmann et al., 2003).
• Family violence has different effects on children at different ages. In utero, the mother's physical and emotional distress has a direct impact on the developing foetus (Jordan & Sketchley, 2009). Assault of the mother may result in miscarriage, premature birth, physical injury or disability (Cleaver et al., 1999; McGee, 2000). Infants and younger children are at risk of being harmed while being held in the mother's arms during an assault; older children may be harmed while intervening to defend their mother from assault (Humphreys et al., 2008).
• The presence of domestic violence puts children at high risk of experiencing physical abuse with rates of co-occurrence ranging from 45% to 70% (Holt et al., 2008).
• There is evidence that the presence of domestic violence also increases the risk of child sexual abuse (Holt et al., 2008). If children are sexually abused, they may also be less likely to disclose. Perpetrator manipulation, threats and intimidation, damage to mother–child relationship and a belief that their mother cannot protect them may delay or decrease the likelihood of disclosure.
• The effects of domestic violence on women can result in mothers who are emotionally distant, unavailable or unable to meet their children's needs and therefore increase the risk of children experiencing neglect.

How can parental mental health problems impact parenting?

Individual impacts

• The term "mental illness" is usually used when referring to a specific, diagnosable disorder, such as schizophrenia, while the term "mental health problem" is broader and includes problems that interfere with a person's daily functioning but to a lesser extent than a "mental illness" (Huntsman, 2008).
• The main mental health problems that are likely to affect parenting are depression, bipolar disorder, schizophrenia, borderline personality disorder, post-traumatic stress disorder, and antisocial personality disorder.
• Depression is a mood disorder. Symptoms include: depressed mood (sadness, emptiness); sleep disturbances (either not being able to sleep well or sleeping too much); loss of interest, motivation and energy; difficulty in concentrating, in holding a conversation, in paying attention or making decisions that used to be made fairly easily; and suicidal thoughts or intentions (American Psychiatric Association, 1994).
• Bipolar disorder is also a mood disorder, in which the individual experiences episodes of mania and depression. Mania is an intense high where the person feels euphoric, may have elevated self-esteem, be talkative, have reduced need for sleep and be easily distracted. The high quickly fades, after which intense depression is often experienced, which can be exacerbated by rash decisions made while manic (e.g., spending too much money, misuse of drugs or alcohol) (American Psychiatric Association, 1994).
• Schizophrenia is a psychotic disorder typically emerging in adolescence or early adulthood that may be triggered through stress. Symptoms include: delusions; hallucinations; disorganised behaviour or speech; flattened or inappropriate emotions; and poor social interaction (American Psychiatric Association, 1994).
• Borderline personality disorder is most commonly diagnosed in females and often where there is a childhood history of unstable relationships, sexual abuse, family violence or neglect. Major symptoms are unstable relationships, poor or negative sense of self, inconsistent moods, impulsivity and an intense fear of abandonment. Symptoms are constant, enduring and affect most—if not all—aspects of life and typically emerge during adolescence (American Psychiatric Association, 1994).
• Post-traumatic stress disorder occurs in response to a traumatic event. Symptoms typically emerge shortly after the event, but may take years to fully manifest. Symptoms can be enduring if untreated and include re-experiencing the trauma through nightmares; obsessive thoughts; flashbacks; avoidance (of situations, people or objects that are reminders of the traumatic event); and increased anxiety (American Psychiatric Association, 1994).
• Antisocial personality disorder is sometimes referred to as psychopathy or sociopathy and is characterised by a pervasive disregard for others' rights. It is preceded by a history of conduct disorder through childhood and adolescence, marked by violations of norms relating to aggression towards people and animals, destruction of property, deceitfulness or theft, or serious violation of rules. Other characteristics that may be associated with this disorder include engagement in unlawful behaviour; being arrogant, opinionated and superficially charming; indifference to others' wishes, rights or feelings; being deceitful and manipulative; impulsiveness; aggression and irritability; reckless disregard for their own or others' safety; being irresponsible with respect to work and money; and showing little remorse (American Psychiatric Association, 1994).

Impacts on parenting behaviour

• Research on the effects of mental health problems and their effects on parenting is limited. Research that has been done has mainly concentrated on depression (Huntsman, 2008).
• The symptoms of a mental health issue can influence a parent's perception, cognition and communication (Hegarty, 2005; NSW Department of Community Services, 2004). Problems in parenting associated with mental health conditions have included being emotionally unavailable, withdrawn, unresponsive, overly critical, being disorganised, inconsistent, tense, less happy and active with children (Mowbray et al., 2000).
• Difficulty controlling emotions can cause parents to become unnecessarily angry with their children. A mental health problem may make it difficult for parents to get out of bed in the morning to take their children to school. A loss of motivation can also cause difficulties in performing basic tasks such as doing housework or the shopping (Hegarty, 2005).
• The characteristics of antisocial personality disorder can lead to a lack of responsible parenting in the areas of safety; hygiene; nutrition; responsive nurturing of feelings; dealing adequately with illnesses and physical injuries; and managing money for household goods. Some parents may be fearful of abusing their children and so become withdrawn, or alternatively they may feel an intense need to protect their children and so appear intrusive and anxious (Newman & Stevenson, 2005).

Risks to children

• Children of parents with an uncontrolled mental illness face a high risk of physical neglect. Basic needs may not be met, such as having regular healthy meals and clean clothes (Cowling, 2004). Parents may fail to attend to children's emotional needs, which can instil a sense of isolation and possible mistrust in children. There are risks of physical and psychological abuse by parents, if symptoms of illness contribute to the parent being violent, reactive or punitive (Cowling, 2004).
• Parental mental health problems can also increase the risk of peri-natal complications due to possible side effects of medications, (e.g., antidepressants) during pregnancy and high stress levels in mothers (Cowling, 2004; Huntsman, 2008). Attachment difficulties may arise for babies and infants of mothers with maternal mental health problems such as depression (Cowling, 2004).
• Children may become "parentified" and assume the role of a carer for an ill parent or sibling. This can cause significant emotional stress and disrupt a child's general development (Huntsman, 2008).
• Children of parents with mental health problems have also been found to be at risk of developing mental health problems of their own (Cowling, 2004). Problems in a child's cognitive development may also arise due to the parent's inconsistent and neglectful behaviour (Cleaver et al., 1999).
• The recklessness associated with antisocial personality disorder and the tendency of those suffering from it to minimise the harmful consequences of their actions can put a child at risk of serious or chronic illness, injury and death. In addition, the promiscuity and poor relationship choices made by some adults with antisocial personality disorder may put a child at risk of abuse from others (Newman & Stevenson, 2005).

Social exclusion: The wider context of multiple and complex problems

Responding to families with multiple and complex problems

In summary, parental substance misuse, mental health problems and domestic violence affect parenting and place children at risk of abuse and neglect. Families with multiple and complex problems are also often situated within a wider context of poverty and exclusion. In reviewing the literature it is therefore evident that families with multiple and complex problems have emerged as the primary client group of contemporary child protection services. This has several implications for practice and for the structure and capacity of the child protection system.

The structure of the service system: A whole-of-government approach to service delivery

Child protection service systems across Australia are struggling to meet the needs of families with multiple and complex problems (Wood, 2008). This is not only because of a lack of services for children and families but because the service system is designed as completely separate organisations and agencies or, in effect, "silos" (Bromfield & Holzer, 2008). Services for children and families come from a variety of sources (and not just child protection departments) including other government departments (e.g., health, education, juvenile justice) and the non-government sector, yet most services tend be focused on one problem. For example, a parent with a dual diagnosis maybe referred from child protection to a rehabilitation service for a substance abuse problem, but then referred on to a mental health service without either service providing background information on the family, or either service knowing that their client is a parent. Worse still, a parent may be refused mental health services because of a substance abuse problem. A further example of the difficulties with a "siloed" system is that families may be unable to claim social welfare benefits due to homelessness or housing instability. Services may be available (albeit often with a substantial waiting list) but families who need them these services the most may not know how to access them. In many instances, a siloed service system further compounds disadvantage and exclusion.

Bromfield and Holzer (2008) concluded that, to respond more effectively to families with multiple and complex problems, a whole-of-government approach is needed that facilitates integrated working relationships between child protection and different government agencies and the non-government sector (e.g., adult services, family support services and child care). A systematic, multi-agency approach promotes multilateral departmental initiatives to protecting children, whereby service provision is jointly funded between departments such as health, education, the police and child protection/communities in collaboration with the non-government sector. A holistic approach promotes greater service collaboration and information sharing so that families are provided with the most appropriate support (Wood, 2008). Services that have first contact with a family play a more active referral and linking role. Joining up services may help to reduce situations where families with multiple and complex problems are referred from one service to another where little or no history of the family is known before their first visit.

An example of a whole-of-government cross-departmental approach to protecting children is the Think Family program in the United Kingdom. The aim of the approach, developed in 2008, is to make sure that the support provided by child, adult and family services is coordinated and takes account of how problems affect the whole family. The initiative was designed to build on the capacity of all services to reduce the negative impact on children of parents with multiple and complex problems. The core principles of the initiative have been that:

• there is no wrong door - contact with any service offers an open door to joined-up support;
• services look at the whole family - they take into account family circumstances, and adult services consider clients as parents;
• services build on family strengths - relationship and strength-based engagement; and
• services provide support tailored to need - rather than a "one size fits all" approach (Scott, 2009).

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