What is the Toxic Trio?

The toxic trio is used to describe the three issues of:

• Domestic abuse.
• Mental ill health.
• Substance misuse.

These issues often co-exist and have been identified particularly in families where significant harm to children has occurred. A clear link between the toxic trio and an increased risk of abuse and neglect has been identified. In a situation where the toxic trio occurs, this is viewed as an indicator of increased risk of harm to children or young people.

There are several reasons why the three issues often co-exist. One of these reasons is that a parent or carer who misuses drugs or alcohol is also statistically more likely to be in a relationship where domestic abuse also occurs. It could be that they are the victim or the perpetrator of the abuse.

Additionally, misusing drugs and alcohol also increases the likelihood that the individual will experience mental ill health. In fact, the Mental Health Foundation stated that in 2014, half of the individuals with drug dependence issues were also receiving help for mental health difficulties.

It is important to note that experiencing one of these issues may not result in the toxic trio developing. Nor does it mean that a parent who is experiencing one or more issues is abusing or neglecting their child.

However, the combination of all three risk factors can significantly increase the risk of abuse or neglect of children or young people. Ensuring relevant professionals are aware of the toxic trio and are able to identify it can help protect children and young people from significant harm.

What is the toxic trio of abuse?

The impact of the combination of all three issues can significantly increase the risk of harm to children and young people. The neglect or abuse a child experience as a result of the toxic trio can have significant short-term and long-term consequences.

These consequences may include:

• Physical consequences – If a child is physically abused by a parent experiencing the toxic trio, they may experience physical injuries such as broken bones, cuts, bruises, burns, swellings, and seizures. These injuries may cause long-term consequences for the child, especially if treatment is not sought when the injury occurs. There may also be physical consequences for a child who experiences neglect, such as dehydration, low weight, anaemia, repeated illness, and poor dental hygiene.
• Behavioural consequences – The behavioural consequences of experiencing abuse or neglect can be serious and lifelong. A child who experiences abuse is more likely to engage in criminal activity or anti-social behaviours and be at a higher risk of substance abuse. They are also more likely to be involved in a domestic abuse relationship themselves.
• Psychological consequences – Children who have experienced abuse or neglect are more likely to experience mental health difficulties, such as depression, anxiety, Post-Traumatic Stress Disorder (PTSD) and low self-esteem.

What is the toxic trio now called?

The term ‘the toxic trio’ was first coined by Marion Brandon in 2009. The term quickly gained traction and became commonplace amongst healthcare professionals. However, the term has recently been seen to be problematic.

One of the reasons for this is that it is seen to be stigmatising. The negative connotations associated with the terminology can lead the parents or carers to be blamed or perceived negatively. This could result in them failing to seek help and support from professionals or others in their community.

In particular, the inclusion of the word ‘toxic’ in the term can be especially damaging. The toxic trio has been frequently misinterpreted and misunderstood amongst healthcare professionals and wider society. The toxic trio has also been known as ‘the trilogy of risk’ or people with multiple and complex needs.

The NHS now uses the term ‘the trio of vulnerabilities’ to describe individuals experiencing domestic abuse, mental ill health and substance misuse.

The toxic trio: Domestic abuse

Domestic abuse, previously known as domestic violence, includes behaviour that is violent, threatening, bullying, controlling or abusive in any way. Domestic abuse is not limited to physical violence, it can also include emotional, psychological, sexual, or financial abuse.

Domestic abuse usually occurs between two adults. Both men and women can be the perpetrators of domestic abuse, although women are statistically more likely to be abused than men. The Office for National Statistics (ONS) found that in 2020, 74% of domestic abuse victims were female.

Domestic abuse can be extremely harmful to children or young people. Witnessing domestic abuse can have both short- and long-term consequences for the child involved. This includes increasing their likelihood of developing substance misuse issues or later being involved in an abusive relationship themselves.

A parent who is an abuser may also be more likely to become violent to the child.

The toxic trio: Mental ill health

Mental ill health encompasses a wide range of mental health difficulties. In relation to the toxic trio, mental ill health refers to mental health difficulties experienced by a parent or caregiver.

Mental ill health could include:

• Mood disorders – Such as depression or bipolar disorder.
• Anxiety disorders.
• Psychotic disorders – Such as schizophrenia.
• Personality disorders – Such as borderline personality disorder (BPD).
• Eating disorders – Such as anorexia.
• Trauma-related disorders – Such as Post-Traumatic Stress Disorder (PTSD).

According to the NHS, one in four adults in the UK experience mental illness. Although this does not automatically result in a child being abused or neglected, having a parent with mental ill health can be a significant risk indicator.

A parent who experiences anxiety, depression or low self-esteem may find it much more difficult to protect themselves and their children from domestic abuse. Some adults also use drugs or alcohol as a coping mechanism when dealing with mental health difficulties.

For example, a parent who experiences depression or agoraphobia may be more likely to self-medicate as a way of coping with the difficulties they face.

In the case of mental ill health, early intervention could be key. Professionals involved with the family, such as social workers, the GP, and the health visitor, should understand the potential risk to the family and ensure they are offering adequate support.

The toxic trio: Substance misuse 

Substance misuse can be a particularly difficult issue in the toxic trio. Individuals who struggle with substance misuse, particularly drugs and alcohol, have often experienced an event or experience that may have initially triggered the substance misuse.

This is known as the root cause of the behaviour. Without addressing this root cause, it can often be very difficult for the individual to stop misusing the substances, especially in the case of addiction.

Root causes can vary significantly from one individual to another but may include:

• Childhood experiences of abuse, neglect, or loss.
• Mental ill health.
• Being in a physically, emotionally, or sexually abusive relationship.
• Family history of addiction.
• Being exposed to substances at a young age.

Many individuals misuse substances as a way of coping with their experiences.

Substance misuse often creates a particularly high-risk environment for children and young people for several reasons:

• Alcohol can increase the tendency for violent or aggressive behaviour. This can result in the physical abuse of a parent or child.
• Misuse of substances can result in neglect or abuse. A parent with a drug addiction may spend all the family money on drugs, leaving little or no money for food or other essentials. They may also physically and emotionally neglect the child.
• Parents who misuse substances may intentionally or unintentionally emotionally abuse their children. They may be less responsive or interactive and less willing to engage. They may ignore their child or become withdrawn from them.
• Substance misuse can result in physical abuse. Parents who misuse substances may have difficulty controlling their emotions or lose their sense of right and wrong.

There are a variety of substances that a parent may misuse. These include alcohol, illegal recreational drugs, and prescription drugs. For more information about the different types of substance misuse, consult our knowledge base.

What is the toxic trio in social work?

As the occurrence of the toxic trio can significantly increase the risk of abuse or neglect of children and young people, supporting families where the toxic trio occurs is essential. Social workers can work with the family and other professionals to address the issues, any underlying causes and any wider implications or further harm the issues may be causing.

Experiencing any or all the three issues does not automatically mean that abuse or neglect is taking place. Early intervention and adequate support may be key. Support can be given to the parent or parents experiencing the toxic trio and to the children involved.

Even if a child grows up in an environment where the toxic trio exists, with the correct support social workers can protect both their short- and long-term physical and emotional well-being.

It is essential that social workers and other professionals have a thorough understanding of the toxic trio and the link between the three issues. This helps them to identify the toxic trio and offer effective support to everyone involved. Interventions and safeguarding measures can be put into place to promote the safety and well-being of both the children and the parents.

Effective practice from social services and other healthcare professionals

Ensuring effective practice in situations where the toxic trio occurs is vital. It is important that all professionals are aware of the three issues and how they interlink. Supporting the family and ensuring that effective interventions are in place can significantly reduce the risk of harm to children and young people.

There are several things practitioners can do to ensure effective practice and protection from harm.

• Early intervention – The earlier an individual can access help and support, the more successful it is likely to be.
• Be aware of the toxic trio risk factors – If a parent or child is engaged with practitioners because of one of the issues (such as domestic abuse) it may be that the other two issues are also occurring. It is vital that professionals are aware of the toxic trio and how the three issues link together and that they can identify and understand it.
• Use language that can be easily understood by all individuals – Using overcomplicated jargon and medical terminology can be confusing and overwhelming for some individuals. It is important that individuals understand what is being said to them and feel comfortable asking any questions.
• Specialist services for each of the three issues – Each of the three issues require very different support. It is essential that the individual has access to support for all issues. This could include a rehabilitation programme for substance misuse, Cognitive Behavioural Therapy (CBT) or psychotherapy for mental ill health, and the support of social services for domestic abuse.
• Work in partnership with other agencies – Multi-agency collaboration is essential in cases of the toxic trio. The family will likely need support from a variety of practitioners who specialise in the different issues. Sharing information and ensuring all professionals work in partnership can help to support the family more effectively. However, it is important to note that only relevant information should be shared, and the privacy of the individual should be respected.
• Show professional curiosity – This can include speaking to all members of the family. Practitioners could also consider contacting the child’s school, the GP, or other relevant agencies.
• Speak to the child separately – Children experiencing abuse and neglect may not want to disclose the abuse for a number of reasons. This could include feelings of fear or shame, not wanting to get their parent into trouble and the fear of not being believed. However, children may be much more likely to make a disclosure in a 1:1 situation and if they feel they can trust the practitioner. For more information about why children may not disclose abuse, consult our knowledge base.
• Focus on the safety and protection from harm of the child and the victim – In cases of domestic violence, professionals should aim to support both the victim and any minors. However, if both parents refuse to engage, social services should focus on ensuring the safety of the child. If the parents or caregivers will not engage with professionals, a child protection plan may need to be put into place.
• Listen, engage, assess, document and action – It is important to gather and analyse information. Professionals should ensure they engage with all family members and consider all the information carefully. All information should be thoroughly documented, and relevant actions should be implemented.

Can you avoid the toxic trio?

If a parent is experiencing one or more issues related to the toxic trio, it is not inevitable that all three issues will develop, or that any minors in the family are at risk of harm. There are several factors that can help the family and relevant professionals to avoid the toxic trio.

• Parent motivation – This is a major factor that can help prevent the toxic trio. If a parent is experiencing one or more of the issues but is motivated to ‘get better’ or ‘change’, they are more likely to engage with professionals. A parent who has a substance misuse issue but is motivated to stop using substances is much more likely to achieve long-term success.
• Access to support – There are several factors that can affect the ability to access support, some of which are outside the control of the family. These factors may include a referral being made, the response of practitioners, the available support, and waiting lists.
• A combination of therapeutic and practical approaches – Practical approaches could include access to housing and financial support, access to rehabilitation programmes and family support. Therapeutic approaches could include help and support for mental ill health and access to therapy.