Home > Protecting Children in Substance-Abusing Families > Protecting Children in Substance-Abusing Families : Comprehensive Family Assessment

	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

Comprehensive Family Assessment

CASE VIGNETTE: Following the referral to CPS by newborn nursery personnel, Lisa became angry at the hospital and its staff and did not want to bring Timmy back to the hospital for well-child care. She also refused to cooperate with the CPS assessment, and Timmy's father became verbally abusive towards the CPS workers. The maternal grandmother was contacted. Although she was hurt and angry about CPS involvement with her daughter and grandchild, Lisa's mother eventually shared what she knew, describing her daughter's unstable lifestyle and addiction. Upon questioning, she indicated that she would be willing to care for Timmy and encourage her daughter to enter a substance abuse treatment program. Further assessment revealed that the grandmother's home life was stable and that she would be able to provide a safe and nurturing environment for her grandson.

The assessment process for any troubled family that has come to the attention of professionals should involve an inquiry that addresses both the problem of substance abuse and the problem of child maltreatment. In addition to the initial determination of risk of harm to the child, information about family dynamics and the service needs of parents and children needs to be addressed. Thus, the initial assessment of chemically involved families overlaps substantially with the initial assessment process for nonsubstance-abusing families, and the reader is referred to the companion manual in this series, Child Protective Services: A Guide for Caseworkers, for a detailed description of factors that need to be evaluated to determine a child's immediate safety.

Once the initial assessment has revealed a family problem related to alcohol and/or other drug use, a more comprehensive assessment of the chemically involved family's functioning is critical to the overall intervention process. Such an assessment lays the groundwork for building on family strengths and selecting services to meet the complex needs of both parents and children. Because parental abuse of alcohol and other drugs impacts all family members and all aspects of their life together, it is essential that the assessment process be family focused. Furthermore, since the circumstances within chemically involved families, especially those with special needs children, can change rapidly (sometimes in ways that can be dangerous to children) the process of assessment must be ongoing. A comprehensive, culturally sensitive, and continuing assessment is pivotal to the development of a realistic service plan and provides a framework for evaluating the effectiveness of intervention whether the assessor works in CPS, health care, education, substance abuse treatment, mental health, or the juvenile justice system.

This chapter begins with a discussion of how to gather family assessment data and then details the types of information professionals should explore during the assessment process. The reader should remain aware that the comprehensive assessment is a process that takes time. As professionals become more experienced with the general areas of the comprehensive assessment, and as they become more familiar with individual families, the assessment questions will become more evident, often becoming part of the intervention process itself.

Gathering Information

To gather sufficient information regarding the chemically involved family's functioning, professionals need to:

• Conduct interviews with parents and other family members.
  
  
• Make a series of visits to evaluate the home environment, family dynamics, and interactions among family members.
  
  
• Contact other service providers and agency representatives who have been, or are currently, involved with the family.
  
  
• Obtain or arrange for a variety of standardized evaluations for the parents as well as for the children.

Interviews With Family Members

Interviewing all family members is important. Alcohol and other drug problems affect every member of the family, and it is important for professionals to assess how a parent's substance abuse has affected the health, schooling, and social life of each individual within the immediate and extended family.

Professionals should not rely solely on interviews to gather information. Observation of nonverbal behavior, appearance, and environment may substantiate or contradict information gained during the interview process. For example, a parent may deny substance abuse but exhibit behavior that is suggestive of drug or alcohol use such as slurred speech, staggering gait, and/or drowsiness.

Home Visits

Home visits are critical because the home environment can reveal a great deal about a family's day-to-day functioning, cultural beliefs and affiliations, strengths, and problems. Compared with a clinic or office interview, a home visit provides less structure, and families may present themselves quite differently. Further, many families feel more comfortable being interviewed in their own homes.

Collateral Contacts

Denial of alcohol or other drug abuse is common in chemically involved families. Moreover, parents may minimize the extent of their drug and/or alcohol use or deny any relapses because of fears that their children will be removed from their custody. Thus, to make an accurate assessment, it is important to obtain information from knowledgeable sources outside the family system. These sources may include physicians, nurses, social workers, teachers, members of the clergy, employers, neighbors, child care providers, mental health professionals, substance abuse counselors, parole and probation officers, and CPS caseworkers. In gathering information from these sources, the interviewer should be familiar with the guidelines for confidentiality that govern individual and agency practice with respect to the sharing of information. Federal Law 42 CFR, Part 2, for example, governs the release and exchange of confidential information about an individual's use of alcohol and other drugs.

Standardized Evaluations

Standardized assessment tools are used to monitor a child's developmental progress and to help identify developmental and educational service needs. Use of standardized evaluations with parents, as well, can be helpful in identifying developmental disabilities and underlying psychiatric problems. For a description of specific evaluation tools, the reader is referred to companion manuals in this series, Treatment for Abused and Neglected Children: Infancy to Age 18 and The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect.

Areas of Assessment

Appropriate planning and intervention with substance-abusing families begins with a careful assessment of a number of infant/child, parental, and environmental factors. It is the combination and interaction among these factors that help the professional evaluate the child's safety in the home and determine the types of services needed by the family. The following sections are intended to provide guidelines for the professional regarding factors that should be explored as part of a comprehensive family assessment.

Assessment of the Infant and Child

Children prenatally exposed to alcohol and other drugs, and children living with substance-abusing parents are vulnerable populations. Often, such children are both biologically and environmentally at risk of developmental lags; many have special needs.

Infant Assessment

Because the minimum standards for adequate parenting may be higher for an infant prenatally exposed to drugs, it is especially important for the professional to assess carefully the infant's health and care requirements. This information generally is gathered through standardized examinations and observations of the infant as well as through interviews with the primary caregiver(s) and involved health care personnel.

In assessing the infant's needs, professionals should consider the following:

• Does the newborn exhibit symptoms of drug exposure? (These may occur within several hours of birth, although some newborns may not show symptoms until much later.) Of particular concern are infants who have diarrhea, sleep poorly, are lethargic or irritable, or are on medication for drug-related symptomatology.
  
  
• Were toxicology screens conducted? If so, what were the results?
  
  
• Was the infant born prematurely (before 37 weeks of gestational age)? Symptoms related to pre-natal substance exposure may be masked by the infant's degree of illness or the immaturity of the CNS.
  
  
• Will the infant require special medication and/or equipment such as an apnea monitor or oxygen? If so, caregivers may require special instruction or training.
  
  
• Does the infant have medical or physical problems that could significantly impact critical life functions or long-term physical and intellectual development? For example, does the infant have a cardiac defect, seizures, or other congenital anomalies? Will the infant require close medical monitoring and frequent pediatric visits? If so, does it appear that the parents' substance abuse may interfere with their ability to provide the needed level of care and to obtain the medical followup required?

Child Assessment

Children can be harmed not only through prenatal drug and alcohol exposure, but also by being raised in environments in which these substances are abused. Often, the basic care of children is inadequate in households with chemically involved caregivers. In comparison with the general population, child maltreatment occurs with greater frequency in substance-abusing families.¹⁵ Alcohol and other drugs can be passed to an infant through breast feeding; fumes from drugs that are smoked may be inhaled by children within the home; substances may be accidentally ingested by children; and youngsters can be deliberately given drugs or alcohol by substance-abusing adults. Professionals should consider the following:

• How many children are there in the home? What are their ages?
  
  
• With whom do the children spend most of their time? What are their activities as well as their relationships with their parents, peers, and other adults? Chemically involved parents/caregivers frequently provide inadequate supervision. Without appropriate parental oversight, young children are at increased risk for victimization and injury.
  
  
• Are there adequate and appropriate supplies and provisions for the children? Chemically involved parents may use money that should be spent on basic life necessities for the purchase of drugs and/or alcohol.
  
  
• Are the children receiving ongoing health care? Do any children have chronic illnesses? Are immunizations current? Are there any untreated medical conditions? Do any children have histories of prior injuries, and if so, were these accidental or inflicted? Are the children's growth patterns within expected ranges or is there evidence of failure to thrive?
  
  
• Are the children enrolled in school? Do the parents meet with school personnel when indicated? Do the children generally appear clean and appropriately dressed when they go to school? How are the children functioning academically? When a chemically involved family has had repeated disruptions in daily routine or frequent changes of address, the children may have missed much school or had to change schools often. Because learning deficits and short attention spans may occur as a result of prenatal substance exposure or environmental instability, it is important to assess all children living in the home with respect to these problems. Children may appear to be physically healthy but may nonetheless have developmental and educational deficiencies.
  
  
• Because role reversal is common in chemically involved families, has a child assumed the role of a parent by performing adult caregiver tasks? If so, what resources are needed to support the family so that the child can be freed from inappropriate and/or dangerous responsibilities?

Careful observation of all children in a chemically involved family is essential in assessing and planning for the family as a whole, and for making appropriate health care and educational referrals for the children.

Assessment of the Adolescent

Adolescents with alcohol or other drug use problems are often experiencing other problems as well. These problems may include mental health problems, violence between family members, child abuse, and involvement with the criminal justice system. Adolescents living in such troubled environments are likely to be experiencing difficulties in a number of areas, including family relationships, physical abuse/sexual victimization, educational performance, and emotional/psychological functioning. Many of these difficulties can be traced to an early age and, if not addressed, place these youths at high risk of future drug use and delinquency/crime.

In view of the often interrelated nature of these problems, it is important that the assessment of adolescents in substance-abusing households be holistic and comprehensive–rather than in one-problem-at-a-time terms. Information needs to be collected on their experience of specific problems so that service needs can be identified and appropriate interventions developed.

Before comprehensive assessment begins, it is important for the assessor to determine what constitutes the "family" for the adolescent who is to be evaluated and to be respectful of cultural and ethnic variations in family structure. For many members of society, the traditional definition of family is no longer applicable. A given adolescent may derive his/her physical (e.g., food and shelter), emotional, spiritual, and cultural needs from different individuals. Persons who serve as family in the adolescent's life by virtue of providing for physical, emotional, and/or spiritual needs should be included in the assessment process. ¹⁶

Within available time and resources, efforts should be made to assess the adolescent in a range of domains, including health history, psychosocial background, educational experiences, and community agency involvement, as detailed below:¹⁷

• medical history (including illnesses, infectious diseases, and HIV status);
  
  
• mental health problems and history (including previous evaluations and treatment);
  
  
• family environment and how the adolescent perceives this situation--including perceptions and evaluations of any parental alcohol and other drug use, mental or physical health problems (e.g., chronic illnesses), family interrelationship problems, incarceration, or illegal activity;
  
  
• physical or sexual abuse experiences, as well as other developmental issues;
  
  
• strengths or resiliency factors, including self-esteem, family, other community supports, and coping skills;
  
  
• alcohol and other drug use, including the use of over-the-counter and psychotherapeutic drugs, tobacco, and caffeine;
  
  
• peer relationships, including gang involvement;
  
  
• leisure and spare-time activities;
  
  
• educational history, including academic performance, learning difficulties, and school behavior or attendance issues;
  
  
• history of involvement with social service agencies, including child welfare and foster home placements; and
  
  
• nature and degree of involvement with the juvenile justice system.

It is important to appreciate that assessment of the adolescent does not constitute an end in itself. Rather, the assessment process carries the implicit promise that identification of problems in the various domains that are assessed will lead to a written report that will be used as a basis for linking troubled adolescents with needed services. The report should specify treatment recommendations as well as need posttreatment services. It should represent an action plan that the family and the adolescent can accept and support. Rather than serving as a passive agent in the assessment process, the assessor should be a broker who sees to it that needed services are arranged for and provided.

Assessment of the Parent

Professionals working with chemically involved families may experience difficulty assessing the parents. First, their training may not have provided these professionals with a knowledge base for understanding substance abuse and its impact on individual and family functioning, parenting, and child health and development. Second, some professionals may feel uncomfortable and intrusive when inquiring about alcohol or other drug use and related lifestyle activities because of the legal and moral implications of illicit use. Third, often child abuse, substance abuse, developmental disabilities, and mental and physical health care problems are connected in chemically involved families, whereas individuals working in each of these specialized areas commonly have little contact with each other or knowledge about each other's related fields. Fourth, stereotypes of drug-addicted or alcoholic individuals may lead professionals to mistake or overlook chemical dependency.¹⁸

To overcome these obstacles, it is imperative that professionals learn to recognize, identify, and assess for substance abuse and to determine how substance abuse is perceived within the family and within the context of the family's culture. Only then can they develop a service/treatment plan that is appropriate to the needs of the family. In addition, by having supervision and consultation services readily available, professionals can be assisted in developing and maintaining an empathic, nonjudgmental, and informed approach. As part of the comprehensive assessment, the following parental factors should always be evaluated, including substance abuse history, drug and alcohol treatment history, health and health care, mental health and history of psychiatric treatment, criminal history, level of cooperation, awareness of the impact of alcohol and other drug use on the child, parenting skills and responsiveness to the child, history of abuse and/or neglect, and work history and education, as detailed below.

Substance Abuse History

Exploring a parent's history of alcohol or other drug use provides the professional with an understanding of the chronicity of the problem, and also helps in determining which treatment resources are most appropriate for individual parents. Although the information obtained during an initial interview may not be complete, talking with parents over time frequently reveals accurate information regarding substance abuse. Communication with members of the extended family, significant others, and professionals from other agencies can be particularly helpful in gathering a parent's substance abuse history. For many reasons, parents frequently deny the length and severity of their drug or alcohol use.

In assessing a suspected alcohol and/or other drug abuse problem, it is important to keep questions open-ended and assume use in order to elicit more realistic responses. The following are possible questions a professional might ask to gather information about patterns of use and the parent's perceptions about use:

• How often do you drink beer, wine, liquor?
  
  
• How many drinks do you generally have when you are drinking?
  
  
• How old were you when you had your first drink?
  
  
• When do you tend to want a drink? When alone or with others? If you drink with others, with whom? When bored or when you want to "party"? When you are angry, frustrated, or stressed?
  
  
• What drugs have you tried?
  
  
• How often do you use?
  
  
• How do/did you use/take it?
  
  
• How long have you been using? How long did you use?
  
  
• How much do you smoke?
  
  
• When do you usually want a cigarette?
  
  
• When you were pregnant, what was your drinking/use like?
  
  
• How does your behavior change when you drink/use?
  
  
• How do you feel when you drink/use?
  
  
• What impact has alcohol and/or other drug use had on your own health?
  
  
• What legal problems have you encountered as a result of your alcohol and/or drug use?
  
  
• How has the use of alcohol and/or other drugs affected your employment?
  
  
• How has your use of alcohol and/or other drugs affected your social relationships?
  
  
• Has the use of alcohol and/or other drugs resulted in violence or abuse in the home?
  
  
• What concerns do you have about your use of alcohol and/or other drugs?

It is also helpful to assess the impact of use on the family, since this information can be used in developing an effective intervention plan. The following are areas a professional can explore with other family members to gather information about a parent's alcohol and/or other drug abuse problem:

• How do family members view alcohol and/or other drug use?
  
  
• Do family members deny use and/or its impact?
  
  
• Do family members express worry about the user?
  
  
• Do family members feel tense, anxious, or overly responsible?
  
  
• Are family members angry with the user?
  
  
• Do children in the family exhibit adult behaviors or assume adult parenting roles?

Drug and Alcohol Treatment History

Professionals also need to explore parents' attempts at substance abuse treatment in order to understand how parents have dealt previously with their abuse of alcohol or other drugs. Obtaining the parents' treatment history helps ensure that current treatment referrals will be appropriate. For example, parents who have been repeatedly unsuccessful in outpatient treatment may benefit more from a referral to a residential setting than from a referral to yet another outpatient program. Professionals should determine the following:

• Have the parents ever been in a drug or alcohol treatment program? If so, where and for how long? What was the motivation for seeking treatment, and what were the circumstances under which the parents left treatment? Any indication of motivation should be pursued as a possible strength.
  
  
• For parents currently participating in a treatment program, what is the frequency and extent of their participation? Some parents, for example, may attend a treatment program only sporadically, whereas others may attend regularly but still continue to abuse drugs or alcohol. Other parents may be appropriately engaged in treatment. In evaluating compliance, it is important to remember that, although the parents' participation may provide a clue to their level of commitment, it also may indicate the need for different or supplemental treatment approaches.
  
  

Health and Health Care

Often, substance-abusing parents have health problems related to their alcohol and other drug use. Such problems can adversely affect the parents' ability to care for both themselves and their children. Thus, professionals should assess the following:

• What is the parents' general state of health? Are there any untreated medical problems or chronic illnesses? Chemically involved parents are at high-risk for communicable diseases such as tuberculosis and sexually transmitted diseases, including acquired immunodeficiency syndrome (AIDS), and may need to be referred for medical evaluations.
  
  
• If medical care is needed, does the parent have financial and logistical access to services?

In situations of perinatal substance abuse, the professional should determine whether prenatal care or drug treatment services were available to the mother during pregnancy. It then is important to learn whether the mother obtained regular and consistent care; this information can reflect a parent's ability to use health care systems and also may be an indicator of the mother's ability to plan and obtain appropriate medical care for her infant. In this respect, it is important to communicate with health clinic personnel or private physicians who may have treated a mother during pregnancy. Although it would be of concern if a mother had obtained no prenatal care, this information could be viewed quite differently if the woman had sought services and none existed, or if services were difficult to access.

Mental Health and History of Psychiatric Treatment

Parental mental health problems require careful evaluation but may be difficult to assess due to current intoxication or chronic substance abuse. However, identification and assessment for coexisting psychiatric problems is essential for appropriate case management. In evaluating mental status, it is imperative for professionals to determine the following:

• Have the parents ever obtained assistance from a mental health counselor? Have they ever been hospitalized for psychiatric reasons? If so, the history of hospitalization, length of stay, and reasons for admission should be explored.
  
  
• Have psychotropic medications been prescribed for the parents? If so, why were they prescribed, and are the parents currently taking the medications? This information is particularly relevant to making an appropriate substance abuse treatment referral because some chemical dependency treatment programs may be reluctant to accept clients who are currently taking psychotropic medications. In addition, a lapse in taking necessary medications or the mixing of psychotropic medications with other substances may exacerbate psychiatric symptoms that can place a child at risk of maltreatment.
  
  
• Do the parents have a history of violence toward others? Is there a history of domestic violence? Substance abuse, psychiatric problems, and problems with impulse control can be closely intertwined.

Criminal History

Because chronic substance abuse often entails contact with law enforcement agencies, reviewing a parent's criminal record is an important part of the assessment process. Professionals should determine the following:

• Does the parent have a criminal record? If so, what was the charge?
  
  
• Is the parent currently on probation or parole?
  
  
• Has the parent ever served time in jail or prison? Parental incarcerations mean that a child has been separated from a parent and also may have been left with nonparental caregivers.

Exploration of a criminal history can help the professional gain further information about the parent's lifestyle and about unhealthy situations and illegal activities to which children in the family may have been exposed. Further, information about how the family handled periods of incarceration (including visitation and reunification) can help the professional determine family members' sensitivity to the child's feelings and need for security.

Level of Cooperation

Parents' willingness to work with professionals to strengthen the family and protect their children is of considerable importance. A parent who initially seems disinterested, evasive, or hostile may, in fact, prove uncooperative with service/treatment plans. However, here, as in all other areas of assessment, clinical judgment is extremely important. A parent's initial uncooperativeness may also indicate feelings of guilt about substance abuse and defensiveness about the assessment process. Parents may be angry or feel vulnerable because of the power differential between themselves and the professional, and they may perceive a loss of control. Parents also may be fearful of legal consequences. To evaluate cooperation, professionals should consider the following areas:

• Does the parent verbalize a willingness to work with the agency?
  
  
• Does the parent generally follow through with various aspects of the service/treatment plan?

Subsequent behavior and follow through are critical in accurately evaluating cooperation. A parent may appear to be compliant and yet, in fact, may be unable or unwilling to meaningfully engage in the service/treatment plan.

Awareness of the Impact of Alcohol and Other Drug Use on the Child

It is important to assess parents' understanding of the relationship between their substance abuse and their children's care. Parents' willingness to acknowledge the impact of their substance abuse may indicate their receptivity to services for themselves as well as for their children. Professionals should consider the following:

• If the parents were under the influence when the suspected child abuse or neglect occurred, and this was a contributing factor, do the parents acknowledge this relationship, and are they willing to make the changes necessary to avoid repeated injury or neglect?
  
  
• How have the parents provided for their children's needs in situations of relapse? It is helpful to determine whether parents have exercised the judgment to leave their children in the care of responsible relatives or friends, or whether the children have been left with strangers or brought along with the parents into dangerous situations.
  
  
• In cases of prenatal substance abuse, how do the parents view the infant's symptoms? Initially, parents may deny that symptoms or developmental problems exist. Although this initial denial can serve as a protective coping mechanism for parents, continual denial may interfere with the parents' obtaining needed services for their children.

Parenting Skills and Responsiveness to Child

Evaluation of parents' caregiving skills and responsiveness to their children's needs is a particularly critical aspect of the assessment process. Because many chemically involved parents themselves were poorly parented as children, they may lack healthy role models for parenting their own children. The professional can obtain much information by listening sensitively to parental comments and by observing parent-child interactions. Such information can help the professional determine the need for parents' involvement in parenting education programs or individualized counseling.

• How do the parents react to the children's behavior? How do they provide praise and discipline? Are the parents' expectations age-appropriate? When the parents' expectations are incongruent with the children's capacities or when parents are prone to extremes in physical discipline, the children's risk for abuse may be increased.
  
  
• How do the parents respond to their children's emotional needs? For example, how do the parents respond to the children's crying? Do the parents and children make eye contact? For a hospitalized child, how frequent are parental visits? Such information may be used to determine the need for therapeutic counseling and educational services to strengthen the attachment between parent and child.

History of Abuse and/or Neglect

Chemically involved parents may already be involved with child welfare agencies, have children in foster care, or have suspected or substantiated histories of child abuse or neglect. Professionals need to determine the following:

• Have there been previous child abuse or neglect investigations, substantiated reports of abuse or neglect, and/or other children under juvenile court jurisdiction? The facts surrounding these situations should be obtained and integrated into the total assessment so that plans and decisions can be made on the basis of long-term patterns rather than on the basis of an isolated and perhaps ambiguous situation. The professional will need to contact appropriate child CPS agencies for this information.
  
  
• If the parents have other children in out-of-home care, what were the reasons for placement? What arrangements have professionals made to support parental visitation? What has the parents' level of participation with these children been? Do the parents phone or visit the children? Do they respond appropriately to their children and the foster parents during home visits? Have the parents ever visited while under the influence?

Work History and Education

Information regarding parents' work histories and educational backgrounds can help professionals better understand the parents' level of literacy and survival skills as well as the extent to which their substance abuse has had an impact on their day-to-day responsibilities.

• What are the parents' occupations? When were the parents last employed?
  
  
• What are the parents' educational levels? How do they describe their school years? Do the parents have difficulty with reading, writing, and/or comprehension? This is critical to understanding parents' ability to function within community programs and will help the professional minimize barriers to appropriate treatment and services.

Assessment of the Home Environment

Much of the information described above may be obtained during interviews conducted outside the family home, but there is some information that can only be obtained through home visits. Because home visits allow the professional to assess the physical and social environment in which the family lives, these visits may reveal crucial information about family functioning and the parents' ability to provide safety for their children. For example, chemically involved parents sometimes give false addresses that turn out to be parking lots or empty stores. These parents also may list addresses of residences where they do not live. In some instances, parents may not actually have a permanent residence because they move frequently to avoid detection by authorities or because they have used their income to purchase drugs and/or alcohol. A family's situation may appear to be stable on the basis of interviews within an agency setting, but home visits may reveal a different picture. Assessment of environmental conditions, partners or parent substitutes within the home, and family support systems can help provide a more realistic picture.

Environmental Conditions of the Home

It is important to evaluate the family's environment because general living conditions can pose risks for illness or accidents. Furthermore, certain environmental conditions may be essential to a child's basic health and, in some instances, may even be lifesaving.

Here, as in the other assessment areas, sound clinical judgment and cultural sensitivity are of the essence. A family may live in poor circumstances, on the street, or in a shelter because of poverty, bad fortune, or hardship. However, a family's lack of residence or impoverishment also may be due to parental substance abuse. Understanding the reasons for a family's impoverishment is useful for determining the types of services that should be offered. In evaluating the home environment, professionals should assess the following:

• How long has the family resided at the current address? Is a recent move related to an attempt to provide a safer environment for family members? Is there a pending eviction? Is this a stable residence? Often, planning for services, especially in-home services, depends on a family remaining at a particular address or within a specific geographic area.
  
  
• Are there safety or health hazards? Are there rodents or other infestations? It is helpful to determine whether the family has attempted to remedy these situations as well as whether the family's housekeeping habits have contributed to these problems. Depending on the situation, advocacy, homemaking services, or parental education may be needed.
  
  
• Is there food in the home?
  
  
• What is the condition of the electrical system, gas lines, water supply, and sanitary facilities? Does the family have a telephone? If not, is there a nearby phone where messages can be left? These factors are particularly critical when a child in the family is medically fragile. For example, because children who have problems with their immune systems are highly susceptible to infections, unsanitary conditions may be life-threatening. Likewise, refrigeration is required for safe storage of many medications and special feeding supplements. For some children, such as those who require apnea monitors, a telephone in the home is essential.
  
  
• If there is a newborn child, what supplies do the parents/caregivers have for the baby? Has a sleeping space for the infant been prepared? Assessment of these factors may tell the professional much about the parents' ability to plan ahead as well as about their understanding and acknowledgment of the infant's needs. If there are limited preparations for a newborn child, it is important to attempt to determine the extent to which poverty has played a role, or if the need for drugs or alcohol has greater priority than the infant's needs.
  
  
• For older children, has basic clothing been provided? For example, do children have clothes that are appropriate for the season?
  
  
• What toys are available for the children? Do they have a safe play space? This information can help the professional gain a better understanding of the way children's developmental needs are currently being met, as well as determine the need for referrals to day care, preschool, or Head Start programs.

Partners or Parent Substitutes Within the Home

Partners or other parent substitutes living in the home may be supportive, stabilizing individuals who can help with caregiving. However, these persons may be substance abusers, involved in illegal or violent activities, or may have histories of abusing or neglecting children. Because substance abuse can lead to a lessening of inhibitions and controls and because family stresses can increase in connection with the quest to maintain an addiction, chemical dependency on the part of persons living within the home can easily lead to violence. In assessing the home environment, professionals should note the following:

• Who else lives in the home? What are these individuals' relationships with the children? Do they provide child care?
  
  
• Is there a suspicion that others living in the home are involved in the use, manufacture, or sale of illicit substances or other criminal activities?
  
  
• Do others within the home display poor impulse control? Is there evidence of domestic violence? Child abuse? Other forms of violence in the home?

Family Support Systems

Another important part of the assessment process includes learning about the family's support systems. As a result of their substance abuse, some chemically involved parents lead isolated lives or have few friends, relatives, or contacts within community groups who can be helpful to them. Parents who have more resources upon which to rely during difficult times are more often able to provide a "safety net" for their children. Community and family supports are particularly significant for this population of vulnerable parents and children. Professionals should determine the following:

• What are the parents' relationships with extended family, friends, and neighbors? Do family members live in the area? Are they a source of support or stress?
  
  
• Are the parents involved with a church, temple, or community or social group? Is there a member of the clergy who can become involved in strengthening and counseling family members?
  
  
• Are the individuals identified by the parents as supports alcoholics or involved with other drugs? (The professional can explore this factor by asking about these individuals' employment and lifestyle, as well as about the kinds of support they provide.)
  
  
• How do relatives and friends support parental attempts to make lifestyle changes? Do they collude in the parents' denial?

In assessing the family support system, it is critical for the professional to talk with relatives and friends to determine their level of commitment and the circumstances under which they can be available to help and support the family.

Assessment of Relative Caregivers

When they cannot be protected from harm within their own parental home, children must be placed elsewhere to ensure their safety. Placement with relatives is often the first choice in such cases. To ensure that infants and children receive appropriate care from relatives and that services will be provided to relatives that will support them in the care of the children, it is essential that professionals assess the relatives' abilities and vulnerabilities in the areas of parenting skills and history of abuse, neglect or violence; alcohol and/or other drug use; quality of the relationship with the parent and ability to protect and nurture the child; and cooperation, receptivity, and access to services.

Parenting Skills and History of Abuse, Neglect, or Violence

Because of the intergenerational nature of substance abuse and child maltreatment, it is important to carefully evaluate relatives' past and present functioning with regard to their ability to meet the child's basic needs and to ensure that the child is protected from harm. Professionals should assess the following:

• Has the relative had previous involvement with CPS agencies? If so, when did this occur and for what reasons? How was the situation resolved?
  
  
• Does the relative have a history of poor impulse control evidenced by violence in the home?
  
  
• Does the relative have a history of criminal activity that potentially could impact the care of the child?
  
  
• Does the relative have emotional, physical, or intellectual limitations that would impair his/her ability to provide adequate care and supervision for the child?
  
  
• How do the relative and the child relate to each other? What has been their pattern of interaction? How does the relative respond to the child's behaviors? How does he/she provide praise and discipline? Are expectations age-appropriate?
  
  
• If the child has special needs, does the relative have access to needed services, and are services properly utilized?

Alcohol and/or Other Drug Use

Assessment of the relatives' drug and/or alcohol use is critical. Because intergenerational substance abuse characterizes so many chemically involved families, it is helpful to inquire into this area so that a child is not placed with another substance-abusing caregiver. Professionals need to assess the following:

• Does the relative have a history of chemical dependency? If so, what was the extent of the addiction? How long has the relative been in recovery?
  
  
• What impact has substance abuse had on this relative's life and functioning?

Quality of the Relationship With the Parent and Ability to Protect and Nurture the Child

It is essential to assess the dynamics of the relationship between birth parents and relative caregivers. Often, this relationship has implications for the child's physical safety and emotional well-being especially in situations in which there is ongoing conflict between parents and extended family members. In kinship situations, it is important for professionals to evaluate the following:

• How have the parent and relative handled past conflicts? Is the parent violent or disruptive such that placement of the child with the relative might threaten the safety of either the child or the caregiver?
  
  
• Does the relative acknowledge that the parent has a substance abuse problem? Does the relative acknowledge its impact on the child? Is the relative familiar with signs of drug and alcohol intoxication? Is the relative able to report honestly about parental visits and behavior? Such information may help the professional better assess whether the relative caregiver has the will, ability, and strength of character to set limits on the parent's behavior in order to protect the child.
  
  
• Is the relative angry with the parent or so "burned out" with the parent's behavior that support for the parent-child relationship will be compromised?
  
  
• Is the child likely to be used in a power struggle between the parent and the relative caregiver?
  
  
• Is the relative caring for other children? If so, how many? How does the relative manage the care of all the children in the home?
  
  

Cooperation, Receptivity, and Access to Services

A relative caregiver's receptivity to education and intervention significantly affects the child. For some relative caregivers, access to medical, psychological, and educational services may not have been as critical in raising their own children as it is for a special-needs child, and therefore they may be unfamiliar with how to use community resources and unaccustomed to asking for assistance. Further, some relatives have difficulty acknowledging substance abuse on the part of persons close to them. They may perceive substance abuse as a "moral failure" and may wish to keep family problems private, considering involvement with professionals to be stigmatizing. Other relative caregivers may have histories or backgrounds of their own that they do not wish to discuss, and thus the involvement of other agencies may be viewed as intrusive or threatening. Relatives who are more accustomed to privacy may be confused and overwhelmed by the comprehensive assessment process. However, because a relative's willingness and ability to work with agencies can be critical to the child's health and safety, it is important for professionals to assess the following:

• Does the relative only give "lip service" to being cooperative with agencies' service/treatment plans, or does the relative demonstrate appropriate follow-through?
  
  
• Is the relative able to share concerns and problems related to the child's placement as they arise?
  
  
• Does the relative have access to transportation and a telephone? Is there access to medical resources? What arrangements can be made in the case of an emergency? For some children with special needs and equipment, the presence of a telephone and access to transportation may be lifesaving.

Assessment of Foster Parents

At times, foster care placement may be required. In order to identify services that are required to meet the child's needs in foster care, the foster parents' attitudes towards the birth parents, caregiving, perceptions and expectations of the child, receptivity to services, and family supports should be carefully evaluated.

Attitudes Toward Birth Parents

The foster parents' feelings and attitudes toward birth parents greatly influence reunification and case management services. Professionals should explore the following:

• What is the foster parent's attitude toward alcohol and other drug abuse? Does the foster parent believe that chemical dependency is treatable? If foster parents have a hopeless and punitive attitude toward substance abusers, this can negatively impact a child's feelings about his/her parents as well as the child's own self-esteem. This attitude also may affect a foster parent's willingness to cooperate with the visitation plan.
  
  
• What is the foster parent's attitude about having contact with parents who have a history of substance abuse? Is the foster parent fearful for his/her own family's safety? Does the foster parent feel able to set limits on parental behavior when necessary? Eliciting and evaluating a foster parent's concerns can help the professional in determining whether visitation schedules and locations need to be modified or whether, instead, more guidance and education for the foster parent are indicated.
  
  
• Is the foster parent appropriately supportive of the relationship between the chemically involved parent and child? Does the foster parent respect the biological family's cultural/religious beliefs? This is a critical area for evaluation because a foster parent's ability to work with chemically involved parents will have an impact on reunification plans and can affect how children feel about themselves and their families of origin. When there are concerns about a foster parent's attitudes toward biologic parents, professionals may need to increase their own involvement with the foster parent as well as facilitate referrals for further education and guidance for the caregiver.

Caregiving

Because some children in chemically involved families have special medical or educational needs, it is critical to assess the foster parent's ability to care for special-needs children. Professionals need to consider the following:

• If the child has had prenatal alcohol or other drug exposure, has the foster parent ever cared for a prenatally substance-exposed baby? If not, is the foster parent willing to attend training programs or work with professionals to acquire the necessary skills?
  
  
• If the child has special needs, is the foster parent able and willing to keep multiple appointments, or do the needs of other family members in the home make this too difficult? Does the foster parent have access to necessary pediatric and subspecialty care, or does the foster parent need advocacy and referrals for such services?

Perception and Expectations of the Child

The foster parents' observations of the child can help professionals determine the need for health, developmental, or educational services. In addition, foster parents' perceptions and expectations can greatly affect the quality of care provided. Because there is much misinformation about children from chemically involved families and often much uncertainty about how a child's vulnerabilities may manifest, it is important for professionals to determine the following:

• Does the foster parent have concerns about the child's health or development? Foster parents may observe previously unrecognized conditions that may require further evaluation.
  
  
• Is the foster parent able to identify the child's positive attributes? Are expectations age-appropriate? Are difficult behaviors personalized? When there are difficulties in these areas, a foster parent may require counseling and education to help him/her find strengths within the child, understand the dynamics that underlie the child's behavior, and learn how best to help the child with these problems.

Receptivity to Services

It also is necessary to assess a foster family's receptivity to help and services. Because children from chemically involved families often require a range of services, professionals need to consider a foster parent's willingness to work with a variety of agencies and individuals. Questions that the professional should consider in this area include:

• Is the foster parent open to new information, strategies, and resources?
  
  
• Does the foster parent demonstrate willingness to work with the agency and follow the service/treatment plan?
  
  
• Does the foster parent recognize the need for recommended services?

Family Supports

The professional needs to explore the effect of an infant's or child's placement on the entire foster family system. Because caring for children from chemically involved families can be stressful for the whole family, the professional needs to assess the following areas to determine the need for respite services or referrals for foster family support:

• If the child has special needs, how is the foster family handling the increased stress caused by this placement? Are supports in place to help with caregiving and provide respite?
  
  
• Are the child's special needs placing excessive stress on other children in the family?

Guides for Assessment

To help professionals better assess the comprehensive needs of chemically involved families, relative caregivers, and foster parents, special assessment/intervention guides have been included in Tables 3, 4, and 5.¹⁹ Divided into three broad areas (the child, the caregiver, and the environment), these guides rely heavily on an ecological model of human development and family functioning and on the assumption that child abuse and neglect is determined by the interactions of multiple factors within the individual, the family, the community, and the culture.²⁰ These guides are not intended for use in a mechanical fashion; no numerical scores should be assigned as the basis for decision making.²¹ Rather, these assessment guidelines are intended to be used as tools to enhance professional clinical judgment. Although these guides are not predictive of future child abuse or neglect, they may be helpful to staff in a number of ways:

• They can help remind professionals of the kind of questions they need to ask parents and the kind of information they need to gather during home visits and through collateral contacts. Used in this way, the guides may help standardize the assessment process, ensuring that all areas of risk of child maltreatment are covered during each assessment.
  
  
• The guides can help professionals prioritize interventions for families and assist them in matching families with appropriate services.
  
  
• Professionals can use the guides longitudinally, comparing families along the various factors at certain intervals to examine the effects of intervention and family changes over time.
  
  
• Professionals may elect to use the assessment/intervention guides with chemically dependent parents to help them see areas of strength as well as areas of concern. This can help family members understand the criteria by which they will be evaluated, which in itself can be empowering.
  
  
• The guides can provide a common language and framework for clinicians from different agencies who are working with the same family. This common reference point can help minimize interagency friction and professional misunderstanding.
  
  
• When used as an interagency tool, the guides encourage the development of a common plan for intervention and can be used to determine the appropriate professionals and agencies to address each area of need.

Summary

A thorough assessment of all family members is the key to determining the specific constellation of support services that can foster the overall health and well-being of an individual substance-involved family. In order to do a thorough assessment, professionals need a solid knowledge base within their own disciplines as well as an understanding of the problem of alcohol and/or other drug abuse. Further, an awareness of the importance of other professional disciplines in working with substance-affected families is critical.

Assessment is a dynamic and ongoing process. During the initial period of involvement with a family, professionals generally will be able to elicit only partial information regarding family strengths and needs. Additional information can be obtained over time as professionals work together, moving the family forward towards alleviation of stressors and resolution of identified problems. In order to accomplish this goal, it is important for professionals to develop strategies for putting various pieces of assessment information together and for updating service plans on a periodic basis. One professional, one agency, or a core group needs to take the lead in compiling and communicating the facts that lead to decisions about appropriate services for the family. This approach also helps to relieve family stress, since it means that family members, not to mention other professionals, can count on a single designated "contact," rather than needing to go to various sources for information.

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