Family focused interventions should ideally be offered to one or more members of the families of all young people who have engaged with the service. The terms and timing of family involvement should be discussed with the young person during assessment and care planning, and should be initiated only after they have given fully informed consent.
In order to plan and manage family work most effectively assessment and care planning with adolescents needs to be family inclusive or family sensitive. It should consider whether and how the family system, or relationships between the adolescent and particular family members, may be strengthened to enrich the social supports available to the young person.
Not all young people will want to involve family members directly. Sometimes family involvement is inappropriate, and sometimes the young person will benefit from working individually for a period of time and become open to family involvement at a later stage. It is possible to work on family issues in the absence of direct family involvement. Family inclusive practice involves direct communication with family members. Family sensitive practice considers how family connections can be improved but stops short of involving them if that is the limit of what is possible or the preference of the adolescent.
Engaging and orienting family members should ideally begin as early as possible for two reasons: (i) to harness positive factors that will facilitate the young person’s engagement with services (e.g. parental concern and encouragement), and (ii) to identify and address barriers sooner rather than later (e.g. lack of concerned adults willing to help the young person).
The practice elements described in this module should be employed in a staged manner. The most basic orientation, engagement and information provision should ideally be offered to all families, with the higher level education and skill-based elements reserved for those young people and families assessed as in need of further assistance.
Some of the most well recognised ‘risk’ indicators of need for family focused education and skill development in the context of AOD use problems are shown in Box 1. This list is illustrative, not exhaustive.
Box 1: Indicators of family stress and acute risk of harm
- High levels of AOD use by family members within the home
- Primary caregiver experiences a mental illness that is untreated or poorly managed
- Frequent conflict in the home is a trigger for self- or other-harming behaviours (i.e. AOD use, violence, aggression, self-harm or angry withdrawal) by the young person
- Any factors in the home environment that are making it difficult for the young person to attend school or employment (e.g. illness of a family member, AOD use, excessive level of domestic responsibilities for the young person, lack of access to quiet work space for homework)
- Young person has left the family home previously for an unstable housing alternative or contemplates doing so in the near future
- Parents are thinking of asking the young person to leave the house (or foster parents are contemplating terminating the placement)
- Young person is unhappy with the quality of his or her relationship with parents or caregivers
- Young person feels unsupported, misunderstood, unloved or poorly cared for
‘Need’ for family intervention at the level of education and skill development is not indicated solely by the presence of problems such as conflict or perceived lack of support by the young person. Whether or not they are functioning poorly, many families possess under-utilised and under-recognised resources that can be helpful for young people. The following indicators in Box 2 point to the potential benefits of interventions targeting family in its broadest sense (i.e. parents, older siblings, other family members, statutory caregivers, and other caring adults) aimed at harnessing potentially under-utilised resources.
Box 2: Indicators of potential social disconnection
- Young person is poorly engaged or disengaging from school or work
- Young person is often unsupervised, left alone, or his/her whereabouts are unknown
- Young person has very few ‘bridging’ connections to responsible adults outside of the immediate family
- Young person does not feel comfortable to invite friends into the home
- Parents / caregivers do not know the young person’s friends
- The young person has no friends, very few friends, or wishes to ‘let go’ of an old peer group and make new friends
In the circumstances outlined in Box 2, relationships with parents and caregivers might be perceived as unproblematic, however there may be more that they can do to support the young person to negotiate his or her way through key adolescent transition processes. Relatives in the extended family, siblings or other caring adults may have previously unrecognised resources to contribute here.
While family-based risk factors for substance misuse problems and other negative outcomes often relate to under-involvement on the part of the primary caregivers, a different set of risks can arise when caregivers are overly anxious about their adolescent and his or her substance use, and are interacting with their child in ways that may inhibit universal developmental transitions.
Box 3: Indicators of potential parental over-involvement
- Parents / caregivers are experiencing very high levels of concern and anxiety about their adolescent’s substance use (i.e. imagining harms that are very unlikely given the objectively assessed level of severity and risk)
- Parents / caregivers have initiated contact with the service on behalf of, and against the wishes of, the young person
- Placing restrictions on the young person’s activities to an extent that they feel oppressed and unable to participate in activities that most of their peers are enjoying
- Parents do not like their child’s friends and openly criticise them
- Caregivers expect to be fully informed of all therapeutic activities and developments involving their child and have difficulty accepting the confidentiality of the therapeutic relationship
Parental over-involvement can inhibit effective engagement by an adolescent in treatment for substance misuse problems. When young people feel coerced it is often natural for them to resist pressure to change. Even if the young person is not using substances in a harmful manner, a few hours invested on education and skill development could help establish more realistic expectations, reduce anxiety, and improve the quality of communication and problem-solving within such families.
Having said this, research has consistently shown that a healthy degree of parental interest and involvement is associated with better engagement and better outcomes for young people.
There are times, however, when it is inappropriate to engage families. Practitioners are advised to exercise caution where there is, or has been, maltreatment or domestic abuse. Practitioners should also be mindful that some young people do not consent to the involvement of their families or specified significant others.
When relationships are damaged and difficult, involving families can be very challenging. Some parents and other types of carers may have lost hope and interest in their adolescent and will be unmotivated to reach out. Others may have substance use problems of their own or difficulties with availability (Chassin, 2008; Schuetz & Berry, 2009; Waldron et al., 2007). However, given the evidence of positive effects on engagement and outcomes, the potential benefits may frequently outweigh the costs involved in pursuing family involvement. It is also vital to remember that most adolescents attending youth AOD services want to improve relationships and to get more care and support from their families, even when relationships have been harmful in the past (Green et al., in press). For family members with low motivation and few resources, the aim of involving them may be limited to identifying and securing one or two simple forms of support that they can provide to help the adolescent move away from problematic AOD use and work towards their personal goals.
Special efforts may be necessary to make family involvement more accessible and feasible for ‘hard-to-reach’ families. Statham (2004) has argued that vulnerable families are more likely to maintain attendance if they feel respected and supported, and if they perceive that a range of their life concerns are being listened to such as job stress, health problems and personal worries. There is considerable evidence that specially designed, culturally sensitive strategies can be very effective in achieving high rates of family engagement (Liddle, 2004).