This advice outlines:
- the definition of substances, substance use and abuse
- the prevalence of substance use in child protection clients and their families
- identifying the need for parental drug and alcohol assessment
- utilising the drug and alcohol assessment for the child to develop their case plan
- neonatal abstinence syndrome.
The impact of parental substance abuse on a child requires thorough assessment. A stable and nurturing environment is crucial in the development of a healthy and emotionally secure child. Parents using substances may have significant difficulties caring for their children and their commitment and ability to provide care and protection may be significantly compromised by the effects of their substance abuse on mental health, physical health, lifestyle and functioning. Children rely on their parents to meet their physical, emotional, social, developmental and economic needs. When a parent is dependent or users of substances their primary commitment is often to the substance, not to their children. A parent may find it difficult to prioritise the child's needs. The lifestyle associated with substance abuse may preclude rational and long-term decision making. Day-to-day decisions can be oriented towards maintaining an addiction. Consequently, a parent's capacity to respond appropriately to their child's needs can be limited, even though the parent may express the desire to care for their child.
Department data indicates that parental substance abuse as a factor in child protection cases is increasing. Research indicates that substance abuse as a parental characteristic increases the likelihood of abuse and neglect of a child and therefore there is an increased likelihood of the removal of that child. Substance abuse assessment is a feature of child protection practice, whether substance use is by a parent or a young person. Intervention strategies vary in form and timing, with the protection of the child requiring immediate attention and action, whereas parental acknowledgement, treatment and the maintenance of a substance free lifestyle will only be achieved over time. Therefore, child protection practitioners need to develop knowledge about substance abuse in order to make informed decisions and implement interventions, which can be supported with research findings and theory in court reports and utilised in case planning. See Parental substance use assessment tool.
For the purposes of this advice, a drug is a substance which is psychoactive, that is it produces a mind altering effect on an individual.
The term 'substance' is used to refer to all drugs, licit and illicit, including alcohol.
Examples of substances include, though are not limited to:
amphetamine (speed, crystal meth, ice), opioids (heroin, morphine, methadone, pethidine, opium), alcohol, cannabis, cocaine, hallucinogens (LSD, PCP), inhalants (glue, petrol, aerosol, paint), benzodiazepines (valium, librium, mogadon, serapax, temazipan, normison), other prescribed medications.
It is part of the child protection practitioner's role to assess the impact of substance abuse by the parent and potential or actual harm to the child. Therefore, the child protection practitioner is required to ask questions relating to past and current substance use, including the effects of substance use on the persons' physical and emotional wellbeing and level of functioning. The parent may not provide complete or accurate details of their substance use. It is vital that information is gathered from other family members as well as any professionals involved with the parent or family. See advice Drug screens.
The child protection practitioner will need to be aware of physical indicators of possible substance abuse. The following list is illustrative, and not exhaustive, of possible physical indicators of substance abuse:
disorientation, loss of inhibition, relaxation, dizziness, poor coordination, slower reaction time, blurred vision, slurred speech, aggressive disposition, depression, dilated pupils, pin-point pupils, increased or decreased appetite, paranoia or hallucinations, anxiety or panic attacks, confusion, restlessness/irritability, weight gain or loss, sweating, sleepiness, nausea and vomiting.
It should be noted that the above are only indicators of substance abuse as there may be other possible explanations for a parent’s presentation, which should be explored and considered.
When symptoms listed above are evident and there is a possibility that a parent may be using substances, a drug and alcohol assessment is required.
This is the most effective way to understand a parent's drug and alcohol use. A drug and alcohol assessment may be helpful when:
- there is a known history of drug and alcohol use by a parent
- there is information to indicate current drug and alcohol use by a parent
- a parent has disclosed current drug and alcohol abuse
- you require a comprehensive assessment and understanding of a parent’s use of substances and impact on their parenting capacity
- you require information about support services necessary for a parent to address their substance abuse
- there is a need to identify the most appropriate treatment for a parent’s substance abuse.
A drug and alcohol assessment includes an interview process designed to gather information about a parent’s history of substance use, current substance use, triggers for use, impact on level of functioning, treatments undertaken and to ascertain the most suitable treatment for the parent. A drug and alcohol assessment is undertaken by a drug and alcohol clinician.
In situations where a parent’s drug and alcohol abuse may meet the criteria for substance dependency under the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), this assessment must be undertaken by a psychologist with relevant experience in this area.
The child protection practitioner may need to consider the possibility that a parent may have an alcohol related brain injury (ARBI). In these situations, a parent’s cognitive ability may be compromised due to excessive alcohol consumption and this may impact on their ability to learn new information, cope with and adapt to change and on their memory. Consequently, this would have significant implications for a parent’s ability to care for and protect their child or engage in a plan to address specific concerns. The most effective way to diagnose ARBI is a neuropsychological assessment. This can only be conducted by a neuropsychologist who has completed specialised training in acquired brain injury. The neuropsychologist will diagnose brain injury and make recommendations about rehabilitation and management needs.
Requesting a purposeful drug and alcohol assessment
The purpose for which the drug and alcohol assessment is required and the specific circumstances of the case will dictate what information is required. It is important for the child protection practitioner to clearly identify the assessment information required to the drug and alcohol clinician. The following are some likely areas to be covered:
- the age of the parent when the substance abuse began, including experimentation with substances
- the frequency, pattern and extent of substance abuse, including periods of abstinence and relapse
- reasons for initial substance abuse and the reasons for continued use
- types of substances used, including licit and illicit, and whether the parent engages in poly-substance use and substitute substance use (using another substance when the preferred substance is not available)
- the impact of different substances used concurrently on the parent's level of functioning
- triggers for substance use and ascertaining high risk situations in which a parent is more likely to use
- the effect of substance abuse on the parent’s level of functioning, including physical health, emotional wellbeing, cognitive capacity
- source of licit or illicit substances – including lifestyle factors, association with other substance uses or sellers, the children's exposure to the drug culture
- observations of the impact of the parent’s substance abuse on their parenting capacity and ability to care for and protect the child (it is not appropriate to expect a parenting capacity assessment. A drug and alcohol assessment will usually not include this aspect, unless the agency provides a specific service that addresses parenting and substance use issues with the parent)
- the stage the parent is at in the 'model of change' and therefore their prognosis and likelihood of the successful completion of treatment, and likely timing
- recommendation of most appropriate treatment plan for the parent, that is, residential detoxification, home detoxification, counselling.
A drug and alcohol assessment has the potential to provide the child protection practitioner with a comprehensive understanding of the parent’s drug and alcohol abuse, inform risk and needs assessment for the child. It provides a framework for planning interventions when working with families where one or both parents are abusing substances and decision-making to protect the child.
The child protection practitioner's primary focus should always be the protection of the child. Therefore if issues of immediacy and risk to the child are identified in the drug and alcohol assessment, this must be dealt with first. Once the safety of the child is assured then other issues such as substance abuse, treatment and parenting can be addressed.
Risk and needs assessment
The drug and alcohol assessment is a valuable source of information that can be utilised by the child protection practitioner in articulating a risk and needs assessment for the child, particularly for the purposes of a court report and case planning. The information used in conjunction with observations of the parent’s behaviour by the child protection practitioner, family members, child and other professionals can highlight the type and level of risk to the child. For example, if the effect of the parent’s substance abuse is that the parent falls asleep or becomes aggressive and this has been observed to occur by a family member, then the child (particularly an infant) is assessed to be at an increased risk of significant harm.
The drug and alcohol assessment will assist the child protection practitioner when determining the permanency objective and making decisions concerning the child for their present and future care and wellbeing, as set out in the case plan. The child protection practitioner will be able to clearly identify the tasks or actions that the parent must undertake to achieve the goal of adequately addressing the protective concerns. These will be noted in the actions table. Introduction of tasks should be tightly managed to avoid overwhelming the parent and give the greatest opportunity for timely success.
The prognosis of a parent's ability to address their substance abuse in a timely way and where they are at on the 'model for change' will enable the practitioner to assess the viability of reunification, if the child is placed out of the parent's care. Substance abuse is a complex life struggle for those individuals consumed by dependence and addiction. Addressing substance abuse is a challenge characterised by deception, manipulation and relapse. It is not uncommon for a parent to display frequent and unpredictable relapses into substance abusing behaviour, despite acknowledging the issues and articulating a commitment to change. The child protection practitioner must always make decisions in the best interests of the child taking into account their age and stage of development. Therefore if a parent has not been able to adequately address their substance abuse within an appropriate timeframe, a review of progress towards the permanency objective considering its achievability, may lead to determining that the child requires alternative permanent or long-term care.
In implementing the case plan, strategic management will be required.
The drug and alcohol assessment can be used to assess parenting capacity and the parent's ability to ensure the child's safety and meet their developmental needs. The child protection practitioner can utilise the information regarding the parent's use and the impact of this on their level of functioning to articulate current, potential and future parenting capacity. The child protection practitioner should be conscious of the age and stage of development of the child when assessing parenting capacity. For example, the parenting required of a parent with the care of an infant is very different in some respects from the parenting required to care for an older child.
Referral to support services
A drug and alcohol assessment identifies and enables response so that parents are offered support as soon as possible in their parenting role and treatment for their drug and alcohol issues. The child protection practitioner can refer a parent to appropriate drug and alcohol support services so that they can undergo relevant treatment to address their substance use. See Drug and alcohol assessment and treatment services.
Parents whose children are subject to family reunification orders, where there is a condition attached for the parent to engage in alcohol or drug treatment, are eligible to be seen immediately, through particular services providers. The objective of this initiative is to engage parents requiring assessment and treatment in a timely manner in order to maximise the likelihood of reunifying with their child within the timeframes of a family reunification order. See AOD treatment initiative for family reunification (pdf, 425.76 KB) for further information and provider contact details.
If the mother is known to have used substances during pregnancy, the child protection practitioner should discuss with the hospital whether the neonate (newborn) is exhibiting signs of Neonatal Abstinence Syndrome (NAS). Statistics from the Women's Alcohol and Drug Services, Royal Women's Hospital, indicate that more than 66 per cent of infants born to substance dependent mothers exhibit some signs of NAS. Twenty-five percent of infants exposed to narcotics (primarily heroin and methadone) require medication for symptomatic narcotic withdrawal.
The Neonatal Abstinence Scoring System is used when scoring newborns to determine if treatment for NAS is required. The two types of treatment include:
- non-pharmocological (holding, rocking, demand feeding, reduced lighting and noise levels), and
- morphine therapy, with which the process of withdrawal management may take approximately four weeks.
Knowledge as to whether an infant was born with symptoms of NAS is critical when planning for the infant's discharge from hospital and for their short to medium term care requirements, as sub-acute withdrawal (irritability, sleep problems, hyperactivity, feeding problems) may last four to six months and there is an increased risk of Sudden Infant Death Syndrome (SIDS). This information is useful when assessing whether an infant can be placed in the care of the parent and whether the parent will be able to meet the infant's special physical and emotional needs.
The practitioner should consult a practice leader to determine the level of risk to the neonate, undertake case planning and identify relevant support services that may benefit the neonate and the mother.
The child protection practitioner may have responsibility for a young person who is using substances. Therefore it may be necessary to refer the young person to a youth drug and alcohol service for an assessment, treatment and support. The purpose of a drug and alcohol assessment of a young person is to:
- identify the frequency and type of use
- ascertain the impact on their level of functioning
- identify treatment options for the young person
- provide education to the young person regarding the effect of substance abuse on their development.
While a young person cannot be forced to undergo drug and alcohol assessment or treatment, the child protection practitioner must consider the young person's best interests and should strongly encourage the young person to do so and develop a safety plan that ensures they do not place themselves at significant risk of harm. This may include accessing secondary consultations with a youth drug and alcohol service, referral to an outreach youth drug and alcohol service for assertive engagement, or placement at a secure welfare service where the young person meets the statutory criteria for such a placement.
The practitioner should consult with their supervisor to determine the level of risk to the young person, undertake case planning and identify relevant support services that may benefit the young person.
At any point a child protection practitioner may require advice from a range of professionals to assist with developing an intervention to address the child's safety, developmental needs or to provide for their care and wellbeing.
When assessing substance abuse issues of a parent or young person, the child protection practitioner may contact a drug and alcohol service for information and advice. The child protection practitioner may seek to gather information on the range of treatment options available or seek the expertise of the drug and alcohol clinician about the particular alcohol and other drug use issues without making a referral to that service.
Poly-substance use and abuse of prescribed medication
When assessing drug and alcohol issues for a parent or young person, the child protection practitioner should be conscious of the possibility that the parent may be using more than one substance at any given time. Poly-substance use is when an individual uses more than once substance concurrently and not when they have used different substances at different stages of their life. For example, a parent may smoke cannabis and consume alcohol at the same time, may smoke cannabis after taking prescribed medication, a young person may consume alcohol and inhale solvents at the same time.
Sometimes a parent may use excuses or rationalise that they are not abusing substances because what they are consuming may be prescribed medication. The child protection practitioner must be aware that the parent may be consuming large amounts of the prescribed medication in order to have the desired effect, may have substituted prescribed medication for illicit substances, or may be attending different doctors ('doctor-shopping') to obtain various prescribed medications. All of the above may not be known to the regular general practitioner. These issues are highly concerning when assessing risk to a child and if identified by the child protection practitioner, then a drug and alcohol assessment is highly recommended to obtain a comprehensive assessment of the parent’s substance abuse, impact on level of functioning, the effects and consequences of poly-substance use and appropriate treatment.
There is a significant co-morbidity of mental illness and substance abuse. Adults with this dual diagnosis are more difficult to treat and their treatment outcomes are poorer than adults who either have only a mental illness or only a substance abuse problem.
The child protection practitioner may need to explore the possibility that the parent may be 'self-medicating', by using illicit substances or using prescribed medication. Severe substance abuse significantly reduces the efficacy of treatment for mental illness. The practitioner needs to be aware of the impact of the parent’s substance use on their mental illness. The major implication of the research literature is that dual diagnosis is an interactive phenomenon, placing people with a mental illness at increased risk of substance abuse and substance abusers at higher risk for mental illness. People who have a serious mental illness and abuse substances are likely to have a number of distinct and related clinical problems. Treatment approaches need to address individual issues while considering possible interactions between mental illness and substance abuse.
Therefore, it is important for the child protection practitioner to consider if the parent has a mental illness or shows evidence of a mental/emotional disorder. If so, then there should be consideration for a mental health assessment as well. In these situations, dual treatment and regular liaison with both specialist services is imperative.
Associated risk factors
The presence of family violence in the parents' relationship where one or both are abusing substances significantly increases the risk of harm to the child. For example, alcohol abuse is common in physical abuse cases and is usually associated with violence in the home.
The child protection practitioner must explore family violence, mental health and substance abuse issues when investigating child protection cases. Any combination of these risk factors should be carefully assessed, as there is an increased likelihood of significant harm and neglect to the child and serious impact on a child’s development and emotional wellbeing.