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.

Signs of Methamphetamine Use and Manufacture⁷⁹

With the increased use of methamphetamine, first responders are now more likely to work with clients who are users or manufacturers of this drug. The following information can assist them in identifying methamphetamine use or manufacturing.

Signs of possible methamphetamine use include:

• Increased breathing and pulse rate
• Sweating
• Rapid/pressured speech
• Euphoria (an exaggerated feeling of well-being)
• Hyperactivity
• Dry mouth
• Tremors (shaking hands)
• Dilated pupils
• Lack of appetite
• Insomnia or lack of sleep
• Bruxism (teeth-grinding)
• Depression
• Irritability, suspiciousness, paranoia
• Visual and auditory hallucinations
• Formication (the sensation of bugs crawling on the skin)
• The presence of white powder, straws, or injection equipment.

Signs that methamphetamine is possibly being manufactured in a home include:

• Laboratory equipment (e.g., flasks, rubber tubing, beakers, large amounts of coffee filters)
• Large quantities of pills containing ephedrine or pseudoephedrine (e.g., certain cold medicines)
• A chemical odor
• Chemicals not commonly found in a home (e.g., red phosphorous, acetone, liquid ephedrine, ether, iodine, phenylacetone [P2P])
• Unusually large quantities of household chemicals (e.g., lye, paint thinner)
• Chemicals usually found on a farm (e.g., anhydrous ammonia)
• Residue from the manufacture of methamphetamine (usually of a maroon color) in bathtubs, sinks, toilets, or on the walls
• Containers used for purposes not originally intended (e.g., glass milk or beer bottles with unfamiliar liquids)
• No visible means of income
• Unusual security precautions (e.g., extra locks, barred or blacked-out windows, expensive alarm systems).

Safety Issues When Encountering a Suspected Methamphetamine Lab

First responders should use extreme caution and seek assistance from law enforcement, fire/rescue personnel, hazardous materials crews, or other appropriate individuals or groups if they are visiting a home that has a suspected methamphetamine lab because these homes may have:

• Individuals under the influence of methamphetamine or other drugs and/or who may be armed
• Defense systems, including explosive devices and other booby traps
• Vicious animals
• Dangerous and volatile chemicals.⁸⁰

First responders who enter a methamphetamine lab that has not been properly ventilated and cleaned—or who are not properly equipped to avoid exposure to chemicals (i.e., have respirators, protective clothing)—may experience shortness of breath, coughing, chest pain, dizziness, vomiting, lack of coordination, burns, and, in some cases, death. If first responders do come into contact with possibly dangerous chemicals, they should wash the exposed skin with liquid soap and water or, depending on the type of chemical exposure, a chemical solution. They also should remove contaminated shoes and clothing. First responders should be knowledgeable about agency protocols for the evacuation, decontamination, and health screenings of children and others found at the home, including which, if any, of the child's possessions (e.g., medications, eyeglasses) should be retrieved from the home and how they should be decontaminated.

First responders who determine they are in a home that has a suspected methamphetamine lab should immediately leave the residence, taking care not to:

• Touch anything in the lab
• Turn on or off any electrical switches (e.g., lights)
• Eat or drink anything
• Open, move, or sniff containers with suspected chemicals
• Smoke anywhere near the home
• Alarm or act in a way that could be perceived as aggressive by others in the home (i.e., suddenly running from a room, pushing someone aside), especially suspected methamphetamine users, who may experience paranoia and extremely aggressive behavior.⁸¹

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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.

General Home Visit Safety Tips

Families experiencing multiple issues (e.g., SUDs, mental health problems, domestic violence, criminal behavior) can make it more dangerous for CPS caseworkers going into homes to investigate cases of child maltreatment. While on a home visit, caseworkers should remember the following safety tips:

• Ensure that the CPS supervisor knows the time and place of the appointment and the expected time of return.
• Dress appropriately and in a manner that blends into the community.
• Walk close to buildings or close to the curb in an effort to have at least one safe side. Stay away from bushes, alleys, and dark corners, if possible.
• Know the route in and out of the area by examining a map or by talking with others beforehand. Do not wander or appear lost or confused.
• Park as close to the home as possible and in a way that helps ensure an easy exit. Keep the car keys in hand while entering and exiting the home so they are easily available.
• Be aware of your surroundings at all times. Enter and leave homes carefully, noticing doors, windows, neighbors, loiterers, and anything or anyone that may be a risk to safety.
• If unsure of the safety or surroundings of the location, move to another spot by suggesting taking a break or getting a cup of coffee and finish talking there.
• Attempt to keep a clear path to an exit.
• Be aware of dogs that may pose a threat.
• Follow intuition and take action if feeling afraid or threatened. Leave the home or call 911 if necessary.
• Have access, if possible, to technology that may assist with safety issues (e.g., GPS systems, cell phones).

In cases where drugs and alcohol may be an issue in the family or the surrounding community:

• Go to the home with another caseworker or law enforcement officer, particularly if the home is in an area known for drug dealing.
• Know the local signs that indicate a drug deal is occurring. In such situations, do not enter the home without law enforcement personnel.
• Be aware of homes or other living environments that may be used as a clandestine drug factory. Do not attempt to investigate such places alone, and immediately contact the police or sheriff if such a lab is suspected. Anyone without proper training and protective gear should stay at least 500 feet away from any suspected laboratory. The following are signs of a possible lab:
  • Strong or unusual chemical odors
  • Laboratory equipment, such as glass tubes, beakers, funnels, and Bunsen burners
  • Chemical drums or cans in the yard
  • A high volume of automobile or foot traffic, particularly at odd hours
  • New, high fences with no visible livestock or other animals.
• If one or both parents appear to be intoxicated, high, incoherent, or passed out, ensure the safety and supervision of the children. Once that has been accomplished, it is appropriate to reschedule the appointment. It may be appropriate to call the supervisor for guidance.⁸²

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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.

Exhibit 4-1
Sample Screening Instruments for Substance Use Disorders

The CAGE Questionnaire (amended for drug use)

C Have you ever felt the need to Cut down on your drinking or drug use?

A Have you ever felt Annoyed by people criticizing your drinking or drug use?

G Have you ever felt bad or Guilty about your drinking or drug use?

E Have you ever had a drink or used a drug first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener)

Scoring: If the answer is "yes" to one or more questions, the responder should receive a formal alcohol and drug assessment. Answering "yes" to one or two questions may indicate alcohol and drug-related problems. Answering "yes" to three or four questions may indicate alcohol or drug dependence.⁸³

UNCOPE

U Have you spent more time drinking or Using than you intended?

N Have you ever Neglected some of your usual responsibilities because of alcohol or drug use?

C Have you ever felt you wanted or needed to Cut down on your drinking or drug use in the past year?

O Has your family, a friend, or anyone else ever told you they Objected to your alcohol or drug use?

P Have you found yourself thinking a lot about drinking or using? (Preoccupied)

E Have you ever used alcohol or drugs to relieve Emotional discomfort, such as sadness, anger, or boredom?

Scoring: Two or more positive responses indicate possible abuse or dependence and a need for further assessment by an SUD treatment provider.⁸⁴

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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.

Drug Testing Parents

Physical drug testing of parents for evidence of substance use brings to the surface complicated and interrelated issues of public policy, science and technology, and ethics. Drug testing of adults has different goals in different contexts. For example, parole and probation officers use drug testing to monitor compliance with the conditions of parole and probation; employers use them to make hiring decisions; and alcohol and drug abuse treatment programs use tests to assess whether a person is complying with the treatment plan. Parents involved with CPS who are known to have an SUD are likely to be tested as part of their alcohol and drug abuse treatment or to meet court requirements. CPS may rely on the results of drug tests to inform decisions about providing services or reunification, or they may consider drug testing as a means of determining if there is an SUD. Whichever way drug testing is used, it is important for CPS caseworkers and administrators to understand the following uses and limitations:

• Drug tests do not demonstrate patterns of drug use or demonstrate if a person is abusing or is dependent on substances. Test results simply indicate the recent use of a substance and, for some substances, the amount used.
• Common drug tests do not provide accurate information about alcohol use because alcohol metabolizes quickly and is not detectable after approximately 8 hours.
• Whether drug use is detected by tests depends not only on the drug used, but also on other factors such as the characteristics of each drug, an individual's metabolism, and the cut-off levels established by the agency requesting the test or the laboratory analyzing it.
• Drug tests are typically physically invasive procedures, which raises questions about an individual's right to privacy.
• Individuals may be afraid to discuss problems if they believe they will be tested.
• Positive results from drug tests require that there be qualified and trained staff available to initiate careful and sensitive follow-up discussions with family members.⁸⁸

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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.

Exhibit 4-2
Decision Tree for Child Welfare Cases Involving Caregiver Substance Use Disorder⁸⁹

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.

 

 

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