Toolkit for school nurses

Issues and opportunities for school nurses

The issues and suggestions raised in this section have been identified through those involved in schools at both primary and secondary levels.

General awareness of the issue
As suggested in the introduction, school nurses will, despite their training, have varying levels of knowledge - and views - about alcohol and alcohol-related problems. They are unlikely to have received training about the effects on children of parental alcohol misuse or about resilience factors.

Situations arising in schools
Alcohol-related issues are most likely to arise either as a concern about children drinking or in dealing with a parent whose behaviour is difficult due to their alcohol misuse. Awareness of, or concern about, a child who may be affected by parental drinking problems is not an issue which is commonly considered by professional staff in schools, even though 1 in 4 adults drink at levels likely to be harmful and 1 in 20 will be alcohol dependent.

However, the work undertaken in schools by School Nurses offers at least 3 possible scenarios that may yield opportunities for interventions on or about the effect of parental drinking. These are:

Where a child has asked to see the school nurse about something and the school nurse suspects (or could do, with better information) that parental alcohol misuse is a factor

Where the school nurse is the person to whom a child chooses to unburden him or herself (perhaps where the child asks to see the nurse at a drop-in, or has come to the nurse for another reason)

Where a teacher or other professional asks for an opinion on a child they are generally concerned about.

Where the issue of parental drinking arises in the wider school context, school nurses are more likely to be asked to consider such issues on a ‘pan school’ basis, in contrast to teachers who, unless they have a specific PHSE responsibility, are only likely to be able to identify and address individual cases. A head teacher may well consult a school nurse about problems affecting pupils more generally and ask for assistance, say, through the provision of training for teachers or of sessions for children on a particular topic.

Concern about an individual child
As we have seen in earlier sections, the effect of parental alcohol misuse on children is not likely to be focused on at all, except in rare cases of child neglect and/or abuse where parental alcohol misuse is a known factor. In these cases a school nurse will, just as any other professional, be concerned to ensure any issue concerning alcohol is dealt with appropriately within the framework of child protection policies and procedures.

Concern about an individual child is most likely to arise due to changes in a child’s appearance, performance and/or behaviour. Sometimes the causes are specific and are quickly identified by the teacher - illness or disability of a parent or a family crisis such as divorce. However the changes are most often seen as multi-causal – child having a difficult home environment generally (poor housing, parents in financial difficulties, unsupported single parent families, parental disharmony etc) with no specific concern about parental drinking. Unless there is a specific reason for thinking about parental alcohol misuse (the parents might be known to have drinking problems or informal enquiries might reveal this) there seems no purpose in going down this road for two reasons:

It is not going to be clear what is causing what – alcohol misuse causing family tension, parental distraction and financial problems, etc or being a symptom of these things and there is little awareness that parental alcohol misuse will have an increased adverse effect on families in difficult circumstances compared to better off/better situated families.
Concerns about the implications of child protection procedures. This is covered in more detail in Addressing child protection, but a particular concern is that making enquiries of the child can, if later a case of child abuse becomes a police matter, be seen as probing, which may in turn lead to a child disclosing something that did not happen. This opens up a line of defence for a potential perpetrator and police may not be prepared to pursue a case if they feel that the robustness of the evidence from the child is open to this challenge. As there is a correlation between alcohol misuse and domestic violence this is a valid concern, but one which should be covered by normal child protection policy and procedures. This issue is not alcohol specific and applies to any situation where concerns are raised with a child whom they suspect may have been neglected or abused.

See section Signs and symptoms

Child initiating disclosure
It is possible that a child under pressure will suddenly choose to talk to an adult within the school. This might be the form teacher or a favourite teacher, but teachers also report that some children especially avoid those with whom they are familiar or particularly like. In these cases the child might choose to confide in a more distant figure, yet one with a clearly identified caring role, such the School Nurse or Counsellor , preferring the feeling of anonymity offered by this scenario. School staff have requested specific gu idance as to when what is said is something that can just be listened to and acknowledged and when it is something on which action needs to be taken; there are two key points to bear in mind:

Firstly that the school’s existing guidance on policy and procedures concerned with child protection (presuming these are up to normal standards) are adequate for application to concerns about the effects of parental drinking on a child. The nurse’s professional judgment should be used as to when to invoke such procedures, in exactly the same way as if a child discloses other sorts of information
However, research shows that, on the whole, professionals tend to be more likely to invoke child protection procedures when parental alcohol misuse is known, compared to other parental problems mentioned by the children; this may be inappropriate and could be harmful to the child.

The issues and difficulties faced by a range of professionals in relation to child protection and alcohol misuse have been a prominent feature in the discussions surrounding the development of toolkits for different professional groups. An expert view on this matter is available and nurses are advised to look carefully at this in the section on Addressing child protection.

Children as carers
Children who take on caring responsibilities for siblings (and sometimes parents) may come to the attention for the same reasons as those given above. The situation of a child acting as a carer is a relatively common occurrence within schools. In some areas (particularly those in deprived parts of the country) the situation is so well recognised that the school itself provides specific support for groups of children in this situation. In these areas the issues of parental alcohol (and drug misuse) is likely to be a known cause of children taking on responsibilities for the family (because substance misuse is high in the immediate population) but in more affluent areas this is unlikely to be picked out as a specific cause, although school staff will be familiar with working with children in this general situation.