Finding more effective ways of working with serious parental alcohol (and drug) misuse has become a major policy concern. Around 60% of children entering care involve serious drug or alcohol problems (Forrester and Harwin, 2011). Increasing numbers of children are entering care, with alcohol and drug misuse considered to be one of the main reasons for this increase.
Perhaps surprisingly there is remarkably little research evaluating what approaches might be effective in working with these high risk and complex families. Indeed, a recent review for the Scottish Government of effective social work interventions for substance misuse found only one published UK evaluation using a comparison group in children’s services, and that was an initial evaluation of the “Option 2” project in Wales (Galvani and Forrester, 2011).
The initial evaluation of Option 2 (funded by the Welsh Government) included There ised the service, it reduced the need for public care and as a result it produced significant cost savings (Forrester et al., 2008). These are encouraging findings and they are contributing to significant developments in the development and delivery of services. For instance, teams based on the Option 2 model are being rolled out across Wales (Welsh Government, 2008) and the Option 2 model is being used as a basis for service developments across England.
However, in addition to evidence that Option 2 reduces the use of care it is important to know what impact Option 2 has on parental substance use, child welfare and family functioning. Given the importance of this area Alcohol Research UK funded the current study which aimed to examine these issues. The evaluation also aimed to explore what – if anything – about the service had an effect on families.
What is the Option 2 Service?
Option 2 is based on a crisis intervention model named “Homebuilders”, though it has been adapted in important ways. The “crisis” is usually the possibility of a child entering care, though it can be them becoming subject to a child protection plan. Option 2 works in a very intensive way with families referred by child and family social workers. The key elements of the service are:
- Intervention at the crisis point. The response is shaped by crisis intervention theory and focuses on immediate intervention. Families are seen within 24 hours of referral.
- Intervention in the home. Services are primarily delivered in the client’s home.
- Accessibility and responsiveness. Therapists are on call to their clients 24 hours a day, 7 days a week. Families are given as much time as they need, when they need it. This accessibility is intended both to be helpful and to allow close monitoring of high risk situations.
- Intensity. Services are time-limited and concentrated in a 6 week period. The service is designed to help the family to resolve the immediate crisis, and make the changes needed to remain together. Each family receives a large amount of direct contact.
- Low caseloads. Therapists carry only one family at a time. This enables them to be accessible and provide intensive services.
- Flexibility. Services are provided when and where the clients wish. Therapists provide a wide range of services tailored to the needs of the family.
- Follow-up. At the end of the period of intervention the aim is that there will have been considerable improvement in family wellbeing and safety for children. Other services will be involved with families as appropriate. Families are provided with follow-up visits in the months following Option 2 to support changes achieved and identify any recurrence of problems.
The study takes advantage of the fact that Option 2 (as a crisis intervention service) does not have a waiting list. If a referral is received when the service has no spaces, details are taken but the family will generally not receive the service. This provides a natural comparison group to investigate the impact of Option 2 on outcomes.
The intention was to recruit 25 comparison families and match them to Option 2 families. In fact recruitment proved very challenging, with only 36% of families interviewed. As a result the recruitment was widened to obtain sufficient families. However, as a result there were some significant differences between the samples. For instance, there was far more drug use in the group receiving the Option 2 service and more alcohol use in the comparison group. Attempts have been made to allow for some of these differences through triangulation of qualitative and quantitative data and the use of multivariate analyses, however the most important implication is that care should be taken in drawing conclusions as discussed below.
The study compared outcomes for a sample of 27 families (84 children). These were composed of:
- 15 Option 2 families (52 children) and
- 12 comparison families (32 children).
Data was gathered through research interviews. A distinctive feature of the study was that the follow-up was very long: on average 5.6 years after referral.
Research interviews gathered qualitative accounts from parents about family functioning and wellbeing and the contribution of services to changes over time. Standardised measures of outcomes were obtained for:
- Child’s emotional and behavioural welfare (Strengths and Difficulties Questionnaire (SDQ) for emotional and behavioural development)
- Parental substance use (Maudsley Addiction Profile (Section B) (Marsden et al., 1998))
- Parental risk of psychological problems (General Health Questionnaire (GHQ-12)
- Family functioning (Family Environment Scale (sub-scales for family cohesion, open expression of emotion and open conflict)).
There were commonalities across both groups and given the relatively small sample it was felt that important stories relating to the long-term outcomes of families involved with social services were best considered through a description of the whole sample. The study then undertook quantitative and qualitative analysis comparing the Option 2 sample and those who did not receive the service.
Over the whole sample, the families had had very serious problems related to alcohol and drug misuse by parents. These were related to very high levels of concern about risks to children, including children being assaulted, born withdrawing from drugs, experiencing severe neglect or witnessing violence in the home. These issues took place in complex contexts of multiple other problems, including most prominently inter-generational abuse, low maternal self-esteem, high levels of violence and poverty.
Over the years the families had received inputs from a wide range of agencies. Services that were available when needed, where professionals were caring and committed and that provided long-term support were particularly valued. Across a wide variety of professionals, including GPs, social workers and alcohol services, workers working in this way were identified by parents. Such services maximised the likelihood of parents addressing their alcohol and drug problems
At follow-up most parents had considerably reduced their drug and alcohol use. Despite this, overall the families had high levels of family difficulty at follow-up, with parents having scores suggesting many were stressed and at risk of psychological problems, many of the families were experiencing discord and a relatively high proportion of the children had emotional and behavioural difficulties. This evidence was supported by qualitative accounts of family difficulties and often the inter-generational transmission of problems.
Option 2 and Comparison Group
Families that had received the Option 2 service had better outcomes than those who had not. In particular there were statistically significant differences (p<0.05) in relation to:
- Parental alcohol or drug misuse (Option 2 parents were more likely to have considerably reduced or stopped their self-rate substance use (94% to 58%));
- Parental stress and risk of psychological problems (Fewer Option 2 parents had high scores on the GHQ-12 (44% to 85%));
- Families had significantly more cohesion (Family Environment Scale).
- The finding from the previous study that Option 2 children were less likely to enter care was strongly supported:
- Only 8% of Option 2 children entered care (compared to 44%)
- None were in care permanently (compared to 38%)
There was no significant difference in the emotional and behavioural welfare of the children in the two groups. It appeared that children receiving the Option 2 service were being kept in their family homes without an increase in poor outcomes.
In the qualitative analysis the families were grouped into those with ongoing problems (9), those where improvements had been recent or partial (7) and those where there had been obvious and sustained improvements since the time of the referral (10) (analysis was not possible for one family). Option 2 was strongly associated with better outcomes, with 70% of those with sustained improvements having received the service, compared to 57% of the mixed group and only 33% of the no change group.
Overall, parents reported that the Option 2 service was extremely positive for them. In particular they tended to highlight that it:
- Was there when they needed it
- That the workers were caring and seemed to understand their problems
- The focus on recognising and building strengths was helpful
- That the workers managed to help families make achievable plans for change and support them to carry out changes
- That workers were able to raise concerns and be honest and open about the possibility of children being removed or other serious outcomes
- And that workers were helpful in negotiating with other agencies and professionals.
The main criticism that parents made was that the service was not available for long enough, or that they would have liked to be able to be re-referred when they had later problems.
Care needs to be taken in drawing conclusions given the relatively small numbers and challenges experienced in recruitment. However, the study follows an initial evaluation with data on care entry from a far larger sample of children (n=367). It is in line with findings from that study. The combination of qualitative and quantitative data allows a rich picture of the interaction between receiving a service and outcomes to be explored.
It is important to highlight that the evaluation involved a very long follow-up (5.5 years) for a 6 week intervention. The comparison group also received a variety of other services, some of which were of a very high quality. (Indeed, some were delivered in the same building as Option 2 by alcohol counsellors). These factors make demonstrating the effectiveness of Option 2 particularly challenging. In this context it is particularly impressive that over the two studies combined Option 2 seems to deliver some consistently positive outcomes. In particular the service:
- Significantly reduces the need for children to enter care
- Appears to improving family and parent wellbeing
- There are no indications that children are left at risk or suffer harm despite the reduced use of public care
- It produces very significant cost savings for local authorities and other social care, health and criminal justice agencies
- Option 2 appears to be an effective way of engaging and helping parents with serious drug and alcohol problems to significantly reduce their drug or alcohol use and thereby reduce the need for their children to enter care.
Option 2 appears to be the most thoroughly evaluated service aimed at preventing children entering care in the UK. It is successful in doing this and as a result saves local authorities and other public services significant amounts of money.
This excellent and innovative service should be replicated and adapted to suit local needs. It forms a first rate basis for the development of any service aimed at reducing the need for children to enter care.
New services based on Option 2 should be carefully evaluated in order to ensure that they are delivering the service to the same level of quality and achieving at least equivalent results. There are many examples of services based on the Homebuilders model that do not achieve the same outcomes as the Option 2 service (see Forrester et al, 2008b). It is likely that the quality of the service is at least as important as the structure and model used.
Other services likely to work with families with complex substance misuse issues could learn lessons about effective service provision, for instance by replicating the use of Motivational Interviewing or solution focussed approaches in more general services for families. This seems particularly applicable to child and family social work.
Forrester, D. and Harwin, J. (2011) Parental misuse of drugs and alcohol: effective intervention and assessment, Wiley; Chichester
Forrester, D., Pokhrel, S., McDonald, L., Giannou, D., Waissbein, C., Binnie, C., Jensch, G. and Copello, A. (2008) Final Report on the Evaluation of “Option 2”, Welsh Assembly Government, 90 pgs, April 2012.
Galvani, S. and Forrester, D. with Glynn, G., McCann, M., Guppy, A., Hemsley, C., Hillson, M. and Thurnham, A. (2010) Social Work Services and Recovery from Substance Misuse: A Review of the Evidence, Report for the Scottish Government, November 2010
Welsh Government (2008) Stronger Families – Supporting Vulnerable Children and Families Through a New Approach to Integrated Family Support Services, Consultation Document.
D Forrester, S Holland, A Williams and A Copello