Title: Improving Outcomes for Children and Families affected by PATERNAL Substance Misuse: A Feasibility Study of the PARENTS UNDER PRESSURE(PuP) Programme for Fathers
Funder: Chief Scientist Office, Scotland

Abstract: Parental drug misuse is closely associated with poor child development, child maltreatment, and a greater likelihood that children will develop substance misuse problems themselves [7,8]. It is well known that fathers play an important role in child welfare and family functioning [9], and drug problems are far more prevalent in men than women [10]. Failure to involve fathers in family services has been repeatedly highlighted in child abuse inquiries [11]. However, efforts to involve fathers in parenting programmes remains a significant challenge, with services reporting low rates of engagement, especially in regard to fathers with complex needs [12]. Furthermore, there is little data on the effectiveness of mainstream parenting programmes for improving father-child relationships and fathering capacity. Fathers are rarely involved in parenting intervention trials, and where they are, outcomes for fathers are seldom measured or reported [13]. Thus little is known about what kind of interventions specifically for fathers, and services for couples, work best to improve outcomes for children. Only two pilot studies, conducted in the US, have focused solely on substance-using fathers with young children. Lam et al [14], found greater improvements on measures of parenting and child protection involvement when alcohol dependent fathers received a combined parenting and couples approach. Similarly, Stover et al [15] found gains in measures of quality of caregiving in substance-using fathers with a history of interpersonal violence. Notably, this intervention included a focus on quality of the father-child relationship and development of coping skills for impulsive behavior and aggression. In a recent review on parenting interventions which included men as parents or coparents, Panter-Brick et al [13] recommended that future research should prioritise engaging fathers and coparenting couples, examine process and impact data by fathers, mothers, and coparents, and pay greater attention to sustainability, cost, equity, reach and scale-up. Our study is designed to tackle this vital next step in parenting intervention research. Crucially, we will focus on opioid-dependent fathers and their preschool aged children. We propose to undertake a mixed methods feasibility study of the PARENTS UNDER PRESSURE (PuP) programme that has been specifically designed to improve parental emotional regulation and quality of caregiving, thus reducing child abuse in drug-using families. We will recruit 24 families with preschool aged children by targeting fathers in treatment for opioid addiction. PuP is 24 week home-visiting programme that places an emphasis on the quality of the caregiving environment and the parent’s capacity to provide a safe and nurturing environment. PuP moves beyond teaching ‘parenting skills’ to address dysregulated affect through the use of mindfulness exercises and other emotion regulation strategies. PuP will be delivered by eight PuP practitioners employed by two non-NHS agencies. Our innovative study will determine: the potential pool of eligible fathers/families; successful recruitment strategies; acceptability of outcome measures; up-take, retention, completion and follow-up rates; and acceptability of PuP among parents, staff and services involved with the programme. The AIM OF OUR STUDY is to estimate the parameters needed to design a pilot RCT and viable, sufficiently powered full evaluation, including an economic evaluation.

Lay abstract: WHY WE NEED THIS RESEARCH Around 350,000 children in the UK are living with a parent who has a serious drug problem [1]. Research shows that these children often suffer abuse and neglect [7]. Health and social care services have a responsibility to help children at risk of abuse and provide additional support to parents who need help to look after their children. Strategies include engaging families in parenting services and helping parents access drug treatment. To date, parenting services have focused almost entirely on drug-using mothers [2,3]. However, children in the UK are as likely to be living with a drug-using father as a drug-using mother [1]. Studies also show that drug-using fathers can pose a serious risk to children and mothers [4]. Parenting research on fathers, especially fathers with a drug addiction, is very limited. Most studies exclude fathers, have not made a concerted effort to involve them, or do not report father-specific results. One promising programme, called ‘Parents under Pressure (PuP)’ http://www.pupprogram.net.au/, has been specially designed for drug-using parents [28]. Developed in Australia, PuP has been shown to improve parenting and child welfare and reduce drug use [5], but studies so far have not focused on fathers and coparenting. A recent evidence review [13] recommended that this is a vital next step in parenting research. However, before carrying out a large study to test PuP, it is essential to know: •If PuP is acceptable and helpful to drug-addicted fathers and their families •Whether PuP can be established properly within social work and charitable sector services •If fathers can complete the correct tests, and in enough numbers, for a future evaluation. THE INTERVENTION PuP is a 24 week home-visiting service which aims to reduce child abuse. It involves a 2 week assessment, a personalised plan for the family, and 12 learning ‘modules’ where parents practice good parenting skills (e.g. mindful child play, dealing with stressful situations, managing emotions, coping with relapse, improving social networks). It involves the use of parent workbooks and an online tool and will be delivered by trained PuP practitioners. THE STUDY involves two parts: 1) a focus on testing how well PuP can be put into practice with drug-addicted fathers and their families, and 2) a focus on whether we can test how effective PuP is with these fathers in a future study. PART 1: We will establish how many fathers in NHS drug treatment could take part in the study. Then we will invite 24 fathers and their families to join. Before starting PuP, we will interview parents separately to find out about their current knowledge and use of family support services. We will interview parents, PuP practitioners and referring staff to evaluate how well the programme is working. PART 2: We will also ask parents to complete several measures to assess parenting, child welfare, family relationships and functioning, and their substance use. This will be done three times: before starting PuP, at the end of PuP, and 6 months after families finish PuP. We will also collect information to establish whether it is possible to measure how cost effective PuP is in a later study. Our multidisciplinary research team and Steering Group, including drug-using parents, will help to conduct this study and present findings to a wide audience. Results will inform decisions about a future study.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH