Protecting Children in Families Affected by Substance Use Disorders

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You are in section: Table of Contents Preface Acknowledgments 1 - Purpose and Overview 2 - The Nature of Substance Use Disorders 3 - How Parental Substance Use Disorders Affect Children 4 - In Home Examination, Screening and Assessment… 5 - Treating Substance Use Disorders 6 - The Role of Child Protective Services… 7 - Child Protective Services and Substance Use Disorder… 8 - Putting It Together: Making the Systems Work for Families Endnotes Appendix A - Glossary of Terms Appendix B - Resource Listings of Selected National Organizations Appendix C - State Telephone Numbers… Appendix D - Diagnostic and Statistical Manual… Appendix E - Commonly Abused Substances Appendix F - Commonly Used Screening Instruments Appendix G - State of Connecticut Department of Children… Appendix H - Memorandums of Understanding Appendix I - Confidentiality and the Release of Substance… Appendix J - Sample Qualified Service Organization Agreement…

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Chapter 4
In-home Examination, Screening and Assessment of Substance Use Disorders

In This Chapter

• In-home examination
• Screening
• Assessment

The previous chapter described some of the effects of parental substance use disorders (SUDs) on children, but how does a child protective services (CPS) worker determine if SUDs exist in the family? This chapter discusses in-home examinations, SUD screening instruments, and SUD assessments, including their methods, benefits, and limitations, and how caseworkers can incorporate them into their practice.

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In-home Examination

An in-home examination includes observations by the CPS caseworker of the people and the environment in a home. When visiting a home as part of an investigation, the caseworker should check for the following indicators of possible SUDs:

• A report of substance use is included in the CPS call or report



• Drug paraphernalia (e.g., a syringe kit, charred spoons, a large number of liquor or beer bottles)



• The scent of alcohol or drugs



• A child or other family member reports alcohol or drug use by a parent



• A parent appears to be under the influence of a substance, admits to having an SUD, or shows other signs of addiction or abuse (e.g., needle marks).

This list can be used pre- or post-screening and can be incorporated into every home visit.⁷⁷

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Screening

Screening is the use of a simple, and usually brief, set of questions that have been validated (i.e., tested to show that they accurately indicate the presence of an SUD). Results are easy to interpret. Generally, individuals who are not trained SUD treatment providers use the instruments.

The goal of screening is to determine whether a family member requires further evaluation for SUDs.⁷⁸ CPS caseworkers can use screening as a part of their standard home visits or family assessments. This section describes the importance of screening, sample screening instruments, benefits and limitations of screening instruments, and what to do when an instrument indicates an individual may have an SUD.

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Importance of Substance Use Disorder Screening

Screening for SUDs should be a routine part of CPS investigations, risk and safety assessments, and case planning and monitoring. Evidence of SUDs may not be noticeable upon initial investigation, but may emerge over time as caseworkers develop relationships with a family or notice that family members are unable to participate in program activities. Given the prevalence of SUDs among families involved in the child welfare system, CPS caseworkers should consider screening during all stages of the case.

CPS caseworkers understandably may be uncomfortable discussing SUDs with family members who already feel threatened because of being under investigation for child maltreatment. Abuse and addiction are not always visible, and family members are likely to be reluctant to disclose activities that may be illegal or that could further jeopardize custody of their children. As described in Chapter 2, The Nature of Substance Use Disorders, SUDs often are masked by other problems, such as mental illness or domestic violence, and can be overlooked if those other problems are more apparent. The opposite also can be true; an SUD may mask other problems, such as domestic violence or disabilities. Moreover, addiction often is characterized by denial, and family members may not recognize that they have an SUD. For example, they may feel that their drinking is within an acceptable range or that their marijuana use is not problematic.

Screening is just one of many approaches used to identify SUDs. It is not completely accurate nor will it work all the time (i.e., not all positive responses will demonstrate an SUD, and not all negative responses will rule out a disorder). CPS caseworkers should also rely on additional techniques, such as observation, medical histories, reports from family members or friends, or arrest records. Nevertheless, using a brief screening instrument takes little time and provides an objective method for caseworkers to use in opening a discussion about sensitive issues. In this way, screening becomes part of a continuum of activities aimed at addressing families' problems with SUDs.

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Sample Screening Instruments

Ideally, screening instruments used by CPS caseworkers should be brief, easily administered, inexpensive, and capable of detecting a problem or condition when it exists. Two screening tools available for CPS caseworkers are the CAGE and UNCOPE questionnaires, which are shown in Exhibit 4-1. These quick screens should be used with other information and observations.⁸⁵ For a list of screening instruments, see Appendix F, Commonly Used Screening Instruments. A sample instrument is available in Appendix G, State of Connecticut Department of Children and Families Substance Abuse Screening and Information Form.

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Benefits and Limitations of Screening Instruments

Screening for SUDs is harder and requires more skill than screening for other problems among child welfare populations, such as barriers to work or stress. This is because SUDs often are characterized by stigma and denial and frequently involve illegal activities. Although screening instruments can provide useful information, they are not without flaws. Without informed interpretation and communication of their results, these instruments will not be effective. It is important to understand both the benefits and the limitations of screening instruments in order to use them properly.

The benefits of screening instruments include the following:

• Instruments provide a consistent structure for caseworkers to use in interviewing family members.



• Instruments can provide a starting point and context for further discussion and service planning.



• Instruments offer parents a chance to disclose an SUD and give caseworkers a chance to refer the parent to an SUD treatment provider for assessment.



• Screening instruments allow caseworkers to weigh an individual's responses to estimate whether SUDs might be a problem.



• Many instruments are widely available and accessible.



• Several instruments have been empirically tested for validity (i.e., the instrument is accurate) and reliability (i.e., the instrument is consistent).



• Many instruments take little time to administer and are not difficult to interpret.⁸⁶

The limitations of screening instruments include the following:

• Screening instruments have been tested and found valid with a variety of populations, but every instrument may not be appropriate for every population. For example, some instruments may have been tested in settings where individuals go for health care and treatment, but not in public agencies or in situations where families know they risk losing their children. Before using a particular instrument in a CPS setting, it is important to check the literature regarding the appropriate use of that instrument.



• Screening instruments rely on self-disclosure. Even the best instruments administered under optimal circumstances will yield valid information only to the extent that families respond honestly.



• Denial is a characteristic of SUDs, and because of this, family members may not understand or acknowledge that their pattern of substance use represents abuse or addiction.



• Information obtained from the screening alone will be of little benefit unless it is part of a continuum of identification, assessment, and treatment.

Instruments are only one technique that caseworkers should use in exploring SUDs with family members. They should complement rather than replace other techniques to identify SUDs. Additionally, instruments are not always correct. If a caseworker suspects an SUD, but the screening instrument does not indicate a problem, the caseworker's best judgment always should take precedence.

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What to Do When a Screen Indicates a Substance Use Disorder

If the results of a screening instrument or an in-home check indicate that a parent may have an SUD, the CPS caseworker should take the following steps:

• Ensure that the parent receives an SUD assessment from a qualified SUD treatment provider.



• If an SUD is present, address it in the case plans for both the parent and the child.



• Ensure that a qualified professional assesses the child for the impact of parental SUD or for the possibility of the child's own use of substances.



• Coordinate service plans with the treatment professional.⁸⁷

Even if an SUD initially has been ruled out as an important factor in the family's case plan, the caseworker should reassess if the family is not making progress in dealing with other issues. An unidentified SUD can hamper a family's progress for years.

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Assessment

Once screening indicates that an individual may have an SUD, an assessment is the next step in a continuum of activities to address the problem. An assessment is a detailed evaluation used to determine whether treatment is needed. If so, then the assessment is utilized to design an appropriate treatment or service plan. Assessments should include various aspects of family living, such as housing, health issues, child behavior problems, and family strengths. In general, only professionals who are trained in administering assessments and in interpreting their results should conduct them.

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Importance of Sharing Information

Ideally, the CPS caseworker and the SUD treatment provider who is conducting the assessment will share information. Information from the CPS caseworker about the case provides the context for the assessment. Likewise, results from the assessment can assist the CPS caseworker in developing a comprehensive and coordinated service plan. The caseworker should provide the following information, if available, to the SUD treatment provider along with the referral:

• The family member's arrest history related to substance use



• The condition of the home when home visits were conducted



• A history of SUD treatment participation by the family member



• Any other SUD-related information.

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Key Points for Making Referrals and for Using Assessments

The following are key points to remember when making referrals for and conducting SUD assessments within the context of CPS:

• The quality of the assessment is directly related to the quality of the information provided to the counselor conducting the evaluation. Frequently, counselors rely on self-reported data in their evaluations. Self-reports often are criticized because there is a perception that individuals with SUDs often lie. This issue can be addressed by comparing the client's view of the problem with information available from other sources, such as a CPS caseworker, other service providers, and family members.



• A good assessment should address the following family and parenting issues:



• How substance use affects the client's ability to be a good parent;



• The level of care or intervention that would be most appropriate for this individual to address the current level of substance use;



• What should be required of the parent in order to demonstrate the ability to rear the child safely in light of a problematic use of substances.


• SUD treatment providers may feel that family-relevant assessments are beyond their professional scope of practice. If a CPS caseworker encounters a situation in which the only SUD assessment available is conducted by someone with limited experience in addressing family issues, this should be stated explicitly in the caseworker's case notes and in court reports. Additionally, caseworkers should consult with a supervisor if they do not have confidence in the assessment.



• Communication is critical. Confidentiality issues surrounding SUD treatment records frequently are cited as a reason why CPS and SUD treatment agencies do not work well together. (Confidentiality is discussed in more detail in Chapter 8, Putting It Together: Making the Systems Work for Families.) Clear communication among the various parties is critical for ensuring that case plans and treatment plans are created properly and followed. Additionally, an understanding of each professional culture is crucial to working well together.

See Chapter 8, Putting It Together: Making the Systems Work for Families, for more information on how CPS and SUD treatment systems can work together effectively. Additionally, refer to Exhibit 4-2 for more information regarding how SUD issues should be taken into consideration in child maltreatment cases.

Adapted from Tough Problems, Tough Choices: Guidelines for Needs-based Service Planning in Child Welfare, a publication developed by Casey Family Programs, The Annie E. Casey Foundation, and American Humane. It is available at http://www.americanhumane.org/protecting-children/resources/casey-decision-making-guidelines/products.html.

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previous

You are in section: Table of Contents Preface Acknowledgments 1 - Purpose and Overview 2 - The Nature of Substance Use Disorders 3 - How Parental Substance Use Disorders Affect Children 4 - In Home Examination, Screening and Assessment… 5 - Treating Substance Use Disorders 6 - The Role of Child Protective Services… 7 - Child Protective Services and Substance Use Disorder… 8 - Putting It Together: Making the Systems Work for Families Endnotes Appendix A - Glossary of Terms Appendix B - Resource Listings of Selected National Organizations Appendix C - State Telephone Numbers… Appendix D - Diagnostic and Statistical Manual… Appendix E - Commonly Abused Substances Appendix F - Commonly Used Screening Instruments Appendix G - State of Connecticut Department of Children… Appendix H - Memorandums of Understanding Appendix I - Confidentiality and the Release of Substance… Appendix J - Sample Qualified Service Organization Agreement…

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