Organized by the Pompidou Group of the Council of Europe with the support of Czechia, Mexico and the Executive Secretariat of the Inter-American Drug Abuse Control Commission of the Organization of American States (CICAD-OAS)

Florence Mabileau, Deputy to the Pompidou Group Executive Secretary: Welcome everybody. I’m very happy to see you here at this side event on children whose parents use drugs. My name is Florence Mabileau. I’m Deputy Executive Secretary of the Pompidou Group. I’m pleased to pass the floor to Denis Huber for a few words of introduction.

(Welcoming Remarks) Denis Huber, Executive Secretary of the Pompidou Group: Thank you, Florence. I’m happy to start this side event at the 66th session of the CND dedicated to the topic ‘Children whose parents use drugs’. The Pompidou Group is the Council of Europe’s cooperation platform in the field of drugs and addiction. It is obvious that human rights are at the centre of our work and we are working together with all Member States in order to make sure that drug policies are in line with the obligations in regards to human rights.

This topic ‘Children whose parents use drugs’ is quite new. We started to work on it in 2021 when the Pompidou Group was celebrating its 50th anniversary. And I am grateful to all who have taken the initiative of starting the work in an area which has been overlooked in the international scene and has led to very interesting findings. And I thank Corina Giacomello who has been much engaged in this work. We decided to have it again in our work program which has been adopted last December and will run from 2023 – 2025.

This is a very short introduction. I would like to thank all the speakers who are present – Corina Giacomello, Florence Mabileau, and Kateřina Horáčková who is the Permanent Correspondents of the Czech Republic in Pompidou Group, and the two speakers who are online – Jiří Richter from Czech Republic and Catherine Comiskey from Ireland.

Florence Mabileau, Deputy to the Pompidou Group Executive Secretary: Just to explain how we started our project. It came into being by the fact that we participated in the preparation of the Council of Europe change in strategy and I noticed while participating in the discussions that there was no mention at all of the children whose parents use drugs. They are invisible if we don’t speak of them and if we don’t do anything for them.

So that’s how it started and we invited our Pompidou Group member states to join us in a research project conducted by Corina Giacomello and 14 countries decided to participate in the project. And last year, the Council of Europe Strategy on the Rights of the Child was adopted. This strategy does mention now the children whose parents use drugs and the children who are in difficulty facing drug addiction. It was quite an achievement because we are part of the Council of Europe. We place human rights first in our mission and for drug policy. And we want to continue to introduce the rights of a child as a human right. And we have done it starting in 2021 and we continued with the research project. One was the interview with children. One was the interview with women who use drugs and one was a collection of an analysis of actions and programs targeting people who use drugs and their families. Now I’m very happy to introduce Corina Giacomello, Associate Professor at the Autonomous University of Chiapas (Mexico), who is our consultant in this field. Corina conducted research which was then published in this book.

Corina Giacomello, Consultant for the Pompidou Group and Associate Professor at the Autonomous University of Chiapas (Mexico): Since the project began in November 2020 until now, more than 300 people and 18 countries have been involved in this project. The knowledge, skills, information come from all the policymakers, public institutions, NGOs, women who use drugs and children that have been interviewed for this project. So I’m going to divide the presentation in two parts. The first one would be to present to you what’s included in this publication, which is the product of the 2021 edition of the project that was published in 2022. And then I will tell you what we did in 2022, which will be published in 2023.

So first of all, just a few clarifications because of the time limistation of the presentation—some generalisations will be made. When we refer to drug use in the project, we do not talk about any drug use. We know that most people do not use drugs, and then most people do not use drugs in a way that compromises or makes it difficult to look after themselves and their loved ones. So we only refer to the drug use like the one in the testimony [“Children blame themselves and they wond “why doesn’t she love me?” but it’s not true: the mother loves her child, but the substance is too strong.”] The project lies in that intersection. When on the one hand you have children who want to be loved, and want their parents to take care of them. And on the other hand, we have parents who are struggling with being a parent. And then on top, they’ve developed a relationship with a substance. At the beginning, they might be in control of the substance, they were taking it for pleasure to overcome some trauma, to face difficulties, as a coping strategy in a way, as a show of strength, of trying to work out things. But at some point, the substance takes control, and the relationship changes. And then we have services. And how can services bring the division together again, to make sure that children know what’s going on and that parents who need help actually have it. So this is where the project stays.

So this publication, chapter one is an introduction looking at family and children oriented services that take into account drug use. We have several examples from Ireland. Ireland has been participating very eagerly in the project with the national government and NGOs. We have prevention programs from Cyprus. So basically actions in the field of social services and child protection that are aware and also work on dependence. Then we have services in the field of drug treatment and prevention that also take into account the parental role of the clients, which aren’t always available. Often, the treatment approach is quite clinical, individual-based and does not necessarily look at families and children. So we show examples of treatment services where the parent role is also taken up, made visible and worked upon. We have examples from Iceland, Ireland, Mexico, Croatia and Switzerland. And then because women face more challenges and often they are the primary or sole caregivers of their kids and they face more stigma if they use drugs, they’re more exposed to violence, including sexual violence, then there was a need to also look at those services that work specifically with women and then also let women go into residential treatment if they need it and accompanied by their kids. Chapter 5 looks at another very overlooked issue, which is women who are victims and survivors of violence and use drugs. Usually they are excluded from refugees. So we bring the experience of two refugees: one in Cyprus, and one in Ireland where women who use drugs are accepted in the refuge and drug dependence is addressed as any other issue that these women have to face. This acceptance of women who use drugs in the refuge was based on the acknowledgement that closing the door for women to use drugs, telling her to go and get treated and then come back, was a form of institutional violence that put them in a heightened risk because they would go back to the perpetrator. So these are the main concerns. Then we have a series of findings and recommendations—very operational ones. They can be transformed into concrete actions quite easily.

And there are four topics of key messages and recommendations. One has to do with how countries can develop integrated strategies to take into account children’s rights, parents’ rights and drug dependence. How also data gathering could be improved in countries and also data sharing to make sure that we know the dimension of this phenomenon—how many children there are out there, then come to substance treatment services, how they could engage and make sure that their clients’ parenthood is actually taken up and be part of the treatment process. And then at the end, also to analyse the availability and quality of the services targeted at women who use drugs. If you look at the publication, you will find all these issues much more developed. So this is 2021. It’s a project that generated a lot of enthusiasm and synergies between countries and NGOs. And everybody said, let’s continue.

So in 2022, with 11 countries under the Pompidou Group, these are three studies which would soon available. One is another study based on service providers—what actions are there on the ground that can be an inspiration for other countries or local stakeholders—which is the first study with 33 programs and actions from 11 countries. Then we have “We are warriors”, which is based on 110 interviews with women who use drugs in 9 countries. When you read the report, you will see that even if they come from so many different countries and realities, their story can read like one. And you will not be surprised by it, but gender-based violence is always there in the background. And then, “Listen to the silence of the child”—we had interviews from 5 countries out of 11, 33 children and young adults between the age of 8 and 34 participated answering questions about what is it like in their life to face their parents’ dependance. And they have amazing recommendations for their peers, which is what I want to look into. I want to show you some of the testimonies. So the first one is from Ireland who said: “You think it’s hard being in recovery? Try and be a woman in recovery, you’re so much more vulnerable. You are not only powerless over substances, you’re powerless over everything in your life. You are powerless over whose bed you wake up in. You’re powerless over the company you keep. You’re powerless over everything. You’ve lost your power of choice. It’s because the substance has the power. The choice is gone. As a woman, definitely you have more vulnerability. You must have a thick skin and you are playing the actress, so you’re trying to be as tough as you possibly can, but it’s all just a bit sad. So this is where these women are when they started to be involved in the interview—when they’ve lost their power of choice, and they’re trying to get the choice back.

These are some data on women. 89% of them were mothers. 66% experienced drug use in the family. 66% of them did experience problematic parent drug use in their family when they were a child and they relate it to their own drug use. And so that’s also an important issue—the transgenerational dimension of this phenomenon—not as something that is related to families or individuals, but to us as a society. What are we doing? Where are the service provisions? Why don’t we manage to stop this transgenerational dimension or why do these stories keep repeating over and over? Then another interesting data is that 51% of them reported being victims of violence. There was no specific question. They reported it spontaneously going from verbal violence to sexual violence. So imagine if we asked the question, the number we would have there would be much higher. So again, just some testimonies to show you some of the voices. It was Jenny from Switzerland: “In fact, I started using at the age of 15 because there was abuse. And in fact, afterwards it allowed me to have a sort of band-aid for my suffering.” That’s how they refer to drug use in the first place. A source of health, a coping strategy, a way of curiosity going out of boredom. But then again, the relationship changes. And from Mexico: “The women I have met in rehabilitation centres, they all come for the same reasons. They all come for abuse or mistreatment because their father is on drugs. They come for different stories of connection. But I think we all go through a rape.” and then I will skip the other one, although I recommend you to read it, because it really gives this idea of stigma and shame. But the third one is: “They told me I’m a drug addict, but they don’t ask me-Why do you do it? What do you feel? Or Have you eaten kid?

So “Listen to the Silence of the Child”, the title is based on the intervention of a very young boy from Greece. You can see how he presents himself: “My name is Alexis and I’m a 14-year-old. I would like to have a family with no drug issues, people who take care of me and I would like not to leave anybody. That was the first answer to the question—What can you tell me about yourself? And then he says, when asking about recommendations: “Teachers and services must be patient with children. They must hear the voice of the child and the silence of the child. It helps to be supported in everything without the danger to lose your house and be in an institution. It helps if the child can have a quiet home, therapist for their parents, a support that understands and a network that supports in food, clean clothes, clean house, quiet sleep, studying, going to school on time. Therapies are helpful, but children do not like going to therapy.” He doesn’t only tell us what they need, he tell us what he doesn’t have. He doesn’t have a quiet home. He doesn’t go to school every day. He doesn’t always have food on his table. And the next one is Milo, 18 years old. When we ask him, what do you recommend for parents? What should services and parents do? He says: “We help mom and dad. We help them get used to cooking, driving, everything. We teach them how to read and write.” Isaac, 9 years old from Mexico: “Help me to be more polite because sometimes I get out of control when I get angry with my sister, I hit her.” So he’s starting to externalize the things that he’s living and is basically asking for help. So the children have all the answers. They know what the protective factors are and they ask for them, as Alexis showed in his message. The next one, Maria, 15 years old, Greece—“When someone is using drugs means that they were in trouble. They must not be feeling well. On the other hand, that is not a reason. How can I explain this?—“It does not justify their actions, you mean?”—“Yes. But from their perspective, it is a good reason to start doing drugs. But on the other hand, why does someone do this? There is no reason. They should show their children that they take care of them.” As we can see from the several testimonies from the children, the main feelings they express are anger, sadness, and empathy. They understand that their parents are doing what they are doing because they have some reasons to do it. But still, they don’t like the consequences it has for themselves. So again, this is the intersection where the project is trying to have an impact.

In the last slide, you can see several testimonies which are recommendations from the children to other children. So one of them, Maria, 15  years old: “I would tell them not to be affected or bothered by what their parents do. Don’t be like them. Such a mess and bad example for their kids. And it would be good to have someone to talk to and not feel embarrassed. There’s no need” The last one, Fatima, 13 years old: “They should not keep quiet. They should speak out. They should express themselves to people with whom they feel protected.” I would only like to end by saying that this is one of the core purposes of this study to make sure that we start listening to children not only as an episode event, but as something that becomes part of services, part of international organizations. Because as you can see just from these small extracts and you will see once the publication is ready, they have all the knowledge, all the understanding. They know exactly what they need for themselves, for their peers and for their parents.

Catherine Comiskey, Professor in Healthcare Modelling and Statistics at Trinity College, Dublin University (Ireland): So I’m looking at adults now and what we would call hidden harms. And these are harms that adults may have experienced as a child living with a parent who uses drugs. So this is work carried out with David McDonagh, a Ph.D. candidate of mine, and Dr. Jan de Vries, a psychologist and a colleague. And we explored adverse childhood experiences among people in opiate agonist treatment. I want you to remind us, out of respect for parents who love their children, that not all children are impacted, but of course, many are. And many children do grow up to thrive but many do not.

What are adverse childhood experiences? So these are events that occur in a child’s life, and individuals with 4 or more of these adverse childhood experiences are likely to suffer from a range of health-related problems, including early death, and are ten times more likely to use intravenous drugs. So children who experience these adverse experiences during their childhood, if they had more than four of these, the research has shown that they are 10 times more likely than the usual population to use intravenous drugs. Furthermore, we’ve also seen through the research that between a third and a half of people in substance use treatment have a lifetime diagnosis of post-traumatic stress disorder. That’s quite a substantial amount of adults experiencing PTSD. We also know from the literature that the summit to the fact that if we add up the number of ACEs, the more adverse childhood experiences you experienced, the more you are likely to suffer poor psychological well-being and in particular, PTSD as an adult. And the research has also shown that sexual and physical abuse are implicated in adults experiencing post-traumatic stress. But we were interested in seeing what other adverse childhood experiences are. So we conducted a study and interviewed 131 service users. We did both quantitative measures and qualitative open-ended questions, asking people about their experiences. And at the time when we first started the study we weren’t asking about adverse childhood experiences. But David McDonagh, who was doing this work for me as part of his Ph.D., we discovered that people started telling us their stories about their childhood. So when we then went back to follow the people up 2 years later, we said we need to have this evidence on adverse childhood experiences and on PTSD. And we started to measure that.

So what did we find? So among this group of 131 interviews were people who have used different opiates and are in substitution treatment. We found that the mean age was 42 years. So not the youngest, but people had been in treatment for quite a long time. The average time of treatment was 11 years. And it ranged from people who just entered treatment to somebody who’d been in treatment for 27 years. For about 2/3 of people with their second treatments. Over half of the people in treatment had 4 or more adverse childhood experiences. And we know that this number 4 is a magic number because research has shown that if you have 4 or more adverse childhood experiences, you are more likely to use intravenous drugs as you age into adulthood. Nearly a quarter have experienced more than 7 adverse childhood experiences. But we looked at their PTSD score. The average score was 30. Women had an average score of 37 and men of 26. What we know of this post-traumatic stress score, that if you have a score of between 31 to 33, there are some important cultural scores that you are more likely that you are appropriate for a PTSD diagnosis. So 45% had a score of more than 31 and 40% had a score of over 33. Of these people in long-term opiate agonist treatment, over half experienced more than 4 adverse childhood experiences. And again, over 40% were above the cut-off for PTSD. So these are very significant numbers. And here you can see the list of the ten adverse childhood experiences. And you can see how many actually experienced these when they were children. If you look and again, going back to Corina’s point about intergenerational use, you can see that nearly 60% had grown up in a family with alcohol or drug use. So these adverse childhood experiences are substantial among current adults who are in treatment.

We looked at the association between individual adverse childhood experiences where some are more important than others and relationship with current PTSD. And remember, these people have been in treatment, on average, 11 years, and they’re still experiencing this PTSD. You can see here 9 of the 10 adverse childhood experiences actually had a significant relationship or correlation with the current PTSD. Then we said, okay, are there some more important than others in predicting current post-traumatic stress disorder among these adults? And we found this being unloved. And going back to your opening slide: Why doesn’t she love me? Feeling unloved was the strongest predictor of current PTSD. Living with problem drinker and household with the mental illness and verbal abuse are also important. These were the strongest predictors but feeling unloved is the strongest. We had a very interesting discussion with the psychologist about this because we know sexual abuse is a predictor of PTSD. But in actual fact, the strongest predictor is feeling unloved. And we were saying, would it be because verbal abuse and sexual abuse are something that are done to you, they are external to you that maybe you didn’t have control of as a child, but feeling unloved is perhaps something internal that you take on board within you, that you were unworthy or that you were unloved. I mean, we don’t know. This is just our trying to explain why does this feeling unloved has such a strong predictor on current PTSD.

So to conclude, I think it is really important to remember that these people were adults, that they were in treatment for 11 years, and yet they’re still experiencing this post-traumatic stress disorder. And in our feelings as a team is that current treatment is effective. It is reducing harm, but it’s maintaining people—40% of the people were at risk for post-traumatic stress disorder. We did find that childhood emotional neglect was found to be more significant to physical abuse or sexual abuse to projecting PTSD. We also can say quite clearly that this was significantly higher in post-traumatic stress disorder among females and again, the need for gender-specific services is great. From my work, I believe that treatment services need to be trauma-informed to avoid retraumatizing and stigmatizing people on OAT. You’re being asked to give a urine sample and somebody is following you. Maybe the security person is following you into the bathroom. And if you have been physically and sexually abused, what’s it like to have somebody walking behind you as you go to give your urine sample? These are simple things that we can look at to be trauma informed. Given our results here on this being unloved, for people in long-term treatment, we need to be addressing these past traumas and particularly this neglect and being unloved during childhood. I’m a strong advocate of harm reduction, but we also need to look at getting people their lives back. These are people in 11 years in treatment on average, and we need to do better to improve their lives so that while they can continue in harm reduction services, we need to improve and work with them on their needs in terms of their mental health and their past problems. And I would like to just highlight that we have with our nurses that we did this work across north Dublin. We developed a free online learning for practitioners in order to help nurses and practitioners working in treatment services look more at addressing the specific needs of their clients.

Jiří Richter, Executive Director of SANANIM (Czech Republic): What I’m trying to do today is introduce a bit of our work, specifically on children and mothers. SANANIM, founded in 1990, was the first NGO in Czech Republic. In 1991, we opened the first centre. In the 90s, we had opened 7 other basic facilities creating the basic network for addicted people—outreach drop-in, prison service—after that, it was used as a model facility or useful for the standards in the Czech Republic. Nowadays, we’re one of the largest providers of complex services on addiction. Some brief numbers from 2021, over 15,000 clients are in treatment—over 13,000 people who use drugs, 7,800 clients in  low threshold facilities, 2,600 clients, almost 400 in residential treatment, and 4,600 for online intervention. Almost 2 million needles were distributed which means 1/3 of needles in the Czech Republic, so we’re in good contact with people from the government. This is also necessary for the follow up to the treatment. 2,100 non-users use our services for counselling and other services. Many of our clients are drug addicted mothers…we opened specific program with existing facilities for the children and mothers. One of them is a day care centre, which we run specific programs for mothers. And the program also focuses on preparation for the treatment in Therapeutic Community. They work in close cooperation with the hospital where there is a day care for the child and accommodation for mother. Another one is aftercare centre with programs offering aftercare for mothers and children. It’s an important bridge for social stabilisation…

Kateřina Horáčková, Head of the Coordination and Funding Unit, Drug Policy Department, Czech Republic (Closing Remarks): As a representative of the Czech Republic, I am really proud that my country actively contributes to this activity. And I am really happy that Pompidou Group is focused on this specific, but really important activity during the incoming programs to 2025. Because I’m the last speaker, I would like to highlight the two key aspects. One is the human rights approach and the rights of children. And I’m really happy that during this CND, we can see more and more vocal on a human rights approach in human rights in drug policy. So I think that it’s really needed and more and more states and organisations and civil society put this approach on the table. The second aspect is multidisciplinary work and collaborative efforts among different services. If we are talking about the need to provide integrated services to children whose parents use drugs, and if you want to effectively reply to the needs of the persons who use drugs and their families, I’m not only talking about the social services and child protection services, but also about schools, about treatment and harm reduction services, also services for vulnerable groups that reflect the specific needs, for example, of woman who are victims of abuse or violence. So if we are talking about the people who use drugs, I’m really proud that in the coming years we will not focus only on children, but we will focus also on the father who use drugs. And we will see what is the current approach. What is the existing services to actively promote the fatherhood. As Corina said, we will not only focus on existing service providers but we will also listen to the voices of fathers. We have different ways, for example, focus groups or other forms of interview. And we will also extend our work to prevention, treatment and care programs available for children and adolescents.

So at the end of my speech, I would like to briefly announce the work that the Pompidou Group will focus on in the coming months. In this year we will continue to work on children and families affected by current drug use, and we will produce three publications which will cover the voices of children, the voices of the women and current practices on how to take care of children whose parents use drugs. We will also prepare human rights-based guidelines in order to provide integrated services to children whose parents use drugs. And on the 21st of June in Venice, under the Italian Presidency, we will hold a seminar on prevention and young people.