In speaking at the recent ‘Just Ice?’ Symposium, Professor Sharon Dawe posed the conundrum of making decisions in the context of uncertainty. She then offered a potential solution, proposing that a Capacity to Change assessment would shift the focus from cross sectional to a dynamic assessment and support process that allowed for a more informed judgement to be made about parental capacity to change. This keynote presentation was central to the Symposium. How can our key stakeholders within our child protection system understand and work with families where amphetamine use is evident? These issues need to be addressed.
Professor Dawe argued that substance misuse influences parent’s state of mind. Particular substances matter. While substances such as opioids and cannabis are not directly associated with an increase in the likelihood of aggression, this may not be the case for amphetamines. Amphetamine use is associated with a range of aggressive/psychotic behaviours, paranoia and delusional thinking.
However, regardless of substance used, she argued that having a clear picture of the quality of the caregiver and child relationship was essential to good decision making. Importantly, she drew attention to the research literature that indicates that 30-40% of infants of opioid dependent mothers have secure attachments. So the issues that arise in considering child protection risk are typically complex and need to be assessed alongside methamphetamine/drug use. She proposed a series of questions that need to be considered:
- What is the evidence that this parent’s use of methamphetamine is impacting on their own wellbeing?
- In turn, what is the evidence that this parent’s wellbeing is affecting their ability to provide (i) a structured environment that meets a child’s needs and (ii) a warm, nurturing and safe environment that provides a quality caregiving environment?
- In turn, what evidence do we have that the child’s outcomes are compromised?
The Capacity to Change model is key to making assessments about children in families where amphetamine use is evident. It begins with a standard approach to history taking and assessment of current family circumstances: this is a skill that is well developed in child protection and family support practice. She argued, however, that there is less skill around assessing the quality of parent/child relationship and the home environment. The Capacity to Change assessment model affords the practitioner the capacity to assess the child and family’s current functioning and historical features that will impact on this, develop a case conceptualisation, identify and define goals for change, provide a time-limited evidenced based intervention to support the family in reaching goals. This is followed by a re-assessment of parent’s responses to intervention and success in attaining goals. Then the preparation of clear and specific recommendations based on the results of changes found across the assessment period can happen.
The parental ‘buy in’ to the goals is significant and can’t be understated. The assessment of a parent’s response to the intervention includes:
- Evaluation of the extent to which specific targets were achieved—through ongoing monitoring of parent’s success in carrying out Action Plans and achieving stepping stones and goals.
- Changes on a battery of standardised assessments, ideally including direct observation of parent-child interaction.
- Qualitative and quantitative observations of parent’s motivation to engage in the Capacity to Change process.
- Descriptive information about presenting problems and symptoms and inferential reasoning to generate a series of hypotheses that inform an individually tailored treatment plan.
Importantly, obtaining a large amount of information about a particular family is not sufficient. Professor Dawe argued that we need to take a further step towards the development of a case conceptualisation: that is taking descriptive information and (i) working out what the key issues are for the family and (ii) developing a set of working hypotheses about the factors that have led to the current situation. This can be done within a context of support and a focus on family strengths. She proposed that one way of advancing understanding is to have a model or framework that allowed for the integration of important theoretical understanding including attachment, parenting and adult psychopathology. She provided an overview of the Integrated Theoretical Framework (Fig 1. above).
The Integrated Theoretical Framework was developed to assist practitioners apply current theoretical models of child development and family functioning to understand the functioning of complex families. The model starts with the assumption that positive child outcomes derive from a healthy parent-child relationship that this is achieved through responsive, sensitive, nurturing caregiving from a primary carer. Sensitive and responsive parents structure the environment with predictable routines and consequences to help the child organise their behaviour and emotions. They are able to show genuine warmth and nurturance that allows the child to feel loved, and present opportunities and scaffolding to promote cognitive and physical development. Importantly, the framework helps to identify the aspects of family life that prevent the primary carer/s capacity to provide the optimal caregiving environment. That is, the Integrated Framework provides a model that clearly articulates both the strengths and areas of difficulties in different domains of family functioning that are important in estimating risk and helpful in identifying goals for change. Thus, the Integrated Theoretical Framework provides a way of classifying descriptive information and allows for the development of hypotheses about the factors that are either maintaining the current situation or are impediments to change.
Professor Dawe then provided a brief overview of the Parents under Pressure program. She argued that this program was one in which families could be supported to see if they were able to demonstrate capacity to change. The key program aims are:
- To empower parents to believe that they can be the parent their baby or child needs: parental self-efficacy.
- To develop nurturing and loving relationships with their babies and children: attachment is critical.
- To ensure that parents are able to understand and manage their own emotional state: emotional dysregulation prevents parents from connecting with their child/infant and supporting optimal development.
The overall message of Professor Dawe’s presentation was the need for practitioners to address their own assumptions and biases and work within frameworks that allow this reflective practice. Drug use isn’t the issue in and of itself; such use exists within a complex dynamic of multiple issues that usually include trauma, mental health difficulties and current adversity. As such, holistic models of intervention such as those she proposes are key considerations in expanding our work with children and families impacted by methamphetamine use.
Ultimately, she was very clear that connection is key. In our assessment, analysis and interventions, she urged us all to look for evidence of love and nurturance as key components of the caregiving relationship. Then work forward from there.