Piloting PERCS: An early intervention and prevention strategy for children living with violence and parental substance use
Emerging Minds, Australia, December 2020
Emerging Minds (EM)’s family and domestic violence (FDV) and alcohol and other drug (AOD) use conversation guides (PERCS-FDV and PERCS-AOD) aim to provide a set of questions that will support practitioners to consistently ask about children’s social and emotional wellbeing when working with parents who are perpetrating or being subjected to violence, or using alcohol or other drugs in harmful ways. This pilot involved semi-structured interviews with 19 practitioners across eight services (13 from FDV services, six from AOD), to evaluate the contribution PERCS-FDV and PERCS-AOD made to their self-assessed level of understanding and confidence in child-focused practice where there is FDV or parental substance use. Interviews were conducted before the practitioners used the conversation guides, and after they had been using them for three months. The evaluation showed that, after regularly using the guides, practitioners overwhelmingly reported increased confidence and were more consistent in asking questions about children’s wellbeing. There were numerous insights provided by the practitioners that require further interrogation.
‘Women and children don’t necessarily go to domestic and family violence services. It is, in fact, the last place they want to go.’ – Meghan Hughes, Executive Manager – Strategic Projects, Women’s Safety Services (South Australia)
‘We often think about the men’s behaviour change as being the only space where work with men happens. I think in reality it’s the minority of where the actual work happens. There’s a huge amount of people working with men using violence in other contexts, or who have had supportive conversations that have nudged the guy in the direction towards maybe thinking about his own behaviour.’ – David Tully, Practice Manager, Specialist Family Violence, Relationships Australia (South Australia)
‘If I had been able to tell my story someone could have seen that my children were my motivating factor for why I wanted to quit.’ – Phoebe, Emerging Minds Child and Family Partner
‘Clients do want to talk about their children, whether they are in their lives or not. They do want to talk about the kind of parent they want to be and be supported in that.’ – Suzie Hudson, Clinical Director, Network of Alcohol and Other Drug Agencies
The PERCS conversation guides have been designed by Emerging Minds to support practitioners to have child-focused conversations with parents affected by FDV – either as perpetrators or victims – and/or substance use. The name incorporates five domains of a child’s life:
- Parent-child relationship;
- Emotions and behaviours;
- Communication and meaning-making; and
- Support networks.
The guides have been adapted from Let’s talk about children (Let’s Talk): a brief, evidence-based method that supports professionals in their work with parents who experience mental illness, focusing on parenting and their child’s needs.
The PERCS-FDV and PERCS-AOD conversation guides were launched as part of the 2019 e-learning courses, Family and domestic violence and child-aware practice and Parental substance use and child-aware practice.
Australian studies show children’s mental health conditions are increasing, while a lack of access to supports is leading to poorer social and economic outcomes for these children (Lawrence et al., 2015; Segal, Guy, & Furber, 2017).
Children who live in a climate of fear, coercion, intimidation or threats, or with one or both parents who are using substances regularly or harmfully, are more likely to experience negative outcomes in social and emotional development and disruption to their relationships, education, routines, consistency and safety (Roberts, Campbell, Ferguson, & Crusto, 2013; Roche et al., 2014; Mohammad, Shapiro, Wainwright, & Carter, 2015;). They are also more likely to experience verbal abuse, inappropriate behaviour, and unsupervised or unsafe situations (Laslett et al., 2015).
These circumstances can have marked effects on children’s mental health, resulting in behavioural, emotional or cognitive problems (Moore, Noble-Carr, & McArthur, 2010). Negative outcomes are more likely to occur if service systems are unable to identify children’s risk early, and do not proactively seek to negate the effects of FDV and parental substance use on children. The ability of all services to identify and respond to circumstances that put children at risk has been at the forefront of contemporary child protection policy development in Australia (Council of Australian Governments [COAG], 2009a, 2009b).
Recent research and adult and family service data has confirmed what many practitioners have long understood: parents (particularly disadvantaged mothers) who attend services often experience co-existing issues including substance use, child protection involvement, mental health difficulties, poverty, family and domestic violence, and a history of trauma (Bromfield, Lamont, Parker, & Horsfall, 2010; Heward-Belle, 2017). Many of these parents have had their first child at a young age, without the social structures or parental relationships to support nurturing relationships with their own children (Early Intervention Research Directorate, 2019).
Practitioners who are attuned to presentations of FDV and the ways in which parental substance use can intersect with other socio-economic disadvantages, are well-placed to provide critical prevention and early intervention support for children’s safety and mental health (McIntosh, Wells, & Lee, 2016; Wells, Lee, Li, Tan, & McIntosh, 2018). The PERCS conversation guides help practitioners to consistently ask questions about the important domains of a child’s life, where they know or suspect the child is living with a parent who is perpetrating or experiencing FDV or using substances at harmful levels.
The PERCS pilot evaluation included interviews with 19 practitioners both before and after their use of the conversation guides. The pilot aimed to understand the contribution the guides made to practitioners’ work with parents; in particular, their ability to consistently ask about the effects of FDV or parental substance use on the child. Practitioners were asked a series of questions about their understanding of FDV or parental substance use; their practice in engaging fathers who were perpetrating violence, mothers who were experiencing violence or parents who were using substances at risky levels; and their strategies for asking child-focused questions.
In 2013, Emerging Minds (then the Australian Infant, Child, Adolescent and Family Mental Health Association) worked intensively with adult mental health services and parents with lived experience of mental illness to develop the Let’s talk about children (Let’s Talk) e-learning course into the Australian context. The course was adapted from the ‘Let’s Talk About Children’ materials originally developed in Finland by Professor Tytti Solantaus for the National Institute for Health and Welfare. ‘Let’s Talk’ is an evidence-based intervention for adult mental health professionals. It supports practitioners to focus on the effects of parental mental health on the child and work with the parent to explore the parent-child relationship.
‘Let’s Talk’ has been implemented intensively in adult mental health and drug and alcohol services in Australia and abroad. However, like other interventions seeking to bring family-focused practice into adult-focused services, ‘Let’s Talk’ has faced a number of barriers to consistent implementation, including time and resource challenges (Allchin, Goodyear, O’Hanlon, & Weimand, 2020).
In 2018, Emerging Minds conducted an intensive needs assessment in adult-focused services, analysing their ability to provide an early intervention and prevention focus for children’s mental health. Practitioners’ responses indicated they were challenged by time restraints, confidence, and a lack of clear guidelines for regularly incorporating child-focused questions into their work with adults.
Time restraints and the adoption of other mechanisms that prompted child-focused questions were commonly reported as barriers to the use of ‘Let’s Talk’ during Emerging Minds’ consultations 2013–2018. At the same time, a co-design process was being undertaken with 12 general practitioners across Australia, to develop a tool that would support child-focused practice with patients who presented to doctors because of adult adversity. General practitioners were also aware of their time restraints and advocated for an intuitive and efficient conversation guide that would prompt them to ask parents about how their experience of adversity was affecting their children.
In 2018, the PERCS conversation guide for general practitioners was launched as part of the e-learning course, Supporting children’s resilience in general practice.
Feedback from GPs suggested the guide would be particularly beneficial when working with parents who were affected by both substance use and FDV, and its development became the catalyst for an intensive period of consultation. Emerging Minds worked in partnership with the Flinders University Social Work department, non-government organisations, and parents with lived experience to explore the possibility of adapting the PERCS conversation guide to support generalist and specialist practitioners working with parents affected by FDV or substance use. The aim was to develop a series of questions which supported conversations with fathers whose perpetration of violence was adversely affecting their children, mothers whose ability to parent was being negatively impacted by FDV, and pregnant women and parents whose substance use was taking a toll on their child.
It should be noted that the conversation guides are not intended to teach generalist practitioners to be specialist family violence workers or to become specialists in working with substance use.
The PERCS conversation guides
The PERCS conversation guides explore the five domains of a child’s life:
This domain recognises the importance of a safe, secure, responsive and nurturing relationship between a child and a parent/adult caregiver.
The parent-child relationship is significantly compromised by the father’s use of violence or the parent’s use of substances.
When working with a mother, explore the effects of the violence or substance use on the mother-child relationship, and how she has responded to protect this relationship (despite the violence).
When working with a father, seek to understand what he wants for his relationship with his child, and how the violence/substance use gets in the way of this.
Emotions and behaviours
Children need to feel loved, safe and nurtured. They also need to be able to express emotions and have these emotions listened to, and responded to, in a nurturing way. Strong worries or emotions in a child’s life will often present as behaviours.
Children’s emotions and behaviours are significantly affected by the father’s use of violence/parent’s use of substances.
When working with a mother, explore what they have noticed about their child’s emotions and behaviours – how they have been affected by the violence/substance use, and how she has responded to this (despite the violence).
When working with a father, seek to understand how he interprets his child’s emotions and behaviours, and whether he is able to respond to these safely.
Routines are daily activities which can support areas of children’s wellbeing – from shared activities such as reading, to expected meal and bedtimes. They provide the child with a stable foundation, especially in times of adversity.
A father’s use of violence/parent’s regular or harmful use of substances is likely to significantly disrupt children’s routines.
When working with a mother, identify the routines that are important to her and her child, and how these have been affected by the violence/substance use.
When working with a father, seek to understand what he is noticing about the effects of his violence/substance use on his child’s routines.
Explore with both parents what they can do to help establish or reconnect the child and family to these routines.
Communication and meaning-making
Respectful and effective communication enables children to express thoughts and emotions and make meaning from any experiences.
Children’s abilities to communicate their thoughts and feelings and make sense of their experiences are significantly affected by the father’s use of violence/parent’s use of substances.
When working with a mother, explore how her child has made sense of the violence/substance use issues, and how she might have supported the child to not blame themselves.
When working with a father, explore how he can understand his responsibility for the violence, and understand that this responsibility should never be directed towards his child.
Safe and supportive networks beyond their immediate family can be a key protective factor for children’s social and emotional wellbeing. It is important for children to have many sources of adult support in their lives, through networks which provide them with consistent, positive and strengths-based messages.
The negative side effects of FDV and substance use (e.g. feelings of shame, fear of judgement, mood swings, depression, anxiety) can isolate the mother and child (in the case of FDV) or cause parents to withdraw from their extended family and friends, eroding their child’s support networks.
When working with a mother, explore what support networks exist for her child, despite the violence/substance use, and how these networks might support the child’s social and emotional wellbeing.
When working with a father, seek to understand how important he thinks support networks are for his children, and how his use of violence/substance use might impact these supports.
Eight services in three government and two non-government community service organisations participated in the pilot. All eight work with adults in the context of family violence or problematic substance use and have an understanding of FDV and substance use presentations and their impact on children. Some services work exclusively with parents, while others commonly work with parents and children together and separately. These services show a commitment to employing prevention and early intervention strategies with parents who are affected by FDV or substance use, in ways that could minimise the mental health risks to children.
Nineteen practitioners with a wide range of practice experience in the sector were interviewed (13 from FDV services, six from AOD). Practitioners described their profession as either social worker, counsellor, AOD coordinator, nurse (complex maternity), therapeutic worker or occupational therapist.
It should be acknowledged that all 19 practitioners were supportive of the understandings that are key to the PERCS-FDV and PERCS-AOD conversation guides: an alignment with gendered understandings of FDV, a harm minimisation and strengths-based approach and a commitment to working with parents in ways that increase the social and emotional wellbeing of children.
All 19 practitioners had the explicit support of their service manager to participate in the pilot; and were supported by supervisory processes which assisted them to reflect on the conversations they were having with parents. Further, all participants worked in services that had developed practice positions on working with families where violence or problematic substance use is present.
Practitioners were divided into two groups according to their sector (FDV or AOD) and initial semi-structured interviews were conducted. Questions were designed to ascertain the practitioners’ understandings of FDV or substance use (depending on their focus) and its impacts on children. Practitioners were invited to share their insights regarding presentations of parents who came to their services, and some of the conversations they currently had about children’s social and emotional wellbeing.
To varying degrees, all 13 FDV practitioners who work with families where FDV is present described the following during the initial conversation:
- They commonly worked with mothers who were or had been subjected to intimidation, control, threats, coercion or violence by a male partner/ex-partner.
- Working with fathers who were practising intimidation, control, threats, coercion or violence was a less familiar area of practice. For some practitioners, this was only occasionally a part of their work.
- A common practice challenge was focusing on the effects of FDV on children, while at the same time not engaging in practices that were inadvertently disrespectful or shaming of parents.
- They had a level of confidence and competence in having child-focused conversations with parents where there was FDV but recognised the potential benefits of using the PERCS-FDV conversation guides in their practice.
All six AOD practitioners felt confident and competent in having child-focused conversations with parents where there was substance use, but recognised the potential benefits of using the PERCS-AOD conversation guide in their practice.
The post-pilot semi-structured interviews explored the practitioner’s
evaluation of the FDV and substance use e-learning courses – in particular, the usefulness of the PERCS-FDV and PERCS-AOD conversation guides in supporting the consistent application of child-focused practice – as well as their perceived confidence and skill levels in asking parents about their children’s social and emotional wellbeing. Practitioners were interviewed about:
- what they noticed about parents’ willingness to engage in conversations about their children’s wellbeing, and the extent to which (in the practitioner’s view) the effects of stigma or shame were reduced;
- the five PERCS domains: what were the most useful aspects of the questions, and what could be changed to make the conversation guide more useful;
- the extent to which the six practice positions advocated by the PERCS guides were useful in supporting child-focused practice; and
- opportunities that arose from using the conversation guides, and what differences (if any) they noticed in the quality of their engagements with parents when they asked about the domains of the child’s life.
Thematic analysis was used to analyse data in the interview transcripts. This analysis seeks to define recurring patterns within data through identifying, analysing and reporting on common themes (Braun & Clarke, 2006). Post-pilot interview transcripts were initially coded for any interesting comments participants made, with a focus on these comments recurring throughout each of the transcripts. Excerpts within each participants’ transcripts were highlighted and labelled with a basic theme. Transcripts were then analysed to determine where these basic themes reoccurred across all interview data.
Nine distinct themes were identified, describing both participants’ familiarity with PERCS, as well as the ways in which it contributed new knowledge and skills to their practice. The highlighted excerpts were collated under their respective theme; then each theme was further analysed and summarised to draw out the details and nuances of participants’ comments. These summaries were compiled into a detailed analysis of the interviews. Finally, specific quotes to summarise each theme were selected.
Results - PERCS-FDV
General comments about the course
Participants were asked to provide general comments about the Family and domestic violence and child-aware practice e-learning course. Although the pilot was more specifically concerned with the PERCS-FDV conversation guides, the understandings and practices within the course were seen to provide an important accompaniment to the guides. Practitioners who were less engaged in the course, it was reasoned, would be less likely to use the conversation guides in their practice.
All 13 participants saw the course as providing practices to respond to parents when FDV is a presenting issue, without expecting them to become FDV specialists. This gave practitioners the confidence to respond to parents in a way that ensured children’s wellbeing was considered, rather than just referring the client to a specialist service.
‘I like that it was a precursor to working with FDV; it is not “the be all and end all”, but it is a good, solid platform and I think that it’s something that will enhance my work.’
‘The biggest thing for me is bringing the invisible child into the room.’
Alignment with existing practice
Nine participants commented that the PERCS-FDV conversation guides, particularly the practice positions and domains, were closely aligned to their existing practice, and confirmed the guides’ relevance when working with parents where family violence is present.
‘A lot of the conversations I have are very child-focused, around kids’ behaviour and challenges, so I think it resonated with me because it is like a foothold. I am already using them [the practice positions and domains], but I can elaborate and make it fit with the context of violence.’
A holistic framework for practice
Eight participants described the overall structure of the framework as providing a helpful guide for practice. They thought it offered ideas for entry points into difficult conversations with parents about children’s wellbeing, as well as shaped practitioners’ intentions for working with parents.
‘Sometimes we see clients in this kind of situation [and] it’s quite messy and complicated, so we get caught up with that complexity. The structure [of the conversation guides] gives me a clear picture of how we can kind of address the issues and how we can focus on the topics we need to focus on.’
‘It made it more attainable to have those conversations with parents in a respectful way.’
Three participants commented that the PERCS framework provides a useful tool for reflective practice.
‘Even in the moment with the family, the client, even if you don’t have [the framework] then and there, you might go back to the office or might go to write your notes and think, “I feel like I’ve missed something”, and if you were to look over some of these domains, you might think, “Oh, I’ll follow up on that one next time”.
‘It’s something to come back to, to reflect on; and there’re so many different directions that it covers, you know – what are the supports? What are the emotions and behaviours? Wherever the conversation goes, we can kind of bring it back to the PERCS guide and the positions that we take in there.’
New areas of enquiry
Nine participants reported that although the five PERCS domains were aspects of children’s lives they were already familiar with, the framework supported them to focus on domains they may not otherwise pay significant attention to.
‘I guess it definitely gets me thinking more strategically, ensuring that all of those domains are considered rather than focusing on, you know, one more than the other.’
Unsurprisingly, participants varied in regard to which domains extended on their practice.
‘I’m doing more of asking parents [about] their insights of the impacts FDV has had on their child and what they think of their behavioural issues. What do they notice in their child’s emotions and behaviours and what sense do they make out of it?’
‘It helped to develop skills in talking with mums, to build their confidence about what they are already doing to support their children, in each domain. Also, in parent-child relationships, what do their children say about the relationship?’
New practice skills
Participants reported that the suite of questions provided in the guides supported their practice in a number of ways. A couple of the more experienced practitioners suggested the questions could help support new practitioners to conduct difficult conversations with parents in supportive, non-judgemental and curious ways.
‘For someone who is quite new, I think it could be quite daunting to think, “Oh goodness, now I’ve got to talk to this mum about their children and how this hard time they have been through is impacting them”. But to see these examples and have some guidelines or some suggestions on how to deliver that conversation would really make a new worker feel more equipped to be able to do that.’
Ten participants also said the wide range of questions offered in the guides supported them to work from a position of curiosity and collaboration.
‘The PERCS guide is helpful because of the example questions you can use. Not judging but opening-up the space to allow parents to explore what’s happening in their lives and their children’s lives. To be listening, supportive, non-judgemental – then you can move forward from there.’
‘They are good, open-ended questions. Instead of saying, “It’s good for you to do things with your child”, ask “what is it you do with your child?”. It helps me to remain curious rather than think “I know”. The two sets of questions were good, especially the questions for men, for fathers.’
Two practitioners also commented that the questions in the guides helped them to utilise their existing skills to improve enquiries with parents.
‘The course gave me confidence to ask them [the questions]; it gives me a licence to think, “do the questions fit with the client? When should I ask them, and how?”’
Practical usefulness of the guides
Five participants noted that being able to print the guides out and keep them after completing the course was a valuable and highly effective addition to the information and demonstrations presented in the e-learning courses.
Six participants noted that the brief and simple layout of the guide enabled them to use it as an on-the-spot, quick prompt whilst conversations were happening. This helped practitioners to make sure they were covering certain domains, and provided guidance when they needed help forming a question.
‘The guide is brief enough to have close by. I can have it on my desk, and turn around and refer to it, and think “have I covered each section?” or “here’s a question if I can’t think of one of my own.”’
Three participants described the usefulness of having a printed guide to refer to in more of a general sense, rather than using it as a reference point during sessions.
One participant thought that having this reference point could support child-focused practice to eventually become a more natural process.
‘It’s a useful resource to keep. It has example questions that can become natural ways of making sure that the effect on children is talked about.’
Working with both mothers and fathers
The structure of the PERCS-FDV conversation guides reflects the gendered nature of family violence and, as a result, participants separated their comments on working with fathers and working with mothers. Some participants noted the nuances present in this work and that PERCS supported the different skills needed to address common barriers to engagement in these client groups.
‘What’s challenging is not to increase blame and shame, but to increase chances for change. It’s respectful for perpetrators’ and survivors’ own experiences. The challenge is not to shame and blame both.’
Supporting non-blaming practice with mothers who experience violence
Participants commented that the questions within the guides helped conversations to focus on strengths and to highlight the actions mothers were already taking to ensure the safety and wellbeing of their children. Furthermore, four participants felt that the guides gave them confidence to ask difficult questions that could help mothers to recognise and understand the impact of the violence on their children, framed in a way that did not place any blame on mothers for the violence, nor shame them for not removing their children from the situation.
One participant shared their experience of engaging in one such conversation with a mother who had experienced violence.
‘A woman I was working with who already had children in care, upon the birth of another child they were also taken into care. She felt a lot of guilt and shame. “Why didn’t I leave?”, “Why didn’t I recognise what has happening?”. It helped to be asking about strengths and resilience and hopes – “what did you do to protect the unborn child?”. She hadn’t thought about it that way, that she was protecting her child. This reduced her shame and guilt; it was a big thing for her, because it helped her to recognise some of the things she was doing, to see her strengths, and helped her feelings of self-worth.’
Supporting respectful practice with fathers who use violence
Nine participants commented on how valuable it was for them to have a guide that focused specifically on conversations with fathers, for two reasons. Firstly, holding conversations with fathers who use violence was not a common opportunity for many of the practitioners interviewed, who worked more commonly with mothers and/or children. Secondly, working with fathers who use violence was not usually included in professional development on FDV.
‘The questions for fathers as well were really great because I think that a lot of people coming into the field expect to be working with victims; not a lot think about the fact they are going to come across perpetrators in their time. So, I think that’s a really important resource to have, that it covers both in a respectful way.’
Participants found the guides supported respectful engagement with fathers who use violence; and assisted them to understand how this can be achieved without colluding or being perceived as agreeing with fathers’ narratives. The questions provided an opportunity for practitioners to highlight a discrepancy between a father’s actions (use of violence) and their values. This was seen as a catalyst for change for fathers, whilst allowing practitioners to remain respectful and maintain the therapeutic relationship.
‘Coming from the stance of using the father’s values in their parenting to be able to support them in change is really helpful. So I guess being able to take it back a bit and think, “okay, yes, there is that potential for change and their values go against their actions”, and really holding on to that, I think is going to be super helpful for me moving forward with clients.’
‘I do see myself applying it, especially in working with perpetrators – staying respectful, curious, strength-based, but not colluding, not validating.’
Basis for parents’ actions
Five participants commented that the conversations encouraged by the guides formed a solid foundation for parents to take action in supporting their children’s wellbeing. Conversations about the impacts of FDV on children were reported to help parents frame their concerns about their children’s emotions and behaviours differently. Linking their concerns about their children to the children’s experience of violence helped parents to become more open to conversations about change. This was highlighted by practitioners as an entry point into raising difficult topics with parents in a sensitive and collaborative way.
‘Once the effects are discussed – what they are noticing is different about their children’s behaviour – it’s easier to have those conversations; they’re more receptive to those suggestions and tools [and] we can move on to talking about what to do differently.’
As in respectful practice with fathers, participants spoke more generally about aligning values and actions to support parents to make changes. In highlighting the experience of the child, practitioners were able to support parents to consider their parenting values and how these might misalign with their child’s actual experience due to the violence.
‘“Communication and meaning-making” probably stood out to me the most, because I think that’s [what] a lot of parents would be able to connect with the most – “this is actually impacting my kids: what can I do differently or what could be done differently?”. It sort of aligns it [the violence] with their values as well which … will prompt a lot more of the change.’
The guide also appeared to support participants in creating a reflective space for parents to consider their children’s experience, and consider (perhaps for the first time) what they might be able to do differently, or more, to support their children’s wellbeing. This was contrasted with an approach of telling parents what their children’s experience might be and what they as parents should be doing differently.
‘If it comes from them, this insight, rather than another thing they are being told about, it’s more likely to shift their behaviours. When it comes to family violence, there’s a lot of shame and blame, so to not enter into that blame and shame space [is important]. It will lessen the impact of the violence, for [the father] to know the things he was doing well, to strengthen his desire to be a good dad, [to know] he’s already doing some good stuff and we can strengthen [these things].’
Increased practitioner confidence
Six participants described the PERCS framework as contributing to a sense of increased confidence in engaging parents in difficult conversations about their children’s wellbeing.
‘I’m more comfortable asking direct questions, especially how the domestic violence is impacting on the children – that type of conversation. So, I feel a bit more equipped because of the learning about how to open conversations and those skills I think I’ve learned.’
‘It’s increased my confidence in working with men. I noticed I do things differently. It gives me more tools, questions to help get into the parent’s experience and help them [to] be aware of the impact of violence on their children, not just me telling them. I don’t want to do that. This is a way of staying open and curious, and have parents come to their own understanding. I can help the parents see the impact of the violence in a way that’s not blaming and shaming – that’s the skill, it’s helped me to do that better.’
Four participants reported that increased confidence supported them to take an earlier intervention stance in relation to children’s wellbeing, rather than only initiating a referral.
‘I liked that it was different from the learning I have done before in the sense that it wasn’t just… “if you are working with a family that has FDV refer them to an FDV counsellor”, because that seems to be a lot of the information that we get.’
‘It gives me confidence not to shy away from the questions. If I can make an impact to help [the father’s] children now…so he thinks of his behaviour, some tools to help him stop, stop arguments escalating in front of his children.’
‘It’s a really good tool for getting a hang of those tough conversations, especially if you’re not expecting them, which is often the case. That preparedness and just developing those skills to think on your feet, rather than just clamming up and being like, “Do you want some numbers to call?”’
Ongoing usefulness of the PERCS guide, including new and unanticipated uses
Seven participants commented they would continue to keep the PERCS guides on hand for use in the future. A further two spoke about reviewing existing questions within their assessments and integrating some of the language used within the guide.
Participants also felt that the guide had much wider applicability and indicated that going forward, they would use it to support parents and children with issues other than FDV.
‘The PERCS [domains] and conversation guide … can be for all aspects of [the family’s] lives. So, I think that’s going to be really useful for me, not just in the FDV space.’
There were a couple of unanticipated uses for the guides that participants described. One practitioner, who works directly with children, revealed they had used the guide to form questions to ask children.
Another commented on the structure the guide gave to case management and a shared understanding across a team.
‘It gives people a good basis of information to create discussion and to create that sense of curiosity, even between team members … It also gives, on a more global level, a funding or case management perspective. “Where are you up to with the case?”, “Oh I’ve done some ‘parent-child relationships’ and ‘emotions and behaviours’ and now I am up to ‘routines’”. So, from that perspective, it adds some meat to it. Not only so I can explain for myself, but also managers and funders, “this is the way that I work with my families.”’
Results - PERCS-AOD
The results from the pilot with six AOD practitioners were also very positive. All participants reported that they found the PERCS-AOD framework really helpful in supporting them with child-focused practice with the adults that they work with.
‘I would like it to be compulsory in our sector. I think it is very useful and I hope that it gets rolled out.’
Two participants reported that the resource was very useful for training and supervising other practitioners in child-focused strategies for working with parents with substance use issues.
‘So, a number of the services that I’ve demonstrated the guidelines [to] and had a bit of reflective workshop around, certainly talked about how it was in keeping with a new direction that they were wanting to go in within their own organisation.’
All of the practitioners interviewed stated that the PERCS structure gave them the tool that was missing in this work. They spoke of the usefulness of the framework in helping them to adopt a child-focused approach.
‘I didn’t have a tangible tool. I never had a tool to say “hey, have a look at this, and then let’s [figure out], how do we incorporate collaboration? What would that look like? How would you do that?”’
Providing a simple framework for child-focused practice
Four participants found the PERCS framework simple to use and very helpful in learning how to keep children’s needs in mind when working with parents with substance use issues. They said PERCS provided them with practical strategies and tools that made child-focused practice accessible in their context.
‘I just really like that it’s a framework; that it’s easy to learn. It’s client friendly. It’s user friendly. It’s easy to remember the questions and to have an access point and to remember the framework around the PERCS questions as well … It’s simple, but it’s also really effective.’
‘I found it incredibly useful as a clinician, as well as a resource to help [parents] work through being more reflective with their parenting while substance use is in their life.’
Bringing the child into the room
Three participants reflected on the fact that children’s needs are not always considered in the support provided to their parents, and that there are consequences for this oversight.
‘It’s really helped to sort of formalise a way of speaking to them [clients] about their concerns and bringing the child into the room, [in a way] that I didn’t have before.’
‘[It] allows me then to discuss what impacts [the parent’s] use is having on the children and also on the unborn [baby]. So, we’re not gonna forget about the unborn baby and that direct impact, you know, on a baby when the pregnant mum is using substances.’
All of the practitioners reported that their ability to adopt a child-focused approach was enhanced by the use of the PERCS framework.
‘[PERCS is] a gentle way of helping to keep child focus within the intervention and the planning space, particularly the care planning to help parents engage more with their children, as well as really working with their values – that they’re often wanting to work with their family around their substance use.’
‘It’s been helpful to use the framework to help [parents] unpack what’s going on, and to look at risks and the wellbeing of the child and put that in the centre of the conversation.’
Enhancing parents’ engagement and motivation
Two participants, one of whom was a clinical supervisor, reported that team members had often been concerned that asking parents about their children was likely to ‘ruin my relationship’ and cause parents to disengage from AOD treatment. Practitioners who undertook the pilot found the opposite to be true.
‘We’re not severing that [relationship]; we’re enhancing it.’
Five of the participants reported that parents often named their children as a motivating factor for positive change, while two found the PERCS framework to be helpful in supporting parents to make these changes.
‘One of the other things I’ve noticed is that when parents start reflecting on what their child might actually be saying or being exposed to, that can be a huge light-bulb moment and can cause a paradigm shift in how they are feeling about their substance use as well. And that’s the power of this framework.’
‘This can be a way of [parents] accessing their motivation that can help them decide where they are in the cycle of change and whether they are actually ready to make changes that will support their children to have a better life and increased wellbeing.’
Addressing barriers such as shame and stigma
Five participants stated that the PERCS principles were validating of their current practice.
‘PERCS is along the model of what we do – because the clients feel like someone is valuing them, it helps them to value themselves and others.’
The framework also brought these practice principles to life for participants. Four interviewees reported an increased understanding of how exactly these principles could be used as part of child-focused practice.
‘One of the things I’ve really noticed is that the framework takes away a lot of the stigma and shame and presents questions about the children’s wellbeing in a really respectful and honouring way that helps a parent almost separate from themselves. And look at it from a child’s perspective, which makes it much easier to have the discussion and ask difficult questions too.’
‘I think it’s really helpful acknowledging that there is stigma for women who are pregnant, and that stigma goes with shame. [PERCS] provides a really kind, compassionate way of asking those questions while being mindful of those things.’
Supporting a collaborative approach
Four participants found that the PERCS framework helped them better position themselves in a way that conveyed support to parents and a team approach. It gave them the skills to respond to risks to children in collaboration with parents, rather than jumping straight to filing a child abuse/neglect report; and to focus on the child’s wellbeing rather than just the risks present.
‘It’s been enabling the parent to kind of connect with us around their children, like we’re on their team and we’re on their side and we’re there to support them around their parenting and substance use.’
Three participants found the framework to be useful in developing plans with parents to work on specific areas of their child’s life and to explore and manage any risks that are identified.
‘I found that that’s been a really handy tool to be able to bring into care planning and assessment and intervention, because it’s a very visible thing that we can then use with parents to help shape the course of intervention; that we can keep coming back to.’
‘…that they [parents] can expect that these are the different areas that we’ll keep coming back to and checking-in about how their children are, and how they’re doing with putting some of these things in place [is helpful] … because I think all parents actually want to make sure that they’re meeting the needs of their children.’
‘I think the PERCS framework has really given me a way of asking the difficult questions, knowing how and when to offer support and who to.’
Supporting a strengths-based approach to working with parents
All practitioners talked about how they used a strengths-based approach in their core work.
Five stated the PERCS framework helped extend that skill to take a strengths-based approach to parenting with their clients.
‘I think that one thing that came through with the role plays in the package, was that the counsellor would always put it back to the parent and help them focus not on the negatives but on the positive things that they were doing, but always bringing it back to the child or in my case, the unborn [child], as well.’
‘Using [the framework] as that conversational prompt helps us to tap back into what’s happening in the family with everything else that’s going on. And certainly, with mums and dads that I’ve been working with, they’ve certainly been [able] to probably reflect a few more times on positive engagements that they’ve had with their kids, which has been great. That’s really positive. And sharing those little wins, yeah; the joys of parenting.’
Integrating with current practice
All participants found that the PERCS framework fit quite comfortably with their current practice and helped extend it to better incorporate a child-focused approach.
‘It fits with our assessment, too. So, I’ve been using it right from our intake assessment where I’m framing questions that are around the children and I’m thinking about them as though they’re actually in the room.’
‘Very user friendly, practical, easy to navigate. Easy to implement [at a] policy [or] leadership level – something tangible that you can use on the floor level.’
Two practitioners also adapted the framework to suit the needs of their specific client groups and settings.
Enhancing current practice
Four participants found that the framework actually enhanced their current practice and the work they did with parents around their substance use issues. It offered another way of framing the parent’s experience of recovery by bringing their children into every step of their journey, making the work more meaningful for parents.
‘… often their motivation is really around improving their family, and their substance use is often getting in the way of their attachment with their family. So, I think using the tool where it’s very child-focused that they can actually look at – look at something in their hands and be able to, I guess process a little bit through what they’re reading as well as in conversation. It can really help bolster the different strategies that they might be able to use within their own routines, within in their own way of engaging with their children, that’s gonna help with their own substance use and decreasing urges, as well as distraction and delaying and how they can actually bring some of those management techniques and strategies into what’s happening in their family life.’
Guiding child-focused conversations and practical strategies
All six practitioners described feeling like the PERCS framework gave them ‘more scope to poke around in that space’ with regard to child-focused conversations.
Three practitioners also described how these conversations resulted in them working on very practical strategies with parents to minimise the impacts of their substance use on their children.
‘Try to reframe clients’ drug use to how it affects their kids and [encourage them] to take ownership. For example, “Don’t leave your bong out, stop normalising use in front of your kids.”’
‘There’re lots of little routines that are really so important to be the building blocks of families as well as really great functioning for little people. And I think that where substance use is involved in a parent’s life, sometimes those routines, those building blocks aren’t able to be implemented as well … how can we actually improve [parents’] routines with the kids with predictability and giving them that extra sense of support that routines often can provide.’
Supporting challenging conversations with parents
Four participants reported that they often had to have challenging conversations with parents who may not be attending their service voluntarily. They found that the PERCS framework helped them to have supportive but purposeful conversations where potential impacts of substance use on children are not only explored but are also addressed.
‘We always have in the back of our minds who’s being exposed to this. Where are the children when substances are being used? But this [framework] goes another step further and plans for that and raises it with the parents and makes it explicit. And that’s the beauty of it.’
‘Yeah, I think some of the questions we have to ask are really difficult. And if people are engaged with other agencies, government agencies like child safety, probation and parole, they sometimes feel cagey about their information and not willing to reveal too much because of what you might do with that information. So I think PERCS gives you a framework to address those questions, but also to be kind and compassionate to the parents about what’s going on for them and putting the child at the centre of the work.’
Supporting work with parents where child protection is involved
Four practitioners reported that some of the most challenging work they encountered with parents was supporting them when child protection agencies were involved. They found that the PERCS framework was helpful in working through child protection concerns with parents.
‘I have a few clients at the moment who have child safety involvement and it’s been helpful to use the framework to help them unpack what’s going on; to look at risks and the wellbeing of a child and put that in the centre of the conversation. I think that just takes away the pressure from the parents about judgment and stigma and feeling as though they’re being questioned, and also separates us from the child safety system as well and other systemic things [they] might be involved in. Because we’re not part of that system. I think it’s really important to be clear with parents about what our responsibilities are in terms of notifying child safety about issues around risk and safety, but also that we’re there to support the parents. And, you know, we have their best interests at heart in the interests of their children.’
‘The guidelines have been helpful with addressing some of the more challenging aspects of working with parents [where] substance use is involved. Often parents come to services … with a lot of fear around what’s happening in their life, what’s happening in their children’s lives. And often when child protection-based services are involved, there’s a little bit of the unknown and real concern around what they can and can’t talk about, as well as how much they’re able to be really open and transparent when working through what is really a very difficult issue for them to possibly for the first time talk about, as well as get an understanding of what recovery might look like if they’re in that space and they’re wanting to look at making some changes.’
Highlighting the importance of integrated care
Three participants reported that the PERCS framework was helpful in facilitating a wrap-around approach to treatment planning with parents that incorporated the needs of children.
‘It’s that integrative approach to working with parents, working with stakeholders, and sometimes working in that kind of more trauma-informed care [way], collaboratively.’
Two practitioners also reported using the framework to provide some education to other practitioners around child-focused practice.
‘I think that one of the really fantastic aspects of the role that I’m working in is actually working with the other services that are often involved in a family’s life, where it might be an IFS service, family and child connect, or sometimes even child protection. I’ve found that it’s really been a great opportunity using the framework and the domains to work with individual practitioners within each of the services to sometimes provide a little bit of education. And even when doing consultancy, using the domains to really flesh out the impact of substance use and what supports we might be able to put into each of those different domain areas.’
Identifying intergenerational factors impacting upon parents and children
Interestingly, three participants found that the framework helped them to uncover the impacts of intergenerational substance use and disadvantage more broadly on parents and the ways in which these intergenerational cycles were being passed on.
‘Clients have no concept that their use can affect and influence their children’s use.’
‘[We] can explore intergenerational factors with clients, their history of abuse – when did they start, who did they start with?’
Through using the PERCS framework, two of these practitioners talked about working with parents to develop insight and practical strategies to address and potentially disrupt these intergenerational cycles.
‘The parents need to learn some basic life skills that have been missed due to intergenerational trauma/drug use/family dysfunction before they can help their kids.’
‘They were able to develop a strategy at the beginning of the program – around what messages their clients received as a child, who/what were their childhood influences, did they have positive or negative messaging? – and are now able to have clients reflect on who they influence now.’
Child-focused practice: A lack of time or confidence?
All 19 participants agreed that the targeted approach of the PERCS conversation guides supported parental engagement and child-focused practice where parents experiencing FDV and/or substance use issues presented to services. None of the practitioners interviewed reported time limitations as a barrier to engaging parents in conversations about their children’s wellbeing – a significant contrast to many of the responses received in Emerging Minds’ 2018 needs assessment.
This is most likely because the practitioners and organisations recruited for the pilot described a strong commitment to child-focused practice. While this narrow sample is a limitation of this pilot, many of the insights provided suggest the PERCS guides offer new possibilities for engaging with parents in ways that support children’s safety and wellbeing. The guides were seen to help practitioners support fathers to connect with ethics about safe and respectful behaviour; support mothers to articulate the effects of violence on their most important relationships; and support all parents to consider how their use of substances affects their children, and to take further steps and access additional supports.
Rather than time constraints, some participants described confidence in asking parents about their children as an important challenge to acknowledge. Even those who described long histories of having child-focused conversations with parents mentioned occasions when confidence was an issue. While the authors of this pilot want to avoid general statements about other workforces, time constraints may be more likely to be provided as a reason for avoiding child-focused conversations where practitioners feel unsupported or underconfident in firstly identifying FDV/substance use as an issue, and then asking parents about their children’s wellbeing where it is.
Organisational drivers to support child-focused practice
The overwhelming advice from participants was that consistent use of the PERCS conversation guides aided confidence in talking to parents about how FDV and substance use could be affecting their children. Even those practitioners who were experienced in child-focused practice reported that they don’t always ask child-focused questions, especially when they make assumptions that parents do not want to discuss the social and emotional wellbeing of their children. The PERCS domains provided these practitioners with a physical practice reminder that parents, overwhelmingly, will answer questions about their children if asked.
Limitations and future research
As well as a strong commitment to child-focused practice, participants all enjoyed strong support from their organisation and practice leaders in employing this practice. Further investigation is needed into the organisational support systems that allow a conversation guide such as PERCS to be used effectively with parents affected by FDV and substance use. What is the kind of authorising environment required for a practitioner to effectively utilise the conversation guides in their practice? What organisational drivers can adult-focused services put in place to ensure practitioners are supported to focus on the social and emotional wellbeing of children living in contexts of family violence or parental substance use? These are important questions to be investigated if children’s safety is to authentically become everyone’s business.
This pilot relied heavily on practitioners’ reflections of their own confidence and skills, through the use of semi-structured interviews. An extension of this pilot would include quantitative and qualitative data from clients to assess the outcome on children.
This pilot evaluation engaged a group of 19 practitioners to analyse the contribution of the PERCS conversation guides to their child-focused practice with parents affected by violence or substance use issues. The results of the semi-structured interviews showed that for this cohort, the conversation guides had a positive effect on their child-focused practice with fathers who were perpetrating violence, mothers who were the victims of violence, and parents who were using substances. The pilot actively recruited staff who had strong understandings of FDV and substance use; their interaction with mental health, social isolation and past trauma; and their effects on children. The FDV practitioners were all supported by their organisations to hold child-focused conversations where they suspected, or parents disclosed, violence, abuse, intimidation, threats, coercion or control.
Despite the support and commitment of all the practitioners to child-focused practices, they nonetheless described challenges and dilemmas when faced with options to directly ask parents about their children’s social and emotional wellbeing. Participants cited a range of challenging factors including confidence level, missed opportunities and the lack of practice cues, as well as other complex considerations. The PERCS conversation guides were shown to improve practitioners’ confidence in holding challenging yet respectful, collaborative and curious conversations with parents, providing them with a practical suite of options to weave child-focused conversations into their practice.
This pilot has provided confidence in the PERCS conversation guides, particularly where practitioner understandings and organisational commitment support child-focused practice. The next steps involve work with practitioners and organisations where confidence in child-focused practice is not as high, or where commitment has not been as strong. Findings suggest the conversation guides can be used as part of an overarching framework that supports practitioners to ask child-focused questions of parents who are experiencing FDV and/or substance use issues, as part of a prevention and early intervention strategy. Ultimately, this strategy should be tailored to improve the short- and longer-term outcomes for children’s mental health and social and emotional wellbeing.
The Emerging Minds: National Workforce Centre for Child Mental Health would like to acknowledge the staff, child and family partners and dedicated professionals who helped in the creation of this resource.
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