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Submission by the Department of Family and Community Services to The House of Representatives Standing Committee on Family and Community Affairs Inquiry SUBSTANCE ABUSE IN AUSTRALIAN COMMUNITIES June 2000 TABLE OF CONTENTS Abbreviations Executive summary Introduction Chapter 1 Recent research Chapter 2 Working with substance abuse in established FaCS programs Chapter 3 A prevention/early intervention focus Chapter 4 Towards a comprehensive service response – issues for consideration Chapter 5 Estimating the prevalence and cost of substance abuse among FaCS clients Appendix 1 Terms of Reference Bibliography Page 3 4 7 10 18 29 40 51 54 55 2 ABBREVIATIONS AIFS Australian Institute of Family Studies AIHW Australian Institute of Health and Welfare DV FaCS FRSP domestic violence Commonwealth Department of Family and Community Services Family Relationships Services Program NATSEM National Centre for Social and Economic Modelling NIDS National Illicit Drugs Strategy SAAP Supported Accommodation Assistance Program Full details of all publications mentioned are provided in the Bibliography.
Reference to the publications in the text is abbreviated.

3 EXECUTIVE SUMMARY The Department of Family and Community Services’ role in delivering the social policy outcomes of stronger families, stronger communities and economic and social participation through its prevention, capacity building and early intervention strategies shapes its interest and understanding of the social and economic consequences of substance abuse.
The FaCS policy context Social policy development within FaCS is focused around a number of key principles, particularly the importance of prevention and early intervention in retarding or preventing the development of major family and social problems.

Related principles include capacity building, mutual obligation and the importance of partnerships between government, community, business and individuals (the Social Coalition) to deal with social issues.
These principles have recently been comprehensively articulated in the Stronger Families and Communities Strategy, announced by the Prime Minister in April 2000.

Both the principles and delivery approaches underpinning the Stronger Families and Communities Strategy measures are relevant to understanding the complexity of substance abuse issues and shaping a coordinated service response.
Initiatives to develop early intervention and parenting support strategies around child care services targeted at families in crisis, including for children of drug dependent parents, are being developed under the auspices of the Strategy.

The nature of FaCS contact with substance abuse A very broad range of Australian families and individuals come within the purview of FaCS income support and services programs.
They are FaCS clients because they receive family or child care payments or require other generic income support or services which are primarily met through this portfolio.

Our understanding of the presence and impact of substance abuse on the lives of those affected by it tends to emerge from engagement around other events such as family relationship breakdown, child abuse, domestic violence, financial hardship or homelessness.
However from such contacts a substantial knowledge base on the impacts of substance abuse has been derived, drawn from relevant research on prevention and early intervention strategies for supporting families, and both qualitative, and to a lesser extent, quantitative information The only initiatives currently within the range of the portfolio activities which are explicitly related to substance abuse are the family crisis child care pilots and a new measure, Strengthening and Supporting Families Coping with Illicit Drug Use which is being developed by FaCS with funds from the National Illicit Drugs Strategy.
These are discussed more fully in chapter 3 of the submission.

The most substantial information on the implications of substance abuse has been derived from the case work of Centrelink social workers, the SAAP and Emergency 4 Relief programs, employment support services in relation to links between mental health and substance abuse, and the Reconnect program.
Some data is available on the incidence of substance abuse among Newstart and Youth Allowance recipients, with more substantial data (albeit on a small population) being collected from SAAP clients identifying drug or alcohol abuse as their main reason for seeking access to SAAP services.
Substance abuse – a complex multi-dimensional problem Chapter 1 of the submission contains a brief review of national and international research in the areas of early intervention and prevention (including research shaping the development of the Stronger Families and Communities Strategy).
This establishes that substance abuse has a frequent association with other risk factors for problematic development of children including child abuse, domestic violence, health issues, educational attainment, mental health and other disabilities.

Harsh parenting practices, substance abuse linked with low socio-economic status and poor links to the community compound the potential to create environments damaging for children’s development.
The same patterns of harsh parenting behaviour, abuse, poverty and poor social attachment in families are also implicated in subsequent alcohol or drug abuse by young people, when combined with parental substance abuse.

There is a strong convergence between the research findings and practice experience from within the portfolio and from the partner organisations which deliver FaCS services.
Community attitudes have a significant role in how substance ‘abuse’ is defined and can influence service delivery models and access.

Links between substance abuse and relationship breakdown, violence against women including domestic violence, financial hardship, homelessness and mental health are confirmed from the practice experience.

Exclusion and marginalisation are common outcomes.


Systematic under- reporting of substance abuse issues or having these emerge peripherally from other interventions is a consistent theme.

Policy development work within the Department around problem gambling and the commercial sexual exploitation of children has also provided perspectives on the connections between substance abuse and these issues.
The particular impact of substance abuse in indigenous communities is discussed in chapter 4, together with some culturally appropriate interventions which are being developed by the communities, and the creation of the National Indigenous Substance Misuse Council.

5 Quantifying the costs of substance abuse The social and economic impacts of substance abuse on families are far reaching and emerge clearly from the qualitative information provided in this submission.
Establishing the costs of substance abuse in terms of FaCS program outlays is more difficult, and the submission concludes that it is not yet possible to quantify these costs in a reliable and meaningful way.

Both the research and practice experience reflect that one complex feature of substance abuse is the absence of a simple linear causal relationship between the abuse and other frequently co-existing problems.
With the exception of the costs attributed to a cohort of SAAP clients, and those related to the programs specifically supporting families affected by illicit drug usage, it is not possible to measure empirically the extent to which substance abuse translates directly into program expenditure.

Similarly the lack of a causal relationship with unemployment or family breakdown means that removing the substance abuse problem may not translate into savings.
Under reporting of substance abuse also increases the likelihood that cost estimates will be understated.

Issues for a service response The submission proposes reconceptualising ‘abuse’ of licit or illicit substances from a clinical to a functional definition which considers whether the substance usage has detrimental effects on an individual’s capacity to manage various roles within society including parenting and family relationships, employment community participation and self management.
This points to the need for intervention to begin at any one of multiple life transition points and focus on the most pressing problem as defined by the client (which may not be the substance abuse issue, at least initially).

Delivery of a holistic response to the individual in their environment also requires co- ordination across a broad range of disparate services including education, the criminal justice system and strong linkages to specialist health services.
The approach being taken in other areas of policy development around youth and family law transitions to articulated ‘pathways’ may also prove useful in developing a more comprehensive and coordinated system to deal with substance abuse.

The principles underpinning the Stronger Families and Communities Strategy could be equally applied to the development of a comprehensive service response to the complex issues of substance abuse.
Early intervention and prevention approaches, a focus on life transition points to provide support and intervention, the need for better coordination and integration of service delivery across a range of partners, capacity building of individuals and communities to deal with the social issues confronting them and action learning and evaluation are all themes which emerge from an analysis of current activity and its limitations.
6 INTRODUCTION Substance use or abuse, whether of licit or illicit drugs, can adversely impact on family life, and in aggregate can also impact on community life.

It is implicated in a number of damaging behaviours or conditions such as domestic violence, child abuse, family relationship breakdown, homelessness, child sexual exploitation, disability (especially psychiatric disability) and unemployment or employability.
The prevention or amelioration of many of these conditions is the focus of service delivery and policy development within the Department of Family and Community Services, portfolio agencies and non government service partners.
This submission to the House of Representatives Standing Committee on Family and Community Affairs inquiry into ‘Substance Abuse in Australian Communities’ will particularly concentrate on the social implications of substance abuse as it affects family relationships, including domestic or family violence.

The costs which will be described are opportunity rather than dollar costs.
Because of a lack of data and the absence of direct causal links between the receipt of income support payments or services from Centrelink/FaCS, the submission concludes that it is not possible to accurately attribute program and income support costs to substance abuse, except in the case of one or two programs dealing specifically with the issue.
How FaCS can contribute The FaCS vision is ‘towards a fair and cohesive Australian society’, its purpose ‘delivering social policy outcomes for Australian families, communities and individuals’.

Within that framework, the issue of substance abuse is relevant to all three major outcome areas – stronger families; stronger communities; and economic and social participation.
Evidence gathered from FaCS’ own activities and broader social policy research will show the destructive effect that substance use and abuse can have on individuals, families and communities, many of whom may in some degree be clients of portfolio services.

However it should be emphasised that they are FaCS clients because of some other need which is primarily met through this portfolio.
Generally their addictive behaviour or its impact in families is not central to their engagement with the department or its portfolio agencies, except in the case of a couple of small new initiatives.
Relevant FaCS program activity The portfolio activities where substance abuse by clients may most commonly come to the attention of service providers are: the broad spectrum of Centrelink delivered programs relating to income support; • • Centrelink social worker services; • Child Support Agency services; • • child care services; • Reconnect (formerly the Youth Homelessness Early Intervention Program); rehabilitation and employment support services for people with a disability; 7 • Supported Accommodation Assistance Program (SAAP); • Emergency Relief; • Family Relationships Services Program (FRSP); • The Commonwealth Financial Counselling Program.
These services and programs are delivered through a range of partnership arrangements.

Some programs are delivered by community based non government organisations (via a Commonwealth-State partnership in some cases), while others are delivered face-to-face by portfolio agency staff, for example through Centrelink.

Centrelink social workers in particular have the opportunity for a broad view of the circumstances of their income support clients.
Case studies and evaluation material from existing programs and services are used in this submission to augment limited statistical data.

The qualitative information illustrates the complexity of client issues and points to service gaps and emerging service delivery principles and partnerships which might combine to provide more a multi-dimensional and coordinated service system to address issues of substance abuse impact in the community.
The FaCS policy context Social policy development within FaCS is focused on the principles of prevention and early intervention as a critical means of retarding or preventing the development of many major social problems.

The benefits of this approach will be felt by individuals, communities and society as a whole.
Related principles are those of capacity building, mutual obligation, and of the importance of forging a partnership of government, community, business and individuals (the Social Coalition) to deal with social issues.

At the same time, effort continues to maintain a strong and sustainable safety net for those who do encounter difficulties.

Prevention and early intervention initiatives have been built on national and international research on the causation of many, often interlinked, social problems.
The research has found in relation to some key social issues that properly targeted intervention at critical life phases of individuals can do much to prevent later problems developing, and promote individual capacity to participate fully in their communities’ social and economic life.

A recent comprehensive articulation of these policy principles is contained in the Stronger Families and Communities Strategy, announced by the Prime Minister on 16 April 2000.
Building on existing FaCS programs and activities such as those discussed in Chapter 2 of this submission, the Strategy represents a major new direction for family and social policy involving new partnerships and service delivery models and a commitment to engaging families and communities in finding local solutions to local issues.

Implementation of the Strategy will have a significant impact on current and future ways of delivering programs within the Department.
The principles underlying the Strategy are those that emerge and will be recommended as relevant in dealing with substance abuse issues.

These include the 8 principles of prevention and early intervention, as far as is possible in the current state of knowledge.

Continued research, data gathering and evaluation to underpin continuing policy development and service delivery improvement will contribute further to the knowledge base about effective interventions in this complex area.
The focus on life transition points as the events where intervention and support are most likely to be required emerges as a critical service delivery strategy, as does the need for further work to integrate and coordinate service delivery across all levels of government and the business, community and volunteer sectors.

The Strategy’s emphasis on better integrated and coordinated service delivery will lead to exploration of innovative, more responsive and more flexible ways of delivering social policy.
The kind of collaborative working to map and use referral pathways for substance abuse from a range of “gateways” may well be modelled in some of the initiatives tested under the Strategy.

In addition, its testing of the early intervention model in well-researched areas, augmented by action research, will further explore many risk factors relevant to finding better ways of dealing with substance abuse.
9 Chapter 1 RECENT RESEARCH 1.1 Introduction The volume of research evidence linking substance abuse with social policy issues of relevant to the FaCS portfolio would make a comprehensive review beyond the scope of this submission.

Further, some of the relevant research is likely to be discussed in submissions from other government agencies, service providers, academics and community groups, many of whom are responsible for conducting or commissioning the research.
This chapter will concentrate on some of the recent research commissioned by FaCS and briefly describe the type of evidence behind the prevention and early intervention approach that underpins the Government’s social policy in relation to families.

Specific research findings, including evidence suggestive of the possible scale of substance abuse among clients of FaCS programs, appears throughout the submission, particularly in Chapters 2 and 5.
A selected literature review prepared by the National Child Protection Clearinghouse, which bears on relevant issues, has been submitted separately to the inquiry by the Australian Institute of Family Studies which hosts the Clearinghouse.

In general, the research basis for policy in the area of substance abuse is relatively underdeveloped, particularly in relation to Australian conditions.
For example, ‘there have been few Australian attempts to determine accurately the extent to which child maltreatment and substance abuse interact’ 1.

Tomison 2 also concludes that research to date is in critical ways not yet able to draw strong conclusions about causality between substance abuse and other factors.
Moreover, different studies use different definitions within a global term of ‘substance abuse’; and while most work has been focused on alcohol abuse, results are not always comparable, particularly in relation to the different types of child abuse and neglect.

Work on abuse of other licit drugs and on illicit drugs is even less prevalent 3 4.

Some Australian studies cited also rely on fairly small numbers of cases, and there is a dearth of longitudinal data.
Research in this area needs to take account not only of multiple variables, but also of the fact that different variables may be involved at different life stages.

Further, intervention and prevention strategies may themselves, by interaction with each other and with other variables, change the situation under study.

Tomison 5 stresses the importance of prospective studies if causal relationships are to be properly identified.
It would seem likely that the policy principles of early intervention and prevention, and of diagnosing key life transition points where such action would be most effective and beneficial, would be as important in relation to substance abuse as to other 1 Tomison,Adam, “Child Maltreatment and Substance Abuse” p 3 2 ibid p 5 3 ibid pp 2 and 7 4 Moon et al, Australia’s Children: Their Health and Wellbeing p 175 5 ibid 10 damaging intergenerational family health issues.
However, further research and data collection, and particularly longitudinal studies, will be necessary before policy can be well based in these areas, and intervention effectively targeted.

1.2.

Research and the basis for early intervention/prevention To assist the development of the Stronger Families and Communities Strategy, FaCS commissioned several research surveys of recent investigations and findings.
Initiatives associated with the National Council for the Prevention of Child Abuse and Neglect have also produced valuable findings.

These include Tomison’s paper on ‘Child Maltreatment and Substance Abuse’ (op cit) and the paper by Denton et al6 on an ACT Government service for drug-using parents and their children (see section 3.5 for more detailed discussion).

There are some interesting gaps in areas of relevance.
In their study Work and Family: Current Thinking, Research and Practice, Russell and Bowman point out that the most common problems in terms of work and family conflict are those arising from aspects of work interfering with the performance of family-related tasks, rather than aspects of the family that interfere with the performance of work-related tasks.

Nevertheless, there is less understanding of the impact of work on family life.
However, it appears that ‘work experiences are likely to have indirect mediating and sequential effects on family variables such as marital satisfaction, mental health and abuse of alcohol’ 7.

1.2.1 Prevention in early childhood The FaCS-commissioned research of most relevance to this inquiry is the Centre for Community Child Health’s Review of the Early Childhood Literature.
To assist with the development of the Stronger Families and Communities Strategy, the Review examines selected literature about the major risk and protective factors that may influence children’s developmental outcomes in preschool years, and selected studies of possible preventive and early interventions.
Parental substance abuse is listed as an important risk factor for a child’s welfare and development, along with perinatal stress; difficult temperament; poor attachment; harsh parenting, abuse or neglect; parental mental illness; family disharmony, conflict or violence; low socio-economic status; and poor links with the community.
Current thinking is that outcomes for a child result from a complex transaction between factors within the child (such as genes, central nervous system development, temperament) and environmental factors (such as parenting style, amount of stimulation, socio-economic status).

Action can be taken to try and minimise both types of risk factors, and maximise protective factors.

An important point is that ‘risk factors for adverse outcomes often co-occur, and they may have cumulative effects over time’ 8.
While ‘risk is not destiny’, one study has demonstrated that ‘children exposed to six indices of family adversity had 20 times 6 Denton, Barbara et al., “A welcome place: A health service for drug using parents and their children nine years on “, National Centre for Epidemiology and Population Health.

7 Ibid p 19 88 Review of the Early Childhood Literature p 5 11 the risk of adverse behavioural or cognitive outcomes compared to children exposed to one or none of the same risk factors’.
Further, genetic and environmental risk or protective factors may interact in a very complex fashion 9.
In terms of possible interventions, it is also important that risk and protective factors may change over time; and ‘the salience of risk or protective factors may vary with age, and this may vary by gender, race or the cultural context in which a child develops’ 10 The Kauai longitudinal study found correlations between parental alcoholism, together with other risk factors, and serious learning or behaviour problems at age 8; and delinquency, mental health problems and teenage pregnancy at age 18 11.
Another study (the Californian Child Health and Development Study)12 found a relationship between maternal smoking during pregnancy and low birth weight; and between heavy alcohol and coffee use in pregnancy and an increase in severe congenital abnormalities.

1.2.2 In utero exposure Tomison 13 provides additional evidence.
From studies he lists the prenatal effects of alcohol and drug use in pregnancy as including spontaneous abortion, premature birth, foetal distress, physical and/or mental retardation, birth defects and withdrawal symptoms on birth.

Longer term effects of in utero exposure to alcohol or drugs include impulsivity, learning disabilities, antisocial behaviour, neurological deficits and increased risk of sudden infant death syndrome.
Children of heroin-dependent mothers had lower birth weights and lower head circumferences, and a high incidence of hyperactivity, inattention and behavioural problems.

Children exposed in utero may therefore need highly skilled parenting, which mothers who are still substance abusing may not be equipped to provide.

In fact, children of such mothers may be more likely to suffer child abuse or neglect.
The additional care needed by such children may also affect the quality of the mother-child bond; and weak bonding can be exacerbated if the child is separated from the mother because of its own drug-withdrawal or other difficulties.

There is some evidence that children exposed in utero can avoid some of these developmental delays/behavioural disorders if they are adopted rather than raised by a still addicted mother.
“Thus, for children exposed to heroin prenatally but not born with any significant neurological damage, developmental outcome appeared to depend more on the home environment than the heroin exposure” 14.

Another study followed the children of mothers who used amphetamines during pregnancy until the children reached the age of eight.
Of the original 71 children, six died before two months of age and 26 were taken into custody within their first year 9 ibid p 6 10 ibid p 13 11 ibid Table 1 12 ibid 13 op cit pp 8-10 14 ibid p 10 12 of life.

After 8 years, 44 (68%) had been adopted or were living in foster homes.

By 8 years also the extent (amount and duration) of foetal amphetamine exposure was significantly correlated with children’s behavioural problems, especially aggressiveness and poor peer relations15.
1.2.3 A multi-dimensional problem A theme of this submission is how often substance abuse is linked with other health and social problems, and this link is clear in the Review of the Early Childhood Literature.
The major adverse outcomes associated with early childhood risk factors include: • poor physical health and child abuse and neglect; • along with substance abuse, behavioural problems such as aggression, attention difficulties, associating with a deviant peer group, delinquency, offending; • difficulties at school such as poor reading/illiteracy, poor cognitive and/or speech/language development, academic failure or early school leaving; and • emotional/mental health issues (poor attachment, anxiety, depression, alienation, suicide)16 The value of a range of possible interventions discussed in the Review may be limited to an extent where the programs described are being implemented overseas and would require careful adaptation for Australian conditions.
Nevertheless these findings are shaping the activities to be supported under the Stronger Families and Communities Strategy.

It is clear that some interventions, especially in the very early years, can have quite powerful effects, and in some cases have their strongest effect on the lives of socio-economically disadvantaged children 17.
1.3 Some specific issues 1.3.1 Risk factors for children’s taking up substance abuse A range of parental behaviours may constitute risk factors for children’s taking up substance abuse.

One study, for example, found that children who abused alcohol were likely to have a background of harsh physical punishment or child abuse, and exposure to inter-parent violence.

(See table 1 in the Review.)


15 Tomison ibid p 10 16 Review of the Early Childhood Literature op cit table 4 17 op cit pp 1-2 13 A much larger analysis of dysfunctional families and a number of environmental risk factors was placed before the New South Wales Drug Summit (1999).
This showed the following correlations with a person’s likelihood to misuse drugs : • poor parenting or abuse; • family illness especially psychiatric illness; • a family’s lack of social or local attachment; • substance abuse by parents; • long-term unemployment; • poverty; • poor or crowded housing; • poor support services; • peer pressure.

It was noted that these risk factors are also very similar to those that correlate with a person’s likelihood of offending.
It was also suggested that people with poor school performance, low self-esteem and failure to complete secondary school could be at risk of abusing drugs.

Of NSW secondary school students it was reported: “… alcohol, cannabis and opiate use all had a general amplifying effect on participation in violent crime, destructive property crime and acquisitive property crime.

Cannabis use, however, was a particularly strong predictor of acquisitive property crime”18.
Here, as elsewhere, it should be emphasised that it is not inevitable that all who experience these factors will misuse drugs, or that those whose lives are free from these factors will be drug free 19.

Important information relating to the influence of parental substance use, and providing some data about substance abuse among children is contained in Moon et al, Australia’s Children: Their Health and Welfare.

The first set of figures related to parental use, not abuse.
Research is quoted 20 that demonstrates strong linkages between parents who smoke tobacco or drink alcohol and adolescent usage of those substances.

Nearly 42% of adolescents (12-16 years) with a parent who smoked had smoked at some time, compared to only 20% of children of non-smoking parents.

Fifteen per cent of adolescents with a smoker parent had smoked the previous day, compared to only 4% of adolescents whose parents did not smoke.
The proportions of adolescents with a parent who drank alcohol daily compared with those whose parents did not drink was 61% compared to 41%.

Over 14% of adolescents with a parent who drank alcohol daily had drunk alcohol three or more times in the last month, compared to less than 1% of adolescents of non-drinking parents.
18 Parliament of New South Wales, First Report of the Inquiry into Crime Prevention through Social Support 19 ibid pp 46-48 20 Moon et al p 187-8 14 However, Moon et al go on to state: “Attitudes towards drugs early in childhood presage future use.

There is some support for the theory that children who use cigarettes, alcohol and other illegal substances run a greater risk of moving to harder, more addictive drugs.
There is also the evidence that peak time for starting tobacco smoking is in early teens” 21.

They quote evidence that tobacco smoking, binge drinking and marijuana use have been reported among children of 11 or 12 (some 9% of children had smoked at least one full cigarette before the age of 11).

Parents who smoke clearly put their children at risk of the health effects of passive smoking, including creating a risk factor for new cases of asthma in children.
It has been estimated that over 40% of under 5 year olds lived with at least one smoker in 1995.

The proportion for 5-9 year olds was around 39% and for those 10 to 14 years of age more than 36% (pp172-3).

It has been reported that exposure to tobacco smoke in the home contributed to the symptoms of asthma in 46,500 children.
The community’s ambivalent attitude towards alcohol use means that children are even more exposed to the use of alcohol than tobacco, according to Moon et al.22 More than three-quarters of children younger than 13 years of age had drunk alcohol, increasing to 90% by 15.

For ‘current drinkers’, the mean number of drinks per week was 5 for boys and 3.9 for girls aged 14.

Almost one in ten of the current drinkers aged 12 to 15 years had engaged in binge drinking 23.
In relation to illicit drug use by children, information is patchy, deriving only from a couple of Australian states.

The drugs include non-prescribed use of opiates, cannabis, hallucinogens, stimulants (cocaine and amphetamines) and anabolic steroids, as well as any non-prescribed injecting drug use.

A Tasmanian survey in 1996 found that illicit drug usage began early: 4% of 12 year olds had used amphetamines and 3% had used ecstasy in the previous year.
The proportions for 14 year olds were 6% and 4% respectively24.

1.3.2 Issues for youth in rural areas Drug use (licit and illicit) in rural areas is also an issue for concern, because interventions such as assistance to withdraw from illicit drugs can be less readily available than in metropolitan areas.

A recent study by Paul Williams for the Australian Institute of Criminology has interesting findings in relation to alcohol.
Alcohol consumption for those aged 14-24 increased between 1993 and 1998 in both metropolitan and rural areas of Australia.

‘Proportionally, in 1998 there were more alcohol consumers and more hazardous and harmful drinkers among youth in rural 21 ibid p 170 22 ibid p 173 23 ibid p 175 24 ibid 15 Australia.’ 25 During the same time period, the rate of alcohol-related disorder declined in rural areas.
However, one-third of persons aged 14-19 years, and two-thirds of those aged 20-24 years in rural Australia were victims of alcohol-related personal abuse in 1998.

In rural areas the abuse was more likely to occur in pubs and clubs than was the case for metropolitan dwellers.

Otherwise, the alcohol-related disorder in rural areas was generally in the home, particularly in the case of female victims 26.
In rural Australia, about three-quarters of all alcohol-related social disorders were committed by people aged 14-24, and about three-quarters of the disorders were committed by just 12 per cent of the age cohort 27 In terms of some possible solutions, Williams sees a role in rural areas for promoting and observing responsible serving practices in pubs and clubs, as well as appropriate treatment and education for those who repeatedly offend in terms of hazardous drinking and perpetrating social disorder.
Chapter 3 describes other connections between substance abuse and the addictive behaviour of gambling; and substance abuse as a risk factor for children who are commercially exploited for sexual purposes.

1.4 Conclusion The current research base is adequate to give some idea of the importance of substance abuse as one of a number of interlinked risk factors at individual and family level.
There are strong associations between substance abuse of all types and a range of problem behaviours and other social issues, particularly domestic violence, child abuse and neglect, health issues, poor educational attainment, mental illness and other disabilities.

Within the family, the research indicates that parents who use or abuse substances, or adopt harsh parenting practices, can create damaging environments for their children.
If the risk factors of such parental behaviour combine with others, such as low socio- economic status or poor links with the community, the prognosis worsens.

Particular parenting behaviours, again often combined with environmental risk factors, can also make it more likely that a child in turn will become a substance abuser.

However, many findings on particular correlations of risk, while suggestive, presently derive from only one or a small number of studies.
A better research base on what interventions may work in what conditions is needed for an issue that goes so much to the heart of family functioning.
At the same time, research into early childhood does support the idea that early intervention with high risk families can do much to improve the overall chances of the 25 ‘Alcohol -related Social Disorder and Rural Youth: Part 1 - Victims’, Trends and Issues in Crime and criminal justice, no 140 26 ibid p 5 27 Williams, ‘Alcohol–related Social Disorder and Rural Youth: Part 2 – Perpetrators’ p 1 16 children of such families.
The causes of substance abuse are not clear cut – relationships with risk factors are all that is available so far.

Nevertheless it is fair to assume that interventions to improve factors such as the health and socio-economic prospects of families will also have benefits in reducing the risk factors for substance abuse by adults and children.
To improve the effectiveness and targeting of such intervention in relation to substance abuse further investigation is required in a number of areas: • much improved data and understanding of the Australian situation and national • • and sub-national levels is required before the scale and causality, and thus the best means of intervention, can be clarified; the complexity of the genetic, personality, socio-economic and other environmental factors involved makes it imperative that future investigations involve multi-disciplinary, prospective and where necessary longitudinal studies; illicit drug users in particular may never deliberately approach any part of the welfare or health system.
Ways of working with those so isolated need to be explored, and research is needed to understand the circumstances causing such extreme cases of abuse; • Research may also be needed into what triggers an individual’s motivation to change in this very personal area, where addiction may have very strong physiological and psychological effects after long periods of abuse.

To quote Tomison again, holistic approaches are essential ‘to address what are often multi-problem, disadvantaged, dysfunctional families’.
He observes that such approaches are developing in relation to child abuse and neglect “in response to the understanding that violence may lead to substance abuse, substance abuse may lead to violence, and environmental pathologies may result in either or both behaviours” 28.

The same can be true for substance abuse.


28 Tomison op cit p 11 17 Chapter 2 WORKING WITH SUBSTANCE ABUSE IN ESTABLISHED FaCS PROGRAMS 2.1 Introduction The Department funds a range of services predominantly provided by the non- government sector to provide supports to families and communities.

Many of these are mainstream services relevant to families at different stages of the family life course.

These include parenting and relationship support services, financial counselling services and child care.
For families and individuals experiencing more extreme relationship stress and breakdown, or other forms of crisis, there are preventive and crisis oriented services including domestic violence prevention services, the Supported Accommodation Assistance Program and Emergency Relief.

Centrelink social workers also have a direct relationship with a segment of the customers of the various income support programs delivered by Centrelink on behalf of FaCS.
This section documents the experience and information available in relation to the impact of substance abuse on individuals and families derived from these program sources.

In the absence of relevant data generated from the income support programs the direct service and ‘once removed’ service delivery arms of the portfolio yield the most productive insights.

However, where data is available it has been cited.
2.2 Family Relationships Services Program The Family Relationships Services Program (FRSP) is designed to contribute to the development of an Australia in which: • children, young people and adults in all their diversity are enabled to develop and • sustain safe, supportive and nurturing family relationships; and the emotional, social and economic costs associated with disruption to family relationships are minimised.
It funds nearly 100 community-based organisations around Australia to deliver a range of programs to enhance people’s capacity for achieving and sustaining valued family relationships.

The major services provided are relationship education, counselling, mediation and family skills training.

Other services offered include pilot services focusing on men’s needs and those providing safe places for contact between children and a separated parent.

Total annual funding for 1999-2000 is $46m.


2.2.1 The link between substance abuse and relationship breakdown Substance abuse is frequently an issue in relationship conflict and relationship breakdown.

Counsellors are wary of attributing behaviours such as domestic violence to alcohol abuse, but research has shown that alcohol abuse is present in up to 40% of 18 households where family violence is present.
Organisations funded under the FRSP also estimate that family violence is an issue in about 40% of their service activity.

Substance abuse is often used as a coping mechanism following relationship breakdown, especially among men.

Workers running groups for separated men report that on entry into programs up to 60% of participants report that they ‘numb out’ using drugs or alcohol.
In the Australian Divorce Transitions Project, a national telephone survey conducted by the Australian Institute of Family Studies, 11 per cent of women and 3 per cent of men reported alcohol or drug abuse as the main reason for divorce.
Although the responses did not distinguish whether it was the respondent or their partner who had an alcohol or drug abuse problem, previous studies have found that wives are much more likely than husbands to nominate negative personality traits of their spouse including alcohol and drug use and emotional and physical abuse (Kitson and Sussman 1982; Cleek and Pearson 1985).
FRSP service workers will thus encounter substance abuse under a number of guises in the course of delivering their mainstream services.

In some cases they may have the capacity to refer clients with substance abuse or other addictive behaviours such as gambling to other services they run, funded either by State/Territory governments or non-government sources.

The extent to which they do so refer, or advise their clients about other organisations’ programs (eg health) is not known.
2.3 Emergency Relief This program provides funding in the form of grants to community organisations to provide emergency financial assistance to individuals and families in financial crisis.

Assistance can be in the form of cash, vouchers or payment of outstanding accounts for the client.

In the last two years, NSW Emergency Relief funded agencies have reported increasing incidence of violence and aggression from clients dependent on alcohol or drugs.
In the last twelve months, up to three Emergency Relief funded (ERP) agencies have withdrawn from the program, stating that the primary issue has been the increasing incidence of aggressive and/or violent behaviour from clients.

Training and support for managing difficult and aggressive behaviour is one of the most requested areas of support by ERP agencies in NSW.

Similar trends are being identified in Victoria.


In a recent survey, agencies reported an increased demand for emergency relief together with increased complexity of issues people present with - drug and alcohol issues are a significant part of this, particularly heroin use.

For example, a client of one service, claiming she was going outside for a cigarette, left her baby for hours while she found a ‘score’.

This presents safety issues for agency workers from people who are angry, unwell, or desperate.
The risk of violence is especially an issue for agencies that work with cash, such as the Smith Family.

It also highlights the increasing demand on volunteer workers to respond to situations for which they have no training or adequate support.

19 Agencies in Victoria are indicating a need for regular training at minimum cost to deal with drug and alcohol related issues.
Some agencies report they are being asked to assist with the costs of methadone programs - at $40 per week this cost is difficult to manage for a person on income support with increasing housing costs.

These problems have traditionally been focused in metropolitan and suburban areas where trafficking is visible.

However, they are also now being reported by agencies in rural areas.

There are some examples around the country of specialist drug and alcohol agencies managing Emergency Relief funds.
This has proved to be valuable in enhancing the range of assistance that clients may be immediately referred to (the 'one stop shop' model).

2.4 Supported Accommodation Assistance Program (SAAP) The Supported Accommodation Assistance Program provides support services for people who are homeless or at risk of homelessness.
Services are directed at finding safe, secure and affordable housing, achieving independence through participation in work, training and other activities, and maintaining or re-establishing family relationships.

The profile of SAAP clients typically reflects the complex interaction of risk factors identified in research as contributing to family dysfunction, including escaping from domestic violence and relationship breakdown.

The presence of substance abuse is reflected as part of that pattern.
A 25 year old woman with two young children makes her third application for parenting payment single following another incident of alcohol related violence from her partner.

She is self blaming as she feels she should be able to make the relationship ‘work’ and is scared about the prospect of living alone with her children when she leaves the refuge.
Centrelink case study SAAP service delivery generally occurs within a case management framework that emphasises working with clients in a collaborative way to determine their needs and goals and develop flexible strategies to assist them.

The majority of SAAP clients (86%) have support plans.

An important aspect of service delivery is providing the client with appropriate referrals.
20 The 1998-99 SAAP National Data Collection indicated that a total of 6.1% of clients listed substance abuse as the main reason for seeking support.
Support periods: main reasons for seeking assistance by primary target group, Australia Main reason for seeking assistance Drug/alcohol/substance abuse Young people 946 3.1% Single men only 2,499 17.6% Single women only Families Women escaping DV 192 6.4% 175 2.5% 303 1.0% Cross target/ multiple/ general 2,621 10.4% Total 6,710 6.1% Total number 30,500 14,200 3,000 7,000 30,300 25,200 110,000 Source: extract from Table 4.10, SAAP NDCA Report 1998–99, p 46 In that same period, 11.7% of all men and 2.4% of all women approaching SAAP services stated that substance abuse was the main reason for seeking support.
Of these, 17.6% of clients from single men’s SAAP services, 6.4% of clients in single women's SAAP services and 10.4% of clients from cross program/multiple target SAAP services identified substance abuse as the main reason for seeking assistance.

Individual state figures show higher incidence rates in some cases.

Across NSW 16% of male clients and 4% of female clients indicated that substance abuse had led them to their seeking SAAP support.
The statistics from Western Australia are even more alarming, with 13% of all clients (24% of all males and 4.7% of all females) reporting substance abuse as their main reason for seeking support.

Drug and alcohol support and rehabilitation services were provided to 6.6% of all SAAP clients.

Eight percent of single men and young people received drug and alcohol support services, while 4% of families received these supports.
Support periods: support services provided by primary target group, Australia Support services provided Drug/alcohol support/rehabilitation Total number Young people Single men only Single women only Families Women escaping DV Cross target/ multiple/ general Total 3,026 7.7% 3,168 8.0% 39,300 39,600 235 6.7% 3,500 348 4.4% 7,900 794 2.3% 3,141 8.2% 10,771 6.6% 34,500 38,300 163,200 Source: extract from Table 5.3, SAAP NDCA Report 1998–99, p 78 Drug and alcohol support services and rehabilitation were provided to 5% of young SAAP clients below the age of 20 years.
Support periods: support services provided by age of client, Australia Support services provided Drug/alcohol support/rehabilitation Under 15 years 75 2.6% 15–19 years 1,859 5.6% 20–24 years 1,894 7.2% 25–44 years 5,828 7.5% 45–64 years 65 years and over 1,502 7.4% 127 4.9% Total 11,240 6.9% Total number 2,900 33,200 26,300 77,700 20,300 2,600 162,900 Source: extract from Table 5.5, SAAP NDCA Report 1998–99, p 80 21 As shown in the following table, the provision of drug and/or alcohol support services featured prominently in the range of services provided to clients identified as having high needs requiring a high level and complexity of service provision.
Around 18% of SAAP clients are considered to have high and complex needs.
Completed support periods for high need clients, support services needed by agency target group, Australia 1996-97 Young people requir- ing support 4121 % Single men only % Single women only % Families % Women escaping domestic violence % Cross- target/ multiple/ general % Total % Intense Support Needed Family/ Relationship counselling Other counselling Psychological services Psychiatric services Living skills/personal development Pregnancy/ Family planning support Drug/alcohol support or rehabilitation Physical disability services Intellectual disability services Source: Final Report: Appropriate Responses for homeless people whose needs require a high level and complexity of service provision, SAAP November 1999, Table 13, p 84.
In Victoria it is reported that the impact of heroin use in crisis residential facilities and refuges is rising.

The numbers of residents using heroin or selling it (or both) is increasing, and crisis accommodation is in some places becoming a de-facto safe injecting facility, with frequent overdoses.

There are corollary safety issues for residents (who may include children) and staff.
The NSW Department of Community Services has identified substance abuse as a significant enough issue to include a Drug & Alcohol Module within the NSW SAAP Training Calendar.
22 2.5 Services and payments for young people 2.5.1 Youth Allowance Youth Allowance is an activity tested income support payment for young unemployed people between the ages of 16 and 20 (and students up to the age of 25), which aims to ensure that young people have adequate levels of income while they are studying, looking for or preparing for paid employment.
It is also designed to encourage young people to continue with further education and training to improve their opportunities in the labour market, and to be involved in activities which will promote employment entry.

The payment was introduced from 1 July 1998.

Data is recorded on Youth Allowance clients exempt from the activity test because of substance abuse issues.
Figures from April 2000 indicate that of 677 young people exempt from activity testing, 60 (8.8%) were exempt because of substance abuse, with drug abuse being specifically identified for 52 young people.

Their ages range from 15 to 17 years.


The identification of a substance abuse based exemption may result in referral to a Centrelink social worker or to the Department of Employment, Workplace Relations and Small Business’ Community Support Program which is designed to overcome severe barriers to employment.

The case-by-case decision-making for eligibility for this program may lead to the exclusion of substance abusers.
More consistent and formalised procedures for referral and case management of young people with identified substance abuse would be a positive service response.

2.5.2 Youth Activities Services These services aim to provide young people between the ages of 11 and 16 years in disadvantaged areas with structured activities and positive peer supports outside school hours, to help prevent them from developing patterns of destructive behaviour and keep them engaged with the community.
The extent to which these services provide positive outlets and activities to young people who might otherwise drift into lifestyles and activities encouraging alcohol and drug usage is anecdotal.

Youth Activities Services are located in low socio-economic areas where the interaction of multiple risk factors described in chapter 1 has been associated with significant drug problems.
2.5.3 Family Liaison Workers These workers operate within Youth Activities Services to provide practical support and guidance to young people and their families on issues such as family conflict and lack of communication, and to refer them on to other specialist services as required.

Their aim is to strengthen family relationships.

Drug usage, in particular, can be a significant source of family conflict so the roles of these workers may bring them into contact with young people with substance use issues.
One service in the Northern Territory is known to be working with young people who are petrol sniffers, providing them with one to one counselling and organising activities.

Anecdotal reports indicate that the number of petrol sniffers has declined.
23 2.5.4 Issues for young people Research into the interaction of family risk factors and outcomes for children establishes links between childhood neglect and later issues with delinquency and substance abuse, which suggest the relevance of early intervention and prevention approaches as a response.
According to the report The Nature and Treatment of Adolescent Substance Abuse (NDARC 1996), ‘there is substantial evidence that children who have been abused or neglected are at a high risk of detrimental outcomes such as illicit substance use and delinquent/criminal behaviour, self destructive and suicidal behaviour’.
The report Accommodation and Support Services Provided to Young People Unable to Live at Home (Western Australia Office of the Auditor-General, 1998) contends that there are significant consequences of not adequately addressing complex issues at the time they present in young people.

They may drift into the juvenile justice system, become homeless, or develop serious psychological or social problems.
Effective early treatment services can help reduce the impact and hence the cost of these problems to the community.

Family relationships are subject to severe stress by the presence of inappropriate use of alcohol and drugs.

Problematic substance use in families is not confined to the behaviour of young people but can equally be an issue for the young person exposed to the consequences of substance abuse by adult family members.
The experiences of Centrelink social workers provided several revealing case studies, in addition to reports of daily contact with young people who consider that they could no longer live at home; either as the result of a parent’s level of substance abuse or because parents were unable to cope with the substance abuse of the young person.

A 15 year old boy is successful in his application for youth allowance on the basis that his parents are unable to tolerate his marijuana use.
Both parties are unable to compromise in any way leaving the boy to manage without any real adult influences.

Centrelink case study The vulnerability of young people in such cases of family breakdown is clearly highlighted.

A 15 year old girl recently claimed the ‘unreasonable to live at home rate’ of youth allowance.

The assessment for this payment revealed that her mother had a long history of dealing in amphetamines and involvement in other criminal activity.
The girl had sought no assistance from the state welfare department for fear of getting her mother into trouble and had waited until she was 15 to claim any income support for similar reasons.

Her mother is now in gaol and the girl is doing her best to live independently.

Centrelink case study 24 A 17 year old young man who left home as a result of abusive behaviour on the part of his stepfather.

The stepfather was a heavy cannabis user and refused to accept any responsibility for his stepson.
The young man's mother was extremely upset about her son leaving but felt unable to confront her partner about this.

Centrelink case study 2.6 Child care The Commonwealth Child Care Program provides access for families to quality child care which supports their choices about managing their parenting and caring responsibilities and their participation in the workforce and the general community.
Financial assistance with the costs of child care is available to low and middle income families, including special provisions to meet costs of care for families in crisis circumstances.

The focus of child care has until recently been predominantly on the labour force support aspects of the program for families with young children.
While the majority of families using child care do so for work related purposes, the 1999 Census of Child Care Services indicated that around 10% of children in long day care services were attending for non work related care.

Childcare Assistance (and the new Childcare Benefit which replaces Childcare Assistance from 1 July 2000) is available to eligible families to help offset the costs of care.
The Childcare Rebate (also to be combined into the new Childcare Benefit) is currently available only to families using work related care.

In 1998 a fifty-hour limit per week on Childcare Assistance for work related care was introduced together with a provision for access to Childcare Assistance for up to 20 hours a week for non work related care.
These measures effectively marked a recognition in policy terms of the value and role of quality child care in providing developmental experiences for children irrespective of the labour force status of their parents.

The 20 hour measure also introduced some measure of equity into the availability of care for developmental and family support purposes, where the previously unlimited access to Childcare Assistance had benefited some families to the exclusion of others.
The role of child care in supporting children at risk of abuse or neglect is recognised in the priority of access guidelines for care.

Some children of substance abusing parents may have been picked up under these provisions.

With the increased interest in early intervention to support the development of disadvantaged children in the 0-3 age range, quality child care has become a focus for delivery of such programs.
The new flexible child care services for families in crisis, including services for the children of drug dependent parents, are discussed in more detail in the next chapter of this submission.

25 2.7 Disability Employment Support Services Specialist psychiatric employment services report self-medication is prevalent amongst their client group.
It appears that marijuana is the drug of choice although service users are known to use a variety of licit and illicit drugs (alcohol is less used due to adverse reaction with any psychotropic medication clients may be using).

One service estimated one in two clients would be self-medicating, although there was some discussion about when this practice might be considered substance abuse and when it could be considered under control.
Some forms of brain injury are a direct outcome of certain types of substance abuse.

However, people with acquired brain injury (ABI) from sources such as accident or trauma are also significantly at risk of substance abuse, to the extent that at least one service provider in NSW reports that it has developed an entry/exit policy which requires substance abusers to participate in a rehabilitation program.
ABI is marked by impulsivity and low frustration tolerance, which can lead to misuse of licit and illicit substances.

It was noted that a significant proportion of this group might have pre-morbid alcohol abuse.

Others, following brain injury, are unable to cope with the limitations imposed by the ABI, which leads to depression, which may then lead to increased alcohol consumption.
2.8 The social work experience The Centrelink social workers consider their knowledge of the incidence of substance abuse to be understated because many customers make contact with social work services for other reasons.

However, their practice model involves looking more holistically at clients and their environment, from which substance abuse issues may emerge either as a symptom of some other issue such as depression or sexual abuse or as a contributing factor to another problem.
For members of the extended family of substance abusers (often grandparents who have taken on the support of their grandchildren), contact with Centrelink may be prompted solely by the relationship as the source of their income support and the absence of other networks.

A call to a social worker in one of Centrelink’s call centres came from a woman in receipt of the aged pension who had her belongings stolen by her adult daughter who had an ongoing substance abuse problem.
The woman was wanting to support her daughter in any way she could and was at a loss to know where to go to from here.

Centrelink case study No comprehensive information is available about the extent to which substance abuse emerges as an issue in the casework of Centrelink social workers.

However, selective review of caseloads provided the following indicative information.
In a couple of inner city areas with very mobile populations of Centrelink customers, social workers estimated that up to 70% of the people they saw on a daily basis had issues 26 concerning substance abuse, while a regional centre estimated the proportion to be around 45%.
The very high inner city figures would reflect the congregation of crisis and other services for transient populations in these areas as well as the lifestyle and drug availability which attracts substance abusers to areas like Kings Cross.

Centrelink social workers agree there is under reporting of substance abuse and confirm the absence of a simple cause and effect relationship between substance abuse and other presenting issues.
The patterns of family breakdown, domestic violence and intergenerational cycles of poverty, violence and substance abuse documented in the research on risk factors and early intervention are typical experiences for their clients.

Counselling and support has yielded varying degrees of success with this group.

However, the social workers’ experience emphasises that the complexities of many of the presenting situations require more intensive support than can generally be provided.
Successful referral for ongoing assistance depends on the client having the ability to recognise the extent of the problem, and the availability of suitable services for them to be referred to.

2.8.1 The proposed social work intervention pilot The complexities of the individual and family situations generally require some form of intensive intervention to achieve any lasting positive change.
This recognises that addiction by its very nature can only be dealt with through a combination of the person's individual motivation and the availability of the necessary supports.

One of Centrelink's key advantages in offering support is their role as a ‘gateway’ to a very broad cross section of the community in relation to income support.

This provides both an important incentive and a ‘safe’ reason for contact.
Many people with a substance abuse problem would have contact with the agency to access income support when they would not otherwise have contact with any other service.

In working with substance abuse the most effective intervention has been found to be achieved when it is possible to provide a more intensive service to the person wherever they present (be it Centrelink, a hospital or any other service).
For this reason social workers are interested to assess the effectiveness of piloting a program of more intensive assistance at a few Centrelink sites.

This would involve beginning to assist the person (or family if appropriate) to deal with their substance abuse over the course of a couple of months (say, 6 to 8 sessions).
The aim would be to develop sufficient level of trust to enable the person to be successfully referred to a specialist service, after they had begun to experience some improvement in their own situation and hence some intrinsic belief that change is possible.

In some situations the assistance provided would be sufficient in itself to deal with the problem if the substance abuse had not become too entrenched.
27 2.9 Conclusion Although (and perhaps because) none of the FaCS mainstream programs and services has a specific substance abuse focus, there is a substantial, if not systematic, body of information about the impact of substance abuse on individuals and families.
The service characteristics best supporting engagement with the issues of substance abuse emerge as some form of ongoing, relatively intensive intervention which recognises the complexities of the issues, and case management and effective referral networks.

28 Chapter 3 A PREVENTION/EARLY INTERVENTION FOCUS 3.1 Introduction The policy context of existing and emerging FaCS programs is underpinned by the principles of prevention, early intervention and capacity building both in families and communities.
While the ‘Stronger Families’ outcome reflects the prevention and support focus of established programs, the nine new measures making up the recently announced Stronger Families and Communities Strategy will operationalise the prevention/early intervention themes reflected in research as innovative new responses to support families and build community capacity.
With the Strategy the Government will make a substantial investment in prevention and early intervention services, particularly from an early childhood perspective.

Some of these services will provide parenting support, marriage and relationship education and family counselling.

A national Study of Australian Children will also be commissioned to focus on early childhood and effective early intervention and prevention strategies in areas of health and education.
Broad-ranging partnerships are a feature of the service development and delivery, and action research and evaluation of projects will contribute Australian experience and data to the research base on the effectiveness of early intervention strategies.

The Stronger Families and Communities Strategy includes flexible child care initiatives, with child care options designed to support families in crisis, including initiatives tailored specifically to the needs of children of drug dependent parents.
In this model, quality child care becomes a mechanism to deliver positive developmental programs to children and the service acts as a gateway to parenting support and health services.

This chapter examines the flexible child care initiatives and two emerging program responses with particular relevance to an understanding of the impact on families of substance abuse; the Reconnect program and the Strengthening and Supporting Families Coping with Illicit Drug Use program.
The last is a series of partnership agreements with State Governments to develop, purchase and deliver services for families suffering from the effects of illicit drug use by a young family member.

Other emerging policy work in relation to problem gambling and the commercial sexual exploitation of children (issues which have links to substance abuse) is also outlined.
3.2 Reconnect 3.2.1 Background The objective of Reconnect (formerly the Youth Homelessness Early Intervention Program) is ‘to improve the level of engagement of homeless young people or those at 29 risk of homelessness in family, work, education, training and the community’.

Aims are achieved by reconciliation, wherever practicable, between homeless or at risk young people and their families; and engagement of these young people with employment, education, training and community activities.
Assistance is provided on a case management basis to young people between the ages of 12 to 18 years and their families, with the clients being assisted to access a range of services either in-house or through other agencies.

Services explore new models of family reconciliation with a focus on early intervention, and improvement in the coordination of services delivered by government and the community sector.
They also examine ways of ensuring that income support paid at the away from home rate on the basis of it being unreasonable to live at home (formerly the independent homeless rate) is available to young people properly entitled to it.

In May 1996, the Prime Minister announced the membership of the Prime Ministerial Youth Homeless Taskforce.

The Taskforce managed the implementation and evaluation of 26 community based services operating in areas of high need across Australia.
The projects were referred to as the Youth Homelessness Pilot Program.

In December 1998 following an evaluation of the program the Prime Minister committed the Government to spend an additional $60 million over four years (with ongoing funding of $20 million a year) to establish an early intervention youth homelessness program: Reconnect.
The Reconnect program is based on the framework and key concepts identified by the Taskforce and draws on good practice principles developed during the Youth Homelessness Pilot Program.

Twenty nine services commenced in December 1999 - January 2000 and a further 36 were announced in May 2000, and by 1 July 2000 there will be around 100 Reconnect services.
3.2.2 Statistical information on substance abuse from the Youth Homelessness Pilot Projects In many projects, either the young person or their families cited drug and alcohol issues as one of the major factors creating difficulty in their relationships.

Perceptions of the problem varied.

• The rate at which young people reported their own abuse as a reason for imminent or early homeleaving was 8% of all reasons given, and the main reason in 1% of cases.
The rate reported by parents/guardians was 17% of all reasons given and the main reason in 5% of cases, ie, a considerably greater proportion of adults saw drug/alcohol abuse by the young person as a problem than did the young person.

• Young people reported abuse by another household member as 5.4% of all reasons and 1.7% of the main reason, while parents reported that abuse by another household member was 3% of all reasons and the main reason in 1% of cases.
• Service providers considered that 8.1% of clients for whom data was available, and 2.8% of parents/guardians/other family members needed drug/alcohol support or rehabilitation.

30 The reliability of these rates is limited by the voluntary nature of client participation in the data collection.

The non-response rate of 26% has implications for the extent to which the data is representative of all clients.
Families with less complex difficulties are more likely to agree to participate with a subsequent under-reporting of drug/alcohol problems.

In addition, substance abuse may be factor in a range of other reasons given for early or imminent home leaving, such as domestic violence, family conflict or mental illness.

For instance, parents report seeing the ‘inertia, lying and stealing that often flow on from heavy dope smoking’.
3.2.3 Pilot projects' experience Some projects found that there was a stronger risk that a young person would become a substance abuser if there was a problem already established within the family.

However, the incident rate of young people's use of various substances increased once they became homeless.

For some families there was also drug-induced psychosis to deal with.

Projects have reported difficulty in being able to access appropriate services to assist clients in dealing with these issues.
In rural areas, there are few specialist drug and alcohol services.

Where these services do exist (whether in rural or urban areas), projects found that they are usually based on adult models and are not effective in working with the issues of young addicted people.

Some projects noted that most detoxification units are set up for people using hard drugs such as heroin and little support is available for young people who are habitual users of marijuana.
It is not appropriate to send such young people to an environment where they will be mixing with users of harder drugs.

Services felt that education programs dealing with drugs and alcohol are also not properly targeted for young people.

There are no simple answers.
The key to success was seen as: • being able to provide long term support on demand; • keeping the lines of communication open with parents; • finding employment for the young person, as a pay packet is a great incentive and most soon realise that they have to control their own drug usage to maintain their job; • encouraging relationships with other young people who do not reinforce the drug usage; • considering and providing support around other related issues, such as juvenile justice and mental health.
3.2.3.1 What has been tried • One project trialed sharing premises with an early psychosis project run by the health department.

The person from the early psychosis project was also a member of the project’s reference group, which strengthened ties between the two parties.

• One project played a brokerage role in trying to link up drug and alcohol work and schools, and encouraged an outreach model of service delivery.
• One project successfully conducted support/information groups for parents of 31 young people regularly using marijuana, facilitated by a drug and alcohol worker experienced in working with adolescents.

3.2.3.2 Suggestions about what could be tried or is needed • More parent support/information groups for parents with young people using marijuana that present realistic approaches to the issues drug use raises in families.
• Specific drug and alcohol treatment and education services geared towards young people which provide a range of services including assistance for young people using marijuana heavily.

3.3 Strengthening and Supporting Families Coping with Illicit Drug Use measure 3.3.1 The policy context In April 1999, the Council of Australian Governments announced a package of additional measures for funding under the National Illicit Drugs Strategy (NIDS).
New initiatives covered prevention, early intervention and education services, and the diversion of drug users to counselling and treatment.

Approximately $220 million has been allocated for these additional measures.

Part of this funding has been dedicated towards providing support to parents and families affected by illicit drug use.

FaCS is responsible for implementing the Strengthening and Supporting Families Coping with Illicit Drug Use measure.
This measure is consistent with two key FaCS strategic outcomes: Stronger Families, and Stronger Communities.

3.3.2 Aim and implementation This measure is designed to assist communities establish support and advice mechanisms for families, provide outreach services to link and coordinate pathways to health related counselling services, and encourage links to other NIDS services.
It will provide approximately $11 million in funding over 4 years to State/Territory Governments to provide services to parents and families who are suffering from the effects of illicit drug use.

A Memorandum of Understanding (MOU) has been developed to formalise funding and program arrangements between FaCS and State and Territory Governments.

Most of the proposals involve State/Territory Governments purchasing services from community based organisations.
The nature of the programs proposed for funding under this initiative varies considerably between different jurisdictions.

FaCS is adopting a strong partnership approach to the development of proposals and is working with State/Territory Governments to develop proposals that address the local needs of parents and families affected by illicit drug use.

In addition, the Australian National Council on Drugs is providing FaCS with advice in relation to each of the proposals submitted.
This is to ensure that there is a clear opportunity for a non-government perspective to be considered for each 32 proposal.

While this approach is more time intensive, it allows for the development of more diverse and locally appropriate services for families.

Proposals to date outline a diverse range of projects.
For example: • parent education and support programs; • telephone advice and referral services; • on-line information services; • family education drug kits; • training material for service providers; • family support in rural and remote areas; • kinship support services targeted to indigenous families.
3.4 The Child Care Family Crisis Pilots 3.4.1 Background The impetus for these pilots grew out of the Minister for Family and Community Service’s interest in assisting children, particularly in the 0-3 years age group, who are at risk, and concerns about support for the children of parents undertaking drug treatments raised from within the child care sector.
In November 1999 Minister Newman approved funding for Child Care Family Crisis Pilot projects to be implemented in Queensland and NSW, and endorsed further work in other States as similar opportunities arose.

The pilot projects are designed to assist families who are in extreme crisis.

‘Extreme crisis’ can include drug and alcohol dependence, parent/s who are deceased or terminally ill, stress or breakdown in family relationships, or parenting problems.
The projects aim to bring children with particular needs into mainstream child care programs, at no cost to the family (where cost would be a barrier).

With their children in suitable child care, the parents will be able to access family support services such as rehabilitation, parenting skills and legal advice, knowing that their children are being well cared for.

These projects will help link the Government’s Stronger Families and Communities Strategy and the National Drug Strategy.
3.4.2 Project descriptions Projects approved to date include: • • the Young Families Support Project, which began on 17 January 2000 in Townsville and involves a partnership between Centrelink, other Commonwealth and State agencies and child care services.
It will provide a creative early intervention and prevention service for young parents and their children who are experiencing, or are at significant risk of, extreme crisis due to drug dependency, family breakdown or other issues; the Waterloo Parent Resource Program, which began on 27 March at a child care centre located in a housing commission estate.
The project aims to enhance the ability of vulnerable families with young children (below school age) to manage stress factors through the provision of subsidised child care, a facilitated 33 playgroup modelling parenting skills, and support in accessing other services and in building networks in the community; and • a third project which commenced in early May.
The Mirabel Foundation in Victoria will facilitate/broker access of children to a range of support services, depending on their specific needs and circumstances.

The initial target group will be kinship families who have taken on the care of children (aged 6 and under) whose drug dependent parents have left them orphaned or abandoned as a result of parental illicit drug abuse.
A fourth project, recently approved in the town of Onslow in WA, will involve both the local community and the Bindi Bindi Community Aboriginal Corporation.
The project aims to raise awareness among child care services of parents’ specific child care needs, including cultural appropriateness; Other aims include: • • • to negotiate appropriate child care arrangements; to facilitate acceptance of such services within the community as a whole; and to assess the needs of families experiencing difficulties with various health, social and cultural problems, such as drug and alcohol, mental health, domestic violence, and nutrition, as part of a case management approach/program including ongoing referrals and placements.
The project also aims to maintain and build closer partnerships between the three tiers of government, the affected community, community-based organisations and others such as the medical profession, in building stronger families and communities.

An additional project is being developed in the ACT, with possibly one in SA and another in Victoria.

3.4.3 Issues arising from data and experience Some preliminary information is available from the Young Families Support Project in North Queensland.
As at early April, there had been 30 referrals since the project commenced, with 18 accepted into the program, 8 referred on and 4 still to be assessed.

The ages of those referred have fallen in almost equal numbers into two groups: 15-20 years and 21-25 years.

A wide range of brokerage services has been provided including counselling, education support, driving lessons and parenting group referrals.
The majority of contact with the clients is through home visits, with a small number at Centrelink (a separate room is provided).

Good linkages are being forged between the child care pilot and other Commonwealth, State and local government and private referral/support agencies.
The main positive outcome of the pilot to date is improved client ability to deal with past and present emotional problems and stress, including those associated with domestic violence, drug use, parenting issues and financial problems.

In one instance this has resulted in a cessation of drug use, the seeking of a driver’s licence and the taking up of casual employment.
These outcomes have been attributed to attendance at a parenting group and the provision of intensive support through a therapeutic counselling program, aided by the provision of child care as well as the joint support provided by the pilot project and the counselling service.
The case manager has identified the following issues that impact on clients: 34 • difficulties accessing bureaucratic organisations (government and non government) who are perceived as not listening to the client or fully understanding their circumstances, or as giving incorrect and misleading information.
At other times the information provided has been difficult for families to understand, which has resulted in inappropriate follow up; reluctance of young mothers to use child care or other services because of the expectation of being able to cope alone; lack of services to assist young parents with a basic practical understanding of parenting before problems occur; transport availability and cost; • • services unable to respond in a timely and flexible manner to prevent a crisis from • • occurring due to funding restrictions and policy guidelines; • parents unaware of services available to them and how they can be accessed; • reluctance to re-approach services or organisations where there has been a negative experience, thus limiting choices; and • young drug dependent parents’ reluctance to access the service.
There have been a number of referrals; and while the case manager has contacted all of these clients personally, none has kept their interview times.

Home visits are included as an option.

Where clients are not motivated to participate, early intervention is very difficult.

The Alcohol, Tobacco and Drug Service has indicated that their clients are mostly around 30 years of age, and they believe it is at that point clients become motivated.
3.5 Playgroup for drug-using parents The National Council for the Prevention of Child Abuse (funded within the FaCS portfolio) has recently commissioned a study of a playgroup for drug-using parents that is funded by the ACT Government.
A paper by Denton et al finds that the Parents’ and Children’s Clinics, started in the ACT as playgroups in 1990 and ‘run on a shoe-string’, ‘provide effective prevention and early intervention against child abuse and neglect because the staff are a trusted source of referral and advice and because effective parenting skills are both taught and modelled’1 The clinics aim to provide drug-using parents and their children with a ‘relaxed and non-judgemental service that focuses on their health, welfare and advocacy needs’.
As well as providing information on parenting issues and pre-natal, birth and post- natal support, the clinics also provide advice and advocacy on a number of other issues which research shows are likely to be of critical concern to drug users: for example housing, welfare, financial, legal, domestic violence.

1 “A welcome place: A health service for drug using parents and their children nine years on”, National Centre for Epidemiology and Population Health.
35 3.6 Problem gambling 3.6.1 Background The Productivity Commission's Inquiry Report into Australia's Gambling Industries found that around 290,000 Australians are problem gamblers.

In releasing the report the Prime Minister announced that the Commonwealth would respond by taking a leadership role in coordinating a national response to problem gambling.
The Government adopted the Productivity Commission's recommendation to establish a Ministerial Council on Gambling, appointing the Minister for Family and Community Services as the Commonwealth representative.

FaCS' role is to coordinate the Commonwealth response to problem gambling and support the work of the Ministerial Council on Gambling.
3.6.2 Link with substance abuse Although Commonwealth concern is primarily directed at problem gamblers, a broader issue is whether a relationship exists between recreational gambling and the increased consumption of legal and illegal drugs, with a potential for abuse.

Several pieces of research point to the coexistence of gambling and other forms of addictive behaviour.

• The Productivity Commission’s report suggests that many problem gamblers experience other dependencies.
The report cites a number of studies in support of this view.

One Australian study conducted in 1995 (for the Casino Community Benefit Fund Trustees in New South Wales) found that the higher the risk of gambling related problems found in the survey respondents, the higher the risk of hazardous use of alcohol.

• A study prepared in March 2000 for the Victorian Casino and Gaming Authority concluded that some relationship between gambling and alcohol does exist.
The study analysed the 1993-94 Household Expenditure Survey data and found that the incidence of purchasing tobacco or alcohol is almost twice as high for persons that spent money on electronic gaming machines than for those who did not.

The report concludes that even for average gamblers there are increases in complementary expenditures such as alcohol and tobacco.

These results suggest a link between alcohol consumption and gambling activities within licensed venues such as clubs and hotels.
As with other frequently associated risk factors such as relationship breakdown, domestic violence and homelessness, associations between gambling and substance abuse are not clear and evidence of the existence, and the direction, of any causal links is inconclusive.

However, gambling-related problems often do not present as first-order issues for people seeking treatment for other dependencies.
As a result, there appears to be the same issue of significant under-reporting of circumstances where there is a co-occurrence of gambling problems and other dependencies.

Further and more comprehensive research is needed to examine the extent of the relationships between substance abuse (particularly legal substances such as alcohol and tobacco) and gambling, the direction of any causal relationships and the 36 exacerbated social costs that are likely to arise when a co-occurrence exists.
3.7 Commercial sexual exploitation of children 3.7.1 Background On 28 August 1996, the World Congress Against the Commercial Sexual Exploitation of Children was held in Stockholm.

The Congress adopted a ‘Declaration and agenda for action to assist in protecting child rights, particularly the implementation of the Convention on the Rights of the Child and other relevant instruments, to put an end to the commercial sexual exploitation of children and young people worldwide’.
Australia was a signatory to that Declaration and Agenda for Action.

The signing of the Declaration committed Australia to the development of a National Plan of Action by the year 2000.

The Plan is to provide the basis for developing a coordinated cross- sectoral and intergovernmental response to commercial sexual exploitation of children and young people.
FaCS is the agency responsible for the overall production of Australia’s National Plan of Action and for the ongoing monitoring of activities related to the prevention and control of the commercial sexual exploitation of children in Australia.

3.7.2 Research As a first step in developing the National Plan of Action, the Australian Institute of Criminology was commissioned to research the current situation on the commercial sexual exploitation of children and young people in Australia.
The objective of this research (not yet published) was to identify the nature of commercial sexual exploitation of children and young people in Australia, its extent, and factors contributing to the placement of those children and young people at risk.

The research found that, although no single factor could necessarily be identified as contributing inevitably to such exploitation, a major risk factor was family dysfunction.
A significant proportion of children identified as ‘at risk’ has been subjected to physical, emotional and or sexual abuse within the family.

3.7.3 Risk factors The research concluded that there are a number of risk factors, present at various stages of a child’s development, which may contribute to a child’s vulnerability.
These included family breakdown, prior experiences of sexual victimisation, homelessness, poverty, drug use, youth unemployment, a lack of suitable alternative accommodation and social isolation.

The more of these factors that were present, the greater was a child’s or young person’s subsequent vulnerability.
The vast majority of exploited children encountered during the time of this research (June/July 1998) had economically disadvantaged family backgrounds, experiencing multiple risk factors such as family conflict, substance abuse, lack of parenting skills and mental illness.

“The connection between drugs and opportunistic prostitution is a complex one.

Many young people said that they had either ‘worked’ 37 for drugs, or took drugs to cope with having to ‘work’.
Whichever way, young people felt like they were caught in a vicious cycle”2.

The majority of participants agreed that the lifestyle associated with drug use compounded other problems such as unemployment and homelessness.

The types of drug use identified in studies such as undertaken by the Brisbane Youth Services suggests the use of a wide range of legal and illegal substances.

Some of the identifiable drugs included heroin, cocaine, LSD, tranquillisers, barbiturates, marijuana and alcohol.
Often these drugs and over-the-counter medications such as cough mixture and aspirin are used in combination with other drugs such as alcohol.

“It (drugs) functions in a very specific way… It relieves emotional and psychological distress.

Basically it provides emotional anaesthesia.

It can operate to maintain the present-centredness that blocks out the past and helps avoid thinking about the future”3.
The research found that children and young people who are engaging in or who are at risk of commercial sexual exploitation were not a representative cross-section of Australian youth.

Many of these children and young people have backgrounds that can accurately be characterised as disadvantaged and/or dysfunctional.
3.7.4 Future initiatives • The development of more targeted approaches to those programs providing support in managing difficult life transitions such as family dysfunction and breakdown, will be an important tool in decreasing the marginalisation of children and young people who are at risk.

• National and international research has shown that prevention is more effective in the long-term than providing a response only to the immediate crisis.
Australian governments at federal, state and territory level are focused on prevention, on addressing the vulnerability factors that contribute to children and young people being placed at risk.

3.8 Conclusion This chapter has described a number of important initiatives within FaCS that embody the Government’s early intervention/prevention policy focus, the desire to assist individuals and communities to live independent, resilient, economically and socially engaged lives.
All involve substance abuse as one of the variables with which they are working.

In the case of Reconnect, the previous pilot experience already suggests some areas for further exploration.

As the various initiatives described in this chapter develop further their activities will yield important insights into issues relating to the provision of services in areas where substance abuse is part of a linked set of problems affecting an individual and his or her family.
Because these services are designed to be 2 Brisbane Youth Service, Between a Rock and Hard Place 3 Burdekin Report, 1989 38 responsive to the community context in which they operate, their activities will equally highlight the roles that different communities can play in assisting those of their members who are substance abusers, and thus strengthen the community as a whole.
Given the multi-dimensional, holistic responses that are necessary for effective interventions with substance abuse, the services will also do much to develop model pathways for better coordination between all kinds of government and community service providers.

The learning from these services can then be drawn upon by other agencies to modify their own practices.
39 Chapter 4 TOWARDS A COMPREHENSIVE SERVICE RESPONSE – ISSUES FOR CONSIDERATION 4.1 Introduction FaCS’ experience has highlighted a number of issues which need to be understood in pointing the way to an effective service context for addressing the impact of substance abuse on families.
This chapter summarises the themes where there is convergence between research and the FaCS and partner agencies practice experience around substance abuse and suggests some implications for a comprehensive service response.

A comprehensive and coordinated service system to manage the complex functional and clinical issues around substance abuse will necessarily be based on broad partnerships across portfolios, levels of government and communities, and be larger than the interests of any single department.
4.2 Community attitudes Community attitudes to the use and abuse of tobacco, alcohol, prescription drugs and illicit substances create a context which colours the way in which society defines and responds to the issues.

This in turn influences the way in which services are planned and delivered and families and individuals affected define their needs (or have them defined).

There are conflicts and inconsistencies inherent in this context, which need to be managed.
Community attitudes to substance use and abuse are significantly value laden.

The legal status and ready availability of alcohol and tobacco products reflect their general acceptability in the community.

However the increasing restrictions being placed on smoking in public places indicates the beginning of a change in attitude to tobacco use in a delayed response to the evidence of significant health risks and costs associated with active and passive smoking.
There are strong cultural dimensions to the use/abuse of alcohol and tobacco and the way these are perceived in the community.

For example, excessive consumption of alcohol is perceived as a ‘rite of passage’ for young men and celebrations and disappointments are routinely marked by the consumption of alcohol.

Advertising continues to make subliminal and overt connections between alcohol and social status, success and desirability.
However, community acceptance of even moderate smoking and drinking by adults is strongly qualified if the income of the user is not sufficient to support their levels of use.

The legality of the substance being used and/or the extent to which its use is seen as a 40 threat to the safety or wellbeing of the general community is much more likely to evoke a consistently negative community response (although not necessarily a change in individual’s behaviour).
This is evidenced by responses to alcohol-related road deaths, and the concerns about increased levels of crime against property perceived to be prompted by the need for money to support drug habits.

Conflicting views of parents and young people about the perceived problematic nature of substance usage can be as significant a source of conflict within family relationships as the usage issue itself.
Often the young person raises this as an issue but the substance consumption is denied or minimised by other family members.

“Some parents do not consider it to be a problem to drink 6 to 7 alcoholic beverages per night.

Whereas the young person might.” “Parents do not often associate their usage to the young person's usage.

The difference is that young people would smoke 20 cones [of cannabis] and the parents would smoke less.
Parents have less tolerance for this.” Reconnect service case study Service responses may also be conditioned by value judgements in respect of the substance use.

For example, recreational use of illicit drugs such as marijuana is often perceived as a ‘gateway’ to harder substance abuse.

While there is some research evidence to support the link, the relationship is not clearly established.
There is a body of anecdotal evidence which suggests that this has resulted in inappropriate referrals of young people into drug and alcohol rehabilitation programs, when a more appropriate response might have been to undertake education into patterns of behaviour.

4.3 Reconceptualising the issue Because substance ‘abuse’ can be a matter of subjective judgement, it may be more useful to draw the distinction between appropriate and inappropriate use of substances.
This terminology avoids the value judgement implicit in the notion of abuse and enables the individual’s behaviour to be measured according to the extent to which it significantly hinders their capacity to effectively manage day-to-day responsibilities including employment, parenting, education, community participation and self-management.

A functional definition of inappropriate use may also serve to identify effective points of intervention and contribute to the issue being approached in a holistic way.
4.4 Substance abuse is part of a complex interaction of risk factors Emerging from both external research and available data and case studies from within FaCS is a clear indication that substance abuse is rarely an isolated problem for an affected individual, but typically exists as a part of a complex pattern of interacting 41 risk factors embracing the individual, family and community.
Importantly, there is rarely a simple linear relationship between the substance abuse and other issues and behaviours, and effective service responses need to recognise the complexity of these interactions.

Less clear is the extent to which there are direct causal relationships between the interaction of risk factors and the development of addictive behaviours, which might pinpoint the life transition points and service responses which constitute effective interventions.
Substance abuse is an issue which affects all sectors of the community, although it is likely to impact most heavily on those families and individuals who are already vulnerable from other environmental factors such as poverty, unemployment and isolation.
4.5 A disproportionate impact on low income families As the costs of alcohol and tobacco products increase with the rising tariffs aimed at discouraging use, low income families will spend an increasingly disproportionate amount of their income on these products.

A study published by NATSEM in 1997 (Harding and Percival) showed that people in the lower income ranges spend proportionately more on tobacco than those in higher income ranges.
For example, those in the lowest income decile devoted an average of 1.89% of their household expenditure to tobacco (5.59% in smoking households), compared with 0.73% amongst all households in the highest income decile (2.23% among smoking households).

The same trends are shown for ‘per person’ expenditure as for households.

A comparison of expenditure from between 1975-76 and 1993-94 showed that only the lowest decile increased their overall expenditure on tobacco in that period.
Among smoking households, those in the lowest income decile were estimated to spend around $22.05 a week on tobacco products in 1993-94.

This is likely to place substantial pressures on the weekly budgets of households that are largely dependent on income support payments.

For users with insufficient income it may be a choice between food and cigarettes/alcohol - this may mean families go hungry.
To address this, many agencies distributing food vouchers to those in need endorse vouchers to exclude access to cigarettes and alcohol.

Yet low income families will also be among those least likely to afford the costs of supports available for changing their behaviours.

A man in his 40s is receiving the disability support pension and is addicted to prescription drugs.
His addiction has caused him to borrow money at high rates of interest and he is getting more and more into debt with a growing hopelessness about his situation.

Centrelink case study 42 Centrelink social workers also indicated that many of their customers experiencing extreme financial hardship will raise their own or their partner’s substance abuse as a contributing factor in falling behind with rent and accumulating debts.
Some customers report having sought assistance so often from so many emergency relief agencies that they are unable to obtain any further assistance.

People on payments with activity test obligations are reported as being particularly vulnerable to reduction or cancellation of payments because of failure to meet activity test obligations.

These frequent changes to their financial circumstances further exacerbate their financial hardship.
4.6 Violence against women The 1996 ABS report, Women’s Safety, examined women’s experience of violence from any source, including recent violence (defined as occurring within the previous twelve months) and over their lifetime since the age of 15.

Violence was defined as the occurrence, attempt or threat of physical or sexual assault.

The survey provided an analysis of the experience of violence by the relationship of the victim to the perpetrator, including violence by current or previous partners.
The report showed that the presence of alcohol was a significant factor in the experience of violence from a man, with 41.1% of physical assaults and 38.1 % of sexual assaults occurring in a context where alcohol was involved.
Women who experienced either physical or sexual assault by a man other than their partner were most at risk in a home, with licensed premises being identified as the second most dangerous location (22.8% of recent physical assaults and 21.3% of sexual assaults occurred in licensed premises).

These were also by far the most common location for assaults on women by women (37.1%).

A 65 year old woman is caring for her three grandchildren as a result of the ongoing substance abuse of her adult daughter.
The woman supports the children on her single rate aged pension, as she is frightened of confronting her daughter about the financial support issues.

The daughter has been violent to her mother in the past.

Centrelink case study 4.7 Domestic violence Alcohol abuse remains the most significant, but not the only substance abuse issue in the area of domestic violence.
The link between domestic violence, family breakdown and substance abuse has been well established and the experience of Centrelink social workers substantiates this connection.

The extent of the links between domestic violence and family breakdown are captured in the 1998-99 SAAP National Data Collection.
Data identified domestic violence as the main reason for seeking SAAP support for 23.7% of all clients, with 11.8% citing relationship and family breakdown and a further 3.2% physical and emotional abuse as the main reasons.

43 Once again, care needs to be exercised in seeing the relationship between domestic violence and substance abuse as causal, but it is certainly a significant factor in the equation.
One social worker commented that in her ten years in Centrelink, over half of the customers requesting an exemption from pursuing child support action on the grounds of violence also referred to the alcohol related problems of the non custodial parent.

4.8 Links with mental illness There are established links between substance abuse and mental illness.

In some forms of psychiatric condition there is a direct causal relationship as the condition may be triggered by substance abuse.
Research and the qualitative evidence of service providers both support a frequent association of mental illness and substance abuse.

A new perspective on these links with mental health is provided by evidence of the use of licit and illicit drugs to manage both the symptoms of the condition and the side effects of prescribed medication for the treatment of certain forms of mental illness.

4.9 Homelessness Substance abuse has long been recognised as a significant factor in homelessness.
In some cases an individual’s substance abuse problem can disrupt their life sufficiently to lead to homelessness, while in other cases substance abuse can exacerbate other problems and lead to homelessness.

The report Down & Out in Sydney highlights the prevalence of mental disorder, disability and health service use among homeless people in inner Sydney1.
This report identifies that 49% of men and 15% of women in this group have an alcohol use disorder, while the expected prevalence rate in the general population is 9% and 4% respectively.

In addition, 36% have a drug use disorder, in contrast to an expected prevalence rate in the general Australian population of 2%.
4.10 The indigenous experience of substance abuse Perhaps the most compelling evidence of the interaction of multiple risk factors including substance abuse to create complex disadvantage is contained in the experience of indigenous communities.
There is evidence to suggest that indigenous people suffer depression at a higher rate than non-Aboriginal people; that rates of self-harm and suicide are higher; and that substance abuse, domestic violence and child abuse contribute additional risk factors.2 1 Tracey Hodder et al, 1998 2 Homelessness in the Aboriginal and Torres Strait Islander Context, and its possible implications for SAAP, Final Report, 1998, p 86.
44 A number of alarming anecdotes highlight the impact of substance abuse on indigenous people and communities.

For example: • Child neglect and abuse may result as children are left to fend for themselves whilst their parents spend time in local clubs and pubs.

As a result it was found that a number of youth SAAP services were supporting school children and their younger siblings after school as parents were occupied in the local pub.
In some rural areas, a significant number of children do not attend school, or where they may have attended, drop out at a very young age.

Indigenous women have identified that a common practice among some mothers to soothe babies and get them to sleep has been to dip rags in petrol and tie them onto babies’ jumpers.

• • • The practice of hanging a tin filled with petrol around a person’s neck is not uncommon, presumably to leave the hands free to attend to tasks while sniffing.
Many of the people who do this are children.

As an example of the impact, the local school principal in one area of regional NSW identifies that the top three health issues for the area are drugs and alcohol, petrol sniffing and mental illness.

The age expectancy for indigenous people in the area is 33 years.

• Women and children may be forced to leave the family home due to domestic violence situations, often exacerbated by excessive substance usage.
In some towns, it is generally expected that incidents of domestic violence will be higher on pension days when individuals can access funds to finance their drug and/or alcohol dependency.

These issues are typical of the experiences of indigenous communities throughout Australia.

Solvent sniffing appears to be a significant problem among isolated Aboriginal communities, where it has major health and social implications, particularly as the people becoming addicted to this are so young.
To compound the matter, it has been suggested that this addiction is harder to break than other more commonly understood forms of abuse such as alcohol and heroin.

High levels of substance abuse among young people between the ages of 6 and 21 in communities are often accompanied by nightly violence and lawbreaking which the communities have no resources to alleviate or manage.
In some cases problems of drug abuse are aggravated by lack of adult supervision and the absence of any indoor recreational facilities to provide a focus for young people’s activities during months of the rainy season.

Substance abuse leads to high levels of incarceration among indigenous people.

This results in a whole range of social issues for the individual concerned, their family and dependents, and their community through the loss of social capital.
4.10.1 Indigenous responses Indigenous communities tend to seek their own solutions to substance abuse among their members, partly because of a ‘shame factor’ associated with revealing these issues outside the communities in seeking help from external services.

The lack of indigenous counsellors trained to handle substance abuse issues creates significant pressures in communities trying to deal effectively with complex issues from within their own resources.
45 Some responses which have been tried include: • the use of volunteers to pick up substance users at night and take them home or to a shelter, thus avoiding involvement with the police and the criminal justice system; removal of young drug users to outstations for cultural teaching • Indigenous families will also take responsibility for feeding, housing and supporting individual users and their children, creating further pressures in communities with high existing levels of poverty.
In a number of communities elders are concerned about payment of income support to young drug addicts without any obligation to take part in programs to deal with their addiction, and have proposed the redirection of their payments to the family member taking on the responsibility for their support.

4.10.2 The importance of culturally appropriate responses There have been many reports referring to the high levels of substance abuse and violence on remote Aboriginal communities.
These reports commonly stress that the breakdown of traditional Aboriginal culture is the primary reason for the breakdown of family, child abuse and neglect, substance abuse and violence.
As an example of the kind of culturally based responses made by communities, ensuring children learn about their culture and law is one of the key early intervention and prevention strategies to prevent violence and substance abuse in their community which has been identified by the Anangu women of the NPY lands (located in the cross border region of WA, SA and NT).
This very much supports the principles of the Aboriginal Child Rearing Strategy, and the innovative services FaCS is funding in remote Aboriginal communities.

To be effective, it is important to overcome the overwhelming influence of the dominant culture that is inherent in all service structures in remote Aboriginal communities.

For example, the primary early learning environment for Aboriginal children is mainstream education.
Early childhood services need to be about strengthening Aboriginal culture, so that Aboriginal ways are considered to be of equal or superior value to those of the dominant culture.

This population has continued to challenge mainstream service delivery.

It is increasingly apparent that the matter of ‘cultural appropriateness’ is fundamental to the success of the program.
4.10.3 National Indigenous Substance Misuse Council As a result of significant concerns expressed by agencies with a substance abuse focus, a national body to voice the issues was formed.

In May 2000, a conference was held in Adelaide and the National Indigenous Substance Misuse Council was elected.

Approximately 50 community organisations were represented at the conference, as well as state government agencies and the National Drug Research Institute.
Some of the concerns of the Council are: • substance abuse is currently discussed within a general health framework.

Health issues are so critical that substance abuse becomes a small part of a larger agenda 46 and does not get the attention it needs.
There is a strong feeling, therefore, that substance abuse issues have been neglected even though the impact on individuals and communities is vast; • substance abuse programs have continued to focus most strongly on alcohol while the nature of abuse is changing to polydrug use, and different forms of substances, for example glue, speed and heroin; • agencies and programs set up specifically around substance abuse are associate members (therefore non-voting members) in state health fora and partnerships; • National Aboriginal Community Controlled Health Organisations (NACCHO) have membership from Aboriginal medical services; therefore community- controlled substance abuse programs cannot be members; the single biggest gap identified in substance misuse programs is rehabilitation centres.
• Funding for substance abuse programs is $17 million per year and this includes research.

There are 70-80 programs run nationally.

4.11 Under-reporting of the incidence of substance abuse There is currently very little statistical evidence of the incidence of inappropriate use of substances among clients of the FaCS income support programs.
For example, while psychological/psychiatric medical conditions account for the second largest category of disability support pensioners (around one-fifth), there is no data available on the prevalence of substance abuse within this group.

This is notwithstanding the rich body of anecdotal evidence and case studies available which support a strong correlation between the two.

There are a number of reasons for the scarcity of data and under-reporting.
If an individual or family experiences multiple forms of disadvantage they are likely to define their own needs in terms of the issue most likely to gain them access to a payment or service.

If the substance being used inappropriately is also illicit there may be perceived risks of other consequences flowing from the disclosure, including involvement of the police, child welfare agencies or the juvenile justice system.
There is a very substantial body of qualitative evidence, however, which suggests that under-reporting derives from the often well founded fear of being excluded from a service.

There are, of course, real practice issues in mainstream services about the training and skills needed to manage people with complex needs who may manifest anti-social, disruptive or violent behaviour.

Some innovative responses being introduced are discussed more fully in chapter 2, section 2.3, Emergency Relief.
People with combinations of mental health and substance abuse problems appear to be particularly at risk of exclusion from services.

The presence of substance abuse is a common ground for refusing mental health services, matched on the part of alcohol and drug rehabilitation services if a psychiatric condition is also present.

47 An 18 year old man with a diagnosis of schizophrenia who uses heroin daily.
The man was refused any support by the local mental health service because of his substance abuse and is now in gaol after repeated property crimes.

Centrelink case study The most comprehensive statistical information about prevalence of substance abuse among FaCS’ client groups emerges from the crisis services arm of the Department’s operations, particularly the SAAP program.
The SAAP data very clearly substantiates the complex patterns of disadvantage experienced by SAAP clients of which substance abuse may form a part.

Significantly also, the prevalence of data emerging from what are essentially ‘services of last resort’ may reflect the end point in a trend of non/under-reporting of the substance abuse which continues as long as there is the possibility of other service options being available.
Alternatively, at the point of access to crisis services, the substance abuse issue may have become the most pressing problem for the client.

4.12 A holistic approach to service and the need for linkages A twenty-one year old man on Newstart Allowance lives in a rural area and has to travel to the nearest regional centre for his daily methadone treatment.

Travel costs alone use up over half his payment and he is finding it increasingly difficult to look for work.
Centrelink case study A consistent theme from both human and community service practitioners relates to the importance of engaging the individual or family affected by substance abuse at the point where they present.

This means beginning intervention around the presenting issue as defined by the client and progressively moving to engage with the substance abuse and any other issues.
It may also mean being prepared to offer an outreach service to meet the client at the physical location in which they present.

The consequences of discontinuities in the system can be very significant for a vulnerable group of people as the above case study illustrates.
The continued engagement of clients, supported to the point of motivation to begin to deal with their substance abuse by positive interventions in some other life domains, can be placed at risk due to the absence or inappropriateness of services or the inability to negotiate access to services, particularly of a specialist health or clinical nature.

Furthermore, contact with any service system is often tenuous at best for people affected by substance abuse.
A premature referral to a specialist alcohol and drug rehabilitation service or exclusion from a service until the substance abuse issue is addressed may mean that the contact and opportunities for intervention are lost altogether.

Effective linkages are an integral part of delivering a comprehensive service response.
Through its direct service delivery arm and its service partnerships with other levels of government and with community agencies, FaCS is already a gateway to a number 48 of entry points in the service system for individuals and families affected by substance abuse.

The Department is now moving to a more active and formalised brokering of services and case management in several program areas.
Funding partnerships such as the arrangements supporting the new measure described in Chapter 3 to support families coping with illicit drug use, which build on FaCS’ role in promoting stronger families and communities, suggest a possible future direction for new service development.

The whole of community approaches which characterise many indigenous responses to substance abuse may contribute insights for a broader service orientation.
Initiatives to be funded under the Stronger Families and Communities Strategy may also serve as models of innovative solutions in this emerging area of social policy.

Research findings and action learning from program delivery both point to the need for broad ranging coordination to create a comprehensive service system around individuals and families affected by substance abuse.
One approach to achieving a comprehensive response might be for FaCS and its portfolio and partner agencies to collaborate on a system of formalised protocols to ensure consistent management and referral of individuals and families affected by substance abuse.

This would complement the partnership initiatives under the auspices of the National Drug Strategy.
The protocols approach would enable more comprehensive definition of the necessary linkages and service partnerships, and lend authority and consistency to the processes of cross-referral and case management which are currently being pursued by FaCS and other partner agencies to varying degrees through existing and early intervention program structures.
It builds on the work currently being undertaken by Centrelink (and informing Centrelink social work practice) to develop service delivery approaches based on the life events model.

A protocols approach would address the staff training issues necessary to create within services a network of deliberate scrutiny which would more reliably identify people with substance abuse issues among a range of presenting problems.
It would also make more explicit the role of various community “gatekeepers” who might be involved in implementing holistic responses.

Ultimately the scope and complexity of the substance abuse problem and the broad linkages required across a disparate range of services including health and specialist health services, education and the criminal justice system may also require Commonwealth leadership in a process of articulating pathways for this group.
This would need to be done in partnership across portfolios and levels of government and involving the broad social coalition.

The approaches to policy development in the areas of youth and family law transitions may yield valuable insights to the application of the pathways concept around substance abuse.
49 4.13 Conclusion Drawing both on research findings and the experience deriving from FaCS program activities, this chapter has developed some of the key intersections between substance abuse and other significant social issues.

The description of indigenous substance abuse problems forms a kind of case study of how the issues intersect and the significant damage that can accumulate in individuals, their families and their communities.
Despite the difficulties substance abuse creates for them, Aboriginal communities demonstrate, in their whole of community responses, the potential of the policy emphasis on reciprocal strengthening between families and communities.
The final part of the chapter proposes in general terms some characteristics of a possible model for service delivery and suggests Commonwealth leadership in developing protocols and a pathways approach around substance abuse as offering a framework for consistent and comprehensive support.
50 Chapter 5 ESTIMATING THE PREVALENCE AND COST OF SUBSTANCE ABUSE AMONG FaCS CLIENTS 5.1 Introduction The social and economic impacts of substance abuse on families are far reaching and emerge clearly from the qualitative information provided in this submission.

However, establishing the costs of substance abuse in terms of FaCS program outlays is more difficult.
Both the research and practice experience demonstrates that substance abuse is usually part of a multi-dimensional set of issues for an individual or family.

The coexisting issues may well be linked, but not necessarily in a clear causal way.

And in the case of most FaCS programs, the substance abuse will not be the presenting issue.
Therefore, with the exception of the costs that can be attributed to clients of the SAAP program, where a cohort of clients can be isolated as largely in need of assistance because of substance abuse, and those programs specifically supporting families affected by illicit drug usage, it is not possible to measure empirically the extent to which substance abuse translates directly into program expenditure, nor to conclude that its absence would result in savings.
Under reporting of substance abuse also increases the likelihood that cost estimates will be understated.

5.2 Prevalence rates from research Research by the AIHW has estimated that 17.6% of Australian men aged 18 years and over and 10.8% of Australian women drink alcohol at levels defined as hazardous or harmful by the National Health and Medical Research Council.

Illicit drug use estimates are more problematic and are likely to be an underestimate.
The National Drug Abuse Information Centre estimated in 1988 that opiate addiction at ages 15-39 years is between 0.5% and 0.8%.

What is not known from these statistics is the extent to which the kind of functional problems defined elsewhere in this submission as constituting ‘inappropriate use of substances’ apply to the population groups identified.
It may be that harmful levels of substance use can be sustained for some time before they begin to impact on family relationships and roles in the community.

More recent prevalence data is provided by the ABS survey, Mental Health and Wellbeing (1997), which suggests that 11% of men and 4.5% of women had a substance use disorder (figures include both alcohol and drug related disorders derived from a range of illegal and prescription drugs).
Alcohol use disorders were about three times as common as drug use disorders.

5.3 Difficulties of extrapolation to FaCS program clients It would be misleading to assume that the same percentages might apply to the population of FaCS and Centrelink clients, and to derive some estimate of the impact 51 on the Department’s outlays from this source.
To do so would assume a causal relationship between the substance abuse and receipt of income support which runs counter to both the research findings and practice observations.

The same concerns would apply to extrapolations made from the group of Newstart and unemployed Youth Allowance clients who are exempt from activity test requirements because of an identified alcohol or drug dependency.
There are 8,500 out of a total of 71,200 recipients of Newstart and unemployed Youth Allowance payments or 1.2 % of the client group exempted on these grounds, with around 6,000 (or 0.8%) identified as drug dependent.

This suggests that the identified substance abuse cost to the Commonwealth for these two payment types alone may be around $68.6 million a year.
However, it needs to be emphasised that this data relates only to people whose substance dependence is sufficiently serious to have been acknowledged by themselves and their medical practitioner as grounds for an exemption from activity testing.
It does not capture the number of income support recipients on these payments who manage to comply with activity testing arrangements despite the presence of substance abuse, or the number on non-activity tested payments with substance abuse problems, including the dependent partners of this group.

In this regard the cost estimate is conservative.


It also needs to be acknowledged that many of these people would still be in receipt of income support payments even if there were no substance abuse issues, given the overwhelming evidence of how substance abuse interacts with multiple forms of disadvantage.

What is highlighted again are the problems of quantifying both the costs and the consequences.
SAAP data provide another perspective on the prevalence of substance abuse among users of crisis services.

In charting pathways to homelessness, the SAAP National Data Collection indicated that 6.1% of SAAP support periods in the 1998-99 data collection were attributable to drug/alcohol/substance abuse as the main reason for seeking assistance, involving 6,710 people.

The proportions were higher for single men (17.6%), whereas for young people they are lower than average (3.1%).
2.5% of all families using SAAP services identified substance abuse as their main reason for seeking support (See table at page 21).

Using data on the provision of drug/alcohol/rehabilitation support services to SAAP clients, it is possible to estimate an indicative cost of Commonwealth expenditure on clients receiving these support services as follows: 1998-99 $8.5m; 1999-00 $9.2m; 2000-01 $10.4m.

Source: 1998-99 SAAP NDCA Report (Australia), Table 5.3, p 78.
This estimate is based on the portion of SAAP support periods for SAAP clients who received drug/alcohol support/rehabilitation support services (6.6%) to total support periods (163,200) provided under the program in 1998-99.

52 SAAP data is subject to the same problems of understatement discussed elsewhere in that it represents only the experience of homeless people using SAAP services and not the entire homeless population.
In addition, substance abuse may also be a contributing factor to homelessness for other SAAP clients who have not identified it as their main reason for seeking assistance.

However, the prevalence among SAAP clients of other forms of disadvantage associated with substance abuse, including family breakdown, mental illness and domestic violence, suggests that people with substance abuse issues may in fact be over-represented in crisis services.
5.4 Conclusion Attempts to quantify the cost of substance abuse to FaCS customers will at best be unreliable because of the following factors: • incomplete data on the extent of the problem for affected individuals, and the inability to track broader impacts on their families in terms of their income support payments and use of services; the problems of under reporting; the difficulties of quarantining costs associated with substance abuse from costs associated with other interventions made, for example, for family relationship support or domestic violence; the absence of a simple causal relationship between substance abuse and expenditure on income support or services.
• • • 53 APPENDIX 1 TERMS OF REFERENCE FOR THE INQUIRY INTO SUBSTANCE ABUSE IN AUSTRALIAN COMMUNITIES In view of the level of community concern about the abuse of licit drugs such as alcohol, tobacco, over-the-counter and prescription medications, and illicit drugs like marijuana and heroin, the Committee has been asked by the Minister for Health and Aged Care, the Hon Dr Michael Wooldridge, MP, to report and recommend on: The social and economic cost of substance abuse, with particular regard to: family relationships; • • crime, violence (including domestic violence), and law enforcement; • • workplace safety and productivity; and • health care costs.
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