Issues for the safety and wellbeing of children in families with multiple and complex problems

The co-occurrence of domestic violence, parental substance misuse, and mental health problems
NCPC Issues No. 33 – December 2010

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.

Practice considerations

Child protection practitioners working with families with multiple and complex problems need to recognise the whole experience of parents and children. Practitioners should be supported and prepared to know how to respond to and work with these families as a matter of routine practice.

Assessment

When making assessments of families with complex problems, knowing the types of problems parents are experiencing (e.g., substance addiction and mental health problems) can help to identify issues that may affect parenting (see the sections on impacts). However, it is not enough to simply name such problems—assessments need to examine how such problems affect parental capacity and parent–child relationships. The diagnosis of a mental health or substance abuse problem alone is not sufficient to determine risk (Benjet, Azar, & Kuersten-Hogan, 2003). It does not really matter whether a family is experiencing one or six problems: what matters is how such problems affect parenting and place children at risk of abuse and neglect. An assessment of parenting capacity therefore requires the identification of how the unique constellation of problems and strengths in the family results in children's parenting and safety needs being met or not being met (NSW Department of Community Services, 2005). Assessing parent–child interactions, the quality of the home environment, the parent's perception of child behaviour, the parent's social support networks and his or her ability to solve problems is more important for determining whether a child is at risk of abuse and neglect than simply identifying or diagnosing parental problems such as substance abuse (Mildon, Matthews, & Gavidia-Payne, 2003). Observing these aspects of a parent–child relationship can enable assessment results to have a direct relationship with intervention planning.

Children's knowledge and awareness of parent problems

Completing a functional assessment of the impact of parental problems on parenting behaviours is important for identifying the risks for children. Practitioners will also find it worth exploring, as part of the assessment, the extent to which children are aware of these problems. This will inform the assessment, and may also be a powerful motivator for parents to change.

Parents may minimise or underestimate the impact of their problems on their children due to their assumption that children have only a limited awareness of the problem, however, research with children has shown that they know earlier and in greater detail about their parents' problems than their parents believed (Dawe et al., 2007; Gorin, 2004; Humphreys et al., 2008; Mullender et al., 2002). Based on a review of the research, Gorin (2004) suggested that the average age children became aware of their parents' problems was between 4 and 5 years. Interviews with children have shown that children were able to put the pieces together to form an accurate picture of what was happening in the household, despite parents' attempts to shield them (Dawe et al., 2007; Gorin, 2004; Mullender et al., 2002).

I don't know really - it just kind of crept up on me. All I know is, one day I did know, so it probably happened bit by bit from me not knowing to me knowing. Then I could remember back when things happened when I was younger, but I didn't think anything of it - like when my mum had bandages and she said she banged herself. But now I realise my dad must have done it, but they hid it from me and I just accepted that at the time. We even made jokes about it - like how clumsy she had been to bash herself ... Mum and Dad, me, we all made those jokes. (15-year-old girl in Mullender et al., 2002)

Parents also reported that, while they tried to conceal their problems from their children, as the problems escalated they became less able to put in place the necessary planning and controls to prevent their child from finding out (Dawe et al., 2007; Mullender et al., 2002). Sadly, there was also evidence that parents' attempts to control the situation to prevent their children's discovery of the problem caused their children's needs to be neglected in other ways (e.g., children feeling rejected and unwanted as parents excluded them while trying to shield them from their substance misuse. Children may be forced to constrain their natural desire for play and exuberance as it was a trigger for violence) (Dawe et al., 2007; Gorin, 2004; Mullender et al., 2002).

In the absence of communication between parents and children about parents' problems, research has shown that children frequently misattribute the cause of family or parental problems to themselves (Dawe et al., 2007; Mullender et al., 2002).

Planning an intervention strategy

When working with a parent who is dealing with multiple and complex problems, practitioners are likely to have to try to support them on different fronts. Referring the family to a different service or professional for each problem or trying to tackle all problems simultaneously will be overwhelming for the family. An effective intervention is planned and purposeful, based on a comprehensive assessment and staged to meet the family's needs and capacities over time.

"Maslow's Hierarchy of Needs" is a theory that can assist in the planning and prioritising of an intervention in practice. Maslow suggested that humans have a natural drive to fulfil their potential but this cannot be achieved unless other, more basic needs are first fulfilled. According to Maslow's theory, individuals are unlikely to be able to focus on their intimate relationships and connections if their survival and safety needs are not attended to first (McAdams, 2006). Figure 1 is an adaption of Maslow's hierarchy to indicate how these needs may be met in service provision. Families with multiple and complex problems are often situated within a broader context of poverty and disadvantage. Therefore, parents may derive little benefit from or struggle to benefit from counselling or parenting programs if they are unable to provide their children with appropriate clothing, fix the car, or replace a broken window. Similarly, they may struggle to provide "good enough" parenting if other, more pressing problems such as obtaining food and paying heating bills have not been dealt with.

If families are overwhelmed with multiple and complex problems, a referral to another service that provides material aid may not be optional but a necessary priority. Practitioners may need to then follow through and assist a parent to navigate access to other services. It is only when parents are able to meet the survival and safety and security needs of their family (see Figure 1) that they will be ready to attend any form of parenting intervention.

Figure 1: Maslow's Hierarchy of Needs (McAdams, 2006)

Figure 1: Maslow's Hierarchy of Needs (McAdams, 2006)

Effective parenting interventions

Once basic needs are met, interventions that deal with relational or self-esteem needs, such as good parenting skills, can begin. Parenting is not necessarily something that one knows how to do intuitively; it is learned (Waylen & Stewart-Brown, 2008). The degree to which each of the tasks of parenting can be achieved is influenced by a range of factors, including:

  • the amount and type of material resources available to parents;
  • individual characteristics of the parents, including heredity;
  • parents' own experiences of being parented and observing the parenting of others, their psychological make-up, relationships; and
  • parents' broader circumstances (e.g., employment, health) (Quinton, 2004).

In a meta-analytical review of components associated with parenting intervention effectiveness, Wyatt Kaminski, Valle, Filene and Boyle (2008) found that program components associated with the greatest changes included increasing positive parent-child interactions, encouraging parents to practise new skills, teaching parents to use "time out" and the importance of parenting consistency.

Further research suggests that effective parenting interventions include components that:

  • encourage one-on-one learning;
  • focus on strengths rather than deficits;
  • offer a shared empowerment to families;
  • build strong client-practitioner relationships that are predictable and reliable;
  • develop positive expectations for change and heightened self-efficacy;
  • enhance problem-solving capacity;
  • provide information that is clear and concise (not lengthy and complicated); and
  • praise parents wherever possible (Berry, 2010; Scott & Dadds, 2009; Wyatt Kaminski et al., 2008).

At times, the effects of parents' other problems may influence their ability to take in and apply knowledge and information, and to read, solve problems or follow complex instructions. It is therefore vital that the factors that may diminish a parent's capacity to learn new skills are attended to so that parents have the best possible chance of developing good parenting skills. (See Box 2 on page 18 for strategies for assisting parents to learn new parenting skills).

Assisting to heal the parent-child relationship

Witnessing or experiencing abuse and neglect in the family not only carries with it direct and indirect injuries to parents and children, but also undermines the parent–child relationships. Redressing this damage takes time and requires that parents have reached a point at which they can acknowledge that their parenting or the home environment has had a negative impact on their child. Parents and children may benefit from specific interventions designed to heal the parent–child relationship (Humphreys, 2007). However, deciding to create the space to support parents and children to talk about their experiences of violence, abuse and neglect may be painful and distressing for parents and children. Practitioners need to carefully prepare and adequately support parents and children to be ready for interventions of this nature to avoid causing further harm (Humphreys & Thiara, 2010).

Box 2: Strategies to assist parents to learn parenting skills

For practitioners working with parents with learning difficulties, the Healthy Start website provides a range of resources and tips. Many of these can also apply to work with parents experiencing other difficulties such as mental health concerns and substance abuse.

  • Take an empowering and proactive approach (e.g., structure tasks in ways that success is optimised: i.e., in small, easily achievable steps).
  • Use different methods to teach skills (modelling, video demonstration, realistic pictures, etc).
  • Try to teach skills in context (i.e., where they will need to be applied - usually the home but perhaps at the supermarket or on a train).
  • Play activities can be opportunities for modelling parenting skills, language and safety.
  • Be aware that the parents' own negative experiences at school may still affect their attitudes towards learning.
  • Materials may need to be adapted to suit the particular family: for example, helping them adapt skills and knowledge to suit the age of their child.
  • Provide information in small chunks; avoid long explanations.
  • Offer simple explanations (e.g., it is preferable to say: "doing things over and over helps kids learn", instead of saying: "repeating particular play activities fosters and reinforces the development of neural pathways and builds their cognitive abilities and psychomotor skills").
  • Make room for repetition, reinforcement and practice in different places or with different materials; this helps parents to feel confident in their ability to perform each step.
  • Ensure activities fit the space available (i.e., play activities should be appropriate to the type of accommodation).

Source: Healthy Start (n.d.). Retrieved from www.healthystart.net.au/developing.php?p=practitioner_resources&r=practice_points.

Responding to adult trauma

Practitioners making assessments should include a thorough family history to identify whether current problems, such as domestic violence, mental health problems and substance misuses, are symptomatic of past traumatic events. Parents may need therapeutic intervention to assist them to process the trauma they have experienced and to explore and develop more adaptive coping strategies that will not impede their parenting capacity.

Box 3 identifies five core empirically derived strategies that have been shown to help adults recover from experiences of trauma.

Box 3: Effective strategies for responding to trauma in adults

Research on supporting an individual's recovery from traumatic events has identified five core, empirically derived strategies that have been shown to help:

Build problem-solving skills

Structured problem solving may help when problems appear overwhelming. Working with adults and children in problem solving involves a 6-step process of: defining the problem; identifying possible solutions together; evaluating these solutions; choosing a solution; planning a solution; and reviewing the plan.

Plan and do positive activities

Encouraging adults and children to engage in positive activities may help them to feel more normal. Positive activities may include doing fun things with the kids, continuing family routines, having hope and optimism, helping others, and spending time with friends.

Develop skills for managing distressing reactions

Learning new strategies that may help to manage distressing reactions; for example, calming skills such as controlled breathing.

Develop helpful thinking

Helpful thinking is not the same as positive thinking. Focusing less on unhelpful thoughts and more on helpful ones can help adults and children to move forward. For example, turning a thought such as "absolutely nothing is going well", into "this is a tough time, but I am doing some things well" may help to re-energise parents.

Develop supportive social connections

Working with adults and children to connect/reconnect with family, friends and others can assist in recovery.

Source: included with the consent of the Parenting Research Centre, which developed this content in association with the Australian Centre for Post-traumatic Mental Health.