Identifying substance abuse in maltreating families: A child welfare challenge

Child Abuse & Neglect, Vol. 19, No. 5, pp. 531-543, 1995 Copyright © 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0145-2134/95 $9.50 + .00

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IDENTIFYING SUBSTANCE ABUSE IN MALTREATING FAMILIES: A CHILD WELFARE CHALLENGE MARTHA MORRISON DORE Columbia University School of Social Work, Columbia University, New York, NY, USA

JOAN M. DORIS University of Pennsylvania School of Social Work, Philadelphia, PA, USA PEARL

WRIGHT

Supportive Child and Adult Network, University of Pennsylvania, Philadelphia, PA, USA

AbstractEStudies of the link between parental substance abuse and child maltreatment suggest that chemical dependence is present in at least half of the families who come to the attention of child welfare authorities for child abuse and neglect. Parental substance abuse is thought to be a primary factor in greatly increased rates of children entering foster care over the past decade. It is also a clear risk factor for child mental health problems and poor developmental outcomes in children. At the same time, however, minimal attention is often given to training child protective services workers and other child welfare personnel in identifying and confronting substance abuse in families on their caseloads. The authors explore standardized methods developed for screening for substance abuse among various populations and suggest ways of adapting these screening devices for families reported for child maltreatment. They identify assessment and treatment considerations in substance abusing families as well.

Key Words--Child, Abuse, Maltreatment, Drugs, Family.

INTRODUCTION STUDIES OF THE link between parental substance abuse and child maltreatment suggest that chemical dependence is present in at least half the of families known to the public child ~ welfare system (Murphy, Jellinek, Quinn, Smith, Poitrast, & Goshko, 1991). (The terms substance abuse and chemical dependence are used interchangeably here to denote a psychoactive substance use disorder as defined by the Diagnostic and Statistical Manual [Revised]). Some place this figure nearer 80% (Barth, 1994). A recent survey of voluntary child welfare agencies revealed that 57% of children they serve are affected by familial alcohol or drug abuse (Curtis & McCullough, 1993). Increasingly, researchers are finding significant relationships between parental drug and alcohol abuse and child maltreatment of all types, including physical, sexual, and emotional abuse as well as physical and emotional neglect (Famularo, Kinscherff, & Fenton, 1992; Leventhal, Garber, & Brady, 1989). In addition, parental substance abuse is a clear risk factor for child mental health problems absent overt maltreatment, suggesting indirect as well as direct effects on the psychosocial development of children (Cohen & Brook, 1987). Received for publication May 9, 1994; final revision received July 22, 1994; accepted July 26, 1994. Requests for reprints should be addressed to Dr. Martha Morrison Dore, Columbia University School of Social Work, 622 West ll3th Street, New York, NY 10025. 531

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Despite increasing evidence of the often devastating effects on children of life in substance abusing families, it is our experience that child welfare practitioners, those most likely to come into contact with families with serious drug and alcohol abuse, are often ill-prepared to identify and intervene in this problem. It is little wonder, then, that there are experiences like that of a caseworker of our acquaintance who recognized a client's alcoholism only after two frustrating years of failed efforts at establishing a working alliance with this neglectful mother. In this paper we explore current research on substance abuse among maltreating families who come to the attention of child welfare authorities and review empirical evidence of the effects on children of life in a substance abusing family. We then describe efforts to alert child welfare practitioners to the presence of substance abuse in the families they serve. Finally, we offer ways of enhancing the capacity of practitioners to identify and confront substance abuse in parents who maltreat their children.

The Impact of Substance Abuse on the Child Welfare System Over the past decade there has been a substantial increase in Child abuse and neglect reports and in the number of maltreated children placed in out-of-home care. In 1988 alone the National Committee on the Prevention of Child Abuse reported an increase of 100,000 cases of child maltreatment nation-wide. And, in just 2 years, between 1987 and 1989, the number of children in foster care nationally rose from 280,000 to 360,000, an increase of 29% (Ards & Mincy, 1994). In New York City the foster care caseload, which had declined from 20,000 in 1980 to 16,000 in 1984, rose to nearly 24,000 by 1989, a figure that does not include an additional 10,000 children placed in relatives' homes (Citizens' Committee for Children, 1993). While these increases may be partly attributable to increased public awareness of child maltreatment as well as to better reporting and tracking systems, researchers and those working in the child welfare field agree that the most important factor in skyrocketing protective services caseloads is an increase in parental substance abuse, particularly the crack form of cocaine (Curtis & McCullough, 1993). Citing a study by the National Committee for the Prevention of Child Abuse, Besharov (1989) states that substance abuse has become the "dominant characteristic" in child welfare caseloads in 22 states and the District of Columbia. Further, he contends that, after the influx of crack, reports of drug-related child abuse increased by 72% in one year. In addition to the increase in sheer numbers of drug-affected families entering the child welfare system, cases involving substance abuse are more complex and challenging to caseworkers as well (Sabol, 1994). Crack use, in particular, is associated with heightened interpersonal violence, criminal activity, sexual exploitation of children as well as adults, and transmission of the AIDS virus. These are not the families of yesterday's child welfare caseloads in which child maltreatment might be attributed to lack of parenting knowledge and skill and where family members, friends or neighbors frequently functioned as informal surrogates for a dysfunctional parent. Currently, whole families may be involved in the drug culture so that fewer stable, sober adults are available to support and nurture children. There are multiple reasons for the impact of crack on child welfare caseloads. First, crack has had a much greater acceptance among women than previously available drugs such as heroin. Indeed, crack is reported to be the number one illicit drug used by women of childbearing age (Berger, Sorenson, Gendler, & Fitzsimmons, 1990). Inciardi, Lockwood, and Pottieger (1993) state, "Evidence suggests that, as the use of crack spread across America, it hit women especially hard, resulting in higher rates of dependence than were experienced by men, and correspondingly lower rates of treatment entry and retention in treatment" (p. 12). The disproportionate use of crack by women may be due to the fact that it is relatively inexpensive and, unlike heroin, does not require injection (Inciardi, Lockwood, & Pottieger, 1993; Sabol, 1994).

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Crack also heightens, if only temporarily, the user's sense of personal power and control, feelings not often experienced by women, especially poor and minority women. Effects of Parental Substance Abuse on Children

It is widely recognized that parental substance abuse affects children adversely even before birth. However, researchers debate the actual number of children affected by prenatal exposure to psychoactive drugs, including alcohol. The most widely quoted estimate, from a study by Chasnoff (1988a), is that as many as 375,000 children are born drug-exposed each year. Some of the difficulty in obtaining conclusive data on the effects of any single psychoactive drug on child well-being is that polydrug use is particularly common among women (Bays, 1990; Inciardi, Lockwood, & Pottieger, 1993; Worth, 1991). Alcohol is frequently used in conjunction with other psychoactive drugs, particularly crack, and its teratogenic effects on the developing fetus are well documented (Berger, Sorenson, Gendler, & Fitzsimmons, 1990), Fetal Alcohol Syndrome (FAS) was first described two decades ago (Jones, Smith, Ullenand, & Streissguth, 1973) and since that time researchers have focused on both the long- and shortterm effects of prenatal exposure to this form of substance abuse. Adverse effects include heart defects, hearing and vision problems, facial deformities, small head circumference, decreased height and weight, and increased risk of stillbirth, miscarriage, and infant mortality. Further, FAS is one of the three most common causes of mental retardation and the only one of the three that is preventable (Streissguth & Randels, 1988). Long-term problems associated with FAS include learning disabilities, hyperactivity, short attention span, and antisocial behavior (Bays, 1990). Although as of yet there is little empirical evidence regarding long range outcomes for children exposed in utero to psychoactive drugs other than alcohol, especially crack, there are observable effects on the fetus and on the course of pregnancy. Sixty to 90% of babies exposed to crack shortly before birth experience symptoms of withdrawal (Chasnoff, 1988a; Weston, Ivins, Zuckerman, Jones, & Lopez, 1989). Some studies also report a high risk of cocaineinduced abruptio placentae, caused by maternal hypertension (NAPARE, 1992). Premature labor and contractions increase the risks of low birth weight and infant mortality (NAPARE, 1992). Fetal stroke, fetal distress, and fetal fatalities have all been documented (Chasnoff, 1988b; Fink, 1990). Sudden infant death syndrome (SIDS) is five to ten times more likely to occur in cocaine-exposed infants than in nonexposed infants (NAPARE, 1992). Most commonly, children exposed prenatally to cocaine show significant deficits in weight, length, and head circumference, indicating the possibility of a smaller brain and subsequent neurological deficits (Chasnoff, 1988a; Zuckerman, 1993). Finally, congenital deformities such as neural tube defects, malformed organs and genitals, and missing digits are rarely seen, but have been documented in cocaine-exposed infants (Fink, 1990). Despite these reported consequences of maternal cocaine use during pregnancy, Besharov (1989) points out that not all children prenatally exposed to cocaine suffer such anomalies and Zuckerman (1993) cautions against predictions of adverse developmental outcomes in the absence of consistent and reliable data. These authors also agree that "The development and behavior of an infant exposed to drugs can only be determined by interaction with the social environment" (Zuckerman, 1993, p. 1). The Social Environment in Substance Abusing Families

In view of the potentially fragile nature of prenatally drug-exposed infants, the parenting skills of the primary caregiver are particularly important. As a result of the physical effects of prenatal drug exposure, there are behavioral sequelae in these newborns that make them more difficult to care for. According to Schutter and Brinker (1992):

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Abundant literature describes neonatal behavior exhibited by cocaine exposed newborns: irritability, poor feeding patterns, frequent crying, tremulousness, frequent startles, irregular feeding patterns, hypertonia, increased respiratory and heart rates, vomiting, frantic sucking, and poor consolibility. (p. 91)

Such infants may demonstrate delays and deficits in motor development and language acquisition, as well as difficulties with organization, self-initiation, and state regulation (Howard, Beckwith, Rodning, & Kropenske, 1989; Schutter & Brinker, 1992). As a result, these are newborns with special needs that place high demands on caregivers. Unfortunately, mothers of drug-exposed newborns may be ill-equipped to cope with their infants’ special needs (Lief, 1985). One study of the parenting of substance abusing mothers found a tendency for rigidity and over control in their parenting and little emotional involvement and responsiveness in their interactions with their children (Bums, Chethik, Bums, & Clark, 1991). Further, the mothers in this study reported receiving little pleasure from their interactions with their babies. Other studies support these findings of disturbances in the mother-infant dyad when infants have been prenatally drug exposed (Davidson, 1991; Kelley, 1992; Thurman & Berry, 1992). In addition to problems in caregiving presented to substance abusing parents by drugexposed children, the significant amount of time chemically dependent parents must spend in activities related to getting and using psychoactive substances clearly interferes with optimal, even marginal, parenting (Davis, 1990; Rosenbaum, 1979). Crack is particularly lethal to the parenting role because users often binge for days or weeks at a time, frequently leaving even very young children alone or in the care of virtual strangers. Physical effects of crack use include depression, irritability, restlessness, and hypersensitivity to noise and touch, all conditions that interfere with responsive parenting and may lead to child abuse (Gropper, 1991; Waldorf, Reinarman, & Murphy, 1991). Parental Substance Abuse and Child Mental Health Problems The psychological risks to children of substance abusing parents are well-established through empirical research (Bauman & Levine, 1986; Cohen & Brook, 1987; Werner, 1986; West & Prinz, 1987; Wilson, 1989). Cross-sectional studies of the psychosocial functioning of children from substance abusing families have identified problems such as: (a) increased incidence of hyperactivity and conduct disorder (Frick, Lahey, Loeber, Stouthamer-Loeber, Christ, & Hanson, 1992; Knop, Teasdale, Schulsinger, & Goodwin, 1985; Steinhausen, Gobel, & Nestler, 1984); (b) greater rates of drug and alcohol abuse in adolescence (Merikangas, Weissman, Prusoff, Pauls, & Leckman, 1985); (c) impaired intellectual and academic functioning (Bauman & Dougherty, 1983; Knop, Teasdale, Schulsinger, & Goodwin, 1985; Shaywitz, Cohen, & Shaywitz, 1980); (d) clinical levels of anxiety and depression (de Cubas & Field, 1993; Moos & Billings, 1982; Steinhausen, Gobel, & Nestler, 1984); and, (e) lowered self-esteem and perceived lack of control over the environment (Prewett, Spence, & Chaknis, 1981). Longitudinal studies of child development support these findings regarding the risks of growing up in a substance abusing household (Knop, Teasdale, Schulsinger, Br Goodwin, 1985; Garmezy & Rutter, 1983; Werner, 1986). In Werner’s longitudinal study of a cohort of 698 children born on the Hawaiian island of Kauai in 1955, she followed the psychosocial development of a subsample of 49 children who had at least one alcoholic parent. By age 18, 25% had mental health problems serious enough to require either inpatient or outpatient treatment. This is in contrast to 9% of the study children not raised in substance abusing families. Further, 41% of the subsample from alcoholic families had manifested serious problems at school, at work, or in the community as evidenced by contacts with social service agencies. Only 7% of children from nonalcoholic families had such contacts. Like other studies of children of substance abusing parents, Werner (1986) found psychosocial

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problems greater in male children and in children from families where the mother was the chemically dependent parent.

Substance Abuse and Child Maltreatment With the possible exception of child sexual abuse, few studies have directly explored the relationship between parental substance abuse and child maltreatment (Leonard & Jacob, 1988; Milner & Chilamkurti, 1991). Prevalence rates of substance abuse among parents in substantiated child maltreatment cases range from no identifiable substance abuse (Steele & Pollack, 1974), to 10% of maltreating parents (Simons, Downs, Hurster, & Archer, 1966), to current findings of 50% or more (Curtis & McCullough, 1993; Kaplan, Pelcovitz, Salzinger, & Ganeles, 1983; Murphy, Jellinek, Quinn, Smith, Poitrast, & Goshko, 1991). In one in-depth comparison of substance abusing and nonsubstance abusing parents involved in child protective cases brought to court in Massachusetts, Murphy and his colleagues (1991) found that parents with documented substance abuse histories were more likely than other parents: (a) to be repeat offenders with regard to child abuse and neglect; (b) to fail to follow through with court-ordered services; and, (c) to eventually lose care and custody of their children. In a case-control study Famularo, Stone, Barnum, and Wharton (1986) matched childabusing parents with a community sample of parents not so identified, then assessed both groups using diagnostic criteria for alcohol abuse. The percent of maltreating parents meeting diagnostic criteria for alcoholism was significantly higher than in the community sample (38% vs. 8%). In another case-control study (Kelley, 1992), mothers of infants born with positive toxin screens for maternal cocaine use were matched with control mothers on age, race, and socioeconomic status. Nearly 60% of the drug exposed infants were the subject of subsequent substantiated reports of abuse or neglect as contrasted with just over 8% of control children. At 11 months of age all of the control children were still living with their biological mothers in contrast to just over half of the drug-exposed children. Forty-two percent of the latter had been placed by child protective services in foster care with relatives or others. This study purports to validate the association between maternal drug use and increased risk of child maltreatment in infancy (Kelley, 1992).

Substance Abuse Training of Child Welfare Practitioners Studies of caseworkers in public child welfare agencies indicate that only about one quarter to one third have graduate-level training beyond the bachelor's degree (Doris & Nunno, 1991; Lieberman, Hornby, & Russell, 1988). As undergraduates, most caseworkers majored in fields unrelated to social work, human services, or child development. A recent national survey of child protective services workers found that a high proportion (63.7%) often felt unprepared to help their clients (Fryer, Poland, Bross, & Krugman, 1988). Even those who enter the child welfare field with backgrounds in human services or with graduate social work degrees frequently have little or no training in addictions (Cordgan & Anderson, 1978; Van Wormer, 1987). In one survey of the training needs of 315 frontline and supervisory public child welfare staff in two states, lack of knowledge regarding substance abuse identification and treatment was ranked by line staff as the third most significant hindrance to their effective intervention with maltreating families and their children (Pecora, 1989). Even when substance abuse training is made available to child welfare workers, line staff may fail to attend because of job pressures or other reasons. One nation-wide study of agencybased training of child welfare workers and supervisors found that nearly half of all respondents either had no training on any topic available to them or had not attended any training, even

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when available, in the preceding year (Vinokur-Kaplan, 1987). It seems clear that, despite astonishing increases in numbers of children entering the child welfare system because of parental substance abuse, child welfare practitioners are seldom adequately prepared to identify and intervene in families where substance abuse is the prevailing problem. Substance Abuse and Risk Assessment

Most cases of suspected child maltreatment reported to child protective services do not eventuate in out-of-home placement of children. For children whose reported abuse or neglect is not substantiated or is not severe enough to warrant removal from home, there are other options. One option is to close the case after investigation of allegations of maltreatment, with or without referral to a community agency. Another is to open a case for ongoing services without placing the child out-of-home (Jones, 1993). Each option involves subjective assessment of the presenting situation and assignment of risk. To help protective services workers in their decision making, structured risk assessment procedures have been developed (Doueck, English, DePanfilis, & Moote, 1993; McDonald & Marks, 1991). Risk assessment involves determining the likelihood of future abuse or neglect based on the observed interaction of specified child, family, and environmental factors. Unfortunately, many structured assessment procedures do not adequately address risks to children associated with parent/caregiver substance abuse. For example, one instrument, designed to help mandated reporters determine whether an incident of child maltreatment warranted immediate reporting to child protective services, based decision-making on a matrix described by the degree of observed harm to the child and the ability of the reporting entity to offer ongoing services to maltreating parents (Berger, Rolon, Sachs, & Wilson, 1989). No attention was given to assessing for the presence of substance abuse, which studies show significantly impairs a parent's ability to make use of even court-mandated services (Murphy, Jellinek, Quinn, Smith, Poitrast, & Goshko, 1991). Those risk assessment procedures that do include parental substance abuse as a significant predictor of future maltreatment often fail to provide workers with specific ways of identifying substance abuse in a family under investigation. Because denial is a primary characteristic of addiction, identifying the presence of this problem in maltreating families is more complex than simply asking a caregiver about her or his drug or alcohol use (Deakins, Seif, & Weinstein, 1983; Griffin, 1991). More subtle indicators of the presence of parental substance abuse such as specific health problems or impaired social functioning associated with addiction are clues easily overlooked when relying on a general risk assessment instrument. In addition to limitations of the instruments themselves, those who have studied implementation of various models of risk assessment in child welfare agencies often find that caseworkers are insufficiently trained in their use (Doueck, English, DePanfilis, & Moote, 1993). These studies suggest that structured risk assessment procedures alone cannot replace well-trained staff. This is particularly true with respect to awareness of substance abuse indicators. According to Deakins and her colleagues (1983), "Social and health professionals are rarely taught how to recognize [substance abuse] until...the disease is all too evident." Child welfare practitioners may work closely with families over a period of months without recognizing signs of addiction in one or more family members (Deakins, Seif, & Weinstein, 1983; Griffin, 1991; Thompson, 1990). Even when such signs are recognized, practitioners often choose to ignore them because of inadequate training in how to intervene appropriately (Griffin, 1991; Thompson, 1990). Caseworkers' fears of damaging hard-won relationships with fragile families may preclude directly confronting addiction. However, given the mounting evidence of detrimental lifetime effects of parental substance abuse on the physical, mental, and emotional development of children, failing to actively address substance abuse in child welfare families is tantamount to complicity in the maltreatment of children.

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Screening for Substance Abuse in Child Welfare Families Screening for substance abuse is a critical first step in developing appropriate case plans for maltreating families whether or not their children enter out-of-home care. A standardized screening instrument is a brief structured questionnaire designed to be implemented as part of treatment intake or case investigation. Screening questions identify those individuals most likely to have a specific problem or condition such as alcoholism or depression. Screens are designed to err on the side of inclusion rather than exclusion with the expectation that the next step in the intervention process, a full problem-oriented assessment, will identify and exclude those falsely screened into the problem group. Therefore, a screen is intended only as an initial step in problem identification, to be followed by a fuller assessment focused only on those screened into the problem pool. Substance abuse screens, designed and validated for use in other human service systems, are easily adapted for use with maltreating families in the child welfare system. A sample of such screens is described below. Screens for alcohol abuse are better developed and more widely used than those for other forms of psychoactive drug use. One study of DSM III-R indicators of alcohol dependence found that the four criteria most frequently endorsed by those with alcohol problems are: (a) blackouts; (b) objections by family members or close friends; (c) withdrawal symptoms when the abused substance is not immediately available; and (d) neglect of responsibilities (Hoffmann, Harrison, Hall, Gust, Mable, & Cable, 1989). Using these indicators, Hoffmann and his colleagues developed the following brief questionnaire (the BONS) to be routinely administered at hospital admission to screen for alcohol abuse in a general medical population: 1. Have you ever been drunk enough that the next day you could not remember what you had said or done? 2. Have your family or friends told you they objected to your drinking? 3. Have you ever neglected some of your usual responsibilities when drinking? 4. Have your ever had the shakes after stopping or cutting down on your drinking, or the morning after drinking? A positive response to any one of these four questions identified 99% of those with alcohol problems in a sample of 310 hospital patients (Hoffman, Harrison, Hall, Gust, Mable, & Cable, 1989). Another well-tested screening device is the Short Michigan Alcoholism Screening Test (SMAST) (Selzer, Vinokur, & van Rooijen, 1975). This screen contains 13 questions and is designed to be self-administered. Like the BONS, the SMAST contains questions related to concerns of others about the respondent's drinking as well as questions regarding the respondent's ability to carry out personal and social obligations. It does not, however, include questions about the physical effects of addiction as does the BONS. On the other hand, the SMAST contains several questions about the respondent's help seeking regarding substance abuse that are not part of the BONS. A third screen, also developed primarily for alcoholism, is the CAGE (Ewing, 1971). This brief questionnaire consists of only four questions: (1) Have you ever felt you should cut down on your drinking?; (2) Have people annoyed you by criticizing your drinking?; (3) Have you ever felt bad or guilty about your drinking?; and (4) Have your ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)? These questions are prefaced by the inquiry: Do you ever drink alcoholic beverages? In one extensive reliability study of the SMAST and CAGE, both instruments were shown to have sensitivities to alcoholism of about 90%; that is, they detected this form of substance abuse in 9 out of 10 cases (Bernadt, Mumford, & Murray, 1984). Interestingly, both instruments were found superior to laboratory tests in screening for alcohol addiction.

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Screens for other forms of substance abuse are not as well-developed as those for alcoholism. The most widely used instrument for assessing all forms of addiction is the Addiction Severity Index (ASI), first introduced in 1980 and revised several times since (McLellan, Kushner, Metzger, Peters, Smither, Grissom, Pettinati, & Argeriou, 1992). However, this instrument's length (it requires nearly an hour to complete) and the training required to administer it properly preclude its use as a brief screening instrument in the child welfare system. Recently, McGovem and Morrison (1992) have developed the Chemical Use, Abuse, and Dependence Scale (CUAD), which has potential as a screening device in child welfare. It is relatively brief, its length depends on the number of different substances abused, and can be administered with minimal training, It also captures the polydrug use common to substance abusing women (Bays, 1990; Inciardi, Lockwood, & Pottieger, 1993; Worth, 1991). The CUAD begins with a screen for type and frequency of psychoactive drugs used; a series of seven questions are then asked separately for each drug reported on the initial screen. CUAD questions are based on DSM III-R criteria for substance use disorders and are, therefore, similar to those on the screens mentioned previously, particularly with respect to problems in social functioning and in interpersonal relationships. A concern with all screening instruments for substance abuse is that chemically dependent respondents will simply prevaricate about their dependence, particularly since denial is a major characteristic of addiction. Also, for families under investigation for child maltreatment, the fear of losing custody of their children provides additional impetus for denying substance abuse. Although most brief screening instruments have been constructed to minimize the effects of denim on responses (Selzer, Vinokur, & van Rooijen, 1975), concern regarding validity of client response speaks to the need for embedding screening questions within a routine data-gathering process (Mayfield, McLeod, & Hall, 1974; McGovem & Morrison, 1992). It also points to the importance of having screening questions administered by caseworkers trained in interviewing skills (Gregoire, 1994; McLellan, Kushner, Metzger, Peters, Smither, Grissom, Pettinati, & Argeriou, 1992) who have learned to effectively manage their own negative feelings and judgmental attitudes about substance abusing parents. One technique to maximize validity of responses is to ask screening questions like those on the BONS or CAGE in a more inclusive format, applying them to all members of the household, not just the respondent. That is, "Has anyone in your household or your family ever neglected their usual responsibilities when drinking or taking drugs?" (BONS), or "Have your ever felt someone in your household or your family should cut down on their drinking or drug-taking?" (CAGE). Many substance abusing parents are themselves children of substance abusers. Inquiring about family histories of addiction while completing a three-generation genogram with parents can help them put their own substance abuse in an intergenerational context. This motivates some parents to seek treatment to prevent passing on this self-destructive behavior to their own children as their parents did to them. It can also sensitize parents to the emotional devastation they are causing their children by acknowledging their own childhood experiences in a substance abusing household. Finally, it is important to be clear to families about why such questions are critical to the assessment process. Emphasizing that substance abuse treatment is an essential component of case planning in cases of child abuse and neglect helps parents recognize that chemical dependence is always inconsistent with adequate parenting. Substance Abuse Assessment

Once screening has identified one or more family members with substance abuse problems, a full assessment should be undertaken to determine the history, type, and extent of addiction.

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As more is known about addiction, particularly in women, it is increasingly apparent that there are other factors such as the frequent presence of major depression and histories of early sexual abuse that have important implications for treatment planning (Blume, 1990; Roesler & Dafter, 1993; Weiss, Griffin, & Mirin, 1992). For example, pre or early adolescent onset of substance abuse is believed to indicate both existence of early trauma and possible lags in the psychosocial development of the chemically dependent individual that must be attended to in planning a course of treatment. Griffin (1991) presents useful guidelines for assessing substance abuse in clients in social service settings as do Freeman and Landesman (1992). These guidelines focus on areas of social functioning that tend to pose particular difficulties for the chemically addicted individual. Areas commonly assessed include family and work life, physical health, and the law. Experts in women's addiction advocate assessing all aspects of women's lives to identify potential barriers to achieving sobriety (Reed, 1985). Such barriers might include relationships with substance abusing partners and/or lack of support for sobriety within the family system as indicated by the chemical dependence of a woman's parents or siblings. Previous treatment experiences should also be assessed. It is now recognized that achieving sobriety is often a process of many forward and backward steps rather than the result of a single treatment experience. This is important information for chemically dependent women whose guilt at failing in treatment may significantly inhibit subsequent treatment efforts (Bepko, 1989).

Helping Families Accept Substance Abuse Treatment Our experience with substance abusing families in the child welfare system suggests a number of strategies for successfully enabling families to accept treatment of their substance abuse problems. One is to constantly recognize that the substance abusing parent is a whole person with dreams, desires, and strengths, as well as weaknesses. Acknowledging that "substance abuser" is just one aspect of a caregiver's identity can be the basis of a helping alliance different from others the caregiver has experienced. The focus of concern must be the caregiver's needs as well as those of the children in the home, an approach that is sometimes contrary to standard child welfare practice. In addition, the caseworker must be able to empathize with the substance abusing parent, to recognize and understand the fear and pain that underlies addiction. This requires special training and, even then, can be difficult, especially for child protective services workers who repeatedly observe damage to children resulting from caregiver addiction. If there is concern about the imminent safety of children in the home leading to a recommendation of placement, this must be addressed directly and honestly with the caregiver, but can be done in a way that engages the caregiver in planning for the child and for him/herself in a positive rather than punitive way. If the caregiver is actively abusing controlled substances at the time of contact, he/she may not be able to acknowledge the validity of the caseworker's risk assessment, but can understand the specific risk factors that led to the determination if they are presented clearly and directly. This discussion should include available services to rectify the problems observed in the home, including, but not limited to, addictions treatment. In our experience, substance abusing caregivers are often relieved that someone is stepping in to provide the structure and direction that they cannot. Many times an agreement can be reached for voluntary placement of children for a timelimited period while the caregiver seeks in-patient substance abuse treatment. This agreement, which should be in the form of a written contract signed by the caregiver, must also include a specified period of work with the caseworker after in-patient treatment is completed to address other family problems that may interfere with sobriety, such as limited parenting skills and inadequate social support networks. In addition, provision must be made in the contract for

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continuing support for sobriety through a 12-Step program or other support group. Overcoming addiction is an ongoing process that does not end with the completion of a treatment program. This speaks to the need for caseworkers to be well-informed about a wide range of community resources, including addictions treatment programs. No matter how much substance abusing caregivers may express a desire to seek treatment and attain sobriety, tolerance for frustration is limited in most chemically dependent individuals. If they are misdirected or misinformed about available treatment resources, they quickly become discouraged and disillusioned, and relapse. Also, caseworkers must be informed about childcare provisions in various treatment facilities. Studies show that few substance abuse programs make provisions for childcare, while lack of available childcare is a major barrier to treatment entry and completion for caregivers (Zanowski, 1987). Thus, it is often necessary to assist with childcare services while the caregiver participates in outpatient treatment when children do not enter out-of-home care.

CONCLUSION Some states have attempted to stem the tide of parental substance abuse by enacting laws making psychoactive drug use during pregnancy a form of child abuse. Similarly, giving birth to an infant born with a positive toxicology screen is made prima facie evidence of child neglect, thus mandating foster care placement of such infants (Chavkin, Allen, & Oberman, 1991). However, it is not possible, or even desirable, to provide foster homes to all children with chemically dependent parents. Indeed, there is evidence that motherhood can sometimes be the needed impetus for sobriety for substance abusing women, provided adequate addictions treatment is available (Volpe & Hamilton, 1982/1983). However, for substance abusing parents, as with all chemically dependent persons, the road to sobriety is often perilous and requires constant encouragement and support. Because of the social isolation that characterizes the lives of many substance abusing and maltreating parents, a child welfare caseworker may be the only consistent resource available for this support. In addition, the legal sanctions adhering to child protective investigations give child welfare caseworkers unique access to these closed family systems, as well as singular leverage to pry caregivers into assessment and treatment. Therefore, it is imperative that child welfare practitioners be equipped with the knowledge and skills necessary to identify and intervene appropriately and successfully in substance abusing families.

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Rtsumt----Les 6tudes dtmontrent que dans au moins la moiti6 des cas de maltraitance qui sont signalts aux autoritts de la protection de l'enfance, on retrouve un probltme de dtpendance sur les drogues ou l'alcool chez les parents. Depuis la demi~re dtcennie, on semble noter que cette dtpendance pourrait expliquer le nombre croissant d'enfants placts dans des foyers d'accueil. Ce probl~me serait aussi/l la base des difficultts psychologiques et du dtveloppement chez des enfants. En mtme temps, cependant, les responsables de la protection de l'enfance recoivent peu de formation concernant cette probltmatique, comment l'identifier et transiger. Les auteurs explorent des mtthodes communtment accepttes pour dtceler les pmbl~mes de toxicomanie parmi diverses populations et sugg~rent comment adapter ces outils aux cas de maltraitance, lls discutent des modalitts pour 6valuer et traiter ces families oi~ il y a dtpendance et maltraltance. Resumen----Los estudios sobre la relaci6n entre el abuso de sustancias parental y el maltrato contra los nifios sugiere que la dependencia qufmica es~ presente en por lo menos la mitad de las familias que llegan a las autoridades de bienestar infantil. El abuso de sustancias parental se piensa que es un factor primario en el creciente aumento de nifios que pasaron al cuidado sustituto en la dtcada pasada. Es tambitn un factor de riesgo claro para el abuso y la negligencia contra los nifios y deficiencias en el desarrollo de los nifios. AI mismo tiempo, sin embargo, a menudo se le da una atenci6n minima al entrenamiento de los que trabajan en los servicios de protecci6n infantil y a los demfis que forman el personal de bienestar infantil sobre la identificaci6n y manejo del abuso de sustancias en las familias que tienen que atender. Los autores exploran mttodos estandarizados desarrollados para discriminar el abuso de sustancias en diferentes poblaciones y sugieren formas de adaptar estos instmmentos de dign6stico para las familias reportadas por maitrato a los nifios. Se identifican tambitn, consideraciones sobre evaluaci6n y tratamiento en familias que abusan de sustancias.