A child’s first 1000 days: the impact of alcohol and other drugs

A BASW Pocket Guide for Social WorkersApril 2019

Purpose of the guide

This guide aims to support social workers in theirpractice with parents and carers whose use of alcoholand other drugs is problematic. It focusses on a child’sfirst 1000 days – from conception to aged two.

It highlights potential harm to children from parentalalcohol and other drug use during this period. It offerssome guidance on how to support children, parentsand carers. This guide may also be relevant to othersocial care and health professionals. Information in thispocket guide should be supplemented by otherlearning.

Note: The term ‘substance’ relates to both alcohol andother drugs.

First 1000 days – definition

The first 1000 days relates to the approximate timebetween conception and a child’s second birthday. Thecare given to a child in the first 1000 days plays asignificant role in their health and development and islikely to impact on their life course. It is the periodwithin which we see the most rapid phase of braingrowth which sets the foundation for physical, socialand emotional development.

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Why the first 1000 days matter

The human brain adaptsand changes throughoutlife. However, the mostrapid development occursin the first 1000 days oflife. It is a critical windowfor essential learning –seeing, talking, walkingand thinking. Although wenow have a greaterunderstanding of theopportunities that comefrom the brain’s ability torelearn (plasticity) at all stages of life, some of the bestopportunities for brain learning are in the last 3 monthsof pregnancy and up to 2 years of age. Although it ispossible to lessen the impact of early deficits in laterlife, it is far better to protect the brain from the start.

In utero exposure to substances may impact negativelyon the ability to develop key motor and cognitive skills.Consuming alcohol increases the risk of foetal alcoholspectrum disorders (FASD), including foetal alcoholsyndrome (FAS). The more alcohol consumed, thegreater the risk, but there is no proven safe amount ofalcohol in pregnancy. Neonatal abstinence disorder(NAS) can also develop in babies whose mothers useother drugs or have been prescribed substitute drugs,for example, methadone.

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Parental substance usefollowing the child’s birthcan also have a negativeimpact on theirdevelopment throughlack of: appropriate care,stimulation, supervision/safety and emotionalavailability.

Other factors that canaffect a child’s healthand wellbeing during thefirst 1000 days include;poor nutrition, parentalsmoking, poor parentalmental health, domesticabuse and poor livingconditions.

Role of the social worker

The role of the social worker in supporting parentsusing substances, and their children, is vitally importantbecause of social workers’ core skills in engagement,observation, analysis and holistic bio-psycho-socialassessment with a focus on individual history,relationships and context.

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Key messages

1 Do not be judgemental Women do not use substances in pregnancy

because they want to harm their baby. • They may not be aware that they are pregnant. • They may not know the most current advice. • They may be under pressure socially or from

others, including partners. • They may be coping with difficult life

experiences and stressors.

2 Do integrate care and support for parents andchildren from different services – multi-agencyworking is essential.

3 Do ask questions at the earliest possibility aboutthe parents’ substance use and RECORD this.It might later be key to giving the insight neededfor an FASD diagnosis.

4 Do be aware of fathers/partners who may usesubstances in a harmful way and the impactthis may have on the mother and child.

5 Do be aware of the protective and resiliencefactors that could support positive parentalbehaviour in relation to substance use. Theyshould not be overlooked.

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Alcohol & pregnancy

There are still a lot ofunknowns about theimpact of alcohol onpregnancy. Not allwomen who drinkproblematically willdamage their unbornchild but there is noreliable way of knowingwho will be affected andwho won’t. What isknown is that harm is

likely to vary during different stages of pregnancy andthat heavy or binge drinking on a regular basis canincrease the risk of a baby being born with FASD.

The evidence suggests that risks are higher when thedrinking is frequent but that it is always better to stop atany point in the pregnancy to keep the risks to aminimum. Further guidance is available here:www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking

Alcohol can impact on the way a baby grows in thewomb, including the way the baby’s brain develops.It can increase the risk of: premature labour, stillbirth,illness in infancy, childhood, and as an adult. FASD is aleading cause of neuro-developmental disability and itis preventable.

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Current advice on drinking alcohol in pregnancy

The Chief Medical Officer (CMO) for the UKrecommends that pregnant women, or those planningto become pregnant, should avoid drinking anyalcohol at all to keep risks to a minimum.

The CMO’s advice is if a woman drank alcohol beforeknowing she was pregnant, or in early pregnancy, it isunlikely that the baby will be affected but that sheshould speak to her midwife/GP about it.

However, many people underestimate their alcoholintake. For more information on how alcohol ismeasured see:www.drinkaware.co.uk/alcohol-facts/alcoholic-drinks-units/what-is-an-alcohol-unit

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Foetal Alcohol Spectrum Disorders (FASD)

FASD is an umbrella termthat covers foetalalcohol syndrome (FAS),alcohol-related neuro-developmental disorders(ARND), alcohol-relatedbirth defects (ARBD),foetal alcohol effects(FAE) and partial foetalalcohol syndrome(PFAS).

The effects of alcohol exposure are not alwaysapparent at birth. Therefore, if a child is identified ashaving FASD signs and symptoms, it is important toassess any other children in the family.

FASD is sometimes intergenerational – if you suspect abirth mother might have FASD it is critical to help herget appropriate support for both herself and the child.

The first UK study to estimate screening prevalence ofFASD, published in 2018, suggests that most FASDstudies are likely to underestimate the prevalence ofFASD. In its analysis of existing data, it showedestimates of between 6% and 17% of children born withFASD depending on the methods used. It highlightedhow the UK is one of the countries with the highestlevel of pre-natal exposure to alcohol and that future

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studies need to use more robust methods to assessprevalence.www.sciencedirect.com/science/article/pii/S0091743518303323?via%3Dihub

There is no cure for FASD, but it is possible to get helpfor specific problems.

The ‘golden 1000 days’ is a key time to intervene andlessen the potential impact of any problems.

FASD – How does it present?

Babies with FASD may present with one or more of thefollowing problems:

l Appear irritable, nervous, or sensitive to soundand light.

l Cry often.l Be very quiet and not very responsive. l Low birth weight.l Small head size.l Face and mouth deformities.l Flat shape of the face.l Specific facial features may include a thin upper

lip, flatness under nose, and smaller eyes.

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Neo-natal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a group ofwithdrawal symptoms seen in new-born babies causedby a sudden withdrawal of substances at birth. Theeffects are like those experienced by an adult whosuddenly stops taking substances. Infants are atincreased risk from mothers who have taken drugs(during pregnancy) such as heroin, methadone,subutex, amphetamines, cocaine, codeine, alcohol,benzodiazepines, LSD and some anti-depressants.

NAS – How does it present?

A child affected by NAS presents with symptoms thatrange from mild to moderate and severe. They mayneed more specialised medical care and perhapsmedication too. Signs and symptoms of NAS can bedifferent for every baby. Most happen within 3 days (72hours) of birth, but some may happen right after birthor not until a few weeks after birth. They can last from1 week to 6 months after birth. 

NAS – Signs and symptoms

Signs and symptoms may include: 

l Body shakes (tremors), seizures (convulsions),overactive reflexes (twitching) and tight muscles

l Excessive crying or having a high-pitched cryl Poor feeding or sucking or slow weight gain

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l Breathing problems, including fast breathingl Fever, sweating or blotchy skinl Trouble sleeping and lots of yawningl Diarrhoea or vomitingl Stuffy nose or sneezing

Do remember that most babies with NAS who gettreatment get better in 5 to 30 days once they havewithdrawn from the substance.

Into infancy

Babies developing intoinfancy are inherentlyvulnerable and dependent.Those requiring increasedcare, because of theimpact of parental/carersubstance use, may be

more at risk of harm because of the additionaldemands their care places on their parents/carers.

Note: It’s important NOT to assume there are alwaysparenting issues. Parents can be sent off to parentingclasses, when in fact their child has organic braindamage that has not been diagnosed. It can take yearsbefore this is properly understood.

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Multi-agency working, risk assessment and a clearpicture of whether a child is meeting key childdevelopment landmarks, is crucial.

Do’s and Don’ts

1 Do approach every interaction with parents withempathy, respect and an understanding ofsubstance use in a wider context. This is key toremoving the stigma many parents fear.

2 DO remember that a respectful, helpingconversation that effects positive behaviourchange can happen in just a few minutes.

3 Do work in partnership with parents, families andkey agencies throughout the first 1000 days.

4 Do ask questions about substance use during thefirst 1000 days. You can’t assume that others will.

5 Do ask parents what role substances play in theirlives and note this in the parents and baby’s file.

6 Don’t assume it is an automatic risk to goodenough parenting.

7 Do prepare robust plans and review how parentsare coping where a baby has been born withNAS or FASD/FAS is suspected.

8 Do undertake joint assessments and reviews withpartner agencies.

9 Do be prepared to advocate for the parents/carers. Social workers can help parents tounderstand the decisions they need to make.

10 Do help parents arrange care for other childrenwhen Mum is in hospital.

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Why fathers matter

Fathers’ attitudesand behaviours canimpact significantlyon mothers andbabies duringpregnancy andbirth. It is importantto remember thatduring the first twoyears of babies’lives, most fathersare around.

Expectant and new mothers rely on their partner aboveanyone else and are more likely to receive supportfrom him or her than from any other person, includingmedical staff. Mothers feel more capable and confidentabout breastfeeding when their partner is supportive.Sensitive and supportive father involvement followingthe birth relates to a range of positive outcomes inbabies and toddlers.

Disengaged father-child interactions, as early as thethird month of life, have been found to predictbehaviour problems in children when they are older.The influence of fathers on infant languagedevelopment is equal to that of mothers, so the role offather’s in ensuring babies and toddlers have the bestenvironment to develop and flourish, is crucial.

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Working with fathers

l Do remember that men are motivated by the desireto be a good father. A good starting point forengagement is to ask them, “What does it mean tobe a good father?”

l Do try and get the father’s details for every initialassessment you do and interview the father for everycore assessment done.

l Do give fathers clear information. Research showsthat often they do not see a defined role forthemselves in plans and will assume “parent” inreality, means “mother”.

l Do be mindful that fathers are perceptive ofexpectations of them. If a social worker has lowexpectations, they may live down to them.

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Social work intervention

Intervention is focused on maintaining parents/partners in substance use services and supportingpositive parenting skills and strategies.

It is important to be very clear about the factors thatoffer protection to children from parental substanceuse and identify a trusted adult in the family supportnetwork, who can model good parenting and providesome practical/emotional support.

These measures can have a positive impact in reducingparental stress and promoting the best environment fora child’s development and well-being to flourish. Asummary of key interventions is below:

Brief interventions – Uses motivational interviewingtechniques to facilitate behaviour change. Amongpregnant women, brief interventions have been shownto modestly improve rates of alcohol abstinence.However, few studies have examined the effect of briefinterventions in response to illicit drug use duringpregnancy or in the postpartum period.

See https://motivationalinterviewing.org

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Motivational Interviewing (MI)

One of the most important reasons that many parentsmake positive changes to their substance use, ispregnancy and child-birth. MI is used by suitablytrained social workers to guide parents/carers inmaking positive behaviour change, either pre or postbirth. The earlier that positive behaviour changehappens, the better the long-term outcomes for ababy.

Empathy, compassion and collaboration are key formotivational interviewing practitioners. At its simplest,MI is a helping conversation about change, one inwhich social workers regularly engage.

In a social worker/service user relationship, this isachieved through arranging a conversation, so that theservice user effectively talks themselves into change, byresolving ambivalence and finding their own importantreasons for change.

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Motivational interviewing is acollaborative conversational style forstrengthening a person’s own motivationand commitment to change”. (Miller and Rollnick 2013)

Making Every Contact Count (MECC)Encourages conversations based on behaviour changemethodologies ranging from Alcohol BriefInterventions (ABIs), to more advanced behaviourchange techniques which empowers healthier lifestylechoices.

Gro-Brain – Brain-based parenting for long-termemotional healthGro-brain interventions are targeted at the key first1000 days in a child’s life to increase the opportunitiesfor optimal health and neuro development across thelife-span. The Gro-Brain parenting course can beundertaken pre or postnatally. It can be delivered as agroup or as a one to one with parents or carers. Thetools and resources are visual and interactive andsuitable for a variety of learning styles. The course canbe delivered by anyone.

Parents Under Pressure (PUP)Aims to support parents who are on a substancetreatment programme. The PUP programme helpsparents to: build their strengths as a parent, develop asafe and caring relationship with their baby, feel calmand in control, and learn practical parenting tips andlife skills, like financial management.

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Further contacts/Useful organisations

AdfamNational charity supporting families, friends and carers ofpeople with substance problems. It provides informationand resources to support those affected by another’ssubstance use. Adfam seeks to amplify their voices toensure they have a say in the issues that affect them.www.adfam.org.uk/help-for-families/useful-organisations

NOFAS-UK (The National Organisation for Foetal*Alcohol Syndrome-UK)NOFAS-UK is dedicated to supporting people affected byFoetal Alcohol Spectrum Disorders (FASD), their familiesand communities.www.nofas-uk.org

FASD UK AllianceThis is a coalition of groups and individuals from acrossthe UK who are united together for positive social changefor those affected by Foetal Alcohol Spectrum Disorders(FASD).  Affiliates include small local, regional and virtualgroups as well as some of the country’s longest standingnational organisations.https://fasd-uk.net

Al-AnonAl-Anon Family Groups provide support to anyone whoselife is, or has been, affected by someone else’s drinking,regardless of whether that person is still drinking or not.For some members, their family member or friend may nolonger be a part of their lives or may have died.www.al-anonuk.org.uk

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UK-EU Birth Mother Network – FASDThis is a network of women who may have a child orchildren with Foetal Alcohol Spectrum Disorders (FASD). www.eurobmsn.org

Drugscience UKDrugscience UK is the leading independent scientific bodyon drugs in the UK, providing evidence-based informationwithout political or commercial interference.www.drugscience.org.uk

Talk to FrankTalk to Frank is a national drug education service aimedmainly at teenagers/adolescents, educating on potentialeffects of drugs.www.talktofrank.com

Family LivesFamily Lives supports families in a professional, non-judgemental way that all members of the family can freelyaccess. They provide this through a helpline, extensiveadvice on their website, befriending services, andparenting/relationship support groups. Nearly all of theirservices are accessible at no charge to parents and youcan contact them 365 days a year.www.familylives.org.uk

NIHRNational Institute for Health and Care Excellence providesa database of evidence.www.evidence.nhs.uk/search?q=neonatal%20abstinence

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Screening Tools

This is a link to alcohol screening tools:www.gov.uk/government/publications/alcohol-use-screening-tests

The following link is to a list of alcohol and drug screeningtools provided on the SMART charity website:https://smartcjs.org.uk/professionals/gps/screening-tools

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www.basw.co.uk

Written on behalf of the BASW Special Interest Groupin Alcohol and Other Drugs by Allison Hulmes, BASWCymru. Edited by Sarah Galvani.

To cite this guide:

Hulmes, A. and Galvani, S. (2019) A child’s first 1000days: the impact of alcohol and other drugs. A BASWPocket Guide for Social Workers. Birmingham: BASW

© BASW 2019