BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449
on children: an update
Richard Velleman & Lorna J. Templeton
Richard Velleman is Emeritus
Professor of Mental Health
Research, University of Bath,
and Senior Research Fellow,
Sangath, Goa, India. He is a
clinical psychologist who founded
and managed the Mental Health
Research and Development
Unit (a joint university/National
Health Service (NHS) research
& development unit), as well as
statutory addictions and other
services, helped develop the
families and psychosis service
within Avon and Wiltshire
Partnership Mental Health NHS
Trust, worked as an NHS Trust Board
Director, and published widely on
a range of mental health topics,
especially related to the impact
of addiction on families. Richard
is a Trustee for the Addiction and
the Family International Network
(AFINet). Lorna J. Templeton is
an independent research consultant
and a Visiting Fellow at the
University of Bath. She has been
conducting research in the area of
addiction and the family, including
parental substance misuse, for more
than 15 years. She has co-authored
one book, authored or co-authored
many book chapters and peerviewed articles. Lorna is a Trustee
for Adfam and AFINet.
Richard Velleman, Department
of Psychology, University of
Bath, Bath BA2 7AY, UK. Email:
We review how research over the past decade
both supports existing knowledge about the
risk factors that children in the UK affected by
parental substance misuse face, and adds to
our knowledge about the protective factors,
protective processes and evidence of resilience
which can reduce the likelihood that children will
experience poor outcomes. Further research is
needed to understand what areas of resilience
are most important to target and how other
variables, such as gender or age, may inﬂuence
how protective factors affect the development of
resilience. Longitudinal research is also needed to
better understand how an individual’s resilience
may change over time. Finally, there remain many
considerable challenges which practitioners,
service providers, commissioners and policy
makers face in better meeting the needs of this
population of children.
• Understand effective mechanisms for reducing
risk, developing protective factors and building
resilience in children affected by parental
• Be able to focus on the child’s needs, not the
parental problems, and on maximising the
necessary benefcial factors in their lives
• Be able to incorporate the ideas within this article
into clinical and therapeutic practice
DECLARATION OF INTEREST
In a previous article in BJPsych Advances we
summarised the research on the impact that
parental substance misuse has on children and
on resilience (Velleman 2007a). Nearly 10 years
on, we have been asked to update what more is
now known about building resilience in children
affected by parental substance misuse, drawing
on the wider literature where relevant. We brieﬂy
consider prevalence, impact and risk factors, before
concentrating on recent findings and emerging
understanding relating to protective factors/
processes and to resilience. We also examine what
practitioners and services can do, and are doing, to
modify the impact of parental substance misuse on
children. Finally, we clarify what has been learned
over the past decade and what gaps remain.
Prevalence of parental substance misuse
Estimates of the number of parents and children
who were believed to be affected by these
problems have risen considerably since 2007, with
approximately 3.4 million children under 16 living
with at least one binge-drinking parent, almost a
million living with two binge drinkers, and almost
half a million living with a lone parent who is also
a binge drinker; a further 2.6 million live with a
hazardous drinker, 300000 with a harmful drinker
and >700000 with a dependent drinker (Manning
2009, 2011; Hill 2013).
Regarding illicit drugs, almost a million children
live with an adult who has used any illicit drugs
within the previous year, >250000 live with an adult
who has used a class A illicit drug within the previous year, and >870000 live with an adult who has
used a class C illicit drug within the previous year.
In terms of drug dependence, 335000 children live
with a drug-dependent user, 72000 with an injecting drug user, 72000 with a drug user in treatment,
and 108000 with an adult who had overdosed.
About 430 000 children live with a problem
drinker who also uses drugs, and >450 000 have
parents where problem drinking coexists with
mental health problems. Furthermore, high numbers
of children live with a parent with more than one
problem (alcohol/drugs/mental health diffculties),
and more than 25% of babies under the age of 1 will
have been exposed to at least one type of serious
risk in their frst 12 months (problem drinker, class
A drug user, mental health disorder or victim of
domestic violence). There has also been growing
concern about the emergence and increasing use
of a range of novel psychoactive substances (‘legal
highs’) in this time (European Monitoring Centre
for Drugs and Drug Addiction 2015).
The impact on children
As summarised in our 2007 article, exposure to
parental substance misuse can have numerous
negative consequences for young people. More
recent evidence again corroborates these
BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449 109
Impact of parents’ substance misuse on children
conclusions. Among the negative effects that have
been recorded are:
• emotional and mental health problems, including
depression, anxiety disorders, obsessive–compulsive disorder and attachment-related psychological adjustment (Fraser 2009; Harwin 2010)
• diffculties in dealing with the knock-on effects of
parental substance misuse – emotions, silence, trust
and stigma (Templeton 2009; Houmoller 2011;
Hill 2013, 2015)
• the development of alcohol and drug problems
in adolescence and beyond (Harwin 2010;
• early sexual relationships and relationship
diffculties later in life (Harwin 2010; Kelley 2010)
• academic underachievement (Torvik 2011)
• conduct and behavioural problems (Harwin
Cleaver et al (2011), building on their earlier
work in this area, helpfully summarise how children
of different ages can experience different problems
when exposed to a range of parental problems,
including parental substance misuse.
There are two main pathways through which
children are at increased risk of poor outcomes:
one dictated by the parenting and wider family
environment, and the other influenced by
children’s exposure to additional risks. Our 2007
article showed the range of factors in parents’
lives and relationships which have the potential
to exacerbate their children’s problems, and that
these have a cumulative effect: the more that are
present, the higher the risk of negative outcomes
(Velleman 2007a). Further evidence has emerged to
corroborate and strengthen these fndings.
A number of researchers (Velleman 2008;
Bernays 2011) have reported that disharmony,
aggression and violence signifcantly raise the risk
of negative outcomes for children in families who
misuse substances. Evaluation of calls to ChildLine
and the National Association for the Children of
Alcoholics indicates that children who disclose
that they are living with parental alcohol (or drug)
misuse often have another major problem which is
troubling them and which is the initial reason for
making the call (most commonly physical abuse,
violence or family breakdown) (Mariathasan 2010).
Research into UK social work case-loads has
revealed the signifcant interplay between substance
misuse and child protection concerns, and their
coexistence with problematic parenting, conﬂict
and domestic violence (e.g. Cleaver 2007; Forrester
2007; Brandon 2009, 2010; Munro 2011).
Similarly, a number of researchers have
corroborated the finding that the existence of
problematic parenting or the absence of a stable
adult figure also significantly raises risks for
children in both the short and long term (Cleaver
2007; Redelinghuys 2008; Scaife 2008; Hill
Finally, Adamson & Templeton (2012), Cleaver
et al (2011), Horgan (2011) and Templeton (2013)
have all reviewed literature showing the cumulative
increased risk of poor outcomes when children
face multiple adversities in addition to parental
substance misuse (see also Jaffee et al (2007) for a
‘cumulative stressors model’).
However, children and families are unique,
so rules about risks and outcomes are often not
generalisable: it is unhelpful to look for specifc
and linear links between a particular problem/risk
factor and a particular negative outcome. What is
clear is that risks are greater if:
• there is exposure to multiple problems (the
presence of domestic violence and abuse appears
to be particularly potent)
• the child lives with two parents with problems
• there is greater length and severity of the problems
• there is significant ‘fall out’ associated with
problems, both within the family (e.g. disharmony) and outside (e.g. signifcant disruption,
association with the criminal justice system).
The key points relating to the range of risk factors
which children of problem substance misusers face
are shown in Box 1.
It is easy to understand why many children who
grow up in such environments are at risk of negative outcomes. Yet there is considerable evidence
that children can grow up in all sorts of diffcult
circumstances without developing signifcant problems, and that they sometimes demonstrate good
outcomes, in spite of such serious threats to adaption and development. We reviewed this evidence in
the 2007 article, but much more is now understood.
Protective factors are now seen as being of major
importance. They appear to work in a number of
• they serve to balance out risk factors;
• some are inconsistent with their opposite: if the
protection factor is there, the risk factor cannot be
(e.g. being a consistent parent is not compatible
with being an inconsistent one);
• some also appear to have major protective
features in their own right – the presence of a
stable adult fgure can serve as protection even
if other elements of a child’s life are very risky.
110 BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449
Velleman & Templeton
The complexities of protective factors and how they
interact with risky ones are further discussed later
in this article (see Resilience).
Nevertheless, there have not been many studies
undertaken into protective factors and their
relationship with resilience specifically with
children living with parental alcohol/substance
misuse. Three important and more recent
qualitative studies in this area are from the USA
(Moe 2007), Israel (Ronel 2011) and Scotland
(Backett-Milburn 2008). All three studies talked
directly to children and young people, who offered
their perspective on what might be important
protective factors which can create resilience.
The Backett-Milburn et al study (2008) is also
important because it draws out some complexities
in this area. For example, the authors highlight that
identifed coping strategies and support could be ‘a
double-edged sword’, further stressing that, ‘the
protective factors classically thought to promote
resilience were seldom in place for these children
unconditionally and without associated costs’.
Again, Cleaver et al (2011) list the key protective
factors which might be most likely to inﬂuence
children of different ages.
These and other studies have also drawn attention
to the ‘active agency’ which children/young people
possess in adopting coping strategies, seeking
support, and choosing what they share about their
circumstances and with whom (Backett-Milburn
2008; Holmila 2011; O’Connor 2014; Hill 2015).
For example, Hill’s qualitative study with 30
children/young people (aged between 9 and 20
years) in Scotland highlighted that, ‘a failure to
talk is often seen as a defcit, rather than as an
active choice by some children and young people
that should be respected’ (Hill 2015). Accepting
such agency by children and young people, and the
protective role that this may have for them, is an
important addition to understanding this area, and
should be incorporated into service models.
Although some of this more recent research
focuses on internal protective characteristics it is
still the case that protective factors located within
the family, particularly in terms of parenting and
parent–child relationships, seem to be central. The
early years and key stages of a child’s development
appear to be critical times at which children can
be at increased risk of poor outcomes and when a
protective factor or process can be most inﬂuential.
In addition, the importance of external support
needs to be acknowledged. The Kauai Longitudinal
Study on Hawaii reported that, by age 32 years,
those who coped effectively with the trauma of
parental alcohol misuse had signifcantly larger
numbers of people in their support networks than
those who had problems coping (Werner 2004).
The key protective factors in various domains, as
revealed in the literature reviewed in this article, are
summarised in Box 2.
BOX 1 Risk factors for children of problem substance users: key points
• All areas of a child’s life can be negatively
affected by parental problematic substance use
and children are at risk of a wide range of poor
outcomes across all domains in both the shortand the long-term.
• Children can be affected by the cyclical and
relapsing nature of their parents’ substance use
• Risks are signifcantly exacerbated when
parental substance use and misuse is
accompanied by parental mental illness and/
or domestic violence, both of which frequently
coexist with substance misuse.
• Wider environmental risk factors include poverty
and socioeconomic disadvantage, discrimination,
housing, social exclusion, unemployment and
public health concerns. Often many of these
wider risk factors also coexist.
• Risk factors arise at each of the individual,
parental, familial and environmental levels. No
two children (and no two families) are the same.
Siblings are affected differently. This means
that although there are clear probabilistic associations between various risk factors and poor
outcomes, these associations are not straightforward or generalisable for any given child.
• Children are at greater risk when multiple
problems are present. This risk is cumulative
according to how many problems or risk factors
a child is exposed to. The duration and severity
of the problems also inﬂuence how a child is
• Parental problematic substance use and other
parental problems (e.g. domestic violence) and
wider environmental factors (e.g. social exclusion) can greatly affect parenting, relationships
and attachments between parents and children,
and everyday family life. Conﬂict, disharmony,
and family separation and breakdown are common. The literature suggests that children can be
more affected by these issues than they are by
the problems themselves.
• How children are affected is inﬂuenced by
variables such as gender, age, development and
culture. The presence of problems in a child’s
early years and at key developmental stages or
transition periods is thought to be particularly
• Parental gender inﬂuences how a child is affected, although more research has been undertaken
on the impact of maternal v. paternal problems
and the impact on mothering v. fathering.
• Parental and family problems often lead to
an atmosphere in the home of fear, chaos,
uncertainty, secrecy and stigma of living with
these problems; and these can also act as
barriers to seeking help. It can be hard for
children to understand and articulate what they
are experiencing and feeling, and what they
need. They may also avoid talking to others
because they remain loyal to and protective of
• The presence of domestic violence is believed to
be a particularly signifcant risk factor.
(Based on Templeton, 2013: pp. 82–83)
BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449 111
Impact of parents’ substance misuse on children
BOX 2 Protective factors and resilience in children affected by parental substance misuse, as revealed in the literature
• Internal locus of control – a sense that they can make a difference to their
circumstances and have the power to change their situation
• ‘Active agency’ in adopting coping strategies, seeking support and choosing
what to share about their circumstances and with whoma
• Personal qualities and social skills (e.g. expression of feelings, knowledge,
life choices, self-reﬂection, easy individual temperament/disposition,
emotional regulation, self-effcacy)
• Having a hobby or a creative talent or engagement in outside activities or
interests (e.g. sport, singing, dancing, writing, drama, painting) – anything
that can provide an experience of success and/or approbation from others
for the child’s efforts
• Self-monitoring skills and self-control
• Coping and problem-solving skills – ability to think about and make decisions
• Plans for the future/yearning for a better future
• Intellectual capacity
• A sense of humour
• Sense of self-strength relative to substance-dependent parent. Resisting
over-identifcation with, and maintaining psychological separation from,
• Perceptions of ‘substance misuse’ behaviour. Good knowledge and
understanding of the parental problem(s)
• Not taking drugs or drinking
• Achieving a balance between supporting the parent(s) and looking after
• Religion or faith in God
• Supporting and trusting relationship with a stable (non-substance misusing)
adult (e.g. uncles, aunts, grandparents)
• Close positive bond with at least one adult in a caring role (e.g. parents,
older siblings, grandparents)
• Early and compensatory experiences and a good relationship with primary
carer(s) in frst years of life; low levels of separation from the primary carer
in the frst year of life
• Demonstration of affection from members of extended family
• Parental self-effcacy and good parental self-esteem
• Family observing traditions and rituals (cultural, religious, familial)
• Consistency and stability in everyday family life (e.g. social life, rituals, roles,
routines); families spending time together
• Openness and good communication within the family, including open and
appropriate discussion of family problems
• Child having family responsibilities
• Small family size, larger age gaps between siblings
• Adequate fnances and employment opportunities/income; good physical
• Constructive coping styles and deliberate parental actions to minimise
adversity for children
• Knowledge of protective factors
• Strong family norms and morality
• Characteristics and positive care style of parents (a balance between ‘care’
(parental support, warmth, nurturance, attachment, acceptance, cohesion,
and love) and ‘control’ (supervision, monitoring, clarity about family rules and
boundaries, parental discipline, punishment))
• Parents having high expectations of the child, and clear and open
communication of both expectations (about alcohol use/non-use and also
generally) and potential disapproval if expectations are not met
• Parental modelling of the behaviours expected of or wished for from their
• Absence of domestic violence/abuse, family breakdown and associated
Specifc to parental substance problems
• Parental problems are of mild intensity and shorter duration
• One parent does not have problems
• Parent is receiving treatment
• Drug paraphernalia, activity and associates are kept away from children
• Substance misuse occurs away from the home
• Cultural connectedness, values and identity
• Support from an adult/adult role model (e.g. teacher, neighbour)
• Strong friendships and relationships with peers, including those who a
young person can talk to about the problems at home
• Living in a community where there is a sense of caring, mutual protection
• Community engagement and supportive social networks; strong bonds with
local community/community involvement
• Positive school experiences and inﬂuences; opportunities through education
and employment – out-of-school/community activities
• Attendance at school, achievement, monitoring of progress and
acknowledgement of success
• Teachers’ expectations and discipline
• Positive opportunities at times of life transition
• Support from key community services such as healthcare
Evidence of resilience that these protective factors encourage
• Deliberate planning by the child that their adult life will be different
• ‘Active agency’: see Individual factorsa
• High self-esteem and confdence
• Good self-effcacy
• A sense of direction or mission
• Skills (both verbal and cognitive) and values that lead to good use of
personal abilities to achieve
• A range of problem-solving skills
• An ability to deal with change
• Feeling that there are choices
• Feeling in control of own life
• Previous experience of success and achievement
• Feeling safe and secure, loved and cared for
• An ability to play
a. ‘Active agency’ is both a protective factor in itself and also evidence of
112 BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449
Velleman & Templeton
Resilience is difficult to define (Luthar 2000;
Grotberg 2003), being differingly conceptualised
as a process and as an outcome, as a property that
individuals possess and as something that may or
may not develop and change, as a global (set of)
characteristics and as an attribute which may show
itself differently in different domains. Resilience
can mean: better-than-expected developmental outcomes; competence when under stress; or positive
functioning indicating recovery from trauma.
Nevertheless, psychological resilience has been
defned as ‘the capacity to adapt to and overcome
stress and adversity’ (American Psychological
Association 2014). Gilligan (1997) has similarly
defined resilience as ‘the capacity to transcend
adversity’. Both of these defnitions accept that
being resilient does not mean going through life
without experiencing stress and pain. Rather,
individuals demonstrate resilience when they can
face difficult experiences and rise above them
without major diffculty. Hence, ‘resilience’ has a
number of core characteristics:
• it is a process rather than a trait
• it is not a rare ability but can be found in many
(probably most) individuals
• people may be resilient in some areas and not
• it is also not something that people are either
born with or not; it can be learned and developed
across the lifespan through cognitive processing,
self-management skills and knowledge
• supportive relationships (with parents, peers and
others), as well as cultural beliefs and traditions,
are all crucial.
In sum, it is a ﬂuid process; it is not a single
variable. It is open to change over time and
according to circumstance, and it is inﬂuenced by
a range of individual, family, environmental and
Concepts and theories of resilience
Angell (2014) suggests that thinking about
resilience can be traced back at least to Freud
and his successors in their thinking about
adaptation to stress; and it is the case that there
are many overlaps with ideas such as existential
psychology and ‘will to meaning’ (Frankl 1959),
hardiness (Kobasa 1982), post-traumatic growth
(Tedeschi 2004; Joseph 2012), recovery in mental
health (Velleman 2007b; Slade 2010) and positive
psychology (Seligman 2011). Furthermore, others
are considering resilience in many areas of study,
such as in those at suicide risk (Johnson 2011)
and those experiencing mental health issues
The concept of and theories about resilience
provide a framework for studying the interplay
between risk and protective factors. Research
(e.g. Daniel 2002) has suggested that the three
fundamentals of resilience are:
• a secure base (a sense of belonging and security)
• good self-esteem (an internal sense of worth and
• a sense of self-effcacy (a sense of mastery and
control, along with an accurate understanding of
personal strengths and limitations).
These fundamentals are inﬂuenced by a wide
range of elements, based on three factors: attributes
which the young people themselves hold, aspects
of their families, and characteristics of their wider
social environments (Jaffee 2007). These have
been further broken down into key domains which
underpin resilience: secure family attachments,
education, friendships, talents and interests, positive
values, and social competencies (Daniel 2002).
As was stressed in both our 2007 article and
the section on defnitions above, it is important
not to conceptualise resilience as an all-or-nothing
phenomenon, nor as being fxed in time. Further,
the domains in which resilience can be observed
need to be specifed (Goldstein 2013): an individual
may demonstrate major strengths in some areas
and yet have diffculties in others. Sometimes the
appearance of resilience can mask other diffculties,
and a factor or process which may be protective in
one domain may be less protective in another. For
example, something which may operate positively
and suggest resilience, such as doing well at school,
may mask problems in other areas, whereas
something which may be perceived negatively,
such as taking on a caring role at too young an
age (maybe at the expense of school attendance or
performance), may be viewed positively by a child
because it protects them and/or their family from
harms in other areas (Sawyer 2012). In Velleman &
Orford (1999) we drew attention to how ‘avoidance’
was an effective coping strategy for a child living
with a violent or abusive parent, but one which
might be far less effective once that child grew to
adulthood. It has also been noted that some children
from high adversity backgrounds (e.g. living with
parental substance misuse) are more likely to do
well and be high achievers (Forrester 2011).
The key points relating to the relationship
between resilience and the range of factors which
may serve to protect children of problem substance
users are shown in Box 3.
BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449 113
Impact of parents’ substance misuse on children
Modifying the impact: what can
As we argued in our previous article, because
resilience is the product of an interaction between the
individual and their social context, it is potentially
open to inﬂuence by designing prevention strategies
focused on increasing positive factors instead of
solely reducing risk.
This suggests looking at the interaction between
children and their social contexts (including home,
school and communities), understanding parental
behaviours, focusing on positive coping, and fnding
positive social support. A key advantage of focusing
on resilience is that it shifts attention from a focus
on problems to developing a child’s strengths.
Practitioners should be able to promote resilience
by primarily working on developing protective
factors in both young people and their families, as
well as working on reducing risk factors. We and
others have stated that instead of concentrating
solely on parental presenting problems (e.g. the
risk to a child of a parent misusing substances),
practitioners should focus far more on enabling the
child and the family to develop protective factors,
and thus enhance resilience. For example, Moe et al
(2007) identifed three ways in which practitioners
could help children to develop resilience:
• providing children with a venue in which to
express their feelings;
• educating them about substance misuse;
• showing them that there are other ways to live.
This links with practitioners focusing on and
working with the child’s ‘active agency’ in adopting
coping strategies and seeking support. O’Connor
et al (2014), in their evaluation of a service for
high-risk children exposed to parental substance
misuse, highlighted that practitioners should ‘avoid
unhelpful binaries focusing on either the child’s or
the adult’s needs’ – although successfully bridging
this divide continues to be a perennial problem.
In work which focused on the children of parents
with a mental illness, Hosman et al (2009) and
van Doesum & Hosman (2009) developed a model
which could also be used to aid assessment and
intervention with a wide range of families affected
by parental substance misuse (and/or domestic
violence and abuse and/or parental mental illness
– other problems which may also be present).
Similarly, a comprehensive and holistic childcentred approach to guide practitioners in their
work with children and young people, including
those who are vulnerable and living with distressing
and complex issues such as parental substance
misuse, has been developed in Scotland (Scottish
Government 2010, 2012). The aims of the ‘Getting
it right for every child’ (GIRFEC) model are that
• will feel confdent about the help they are getting
• will understand what is happening and why
• have been listened to carefully and their wishes
have been heard and understood
• are appropriately involved in discussions and
decisions that affect them
• can rely on appropriate help being available as
soon as possible
• will have experienced a more streamlined and
coordinated response from practitioners.
The ultimate aim is to ensure that children grow
and achieve in eight areas of well-being: safe, active,
healthy, respected, achieving, responsible, nurtured
There is a similar approach in England, guided by
the Common Assessment Framework, which offers a
multi-agency framework for the early identifcation
of needs and guidance on how to best meet them
(Children’s Workforce Development Council 2009).
BOX 3 Protective factors and processes, and resilience: key points
• It is not a foregone conclusion that
children living with parental problematic
substance use (even if associated with
other parental or family problems such
as parental mental illness or domestic
violence) will be adversely affected and
have poor outcomes. Many children have
the potential to be resilient.
• Resilience is a ﬂuid process which is not
based on a single variable and which is
open to change over time, and according
to circumstance and the inﬂuence of a
range of individual, family, environmental
and societal variables.
• Protective factors and processes can
reduce the likelihood of poor outcomes for
children and build their resilience. There
are no straightforward and generalisable
associations between a protective factor
and a better-than-expected outcome
or resilience. A protective factor is not
necessarily the opposite of a risk factor.
• Protective factors are inﬂuenced by their
interactions with each other, by the
number and severity of risk factors, and
by variables such as age, development,
gender and culture. The most important
protective factors are believed to be
the presence of a signifcant caring
adult in the child’s life, the child’s own
temperament, engagement with school
and other community activities, positive
parenting and peer support, and a
swift resolution to parental problems.
Relationships, particularly with parents
(and/or other primary caregivers) and
particularly in a child’s early years, are
thought to be the ‘roots of resilience’.
• Parental gender will inﬂuence the role
of a protective factor. It is also believed
that research has not done enough to
consider the specifc impact on children,
and fathering, where paternal problems
• Resilience may be complex. A protective
factor in youth may not operate as such in
adulthood; the same factor (e.g. avoidance
as a coping strategy) may be both
benefcial and detrimental at different
times and stages.
(Adapted from Templeton 2013: p. 40)
114 BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449
Velleman & Templeton
Our 2007 article concluded with the statement: ‘We
believe that it is relatively clear how professionals
can help families to reduce risk, develop protective
factors and promote resilience in young people.
However, further work is needed to encourage
and train professionals to use this knowledge
to work in a more focused and integrated way,
looking at the full range of a child’s needs within
a broader context’ (Velleman 2007a). How far have
professionals moved in using this knowledge to
Guidance and interventions
There has been a noticeable growth in services
and interventions to support children affected
by parental substance misuse, all of which have
incorporated some of the ideas about targeting
protective factors and building resilience into
their delivery models (while also addressing and
prioritising risk as required) (e.g. Forrester 2008,
2016; Adamson 2012; Harwin 2014; O’Connor
2014; Templeton 2014a,b).
To support these developments various guidance
and toolkits have been produced, such as a toolkit
to promote work with ‘alcohol hidden harm’ in
England (funded by Comic Relief to consider
what worked best for the children of parental
alcohol misusers: www.alcoholhiddenharmtoolkit.
org.uk) or one developed in Scotland to support
practitioners working with parental problem
alcohol and drug use (Whittaker 2014).
Although the evaluations of these innovative
interventions report encouraging findings and
highlight the potential for focusing on protective
factors and processes with a view to building
resilience, this work is still in its infancy, and much
more research in this area is needed, work which
should include more rigorous methodological
approaches (such as control groups) and longerterm follow-ups. Furthermore, despite the advances
in this area, the scarcity of service provision has
been repeatedly highlighted (Clay 2010; Adamson
2012; Hill 2015).
Alcohol Hidden Harm Project An evaluation of the
Alcohol Hidden Harm Project (McWhirter 2012)
identifed how services could best target protective
factors to build resilience in children. This
includes: operating in a child-centred and familyfocused way, delivering a range of therapeutic
services ﬂexibly and non-judgementally, building
children’s social networks, and considering the
qualities which services need to work in such a
way (e.g. staff selection, leadership, community
partnerships and evaluation). When services work
in such ways, children can beneft from feeling less
isolated and better supported because they have
the opportunity to (for example) share how they
feel, meet others with similar experiences and
engage in diversionary activities.
This multisite evaluation recommended that
support to children should not necessarily be timelimited, something which O’Connor et al (2014)
also recognised as important in the evaluation of
another service for children affected by a number of
coexisting problems and requiring the involvement
of child protection services. O’Connor et al also
emphasised the importance of immediate, and
briefer, intervention at times of crisis.
Services for children
Work has attempted to understand what children
look for from services, and what characteristics of
help and support are most important. One clear
fnding is that many children want to have some
control over what they keep private/secret, and this
is obviously important when thinking about how
to help these children (Adamson 2012; Hill 2013,
2015; O’Connor 2014).
Adopting resilience in national policy
The growing body of evidence from research and
evaluation studies demonstrates that intervening
with at-risk children and young people, focusing
on protective factors and attempting to develop
resilience as opposed to simply working to alleviate
risk factors, are helpful. One key task is to root
these initiatives within routine practice as opposed
to seeing them simply as part of research studies
(Prince-Embury 2013; Angell 2014). Practitioners
should also be aware of the different risk and
protective factors which might affect children of
different ages (e.g. Cleaver 2011).
One major way of ensuring this would be for
national policy to adopt a resilience approach.
Certainly across the UK over the past decade there
have continued to be improvements, with policy
starting to recognise and respond to children
affected by parental substance misuse, although
there is variation between the UK administrations
(Hill 2013). However, the progress which has been
made has focused largely on parental drug misuse,
meaning that major policy limitations remain
with regard to parental alcohol misuse (Adamson
2012). Furthermore, policy has also tended to
focus on those children and families deemed to be
most at risk (such as those with child protection
involvement or from so-called ‘troubled families’),
and has viewed children as a homogeneous group
rather than as a population with diverse experiences
and needs. Finally, policy has not yet suffciently
embraced ideas of resilience and how those can be
BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449 115
Impact of parents’ substance misuse on children
incorporated into national and local policy, and
What have we learned since 2007 and
where are there still gaps?
The research undertaken in the past decade has
built on the literature that we reviewed in 2007.
Knowledge has continued to advance, although
signifcant gaps remain.
At the start of this article we summarised what
is known now about the numbers of children
who are affected by parental substance misuse in
the UK. Previous work had defned numbers by
concentrating on children of parents in treatment.
Manning et al ’s (2009) work, based on analysis
of multiple national survey results, showed that
numbers were substantially higher than had
previously been thought. Nevertheless, there has
been little new work in this area, and hence a
signifcant gap remains, especially as there has been
an increase in use of novel psychoactive substances
in this time. Understanding prevalence is critical
for developing appropriate policy and practice
responses to this population and to subgroups
within it, which may have different experiences
Some of the recent work which we have
reviewed supports existing knowledge about
how children are affected by parental substance
misuse (including the risk factors that they face),
and about the protective factors, protective
processes and evidence of resilience which can
reduce the likelihood that children will experience
poor outcomes. Where work in recent years has
particularly added to what was already known is
in understanding the complexities associated with
protective factors and resilience. Related to this,
we are gaining greater understanding of the active
role which children themselves play in responding
to their circumstances and how important this is
in working with children to develop the help and
support that they need.
Further research is needed to understand what
areas of resilience are most important to target
(e.g. psychological or behavioural components),
and whether there are differences (in the function
of protective factors and hence the ability to build
resilience) according to key variables such as
gender or age (Cleaver 2011), living with alcohol
or drug problems (Russell 2006), including where
there may be differences between drug types, or
mental health problems (Cleaver 2011), maternal
or paternal problems (Scaife 2008), and how many
risk factors or protective factors a child is exposed
to (Templeton 2013). Such work also needs to bear
in mind that an individual’s resilience may change
over time, with factors or processes operating
positively or negatively at different developmental
or life stages (Velleman 2007a; Backett-Milburn
2008), indicating the need for much more
We have also learned that both policy and practice
have made inroads in recognising this population as
one in need of prioritisation, and we have seen the
emergence of a number of different and promising
ways of supporting which have incorporated ideas
of resilience into service models. However, the
work we have reviewed has also highlighted the
considerable challenges which practitioners, service
providers and commissioners face in better meeting
the needs of children.
Finally, we have reported that there has been
growth and development in services; yet there
are still pressing needs for more services; for their
effectiveness to be more rigorously evaluated
(both in the long term and including their costeffectiveness); and for services and interventions
to more clearly target protective factors/processes
and build sustainable resilience. For services to be
able to do this, they themselves need to be well
supported/funded and sustainable. Instead, many
services are funded in the short term as ‘pilot
projects’ with no clarity over how sustained funding
might be forthcoming if the ‘pilot’ demonstrates
success. Even in the few geographical areas where
services are provided, there is little choice available,
and hence there is also a need for choice and
diversity. Further, most services focus on children
‘at risk’; there is also a need for services to meet the
full spectrum of need, offering help to children in
need of support as well as those at risk of signifcant
harm (Adamson 2012; Hill 2013).
It is clear that supporting children and families
affected by parental problematic substance use
requires an understanding of resilience – and of both
risk and protective factors – at the individual, family
and environmental levels. There are a number of
protective factors and processes which can mitigate
against children having poor outcomes as a result of
their experiences of parental substance misuse and
can build children’s resilience to such adversities.
It is therefore vital that practitioners who engage
with these children and their families develop a full
understanding of resilience and of what protective
factors and processes may be present or available
that can be part of the response and help offered.
Teaching about the effects on children and how
to develop resilience needs to become part of core
training for psychiatrists, social workers and other
116 BJPsych Advances (2016), vol. 22, 108–117 doi: 10.1192/apt.bp.114.014449
Velleman & Templeton
Although there has been progress made in
understanding and modifying the impact of
parental substance misuse, and of how this can
be translated into policy and practice, there is still
much to learn and understand. There is an urgent
need to incorporate ideas of protective factors/
processes and resilience into the routine clinical
practice of a wide range of practitioners who will
come into contact with children affected by parental
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Select the single best option for each question stem
1 In the UK:
a the number of children affected by parental
substance problems has decreased over the
b we have a clear understanding of how many
children are affected
c children face increased risk of poor outcomes if
other family diffculties, such as mental health
diffculties or domestic abuse, are also present
d more children are affected by parental drug
misuse than parental alcohol misuse
e no more than 10% of babies under the age of 1
will have been exposed to at least one type of
serious parental risk.
2 Parental substance misuse problems:
a generally affect only the misuser, and not their
b reduce the likelihood of violence in the family home
c are not likely to lead to emotional and mental
health problems in children
d are often associated with disharmony,
aggression and violence, and these all raise
the risks of negative outcomes for children
e not the existence of problematic parenting or
the frequent absence of a stable adult fgure,
give rise to negative outcomes for children.
3 Protective factors:
a balance out risk factors, may be inconsistent
with some risk factors and may strongly
protect, even if other areas of life are very
b are much more diffcult to create or change
than risk factors
c are often useful in the short term, as a way of
surviving ‘in the moment’, and in the long term
d are especially important if they are related
to internal characteristics such as ‘agency’,
as opposed to ones located within the family,
particularly related to parenting and parent–
e are all external to the child: children are not
active agents in adopting coping strategies or
4 Resilience is:
a a static trait, internal to the individual
b a process that is rarely open to inﬂuence
c different from protective factors, which
increase the chances of a child being more
d a defence mechanism created by a child
who feels worthless, unwanted and lacks
e extremely diffcult to encourage if it is not there
5 Interventions with children who live in
diffcult circumstances should:
a wait until a crisis is reached and damage is
b focus solely on reducing risk factors
c start as early as possible to promote factors
associated with greater resilience
d be made only by specialist child and adolescent
e involve the professional making a very longstanding commitment to working with the child
and their family.