Parental substance use assessment tool

Introduction

Assessing parental drug use and impact on parenting and child safety

Parenting and child safety/wellbeing are the main issues rather than drug use per se.

Drug addiction is associated with increased risk of harm and neglect to children. The role of child protection practitioners is to focus on the possible impact of parental drug use on parenting and child development as well as parental strengths and resources. An understanding of drug use frameworks will help in formulating risk assessment and management, but should not replace more formal drug assessment by drug worker specialists.

Screening for drug use and possible impact on parenting

Drug use is a common coping strategy used by those in anxiety producing situations. It has been estimated that it is a major factor in over 40% of child protection cases.

Drug use by parents is highly stigmatised by the general population. Parents often experience acute guilt and shame associated with their behaviour. Where drug use is not the primary reason for assessment, tact may be required to yield accurate information.

The use of routine screening questions or bridging statements which couch drug use as an adaptive response to stressful situations may help to gently ‘break the ice’ and build rapport.

Definitions

Drug/substance:

Drugs are substances that can alter an individual’s physical and/or psychological functions.

Psychoactive drugs are those substances which act on the central nervous system (CNS) to alter the user’s mood, thinking and behaviour.

The term substance or drug refers to all drugs legal and illegal, including alcohol, tobacco and prescribed psychoactive drugs (e.g. valium) as well as illicit substances such as marijuana, amphetamines and heroin.

Enabling behaviours

Enabling behaviours include those activities which consciously or otherwise support those with drug use problems to continue with current negative patterns of behaviour.

Drug classifications

Psychoactive drug use can be classified in a number of different ways:

• Legality – legal, illegal
• Chemical effects – depressant, stimulant, hallucinogen or other
• Type of use – recreational, medicinal, dependent
• Method of administration – injectable, non-injectable
• Societal standards – acceptance, not acceptable

Drug frameworks

Using drug frameworks may be helpful in assessments as they:

• provide structure from which to conduct assessments
• improves conceptual ability to differentiate and integrate complex information
• may help parents self-assess, sort and understand their drug use
• may shift ‘all or none’ thinking (using vs. abstinence, good vs. bad) to more comprehensive and useful assessments.

Interactive factors

The effect of a substance on users and others will be determined by three interacting factors:

• drug – type, amount, purity, route of administration
• individual – weight, gender, age, knowledge, emotional state, expectations, drug tolerance
• environment – family, peers, community standards and laws, resources, social climate, etc.

Drug use benefits and costs

Benefits or function

• enhance pleasure
• reduce pain (physical and/or psychological – coping mechanism).

4Fs – benefits associated with:

• Fun – feel good, experimentation
• Friends – fit in with peers, fad, image enhancement
• Finance - drug use provides income
• Forlorn – deal with psychological or physical pain

Degree of costs or problems

• Minimal negative impact on self, child, family, others
• Moderate negative impact on self, child, family, others
• Major negative impact on self, child, family, others

Drug use problems

Four other methods of categorising problems are:

Problems on intoxication, regular use, dependence

• Intoxication – short term, episodic use, such as a drink driving accident, overdose
• Regular use – drip, smoke, affecting longer-term physical, finances and relationships
• Dependence – feeling stuck, over-reliance on drugs, withdrawal symptoms

4Ls – Problems associated with:

• Liver – physical and psychological health
• Lover – relationships, children, family, friends
• Livelihood – work, recreation, finances, study, lifestyle
• Law – legal and statutory issues

‘P’ Problems affecting – Parent, Child (progeny), Partner, Peers, Public, Police

An even more simple version is problems to self and others.

Past, present, possible future problems (harms)

Assessment of potential drug-related harm requires an understanding of any current and/or past drug problems, including the management of these problems.

Levels of drug use

• experimental, social, binge/intensive, addictive
• problematic, non-problematic
• chaotic, controlled.

Stages of change

Changing behaviour has been described by Prochaska and DiClemente (1983) as having five stages which also have corresponding processes and suggested strategies:

• Pre-contemplation – not thinking about changing (‘happy user or hopeless user’)
• Contemplation – considering change
• Determination – decision to change has been made
• Action – initial action to change initiated
• Maintenance – change maintained over time, new behaviours replacing old
• Relapse – may cycle a person back to any former stage.

Note: can be at different stages for different behaviours:

• may be a pre-contemplator for one substance but an actioner for another
• may not want to stop using drugs, but be willing to adopt less hazardous methods of use.

Child or young person

Children rely on their parents to meet their physical, emotional, social, developmental and economic needs. Drug use by parents may negatively impact on the development of children at the following times:

• prior to being born – children exposed to substances whilst in-utero are generally smaller and represent one of the highest risk groups
• infant and very young children are particularly vulnerable due to their age and developmental stage. Mothers are at an increased risk of post-natal depression at this time
• later in childhood, accumulated harm and neglect may manifest in developmental delays and inappropriate behaviour
• adolescent may replicate parental drug use and other maladaptive patterns.

Parents who are dependent on drugs often find it difficult to balance their need for substances with parental responsibilities, despite their wishes to do so.

• Drug use may be a maladaptive coping strategy to deal with stress including parental and family responsibilities.
• Time and resources involved in supporting a drug use habit reduces time available to children.
• Parent may not be able to adequately care for children during the ups, downs and in-betweens of drug use.
• Associated drug using lifestyle (procurement of drug, criminal activity, unstable accommodation) may not be conductive to child safety and well-being.
• Supports which may have been otherwise available may be withdrawn in the context of parental substance use.
• Shame and fear of public and professional scrutiny may further isolate and disadvantage children if child care and other professional help is seen as a threat.
• As a result, children who are born into and/or grow up in families where parents are involved in substance abuse are at higher risk of significant harm through neglect, emotional abuse, physical abuse and/or sexual abuse.
• Children often represent a powerful motivation for parents to change drug use patterns.
• Changes in entrenched drug use normally takes time and is characterised by lapses. Ongoing assessment of child safety and parental progress is required during any change process.

Newborn infants diagnosed with foetal substance abuse symptoms are one of the highest protective risk categories for short term and long term damage to their physical, social and emotional health and wellbeing.

The World Health Organisation estimates over 90% of pregnant women use some sort of drug during their pregnancy and that 2% - 3% of all birth defects are due to drug use.

The immediate and unique needs of these infants require parental care and skills not usually evident in substance abusing and addicted parents.

These children are likely to require ongoing medical, community health and welfare services to overcome the damage caused to them prior to birth.

Pregnancy

If the substance using mother pregnant, what prenatal treatment is she receiving? (See below for further questions if pregnant).

Pregnancy history

• Was the child’s mother using substances during pregnancy?
• If so, what type, how much, what method and during what period of the pregnancy were they used?
• Were there any accidents, injury, periods of unconsciousness, overdose or hospitalisation associated with drug use during the pregnancy?
• What was the nature of the prenatal care which the mother received during the pregnancy?

Premature and/or underweight infants are over represented in child homicides, child abuse and neglect

Recognising the biological and medical risk factors is critical in assessing risk to a newborn or very young child

Physical abnormalities may not necessarily be a result of drug use during pregnancy but may increase stress and drug use of parent(s).

Birth history

• Was the baby born at term or prematurely? If so, at what gestation?
• Was the baby’s weight normal or underweight at birth?

Infant

• Does (did) the baby have any physical malformations?
• Does (did) the baby have foetal alcohol syndrome?
• Does (did) the newborn baby show signs of withdrawal or disturbances in their state of self calm? (Consider increased sleep disturbances; restlessness; irritability; feeding with frantic, non-nutritive sucking; poor weight gain.)
• Is the newborn baby alert and visual orientated?
• Are there other infant(s) or children in the care of the parent(s)? If so, how are they progressing?

Impact of parental drug use may negatively impact on children’s emotional, psychological, and social development and physical safety.

Child’s basic needs

Is there adequate food, clothing and warmth for the child(ren)?

General development: psychological, social and physical health

Psycho-social development

• How is the child progressing at day care / pre-school / school?
• What is the child’s chronological age (intellectual, social, physical) compared with their level of functioning?
• Are there indicators that any of the children are taking on a parenting role within the family? (Consider caring for other children, excessive household responsibilities, calling ambulance or cleaning up after sick parent.)
• Does the child show any cognitive and/or motor disturbances? (Consider language, attention and learning deficits.)
• Does the child show signs of poor global disturbances? (Consider delayed personal, social, adaptive and communicative behaviours.)
• Are there age appropriate routines? (Consider regular sleeping hours, meal times, getting to school and so forth.)
• Does the child demonstrate anti-social or delinquent behaviours?
• Does the (older) child engage in substance abuse? Is this problematic?

Physical health

• What is the state of the child’s general health at the present time?
• Is the child receiving any treatment at present? If so, what for?
• Are there any urgent and/or outstanding health or medical issues which need to be addressed?
• Have relevant specialist assessments been obtained? (Consider paediatric assessments, medical examinations or psychological assessments.)

Caregiver history and attachments

• What is the child’s history of out-of-home placement?
• If the parents are separated or divorced, are there any access issues between the parents, or between the parent and the child, which may impact on the relationship?
• From whom does the child seek comfort? Does the child self-comfort or display no expectation of being comforted by carer(s)?

Accommodation and home environment

Quality and stability of accommodation

• Is the accommodation adequate and appropriately stimulating for children?
• Are parents ensuring that rent and bills are paid?
• Does the family remain in one area or do they move frequently?

Associated environmental factors

• Are other drug users sharing the accommodation? If so, are relationships with them harmonious, or is there conflict?
• Could other aspects of the drug use constitute a risk to children? (Consider conflict with or between dealers or exposure to criminal activities related to drug use.)

Child’s observations of drug use

• Does the child know about the parent(s) alcohol and other drugs problem? How do they know?
• What has the child witnessed regarding parent(s) drug use? (Has the child seen a parent buying drugs, administering drugs, drug use equipment (such as syringes), parental behaviour when under the influence, parent unconscious or ill.)

Procurement of drugs

• Are the children ever left alone while their parents are procuring drugs?
• Because of their parents’ drug use, are children being taken to places where they could be ‘at risk’?
• How much do drugs cost and how is this money obtained?
• Is this reducing resources available to children?
• If buying and selling drugs, is the home used for transactions?

Management during periods of intoxication, hangover and withdrawal

• How are children cared for during periods of parental intoxication or drugs?
• How are children cared for during ‘hang-over’ periods?
• How are children cared for during periods of withdrawal?

Storage and access to parent’s drugs and medication

• Are drugs and medications stored in a safe place out of the reach of children?
• Do the children know where their parents’ drugs and/or medications are stored?
• Have the children ever taken (accidentally or otherwise) drugs or medications used by parents? If so, what action was taken?
• If the parent injects, how are syringes disposed of?

Special needs

• Does the child have any special needs? Are there any factors that makes the child more difficult to care for? (Consider: intellectual disability; physical disability; behavioural problems; medical needs; social needs, especially where lack of stimulation is present.)

Substance using parent

History and pattern of parental substance use

• Is one parent, or are both parents, using substances?
• For each substance using parent.

Past drug use history

• What was the age of the parent when the substance abuse began? When and how was it first a problem?
• What has been the frequency and extent of subsequent substance usage?
• Have there been periods of abstinence and/or controlled drug use?
• Any previous drug treatment history? How did this go?

Current drug use

• What is the primary substance(s) used now?
• What other substances are used if the preferred substance is not available?)
• What is the parent’s pattern of substance use? What are the typical ‘ups, downs and in-betweens’ of a typical day or week of drug use? Are there ‘typical days’ or is use more sporadic and/or chaotic?
• What is the current frequency of substance use by the parent? (Occasional; recreational; weekly; continuous, being 3-4 times per week; or daily.)
• Are there signs of dependence? (Consider withdrawal symptoms, time of first drug use in the morning, repeated attempts to quit or cut down or continued use in face of serious negative consequences.)
• Over what period of time has the parent been using substances to this level?
• Are levels of child care and protection different from when the parent was not using substance?

Problems associated with drug use

The highest incidence of abuse and neglect occurs in families where both parents use alcohol excessively. Family violence and physical abuse are common in these families.

• Is the parent using alcohol excessively?
• Is domestic violence present in the home?

Parents using substances continuously or daily may have difficulty expressing or remembering details of their substance use and its impact on parenting and child safety. It is therefore vital that information is gathered from other family members as well as any professionals involved with the individual or family.

Physical health

• What is the current physical health of the substance using parent? (Consider hepatitis, HIV and other blood borne diseases in injecting drug users, general infections, liver and gastric diseases, accidents associated with being intoxicated.)
• When did the parent last see a medical practitioner for a medical check?
• How are children cared for during periods of illness?
• Are parents aware of health risk associated with their drug use?

Psychological health

Depression, anxiety disorders and personality disorders are common amongst people with drug addiction. The treatment of co-existing disorders of drug addiction and mental illness present significant treatment challenges. While most mental illness associated with substance use are transient and treatable, overall outcomes are poorer than for adults with either drug addiction or mental illness.

• What strategies does the parent use to cope with anxiety and stress associated with parenting?
• Does the parent use substances to help cope with emotional difficulties?
• What other coping strategies does the parent use to cope?

Mental health

• Has the substance abusing parent been diagnosed with a mental illness, or do they show evidence of a mental, emotional or personality disorder? (Consider depression, post-natal depression, anxiety disorder, anti-social personality, border-line personality or psychosis)
• Are any specialist assessments and treatments available regarding the parent’s mental illness?
• Has the parent adhered to treatment regimes prescribed by mental health practitioners?
• Is the parent prescribed medication for the mental illness? If so, do they understand possible interactions between these medications and other substances used?
• How are children managed during acute episodes of mental illness?
• How has the mental illness impacted on the children and other family members?

Relationships

• How has drug use affected the relationship with other parents?
• How has drug use affected relationships with other family members?
• How do other family members view the parent(s) drug use?
• How has drug use affected relationships with friends?
• Are most friends drug users or non-drug users?
• If children know of their parents drug use, what do they think about it?

Livelihood

• Has drug use affected the parent’s ability to obtain regular employment or study?
• Does the parent have any hobbies or interests, particularly those which may involve children or does life revolve around drug use?
• Is the family financially stable, or are they in debt?

Legal issues

• Have parent(s) been charge for drug related issues, such as drink driving offences, possession, dealing, illegal activity such as theft or prostitution to raise money for drugs?
• Are there any outstanding charges?
• Has a criminal history check been conducted to establish if a criminal history exists? What is the nature and extent of the parent’s known offending?
• Have parent(s) ever been held in custody? If so, how were children cared for?

Infants

Infants born to substance-addicted parents are vulnerable when forming attachments unless there is a positive supportive environment with responsive caregivers. These infants may exhibit medical and/or behavioural difficulties. They are less available for interaction and may elicit negative reactions from the caregivers. Parental substance use during this time exacerbates attachment difficulties between the infant and parents, particularly between the mother and infant.

Meaning of the child to the parent

• What is the parent’s commitment to the child, and how willing are they to care for the child? (This may be reflected in the hospital visiting pattern and the interactions between the parent and infant during visits)
• What was the impact of pregnancy and the birth of the child(ren) on substance use?
• Have there been any changes in the parent’s coping strategies, or any attempts to engage in treatment or supports, during pregnancy and since the baby’s birth?

Substance addicted parents may deny and minimise the use of substances and their impact on their lives. Those with co-existing anti-social or borderline personality disorders may further challenge assessment and treatment interventions.

Parent perceptions of their drug use and its impact on the family

Perception of child protection

• Do parents see their drug use as harmful to themselves or their children?
• Do parents place their own needs before the needs of their children?

Awareness and knowledge of supports

• Are parents aware of support options open to them such as respite care, drug gender sensitive drug treatment services and so forth?

Goals and stage of change

• Do parents have any overall goals regarding their drug use and parenting requirements?
• Are parents realistic in their goals for change?
• What stage of change category would the parent(s) be in regarding their:
  • substance use?
  • willingness to engage in less risky drug use behaviours (harm reduction)?
  • willingness to enhance their parenting skills where indicated?
  • willingness to engage in treatment options?

Barriers and obstacles

• What barriers or obstacles do parents identify for progressing treatment goals?

Reasons for drug use and alternatives

• How does drug use help parent(s)?
• How well does this work?
• Have parent(s) ever successfully used other strategies to achieve similar results?

The historical pattern of family structure and care of children should be considered in terms of parenting subsequent children.

• Does the parent have or had any other children placed in out-of-home care?
• If so, what were the circumstances surrounding the move or placement?

Psychosocial history

• What was the parent’s childhood and adolescence like?
• Was the parent abused as a child?
• Was the substance user’s parents addicted to substances and have other addiction problems?
• Was the substance addicted parent placed in alternative care as a child? What were the reasons for this?

Substance addicted parent(s) may have their own unmet dependency needs as a child. Subsequently, the parent becomes easily overwhelmed by the demands of care from their own child, as this awakens their own underlying sense of deprivation.

• Does the substance addicted parent have unresolved dependency needs?
• What is the nature of the substance abusing parent’s relationship with their partner?
• Does one or both partners appear to be overly dependent on the other?

Non-substance abusing parent/other carer

• Does the other parent/carer use substances?
• Does the partner acknowledge the protective concerns and the impact of the substance abusing parent’s activities on their lives?
• Is the partner prepared to be the child’s primary caregiver?
• Is the partner prepared to engage in protecting the child?
• How responsive, both physically and emotionally, is the partner to the child?
• How willing is the partner to be involved with services, or to be involved with the substance addicted parent in treatment?
• What is the partner’s level of emotional functioning?

Networks and supports

Friends

Families with substance abusing parents tend to be more isolated and less involved in recreational, social, cultural and religious activities.

• Is the parent(s) circle of friends likely to be destructive, constructive or neutral in helping parent(s) make positive changes? Are they also drug addicted? What is their attitude to child protection issues and agency support?
• Is the parent(s) circle of friends available to help with positive child rearing practices?
• Do parents feel they are socially stigmatised in their community? If so, how does this affect access to support services and networks?

Relatives

Support provided to substance abusing parents by relatives is often conditional and based on mistrust of the substance abuser’s parenting ability.

• What involvement does the family have with other relatives?
• What capacity do they have to provide care for the child?
• Do relatives know about the level of parental drug use?
• Are relatives willing to provide support?
• What is the relationship between children and relatives?
• Will the family accept support from other relatives?
• Do relatives have access to professional support in understanding and managing drug and other related issues?

Parents who are addicted to substances have a high incidence of having been sexually abused or neglected from their own parents. This should be carefully investigated and considered prior to any placement of children with their grandparents.

• Is there a history of physical or sexual abuse from relatives?

Agency supports

The history of past and current involvement with support agencies and/or professionals is an indicator of the family’s receptivity to intervention.

• With what agencies or professional has the family previously been involved?
• How were these services utilised?
• With what agencies or professionals is the family currently involved?
• What is the nature of the service utilisation?
• If the family relocates frequently, how has (or will) tracking and monitoring be undertaken?

Substance abuse and child abuse and neglect are separate, although interrelated, issues. Consequently, intervention strategies vary in both nature and timing: the care and protection of the child requires immediate attention and action, whereas parental acknowledgement, treatment and the maintenance of a substance free lifestyle will only be achieved over time. Therefore, it is important for child protection practitioners to be able to identify potential barriers that may adversely affect the protective risk assessment and decision-making.

Interagency management

• What is the relationship between child protection practitioners and other agencies?
• Have reciprocal protocols and procedures been developed? Are they working?
• Are roles and boundaries between various agencies clearly identified, and known by all involved including parents?
• Do family focused interventions allow for both treatment planning and protection of children?
• Is their evidence of lack of child protection issues by primary health workers? (Is there a lack of reporting cases of neglect, abuse or risk of harm, parents given repeated changes without full consideration of the effects on children, protective worker’s own values in relation to substance use interfering with quality assessment).

The context of risk in drug using parents

The following list is adapted from Dalgleish L. & Drew E., (1989) ‘The relationship of child abuse indicators to the assessment of perceived risk’. Child Abuse and Neglect, Vol. 13.

Nature of harm

• Actual harm, history of harm and risk of harm and neglect
• Known pattern of child abuse or neglect, previous reports
• Inconsistency of explanation and injury
• Access of the perpetrator.

Assessment of the child

• Child’s age, stage and development including in-utero and neo-natal development
• Impact of parental drug use on child’s social, emotional and physical development
• Child’s assessment of family life and account of events
• Child’s response to the primary caregiver
• Additional needs for a disabled child.

Assessment of parents

• Impact of chronic illness, intellectual disability, or physical disability
• Impact of mental health problems and preparedness to manage them
• Impact of parent’s alcohol and other drug use:
  • how substances are procured, financed
  • pattern and extent of use (occasional/recreational, weekly, continuous use)
  • use by parents of harm minimization strategies
  • effect of substances on attention span, memory, emotional and physical availability (during intoxication, hangover, between and withdrawal)
  • physical safety in the home (consider child access to drugs)
  • former attempts to manage drug addiction, child safety and child development
  • attempts to reduce impact of drug use on children
  • needs satisfied by drug use (reasons for drug use)
  • any alternative methods for meeting these needs.

Aspects of parenting

• Continuity of care
• Cooperation between parents about discipline and other parenting priorities
• Parent’s perceptions of being a parent
• Parent’s attitude to the children
• Ability to understand and meet the child’s developmental needs
• Issues relating to siblings.

Aspects of parent’s relationship

• Ability to resolve conflict
• Domestic violence
• Ability to balance priorities within and between relationships.

Family’s social system

• Viability of family’s social support systems
• Extent of high risk substance use and/or criminality in the family/social network
• Family’s ability to access support and community resources.

Level of cooperation

• Family’s ability and/or willingness to recognise the existence of actual and/or potential risk
• Family’s willingness to work to protect child
• Family’s potential and/or motivation for change re drug use problems and parenting – note stage of change, barriers to change, history of change.

Resources

• Stability of finances, housing and environmental resources
• Availability of community facilities.