Home > Protecting Children in Substance-Abusing Families > Protecting Children in Substance-Abusing Families : Identifying Alcohol and/or Other Drug Use

	Rate this Publication Average Rating: 5.00 (out of 5), 8 Raters Printable Version PDF (142 pgs, 1590 KB) Email This

Protecting Children in Substance-Abusing Families
User Manual Series (1994)

Author(s):  U.S. Department of Health and Human Services Kropenske, Howard, Breitenbach, Dembo, et al.

Year Published:  1994

previous

You are in section: Table of Contents Preface Acknowledgments 1 - Introduction 2 - Identifying Alcohol and/or… 3 - Chemically Involved Parents:… 4 - Children of Chemically… 5 - Reporting Child Maltreatment… 6 - Comprehensive Family… 7 - Juvenile Court Involvement… 8 - Innovative Approaches to… Conclusion Appendix I - The Nature of… Appendix II - Sample Medical… Appendix III - Sample Interagency… Notes Glossary of Terms Selected Bibliography Other Resources Table 1 - Hospital Form For… Table 2 - Sample Interagency… Table 3 - Assessment/Intervention… Table 4 - Assessment/Intervention… Table 5 - Assessment/Intervention… Table 6 - Major Substances of…

next

Identifying Alcohol and/or Other Drug Use

CASE VIGNETTE: Lisa was 19 years old and pregnant with her first child when her mother brought her for her first prenatal visit, which was towards the end of the third trimester. Clinic staff noted that Lisa was tall and quite thin, made poor eye contact, and seemed hostile towards them as well as to her mother. During the clinic appointment, Lisa's mother noted that the baby's father was a substance abuser who was occasionally violent towards Lisa. Just prior to delivery, at a second clinic visit, Lisa revealed to a social worker that she had used phencyclidine (PCP) and cocaine occasionally before her pregnancy. Although Lisa denied that she had a substance abuse problem, staff counseled her about the effects of substance abuse on the unborn child. Two weeks later, Lisa delivered a baby boy who was small for gestational age. Both she and her baby had urine toxicology screens that were positive for PCP and cocaine.

Because of the nature of chemical dependency and the generally illicit use of many drugs, often self-report is not an adequate screening measure to detect drug or alcohol abuse. Professionals commonly encounter denial and withholding of information when interviewing chemically involved clients. Thus, behavioral and physical indications of intoxication, although sometimes ambiguous, can provide important clues. Further, various tests may be recommended to help in the diagnosis and treatment of substance abuse.

Physical and Behavioral Indications of Substance Abuse in Families

The negative impact of alcohol and/or other drug abuse on family functioning and health may become apparent through a variety of physical and behavioral indicators. The following indicators can alert professionals to a possible substance abuse problem among family members:

• personality changes and inconsistent behaviors;
  
  
• financial problems despite an adequate income;
  
  
• sudden, unexplained wealth;
  
  
• frequent automobile or other accidents;
  
  
• self-defeating behaviors (e.g., missed appointments, absences from work, repeated lateness);
  
  
• repeated changes in friends and associates;
  
  
• altered mental status consistent with alcohol or other drug intoxication;
  
  
• withdrawal symptoms;
  
  
• skin lesions such as abscesses or track marks consistent with injection drug use;
  
  
• the presence of drug paraphernalia;
  
  
• frequent absences or tardiness of children at school; and
  
  
• a family member consistently making excuses for an absent family member.

Physical and Behavioral Indications of Perinatal Substance Abuse

The first step in determining a drug- or alcohol-dependent pregnant woman's need for services is to identify the problem. In addition to the general indicators noted above, the following physical signs and symptoms are suggestive of perinatal alcohol and/or other drug abuse:⁴

• lack of prenatal care,
  
  
• previous delivery of a prenatally drug-exposed infant,
  
  
• intrauterine growth retardation in the absence of other identifiable causes, and
  
  
• placental abruption in the absence of other identifiable causes.

Additional indicators of possible alcohol or other drug abuse may include women who deliver outside the obstetrical unit (in the emergency room, in the ambulance, or at home), or women who have abrupt deliveries.⁵ In order to promote consistency in assessment, the provision of appropriate prenatal services must be ensured. To ensure the child's safety after delivery, many hospitals have developed protocols to assist in identification and referral of pregnant and postpartum substance-abusing women and their offspring for treatment and supportive services. Appendix II provides a sample protocol.

Physical and Behavioral Indications of Relapse for Individuals in Recovery

Relapse is inherent in alcohol and other drug abuse. The identification of a substance-affected family is only the beginning of a long process toward healing and maintaining a sober lifestyle. For an individual in recovery, the following behavioral signs and symptoms may alert professionals to the imminent risk of relapse:

• increasing self-pity,
  
  
• increasing depression,
  
  
• setting expectations that are too numerous or unrealistic,
  
  
• feelings of being "all-powerful" or not needing support, and
  
  
• distancing from friends who are clean and sober.

Diagnostic Tests for Alcohol Use

After drugs or alcohol have been ingested, they pass via the bloodstream to various parts of the body, such as the liver and kidneys, where they are converted into substances called metabolites. Different drugs and their metabolites leave the body at different rates. The rate of drug and alcohol excretion is affected by many factors, including the amount of alcohol or other drug taken; the frequency of use; the user's daily liquid intake, health status, exercise, age, sex, body weight, and metabolic rate; and the concurrent use of other drugs, including alcohol and/or nicotine.

The most common tests for alcohol use include an evaluation of blood alcohol levels and a breath analyzer, both of which are routinely used to determine whether an individual is driving while under the influence. Because alcohol passes rapidly through the system, these tests must be conducted very quickly in order to ensure any degree of accuracy regarding alcohol consumption. For this same reason, the urine drug toxicology screens described below are generally not helpful in detecting alcohol use.

Toxicology Screening for Drug Use

Urine is the body fluid most commonly used for drug screening. For infants, meconium (the first stool passed by a newborn at birth) also can be used for toxicology screening. Compared with urine, the recovery rate and concentration of drug metabolites often are higher in meconium. However, collection of a newborn's first stool is not always possible because some meconium is eliminated during delivery. Hair analysis is another method currently being investigated in research studies to test for drug metabolites. Compared with other methods, hair is reported to provide a longer term of history of drug use.

The urine screening methods used by most laboratories generally can detect drug metabolites no more than 48 to 72 hours following drug use. Drugs such as marijuana and phencyclidine (PCP) are fat soluble and are stored in fat, liver, lung, and brain tissue; these substances or their metabolites often can be found in the urine several days after use. Other drugs such as cocaine and amphetamine are water soluble and are excreted from the body more rapidly.

When requesting and interpreting toxicology results, professionals must remember the following:

• There are two types of testing procedures:

  - screening tests such as thin layer chromatography (TLC) and immune assay tests (EMIT), and

  - confirmatory tests such as gas chromatography.

      - Screening tests are highly sensitive, whereas confirmatory tests are more specific. Because screening tests may yield false positive results, it is recommended that, when a positive result is obtained with a general screening procedure, it be confirmed by a less sensitive but more specific confirmatory method. Some laboratories may use a blood test to confirm a positive urine screen.

• There may be considerable variation in what drugs are routinely included in the laboratory screening process. Toxicology screening procedures vary from laboratory to laboratory. A negative toxicology result does not apply to a drug that was not included in the screen. For example, many laboratories do not routinely screen for PCP or marijuana. Thus, without a special request for PCP or marijuana screening, these substances, even if present in the urine, would not be identified.
  
  
• The quality of control over specimen handling and collection procedures greatly influence toxicology results. Because there are a number of ways to alter toxicology tests (e.g., providing someone else's urine or diluting the urine sample with toilet water), it is important that the person collecting the urine sample monitor the specimen collection process closely. Because test results also can be affected by diet and temporary abstinence, random screening without prior notice may provide a more accurate indication of drug use.
  
  
• When screening newborns, it is important to collect the first voided urine. Late collection of urine can yield negative results because metabolites may not be present at a level high enough for detection.
  
  
• In cases of prenatal substance abuse, it is helpful to test both mother and newborn to provide a more accurate picture of prenatal exposure.

In interpreting toxicology results, an important point warrants emphasis. False positive and false negative results do, at times, occur. Therefore, it is unwise to rely exclusively on toxicology screening to identify use of illicit substances. Rather, toxicology screening should be used in conjunction with history taking and observation for signs and symptoms to corroborate suspected use.

Toxicology testing during pregnancy and at the time of delivery can provide useful diagnostic information for health care purposes. The results of toxicology screens often are used by hospital personnel as a part of a suspected child abuse report. Although they indicate use of, or exposure to, a substance at some prior time, positive toxicology test results do not substantiate child abuse. In addition, false positive and false negative test results do occur. Thus, results should always be used in conjunction with comprehensive case evaluations of suspected child maltreatment.

The possible dual use of toxicology results for both medical and legal purposes also raises important questions about informed consent. Community standards vary for obtaining consent in cases involving prenatal substance abuse. Some medical facilities conduct toxicology testing under a general "conditions of admission" form that authorizes various medically indicated procedures. Other facilities require a special consent specifically authorizing toxicology testing. Other hospitals require that a patient be specifically informed of potential legal consequences before testing is conducted.

Many hospitals conduct toxicology screening of newborns, either under the general admissions "conditions of admission" form or in accordance with State child abuse and neglect laws that allow for certain testing and evaluation procedures without parental consent for the purpose of diagnosing prenatal drug exposure. Other institutions, however, require specific parental consent for toxicology screening. If parents refuse permission for testing, a court order can then be obtained in some States.

Because practices vary, it is important that professionals are aware of alcohol and drug abuse confidentiality regulations (e.g., 42 CFR, Part 2), the standards used within their local communities for obtaining consent for toxicology testing and for disclosing test results to child protection agencies. Hospital protocols also provide guidance for staff as well as help ensure consistency in hospital practice.

Summary

The behavioral changes brought on by various substances differ greatly from drug to drug. Alcohol, for instance, is considered to be a sedative/depressant, whereas cocaine and methamphetamine are stimulants. However, because polysubstance abuse is the most prevalent form of addiction, the effects of individual substances often are difficult to determine in any individual. Thus, if a client admits to cocaine use, it is often helpful for the professional to inquire about possible use of alcohol, marijuana, and/or another substance. The identification of alcohol and/or other drug abuse is a complex process that involves history-taking; observation of an individual's lifestyle and behaviors; and, finally, the use of diagnostic tests such as a breath analyzer, urine toxicology screens, and others described above. Once an individual with a substance abuse problem has been identified, professionals need to collaborate in planning a treatment/supportive services program that is sensitive to that individual's needs and family situation.

previous

You are in section: Table of Contents Preface Acknowledgments 1 - Introduction 2 - Identifying Alcohol and/or… 3 - Chemically Involved Parents:… 4 - Children of Chemically… 5 - Reporting Child Maltreatment… 6 - Comprehensive Family… 7 - Juvenile Court Involvement… 8 - Innovative Approaches to… Conclusion Appendix I - The Nature of… Appendix II - Sample Medical… Appendix III - Sample Interagency… Notes Glossary of Terms Selected Bibliography Other Resources Table 1 - Hospital Form For… Table 2 - Sample Interagency… Table 3 - Assessment/Intervention… Table 4 - Assessment/Intervention… Table 5 - Assessment/Intervention… Table 6 - Major Substances of…

next

This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.

Updated on December 10, 2007