Thursday, July 17, 2014

Chapter 6 The Role of Child Protective Services When Substance Use Disorders Are Identified

 

In This Chapter

Once substance use disorders (SUDs) are identified as an issue to be addressed in a family's case plan, the child protective services (CPS) caseworker needs to have a discussion with the family to understand their perceptions of the role and the impact substance abuse or dependence has in their lives. This discussion should include what can be done about the issue and how the family can be motivated to change. Since a discussion about SUDs may be met with denial and even anger toward the caseworker, a focus on the needs of the children generally will align caseworkers and parents in determining the best way to improve the situation. This chapter discusses family assessments and how they can be used in case planning, how to support parents who are in treatment and recovery, and how to assist children whose parents have SUDs.

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Family Assessment and Case Planning

During the initial family assessment or investigation, the CPS caseworker identifies the behaviors and conditions of the child, parent, and family that contribute to the risk of maltreatment, which may include a family member's SUD. During the family assessment, the caseworker engages the family in a process designed to gain a greater understanding of family strengths, needs, and resources so that children are safe and the risk of maltreatment is reduced.114 In particular, the caseworkers work with the family to:

  • Identify family strengths that can provide a foundation for change (e.g., support systems)
  • Reduce the risk of maltreatment by identifying and by addressing the factors that place children at risk
  • Help the children cope with the effects of maltreatment, parental SUDs, and other co-occurring problems.

A family-focused response to address family functioning issues is essential to an effective case plan. Families are involved with CPS because of serious breakdowns in functioning that can be influenced profoundly by a family member's SUD, as well as by the same family member's transition to recovery. Not only must the parents' substance use be addressed, but the behavioral problems and issues that have developed for children over the span of their parents' substance use also must be resolved. To cease substance abuse and to make positive changes in their lives, it is vital for parents to move toward full acceptance of their substance abuse or addiction and its consequences. When parents address their SUDs and other issues, positive changes in family functioning can be achieved while the families also receive services through CPS.

North Carolina Family Assessment Scale

One recognized family assessment tool that addresses alcohol and drug issues is the North Carolina Family Assessment Scale (NCFAS). The following is a list of domains (i.e., areas of influence) that are measured by the NCFAS and could be used in any family assessment. The domain descriptions highlight ways in which alcohol and drug issues can be included in a CPS family assessment.

  • Environment. This domain refers to the neighborhood and social environment in which the family lives and works. Risk factors in this domain may include the presence or use of drugs in the household or community.
  • Parental capabilities. This domain refers to the parent or caregiver's capacity to function in the role of the parent. This includes overall parenting skills, the supervision of children, disciplinary practices, the provision of developmental opportunities for children, and the parent's mental and physical health. The caseworker should assess whether, how, and to what extent the client uses alcohol and drugs and how this may affect the ability to parent the children.
  • Family interactions. This domain addresses interactions among family members as well as the roles played by family members with respect to one another. Many family interactions can be affected by the use of alcohol and drugs. Items in this domain that may point to the possibility of an SUD include a parent's nonresponsiveness to the children or children serving as the primary caretakers of younger siblings.
  • Family safety. This domain includes any previous or current reports or suspicions regarding physical, emotional, or sexual abuse of children, as well as neglect.
  • Child well-being. This domain refers to the physical, emotional, educational, and relational functioning of the children in the family. Parental SUDs can negatively affect various areas of child well-being, such as mental and physical health, academic performance, behavior, and social skills. Caseworkers also should assess if the children are using drugs or alcohol.115

For more information about the NCFAS, visit http://www.nfpn.org/images/stories/files/ncfas_scale_defs.pdfexternal link or http://www.friendsnrc.org/download/outcomeresources/toolkit/annot/ncfas.pdf.

Despite the positive nature of these changes, however, both children and parents may find change difficult. For example, a parent newly in recovery can find coping with a child's needs very taxing. The problems in family functioning that have developed over time can be overwhelming as the parent notices them for the first time. Similarly, children experiencing a parent's recovery may have trouble accepting the parent's attempt to function in a role that he previously was unable to perform due to an SUD (e.g., disciplining the child). Caseworkers and SUD treatment providers should encourage progress, reward success, and support the newly sober parents in their efforts to make changes in all areas of family functioning and in being substance free.

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Supporting Parents in Treatment and Recovery

While SUD treatment should be provided only by trained professionals, CPS caseworkers can maintain an integral role in the process for both the parents and the children.

Providing Support During the Stages of Change

A common theory in the field of SUD treatment is that individuals transition through different stages of thought and behavior during the treatment process. Exhibit 6-1 describes the stages and how CPS caseworkers can assist their clients during each stage.

Exhibit 6-1
Stages of Change and the CPS Caseworker's Tasks116

Parent's Stage
Stage Description
Tasks

Precontemplation
No perception of having a problem or needing to change
Increase parent's understanding of risks and problems with current behavior; raise parent's doubts about behavior

Contemplation
Initial recognition that behavior may be a problem and uncertain about change
Discuss reasons to change and the risks of not changing (e.g., removal of child)

Decision to change
Conscious decision to change; some motivation for change identified
Help parent identify best actions to take for change; support motivation for change

Action
Takes steps to change
Help parent implement change strategy and take steps

Maintenance
Actively works on sustaining change strategies and maintaining long-term change
Help parent to identify triggers of SUD and use strategies to prevent relapse

Relapse
Slips (lapses) from change strategy or returns to previous problem behavior patterns (relapse)
Help parent re-engage in the contemplation, decision, and action stages

North Carolina Family Assessment Scale

The North Carolina Division of Family Services and the Family and Children's Resource Program recently compiled a list of practice guidelines for establishing a safe, family-centered response to methamphetamine use. The following suggestions may be useful to CPS caseworkers in assisting families who are affected by methamphetamine use:

  • Family engagement. Working with clients who use methamphetamine can be frustrating, but the caseworker should avoid prejudging or demonizing them. Assess each family individually and help build upon their strengths.
  • Case decisions. Parental SUDs do not necessarily constitute child maltreatment. Each case needs to be assessed individually.
  • Collaboration. Collaborate with other professionals, such as substance abuse treatment providers, law enforcement, medical personnel, and mental health experts.
  • Placement. Placement in foster care never should be automatic, even in the case of finding a child in a methamphetamine lab. The caseworker should assess each situation thoroughly and explore the possibility of placement with kin. However, the caseworker should keep in mind that methamphetamine use is sometimes a problem for extended families.
  • Permanence. It can be a challenge to achieve family reunification within the time frames set forth in the Adoption and Safe Families Act. This is often because of the time required to recover from methamphetamine use and the fact that some users may be involved in the criminal justice system.
  • Education. Ensure that foster parents and others involved in the case are knowledgeable about methamphetamine use.117

Once the parent is in treatment, the CPS caseworker can coordinate with the SUD treatment provider to monitor progress, to develop ongoing supports, and to intervene in times of crisis. Ongoing communication allows both systems to obtain a more complete picture of the family, which will allow for the development and modification of appropriate service plans.

When working with parents who are in treatment or who are in the process of recovery, CPS caseworkers should be mindful of the process that the parent is going through and address the relevant issues or needs. In early recovery, the client still may be detoxifying from drugs or alcohol and experiencing mood swings. The issues the client may need to address (or may need help in addressing) in order to stay sober typically include employment, housing, transportation, and a connection with an affirmative support system. Further along in recovery, the client may demonstrate several positive life changes that the caseworker can acknowledge, build upon, and encourage.

Throughout the recovery process, the caseworker, as well as the client, should have a clear understanding of the possibility of relapse and have a plan to address the situation if it occurs. Some frequently identified factors that contribute to lapse and to relapse include:

  • Feeling complacent in recovery
  • Feeling overwhelmed, confused, stuck, or stressed
  • Having strong feelings of boredom, loneliness, anger, fear, anxiety, or guilt
  • Engaging in compulsive behaviors such as gambling or sexual excess
  • Experiencing relationship difficulties
  • Failing to follow a treatment plan, quitting therapy, or skipping doctor appointments
  • Being in the presence of drugs or alcohol.

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Using Motivational Interviewing

Motivation can be defined as a willingness or a desire to change behavior.118 Parents in the CPS system who have SUDs may be ambivalent about addressing their issues. They may be comfortable with their substance-related behaviors and believe that they serve a useful function in their lives.119 Caseworkers and SUD treatment providers often find that motivating these parents to make behavioral changes is one of the most challenging aspects of their jobs.

Motivational interviewing is one approach CPS caseworkers can use to increase individuals' willingness to change. This type of interviewing accepts that ambivalence toward change is normal and seeks to engage and to mobilize the treatment participant on this basis.120

The four general principles of motivational interviewing are:

  • Ambivalence about substance use is normal and is an obstacle in recovery.
  • Ambivalence can be overcome by working with the client's motivations and values.
  • The relationship between the caseworker or treatment provider and the client should be collaborative with each participant bringing his own expertise.
  • Argument and aggressive confrontation should be avoided.121

The connections, realizations, new understandings, and solutions should come from the client rather than from the CPS caseworker.

More information on how to support and to facilitate treatment and recovery is available in Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers, a publication prepared by the National Center for Substance Abuse and Child Welfare under contract for the Substance Abuse and Mental Health Services Administration and the Administration for Children and Families within the U.S. Department of Health and Human Services. The publication is available at http://www.ncsacw.samhsa.gov/files/UnderstandingSAGuide.pdf.

For more information on motivational interviewing, go to http://www.motivationalinterview.orgexternal link or www.americanhumane.org/Romaic.external link

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Supporting Children of Parents With SUDs

Caseworkers also have a key role in supporting children as their parents seek treatment for SUDs. As discussed earlier, children in the child welfare system whose parents have SUDs are at risk for a number of developmental and emotional problems. One of the difficulties in providing services to these children is that their problems, which are affected or compounded by their parents' SUDs, might not emerge until later in their lives. In addition, these children also are more likely than children of parents who do not have SUDs to remain in foster care for longer periods of time.122 Because of their greater risks and longer stays in out-of-home care, it is particularly important for CPS caseworkers to assess thoroughly the needs (e.g., developmental, emotional, behavioral, educational) of these children and to link them with appropriate services in a timely manner. Both the assessments and service provision should be matched to the children's developmental levels and abilities. Children from families affected by SUDs do not always move through the developmental continuum in the normal sequential phases.

Children often have misperceptions about their role in their parents' problems. One approach to helping children deal with issues associated with a parent's SUD is to talk through lessons, such as the three Cs:

  • You did not cause it (the parent's SUD).
  • You cannot control it.
  • You cannot cure it (which addresses the issue of the child taking on the role of the parent in the parent-child relationship).

Similarly, caseworkers can discuss a number of other important issues with children whose parents have an SUD, including:

  • Addiction is a disease. Their parents are not bad people; they have a disease and may show inappropriate behavior when using substances.
  • The child is not the reason that the parent has an SUD. Children do not cause the disease and cannot make their parents stop.
  • There are many children in situations like theirs. There are millions of children whose parents have an SUD. They are not alone.
  • They can talk about the problem. Children do not have to be scared or be ashamed to talk about their problems. There are many individuals and groups they can talk to and receive assistance.123

Services for children, such as those offered through the Strengthening Families Program, include problem-solving models that emphasize how to prevent the child from developing an addictive disorder later in life (with an emphasis on abstinence).

Title IV-E Waiver Projects Targeting Families Affected by Substance Abuse

Since 1996, several States have implemented waiver demonstration projects that allow Title IV-E foster care funds to be used to pay for services for families in the child welfare system with substance abuse problems. The following describes some of these projects:

  • Illinois began its demonstration project in 2000, and with a recent 5-year extension, it is scheduled to continue through 2011. Through this project, recovery coaches engage substance-affected families during the treatment process, work to remove treatment barriers, and provide ongoing support. The project emphasized treatment retention for caregivers who already had been referred to substance abuse treatment and whose children already had received out-of-home placements.
    An evaluation of the first phase of the Illinois demonstration project found that compared to parents who received standard services, the parents who worked with recovery coaches:
    • Accessed treatment more quickly
    • Experienced lower rates of subsequent maltreatment
    • Achieved family reunification faster.124
    The evaluation also identified barriers to reunification, including domestic violence, mental health issues, and inadequate housing. The extension addresses these co-occurring problems and broadens the geographic scope of the demonstration.
  • From 1999 to 2005, New Hampshire's Project First Step placed licensed alcohol and drug abuse counselors in two district CPS offices. The counselors conducted substance abuse assessments concurrently with CPS maltreatment investigations, facilitated access to treatment and other services, assisted with case planning, and provided intensive case management services. The evaluation findings were modest, yet they showed some promising trends.125
  • From 1996 to 2002, substance abuse specialists in Delaware were co-located in local CPS offices. The specialists accompanied CPS workers on home visits, consulted on case planning, and provided referrals to treatment and support services. Division of Family Services officials found that the addition of specialists on site was helpful to caseworkers in recognizing the signs of substance abuse, exploring addiction-associated issues with family members, and making appropriate referrals.

For additional information on the substance abuse waivers, visit http://www.acf.hhs.gov/programs/cb/resource/findings-title-iv-e-state-substance-abuse.

 

 

https://www.childwelfare.gov/pubs/usermanuals/substanceuse/chaptersix.cfm