2

1. Families with
multiple and
complex needs:
Toxic Trio

2. Session
Aims
To examine some the individual needs of families
To understand the cumulative impact of complex needs on
the stress of families (Toxic Trio)
To develop an understanding of Substance Misuse,
Domestic Abuse, Mental Health and its effect on the family
To consider the different ways Family Support can help
families with multiple needs

3. Cumulative
effect
Research shows repeatedly that the singular needs within
a family such as Domestic abuse, poverty, substance
misuse and mental health alone will have less of an
impact than if they are coupled with other needs
(cumulative effect)
In order to understand the lives of children living within
families with multiple and complex needs, we must
recognise the impact of the interwoven nature of these
needs.

4. Defining complex needs
 A definition where complex needs imply both:
 Breadth of need: multiple needs (more than one) that are
interrelated or interconnected (e.g Toxic Trio)
 Depth of need: profound, severe, serious or intense needs.
(Rankin and Regan, 2004)

5. Toxic Trio
 The term 'Toxic Trio' has been used to describe the issues of domestic abuse,
mental ill-health and substance misuse which have been identified as
common features of families where harm to children has occurred. They are
viewed as indicators of increased risk of harm to children and young people
 Work in this area has shown that there is complex overlap between these
parental risk factors and cases of child death, serious injury and generally
poorer outcomes for children across all ages (Brandon et al, 2008).
 For example substance use may be have occurred in response to domestic
violence. Mental ill health may be a result of violence or abuse that they have
experienced or depression may lead a parent to misuse drugs or alcohol .

6. Background
 The Cabinet Office’s Families at Risk review (2010) estimated
that around two per cent of families in England experience
multiple and complex difficulties. These difficulties are often
interwoven in nature and are likely to impact significantly on
the life chances and outcomes for children.

7. There are common
themes,
experiences, issues
and problems that
are part of a
family’s experience
including but by no
means limited to:
Poverty
Debt
Mental health issues
Long-standing illness or disability
Substance misuse
Relationship conflict and breakdown
Domestic abuse
Multiple, unresolved traumatic life events
Parenting difficulties
Criminal familial issues

8. Domestic abuse
 Domestic abuse is any incident or pattern of incidents of controlling, coercive or threatening behaviour,
violence or abuse between those aged 16 or over who are or have been intimate partners or family
members regardless of gender or sexuality. This can encompass, but is not limited to, the following
types of abuse:
 Psychological includes coercive control
 Physical
 Sexual
 Financial
 Emotional
 It also includes so called 'honour’ based violence, female genital mutilation (FGM) and forced marriage,
and is clear that victims are not confined to one gender or ethnic group.
 1,796,244 children in England live in households where there is a risk of domestic violence
 Around 1 in 5 children have been exposed to domestic abuse.
 Domestic abuse is a factor in over half of serious case reviews
 130,000 children live in households with high-risk domestic abuse

9. Impact of
Domestic
abuse on
the victims
Some of the mental health problems
that can occur from domestic
violence include: depression,
anxiety, Personality disorders,
posttraumatic stress disorders,
sleeping and eating disorders.
May lead to alcohol or substance
abuse
Physical injuries
Distorted reality
Isolation from friends, family other
relationships
Feelings of poor self worth and
esteem
Financial constraints Social dysfunction, and suicide
Re-victimsed through
oppressive Intervention

11. Why doesn’t
she just leave?

12. Statistics
 One in four women will experience domestic violence within their lifetime.
 Domestic violence makes up between 16-25% of all recorded violent crime.
 An average of two women are killed each week by a current or ex-partner.
 54% of rapes in the UK are committed by current or ex-partners.
 300 forced marriages occur each year.
 There are circumstances when violence may increase and these include:
 At the time when the woman is planning to leave and in the following months after she
leaves.
 During pregnancy – violence may begin or get worse which poses a greater risk to the
pregnant woman and her unborn baby.
(Research information gathered by Women’s Aid)

13. Substance Misuse
 Substance misuse is a term which includes a wide range of
issues and situations.
 Children may have a parent or other family member who is
misusing one or more substances and this is likely to have an
adverse effect on them.
 Some parents choose to use alcohol and/or drugs on a regular
basis, but this does not automatically impair their parenting
ability. However, there are some parents who misuse
substances to such an extent that their behaviour negatively
affects them, their children, their family and the wider
community.
 Becomes destructive when the parent continues to use
substances, despite the severe negative impact on themselves
and their families.
 Parents who misuse substances are usually also coping with
several additional social and financial problems.Shaheen Abbott 2018

14. Parental Mental Health
 Over 2 million children are estimated to be living with a parent who
has a common mental health disorder
 Diagnosable mental health conditions, such as depression, anxiety
disorders, schizophrenia, bipolar disorder and personality disorders.
 Mental health problems affecting mothers and fathers during the
perinatal period, in pregnancy and after birth, can include anxiety,
depression and postnatal psychotic disorders (Hogg, 2013).
 Vulnerability to mental health problems can be the result of negative
or stressful life experiences such as poverty, unemployment, physical
illness, disability, social isolation, relationship breakdown or
childhood abuse or neglect (Cleaver, 2011).

15. Impact of
parental
mental
health on
children
 Increased risk of developing behaviour problems such as physical aggression
by the time they reach school age
 Risk of developing mental health difficulties themselves
 Taking on a caring role, providing emotional and social support, basic
household chores and more intimate tasks.
 Demands of caring may lead to fewer opportunities to have fun and build
friendships, disruption of education.
 Anxiety about their parents' or carers' health and wellbeing and denial of their
own needs and feelings
 Distress if faced with frightening situations such as a parent's suicide attempt,
overdose or volatile behaviour
 A lower standard of living or financial hardship if their parent's illness makes it
difficult for them to work
 Embarrassment or shame over their parents' or carers' condition, limiting their
friendships and social interaction due to the social stigma attached to mental
illness
 Bullying and social isolation
 Separation from parents or carers by children's services or the parent's
hospitalisation
 In the most serious cases, children may suffer abuse or neglect from a parent or
carer with a mental health problem.
 Parental mental illness can cause children enormous anxiety. Research shows
children experience a number of fears and frustrations.

16. Impact of
Domestic
abuse on
children
 Children exposed to domestic violence are more likely to have
behavioural and emotional problems
 Witnessing or experiencing domestic abuse is a form of child abuse.
 But children living in homes where there is domestic abuse are also likely
to experience other abuse and neglect.
 The impact of hearing or witnessing domestic violence can be very
traumatic for a child and result in emotional or psychological abuse
(Cleaver, Unell and Aldgate, 2011).
 Living in a home where there’s domestic abuse is harmful. It can have a
serious impact on a child's behaviour and wellbeing.
 Parents or carers may underestimate the effects of the abuse on their
children because they don’t see what’s happening.
 But children witnessing domestic abuse is recognised as 'significant harm'
in law.
 Domestic abuse can also be a sign that children are suffering another
type of abuse or neglect (Stanley, 2011).
 The effects can last into adulthood. But, once they're in a safer and more
stable environment, most children are able to move on from the effects
of witnessing domestic abuse.

17. Impact of
substance
misuse on
children
 Parental substance misuse can have a negative impact on children at each stage
of their development.
 Women who misuse substances during pregnancy may put their babies at risk of
impaired brain development, congenital malformations, premature delivery, low
birth weight and withdrawal symptoms after birth.
 physical and emotional abuse or neglect as a result of inadequate supervision,
poor role models and inappropriate parenting
 behavioural, emotional or cognitive problems and relationship difficulties
 taking on the role of carer for parents and siblings
 preoccupation with, or blaming themselves for, their parents’ substance misuse
 infrequent attendance at school and poor educational attainment
 experiencing poverty and inadequate and unsafe accommodation
 exposure to toxic substances and criminal activities
 separation from parents due to intervention from children’s services,
imprisonment or hospitalisation
 Increased risk of developing drug or alcohol problems or offending behaviour
themselves.
(Altobelli & Payne, 2014; Cleaver et al, 2011; Cornwallis, 2013; Home Office, 2003; Templeton, 2014)

18. Domestic Violence
 First incidence of DV occurred between Daniel’s mother and
father in 2006
 Both parents were intoxicated at the time, and Daniel’s mother
was pregnant with him
 At her booking appointment for the GP, Daniel’s mother denied
any alcohol misuse. Mr Pelka translated.
 Daniel’s mother reported ‘a domestic problem’ to her GP who
prescribed anti-depressants. She was noted to have two children.
 She did not attend follow up appointments.

19. Toxic Trio: Impact on parenting
 The risks to children are greater when parental mental health
problems exist alongside domestic abuse and parental substance
misuse (Brandon, 2009; Cleaver, 2011).
 Local authorities participating in a study by the Association of
Directors of Children's Services (ADCS) estimated that all 3 of
these factors were present in between 65-90% of their Children in
Need cases (ADCS, 2016).

20. Factors to
consider
when
assessing
risk
Consider if any of the children had to take on caring responsibilities for their parent, carers
or siblings.
Related stresses such as poverty, poor housing, family separation and lack of social support
can also increase the risk of children suffering harm.
The risk of harm to children increases when they‘re exposed to a number of problems at
the same time or over a period of time. A thorough assessment of potential risks should be
conducted if a family is experiencing domestic abuse or drug and alcohol problems
alongside mental health difficulties.

21. Risk and Resilience
 Why do some children who are raised in adverse conditions with
neglectful or abusive parents develop into healthy securely attached
adults?
 Resilience
 Risk
 Protective factors
‘Resilience is the idea that certain people have the capacity to overcome any
obstacle and this capacity is shown through positive-thinking, goal
orientation, educational aspirations, achievement motivation, persistence,
hopefulness and optimism’ (Engler, 2007)

22. A Strength
Based
approach to
family
support
 Focus on the strengths of the family- all families have aspects
that are working well. Give careful attention to these areas.
 Ask what the family would like to see change and how
 Focus on creating small attainable changes
 Include the children in as much as possible by using child
friendly approaches to gathering information (Three houses,
Three islands, the miracle question)
 Identify the families resources
 Offer choices
 Where there are issues of neglect : cooperate with the person,
not the neglect
 Relationship based practice
(See ‘Signs of Safety’, Turnell and Edwards, 1999)

23. Concluding Summary
Working with families with complex and multiple needs is complex
The cumulative effect of Domestic Abuse, Substance Misuse and Mental health issues can have a severe adverse effect on
childhood
Risks must always be balanced with Protective factors when assessing families
Family Support can and does prevent children and families problems escalating into areas of crisis.