Protecting Children in Substance-Abusing Families Vickie Kropenske and Judy Howard with Cheryl Breitenbach Richard Dembo Susan B. Edelstein Kathy McTaggart Annette Moore Mary Beth Sorensen Virginia Weisz 1994 U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families National Center on Child Abuse and Neglect This manual was developed and produced by Circle Solutions, Inc., McLean, VA, under subcontract No. S-105-89-1730 with Westover Consultants, Inc. This page is intentionally left blank TABLE OF CONTENTS PREFACE ix ACKNOWLEDGMENTS xi INTRODUCTION xiii IDENTIFYING ALCOHOL AND/OR OTHER DRUG USE 1 Physical and Behavioral Indications of Substance Abuse in Families 1 Physical and Behavioral Indications of Perinatal Substance Abuse 2 Physical and Behavioral Indications of Relapse for Individuals in Recovery 2 Diagnostic Tests for Alcohol Use 2 Toxicology Screening for Drug Use 3 Summary 4 CHEMICALLY INVOLVED PARENTS : CHARACTERISTICS OF PARENTS AT RISK 5 The Nature of Substance Abuse 6 The Chemically Involved Parent 8 Childhood Deprivation 8 Survival Needs 8 Psychiatric Disorders 9 Denial 9 The Needs of Children and Parenting Tasks 10 Summary 11 CHILDREN OF CHEMICALLY INVOLVED PARENTS : SPECIAL RISKS 13 Neonatal and Infant Complications 14 Neurological Symptoms 14 Prematurity 16 Intracranial Hemorrhages 16 Bronchopulmonary Dysplasia (BPD) 16 Retinopathy of Prematurity (ROP) 17 Diseases That Interfere With Normal Feeding Ability 17 Infectious Diseases 17 Gonorrhea 18 Syphilis 18 iii Herpes 18 Chlamydia 18 Hepatitis B 19 Human Immunodeficiency Virus (HIV) 19 Tuberculosis (TB) 20 Fetal Alcohol Syndrome (FAS) 21 Sudden Infant Death Syndrome (SIDS) 21 Failure To Thrive (FTT) 21 Intrauterine Growth Retardation (IUGR) 22 Central Nervous System (CNS) Disorders 22 Medical Followup Recommendations 23 Developmental Concerns 25 Developmental Assessment 25 Developmental Patterns of Prenatally Drug-Exposed Children 26 Infancy (0 to 15 Months) 26 Toddlerhood (15 to 36 Months) 28 Preschool Years (3 to 5 Years) 29 School and Teenage Years 30 Summary 31 REPORTING CHILD MALTREATMENT IN CASES INVOLVING PARENTAL SUBSTANCE ABUSE 33 Reporting Obligations 33 Reporting Parental Substance Abuse 33 Reporting Substance Abuse During Pregnancy 33 Reporting Drug- and Alcohol-Affected Infants 34 Variations in Reporting 34 Confidentiality 34 COMPREHENSIVE FAMILY ASSESSMENT 39 Gathering Information 40 Interviews With Family Members 40 Home Visits 40 Collateral Contacts 40 Standardized Evaluations 40 Areas of Assessment 41 iv Assessment of the Infant and Child 41 Infant Assessment 41 Child Assessment 42 Assessment of the Adolescent 42 Assessment of the Parent 44 Substance Abuse History 44 Drug and Alcohol Treatment History 46 Health and Health Care 46 Mental Health and History of Psychiatric Treatment 46 Criminal History 47 Level of Cooperation 47 Awareness of the Impact of Drug and Alcohol Use on the Child 48 Parenting Skills and Responsiveness to Child 48 History of Abuse and/or Neglect 49 Work History and Education 49 Assessment of the Home Environment 49 Environmental Conditions of the Home 50 Partners or Parent Substitutes Within the Home 51 Family Support Systems 51 Assessment of Relative Caregivers 51 Parenting Skills and History of Abuse, Neglect, or Violence 52 Alcohol Use and/or Other Drug Use 52 Quality of the Relationship With the Parent and Ability to Protect and Nurture the Child 52 Cooperation, Receptivity, and Access to Services 53 Assessment of Foster Parents 53 Attitudes Toward Birth Parents 54 Caregiving 54 Perception and Expectations of the Child 54 Receptivity to Services 55 Family Supports 55 Guides for Assessment 55 Summary 56 v JUVENILE COURT INVOLVEMENT WITH CHEMICALLY INVOLVED FAMILIES 61 Considerations of the Juvenile Court in Cases of Parental Substance Abuse 62 Child's Health and Psychosocial Status 62 Child's Age 62 Parental History of Substance Abuse and Treatment 63 Parenting Profile 63 Home Environment 64 Family Supports 64 Treatment and Support Services 64 Special Issues Affecting Legal Interventions With Chemically Involved Families 65 Reasonable Efforts 65 Realistic Time Frames 66 Termination of Parental Rights 66 Permanent Placement 68 Adoption 68 Guardianship 68 Long-Term Foster Care 69 Summary 69 INNOVATIVE APPROACHES TO INTERVENTION: IMPROVING THE ODDS 71 Comprehensive Treatment Approaches 71 Programs for Pregnant and Parenting Women With Children 71 Residential Treatment 72 Specialized Child Protective Services (CPS) Units 73 Family Preservation Programs 73 Innovations in Out-Of-Home Care 74 Transitional Group Care for Foster Children 74 Specialized Foster Homes 74 Foster Parent Training 75 Grandparent Support Groups 76 Meeting Health and Educational Needs 76 Comprehensive Health Care Clinics for Substance-Affected Children 76 Early Childhood Programs 77 Support Programs for Parents 77 vi Twelve-Step Programs 77 Programs for Adolescents 78 Programs for Incarcerated Women 78 Day Treatment Programs for Pregnant Women and Their Husbands/Partners 79 Interagency Approaches 79 Interagency Coordinating Councils 79 Interagency, Interdisciplinary Training 80 Interagency Service Teams 80 Summary 81 CONCLUSION 83 APPENDICES Appendix I: The Nature of Substances of Abuse 85 Appendix II: Sample Medical Center Protocol 97 Appendix III: Sample Interagency Agreement 109 NOTES 113 GLOSSARY OF TERMS 117 SELECTED BIBLIOGRAPHY 121 OTHER RESOURCES 127 TABLES Table 1. Hospital Form for Discharge of Infants into Out-of-Home Care 24 Table 2. Sample Interagency Consent Form 37 Table 3. Assessment/Intervention Guide: Biologic Family 57 Table 4. Assessment/Intervention Guide: Relative Caregiver 59 Table 5. Assessment/Intervention Guide: Foster Family 60 Table 6. Major Substances of Abuse 95 vii This page is intentionally left blank PREFACE The Child Abuse Prevention and Treatment Act was signed into law in 1974. Since that time, the Federal Government has served as a catalyst to mobilize society's social service, mental health, medical, educational, legal, and law enforcement resources to address the challenges in the prevention and treatment of child abuse and neglect. In 1977, in one of its early efforts to achieve this goal, the National Center on Child Abuse and Neglect (NCCAN) developed 21 manuals (the User Manual Series) to provide guidance to professionals involved in the child protection system and to enhance community collaboration and the quality of services provided to children and families. The manuals described each professional's roles and responsibilities in the prevention, identification, and treatment of child maltreatment. Other manuals in the series addressed special topics, for example, adolescent abuse and neglect. Our understanding of the complex problems of child abuse and neglect has increased dramatically since the user manuals were developed. This increased knowledge has improved our ability to intervene effectively in the lives of troubled families. Likewise, we have a better grasp of what we can do to prevent child abuse and neglect from occurring. Further, our knowledge of the unique roles key professionals can play in child protection has been more clearly defined, and a great deal has been learned about how to enhance coordination and collaboration of community agencies and professionals. Finally, we are facing today new and more serious problems in families who maltreat their children. For example, there is a significant percentage of families known to Child Protective Services (CPS) who are experiencing substance abuse problems. Because our knowledge base has increased significantly and the state of the art of practice has improved considerably, NCCAN has updated the User Manual Series by revising many of the existing manuals and creating new manuals that address current innovations, concerns, and issues in the prevention and treatment of child maltreatment. This manual, Protecting Children in Substance-Abusing Families, is designed for professionals in the fields of child welfare, mental health, health care, education, law, the faith community, and substance abuse prevention and treatment. The manual is intended to help professionals identify the various forms of parental substance abuse, assess the strengths and needs of families affected by alcohol and/or other drug abuse, develop service plans, and provide intervention. The manual includes a section addressing the identification of substance-abusing clients, a review of the characteristics of substance-abusing parents and the risks to children growing up in households in which alcohol and/or other drugs are abused, a discussion of the legal issues related to child maltreatment and parental substance abuse, a description of approaches to family assessment, and a summary of innovative intervention programs and service delivery strategies. Protecting Children in Substance-Abusing Families is one in a series of User Manuals developed by the National Center on Child Abuse and Neglect. Initiated in 1977, and now being updated, the User Manual Series provide guidance to professionals involved in the child protection system. Some manuals focus specifically on professional roles and responsibilities in the prevention, identification, and treatment of child abuse and neglect, such as The Role of Educators in the Prevention of Child Abuse and Neglect. Other manuals focus on special topics, such as Treatment for Abused and Neglected Children: Infancy to Age 18. Readers are encouraged to review