Protecting Children
 

in Families Affected by
 

Substance Use Disorders
 

ICF International 

2009 

U.S. Department of Health and Human Services
 

Administration for Children and Families
 

Administration on Children, Youth and Families
 

ChildrenÊs Bureau
 

Office on Child Abuse and Neglect
 

Table of Contents
 

PREFACE................................................................................................................................................ 1
 

ACKNOWLEDGMENTS ....................................................................................................................... 3
 

1. PURPOSE AND OVERVIEW....................................................................................................... 7
 

Overview of the Connection Between Substance Use Disorder and Child Maltreatment ................7
 

Organization of the Manual ............................................................................................................8
 

2. THE NATURE OF SUBSTANCE USE DISORDERS ................................................................ 11
 

The Continuum of Alcohol and Drug Use ....................................................................................11
 

Appropriate and Inappropriate Uses of Substances ........................................................................12
 

Characteristics of Addiction ..........................................................................................................14
 

Why Some People Become Addicted .............................................................................................15
 

Negative Consequences of Substance Use Disorders ......................................................................16
 

Co-occurring Issues .......................................................................................................................17
 

3. HOW PARENTAL SUBSTANCE USE DISORDERS AFFECT CHILDREN............................ 21
 

The Impact on Prenatal Development ...........................................................................................22
 

The Impact on Childhood Development ......................................................................................25
 

4. INHOME EXAMINATION, SCREENING, AND ASSESSMENT OF SUBSTANCE USE
 

DISORDERS............................................................................................................................... 27
 

In-home Examination ...................................................................................................................27
 

Screening ......................................................................................................................................27
 

Assessment....................................................................................................................................33
 

5. TREATING SUBSTANCE USE DISORDERS ........................................................................... 37
 

The Goal of Treatment ..................................................................................................................37
 

Treatment Considerations .............................................................................................................38
 

Common Treatment Approaches ..................................................................................................39
 

Support Services ............................................................................................................................41
 

Protecting Children in Families Affected by Substance Use Disorders i 
 

 

 

 

 

 

 

 

 

Gender-sensitive Treatment ...........................................................................................................42
 

Barriers to Treatment ....................................................................................................................44
 

6.	 THE ROLE OF CHILD PROTECTIVE SERVICES WHEN SUBSTANCE USE
 

DISORDERS ARE IDENTIFIED............................................................................................... 45
 

Family Assessment and Case Planning ..........................................................................................45
 

Supporting Parents in Treatment and Recovery .............................................................................46
 

Supporting Children of Parents with Substance Use Disorder .......................................................49
 

7. CHILD PROTECTIVE SERVICES AND SUBSTANCE USE DISORDER TREATMENT
 

PROVIDERS: SIMILARITIES AND DIFFERENCES .............................................................. 51
 

Areas of Similarity .........................................................................................................................51
 

Areas of Diff erence ........................................................................................................................52
 

8.	 PUTTING IT TOGETHER: MAKING THE SYSTEMS WORK FOR FAMILIES ................... 55
 

Setting the Stage: Principles to Guide Collaboration .....................................................................55
 

Collaboration at All Levels ............................................................................................................57
 

Techniques for Promoting Collaboration ......................................................................................58
 

Confidentiality and Information Sharing ......................................................................................59
 

Conclusion ...................................................................................................................................63
 

ENDNOTES ......................................................................................................................................... 65
 

APPENDICES: 

APPENDIX AGLOSSARY OF TERMS................................................................................... 73
 

APPENDIX BRESOURCE LISTINGS OF SELECTED NATIONAL ORGANIZATIONS
 

CONCERNED WITH CHILD MALTREATMENT AND/OR SUBSTANCE
 

USE DISORDERS....................................................................................................................... 79
 

APPENDIX CSTATE TELEPHONE NUMBERS FOR REPORTING CHILD
 

MALTREATMENT .................................................................................................................... 85
 

APPENDIX DDIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
 

DISORDERS CRITERIA............................................................................................................ 87
 

APPENDIX ECOMMONLY ABUSED SUBSTANCES ......................................................... 89
 

APPENDIX FCOMMONLY USED SCREENING INSTRUMENTS .................................... 93
 

APPENDIX GSTATE OF CONNECTICUT DEPARTMENT OF CHILDREN AND
 

FAMILIES SUBSTANCE ABUSE SCREENING AND INFORMATION FORM ..................... 97
 

APPENDIX HMEMORANDUMS OF UNDERSTANDING ................................................ 99
 

APPENDIX ICONFIDENTIALITY AND THE RELEASE OF SUBSTANCE USE
 

DISORDER TREATMENT INFORMATION ......................................................................... 101
 

APPENDIX JSAMPLE QUALIFIED SERVICE ORGANIZATION AGREEMENT AND
 

CONSENT FORM ................................................................................................................... 103
 

ii Table of Contents 
 

Preface
 

Each day, the safety and well-being of children 

across the Nation are threatened by child abuse 

and neglect. Many of these children live in homes 

where substance use disorders (substance abuse and 

dependence) create additional and compounding 

problems. The child welfare and alcohol and drug 

abuse treatment fields are working to fi nd eff ective 

ways to serve families where this overlap occurs. 

Intervening effectively in the lives of these children 

and their families is not the responsibility of a single 

agency or professional group, but rather it is a shared 

community concern. 

Since the late 1970s, the Child Abuse and Neglect 

User Manual Series has provided guidance on child 

protection to hundreds of thousands of multidisciplinary 

professionals and concerned community members. Th e 

User Manual Series offers a foundation for understanding 

child maltreatment and the roles and responsibilities of 

various practitioners in its prevention, identifi cation, 

investigation, and treatment. Through the years, the 

manuals have served as valuable resources for building 

knowledge, promoting effective practices, and enhancing 

community collaboration. 

A number of changes have occurred that dramatically 

affect each community’s response to child maltreatment 

since the last update of the User Manual Series in 

the early 1990s. The changing landscape refl ects 

increased recognition of the complexity of issues 

facing children and families, new legislation, practice 

innovations, and systems reform efforts. Signifi cant 

advances in research have helped shape new directions 

for interventions, while ongoing evaluations show 

“what works.” 

Th e Office on Child Abuse and Neglect within the 

Children’s Bureau of the Administration for Children 

and Families, U.S. Department of Health and 

Human Services, has developed this third edition of 

the User Manual Series to reflect increased knowledge 

and the evolving state of practice on child protection. 

The updated and new manuals are comprehensive 

in scope, while succinct in presentation and easy to 

follow, and they address trends and concerns relevant 

to today’s professional. 

Th is manual, Protecting Children in Families Aff ected 

by Substance Use Disorders, provides a basis for 

understanding parental substance use disorder and 

its relationship to child maltreatment. Th e manual 

is intended to help child protective services (CPS) 

caseworkers identify when drug and alcohol use by 

a parent or other caregiver is a factor in child welfare 

cases and work more effectively to meet the needs of 

all family members involved. The manual encourages 

enhanced collaboration between CPS and alcohol 

and drug abuse treatment agencies. While CPS 

caseworkers are the primary audience, alcohol and 

drug abuse treatment providers may find the manual 

helpful in building their understanding of child 

protection issues among the families with whom they 

work. It also may be useful to other professionals, 

Protecting Children in Families Affected by Substance Use Disorders 1 
such as those working in health care, mental health, 

child care, law enforcement, and child advocacy. 

This manual builds on information presented in other 

publications in the series, particularly A Coordinated 

Response to Child Abuse and Neglect: A Foundation 

for Practice and Child Protective Services: A Guide for 

Caseworkers. Readers are encouraged to begin with 

these manuals as they address important information 

on which CPS practice is based. 

User Manual Series 

This manual—along with the entire Child Abuse and Neglect User Manual Series—is available from Child 

Welfare Information Gateway. Contact Child Welfare Information Gateway for a full list of available 

manuals and ordering information: 

Child Welfare Information Gateway 

1250 Maryland Avenue, SW 

Eighth Floor 

Washington, DC 20024 

Phone: (800) FYI-3366 or (703) 385-7565 

Fax: (703) 385-3206 

Email: info@childwelfare.gov 

The manuals also are available online at http://www.childwelfare.gov/pubs/usermanual.cfm. 

2 Preface 
 

Acknowledgments
 

CONTRIBUTING AUTHORS 

Kathleen Feidler, M.S.W., a consultant with ICF 

International, has more than 15 years of experience 

in the evaluation of substance use disorder programs. 

She also has researched and written several articles 

and papers about the impact of substance use disorder 

in child welfare cases. 

Karen Mooney, L.C.S.W., C.A.C. III, is the women’s 

treatment coordinator for the Alcohol and Drug Abuse 

Division of the Colorado Department of Human 

Services. Formerly, she was a child protective services 

caseworker for 7 years, during which she specialized in 

screening, assessing, and engaging parents of children 

involved in the child welfare system in substance use 

disorder and addiction treatment. Since that time, 

she has served as a child protection and substance 

use disorder treatment consultant to several national 

organizations and universities. 

Mary Nakashian, M.A., is a consultant specializing in 

public policy and management, training, and technical 

assistance with special expertise in the areas of welfare 

reform, child welfare, and substance use disorder. She 

has served as the Deputy Commissioner for Welfare 

in the State of Connecticut, as the Executive Deputy 

Commissioner for Welfare in New York City, and as 

vice president at the National Center on Addiction 

and Substance Abuse at Columbia University. 

Jill Sanclimenti, M.B.A., a consultant with ICF 

International, has spent the last 16 years conducting 

research and writing publications on child 

maltreatment and other issues related to children, 

youth, and families. She previously served as manager 

of product development and program services for the 

National Clearinghouse on Child Abuse and Neglect 

Information (now Child Welfare Information 

Gateway). 

Matthew Shuman, M.S.W., a consultant with ICF 

International, has more than 10 years experience 

in the human services field. He previously worked 

as an analyst in the Office of the Secretary of the 

Department of Health and Human Services on a 

variety of child welfare issues, including foster care, 

adoption, and child care. He also has written and 

edited various child welfare publications, including 

other manuals in the User Manual Series. 

Carl Tacy, M.S.W., has more than 12 years of 

experience working in clinical, policy, and management 

positions primarily addressing substance use disorder, 

domestic violence, health, and child welfare issues. 

He has managed projects responsible for developing, 

marketing, and disseminating products, publications, 

and communications in those topic areas. Additionally, 

he has authored or co-authored several publications, 

including The Underage Drinking Prevention Action 

Guide and Planner, The Tips for Teens Series, and Th e 

Role of Educators in Preventing and Responding to Child 

Abuse and Neglect of the Child Abuse and Neglect User 

Manual Series. 

Protecting Children in Families Affected by Substance Use Disorders 3 
 

ACKNOWLEDGMENT OF PRIOR EDITION 

This manual is an update of the 1994 publication, 

Protecting Children in Substance-Abusing Families, 

by Vickie Kropenske and Judy Howard with Cheryl 

Breitenbach, Richard Dembo, Susan B. Edelstein, 

Kathy McTaggart, Annette Moore, Mary Beth 

Sorensen, and Virginia Weisz. The prior work 

informed and contributed to the content of this 

publication. 

REVIEWERS 

Paul DiLorenzo, Independent Consultant 

Kathy Nardini, National Association of State 

Alcohol and Drug Abuse Directors 

Colleen O’Donnell, National Association of State 

Alcohol and Drug Abuse Directors 

Kathy Pinto, Howard County, Maryland, 

Department of Social Services 

Bob Scholle, Independent Consultant 

Sarah Webster, Texas Department of Protective and 

Regulatory Services (retired) 

TECHNICAL ADVISORY PANEL 

The following were members of the January 2001 

Technical Advisory Panel for the User Manual Series 

contract. The organizations identifi ed refl ect each 

member’s affiliation at that time. 

Carolyn Abdullah 

FRIENDS National Resource Center 

Washington, DC 

Lien Bragg 

American Public Human Services Association 

Washington, DC 

Sgt. Richard Cage 

Montgomery County Police Department 

Wheaton, MD 

Diane DePanfi lis, Ph.D. 

University of Maryland at Baltimore 

School of Social Work 

Baltimore, MD 

Pauline Grant 

Florida Department of Children and Families 

Jacksonville, FL 

Jodi Hill 

Connecticut Department of Children 

and Families 

Hartford, CT 

Robert Ortega, Ph.D. 

University of Michigan School of Social Work 

Ann Arbor, MI 

Nancy Rawlings 

Kentucky Cabinet for Families and Children 

Frankfort, KY 

Barry Salovitz 

Child Welfare Institute/National Resource Center 

on Child Maltreatment 

Glenmont, NY 

Sarah Webster 

Texas Department of Protective and 

Regulatory Services 

Austin, TX 

Ron Zuskin 

University of Maryland at Baltimore 

School of Social Work 

Baltimore, MD 

4 Acknowledgments 
 ADDITIONAL ACKNOWLEDGMENTS 

Th e third edition of the User Manual Series was 

developed under the guidance and direction of Irene 

Bocella, Federal Task Order Offi cer, Offi ce on Child 

Abuse and Neglect, and Catherine Nolan, Director, 

Office on Child Abuse and Neglect. Susan Orr, former 

Associate Commissioner, Children’s Bureau, provided 

critical input that shaped both this manual and the 

series. Also providing input was Sharon K. Amatetti, 

Public Health Analyst, Center for Substance Abuse 

Treatment, Substance Abuse and Mental Health 

Services Administration. 

This manual was developed and produced by ICF International, Fairfax, VA, under Contract Number HHS282-98-0025 

Protecting Children in Families Affected by Substance Use Disorders 5 

 

 

 

CHAPTER 1 

Purpose and Overview 

The relationship between substance use disorders 

(SUDs) and child maltreatment is compelling and 

undeniable. More than eight million children in the 

United States live with at least one parent who abused 

or was dependent on alcohol or an illicit drug during 

the past year.1 These children face a heightened risk of 

maltreatment.2

 One study, for example, showed that 

children of parents with SUDs are nearly three times 

more likely to be abused and more than four times 

more likely to be neglected than children of parents 

who do not abuse substances.3 

According to the National Child Abuse and Neglect 

Data System (NCANDS), in 2006, an estimated 3.3 

million referrals were made to child protective services 

(CPS), representing 6 million children. From this 

population, approximately 905,000 children were 

found to be victims of child abuse or neglect. Of 

the maltreated children, 66.3 percent were neglected 

(including medical neglect), 16.0 percent physically 

abused, 8.8 percent sexually abused, and 6.6 percent 

psychologically maltreated. Additionally, 15.1 percent 

of victims were associated with “other” types of 

maltreatment, such as abandonment or congenital 

drug addiction. A child could be identified as a victim 

of more than one type of maltreatment.4

 Additionally, 

while estimates vary, most studies suggest that parental 

SUDs are a contributing factor for between one- and 

two-thirds of children involved with CPS.5 

OVERVIEW OF THE CONNECTION BETWEEN
 

SUBSTANCE USE DISORDER AND
 

CHILD MALTREATMENT
 

SUDs often affect the way people live, including how 

they function, interact with others, or parent their 

children. Studies suggest that SUDs, by impairing 

parents’ judgment and priorities, can infl uence 

parental discipline choices and child-rearing styles 

and have negative effects on the consistency of care 

and supervision provided to children.6

 The time and 

money parents spend on seeking out or on using 

drugs or alcohol may limit the resources available in 

the household to meet their children’s basic needs. In 

addition, families affected by SUDs often experience a 

number of other problems—including mental illness, 

domestic violence, poverty, and high levels of stress— 

which also are associated with child maltreatment. 

Children of parents who have SUDs and who are 

also in the child welfare system are more likely to 

experience emotional, physical, intellectual, and 

social problems than children whose parents do not 

have SUDs. Additionally, abused and neglected 

children from families affected by substance abuse are 

more likely to be placed in foster care and to remain 

there longer than maltreated children from families 

not affected by substance abuse.7 

Protecting Children in Families Affected by Substance Use Disorders 7 
8

 

 

Note on Terminology 

Those working with individuals, families, and communities affected by the use and abuse of alcohol and 

drugs use a wide variety of terms to describe the same or similar concepts, especially the spectrum of 

substance use. While some readers may be more accustomed to using the term “substance abuse” to mean 

any dependence, addiction, or abuse of a substance, this manual uses the term “substance use disorder,” 

which encompasses both abuse and dependence (addiction). (See Chapter 2, The Nature of Substance Use 

Disorders, for more details about the definitions of these terms.) The phrase “substance use disorder” has 

been adopted by the public health and alcohol and drug treatment fields as less stigmatizing and more 

reflective of the disease’s characterization as a disorder with biological, psychological, and social origins. 

Some within the child welfare field have also begun to use this term. 

Additionally, reliable, consistent, or generalizable data are limited concerning the relationship between 

substance abuse and the frequency of child maltreatment because researchers often define terms such 

as “substance abuse” or “child abuse” differently, they collect data from sources that have divergent 

perspectives, and neither State alcohol and drug abuse treatment nor State child welfare data systems 

consistently require staff to report information about this overlap. When presenting results of studies, this 

manual, where possible, uses the same terminology as used in the research description. 

For more information about terminology related to SUDs, please refer to the following: 

• National Association of Social Work Standards for Social Work Practice with Clients with Substance Use 

Disorders (http://www.socialworkers.org/practice/standards/NASWATODStatndards.pdf ) 

• Substance Use Disorders: A Guide to the Use of Language (http://www.pacdaa.org/pacdaa/lib/ 

pacdaa/Substance_abuse_disorders.doc), a publication of the Center for Substance Abuse 

Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department of 

Health and Human Services. 

CPS caseworkers and SUD treatment providers also 

report conflicting pressures that arise from trying to 

meet concurrently: 

• 	 The timeframes required by the Adoption and 

Safe Families Act to promote permanency for 

abused and neglected children 

• 	 The time required to access open treatment slots 

• 	 The time necessary for successful treatment 

participation 

• 	 The developmental needs of children. 8 

These challenges underscore the need for quick 

and effective screening, assessment, and treatment, 

if necessary, of SUDs among families in the child 

welfare system. Further, they point to the need for 

partnerships between the CPS and SUD treatment 

systems to support parents in obtaining the services 

they need, while ensuring the safety and well-being 

of children. 

ORGANIZATION OF THE MANUAL 

To assist families experiencing SUDs as well as child 

maltreatment, CPS caseworkers must recognize 

and address each problem and their interaction. 

This manual is structured first to provide CPS 

caseworkers and other readers with the groundwork 

for understanding SUDs and their dynamics, 

characteristics, and effects. The manual then places 

parental SUDs into the context of child protection 

8 Purpose and Overview 
and describes its impact on children, as well as its 

relationship to child maltreatment. Several chapters 

are devoted to helping CPS caseworkers understand 

how to recognize and to screen for SUDs in child 

maltreatment cases, to establish plans for families 

experiencing these problems, and to support 

treatment and recovery, as appropriate. Th e manual 

also addresses ways in which CPS and SUD treatment 

providers can coordinate their work, which is critical 

to improving outcomes for both parents with SUDs 

and their children. 

Specifically, the manual addresses: 

• 	 The nature of SUDs 

• 	 The impact of parental SUDs on children 

• 	 In-home examination, screening, and assessment 

for SUDs 

• 	 Treatment of SUDs 

• 	 The role of the CPS caseworker when an SUD is 

identifi ed 

• 	 Similarities and differences between CPS and 

SUD treatment providers 

• 	 “Putting it all together”—making the systems 

work for families. 

Readers should note that no single publication can 

address all the intricate factors and interactions 

related to the connection between SUDs and child 

maltreatment, but this manual can contribute to an 

increased understanding of the issues and identify 

avenues for enhanced services to families. Professionals 

should supplement it with other information, training, 

and professional development activities. 

Protecting Children in Families Affected by Substance Use Disorders 9 

 

 

CHAPTER 2 

The Nature of Substance

 Use Disorders 

In This Chapter 

• 	 The continuum of alcohol and drug use 

• 	 Appropriate and inappropriate uses of 

substances 

• 	 Characteristics of addiction 

• 	 Why some people become addicted 

• 	 Negative consequences of SUDs 

• 	 Co-occurring issues 

Understanding the nature and dynamics of 

substance use disorders (SUDs) can help child 

protective services (CPS) caseworkers in screening for 

SUDs, making informed decisions, and developing 

appropriate case plans for families experiencing this 

problem. 

THE CONTINUUM OF ALCOHOL
 

AND DRUG USE
 

Substance use, like many human behaviors, occurs 

along a broad continuum from no use to extremely 

heavy use. The likelihood of an individual experiencing 

problems stemming from substance use typically 

increases as the rate of use increases. Th e continuum 

for the use of substances includes substance use, 

substance abuse, and substance dependence or 

addiction. 

Substance use is the consumption of low or infrequent 

doses of alcohol or drugs, such that damaging 

consequences are rare or minor. In reference to 

alcohol, this means drinking in a way that does not 

impair functioning or lead to negative consequences, 

such as violence. In reference to prescription drugs, 

use involves taking medications as prescribed by a 

physician. Regarding over-the-counter medications, 

use is defined as taking the substance as recommended 

for alleviating symptoms. Some people who choose 

to use substances may use them periodically, never 

use them to an extreme, or never experience life 

consequences because of their use. 

Substance abuse is a pattern of substance use that 

leads to significant impairment or distress, refl ected 

by one or more of the following: 

• 	 Failure to fulfill major role obligations at work, 

school, or home (e.g., substance-related absences 

from work, suspension from school, neglect of a 

child’s need for regular meals) 

• 	 Continued use in spite of physical hazards (e.g., 

driving under the infl uence) 

• 	 Trouble with the law (e.g., arrests for substancerelated disorderly conduct) 

• 	 Interpersonal or social problems. 9 

Additionally, use of a medication in a manner diff erent 

from how it is prescribed or recommended and use of 

Protecting Children in Families Affected by Substance Use Disorders 11 
 

an intravenous drug that is not medically required are 

considered substance abuse. 

Individuals may abuse one or more substances 

for a certain period of time and then modify their 

behaviors because of internal or external pressures. 

Abuse is characterized by periodic events of abusive 

use of substances, which may be accompanied by 

life consequences directly related to its use. With 

proper intervention, an individual with substance 

abuse problems can avert progression to addiction. 

At this level of progression, the abusers often are not 

aware, or if they are, they may not be honest with 

themselves that the negative consequences they 

experience are linked to their substance use. With 

proper intervention, these individuals are able to 

choose to limit or to cease substance use because of 

the recognition of the connection between use and 

consequences. Other people, however, may continue 

abusing substances until they become addicted. 

Substance dependence or addiction is the progressive 

need for alcohol or drugs that results from the use of 

that substance. This need creates both psychological 

and physical changes that make it diffi cult for the 

users to control when they will use the substance or 

how much they will use. Psychological dependence 

occurs when a user needs the substance to feel normal 

or to engage in typical daily activities. Physical 

dependence occurs when the body adapts to the 

substance and needs increasing amounts to ward off 

the effects of withdrawal and to maintain physiological 

functioning. Dependence can result in: 

• 	 The continued use of a substance despite 

negative consequences. The individual continues 

drug or alcohol use despite incidents, such as 

accidents, arrests, or a lack of money to pay for 

food because it was spent on drugs. 

• 	 An increase in tolerance to the substance . Th e 

individual requires more of the alcohol or drug to 

obtain the same eff ect. 

• 	 Withdrawal symptoms . The individual needs 

to consume the substance in order not to 

experience unpleasant withdrawal eff ects, such 

as uncontrollable shaking and tremors or intense 

nausea. 

• 	 Behavioral changes. Th e individual who is 

dependent: 

–	 Uses more than intended 

–	 Spends a majority of the time either 

obtaining, using, or withdrawing from the 

use of the substance 

–	 Cannot stop using until the substance is 

gone or the individual passes out. 

Criteria for diagnosing substance dependence and 

substance abuse as an SUD have been defi ned in 

the Diagnostic and Statistical Manual of Mental 

Disorders, 4th Edition, Text Revision (DSM-IV-TR), 

the American Psychiatric Association’s classifi cation 

index for mental disorders. (See Appendix D, 

Diagnostic and Statistical Manual of Mental Disorders 

Criteria, for more information on this topic.) 

APPROPRIATE AND INAPPROPRIATE
 

USES OF SUBSTANCES
 

Certain substances, when used appropriately, have 

helpful and even lifesaving uses. Many individuals 

use various drugs to help overcome physical and 

psychological problems. Drugs can alleviate cold and 

flu symptoms, make it easier to sleep, reduce physical 

or emotional pain, and help overcome feelings of 

anxiety, panic, or depression. Some of these drugs 

require a prescription from a doctor to be obtained 

legally, while others are considered safe enough to 

be sold over the counter to the public. Although 

these drugs have many health benefits, many also 

can be used in a higher quantity or in combination 

with other substances to produce either a “high” 

or a numbing effect. Combining these drugs with 

alcohol or other drugs can intensify their eff ects and 

increase risks to the user and to those around the 

user. Individuals who abuse prescription medication 

sometimes resort to forging prescriptions, to visiting 

several doctors who will prescribe the same drug 

without asking questions (“doctor shopping”), or 

12 The Nature of Substance Use Disorders 
 

 

to buying stolen drugs. Exhibit 2-1 provides key 

statistics for commonly abused substances. 

Other substances may not have medicinal qualities 

but can affect users psychologically and physically or 

lower inhibitions and impair judgment if misused. 

For instance, some individuals drink alcohol at social 

gatherings to feel more comfortable talking and 

relating to others. Being of legal age and drinking 

alcohol is a commonly accepted practice in the United 

States. Of course, alcohol often can be misused and 

can negatively affect events ranging from traffi c safety 

to the ability to care adequately for children. 

Exhibit 2-1 

Selected Drug Statistics from the National Survey on Drug Use 

and Health (NSDUH)* 

• An estimated 19.9 million Americans, or 8.0 percent of the population aged 12 or older, were current 

illicit drug users in 2007.** (Th is fi gure refl ects use of the following drugs: marijuana, cocaine, heroin, 

hallucinogens, and inhalants and the nonmedical use of prescription-type pain relievers, tranquilizers, 

stimulants, and sedatives.) 

• The estimated number of Americans who were current users of the following drugs in 2007: 

– Marijuana: 14,448,000

– Cocaine: 2,075,000 (including 610,000 users of crack)

– Hallucinogens: 996,000 (including 503,000 users of Ecstasy) 

– Inhalants: 616,000

– Heroin: 338,000

• In 2007, approximately 6.9 million people aged 12 or older (2.8 percent of the population) were 

current users of prescription-type psychotherapeutic drugs taken nonmedically, including pain relievers, 

tranquilizers, stimulants, and sedatives. This includes 529,000 individuals who were current users of 

methamphetamine, which can be manufactured illegally using existing prescription drugs. 

• An estimated 22.3 million Americans aged 12 or older in 2006 (9.0 percent of the population) were 

classified with substance abuse or dependence. Of these: 

– 3.2 million abused or were dependent on both alcohol and illicit drugs; 

– 3.7 million abused or were dependent on illicit drugs but not alcohol; 

– 15.5 million abused or were dependent on alcohol but not illicit drugs. 10 

* These statistics are drawn from the 2007 NSDUH, an annual survey of the civilian, noninstitutionalized population of the 

United States aged 12 or older. To see the full results of the most recent survey, visit the website of the U.S. Department of Health 

and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies: http://www.oas. 

samhsa.gov/nsduhLatest.htm. 

** “Current users” reflect persons who used the specified drug during the month prior to the NSDUH interview. 

Protecting Children in Families Affected by Substance Use Disorders 13 
 

 

Quick Facts on Alcohol Use 

• 

• 

• 

• 

• 

Slightly more than half of Americans aged 12 or older, or approximately 127 million people, reported 

being current drinkers of alcohol in the 2007 NSDUH. (Current drinkers were defined as having had at 

least one drink in the 30 days prior to the survey.) 

An estimated 17 million people (6.9 percent of the population) were heavy drinkers. (Heavy drinking 

was defined as having five or more drinks on the same occasion on at least 5 different days in the past 30 

days.) 

Among pregnant women aged 15 to 44, an estimated 11.6 percent reported current alcohol use, and 3.7 

percent reported binge drinking. (Binge drinking was defined as having five or more drinks on the same 

occasion on at least 1 day in the past 30 days.) 

Excessive alcohol use is the third leading lifestyle cause of death in the United States and was determined 

to be a key factor in approximately 79,000 deaths annually from 2001–2005. 

The U.S. Dietary Guidelines for Americans recommends no more than one drink per day for adult 

women and no more than two drinks per day for adult men. It also lists several types of individuals— 

including children, adolescents, and pregnant women—who should avoid alcohol completely.11 

For more information on commonly abused substances, see Appendix E, Commonly Abused Substances. 

With respect to child protection, substance use 

becomes problematic when it contributes to the harm 

of children. This can be difficult for CPS caseworkers 

to identify because the distinction between “normal” 

alcohol use and problematic use may be blurred and 

subject to interpretation. (See Chapter 4, In-home 

Examination, Screening, and Assessment of Substance 

Use Disorders, for more information about identifying 

SUDs.) 

CHARACTERISTICS OF ADDICTION 

Knowing the characteristics of addiction can help 

inform effective intervention and practice with 

individuals suffering from SUDs. Characteristics 

include: 

• 	 Progressive Nature . A central feature of 

addiction is a progressive use of a substance, 

whether alcohol, prescription medications, or 

illegal drugs. The physical, emotional, and social 

problems that arise from addiction typically 

continue to worsen unless the SUDs are treated 

successfully. If left untreated, addiction can cause 

premature death through overdose; through 

organic complications involving the brain, liver, 

heart, and many other organs; and by contributing 

to motor vehicle crashes, homicide, suicide, and 

other traumatic events. 

• 	 Denial and Concealment . Addiction can 

be difficult to identify, even for individuals 

experiencing it. People who are addicted to a 

substance often engage in elaborate strategies 

to conceal the amount being consumed and 

the degree to which the substance is aff ecting 

their lives. Another dimension of addiction is 

that individuals who suffer from it often do not 

14 The Nature of Substance Use Disorders 
 

 

 

 

 

perceive that their pattern of drinking or drug 

use creates or contributes to their problems. 

Additionally, the use of substances may aff ect 

their memory or perception of events or of what 

they have said or done. This lack of recognition 

commonly is identified as denial. 

• 	 Chronic Disease . The National Institute on 

Drug Abuse has defined addiction as a chronic 

disease, like heart disease, hypertension, and 

diabetes. Studies have shown alcohol and drug 

abuse treatment is about as effective as treatments 

required for these other chronic diseases. 

Lifetime management of chronic diseases in all 

cases requires individuals to change their habits 

and activities and to take precautions that 

prevent them from relapsing or worsening their 

condition. 

• 	 Lapses and Relapses . Lapses and relapses are 

common features of addiction. A lapse is a 

period of substance use after the individual has 

been clean and sober for some length of time. A 

relapse is not only using the substance again, but 

also returning to the problem behaviors associated 

with it.12 

Addiction is difficult to deal with; many individuals 

lapse or relapse one or more times before being able to 

remain abstinent. If lapses or relapses occur, they do 

not necessarily mean that treatment has failed. Th ey 

can point the way toward needed improvements in 

how those individuals are approaching recovery. Most 

individuals who have lapsed or relapsed can identify, 

prior to the lapse or relapse, certain situations, 

thoughts, or behaviors that contributed to the use of 

the substance. 

WHY SOME PEOPLE BECOME ADDICTED 

Many theories and explanations have been proposed 


to describe the reasons why some individuals become 


addicted to substances and others do not. Research on 

the causes of addiction is not conclusive, and multiple 

factors may contribute to it. Early explanations 

for addiction included moral weakness, insanity, 

demonic possession, and character pathology.13 

These explanations, combined with the problematic 

behaviors that sometimes accompany addiction, have 

created a serious stigma. Recent research, however, 

indicates that substance addiction is a brain disease 

that changes its structure and functioning, which in 

turn affects an individual’s behaviors. Although the 

initial use of a substance may be voluntary, a person’s 

ability to control future use may be seriously impaired 

by changes in the brain caused by prior use.14 

Some research, including adoption and twins 

studies, has demonstrated a biological and genetic 

predisposition to addiction, with scientists estimating 

that genetic factors account for 40–60 percent of an 

individual’s risk of addiction.15 These studies suggest 

that an individual’s genes play a role in vulnerability 

to addiction. For example, one study found that 

children whose parents are addicted to drugs or 

alcohol are three times more likely to develop an 

SUD later in life than children whose parents are 

not addicted.16 Other research emphasizes a social 

factor to explain that addictions appear to “run in 

the family.” These studies suggest that children who 

grow up in families with SUDs may model their adult 

behavior on what they have seen and known in their 

familial experience.17 Risk for addiction can also be 

affected by gender, ethnicity, developmental stage, and 

social environment.18 In other words, both nature 

and nurture contribute to a person’s vulnerability or 

resistance to substance abuse. 

Many self-help groups, such as 12-step programs, 

consider addiction a progressive illness that is physical, 

spiritual, and emotional in nature. They believe that 

individuals who are addicted must admit that they are 

powerless over the substance; that is, they are unable 

to resolve the problem on their own and must seek 

help outside themselves.19 

Protecting Children in Families Affected by Substance Use Disorders 15 
Addiction 

People who are addicted to drugs are from all walks of life. Many suffer from poor mental or physical 

health, occupational, or social problems, which make their addictive disorders much more diffi cult to treat. 

Even if there are few associated problems, the severity of addiction itself ranges widely among people. 

Isn’t drug addiction a voluntary behavior? A person may start taking drugs voluntarily, but as times 

passes and drug use continues, something happens that makes a person go from being a voluntary drug 

user to a compulsive drug user. This happens because the continued use of addictive drugs changes the 

brain. These changes can be dramatic or subtle, but often, without treatment, they result in compulsive or 

even uncontrollable drug use. 

How is addiction similar to a disease? Drug addiction is a brain disease. Every type of drug abuse has 

its own mechanism for changing how the brain functions. Regardless of which drug a person is addicted 

to, many of the effects on the brain are similar. These may include modifications in the molecules and 

cells that make up the brain, changes in memory processes and thinking, transformation of moods, and 

sometimes changes in motor skills, such as walking and talking. These changes can have a signifi cant 

influence on all aspects of a person’s behavior and can cause the individual to do almost anything to obtain 

the drug. 

Why can’t drug addicts quit on their own? In the beginning, almost all addicted individuals believe 

that they can stop using drugs on their own, and most try to stop without treatment. However, most of 

these attempts fail to achieve long-term abstinence. Research has shown that long-term drug use results in 

significant changes in brain function that persist long after the individual has stopped using drugs. Th ese 

drug-induced changes in brain function can have many behavioral consequences, including the compulsion 

to use drugs despite adverse consequences—one of the defining characteristics of addiction. 

Understanding that addiction has such an important biological component may help explain the difficulty 

in achieving and maintaining abstinence without treatment. Psychological stress from work or family 

problems, social cues (e.g., meeting individuals from one’s drug-using past), or the environment (e.g., 

encountering streets, objects, or even smells associated with drug use) can interact with biological factors to 

hinder sustained abstinence and to make relapse more likely. Research studies indicate, however, that even 

the most severely addicted individuals can participate actively in treatment and that active participation is 

essential to good outcomes.20 

NEGATIVE CONSEQUENCES OF SUBSTANCE 

USE DISORDERS 

Negative consequences from alcohol and drug use, 

abuse, and dependence generally fall into three 

categories: loss of behavioral control, psychophysical 

withdrawal, and role maladaptation. 

Loss of behavioral control happens when individuals 

do things they normally would not do because their 

inhibitions and reasoning abilities are impaired. Loss 

of behavioral control can include passing out, having 

a blackout (i.e., short-term memory loss), behaving 

violently, leaving children unsupervised or in a 

potentially unsafe situation, and neglecting children’s 

basic needs. 

16 The Nature of Substance Use Disorders 
 

 

Psychophysical withdrawal occurs when individuals 

experience physical symptoms that result from 

withdrawing from using a substance. Indicators 

of psychophysical withdrawal include becoming 

nauseated or vomiting; feeling feverish, hot, sweaty, 

agitated, or nervous; and experiencing signifi cant 

changes in eating or sleeping patterns. In advanced 

cases, withdrawal may include experiencing, seeing, 

or hearing things that are not there, such as having 

the sensation of bugs crawling on the skin or having 

seizures or convulsions. Physical withdrawal, 

particularly from alcohol and heroin, can be life 

threatening. 

Role maladaptation occurs when individuals 

cannot conform to what are generally considered 

their expected roles (e.g., parent, breadwinner). For 

parents, this can mean diffi culties in caring properly 

for their children (e.g., prioritizing a need for drugs 

over a child’s needs for food and clothing). Other 

examples of role maladaptation due to SUDs include 

relationship problems, failure to keep a job, difficulties 

paying the bills, and criminal activity. 

Problems in one area will not necessarily indicate 

or predict problems in other areas. Someone who 

experiences regular hangovers from drinking (defi ned 

as anxiety, agitation, nausea, and headaches) can 

experience these symptoms without experiencing 

a significant loss of behavioral control or role 

maladaptation. Others struggling with addiction, 

however, may suffer from all three consequences. 

CO-OCCURRING ISSUES 

CPS caseworkers must place SUDs into context with 

the other problems that families may face. In general, 

these families have more numerous and complex 

issues to address than those who are not abusing or 

addicted to alcohol and drugs. Similarly, child abuse 

and neglect seldom occur in a vacuum; these families 

often are experiencing several layers of problems. For 

both SUDs and child maltreatment, common cooccurring issues include mental and physical illnesses, 

domestic violence and other trauma, economic 

difficulties or poverty, housing instability, or dangerous 

neighborhoods and crime.21 All of these challenges 

can constitute barriers to successful participation in 

SUD treatment and, when addressed, can improve an 

individual’s chances of attaining long-term abstinence. 

The following sections describe some of the most 

common co-occurring issues experienced by families 

affected by child maltreatment and SUDs. Th e goal 

is to increase caseworker awareness of the variety of 

symptoms and factors, particularly those most likely 

to affect assessment and decisions regarding services 

for families and children involved in CPS cases. 

Mental Illness 

SUDS have a strong association with mental illness. 

In 2007, an estimated 24.3 million adults aged 18 or 

older had a serious mental illness.22 (Having a serious 

mental illness is defined as having a diagnosable 

mental, behavioral, or emotional disorder during 

the past year that met the DSM-IV criteria.) Adults 

with a serious mental illness are much more likely to 

have used illicit drugs within the past year than those 

adults without a serious mental illness (28.0 percent 

versus 12.2 percent).23 

It is not clear why there is a high correlation between 

SUDs and mental illness. Three ways in which they 

may relate to one another are: 

• 	 The disorders may occur independently of each 

other. 

• 	 The mental health disorder may place an 

individual at greater risk for SUDs. 

• 	 Alcohol or drug intoxication or withdrawal may 

result in temporary mental health disorders, such 

as paranoia or depression.24 

It is common for either the SUD or the mental health 

issue to go undiagnosed. In addition, not all mental 

health problems affecting a parent necessarily will 

appear severe or profound. As a result, when one issue 

is identified, it is important to screen for the other. 

When both are identified, current accepted practice is 

Protecting Children in Families Affected by Substance Use Disorders 17 
 

 

 

to treat both disorders simultaneously, especially with 

individuals who have serious mental illnesses. 

Physical Health Problems 

SUDs can cause or worsen physical health problems. 

For example: 

• 	 Alcohol abuse can cause numerous physical 

problems related to the function of the liver, 

heart, digestive system, and nervous system. 

• 	 Marijuana use is associated with ailments ranging 

from a burning or stinging sensation in the mouth 

or throat, to respiratory problems, to an increased 

likelihood of cancer in the throat and lungs. 

• 	 Individuals who inject drugs, such as heroin or 

methamphetamine, put themselves at risk of 

contracting infectious diseases, such as HIV/ 

AIDS and hepatitis C, through the sharing of 

syringes and other injection paraphernalia. 

Domestic Violence and Other Forms of Trauma 

Trauma can take the form of a physical injury or a 

painful or disturbing experience that can have lasting 

effects. It can result from exposure to a variety of events 

ranging from natural disasters to violent crimes. Th e 

consequences of trauma can be signifi cant, aff ecting 

the victim on biological, psychological, social, and 

spiritual levels. 

Individuals who have experienced a traumatic event 

sometimes turn to drugs or alcohol in an eff ort to 

deal with the resulting emotional pain, anxiety, fear, 

or guilt. If the pattern becomes well established, it 

may indicate that the person has an SUD. SUDs, 

particularly if they are active over a period of time, 

increase the likelihood of further exposure to 

accidental and intentional acts that may result in 

additional trauma. In addition, individuals who have 

not experienced a traumatic event, but have an SUD, 

have an increased likelihood of exposure to events that 

may then result in trauma, such as being assaulted. 

Studies have shown that a high percentage of women 

treated for SUDs also have significant histories of 

trauma.25 Women who abuse substances are more 

likely to experience accidents and acts of violence, 

including assaults, automobile accidents, intimate 

partner violence, sexual abuse and assault, homicide, 

and suicide.26 

Alcohol commonly is cited as a causal factor and 

precursor to adult domestic violence. Research 

studies indicate that approximately 25 to 50 percent 

of domestic violence incidents involve alcohol and 

that nearly one-half of all abusers entering batterer 

intervention programs abuse alcohol.27 Despite 

the evidence that many batterers and victims abuse 

alcohol, there is no empirical evidence that substance 

use disorder directly causes domestic violence. 

However, SUDs increase the severity and frequency 

Post-traumatic Stress Disorder 

Women who abuse substances sometimes cite continued substance use as a perceived aid in controlling 

symptoms of post-traumatic stress disorder (PTSD).30 PTSD is a psychiatric disorder that can occur 

following the experience or the witnessing of life-affecting events, such as military combat, violent or sexual 

assaults, or natural disasters. People who suffer from PTSD often relive the experience through nightmares 

and flashbacks, have difficulty sleeping, and feel detached or estranged. PTSD also is associated with 

impairment of the ability to function in social or family life, including employment instability, marital 

problems and divorce, family discord, and difficulties in parenting. Research has indicated that women 

with PTSD are twice as likely to abuse or to be dependent on alcohol and are four times as likely to abuse 

or to be dependent on drugs.31 When compared to other traumas, sexual abuse and physical abuse have 

been found to be associated with the highest rates of PTSD.32 

18 The Nature of Substance Use Disorders 
 

of the batterers’ violence and interfere with domestic 

violence interventions.28 They also contribute to the 

increased severity of injuries among victims.29 

Poverty 

SUDs cross all socioeconomic lines, but studies show 

that there is a relationship between poverty and 

substance abuse.33 People living in poverty sometimes 

turn to substances for relief from the anxiety and 

the stress associated with economic insecurity. Of 

course, spending money on alcohol or drugs often 

only contributes to economic problems. Dealing 

illegal drugs is viewed by some as a source of income 

and a means of escaping poverty. Unfortunately, 

some individuals suffering from economic hardship 

feel that they have little to lose if they get involved in 

drugs, no matter what the effects are on themselves or 

their families. 

Parents who are distracted by their fi nancial problems 

may have less energy and attention for parenting. In 

some homes, the psychological distress of poverty may 

be directed toward the children. Research has indicated 

a strong association between child maltreatment, 

particularly neglect, and poverty.34 CPS case plans 

invariably need to address issues related to poverty 

and establish service plans for families. 

Homelessness 

In some cases, extreme poverty and other factors may 

lead to homelessness. Homeless people typically 

experience several overlapping challenges, including 

SUDs, mental illnesses, and a variety of physical 

health problems. Parents with children account for 

approximately 11 percent of the homeless population, 

and this number appears to be growing.35 

Crime
 

Crime has a strong association with drug use. In the 

most recent study of its kind, more than three out of 

every four State, Federal, or local jail inmates previously 

were involved seriously with drugs or alcohol in some 

way (e.g., convicted of a drug- or alcohol-related 

crime, used illicit substances regularly, were under the 

influence of alcohol or drugs when they committed 

a crime).36 Another study found that adults who 

were arrested for a serious offense were much more 

likely to have used an illicit drug in the prior year 

(60.1 percent) than those who were not arrested (13.6 

percent).37 In addition, many individuals in prisons 

and jails experience multiple, overlapping problems. 

For instance, research indicates that among inmates 

with a serious mental disorder, 72 percent have a cooccurring SUD.38 It often is challenging for these 

individuals to obtain appropriate services either in 

prison or upon their release. 

Because women are generally the primary caretakers 

of their children, the increase in the number 

of incarcerated women over the past decade is 

particularly relevant to CPS caseworkers. Th e Bureau 

of Justice Statistics reports that the female prison 

population increased from 44,000 in 1990 to more 

than 111,000 in 2006.39 One-third of incarcerated 

women have been convicted of drug off enses, and 

approximately 65 percent of women in prison report 

having used drugs regularly.40 Additionally, 75 percent 

of incarcerated women are mothers, and two-thirds 

have minor children, who often are placed outside the 

home while their mothers are incarcerated.41 

In response to problems arising from low-level, 

nonviolent drug offenses, many States and localities 

have established alternative, less putative programs, 

such as drug courts, to rehabilitate offenders. (For 

more information on drug courts, see Chapter 

8, Putting It Together: Making the Systems Work 

for Families.) 

Protecting Children in Families Affected by Substance Use Disorders 19 
 

Methamphetamine Use and Its Impact 

on Children 

Methamphetamine is a powerfully addictive drug, and individuals who use it can experience serious health 

and psychiatric conditions, including memory loss, aggression, violence, psychotic behavior, and potential 

coronary and neurological damage.42 Its use in the United States has become an issue of great concern to 

professionals working with children and families. In 2007, there were an estimated 529,000 current users of 

methamphetamine aged 12 or older. Approximately, 5.3 percent of the population reported using this drug 

at least once in their lifetime.43 Methamphetamine is also known by ever-changing street names, such as 

speed, ice, crystal, crank, tweak, glass, bikers’ coffee, poor man’s cocaine, chicken feed, shabu, and yaba.44 

As with any children of parents with an SUD, children whose parents use methamphetamine are at a particularly 

high risk for abuse and neglect. What compounds the problem for children of methamphetamine users is that 

the drug is relatively easy to make, and therefore, many of these children are exposed to the additional risks 

of living in or near a methamphetamine lab. During 2005, an estimated 1,660 children were injured, killed 

at, or affected by methamphetamine labs. In each of the prior 3 years, the number of affected children was 

over 3,000.45 The manufacture of methamphetamine involves the use of highly flammable, corrosive, and 

poisonous materials that create serious health and safety hazards. Children affected by methamphetamine 

labs may exhibit symptoms such as chronic cough, skin rashes, red or itchy eyes, agitation, inconsolable 

crying, irritability, and vomiting.46 

Many communities have Drug Endangered Children (DEC) programs that assist CPS caseworkers, law 

enforcement, and medical services to coordinate services for children found living in environments where 

drugs are made. For more information on DEC programs, visit http://www.whitehousedrugpolicy.gov/ 

enforce/dr_endangered_child.html. 

CPS agencies have witnessed the effects of methamphetamine use on the child welfare population. In a 

2005 survey by the National Association of Counties, 40 percent of CPS offi cials reported that the number 

of out-of-home placements due to methamphetamine use had increased in the previous year. In addition, 

59 percent of the CPS officials reported that methamphetamine use had increased the diffi culty of family 

reunifi cation.47 

Because of the dramatic escalation of methamphetamine use and the severity of its effects, further information 

on the drug and its impact on child welfare can be found throughout this manual. Additional resources are 

available at http://www.childwelfare.gov/systemwide/service_array/substance/drug_specifi c/meth.cfm 

and http://www.methresources.gov/. 

20 The Nature of Substance Use Disorders 
 

 

CHAPTER 3 

How Parental 

Substance Use Disorders 

Affect Children 

In This Chapter 

• 	 The impact of substance use on prenatal 

development 

• 	 The impact of substance use on childhood 

development 

The lives of millions of children are touched by 

substance use disorders (SUDs). Th e 2007 

National Survey on Drug Use and Health reports 

that 8.3 million children live with at least one parent 

who abused or was dependent on alcohol or an illicit 

drug during the past year. This includes 13.9 percent 

of children aged 2 years or younger, 13.6 percent of 

children aged 3 to 5 years, 12.0 percent of children 

aged 6 to 11 years, and 9.9 percent of youths aged 12 

to 17 years.48 These children are at increased risk for 

abuse or neglect, as well as physical, academic, social, 

and emotional problems.49 

A predictable, consistent environment, coupled 

with positive caregiver relationships, is critical for 

normal emotional development of children. Parental 

substance abuse and dependence have a negative 

impact on the physical and emotional well-being 

of children and can cause home environments to 

become chaotic and unpredictable, leading to child 

maltreatment. The children’s physical and emotional 

needs often take a back seat to their parents’ activities 

related to obtaining, using, or recovering from the use 

of drugs and alcohol.50 

This chapter discusses how prenatal and postnatal 

substance use by parents affects fetal and early 

A Definition of Child Maltreatment 

The Child Abuse Prevention and Treatment Act, reauthorized in the Keeping Children and Families Safe 

Act of 2003 (P.L. 108-36), provides the minimum standards for defining child physical abuse, neglect, and 

sexual abuse that States must incorporate into their statutory definitions in order to receive Federal funds. 

Under this Act, child maltreatment is defi ned as: 

“Any recent act or failure to act on the part of a parent or caregiver, which results in death, serious physical 

or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk 

of serious harm.”51 

A “child” under this definition generally means a person younger than age 18 or who is not an emancipated 

minor. In cases of child sexual abuse, a “child” is one who has not attained the age of 18 or the age specifi ed 

by the child protection law of the State in which the child resides, whichever is younger.52 

Protecting Children in Families Affected by Substance Use Disorders 21 
 

 

childhood development. It is intended to help child 

protective services (CPS) caseworkers understand 

the behaviors and problems that some children in 

the child welfare system may exhibit and that hold 

implications for their potential need for services. 

THE IMPACT ON PRENATAL DEVELOPMENT 

In 2006 and 2007, an average of 5.2 percent of 

pregnant women aged 15 to 44 years used an illicit 

drug during the month prior to being surveyed, and 

11.6 percent had consumed alcohol.53 Nationwide, 

between 550,000 and 750,000 children are born each 

year after prenatal exposure to drugs or alcohol.54 

These children often are medically fragile or born 

with a low birth weight. Some are born prematurely 

and require intensive care. 

Identifying the effects of drugs and alcohol on fetuses 

has posed challenges for researchers. While there has 

been some success researching the effects of alcohol 

on fetal development, securing accurate information 

regarding the use of illicit drugs from pregnant 

women or women who have given birth has proven 

to be very difficult. In addition, women who abuse 

substances often have other risk factors in their lives 

(e.g., a lack of prenatal care, poor nutrition, stress, 

violence, poor social support) that can contribute 

significantly to problematic pregnancies and births. 

The sections that follow summarize some of what is 

known about the effects of substance use on prenatal 

development. 

Pregnancy and SUDs 

Women who use alcohol or illicit drugs may fi nd 

it difficult or seemingly impossible to stop, even 

when they are pregnant. Moreover, pregnancy can 

be stressful and uncomfortable. For someone who 

commonly uses drugs and alcohol to minimize pain 

or stress, this practice may not only continue, but also 

become worse. Pregnant women can face signifi cant 

stigma and prejudice when their SUDs are discovered. 

For these reasons, some women avoid seeking 

treatment or adequate prenatal care. Other pregnant 

women, however, do seek treatment. According to 

the Substance Abuse and Mental Health Services 

Administration, 3.9 percent of the women admitted 

to State licensed or certified SUD treatment programs 

were pregnant at the time of admission.55 In another 

study, pregnant women aged 15 to 44 years were 

more likely than nonpregnant women of the same age 

group to enter treatment for cocaine abuse.56 

Th e Effects of Prenatal Exposure to Alcohol 

Drinking alcohol during pregnancy can have serious 

effects on fetal development. Alcohol consumed by 

a pregnant woman is absorbed by the placenta and 

Screening Newborns at Birth 

Opinions differ about how best to respond to prenatal substance exposure. Some hospitals are 

reconsidering whether they should test newborns for drugs, and some courts are treating prenatal substance 

exposure as a public health matter, turning to CPS only if they determine the child was harmed. Decisions 

regarding whether and when to screen newborns for prenatal substance exposure are beyond the purview 

of CPS. 

Child welfare legislation has provided some guidance regarding how such cases should be handled. Th e 

Keeping Children and Families Safe Act of 2003 requires that health care providers notify CPS, as 

appropriate, to address the needs of infants born exposed to drugs, and requires the development of a plan 

of safe care for any affected infants. In 2006, statutes in 15 States and the District of Columbia specifi ed 

reporting procedures when there is evidence at birth that an infant was exposed prenatally to drugs, 

alcohol, or other controlled substances. Additionally, 13 States and the District of Columbia included 

prenatal substance exposure in their definitions of child abuse or neglect.57 

22 How Parental Substance Use Disorders Affect Children 
 

 

directly affects the fetus.58 A variety of birth defects 

to the major organs and the central nervous system, 

which are permanent, can occur due to alcohol use 

during pregnancy, though the risk of harm decreases 

if the pregnant woman stops drinking completely.59 

Collectively, these defects are called Fetal Alcohol 

Syndrome (FAS). FAS is one of the most commonly 

known birth defects related to prenatal drug exposure. 

Children with FAS may exhibit: 

• 	 Growth deficiencies, both prenatally and after birth 

• 	 Problems with central nervous system functioning 

• 	 IQs in the mild to severely retarded range 

• 	 Small eye openings and poor development of the 

optic nerve 

• 	 A small head and brain 

• 	 Joint, limb, ear, and heart malformations. 

Alcohol-Related Neurodevelopmental Disorder 

(ARND) and Alcohol-Related Birth Defects (ARBD) 

are similar to FAS. Once known as Fetal Alcohol 

Effects, ARND and ARBD are terms adopted in 

1996 by the National Academy of Sciences’ Institute 

of Medicine. ARND and ARBD encompass the 

functional and physiological problems associated 

with prenatal alcohol exposure, but are less severe 

than FAS. Children with ARND can experience 

functional or mental impairments as a result of 

prenatal alcohol exposure, and children with ARBD 

can have malformations in the skeletal and major organ 

systems. Not all children who are exposed prenatally 

to alcohol develop FAS, ARND, or ARBD, but for 

those who do, these effects continue throughout their 

lives and at all the stages of development, although 

they are likely to present themselves diff erently at 

each developmental stage. Exhibit 3-1 compares 

typical childhood behavior at each developmental 

stage with behaviors and characteristics associated 

with FAS, ARND, and ARBD. 

Exhibit 3-1 

Childhood Behavior and Characteristics Associated with FAS, ARND, and ARBD60 

Developmental 

Stage Typical Behaviors or Characteristics FAS/ARND/ARBD Behaviors 

or Characteristics 

Infants • Develop mental and physical skills 

• Bond with caretakers 

• Problems with spatial and depth perception, muscle 

coordination and development, facility with speech, and 

processing information 

• Attention defi cit disorder 

• Inability to focus 

• Possible attachment disorders 

Toddlers • Develop sense of self 

• Assert independence by saying “no” 

• Difficulty exercising self-control, which leads to selfdoubt and feelings of inadequacy 

5–7 year olds • Try new things 

• Meet or exceed academic standards 

• Learn new social skills 

• Overwhelmed with new situations and interactions with 

other children 

• Inability to pick up social skills by observation 

• Problems meeting academic standards 

8–12 year olds • Increased influence of peers 

• Games become important method 

of bonding and developing 

interpersonal skills 

• Difficulty remembering rules of games 

• Lack of remorse in breaking rules 

• Become depressed and exhibit other behavior problems 

Teenagers • Continued detachment from parents 

• Development of individual identity 

• Learn to identify with larger community 

• May lack skills to become good community members 

• Become socially isolated 

• May find their way to peer groups that engage in highrisk behaviors 

• May withdraw altogether from groups 

Protecting Children in Families Affected by Substance Use Disorders 23 
 

 

 

 

More information on FAS is available from the National Organization on Fetal Alcohol Syndrome (http://www.nofas. 

org) and the National Center on Birth Defects and Developmental Disabilities (http://www.cdc.gov/ncbddd/fas). 

Th e Effects of Prenatal Exposure to Drugs 

Similar to alcohol use, use of other substances can 

have signifi cant effects on the developing fetus. For 

example, cocaine or marijuana use during pregnancy 

may result in premature birth, low birth weight, 

decreased head circumference, or miscarriage.61 

Prenatal exposure to marijuana has been associated 

with difficulties in functioning of the brain.62 Even if 

there are no noticeable effects in the children at birth, 

the impact of prenatal substance use often can become 

evident later in their lives. As they get older, children 

who were exposed to cocaine prenatally can have 

difficulty focusing their attention, be more irritable, 

and have more behavioral problems.63 Difficulties 

surface in sorting out relevant versus irrelevant stimuli, 

making school participation and achievement more 

challenging. 

Pregnancy as a Motivation for Treatment 

Given the dangers associated with substance use 

during pregnancy, women who abuse substances 

during pregnancy should receive treatment as early as 

possible. Research has found that women often are 

more amenable to entering treatment when they are 

pregnant.67 CPS caseworkers and other professionals, 

therefore, should try to use the pregnancy to motivate 

women to change. CPS caseworkers may not have 

much opportunity to interact with women who have 

not yet given birth unless there are other children 

in the family who have entered the child welfare 

system. 

Once their babies are born, significant changes can 

occur in the lives of women who abused alcohol or 

drugs during pregnancy. In the case of babies who 

test positive for substances at birth, the mothers may 

experience remorse and sadness over the actual or 

potential consequences of their substance use, which 

also can be a motivating factor to seek treatment. 

If CPS is involved, mothers may admit to enough 

drug use to explain the positive drug test, but not 

to an addiction, due to the fear of losing custody of 

their children. They may comply with treatment 

requirements in order to compensate for the 

problems their SUD may have caused their children. 

Nevertheless, new difficulties may begin when CPS 

closes the case and the pressure is off the mothers to 

stay clean. For instance, they may be tempted to use 

drugs and alcohol again. (For more information on 

treatment issues, see Chapter 5, Treating Substance 

Use Disorders.) 

Th e Effects of Prenatal Methamphetamine Use 

Prenatal exposure to methamphetamine can cause a wide range of problems, including birth defects, fetal 

death, growth retardation, premature birth, low birth weight, developmental disorders, and hypersensitivity 

to touch in newborns. Older children who were exposed prenatally to substances may exhibit cognitive 

deficits, learning disabilities, and poor social adjustment.64 

Caseworkers should note that methamphetamine users might not be knowledgeable about the potential 

harm to themselves or to the fetus. Like cocaine and heroin users, methamphetamine users tend to avoid 

prenatal care clinics.65 Caseworkers also should be careful of labeling children who have been exposed 

prenatally to methamphetamine. For example, labeling a child as a “meth baby” can cause the child or others 

to have lower expectations for academic and life achievements and to ignore other causes for the physical and 

social problems the child may encounter.66 

24 How Parental Substance Use Disorders Affect Children 
 

 

 

 

 

THE IMPACT ON CHILDHOOD DEVELOPMENT 

Exposure to parental SUDs during childhood also 

can have dire consequences for children. Compared 

to children of parents who do not abuse alcohol or 

drugs, children of parents who do, and who also are in 

the child welfare system, are more likely to experience 

physical, intellectual, social, and emotional problems. 

Among the difficulties in providing services to these 

children is that problems aff ected or compounded by 

their parents’ SUDs might not emerge until later in 

their lives.68 

This section summarizes some of the consequences 

of SUDs on childhood development, including 

a disruption of the bonding process; emotional, 

academic, and developmental problems; lack of 

supervision; parentification; social stigma; and 

adolescent substance use and delinquency. 

Disruption of the Bonding Process 

When mothers or fathers abuse substances after 

delivery, their ability to bond with their child—so 

important during the early stages of life—may be 

weakened. In order for an attachment to form, it is 

necessary that caregivers pay attention to and notice 

their children’s attempts to communicate. Parents 

who use marijuana, for example, may have difficulty 

picking up their babies’ cues because marijuana dulls 

response time and alters perceptions. When parents 

repeatedly miss their babies’ cues, the babies eventually 

stop providing them. The result is disengaged parents 

with disengaged babies. These parents and babies 

then have difficulty forming a healthy, appropriate 

relationship. 

Neglected children who are unable to form secure 

attachments with their primary caregivers may: 

• 	 Become more mistrustful of others and may be 

less willing to learn from adults 

• 	 Have difficulty understanding the emotions of 

others, regulating their own emotions, or forming 

and maintaining relationships with others 

• 	 Have a limited ability to feel remorse or empathy, 

which may mean that they could hurt others 

without feeling their actions were wrong 

• 	 Demonstrate a lack of confidence or social skills 

that could hinder them from being successful in 

school, work, and relationships 

• 	 Demonstrate impaired social cognition, which is 

awareness of oneself in relation to others as well 

as of others’ emotions. Impaired social cognition 

can lead a person to view many social interactions 

as stressful.69 

Emotional, Academic, and Developmental
 

Problems
 

Children who experience either prenatal or postnatal 

drug exposure are at risk for a range of emotional, 

academic, and developmental problems. For example, 

they are more likely to: 

• 	 Experience symptoms of depression and anxiety 

• 	 Suffer from psychiatric disorders 

• 	 Exhibit behavior problems 

• 	 Score lower on school achievement tests 

• 	 Demonstrate other difficulties in school. 

These children may behave in ways that are challenging 

for biological or foster parents to manage, which can 

lead to inconsistent caregiving and multiple alternative 

care placements. 

Positive social and emotional child development 

generally has been linked to nurturing family settings 

in which caregivers are predictable, daily routines are 

respected, and everyone recognizes clear boundaries 

for acceptable behaviors.70 Such circumstances often 

are missing in the homes of parents with SUDs. 

As a result, extra supports and interventions are 

needed to help children draw upon their strengths 

and maximize their natural potential despite their 

home environments. Protective factors, such as the 

involvement of other supportive adults (e.g., extended 

Protecting Children in Families Affected by Substance Use Disorders 25 
family members, mentors, clergy, teachers, neighbors), 

may help mitigate the impact of parental SUDs. 

Lack of Supervision 

The search for drugs or alcohol, the use of scarce 

resources to pay for them, the time spent in illegal 

activities to raise money for them, or the time spent 

recovering from hangovers or withdrawal symptoms 

can leave parents with little time or energy to care 

properly for their children. These children frequently 

do not have their basic needs met and often do not 

receive appropriate supervision. In addition, rules 

about curfews and potentially dangerous activities 

may not be enforced or are enforced haphazardly. As 

a result, SUDs are often a factor in neglect cases. 

Parentifi cation 

As children grow older, they may become increasingly 

aware that their parents cannot care for them. To 

compensate, the children become the caregivers of the 

family, often extending their caregiving behavior to 

their parents as well as younger siblings. Th is process 

is labeled “parentifi cation.”71 

Parentified children carry a great deal of anxiety 

and sometimes go to great lengths to control or to 

eliminate their parents’ use of drugs or alcohol. Th ey 

feel responsible for running the family. Th ese feelings 

are reinforced by messages from the parents that the 

children cause the parents’ SUDs or are at fault in 

some way if the family comes to the attention of 

authorities. Sometimes these children must contact 

medical personnel in the case of a parent’s overdose, 

or they may be left supervising and caring for younger 

children when their parents are absent while obtaining 

or abusing substances. 

Social Stigma 

Adults with SUDS may engage in behaviors that 

embarrass their children and may appear disinterested 

in their children’s activities or school performance. 

Children may separate themselves from their parents 

by not wanting to go home after school, by not 

bringing friends to the house, or by not asking for 

help with homework. These children may feel a 

social stigma attached to certain aspects of their 

parents’ lives, such as unemployment, homelessness, 

an involvement with the criminal justice system, or 

SUD treatment. 

Adolescent Substance Use and Delinquency 

Adolescents whose parents have SUDs are more likely 

to develop SUDs themselves. Some adolescents 

mimic behaviors they see in their families, including 

ineffective coping behaviors such as using drugs and 

alcohol. Many of these children also witness or are 

victims of violence. It is hypothesized that substance 

abuse is a coping mechanism for such traumatic 

events.72 Moreover, adolescents who use substances 

are more likely to have poor academic performance 

and to be involved in criminal activities. Th e longer 

children are exposed to parental SUD, the more 

serious the negative consequences may be for their 

overall development and well-being. 

Child Abuse as a Precursor to Substance Use Disorders 

Many people view SUDs as a phenomenon that leads to or exacerbates the abuse or neglect of children. 

Research also suggests, however, that being victimized by child abuse, particularly sexual abuse, is a 

common precursor of SUDs.73 Sometimes, victims of abuse or neglect “self-medicate” (i.e., drink or use 

drugs to escape the unresolved trauma of the maltreatment).74 One study found that women with a history 

of childhood physical or sexual abuse were nearly five times more likely to use street drugs and more than 

twice as likely to abuse alcohol as women who were not maltreated.75 In another study, childhood abuse 

predicted a wide range of problems, including lower self-esteem, more victimization, more depression, and 

chronic homelessness, and indirectly predicted drug and alcohol problems.76 

26 How Parental Substance Use Disorders Affect Children 
CHAPTER 4 

In-home Examination, 

Screening, and Assessment 

of Substance Use Disorders 

In This Chapter 

• In-home examination 

• Screening 

• Assessment 

The previous chapter described some of the eff ects 

of parental substance use disorders (SUDs) on 

children, but how does a child protective services 

(CPS) worker determine if SUDs exist in the family? 

This chapter discusses in-home examinations, SUD 

screening instruments, and SUD assessments, 

including their methods, benefits, and limitations, 

and how caseworkers can incorporate them into their 

practice. 

IN-HOME EXAMINATION 

An in-home examination includes observations by the 

CPS caseworker of the people and the environment 

in a home. When visiting a home as part of an 

investigation, the caseworker should check for the 

following indicators of possible SUDs: 

• 	 A report of substance use is included in the CPS 

call or report 

• 	 Drug paraphernalia (e.g., a syringe kit, charred 

spoons, a large number of liquor or beer bottles) 

• 	 The scent of alcohol or drugs 

• 	 A child or other family member reports alcohol 

or drug use by a parent 

• 	 A parent appears to be under the influence of a 

substance, admits to having an SUD, or shows 

other signs of addiction or abuse (e.g., needle 

marks). 

This list can be used pre- or post-screening and can be 

incorporated into every home visit.77 

SCREENING 

Screening is the use of a simple, and usually brief, 

set of questions that have been validated (i.e., tested 

to show that they accurately indicate the presence of 

an SUD). Results are easy to interpret. Generally, 

individuals who are not trained SUD treatment 

providers use the instruments. 

The goal of screening is to determine whether a family 

member requires further evaluation for SUDs.78 

CPS caseworkers can use screening as a part of their 

standard home visits or family assessments. Th is 

section describes the importance of screening, sample 

screening instruments, benefits and limitations 

of screening instruments, and what to do when 

an instrument indicates an individual may have 

an SUD. 

Protecting Children in Families Affected by Substance Use Disorders 27 
Signs of Methamphetamine Use and Manufacture79 

With the increased use of methamphetamine, first responders are now more likely to work with clients who are 

users or manufacturers of this drug. The following information can assist them in identifying methamphetamine 

use or manufacturing. 

Signs of possible methamphetamine use include: 

• Increased breathing and pulse rate 

• Sweating 

• Rapid/pressured speech 

• Euphoria (an exaggerated feeling of well-being) 

• Hyperactivity 

• Dry mouth 

• Tremors (shaking hands) 

• Dilated pupils 

• Lack of appetite

• Insomnia or lack of sleep 

• Bruxism (teeth-grinding) 

• Depression 

• Irritability, suspiciousness, paranoia 

• Visual and auditory hallucinations 

• Formication (the sensation of bugs crawling on the skin) 

• The presence of white powder, straws, or injection equipment. 

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

• Laboratory equipment (e.g., flasks, rubber tubing, beakers, large amounts of coff ee fi lters) 

• Large quantities of pills containing ephedrine or pseudoephedrine (e.g., certain cold medicines) 

• A chemical odor

• Chemicals not commonly found in a home (e.g., red phosphorous, acetone, liquid ephedrine, ether, 

iodine, phenylacetone [P2P]) 

• Unusually large quantities of household chemicals (e.g., lye, paint thinner) 

• Chemicals usually found on a farm (e.g., anhydrous ammonia) 

• Residue from the manufacture of methamphetamine (usually of a maroon color) in bathtubs, sinks, 

toilets, or on the walls 

• Containers used for purposes not originally intended (e.g., glass milk or beer bottles with unfamiliar

liquids) 

• No visible means of income 

• Unusual security precautions (e.g., extra locks, barred or blacked-out windows, expensive alarm 

systems). 

28 In-home Examination, Screening, and Assessment of Substance Use Disorders 
Safety Issues When Encountering a Suspected Methamphetamine Lab 

First responders should use extreme caution and seek assistance from law enforcement, fi re/rescue personnel, 

hazardous materials crews, or other appropriate individuals or groups if they are visiting a home that has a 

suspected methamphetamine lab because these homes may have: 

• Individuals under the influence of methamphetamine or other drugs and/or who may be armed 

• Defense systems, including explosive devices and other booby traps 

• Vicious animals 

• Dangerous and volatile chemicals. 80 

First responders who enter a methamphetamine lab that has not been properly ventilated and cleaned—or 

who are not properly equipped to avoid exposure to chemicals (i.e., have respirators, protective clothing)— 

may experience shortness of breath, coughing, chest pain, dizziness, vomiting, lack of coordination, burns, 

and, in some cases, death. If first responders do come into contact with possibly dangerous chemicals, they 

should wash the exposed skin with liquid soap and water or, depending on the type of chemical exposure, 

a chemical solution. They also should remove contaminated shoes and clothing. First responders should 

be knowledgeable about agency protocols for the evacuation, decontamination, and health screenings of 

children and others found at the home, including which, if any, of the child’s possessions (e.g., medications, 

eyeglasses) should be retrieved from the home and how they should be decontaminated. 

First responders who determine they are in a home that has a suspected methamphetamine lab should 

immediately leave the residence, taking care not to: 

• Touch anything in the lab 

• Turn on or off any electrical switches (e.g., lights) 

• Eat or drink anything

• Open, move, or sniff containers with suspected chemicals 

• Smoke anywhere near the home. 

• Alarm or act in a way that could be perceived as aggressive by others in the home (i.e., suddenly 

running from a room, pushing someone aside), especially suspected methamphetamine users, who 

may experience paranoia and extremely aggressive behavior.81 

Importance of Substance Use Disorder Screening 

Screening for SUDs should be a routine part of CPS 

investigations, risk and safety assessments, and case 

planning and monitoring. Evidence of SUDs may 

not be noticeable upon initial investigation, but may 

emerge over time as caseworkers develop relationships 

with a family or notice that family members are 

unable to participate in program activities. Given 

the prevalence of SUDs among families involved in 

the child welfare system, CPS caseworkers should 

consider screening during all stages of the case. 

CPS caseworkers understandably may be 

uncomfortable discussing SUDs with family members 

who already feel threatened because of being under 

investigation for child maltreatment. Abuse and 

addiction are not always visible, and family members 

are likely to be reluctant to disclose activities that may 

be illegal or that could further jeopardize custody of 

their children. As described in Chapter 2, Th e Nature 

of Substance Use Disorders, SUDs often are masked by 

other problems, such as mental illness or domestic 

violence, and can be overlooked if those other problems 

Protecting Children in Families Affected by Substance Use Disorders 29 
 

 

 

General Home Visit Safety Tips 

Families experiencing multiple issues (e.g., SUDs, mental health problems, domestic violence, criminal behavior) 

can make it more dangerous for CPS caseworkers going into homes to investigate cases of child maltreatment. 

While on a home visit, caseworkers should remember the following safety tips: 

• Ensure that the CPS supervisor knows the time and place of the appointment and the expected time of 

return. 

• Dress appropriately and in a manner that blends into the community. 

• Walk close to buildings or close to the curb in an effort to have at least one safe side. Stay away from 

bushes, alleys, and dark corners, if possible. 

• Know the route in and out of the area by examining a map or by talking with others beforehand. Do 

not wander or appear lost or confused. 

• Park as close to the home as possible and in a way that helps ensure an easy exit. Keep the car keys in 

hand while entering and exiting the home so they are easily available. 

• Be aware of your surroundings at all times. Enter and leave homes carefully, noticing doors, windows, 

neighbors, loiterers, and anything or anyone that may be a risk to safety. 

• If unsure of the safety or surroundings of the location, move to another spot by suggesting taking a 

break or getting a cup of coffee and finish talking there. 

• Attempt to keep a clear path to an exit. 

• Be aware of dogs that may pose a threat. 

• Follow intuition and take action if feeling afraid or threatened. Leave the home or call 911 if necessary. 

• Have access, if possible, to technology that may assist with safety issues (e.g., GPS systems, cell phones). 

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

• Go to the home with another caseworker or law enforcement officer, particularly if the home is in an 

area known for drug dealing. 

• Know the local signs that indicate a drug deal is occurring. In such situations, do not enter the home 

without law enforcement personnel. 

• Be aware of homes or other living environments that may be used as a clandestine drug factory. Do not 

attempt to investigate such places alone, and immediately contact the police or sheriff if such a lab is 

suspected. Anyone without proper training and protective gear should stay at least 500 feet away from 

any suspected laboratory. The following are signs of a possible lab: 

– Strong or unusual chemical odors 

– Laboratory equipment, such as glass tubes, beakers, funnels, and Bunsen burners 

– Chemical drums or cans in the yard 

– A high volume of automobile or foot traffic, particularly at odd hours 

– New, high fences with no visible livestock or other animals. 

• If one or both parents appear to be intoxicated, high, incoherent, or passed out, ensure the safety and 

supervision of the children. Once that has been accomplished, it is appropriate to reschedule the 

appointment. It may be appropriate to call the supervisor for guidance.82 

30 In-home Examination, Screening, and Assessment of Substance Use Disorders 
 

 

 

 

are more apparent. The opposite also can be true; 

an SUD may mask other problems, such as domestic 

violence or disabilities. Moreover, addiction often is 

characterized by denial, and family members may not 

recognize that they have an SUD. For example, they 

may feel that their drinking is within an acceptable 

range or that their marijuana use is not problematic. 

Screening is just one of many approaches used to 

identify SUDs. It is not completely accurate nor will 

it work all the time (i.e., not all positive responses will 

demonstrate an SUD, and not all negative responses 

will rule out a disorder). CPS caseworkers should also 

rely on additional techniques, such as observation, 

medical histories, reports from family members or 

friends, or arrest records. Nevertheless, using a brief 

screening instrument takes little time and provides an 

objective method for caseworkers to use in opening 

a discussion about sensitive issues. In this way, 

screening becomes part of a continuum of activities 

aimed at addressing families’ problems with SUDs. 

Sample Screening Instruments 

Ideally, screening instruments used by CPS 


caseworkers should be brief, easily administered, 


Exhibit 4-1 

Sample Screening Instruments for Substance Use Disorders 

The CAGE Questionnaire (amended for drug use) 

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

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

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

E Have you ever had a drink or used a drug first thing in the morning to steady your nerves or get rid of a 

hangover? (Eye-opener) 

Scoring: If the answer is “yes” to one or more questions, the responder should receive a formal alcohol and 

drug assessment. Answering “yes” to one or two questions may indicate alcohol and drug-related problems. 

Answering “yes” to three or four questions may indicate alcohol or drug dependence.83 

UNCOPE 

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

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

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

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

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

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

or boredom? 

Scoring: Two or more positive responses indicate possible abuse or dependence and a need for further 

assessment by an SUD treatment provider.84 

Protecting Children in Families Affected by Substance Use Disorders 31 
inexpensive, and capable of detecting a problem or 

condition when it exists. Two screening tools available 

for CPS caseworkers are the CAGE and UNCOPE 

questionnaires, which are shown in Exhibit 4-1. Th ese 

quick screens should be used with other information 

and observations.85 For a list of screening instruments, 

see Appendix F, Commonly Used Screening Instruments. 

A sample instrument is available in Appendix G, State 

of Connecticut Department of Children and Families 

Substance Abuse Screening and Information Form. 

Benefits and Limitations of
 

Screening Instruments
 

Screening for SUDs is harder and requires more skill 

than screening for other problems among child welfare 

populations, such as barriers to work or stress. Th is 

is because SUDs often are characterized by stigma 

and denial and frequently involve illegal activities. 

Although screening instruments can provide useful 

information, they are not without fl aws. Without 

informed interpretation and communication of their 

results, these instruments will not be effective. It is 

important to understand both the benefits and the 

limitations of screening instruments in order to use 

them properly. 

Th e benefits of screening instruments include the 

following: 

• 	 Instruments provide a consistent structure 

for caseworkers to use in interviewing family 

members. 

• 	 Instruments can provide a starting point and 

context for further discussion and service 

planning. 

• 	 Instruments offer parents a chance to disclose 

an SUD and give caseworkers a chance to refer 

the parent to an SUD treatment provider for 

assessment. 

• 	 Screening instruments allow caseworkers to weigh 

an individual’s responses to estimate whether 

SUDs might be a problem. 

• 	 Many instruments are widely available and 

accessible. 

• 	 Several instruments have been empirically tested 

for validity (i.e., the instrument is accurate) and 

reliability (i.e., the instrument is consistent). 

• 	 Many instruments take little time to administer 

and are not diffi cult to interpret.86 

The limitations of screening instruments include the 

following: 

• 	 Screening instruments have been tested and 

found valid with a variety of populations, but 

every instrument may not be appropriate for every 

population. For example, some instruments may 

have been tested in settings where individuals go 

for health care and treatment, but not in public 

agencies or in situations where families know 

they risk losing their children. Before using 

a particular instrument in a CPS setting, it is 

important to check the literature regarding the 

appropriate use of that instrument. 

• 	 Screening instruments rely on self-disclosure. 

Even the best instruments administered under 

optimal circumstances will yield valid information 

only to the extent that families respond honestly. 

• 	 Denial is a characteristic of SUDs, and because 

of this, family members may not understand or 

acknowledge that their pattern of substance use 

represents abuse or addiction. 

• 	 Information obtained from the screening alone 

will be of little benefit unless it is part of a 

continuum of identification, assessment, and 

treatment. 

Instruments are only one technique that caseworkers 

should use in exploring SUDs with family members. 

They should complement rather than replace 

other techniques to identify SUDs. Additionally, 

instruments are not always correct. If a caseworker 

suspects an SUD, but the screening instrument 

32 In-home Examination, Screening, and Assessment of Substance Use Disorders 
 

 

does not indicate a problem, the caseworker’s best 

judgment always should take precedence. 

What to Do When a Screen Indicates a
 

Substance Use Disorder
 

If the results of a screening instrument or an in-home 

check indicate that a parent may have an SUD, the 

CPS caseworker should take the following steps: 

• 	 Ensure that the parent receives an SUD assessment 

from a qualified SUD treatment provider. 

• 	 If an SUD is present, address it in the case plans 

for both the parent and the child. 

• 	 Ensure that a qualified professional assesses the 

child for the impact of parental SUD or for the 

possibility of the child’s own use of substances. 

• 	 Coordinate service plans with the treatment 

professional.87 

Even if an SUD initially has been ruled out as an 

important factor in the family’s case plan, the 

caseworker should reassess if the family is not making 

progress in dealing with other issues. An unidentifi ed 

SUD can hamper a family’s progress for years. 

ASSESSMENT 

Once screening indicates that an individual may have 

an SUD, an assessment is the next step in a continuum 

of activities to address the problem. An assessment 

is a detailed evaluation used to determine whether 

treatment is needed. If so, then the assessment is 

Drug Testing Parents 

Physical drug testing of parents for evidence of substance use brings to the surface complicated and 

interrelated issues of public policy, science and technology, and ethics. Drug testing of adults has diff erent 

goals in different contexts. For example, parole and probation officers use drug testing to monitor 

compliance with the conditions of parole and probation; employers use them to make hiring decisions; 

and alcohol and drug abuse treatment programs use tests to assess whether a person is complying with the 

treatment plan. Parents involved with CPS who are known to have an SUD are likely to be tested as part 

of their alcohol and drug abuse treatment or to meet court requirements. CPS may rely on the results of 

drug tests to inform decisions about providing services or reunification, or they may consider drug testing 

as a means of determining if there is an SUD. Whichever way drug testing is used, it is important for CPS 

caseworkers and administrators to understand the following uses and limitations: 

• Drug tests do not demonstrate patterns of drug use or demonstrate if a person is abusing or is 

dependent on substances. Test results simply indicate the recent use of a substance and, for some 

substances, the amount used. 

• Common drug tests do not provide accurate information about alcohol use because alcohol 

metabolizes quickly and is not detectable after approximately 8 hours. 

• Whether drug use is detected by tests depends not only on the drug used, but also on other 

factors such as the characteristics of each drug, an individual’s metabolism, and the cut-off levels 

established by the agency requesting the test or the laboratory analyzing it. 

• Drug tests are typically physically invasive procedures, which raises questions about an individual’s 

right to privacy. 

• Individuals may be afraid to discuss problems if they believe they will be tested. 

• Positive results from drug tests require that there be qualified and trained staff available to initiate 

careful and sensitive follow-up discussions with family members.88 

Protecting Children in Families Affected by Substance Use Disorders 33 
utilized to design an appropriate treatment or service 

plan. Assessments should include various aspects of 

family living, such as housing, health issues, child 

behavior problems, and family strengths. In general, 

only professionals who are trained in administering 

assessments and in interpreting their results should 

conduct them. 

Importance of Sharing Information 

Ideally, the CPS caseworker and the SUD treatment 

provider who is conducting the assessment will share 

information. Information from the CPS caseworker 

about the case provides the context for the assessment. 

Likewise, results from the assessment can assist the 

CPS caseworker in developing a comprehensive and 

coordinated service plan. The caseworker should 

provide the following information, if available, to the 

SUD treatment provider along with the referral: 

• 	 The family member’s arrest history related to 

substance use 

• 	 The condition of the home when home visits 

were conducted 

• 	 A history of SUD treatment participation by the 

family member 

• 	 Any other SUD-related information. 

Key Points for Making Referrals and 

for Using Assessments 

The following are key points to remember when 

making referrals for and conducting SUD assessments 

within the context of CPS: 

• 	 The quality of the assessment is directly related 

to the quality of the information provided 

to the counselor conducting the evaluation. 

Frequently, counselors rely on self-reported 

data in their evaluations. Self-reports often 

are criticized because there is a perception that 

individuals with SUDs often lie. This issue can 

be addressed by comparing the client’s view of 

the problem with information available from 

other sources, such as a CPS caseworker, other 

service providers, and family members. 

• 	 A good assessment should address the following 

family and parenting issues: 

–	 How substance use affects the client’s ability 

to be a good parent; 

–	 The level of care or intervention that would 

be most appropriate for this individual to 

address the current level of substance use; 

–	 What should be required of the parent in 

order to demonstrate the ability to rear the 

child safely in light of a problematic use of 

substances. 

• 	 SUD treatment providers may feel that 

family-relevant assessments are beyond their 

professional scope of practice. If a CPS 

caseworker encounters a situation in which the 

only SUD assessment available is conducted by 

someone with limited experience in addressing 

family issues, this should be stated explicitly in 

the caseworker’s case notes and in court reports. 

Additionally, caseworkers should consult with a 

supervisor if they do not have confidence in the 

assessment. 

• 	 Communication is critical. Confi dentiality 

issues surrounding SUD treatment records 

frequently are cited as a reason why CPS and SUD 

treatment agencies do not work well together. 

(Confidentiality is discussed in more detail in 

Chapter 8, Putting It Together: Making the Systems 

Work for Families.) Clear communication among 

the various parties is critical for ensuring that case 

plans and treatment plans are created properly 

and followed. Additionally, an understanding 

of each professional culture is crucial to working 

well together. 

See Chapter 8, Putting It Together: Making the Systems 

Work for Families, for more information on how 

CPS and SUD treatment systems can work together 

effectively. Additionally, refer to Exhibit 4-2 for more 

information regarding how SUD issues should be 

taken into consideration in child maltreatment cases. 

34 In-home Examination, Screening, and Assessment of Substance Use Disorders 
 

 

 

 

 

 

 

Exhibit 4-2 

Decision Tree for Child Welfare Cases Involving Caregiver Substance Use Disorders9 

Do safety indicators show that the caregiver’s substance use has resulted in problems caring for the 

child? Is substance use confirmed by the caregiver or by a SUD assessment? 

Close the case or use a different set of guidelines 

if there is neglect or abuse unrelated to a SUD. Is substance use an underlying factor in physical 

abuse with major injury? 

SUD is an underlying factor in physical abuse with 

minor injury or in neglect. Follow agency protocols for cases involving 

physical abuse with major injury. The immediate 

safety of the child is paramount. 

Yes No 

No Yes

If the child has been neglected, does the neglect 

appear to be situational (i.e., not occurring on a 

regular basis, caused by a particular family 

trauma) or chronic (i.e., exhibiting a pattern of 

neglect over time)? (If no neglect is present, go to 

situational box below.) 

Chronic 

Chronic neglect is associated with profound 

caregiver impairment. The more chronic the 

pattern of maltreatment, the more likely the child 

has been maltreated in a variety of ways. 

Carefully assess for the presence of other forms 

of maltreatment. 

Situational 

Does the caregiver have an extensive history of 

SUD? 

Is the caregiver willing and motivated to cooperate 

with--and commit to--the treatment process and to 

change his/her lifestyle to the extent possible? 

SUD and an open maltreatment case and several 

failed treatment episodes within the last 3 years Yes suggests reunification may not be appropriate. 

Begin concurrent planning and look for an 

alternative permanent placement for the child. 

No 

Note: Some relapse is expected and considered 

part of the treatment process. However, a 

pattern of chronic SUD, treatment, and relapse 

over an extended period of time may require an 

Yes 

Ensure the child is safe at home 

or in a placement and refer the 

caregiver for treatment. Also 

seek to improve parenting, 

address basic needs, and 

achieve permanency and family 

stability. 

alternative treatment method or permanency 

plan. 

No 

If the caregiver does not admit to the problem or is unwilling to change 

certain factors, treatment is unlikely to succeed. A caregiver’s initial

uncooperativeness, however, may spring from feelings of guilt about 

substance abuse and defensiveness about the assessment process. 

Look for a relative placement or foster home. Refer the caregiver to 

treatment, explaining that successful treatment may be the only route to 

reunification with the child. Then determine if the caregiver (a) is willing 

to work with the agency and (b) generally follows through with the 

service plan requirements. Begin concurrent planning if the caregiver is 

unwilling to work with the agency. 

Note: Do not confuse anger at public intervention or at removal of the 

child with lack of cooperation or unwillingness to undergo treatment. 

Adapted from Tough Problems, Tough Choices: Guidelines for Needs-based ServicePlanning in Child Welfare, a publication developed by 

Casey Family Programs, The Annie E. Casey Foundation, and American Humane. It is available at http://www.americanhumane. 

org/protecting-children/resources/casey-decision-making-guidelines/products.html. 

Protecting Children in Families Affected by Substance Use Disorders 35 
For information about how the child welfare system, SUD treatment providers, and the courts can improve 

screening and assessment policies and protocols, refer to Screening and Assessment for Family Engagement, 

Retention, and Recovery (SAFERR) at http://www.ncsacw.samhsa.gov/fi les/SAFERR.pdf. 

36 In-home Examination, Screening, and Assessment of Substance Use Disorders 
 

 

CHAPTER 5 

Treating Substance Use 

Disorders 

In This Chapter 

• The goal of treatment 

• Treatment considerations 

• Common treatment approaches 

• Support services 

• Gender-sensitive treatment 

• Barriers to treatment 

Substance use disorders (SUDs), like other chronic 

diseases, are treatable. Trained SUD treatment 

providers can determine the best treatment path 

for individuals to take and can enlist the assistance 

of other service providers, such as child protective 

services (CPS) caseworkers, in the treatment process. 

This chapter discusses the goal of SUD treatment, 

important treatment considerations, various 

approaches to treatment, issues related to gendersensitive treatment, and barriers that may impede 

individuals from receiving treatment. Th is chapter 

is intended to help CPS caseworkers strengthen their 

understanding of treatment services available to help 

the families with whom they work. The role of CPS 

in supporting the treatment process is discussed in 

more detail in Chapter 6, The Role of Child Protective 

Services When Substance Use Disorders Are Identifi ed. 

THE GOAL OF TREATMENT 

An SUD is a medical condition with signifi cant 

behavioral eff ects. These behaviors may frustrate, 

stymie, and anger treatment providers and CPS 

caseworkers. While individual experiences vary, 

persons with an SUD often have: 

• 	 Little experience or skills with which to cope 

with their feelings. Their substance use tends to 

numb discomfort, at least temporarily. Many of 

these individuals have been turning to drugs and 

alcohol since their teenage years. 

• 	 Difficulty escaping or solving everyday problems 

without using substances. As a result, they can 

feel quite helpless when confronted with the dayto-day challenges of life. 

• 	 Poor communication skills. They may be 

ineffective in some areas and over-emote in 

others. 

• 	 Problematic behaviors, such as being manipulative 

or dishonest. These behaviors may be useful, 

however, in helping them obtain drugs and 

alcohol or hiding the use of these substances. 

Some individuals with SUDs may find it easy to 

be dishonest because they have buried or avoided 

their true feelings. 

Protecting Children in Families Affected by Substance Use Disorders 37 
 

 

 

The goal of treatment is to help individuals break 

the cycle of addiction and dependence so that they 

may learn better ways of dealing with challenges in 

their lives. Caseworkers should keep in mind that 

treatment does not equal recovery. Recovery is a 

lifelong process, with treatment being one of the fi rst 

steps. Recovery entails making lifestyle changes to 

regain control of one’s life and accepting responsibility 

for one’s own behavior.90 

Research has demonstrated that SUD treatment 

works. A number of national studies over the past 

decades have shown that SUD treatment can result in 

abstinence from substance use, signifi cant reduction 

in the abuse of substances, decreased criminal activity, 

and increased employment.91 Recent studies also 

link SUD treatment for mothers with children in 

substitute care to improved child welfare outcomes, 

such as shorter stays in foster care for children and 

increased likelihood of reunifi cation.92 Furthermore, 

treatment has been shown to be cost-eff ective and to 

reduce costs in such areas as crime, health care, and 

unemployment.93 

TREATMENT CONSIDERATIONS 

SUD treatment is not a “one size fits all” service or 

one that remains static over time for a particular 

participant. For example, an individual who drank 

heavily for 10 years and is mentally ill is likely to have 

different treatment needs than an individual who 

recently became addicted to cocaine. When treatment 

is provided, the following should be considered: 

Detoxifi cation 

Some individuals require detoxification services before they are able to participate effectively in ongoing 

treatment and recovery. Detoxification is a process whereby individuals are withdrawn from alcohol and 

drugs, typically under the care of medical staff; it is designed to treat the acute physiological eff ects of 

ceasing the use of substances. It can be a period of physical and psychological readjustment that allows 

the individuals to participate in ensuing treatment. Medications are available to assist in detoxifi cation. 

In some cases, particularly for alcohol, barbiturates, and other sedatives, detoxification may be a medical 

necessity, and untreated withdrawal may be medically dangerous or even fatal. 

The immediate goals of detoxification programs are: 

• To provide a safe withdrawal from the substance of dependence and enable individuals 

to become alcohol- or drug-free. Numerous risks are associated with withdrawal, ranging 

from physical discomfort and emotional distress to death. Th e specific risks are affected by the 

substance on which the individual is dependent. 

• To provide withdrawal that protects people’s dignity . A concerned and supportive 

environment, sensitivity to cultural issues, confidentiality, and appropriate detoxifi cation 

medication, if needed, are important to individuals maintaining their dignity through an often 

diffi cult process. 

• To prepare individuals for ongoing alcohol and drug abuse treatment . While in the 

detoxification program, individuals may establish therapeutic relationships with staff or other 

patients that help them to become aware of treatment options and alternatives to their current 

lifestyle. It can be an opportunity to provide information and motivate them for treatment. 

Detoxification is not needed by all individuals and is not intended to address the psychological, social, 

and behavioral problems associated with addiction. Without subsequent and appropriate treatment, 

detoxification rarely will have a lasting impact on individuals’ substance-abusing behavior. Th e appropriate 

level of care following detoxification is a clinical decision based on the individual’s needs.94 

38 Treating Substance Use Disorders 
• 	 Type and setting . An individual should be 

placed in the type and setting of treatment that 

is most appropriate for the specifi c problems 

and needs. Just as a doctor may determine that 

a patient should receive medication instead of 

surgery to correct a problem, an SUD treatment 

provider must make decisions about the most 

appropriate course of treatment for an individual. 

The type, length, and duration of the treatment 

vary depending on the type and the duration of 

the SUD and the individual’s support system 

and personal characteristics. The duration of the 

treatment may range from weeks or months to 

years. 

• 	 Reassessment and modification of treatment 

plan. An individual’s treatment and service plan 

should be reassessed and continually modifi ed to 

ensure that the plan meets the person’s evolving 

needs.95 

• 	 Involuntary treatment . An individual does not 

have to “hit bottom” or “want to change” in 

order to benefit from treatment. Involuntary or 

mandated treatment can be just as eff ective as 

voluntary treatment. Sanctions or enticements 

in the family, work, or court setting can 

significantly increase treatment entry, retention, 

and success.96 

• 	 Attorney involvement . In instances where the 

parent has an attorney, the attorney also can play 

a key role in the early engagement of the client in 

treatment. CPS caseworkers and SUD treatment 

providers can facilitate this by reaching out to 

attorneys to help them understand the treatment 

process and clients’ needs. This helps them 

represent the clients better and provides a better 

opportunity for reunifi cation. 

• 	 Timetables . Because of the potential confl icts 

between child welfare and treatment timetables, 

treatment should begin as soon as possible 

so that there is time for family reunifi cation. 

Often, however, there are delays in treatment 

either because it is not available or the need for 

treatment is not determined right away. CPS 

caseworkers and SUD treatment providers should 

work together to engage clients in treatment as 

early as possible. 

COMMON TREATMENT APPROACHES 

There are a number of ways to categorize treatment, 

based on the level of care (i.e., intensity of treatment 

and services offered) or the theoretical orientation 

and treatment approach. The following are some 

common treatment approaches: 

• 	 Cognitive-behavioral approaches address 

ways of thinking and behaving. Cognitivebehavioral treatment helps participants recognize 

situations in which they are most likely to use 

Timetables in Child Welfare and Substance Use Disorder Treatment 

CPS agencies and SUD treatment providers have their own timetables for establishing family and 

individual well-being. The Adoption and Safe Families Act (P.L. 105-89) requires CPS agencies to: 

• Establish a permanency plan within 12 months of a child entering the child welfare system 

• Initiate proceedings to terminate parental rights if a child has been in foster care for 15 of the most 

recent 22 months. 

SUD treatment can range from weeks or months to years. CPS caseworkers and treatment providers, 

therefore, should communicate frequently to make sure that this time is productive and to serve the 

children and families most eff ectively.97 

Protecting Children in Families Affected by Substance Use Disorders 39 
drugs, develop strategies for dealing with these 

situations, and build specific skills to address 

behaviors and problems that are associated with 

SUDs. For example, if a woman suggests that 

she is most likely to use cocaine after she has had 

a fight with her partner, the therapist would work 

with her to develop more positive ways of dealing 

with her anger and frustration following a fi ght. 

The treatment provider also may detail possible 

consequences to the individual, such as breaking 

parole and being forced to return to prison, as a 

means of changing behavior. 

• 	 Motivational enhancement treatment incorporates some elements of cognitive-behavioral 

treatment, but focuses on increasing and then 

maintaining participants’ motivations for change. 

Rather than forcing individuals to accept that 

they have a problem, this approach focuses on 

the individual’s needs and the discrepancies 

between their goals and their current behaviors. 

This approach seeks to draw solutions from the 

treatment participants rather than having the 

solutions imposed by therapists. 

• 	 Contingency management includes both motivational enhancement treatment and an 

additional component of reinforcements and 

rewards. For example, credits may be off ered as 

a reward for established positive behaviors, such 

as consistent attendance in group therapy or 

negative urinalysis testing. These credits then can 

be exchanged for items (such as baby products). 

• 	 Th erapeutic community is an approach based 

on both cognitive-behavioral therapy and on the 

notion that treatment is best provided within the 

context of a community of individuals who have 

similar histories. This model was developed to 

provide treatment to individuals with antisocial 

character traits in addition to SUDs and tends to 

be highly confrontational. By having treatment 

participants confront each others’ behaviors 

and attitudes, they learn a great deal about their 

own behaviors and also learn from the other 

participants. Often, therapeutic community 

models of treatment are found within the 

correctional system. Given its confrontational 

nature, a therapeutic community may not be 

appropriate for some individuals. For example, 

women who have experienced intimate partner 

violence likely would not react well to this 

treatment approach. 

• 	 Trauma-informed treatment services generally 

follow one or more of the above treatment 

theories and reflect an understanding of trauma 

and its impact on SUDs and recovery. Th is 

Model Treatment and Prevention Programs 

The following Internet resources provide information about model SUD treatment and prevention 

interventions and their characteristics: 

• The Substance Abuse and Mental Health Services Administration (SAMHSA) has compiled 

a list of evidenced-based programs that have prevented or reduced SUDs and other related 

behaviors. SAMHSA’s National Registry of Evidence-based Programs and Practices has reviewed 

these programs rigorously and assessed their effectiveness. To view this list, go to http:// 

modelprograms.samhsa.gov. 

• SAMHSA’s Guide to Evidence-Based Practices provides listings for more than 35 websites that 

contain information and research on specific evidence-based programs and practices for the 

treatment or prevention of SUDs. Listings can be sorted and browsed by topic areas, target age 

groups, and settings. To view these listings, visit http://www.samhsa.gov/ebpWebguide/index. 

asp. 

• The National Institute on Drug Abuse of the National Institutes of Health offers a list of principles 

for substance use prevention based on a number of long-term research studies. That list can be 

viewed at http://www.nida.nih.gov/Infofacts/lessons.html. 

40 Treating Substance Use Disorders 
 

approach acknowledges that a large percentage 

of SUD treatment participants have sustained 

physical, emotional, and sexual trauma in their 

lives and their disorder may be the result of selfmedicating behaviors to deal with post-traumatic 

stress disorder symptoms. 

• 	 Trauma-specific treatment services go a step 

further than trauma-informed treatment services 

and address the impact of the specific trauma on 

the lives of participants. This approach works 

to facilitate trauma healing and recovery as part 

of the treatment services. Several integrated, 

trauma-specific, treatment models for women 

have been developed in recent years.98 

• 	 Treatment based upon the relational model of 

women’s development acknowledges the primacy 

of relationships in the lives of women and focuses 

upon the establishment and support of positive 

relationships. These positive relationships for the 

treatment participant may be with the therapist or 

with other signifi cant figures, especially children 

and spouses. 

SUPPORT SERVICES 

Along with SUD treatment, supplemental services 

often are provided to give additional support aimed 

at improving treatment outcomes. Th e following are 

important support services for treatment: 

• 	 Case management services are aimed at 

eliminating or reducing barriers to participation 

in treatment and include links to housing, food, 

medical care, financial assistance, and legal 

services. Case management also may include 

problem-solving sessions to assist individuals in 

establishing priorities among the many demands 

made upon them by multiple systems. 

• 	 Twelve-step models that incorporate the 12 

steps of Alcoholics Anonymous into treatment. 

Participants “work the steps” and move through 

treatment by accomplishing each of the 12 steps 

with guidance from a sponsor and with emphasis 

on attendance at meetings. Spirituality or belief 

in a “higher power” is a central component of 12­

step models. 

Treatment Example: Methadone Maintenance 

Treatment can take many forms and can be multilayered and complex in attempting to address the nature 

of SUDs. For example, opioid replacement therapy is a treatment that substitutes a noneuphoria inducing 

and legally obtainable drug (e.g., methadone, buprenorphine) for heroin or another opiate. Th e treatment 

also provides counseling and other rehabilitation services. Methadone maintenance treatment is a type 

of opioid replacement therapy and is very effective. Along with preventing illicit opiate use, methadone 

has been shown to be effective in reducing criminal activity and increasing employment. Additionally, 

this treatment method reduces the risk of HIV-associated behaviors (e.g., needle use and sharing) and 

infection.99 

Individuals engaged in methadone maintenance treatment can face heavy discrimination within the child 

welfare system from judges, attorneys, and caseworkers who believe the ultimate goal of treatment should 

be a completely drug-free individual. Stopping the methadone treatment, however, leaves the individual at 

a very high risk for relapse to illicit opiate use and its associated high-risk factors, including unsafe injection 

practices and illegal behavior in order to support a habit. All of these can significantly increase the risk of 

abuse or neglect to children in the custody of these parents. Hence, the decision to require a detoxifi cation 

from methadone must be considered carefully and based upon sound clinical principles rather than upon 

the stigma associated with methadone treatment. 

Protecting Children in Families Affected by Substance Use Disorders 41 
 

 

 

 

TANF and Substance Use Disorder Treatment 

In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) fostered 

a new vision for public assistance. PRWORA established the Temporary Assistance for Needy Families 

(TANF) block grant, which treats welfare as short-term, time-limited assistance designed to help families 

move to work and self-sufficiency. Its work requirements and time limits allow little room for work 

exemption and, therefore, created an incentive for agencies to examine the needs of those recipients 

overcoming serious and more difficult challenges, such as SUDs.100 National estimates of the welfare 

population who have substance abuse issues range from 16 to 37 percent.101 The 2007 National Survey 

on Drug Use and Health (NSDUH) reports a rate of 8.0 percent for illicit drug use in the general 

population.102 

Both TANF and substance abuse treatment program administrators recognize that treatment in the absence 

of work does not fully meet the needs of TANF clients with substance abuse issues.103 Instead, TANF 

clients should receive treatment while concurrently pursuing work and work-related activities related to 

self-suffi ciency.104 

• 	 Recovery mentor or advocate programs pair 

a person in recovery with individuals in need 

of treatment to support their engagement and 

retention in the process. Recovery mentors or 

advocates offer the unique perspective of having 

been through a similar experience and can off er 

the client insight to matters that CPS caseworkers 

and SUD treatment providers cannot. 

• 	 Abstinence monitoring includes urinalysis 

testing, breath testing for alcohol, and the use 

of the sweat patch and other technologies. Th is 

can be an important component of treatment 

as it provides opportunities for feedback to 

individuals who are working to change addictive 

behavior. Negative drug test results can be used 

for reinforcement of changed behavior, while 

positive test results can be a cue to the treatment 

participant and therapist that the treatment plan 

may need adjusting. 

There also are numerous other support services (e.g., 

mental health counseling, medical care, employment 

services, child care) that may be provided to assist 

families. 

GENDER-SENSITIVE TREATMENT 

Historically, SUD treatment has been focused on 

men, and fewer women had access to treatment 

services. In recent years, however, additional emphasis 

and funding have begun to address women’s specifi c 

needs.105 

Women 

The ability to access and to remain in treatment can 

be difficult for anyone. Motivation, transportation, 

insurance coverage, and waiting lists all can impede an 

individual’s attempts at recovery. Women, however, 

often face additional challenges when seeking 

treatment. 

Both men and woman can have signifi cant others 

who have SUDs. However, women with partners 

with SUDs are more likely to abuse substances 

themselves.106 For instance, some women have 

partners with SUDs and face the loss of these 

relationships when they make the decision to seek 

help. These partners may discourage women’s eff orts 

to obtain treatment. Violence in these relationships 

42 Treating Substance Use Disorders 
 

 

is not uncommon. Not only do these women face 

the loss of a relationship, but many also face the loss 

of economic support. This has particular importance 

when the women are also mothers with young, 

dependent children. 

Even if mothers do not have to contend with 

unsupportive partners, seeking treatment still can 

be difficult. Many women do not want to enter 

treatment because they fear their children will 

be taken away if it is discovered that they have an 

SUD. Women also may fear the social stigma of 

being considered a “bad mother” if others fi nd out 

about their drug use. When women decide to enter 

treatment, child care frequently is a critical hurdle to 

overcome. Few residential programs allow children 

to remain with their mothers while in treatment, 

and few outpatient programs provide child care, 

leaving it up to the mothers to identify a safe, reliable 

place for their children or to pay for licensed child 

care services. 

Th e profile of women who have SUDs diff ers from 

their male counterparts. Compared to men, a greater 

number of women who enter treatment have a 

history of physical or sexual abuse.107 Additionally, 

among persons with AIDS, a greater percentage of 

females than males were exposed through injection 

drug use and may participate in risky sexual behavior 

or trade sex for drugs.108 Additionally, women are 

more likely than men to have co-occurring mental 

health problems.109 

Women receive the most benefit from treatment 

when the treatment program provides comprehensive 

services that meet their basic needs, such as 

transportation, job counseling and training, legal 

assistance, parenting training, and family therapy, 

as well as food, clothing, and shelter. Additionally, 

research shows that women benefit from a continuing 

relationship with the SUD treatment provider 

throughout treatment and that women, during times 

of lapse or relapse, often need the support of the 

community and the encouragement of close friends 

and family.110 For more information on components 

of women-centered SUD treatment, visit http:// 

www.nida.nih.gov/WHGD/WHGDPub.html. 

Men 

Men face many of the same treatment hurdles as 

women, but while treatment historically has focused 

on men, there is still relatively little literature that 

discusses men’s roles within the family, particularly 

how their substance use affects their roles as fathers 

and partners. Most often, mothers are the focus 

of CPS cases and are involved in treatment. While 

some of these women may be reluctant to involve 

fathers in the treatment process, both parents should 

be involved whenever possible, provided it does not 

Involving Fathers in Case Planning 

The importance of involving nonresidential fathers is particularly relevant when the mother is the 

perpetrator of child maltreatment, and the child has to be removed from the home. Fathers can be a 

source of support to the mother of their child, both financially and emotionally; are an irreplaceable fi gure 

in the lives of their children; and can be a supportive presence as the family deals with the problems that 

contributed to the maltreatment, especially when the mother is going through SUD treatment. If it is 

determined that the family is not a safe place for the child, the nonresidential father is a placement option 

that should be considered. 

Of course, there may be times when involving the nonresidential father in the case planning process is 

impossible or ill-advised, including when the father is involved in illegal activities. More often than not, 

however, the nonresidential father can play a useful role, although bringing him into the process may 

require skilled negotiating on the part of the caseworker. 

Protecting Children in Families Affected by Substance Use Disorders 43 
 

increase safety risks. In addition, CPS caseworkers may not be able to receive, or want to receive, SUD 

usually are required by the court to seek and to involve treatment include: 

absent parents. In some cases, it is the fathers of the 

children in the child welfare system who become the 

focus of intervention due to the presence of mothers 

in treatment. In these cases, men’s roles as fathers 

and primary caregivers for their children warrant 

significant attention as they struggle to provide 

appropriate, nurturing, and consistent parenting. 

BARRIERS TO TREATMENT 

Most people who have SUDs do not receive treatment. 

According to NSDUH, approximately 23.2 million 

people in 2007 needed SUD treatment. Of these, 

2.4 million (10.4 percent) received treatment at a 

specialty facility (including hospitals, drug or alcohol 

rehabilitation facilities, and mental health centers), 

and the remaining 20.8 million did not. Of the 

individuals who were classified as needing but not 

receiving treatment, only an estimated 1.3 million 

reported that they perceived a need for treatment for 

their problem, and 380,000 reported that they had 

made an effort to receive treatment.111 Among women 

of childrearing age (18 to 49 years) who needed 

treatment in the past year, only 10.4 percent received 

it, and only 5.5 percent felt they needed it.112 

There are multiple and complex barriers to treatment. 

According to NSDUH, of those individuals who 

did not receive treatment even after making eff orts 

to obtain it, the most commonly reported reason 

was because they were unable to afford it or lacked 

health coverage.113 Other reasons that individuals 

• 	 Lack of available treatment spaces 

• 	 Not knowing where to go for treatment 

• 	 An ambivalence or fear about changing behavior 

• 	 A belief that they can handle the problem without 

treatment 

• 	 Concerns about negative opinions among 

neighbors, community members, or co-workers 

regarding treatment 

• 	 Relationships with partners and with family 

members who still may be using substances and 

who do not support the individual’s eff orts to 

change 

• 	 A perception of “giving in” when treatment is 

mandated by an outside source, such as the court 

or social services department 

• 	 Co-occurring mental health disorders exacerbated 

by the individual’s attempts at abstinence 

• 	 A lack of transportation to and from treatment 

• 	 Economic difficulties in which the need to work 

takes priority over the participation in treatment 

• 	 A lack of available child care during treatment 

times. 

CPS caseworkers can help clients who have SUDs 

identify barriers to participation in treatment and 

support the development of strategies to overcome 

these barriers. 

44 Treating Substance Use Disorders 
CHAPTER 6 

The Role of Child 

Protective Services When 

Substance Use Disorders 

Are Identified 

In This Chapter 

• Family assessment and case planning 

• Supporting parents in treatment and recovery 

• Supporting children of parents with SUDs 

Once substance use disorders (SUDs) are identifi ed 

as an issue to be addressed in a family’s case plan, 

the child protective services (CPS) caseworker needs 

to have a discussion with the family to understand 

their perceptions of the role and the impact substance 

abuse or dependence has in their lives. Th is discussion 

should include what can be done about the issue and 

how the family can be motivated to change. Since a 

discussion about SUDs may be met with denial and 

even anger toward the caseworker, a focus on the needs 

of the children generally will align caseworkers and 

parents in determining the best way to improve the 

situation. This chapter discusses family assessments 

and how they can be used in case planning, how to 

support parents who are in treatment and recovery, 

and how to assist children whose parents have SUDs. 

FAMILY ASSESSMENT AND CASE PLANNING 

During the initial family assessment or investigation, 

the CPS caseworker identifies the behaviors and 

conditions of the child, parent, and family that 

contribute to the risk of maltreatment, which may 

include a family member’s SUD. During the family 

assessment, the caseworker engages the family in a 

process designed to gain a greater understanding of 

family strengths, needs, and resources so that children 

are safe and the risk of maltreatment is reduced.114 In 

particular, the caseworkers work with the family to: 

• 	 Identify family strengths that can provide a 

foundation for change (e.g., support systems) 

• 	 Reduce the risk of maltreatment by identifying 

and by addressing the factors that place children 

at risk 

• 	 Help the children cope with the eff ects of 

maltreatment, parental SUDs, and other cooccurring problems. 

A family-focused response to address family 

functioning issues is essential to an effective case plan. 

Families are involved with CPS because of serious 

breakdowns in functioning that can be infl uenced 

profoundly by a family member’s SUD, as well as by 

the same family member’s transition to recovery. Not 

only must the parents’ substance use be addressed, but 

the behavioral problems and issues that have developed 

for children over the span of their parents’ substance 

use also must be resolved. To cease substance abuse 

and to make positive changes in their lives, it is vital 

for parents to move toward full acceptance of their 

substance abuse or addiction and its consequences. 

When parents address their SUDs and other issues, 

positive changes in family functioning can be achieved 

while the families also receive services through CPS. 

Protecting Children in Families Affected by Substance Use Disorders 45 
 

North Carolina Family Assessment Scale 

One recognized family assessment tool that addresses alcohol and drug issues is the North Carolina Family 

Assessment Scale (NCFAS). The following is a list of domains (i.e., areas of influence) that are measured 

by the NCFAS and could be used in any family assessment. The domain descriptions highlight ways in 

which alcohol and drug issues can be included in a CPS family assessment. 

• Environment . This domain refers to the neighborhood and social environment in which the 

family lives and works. Risk factors in this domain may include the presence or use of drugs in the 

household or community. 

• Parental capabilities . This domain refers to the parent or caregiver’s capacity to function in the 

role of the parent. This includes overall parenting skills, the supervision of children, disciplinary 

practices, the provision of developmental opportunities for children, and the parent’s mental and 

physical health. The caseworker should assess whether, how, and to what extent the client uses 

alcohol and drugs and how this may affect the ability to parent the children. 

• Family interactions . This domain addresses interactions among family members as well as the 

roles played by family members with respect to one another. Many family interactions can be 

affected by the use of alcohol and drugs. Items in this domain that may point to the possibility 

of an SUD include a parent’s nonresponsiveness to the children or children serving as the primary 

caretakers of younger siblings. 

• Family safety . This domain includes any previous or current reports or suspicions regarding 

physical, emotional, or sexual abuse of children, as well as neglect. 

• Child well-being . This domain refers to the physical, emotional, educational, and relational 

functioning of the children in the family. Parental SUDs can negatively affect various areas of 

child well-being, such as mental and physical health, academic performance, behavior, and social 

skills. Caseworkers also should assess if the children are using drugs or alcohol.115 

For more information about the NCFAS, visit http://www.nfpn.org/images/stories/fi les/ncfas_scale_ 

defs.pdf or http://www.friendsnrc.org/download/outcomeresources/toolkit/annot/ncfas.pdf. 

Despite the positive nature of these changes, however, 

both children and parents may find change difficult. 

For example, a parent newly in recovery can fi nd 

coping with a child’s needs very taxing. Th e problems 

in family functioning that have developed over time 

can be overwhelming as the parent notices them for the 

first time. Similarly, children experiencing a parent’s 

recovery may have trouble accepting the parent’s 

attempt to function in a role that he previously was 

unable to perform due to an SUD (e.g., disciplining 

the child). Caseworkers and SUD treatment 

providers should encourage progress, reward success, 

and support the newly sober parents in their eff orts to 

make changes in all areas of family functioning and in 

being substance free. 

SUPPORTING PARENTS IN TREATMENT
 

AND RECOVERY
 

While SUD treatment should be provided only by 

trained professionals, CPS caseworkers can maintain 

an integral role in the process for both the parents and 

the children. 

Providing Support During the Stages of Change 

A common theory in the field of SUD treatment is 

that individuals transition through different stages of 

thought and behavior during the treatment process. 

Exhibit 6-1 describes the stages and how CPS 

caseworkers can assist their clients during each stage. 

46 The Role of Child Protective Services When Substance Use Disorders Are Identified 
Exhibit 6-1 

Stages of Change and the CPS Caseworker’s Tasks 116 

Parent’s Stage Stage Description Tasks 

Precontemplation No perception of having a problem or 

needing to change 

Increase parent’s understanding of risks 

and problems with current behavior; raise 

parent’s doubts about behavior 

Contemplation Initial recognition that behavior may be 

a problem and uncertain about change 

Discuss reasons to change and the risks of 

not changing (e.g., removal of child) 

Decision to change Conscious decision to change; some 

motivation for change identifi ed 

Help parent identify best actions to take 

for change; support motivation 

for change 

Action Takes steps to change Help parent implement change strategy 

and take steps 

Maintenance Actively works on sustaining change 

strategies and maintaining longterm change 

Help parent to identify triggers of SUD 

and use strategies to prevent relapse 

Relapse Slips (lapses) from change strategy or 

returns to previous problem behavior 

patterns (relapse) 

Help parent re-engage in the 

contemplation, decision, and action 

stages 

A Family-centered Response to Methamphetamine Use 

The North Carolina Division of Family Services and the Family and Children’s Resource Program recently 

compiled a list of practice guidelines for establishing a safe, family-centered response to methamphetamine 

use. The following suggestions may be useful to CPS caseworkers in assisting families who are aff ected by 

methamphetamine use: 

• Family engagement . Working with clients who use methamphetamine can be frustrating, but the 

caseworker should avoid prejudging or demonizing them. Assess each family individually and help 

build upon their strengths. 

• Case decisions . Parental SUDs do not necessarily constitute child maltreatment. Each case needs 

to be assessed individually. 

• Collaboration. Collaborate with other professionals, such as substance abuse treatment providers, 

law enforcement, medical personnel, and mental health experts. 

• Placement . Placement in foster care never should be automatic, even in the case of fi nding a 

child in a methamphetamine lab. The caseworker should assess each situation thoroughly and 

explore the possibility of placement with kin. However, the caseworker should keep in mind that 

methamphetamine use is sometimes a problem for extended families. 

• Permanence . It can be a challenge to achieve family reunification within the time frames set forth 

in the Adoption and Safe Families Act. This is often because of the time required to recover from 

methamphetamine use and the fact that some users may be involved in the criminal justice system. 

• Education . Ensure that foster parents and others involved in the case are knowledgeable about 

methamphetamine use.117 

Protecting Children in Families Affected by Substance Use Disorders 47 
 

Once the parent is in treatment, the CPS caseworker 

can coordinate with the SUD treatment provider to 

monitor progress, to develop ongoing supports, and to 

intervene in times of crisis. Ongoing communication 

allows both systems to obtain a more complete picture 

of the family, which will allow for the development 

and modification of appropriate service plans. 

When working with parents who are in treatment or 

who are in the process of recovery, CPS caseworkers 

should be mindful of the process that the parent is 

going through and address the relevant issues or needs. 

In early recovery, the client still may be detoxifying 

from drugs or alcohol and experiencing mood swings. 

The issues the client may need to address (or may need 

help in addressing) in order to stay sober typically 

include employment, housing, transportation, and 

a connection with an affi rmative support system. 

Further along in recovery, the client may demonstrate 

several positive life changes that the caseworker can 

acknowledge, build upon, and encourage. 

Throughout the recovery process, the caseworker, as 

well as the client, should have a clear understanding 

of the possibility of relapse and have a plan to address 

the situation if it occurs. Some frequently identifi ed 

factors that contribute to lapse and to relapse 

include: 

• 	 Feeling complacent in recovery 

• 	 Feeling overwhelmed, confused, stuck, or 

stressed 

• 	 Having strong feelings of boredom, loneliness, 

anger, fear, anxiety, or guilt 

• 	 Engaging in compulsive behaviors such as 

gambling or sexual excess 

• 	 Experiencing relationship difficulties 

• 	 Failing to follow a treatment plan, quitting 

therapy, or skipping doctor appointments 

• 	 Being in the presence of drugs or alcohol. 

Using Motivational Interviewing 

Motivation can be defined as a willingness or a desire 

to change behavior.118 Parents in the CPS system who 

have SUDs may be ambivalent about addressing their 

issues. They may be comfortable with their substancerelated behaviors and believe that they serve a useful 

function in their lives.119 Caseworkers and SUD 

treatment providers often find that motivating these 

parents to make behavioral changes is one of the most 

challenging aspects of their jobs. 

Motivational interviewing is one approach CPS 

caseworkers can use to increase individuals’ willingness 

to change. This type of interviewing accepts that 

ambivalence toward change is normal and seeks to 

engage and to mobilize the treatment participant on 

this basis.120 

The four general principles of motivational 

interviewing are: 

• 	 Ambivalence about substance use is normal and 

is an obstacle in recovery. 

• 	 Ambivalence can be overcome by working with 

the client’s motivations and values. 

More information on how to support and to facilitate treatment and recovery is available in Understanding 

Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers, a publication prepared by 

the National Center for Substance Abuse and Child Welfare under contract for the Substance Abuse and 

Mental Health Services Administration and the Administration for Children and Families within the U.S. 

Department of Health and Human Services. The publication is available at http://www.ncsacw.samhsa.gov/ 

fi les/UnderstandingSAGuide.pdf. 

48 The Role of Child Protective Services When Substance Use Disorders Are Identified 
 

 

 

• 	 The relationship between the caseworker or 

treatment provider and the client should be 

collaborative with each participant bringing his 

own expertise. 

• 	 Argument and aggressive confrontation should 

be avoided.121 

The connections, realizations, new understandings, 

and solutions should come from the client rather than 

from the CPS caseworker. 

For more information on motivational interviewing, 

go to http://www.motivationalinterview.org or 

www.americanhumane.org/rmqic. 

SUPPORTING CHILDREN OF PARENTS WITH
 

SUBSTANCE USE DISORDERS
 

Caseworkers also have a key role in supporting 

children as their parents seek treatment for SUDs. As 

discussed earlier, children in the child welfare system 

whose parents have SUDs are at risk for a number of 

developmental and emotional problems. One of the 

difficulties in providing services to these children is 

that their problems, which are affected or compounded 

by their parents’ SUDs, might not emerge until later 

in their lives. In addition, these children also are 

more likely than children of parents who do not have 

SUDs to remain in foster care for longer periods of 

time.122 Because of their greater risks and longer stays 

in out-of-home care, it is particularly important for 

CPS caseworkers to assess thoroughly the needs (e.g., 

developmental, emotional, behavioral, educational) 

of these children and to link them with appropriate 

services in a timely manner. Both the assessments and 

service provision should be matched to the children’s 

developmental levels and abilities. Children from 

families affected by SUDs do not always move 

through the developmental continuum in the normal 

sequential phases. 

Children often have misperceptions about their role 

in their parents’ problems. One approach to helping 

children deal with issues associated with a parent’s 

SUD is to talk through lessons, such as the three Cs: 

• 	 You did not cause it (the parent’s SUD). 

• 	 You cannot control it. 

• 	 You cannot cure it (which addresses the issue of 

the child taking on the role of the parent in the 

parent-child relationship). 

Similarly, caseworkers can discuss a number of other 

important issues with children whose parents have an 

SUD, including: 

• 	 Addiction is a disease . Their parents are not 

bad people; they have a disease and may show 

inappropriate behavior when using substances. 

• 	 The child is not the reason that the parent has 

an SUD. Children do not cause the disease and 

cannot make their parents stop. 

• 	 There are many children in situations like 

theirs. There are millions of children whose 

parents have an SUD. They are not alone. 

• 	 They can talk about the problem . Children do 

not have to be scared or be ashamed to talk about 

their problems. There are many individuals and 

groups they can talk to and receive assistance.123 

Services for children, such as those offered through the 

Strengthening Families Program, include problemsolving models that emphasize how to prevent the 

child from developing an addictive disorder later in 

life (with an emphasis on abstinence). 

Protecting Children in Families Affected by Substance Use Disorders 49 
 

 

Title IV-E Waiver Projects Targeting Families Affected by Substance Abuse 

Since 1996, several States have implemented waiver demonstration projects that allow Title IV-E foster care funds to be 

used to pay for services for families in the child welfare system with substance abuse problems. The following describes 

some of these projects: 

• Illinois began its demonstration project in 2000, and with a recent 5-year extension, it is scheduled to 

continue through 2011. Through this project, recovery coaches engage substance-affected families during the 

treatment process, work to remove treatment barriers, and provide ongoing support. The project emphasized 

treatment retention for caregivers who already had been referred to substance abuse treatment and whose 

children already had received out-of-home placements. 

An evaluation of the first phase of the Illinois demonstration project found that compared to parents who 

received standard services, the parents who worked with recovery coaches: 

– Accessed treatment more quickly 

– Experienced lower rates of subsequent maltreatment 

– Achieved family reunifi cation faster. 124 

The evaluation also identified barriers to reunification, including domestic violence, mental health issues, and 

inadequate housing. The extension addresses these co-occurring problems and broadens the geographic scope 

of the demonstration. 

• From 1999 to 2005, New Hampshire’s Project First Step placed licensed alcohol and drug abuse counselors 

in two district CPS offi ces. The counselors conducted substance abuse assessments concurrently with CPS 

maltreatment investigations, facilitated access to treatment and other services, assisted with case planning, and 

provided intensive case management services. The evaluation findings were modest, yet they showed some 

promising trends.125 

• From 1996 to 2002, substance abuse specialists in Delaware were co-located in local CPS offices. Th e 

specialists accompanied CPS workers on home visits, consulted on case planning, and provided referrals to 

treatment and support services. Division of Family Services officials found that the addition of specialists 

on site was helpful to caseworkers in recognizing the signs of substance abuse, exploring addiction-associated 

issues with family members, and making appropriate referrals. 

For additional information on the substance abuse waivers, visit http://www.acf.hhs.gov/programs/cb/programs_ 

fund/cwwaiver/substanceabuse/index.htm. 

50 The Role of Child Protective Services When Substance Use Disorders Are Identified 
 

CHAPTER 7 

Child Protective Services 

and Substance Use Disorde

Treatment Providers: 

Similarities and Differences

r 

In This Chapter 

• Areas of similarity 

• Areas of diff erence 

J

ust as there often is an overlap between the clients 

who child protective services (CPS) and substance 

use disorder (SUD) treatment agencies serve, 

there also is common ground in the structures and 

the principles that guide these two systems. CPS 

caseworkers and SUD treatment providers should 

understand the similarities and the diff erences 

between the two systems so that they can off er the 

most comprehensive services possible to children and 

families. This chapter traces the areas of similarity 

and diff erence between the CPS and SUD treatment 

systems. 

AREAS OF SIMILARITY 

There are many areas in which CPS and SUD 

treatment agencies overlap, including programmatic 

goals, the characteristics of the families served, 

management challenges, and new demands regarding 

outcomes. 

Shared Goals
 

Though their primary emphases may differ, both CPS 

and SUD treatment agencies want family members to 

stop abusing substances and want children to be safe. 

In addition, they serve many families in common, 

even though they may be working with diff erent 

family members. Professionals in each fi eld should 

recognize that involving and providing appropriate 

services to the entire family is the most eff ective way 

of addressing the family’s issues. 

Since both systems have common goals, they 

also should share the responsibility for achieving 

them. CPS caseworkers need to know whether 

parents are sufficiently recovered from SUDs before 

recommending that their children live at home, but 

CPS caseworkers cannot treat SUDs. SUD treatment 

providers know that children provide an important 

incentive for parents to enter and remain in treatment, 

but SUD treatment providers cannot make decisions 

regarding where children will live. When each agency 

only emphasizes its own particular objective, it is 

unlikely that either will succeed. When both focus on 

the broader goals of helping the entire family, despite 

pressures and forces that make that focus difficult, 

the odds are better that the agencies and the families 

will succeed. 

Protecting Children in Families Affected by Substance Use Disorders 51 
 

 

Shared Characteristics of Families Served
 

As discussed earlier, individuals with SUDs and 

parents who maltreat their children often have many 

other problems (e.g., mental illness, health issues, 

histories of domestic violence, poverty). Th ey require 

services that are beyond the scope of either CPS or 

SUD treatment agencies. Many of these problems 

overlap, so both CPS and SUD treatment agencies 

find themselves trying to address problems, such as a 

serious mental disorder, criminal records, HIV/AIDS, 

and limited job skills. Too often, each agency tries to 

tackle these varied problems on its own, overlooking 

opportunities to share this enormous responsibility 

with others. 

Shared Management and Operational Challenges 

CPS and SUD treatment program administrators 

and staff often face similar challenges in managing 

their agencies and operating their programs. Th ese 

challenges may be external, such as locating services that 

families need, coordinating with agencies that provide 

those services, navigating complex bureaucracies, and 

responding to political opinions or media coverage 

that portray families as unworthy of support. 

Other challenges are internal, such as difficulties 

in hiring and training staff, high staff turnover and 

burnout, low pay, and outdated computer recordkeeping systems. 

To the extent that administrators and staff can design 

strategies that build on their common management 

challenges, they may ease some of these burdens. For 

example, both CPS and SUD treatment managers 

spend time locating and coordinating services, such as 

housing or mental health counseling, frequently for 

the same families. Time could be saved, and possibly 

outcomes improved, if managers collaborated in 

securing these services. In addition, managers could 

design joint training programs for staff from both 

agencies and seek continuing education units for staff 

who participate. 

Shared Pressures to Attain Measurable Outcomes
 

Federal legislation requires both CPS and SUD 

treatment agencies to achieve measurable results, such 

as employment for adults and permanency decisions 

for children. Therefore, managers from both systems 

are required to design and to monitor their programs 

to attain those results. This means that managers in 

both systems have to: 

• 	 Establish clear goals for staff 

• 	 Create internal monitoring and progress review 

systems 

• 	 Identify problems early and resolve them 

quickly. 

CPS and SUD treatment program managers can 

share ideas for establishing processes that lead to 

measurable results. They also can collaborate in 

designing monitoring and tracking systems in a 

way that provides useful information between their 

agencies as well as within them. 

AREAS OF DIFFERENCE 

Notwithstanding these similarities, CPS and 

SUD treatment agencies may become confused or 

frustrated when trying to work together, even when 

they share overarching goals. The two systems diff er 

in some fundamental ways, including how families 

enter programs, the choices available to families 

while they are participating, and the consequences for 

families if they cannot meet the standards required 

for completion. Th ese different contexts lead to 

different experiences for families involved with each 

system. Likewise, staff in each system face disparate 

experiences and challenges. 

Parents can be angry or frightened when CPS 

caseworkers come to their homes and question their 

children and neighbors, especially when caseworkers 

52 Child Protective Services and Substance Use Disorder 

Treatment Providers: Similarities and Differences 
 

determine that their children have to be removed. 

When families come to the attention of CPS agencies, 

they often become involved with the courts, SUD 

treatment agencies, and other service providers. 

If they refuse to comply with the requirements 

established by these agencies, or if they cannot make 

adequate progress, they know they risk losing their 

children permanently. 

In contrast, people generally enter SUD treatment 

voluntarily when they decide they are ready, and 

they leave when they want, even if they still are using 

substances. At times, however, courts order treatment 

as a condition of probation or parole. Coercive 

treatment has increased over the past several years, 

in part due to the increase in the use of drug courts, 

which are special courts designed for arrestees who 

have SUDs. 

CPS and SUD treatment agencies also differ in the 

following ways: 

• 	 The primary focus of CPS is on the safety and 

well-being of children, and the primary focus 

of SUD treatment is on adult recovery. Staff of 

the two systems may see themselves as serving 

different clients, even if the clients are from the 

same family. 

• 	 The two systems operate under different laws and 

regulations. 

• 	 Funding for the two systems comes from diff erent 

sources and with different conditions, even while 

often serving the same family. 

• 	 CPS caseworkers and SUD treatment providers 

may have different training, professional 

backgrounds and credentials, and disciplines. 

Th ey also commonly use different terms and 

have diff erent definitions of certain terms. 

For example, CPS caseworkers usually do not 

differentiate between substance use, abuse, or 

addiction. Caseworkers generally only want to 

know if the substance use affects an individual’s 

ability to parent. 

• 	 Data collection requirements, computer systems, 

and management reporting requirements are 

often inconsistent or incompatible between the 

two systems. 

Both systems operate within strict confi dentiality 

guidelines and staff can be uncomfortable sharing 

information with each other, which can cause 

frustration. (See Chapter 8, Putting It Together: 

Making the Systems Work for Families, for a more 

detailed discussion of confidentiality issues.) 

Protecting Children in Families Affected by Substance Use Disorders 53 

CHAPTER 8 

Putting It Together: 

Making the Systems 

Work for Families 

In This Chapter 

• Principles to guide collaboration 

• Collaboration at all levels 

• Techniques for promoting collaboration 

• Confidentiality and information sharing 

While many child protective services (CPS) 

and substance use disorder (SUD) treatment 

agencies find collaboration challenging, it is crucial 

to achieving positive outcomes for families involved 

with both systems. This chapter presents principles 

to guide CPS agencies in forming collaborative 

relationships with SUD treatment and other agencies. 

It proposes techniques to improve collaboration at 

both the policy and the frontline levels. Th is chapter 

also discusses confidentiality issues, which often 

determine what types of information can be shared 

during the collaborative process. 

SETTING THE STAGE: PRINCIPLES
 

TO GUIDE COLLABORATION
 

As discussed earlier, CPS and SUD treatment 

agencies often have different structures, funding 

streams, and defi nitions of success. Th ese diff erences 

affect collaboration at the Federal level as well as 

at the administrative and frontline levels in States 

and counties. 

Families whose members have SUDs and who are 

involved with the child welfare system have multiple 

and complex needs as well as strengths. Th eir needs 

often span many social service disciplines. No single 

person, agency, or profession has the capacity to 

address all of their circumstances. Collaboration 

builds on the individual strengths of each agency and 

family member, forging shared approaches that are 

more effective than an individual response. 

Collaboration is grounded in interdependent 

relationships and is more important when the problems 

are complex, the needs are varied, and the systems 

are different. In order to be eff ective, collaborative 

relationships should include the following: 

• 	 Trust that enables individuals to share information, 

to speak honestly with each other, and to respect 

other points of view 

• 	 Shared values that are honored by all participants 

• 	 A focus on common goals in spite of the fact 

that participants come from agencies that have 

different missions, philosophies, or perceptions 

• 	 A common language that all participants can 

understand and that is not unnecessarily technical 

or filled with acronyms 

Protecting Children in Families Affected by Substance Use Disorders 55 
 

• 	 Respect for the knowledge and experience that 

each participant and each profession brings to 

the relationship, which includes recognizing 

the strengths, needs, and limitations of all 

participants 

• 	 A collective commitment to working through 

conflict that encourages participation by all 

group members 

• 	 A desire to share decision-making, risk 

taking, and accountability that supports group 

members in participating in important decisions 

and assuming responsibility for the outcome of 

group decisions.126 

One of the biggest challenges facing both CPS 

caseworkers and SUD treatment providers is securing 

services from other social service agencies with whom 

relationships may not exist. For example, families 

involved with either CPS or SUD treatment agencies 

most likely will need some combination of the 

following services: mental health, domestic violence, 

income support, housing, transportation, health 

care, child care, and early childhood education. 

While collaboration with all these service providers 

is important, the need for mental health, domestic 

violence, and income support services among 

families receiving child welfare services and aff ected 

by substance abuse is especially critical and warrants 

special attention. 

CPS, SUDs, and Court Involvement 

The court system is a key partner of both the child welfare and the SUD treatment systems. Th e courts 

ultimately decide if a child should be removed from or returned to a home. Therefore, judges and other 

court staff should have a general knowledge of SUDs and child welfare issues and how those issues are 

relevant to each case. This requires cross-training as well as ongoing communication and collaboration 

among the three systems. Along with making decisions to remove from or to return a child to the home, 

courts also may be involved with these same families through the criminal justice system or the drug courts. 

If families also are involved in the criminal justice system, caseworkers may want their case plans to require 

the completion of all conditions of probation or parole in order for the parents to care for their children. 

However, the criminal justice system and the juvenile court system may have very different goals with 

respect to parental SUDs, with one focusing on the prevention of further criminal behavior (an emphasis 

on public safety) and the other focusing on the welfare of the children in the family. 

Many States and communities are utilizing drug courts, which serve as an alternative to a strictly punitive, 

non-treatment oriented approach. Drug courts integrate public health and public safety and make 

treatment a priority.127 They use ongoing, active involvement by judges to provide structure and support, 

and they hold both families and agencies, such as CPS, accountable for the commitments they make. Drug 

courts steer individuals with SUDs who commit nonviolent crimes, such as larceny or drug dealing, to 

treatment instead of jail; follow sentencing guidelines that set standards to ensure equity for jail time based 

on the crime; and utilize community partnership programs that encourage police, probation and parole 

officers, treatment providers, and citizens to work together to create healthy and safe environments that 

benefit everyone. Additionally, drug courts: 

• Assess the substance user’s needs 

• Create an effective, mandated treatment plan 

• Provide the necessary follow-up to assist with the treatment process. 

56 Putting It Together: Making the Systems Work for Families 
 

 

Accountability for the participant attending treatment rests with the drug court. In one study, more 

than two-thirds of participants mandated by drug courts to attend treatment completed it, which is a 

completion rate six times greater than most previous eff orts.128 

Drug courts are becoming an increasingly popular alternative for responding to methamphetamine 

use. The ability to respond quickly and consistently to violations of the treatment plan, coupled with 

the accountability measures and the ever-present threat of going to jail due to a violation, make drug 

courts one of the most effective mechanisms for dealing with methamphetamine use.129 For additional 

information on drug courts and methamphetamine use, visit http://www.ojp.usdoj.gov/BJA/pdf/ 

MethDrugCourts.pdf. 

Family Treatment Drug Courts (FTDCs) are specialized drug courts designed to work with parents with 

SUDs who are involved in the child welfare system. A national evaluation found that FTDCs were more 

successful than traditional child welfare case processing in helping substance-abusing parents enter and 

complete treatment and reunite with their children.130 

For more information on drug courts in general, refer to the National Drug Court Institute/National 

Association of Drug Court Professionals website at http://www.ndci.org and the Offi ce of Justice 

Programs Drug Court Clearinghouse and Technical Assistance Project publication, Juvenile and Family 

Drug Courts: An Overview, available at http://www.ncjrs.org/html/bja/jfdcoview/welcome.html. 

For more information on the courts and CPS, refer to the User Manual Series publication, Working with the 

Courts in Child Protection, at http://www.childwelfare.gov/pubs/usermanuals/courts/. 

In many States, CPS and social welfare are housed 

within one umbrella social services agency. While this 

configuration does not guarantee that collaboration 

will occur, it eliminates some of the structural 

problems often encountered when agencies do not 

share a common organizational context. 

COLLABORATION AT ALL LEVELS 

Collaboration among agency officials at the highest 

levels is a necessary, but not always suffi cient, condition 

for collaboration on the frontline. Suggestions for 

fostering collaboration are discussed below. 

Collaboration at the State Level 

There are several steps that State CPS and other 

officials can take to promote collaboration among 

their agencies: 

• 	 Establish ongoing interagency task forces and 

authorize members to make decisions. Th e 

task forces should be charged with addressing 

issues that make it diffi cult for staff to coordinate 

services. Topics might include designing 

integrated screening or assessment instruments, 

developing mechanisms to track participants 

across different agencies, or proposing methods 

for staff to share information under the rules of 

confi dentiality. 

• 	 Create joint mission statements with SUD 

treatment and other agencies and promote the 

mission statement through notices, memos, or 

policy directives that are signed by offi cials from 

each agency. 

• 	 Prepare integrated funding requests to support 

integrated programming activities. Develop and 

execute shared advocacy strategies for securing 

those funds. 

Protecting Children in Families Affected by Substance Use Disorders 57 
 

 

 

 

• 	 Require cross-training of staff and schedule staff 

from other systems to deliver that training. Hold 

these training sessions at other agencies. 

• 	 Co-locate staff in each other’s agency. 

• 	 Create interagency agreements such as 

Memorandums of Understanding (MOUs). For 

more information about MOUs, see Appendix 

H, Memorandums of Understanding. 

Collaboration on the Frontline 

There are several steps that frontline staff and 

supervisors can take to promote collaboration among 

their agencies: 

• 	 Visit each other’s programs , talk to program 

participants, and meet each other’s staff. CPS 

caseworkers should visit SUD treatment 

programs, observe activities, and hear from 

families who are in recovery. Similarly, SUD 

treatment professionals should visit CPS offices 

and accompany caseworkers on some home or 

fi eld visits. 

• 	 Convene multidisciplinary case staffings, some 

of which should include family members. During 

these meetings, caseworkers and families should 

develop shared plans for services, allocate tasks, 

and discuss ways they can share responsibility for 

activities and outcomes. 

• 	 Discuss diff erences in a way that helps everyone 

understand each other’s point of view, the 

rules, each one’s limitations, and the scope of 

authority. 

TECHNIQUES FOR PROMOTING
 

COLLABORATION
 

Collaboration is not likely to occur unless staff 

from participating agencies have opportunities to 

understand their partners and to work together to 

solve shared problems. SUDs and child maltreatment 

are complicated issues; staff who work in one fi eld 

generally know little about the other field. In 

addition, both SUDs and maltreatment are clouded by 

sensational media stories, shame, and stigma, making 

it especially important that frontline practitioners 

have access to accurate information. Information 

sharing, professional development and training, 

and co-location are examples of techniques that can 

promote collaboration. 

Information Sharing 

The easiest way for CPS caseworkers and SUD 

treatment providers to collaborate is to share 

information. Information sharing between colleagues 

can range from general information about each system 

(e.g., agency protocols) to case-specifi c information 

(e.g., a permanency plan or strategy for handling a 

parent’s possible relapse). CPS caseworkers should 

be knowledgeable, however, of any confi dentiality 

laws that restrict what information they are allowed 

to share. Confidentiality issues are discussed later in 

this chapter. 

Professional Development and Cross-training 

Professional development provides structured learning 

experiences that go beyond teaching about new 

rules or forms. Professional development allows 

caseworkers to understand their discipline better, to 

advance their careers, and to feel part of an important 

human services system. Cross-training means 

teaching workers from one field, such as CPS, about 

the fundamental concepts and practices of another 

field, such as SUD treatment. 

CPS agencies can design professional development 

and cross-training programs in ways that mirror the 

interagency relationships they want to develop— 

relationships in which individuals are encouraged to 

explore and to discuss values, ideas, and policies. 

Co-location 

Some CPS agencies have SUD treatment providers on 


site. Co-location demonstrates that agency officials 


consider cooperation and collaboration to be agency.
 

58 Putting It Together: Making the Systems Work for Families 
 

 

 

Online Tutorials for Knowledge-building and Cross-systems Work 

The National Center on Substance Abuse and Child Welfare, an initiative of the Administration for 

Children and Families and the Substance Abuse and Mental Health Services Administration, has 

developed four free online self-tutorials to build knowledge about SUDs and child welfare and to support 

and facilitate cross-systems work. The tutorials are each intended for a specific audience: child welfare 

professionals, substance abuse treatment professionals, judicial officers and attorneys in the dependency 

system, and legislators. A certificate for claiming Continuing Education Units is available upon successful 

completion of each tutorial. The tutorials are available at http://www.ncsacw.samhsa.gov/tutorials/ 

index.asp. 

For more information on training resources, visit http://www.childwelfare.gov/systemwide/training/. 

priorities and integral elements of agency culture. 

If senior officials decide to co-locate staff, they are 

more likely to realize that collaboration is an expected 

method of conducting business, not merely an agency 

buzzword. 

Co-location can be highly effective in helping 

CPS caseworkers and SUD treatment providers 

develop relationships that are essential to delivering 

comprehensive and well-organized services. It can 

change what are often a series of sequential referrals 

into concurrent discussions (case staffings) that 

bring greater expertise to case planning. Caseworker 

stress and burnout can be reduced if several people 

participate in making difficult and sensitive decisions 

regarding child placement. Co-location also may make 

it easier for family members to participate in designing 

their service plan, to comply with requirements that 

come from both treatment and CPS agencies, and 

to understand the roles that diff erent caseworkers 

perform in helping them succeed. 

Co-location, however, is not a perfect solution. 

It does not automatically create relationships or 

guarantee collaboration. Co-location can introduce 

management challenges related to supervision, space, 

pay differences, performance requirements, or work 

expectations. Furthermore, it can be administratively 

complex and, at times, programmatically inappropriate 

when too many people are involved with one family. 

When this happens, families may feel overburdened, 

they may worry that their confidences have been 

violated, or they may think that decisions are being 

made without their involvement. 

CONFIDENTIALITY AND INFORMATION SHARING 

As CPS and SUD treatment agencies work more 

closely, they are faced with deciding how and when 

to share information about families. Both agencies 

recognize the importance of allowing families to 

have privacy to discuss and to address such difficult, 

sensitive problems as SUDs and child maltreatment. 

Both also must adhere to a variety of laws and 

regulations that govern disclosure of information and 

protect family privacy. 

At times, staff within each agency may feel that laws 

regarding confidentiality make it diffi cult to share 

or to receive information, and confi dentiality rules 

may be put forth as a reason for their inability to 

communicate. For example, a CPS caseworker may 

become frustrated if an SUD treatment provider 

cannot share information regarding a parent’s progress 

in treatment; the caseworker may feel that this 

information might inform child custody decisions. 

On the other hand, an SUD treatment provider may 

become frustrated when decisions regarding a child’s 

placement are made without a CPS caseworker 

discussing how it may affect the parent’s progress 

in treatment. However, a study of seven innovative 

Protecting Children in Families Affected by Substance Use Disorders 59 
 

CPS agencies and SUD treatment programs noted 

that while Federal and some State laws are obstacles 

to information exchange, these laws did not create 

insurmountable barriers to collaboration.131 Th is 

section discusses confidentiality laws and ways to 

share information appropriately. 

Confi dentiality Laws 

Laws addressing various aspects of confi dentiality 

involving professional relationships, communications, 

and situations vary. These laws may focus on: 

• 	 SUD treatment privacy requirements 

• 	 Mandated reporting of child abuse and neglect 

• 	 Privacy of CPS records 

• 	 Client-therapist confi dentiality statutes 

• 	 Research programs and data collection on human 

subjects.132 

SUD treatment confidentiality laws are based on the 

view that individuals with SUDs are more likely to 

seek treatment if they know that information about 

them will not be disclosed unnecessarily to others. 

Without the assurance of privacy, the fear of public 

disclosure of their problem possibly could prevent 

some individuals from obtaining needed treatment. 

At times, however, there are important reasons for 

agencies to share information when working with the 

same families. Federal SUD treatment regulations 

specify circumstances under which it is appropriate 

that information be shared, including if the 

information relates to reports of child abuse or neglect. 

See Appendix I, Confidentiality and the Release of 

Substance Use Disorder Treatment Information, for a list 

of circumstances in which patient record information 

can be released. Additionally, the Child Abuse 

Prevention and Treatment Act of 1974 (P.L. 93–247) 

requires that States allow for the public disclosure of 

information regarding a death, or near death, of a 

child when it is the result of maltreatment. 

SUD treatment providers are subject to mandatory 

child abuse reporting laws in their States, requiring 

treatment staff to report incidents of suspected child 

abuse and neglect. However, this exemption from 

standard confidentiality requirements applies only to 

initial reports of child abuse or neglect. It does not 

apply to requests or even subpoenas for additional 

information or records, even if the records are sought 

for use in civil or criminal investigations. Th us, patient 

files and patient-identifying information protected by 

the Federal confidentiality law still must be withheld 

from CPS agencies and the court unless there is 

some other authorization such as patient consent, an 

appropriate court order, or in some cases, a Qualifi ed 

Service Organization Agreement (QSOA). Consent 

forms and QSOAs are discussed later in this chapter. 

Key considerations related to the types of information 

that can be shared between CPS caseworkers and 

SUD treatment providers include: 

• 	 CPS case information . Factors surrounding 

the case, any previous case history, the family 

environment, and other factors that are 

informative to the SUD treatment provider in 

conducting the assessment and in developing the 

treatment plan. CPS caseworkers must obtain 

appropriate consent to share this information. 

Subpoenas 

A subpoena to testify in court is not sufficient to require the release of confidential information, as 

specified under Federal regulations related to confidentiality, nor is a police search warrant. If subpoenaed 

to court to testify, an SUD treatment provider should first refuse, citing Federal regulations related to 

confidentiality. Only with a judge’s subsequent court order that finds a just cause to ignore this law in this 

particular case may a counselor testify without a client’s written consent. 

60 Putting It Together: Making the Systems Work for Families 
• 	 SUD screening information . Federal law and 

regulations allow CPS caseworkers to share with 

SUD treatment personnel information gathered 

during a screening for the purpose of referring an 

individual for an assessment. 

• 	 SUD diagnosis and treatment information . 

An SUD treatment agency may not disclose this 

information without written consent or court 

order. This is true even if the CPS agency referred 

the family member to the treatment program and 

mandated the assessment. For an example of a 

consent form, see Appendix J, Sample Qualifi ed 

Service Organization Agreement and Consent 

Form. 

• 	 Attendance in treatment programs . SUD 

treatment programs may report a family member’s 

attendance at treatment, or their failure to attend, 

as long as the patient has signed a written consent 

that has not expired or been revoked. Attendance 

is often a key component of the family’s case 

plan. 

• 	 A treatment participant’s relapse . SUD 

treatment programs may report information about 

relapse to CPS caseworkers if that information is 

covered by a valid written consent signed by the 

patient. However, for many CPS agencies, the key 

information may be whether the family member 

is making satisfactory progress in treatment, even 

if relapse has occurred. 

• 	 Combined case plan. Most of the discussion 

between SUD treatment providers and CPS 

caseworkers will be permissible as long as the 

information discussed is covered by a valid written 

consent form. It is advisable to tell family members 

that their case will be discussed at periodic 

meetings or telephone calls and specifi cally who 

will participate in the discussions. 

If CPS caseworkers release the results of a substance 

abuse evaluation or any information regarding a client’s 

treatment, they violate Federal regulations related to 

confidentiality. Everyone, not just SUD treatment 

providers, is bound by Federal confi dentiality 

statutes, and CPS caseworkers can be prosecuted 

for violating these laws. Caseworkers should clarify 

with their supervisor or their agency’s attorney any 

questions they may have about this statute and should 

document any legal advice given that pertains to this 

statute. 

Ways to Share Information Appropriately 

In order for the CPS caseworker and SUD treatment 

provider to communicate, it is important to obtain 

the client’s consent early, preferably at the time of 

the referral to treatment. Clients involved with CPS 

agencies may consent voluntarily to information 

disclosures in order to aid investigations of child 

maltreatment because their refusal to cooperate may 

result in losing custody of their children. However, 

information that has been disclosed through consent 

may not be used in criminal investigations or to 

prosecute the person. A consent form is only valid 

until the date, event, or condition on which it expires, 

or at any time when the treatment participant or 

client revokes consent. Therefore, it is a good idea to 

set the expiration date far enough into the future to 

ensure that needed information can be retrieved by 

the other agency. It is permissible to have the consent 

form contain an end date that fi ts circumstances.133 

(See Appendix I, Confidentiality and the Release of 

Substance Use Disorder Treatment Information, for 

details about what should be included in a voluntary 

consent form.) 

Another way that information can be shared between 

systems is through a QSOA. SUD treatment providers 

may disclose information under a QSOA without the 

patient’s consent. A QSOA is an agreement between 

two service organizations to share information about 

and to protect the confidentiality of individuals they 

serve. A QSOA should not be confused with an 

MOU, which usually is an agreement between two or 

more organizations to provide services to a common 

set of clients. 

A qualified service organization is one that provides 

services to the SUD treatment program. CPS 

agencies meet this definition if they provide services 

Protecting Children in Families Affected by Substance Use Disorders 61 
 

that help the SUD treatment agency serve the client. 

The heads of both the SUD treatment agency and 

the CPS agency must sign this agreement. Once 

signed, QSOAs permit disclosure of information to 

enable the organization to provide a service to the 

alcohol and drug abuse treatment program. QSOAs 

cannot be used for other purposes, such as obtaining 

reimbursement. Information obtained as part of a 

QSOA may not be re-disclosed to any other agency 

without permission.134 See Appendix J, Sample 

Qualified Service Organization Agreement and Consent 

Form, for a sample QSOA form. 

Confidentiality is an important part of 

communication. The parameters and limitations 

of communication have to be established locally. 

Furthermore, administrative procedures need to be 

put in place to encourage communication among staff . 

When approached with care, confidentiality rules do 

not automatically limit communication. Rather, they 

set the context within which staff can share important 

information, and families can be assured that sensitive 

aspects of their lives will be protected. 

It is important to note, however, that regardless of 

privacy rules and confidentiality of information under 

Federal laws, mandatory reporters of child abuse 

and neglect are required to report suspected cases 

of child maltreatment, according to an Information 

Memorandum issued by the U.S. Department of 

Health and Human Services in September 2005. 

The memorandum “to affirm the obligation of 

mandatory reporters to report child abuse and neglect 

under State and Federal laws” refers specifi cally to 

exceptions to the confidentiality and privacy rules in 

the Health Insurance Portability and Accountability 

Act (HIPAA), the Public Health Service Act Title 

X family planning program, and the confi dentiality 

rules relating to patient records in federally funded 

alcohol and drug abuse treatment services.135 

Federal Guidelines Regarding Confi dentiality 

The following are examples of Federal guidelines for patient confidentiality in cases involving SUDs or 

child maltreatment: 

• The Code of Federal Regulation, Alcohol and Drug Abuse Treatment Confi dentiality , 42 

C.F.R., Part II, provides guidelines for maintaining patient confidentiality, including rules for 

information sharing, for SUD treatment agencies. They can be viewed at http://www.access.gpo. 

gov/nara/cfr/waisidx_03/42cfr2_03.html. 

• The Child Abuse and Neglect Prevention and Treatment Act (CAPTA), 45 C.F.R. 1340.14 , 

requires States to have guidelines for maintaining confidentiality of child abuse and neglect 

reports. It can be viewed at http://www.access.gpo.gov/nara/cfr/waisidx_03/45cfr1340_03. 

html. 

• HIPAA of 1996 (P.L. 104–191) provides standards for health plans, health care providers, and 

health care clearinghouses to ensure the security and privacy of health information, including 

access to records. HIPAA also upholds mandatory child abuse reporting laws. For more 

information on HIPAA and its relationship to SUD treatment, visit the Substance Abuse and 

Mental Health Services Administration website at http://www.hipaa.samhsa.gov/hipaa.html. 

For more information on child maltreatment legal issues and laws, visit http://www.childwelfare.gov/ 

systemwide/laws_policies/. 

62 Putting It Together: Making the Systems Work for Families 
CONCLUSION 

For staff in any agency, it is easy to lose sight of the 

other systems and agencies that share a common 

client base. Families that experience SUDs and child 

maltreatment have needs, problems, and strengths 

that are diverse and complex. As a result, they often 

require the services of multiple agencies. It is critical 

that CPS caseworkers and SUD treatment providers 

have an understanding of the other system as well as 

the skills and desire to work toward a common goal. 

It is equally important that families are consulted in 

order to make certain that the collaborative structure 

helps them to address their SUDs and to ensure the 

safety and well-being of their children. With all of 

the parties committed to working jointly toward the 

same goals and being open to innovative approaches, 

successful outcomes can be achieved. 

Protecting Children in Families Affected by Substance Use Disorders 63 

 

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72 Endnotes 
APPENDIX A 

Glossary of Terms 

Addiction – the overpowering physical or 

psychological urge to continue alcohol or drug 

use in spite of adverse consequences. Often, 

there is an increase in tolerance for the drug and 

withdrawal symptoms sometimes occur if the drug 

is discontinued. 

Adjudicatory Hearings – held by the juvenile and 

family court to determine whether a child has been 

maltreated or whether another legal basis exists for 

the State to intervene to protect the child. 

Adoption and Safe Families Act – signed into law 

November 1997 and designed to improve the safety of 

children, to promote adoption and other permanent 

homes for children who need them, and to support 

families. The law requires child protective services 

(CPS) agencies to provide more timely and focused 

assessment and intervention services to the children 

and families who are served within the CPS system. 

Alcoholism – a dependency on alcohol characterized 

by craving and loss of control over its consumption, 

physical dependence and withdrawal symptoms, and 

tolerance. 

AOD – alcohol and other drugs. 

Assessment – evaluation or appraisal of a candidate’s 

suitability for substance use disorder (SUD) treatment 

and placement in a specific treatment modality 

or setting. This evaluation includes information 

regarding current and past SUDs; justice system 

involvement; medical, familial, social, education, 

military, employment, and treatment histories; and 

risk for infectious diseases (e.g., sexually transmitted 

diseases, tuberculosis, HIV/AIDS, and hepatitis). 

CASA – court-appointed special advocates (usually 

volunteers) who serve to ensure that the needs and 

interests of a child in judicial proceedings are fully 

protected. 

Case Closure – the process of ending the relationship 

between the CPS worker and the family that often 

involves a mutual assessment of progress. Optimally, 

cases are closed when families have achieved their 

goals and the risk of maltreatment has been reduced 

or eliminated. 

Case Plan – the casework document that outlines the 

outcomes, goals, and tasks necessary to be achieved in 

order to reduce the risk of maltreatment. 

Caseworker Competency – demonstrated 

professional behaviors based on the knowledge, skills, 

personal qualities, and values a person holds. 

Central Registry – a centralized database containing 

information on all substantiated/founded reports 

of child maltreatment in a selected area (typically a 

State). 

Child Abuse Prevention and Treatment Act 

(CAPTA) – see Keeping Children and Families Safe 

Act. 

Protecting Children in Families Affected by Substance Use Disorders 73 
 

Child Protective Services (CPS) – the designated 

social services agency (in most States) to receive 

reports, investigate, and provide intervention and 

treatment services to children and families in which 

child maltreatment has occurred. Frequently, this 

agency is located within larger public agencies, such 

as departments of social services. 

Cognitive Behavioral Th erapy – a school of 

psychotherapy that originated in the United States 

and subscribes to a behavioral emphasis on stimulusresponse relationships and psychological learning 

theory. 

Concurrent Planning – identifies alternative forms 

of permanency by addressing simultaneously both 

reunification and legal permanency with a new parent 

or caregiver, should reunifi cation eff orts fail. 

Craving – a powerful, often uncontrollable, desire for 

drugs, alcohol, or other substances. 

Cultural Competence – a set of attitudes, behaviors, 

and policies that integrates knowledge about groups 

of people into practices and standards to enhance the 

quality of services to all cultural groups served. 

Denial – a psychological defense mechanism 

disavowing the significance of events. Denial also 

can include a range of psychological maneuvers 

designed to reduce awareness of the fact that using 

a substance (or engaging in a behavior) is the cause 

of an individual’s problems rather than a solution to 

those problems. Denial can be a major obstacle to 

recovery. 

Detoxifi cation – process in a structured medical or 

social milieu in which the individual is monitored for 

withdrawal from the acute physical and psychological 

effects of drug or alcohol addiction. 

Differential Response – an area of CPS reform that 

offers greater flexibility in responding to allegations 

of abuse and neglect. Also referred to as “dual track” 

or “multi-track” response, it permits CPS agencies to 

respond differentially to children’s needs for safety, 

the degree of risk present, and the family’s needs for 

services and support. See “dual track.” 

Disclosure – a communication of client- or patientidentifying information or the communication of 

information from the record of a client or patient 

who has been identifi ed. 

Dispositional Hearings – held by the juvenile 

and family court to determine the disposition of 

children after cases have been adjudicated, such as 

whether placement of the child in out-of-home care 

is necessary and the services the children and family 

will need to reduce the risk of maltreatment and to 

address its eff ects. 

Drug – a substance that, by its chemical nature, aff ects 

the structure or function of a living organism. 

Dual Diagnosis (also Dual Disorder) – a term 

used to describe a condition in which a single person 

has more than one major clinical psychological or 

psychiatric diagnosis. Often, this phrase is used to 

describe people who have a severe mental illness as 

well as a co-existing SUD. 

Dual Track – term reflecting new CPS response 

systems that typically combine a nonadversarial 

service-based assessment track for cases in which 

children are not at immediate risk with a traditional 

CPS investigative track for cases where children 

are unsafe or at greater risk for maltreatment. See 

“diff erential response.” 

Evaluation of Family Progress – the stage of the 

CPS case process during which the CPS caseworker 

measures changes in family behaviors and conditions 

(risk factors), monitors risk elimination or reduction, 

assesses strengths, and determines case closure. 

Family Assessment – the stage of the child 

protection process during which the CPS caseworker, 

community treatment provider, and the family reach 

a mutual understanding regarding the behaviors and 

conditions that must change to reduce or eliminate 

the risk of maltreatment, the most critical treatment 

74 Appendix A—Glossary of Terms 
needs that must be addressed, and the strengths on 

which to build. 

Family Group Conferencing – a family meeting 

model used by CPS agencies to optimize family 

strengths in the planning process. This model brings 

the family, extended family, and others important 

in the family’s life (e.g., friends, clergy, neighbors) 

together to make decisions regarding how best to 

ensure the safety of the family members. 

Family Unity Model – a family meeting model used 

by CPS agencies to optimize family strengths in the 

planning process. This model is similar to the Family 

Group Conferencing model. 

Full Disclosure – CPS information to the family 

regarding the steps in the intervention process, the 

requirements of CPS, the expectations for the family, 

the consequences if the family does not fulfi ll the 

expectations, and the rights of the parents to ensure 

that the family completely understands the process. 

Guardian ad Litem – a lawyer or lay person who 

represents a child in juvenile or family court. Usually 

this person considers the best interest of the child 

and may perform a variety of roles, including those 

of independent investigator, advocate, advisor, and 

guardian for the child. A lay person who serves in this 

role is sometimes known as a court-appointed special 

advocate or CASA. 

Habituation – the result of repeated consumption of 

a drug that produces psychological, but not physical, 

dependence. The psychological dependence produces 

a desire (not a compulsion) to continue taking drugs 

for the sense of improved well-being. 

Home Visitation Programs – prevention programs 

that offer a variety of family-focused services to 

pregnant women and families with new babies. 

Activities frequently encompass structured visits to 

the family’s home and may address positive parenting 

practices, nonviolent discipline techniques, child 

development, maternal and child health, available 

services, and advocacy. 

Immunity – established in all child abuse laws to 

protect reporters from civil law suits and criminal 

prosecution resulting from filing a report of child 

abuse and neglect. 

Initial Assessment or Investigation – the stage of the 

CPS case process during which the CPS caseworker 

determines the validity of the child maltreatment 

report, assesses the risk of maltreatment, determines 

if the child is safe, develops a safety plan if needed to 

ensure the child’s protection, and determines services 

needed. 

Intake – the stage of the CPS case process in which 

the CPS caseworker screens and accepts reports of 

child maltreatment. 

Interview Protocol – a structured format to ensure 

that all family members are seen in a planned strategy, 

that community providers collaborate, and that 

information gathering is thorough. 

Involuntary Commitment – process by which 

patients who have not committed any crime are 

brought to SUD treatment against their wishes 

by relatives, police, or through a court proceeding. 

Also known as “protective custody” or “emergency 

commitment.” 

Juvenile and Family Courts – established in most 

States to resolve conflict and to otherwise intervene 

in the lives of families in a manner that promotes the 

best interest of children. These courts specialize in 

areas such as child maltreatment, domestic violence, 

juvenile delinquency, divorce, child custody, and 

child support. 

Keeping Children and Families Safe Act – Th e 

Keeping Children and Families Safe Act of 2003 (P.L. 

108-36) included the reauthorization of CAPTA in 

its Title I, Sec. 111. CAPTA provides minimum 

standards for defining child physical abuse and neglect 

and sexual abuse that States must incorporate into 

their statutory definitions in order to receive Federal 

funds. CAPTA defines child abuse and neglect as “at 

a minimum, any recent act or failure to act on the 

part of a parent or caretaker, which results in death, 

Protecting Children in Families Affected by Substance Use Disorders 75 
serious physical or emotional harm, sexual abuse or 

exploitation, or an act or failure to act which presents 

an imminent risk of serious harm.” 

Kinship Care – formal child placement by the 

juvenile court and child welfare agency in the home 

of a child’s relative. 

Liaison – a person within an organization who 

has responsibility for facilitating communication, 

collaboration, and coordination between agencies 

involved in the child protection system. 

Mandated Reporter – individuals required by 

State statutes to report suspected child abuse and 

neglect to the proper authorities (usually CPS or law 

enforcement agencies). Mandated reporters typically 

include professionals, such as educators and other 

school personnel, health care and mental health 

professionals, social workers, child care providers, 

and law enforcement officers. Some States identify all 

citizens as mandated reporters. 

Memorandum of Understanding – an agreement 

between two or more organizations to define a given 

relationship and each party’s responsibilities within 

the agreement. 

Multidisciplinary Team – established between 

agencies and professionals within the child protection 

system to discuss cases of child abuse and neglect 

and to aid in decisions at various stages of the CPS 

case process. These teams also may be designated by 

different names, including child protection teams, 

interdisciplinary teams, or case consultation teams. 

Neglect – the failure to provide for a child’s basic 

needs. Neglect can be physical, educational, or 

emotional. Physical neglect can include not providing 

adequate food or clothing, appropriate medical care, 

supervision, or proper weather protection (heat or 

coats). Educational neglect includes failure to provide 

appropriate schooling, failure to address special 

educational needs, or allowing excessive truancies. 

Psychological neglect includes the lack of any emotional 

support and love, chronic inattention to the child, or 

exposure to spouse, drug, or alcohol abuse. 

Neurotransmitters – a group of chemicals in the 

brain that transmit nerve impulses from one neuron 

to another across a space called a synapse. Drugs 

act on the brain at the neurotransmitter level. Th e 

presence of a drug in the brain changes how many 

neurotransmitters are available to send nerve impulses 

from one neuron to the next. The level or amount of 

a drug in the brain affects how well diff erent kinds 

of chemical signals are transmitted, changing how an 

individual thinks and feels. 

Out-of-home Care – child care, foster care, or 

residential care provided by persons, organizations, 

and institutions to children who are placed outside 

their families, usually under the jurisdiction of 

juvenile or family court. 

Parens Patriae Doctrine – originating in feudal 

England, a doctrine that vests in the State a right of 

guardianship of minors. This concept gradually has 

evolved into the principle that the community, in 

addition to the parent, has a strong interest in the care 

and nurturing of children. Schools, juvenile courts, 

and social service agencies all derive their authority 

from the State’s power to ensure the protection and 

rights of children as a unique class. 

Parent or Caretaker – person responsible for the care 

of the child. 

Patient Placement Criteria – standards of, or 

guidelines for, SUD treatment that describe specifi c 

conditions under which patients should be admitted 

to a particular level of care, under which they should 

continue to remain in that level of care, and under 

which they should be discharged or transferred to 

another level. They generally describe the settings, 

staff, and services appropriate to each level of care 

and establish guidelines based on diagnosis and other 

specific areas of patient assessment. 

Physical Abuse – the inflicting of a nonaccidental 

physical injury. This may include burning, hitting, 

punching, shaking, kicking, beating, or otherwise 

harming a child. It may, however, have been the 

76 Appendix A—Glossary of Terms 
result of over-discipline or physical punishment that 

is inappropriate to the child’s age. 

Prevention – the theory and means for reducing the 

harmful effects of drug use in specifi c populations. 

Prevention objectives are to protect individuals before 

signs or symptoms of substance use problems appear, 

to identify persons in the early stages of substance 

abuse and intervene, and to end compulsive use of 

psychoactive substances through treatment. 

Primary Prevention – activities geared to a sample 

of the general population to prevent child abuse and 

neglect from occurring. Also referred to as “universal 

prevention.” 

Protective Factors – strengths and resources that 

appear to mediate or serve as a buffer against risk 

factors that contribute to vulnerability to maltreatment 

or against the negative effects of maltreatment 

experiences. 

Protocol – an interagency agreement that delineates 

joint roles and responsibilities by establishing criteria 

and procedures for working together on cases of child 

abuse and neglect. 

Psychological Maltreatment – a pattern of caregiver 

behavior or extreme incidents that convey to children 

that they are worthless, flawed, unloved, unwanted, 

endangered, or only of value to meeting another’s 

needs. This can include parents or caretakers using 

extreme or bizarre forms of punishment or threatening 

or terrorizing a child. Psychological maltreatment 

also is known as emotional abuse or neglect, verbal 

abuse, or mental abuse. 

Recovery – achieving and sustaining a state of 

health in which the individual no longer engages in 

problematic behavior or psychoactive substance use 

and is able to establish and accomplish goals. 

Relapse – the return to the pattern of substance abuse 

or addiction, as well as the process during which 

indicators appear before the client’s resumption of 

substance use. 

Response Time – a determination made by CPS 

and law enforcement regarding the immediacy of the 

response needed to a report of child abuse or neglect. 

Review Hearings – held by the juvenile and family 

court to review dispositions (usually every 6 months) 

and to determine the need to maintain placement in 

out-of-home care or court jurisdiction of a child. 

Risk – the likelihood that a child will be maltreated 

in the future. 

Risk Assessment – the measurement of the likelihood 

that a child will be maltreated in the future; frequently 

carried out through the use of checklists, matrices, 

scales, and other methods. 

Risk Factors – behaviors and conditions present in 

the child, parent, or family that likely will contribute 

to child maltreatment occurring in the future. 

Safety – absence of an imminent or immediate threat 

of moderate to serious harm to the child. 

Safety Assessment – a part of the CPS case process 

in which available information is analyzed to identify 

whether a child is in immediate danger of moderate 

or serious harm. 

Safety Plan – a casework document developed when it 

is determined that the child is in imminent or potential 

risk of serious harm. In the safety plan, the caseworker 

targets the factors that are causing or contributing to 

the risk of imminent serious harm to the child, and 

identifies, along with the family, the interventions that 

will control them and ensure the child’s protection. 

Secondary Prevention – activities targeted to prevent 

breakdowns and dysfunctions among families who 

have been identified as being at risk for abuse and 

neglect. 

Service Agreement – the casework document 

developed between the CPS caseworker and the 

family, which outlines the tasks necessary to achieve 

risk reduction goals and outcomes. 

Protecting Children in Families Affected by Substance Use Disorders 77 
 

Service Provision – the stage of the CPS casework 

process during which CPS and other service 

providers off er specific services to reduce the risk of 

maltreatment. 

Sexual Abuse – inappropriate adolescent or adult 

sexual behavior with a child. It includes fondling 

a child’s genitals, making the child fondle the 

adult’s genitals, intercourse, incest, rape, sodomy, 

exhibitionism, sexual exploitation, or exposure to 

pornography. To be considered child abuse, these 

acts have to be committed by a person responsible for 

the care of a child (for example a babysitter, a parent, 

or a day care provider) or related to the child. If a 

stranger commits these acts, it would be considered 

sexual assault and handled solely by the police and 

criminal courts. 

Substance Abuse – a pattern of substance use 

resulting in clinically significant physical, mental, 

emotional, or social impairment or distress, such 

as failure to fulfill major role responsibilities, or 

use in spite of physical hazards, legal problems, or 

interpersonal and social problems. 

Substance Dependence – see “addiction.” 

Substance Use – consumption of low or infrequent 

doses of alcohol and other drugs, sometimes called 

experimental, casual, or social use, such that damaging 

consequences may be rare or minor. 

Substance Use Disorder (SUD) – a medical 

condition that includes the abuse of or addiction to 

(or dependence on) alcohol or drugs. 

Substantiated – an investigation disposition 

concluding that the allegation of maltreatment or risk 

of maltreatment was supported or founded by State 

law or State policy. A CPS determination means that 

credible evidence exists that child abuse or neglect has 

occurred. 

System of Care – a comprehensive continuum 

of child welfare, SUD, and other support services 

coordinated to meet the multiple, evolving needs of 

clients. 

Tertiary Prevention – treatment efforts geared to 

address situations in which child maltreatment already 

has occurred, with the goals of preventing child 

maltreatment from occurring in the future and of 

avoiding the harmful effects of child maltreatment. 

Tolerance – a state in which the body’s tissue cells 

adjust to the presence of a drug in given amounts 

and eventually fail to respond to ordinarily eff ective 

dosages. Consequently, increasingly larger doses are 

necessary to produce desired eff ects. 

Treatment – the stage of the child protection case 

process during which specific services are delivered 

by CPS and other providers to reduce the risk of 

maltreatment, support families in meeting case goals, 

and address the effects of maltreatment. 

Universal Prevention – activities and services 

directed toward the general public with the goal of 

stopping maltreatment before it starts. Also referred 

to as “primary prevention.” 

Unsubstantiated (also Not Substantiated) – an 

investigation disposition that determines that there is 

not sufficient evidence under State law or policy to 

conclude that the child has been maltreated or is at 

risk of maltreatment. A CPS determination means 

that credible evidence does not exist that child abuse 

or neglect has occurred. 

Withdrawal – symptoms that appear during the 

process of stopping the use of a drug that has been 

taken regularly. 

78 Appendix A—Glossary of Terms 
APPENDIX B 

Resource Listings of Selected 

National Organizations Concerned

 with Child Maltreatment and/or 

Substance Use Disorders 

The following are several representatives of the many 

national organizations and groups dealing with 

various aspects of child maltreatment and substance 

use disorders. Visit http://www.childwelfare.gov to 

view a more comprehensive list of resources and visit 

http://www.childwelfare.gov/organizations/index. 

cfm to search an organization database. Inclusion 

on this list is for information purposes only and does 

not constitute an endorsement by the Offi ce on Child 

Abuse and Neglect or the Children’s Bureau. 

NATIONAL AND FEDERAL SUBSTANCE USE
 

DISORDER ORGANIZATIONS
 

Addiction Technology Transfer Centers
 

address: National Offi ce 

University of Missouri–Kansas City 

5100 Rockhill Road 

Kansas City, MO 64110-2499 

phone: (816) 235-6888 

fax: (816) 235-6580 

email: no@nattc.org 

website: http://www.nattc.org 

A nationwide, multidisciplinary resource that draws 

upon the knowledge, experience, and latest work of 

recognized experts in the field of addictions. 

Community Anti-Drug Coalitions of America
 

address: 625 Slaters Lane, Suite 300 

Alexandria, VA 22314 

phone: (800) 54-CADCA 

fax: (703) 706-0565 

email: info@cadca.org 

website: http://cadca.org 

Builds and strengthens the capacity of community 

coalitions to create safe, healthy, and drug-free 

communities. Supports its members with technical 

assistance and training, public policy, media strategies 

and marketing programs, conferences, and special 

events. 

Join Together Online 

address: 	 715 Albany Street, 580-3rd Floor 

Boston, MA 02118 

phone: 	 (617) 437-1500 

fax: 	 (617) 437-9394 

email: 	 info@jointogether.org 

website: 	http://www.jointogether.org 

Supports community-based efforts across the country 

to reduce, prevent, and treat substance use disorders. 

Focuses attention on strengthening community 

capacity to expand the demand for and supply of 

high-quality substance use disorder treatment. 

Protecting Children in Families Affected by Substance Use Disorders 79 
 

 

 

 

National Alliance for Drug Endangered Children 

(DEC)/National DEC Resource Center 

address: 	 1942 Broadway, Suite 314 

Boulder, CO 80302 

phone: 	(303) 413-3064 

fax: 	(303) 938-6850 

website: 	http://www.nationaldec.org/ 

Promotes the DEC team concept and public 

awareness for the problems faced by DEC through 

multidisciplinary training for communities. It 

supports a nationwide network of professionals 

serving DEC by providing referrals to experts, updated 

research, and best practice information. 

National Health Information Center 

address: P.O. Box 1133 

Washington, DC 20013-1133 

phone: (301) 565-4167 

 (800) 336-4797 

fax: (301) 984-4256 

email: info@nhic.org 

website: http://www.health.gov/nhic 

A health information referral service that links 

consumers and health professionals to organizations 

best able to answer their questions. 

National Institutes of Health 

address: 	 9000 Rockville Pike 

Bethesda, MD 20892 

phone: 	 (301) 496-4000 

email: 	 nihinfo@od.nih.gov 

website: 	http://www.nih.gov 

Seeks to acquire knowledge to help prevent, detect, 

diagnose, and treat disease and disability, from the 

rarest genetic disorder to the common cold. Relevant 

institutes include the National Institute on Drug 

Abuse and the National Institute on Alcohol Abuse 

and Alcoholism. 

National Organization on Fetal 

Alcohol Syndrome 

address: 900 17th Street, NW, Suite 910 

Washington, DC 20006 

phone: (202) 785-4585 

(800) 66-NOFAS 

fax: (202) 466-6456 

email: information@nofas.org 

website: http://www.nofas.org 

Dedicated to eliminating birth defects caused 

by alcohol consumption during pregnancy and 

improving the quality of life for those individuals and 

families affected by fetal alcohol syndrome. 

Office of National Drug Control Policy 

address: 	 Drug Policy Information Clearinghouse 

P.O. Box 6000 

Rockville, MD 20849–6000 

phone: 	 (800) 666–3332 

fax: 	 (301) 519–5212 

website: 	http://www.whitehousedrugpolicy.gov 

Establishes policies, priorities, and objectives for the 

Nation’s drug control program to reduce illicit drug 

use, manufacturing, and traffi cking; drug-related crime 

and violence; and drug-related health consequences. 

Produces the National Drug Control Strategy, which 

directs the Nation’s anti-drug efforts and establishes 

a program, a budget, and guidelines for cooperation 

among Federal, State, and local entities. 

80 Appendix B—Resource Listings of Selected National Organizations Concerned 

with Child Maltreatment and/or Substance Use Disorders 
Substance Abuse and Mental Health 

Services Administration 

address: 	 1 Choke Cherry Road 

Rockville, MD 20857 

phone: (240) 276-2000 

fax: (240) 276-2010 

website: http://www.samhsa.gov 

Seeks to improve the quality and availability of 

prevention, treatment, and rehabilitative services in 

order to reduce illness, death, disability, and cost to 

society resulting from substance use disorders and 

mental illnesses. 

CHILD WELFARE ORGANIZATIONS 

American Humane Association 

Children’s Division 

address: 63 Inverness Drive, East 

Englewood, CO 80112-5117 

phone: (303) 792-9900 

fax: (303) 792-5333 

website: www.americanhumane.org 

Conducts research, analysis, and training to help public 

and private agencies respond to child maltreatment. 

American Professional Society on the Abuse of 

Children 

address: 	 350 Poplar Avenue 

Elmhurst, IL 60126 

phone: 	(630) 941-1235

 (877) 402-7722 

fax: (630) 359-4274 

email: apsac@apsac.org 

website: www.apsac.org 

Provides professional education, promotes research to 

inform eff ective practice, and addresses public policy 

issues. Professional membership organization. 

American Public Human Services Association 

address: 810 First Street, NE, Suite 500 

Washington, DC 20002-4267 

phone: (202) 682-0100 

fax: (202) 289-6555 

website: www.aphsa.org 

Addresses program and policy issues related to the 

administration and delivery of publicly funded human 

services. Professional membership organization. 

AVANCE Family Support and Education Program 

address: 	 118 N. Medina 

San Antonio, TX 78207 

phone: 	(210) 270-4630 

fax: 	(210) 270-4612 

website: 	www.avance.org 

Operates a national training center to share and 

disseminate information, materials, and curricula 

to service providers and policymakers interested in 

supporting high-risk Hispanic families. 

Child Welfare League of America 

address: 	 2345 Crystal Drive, Suite 250 

Arlington, VA 22202 

phone: (703) 412-2400 

fax: (703) 412-2401 

website: www.cwla.org 

Provides training, consultation, and technical 

assistance to child welfare professionals and agencies, 

while educating the public about emerging issues 

aff ecting children. 

Protecting Children in Families Affected by Substance Use Disorders 81 
 

National Black Child Development Institute
 

address: 1313 L Street, NW 

Suite 110 

Washington, DC 20005-4110 

phone: (202) 833-2220 

fax: (202) 833-8222 

email: moreinfo@nbcdi.org 

website: www.nbcdi.org 

Operates programs and sponsors a national training 

conference through Howard University to improve 

and protect the well-being of African-American 

children. 

National Children’s Advocacy Center 

address: 	 210 Pratt Avenue 

Huntsville, AL 35801 

phone: (256) 533-KIDS 

fax: (256) 534-6883 

website: http://www.nationalcac.org 

Provides prevention, intervention, and treatment 

services to physically and sexually abused children and 

their families within a child-focused team approach. 

National Indian Child Welfare Association 

address: 	 5100 SW Macadam Avenue, Suite 300 

Portland, OR 97239 

phone: 	(503) 222-4044 

fax: 	(503) 222-4007 

website: 	www.nicwa.org 

Disseminates information and provides technical 

assistance on Indian child welfare issues. Supports 

community development and advocacy eff orts to 

facilitate Tribal responses to the needs of families and 

children. 

National Resource Center for Child Protective 

Services 

address: 	 925 #4 Sixth Street, NW 

Albuquerque, NM 87102 

phone: 	 (505) 345-2444 

fax: 	 (505) 345-2626 

website: 	http://www.nrccps.org 

Focuses on building State, local, and Tribal capacity 

through training and technical assistance in child 

protective services, including meeting Federal 

requirements, strengthening programs, eligibility for 

the Child Abuse Prevention and Treatment Act grant, 

support to State Liaison Offi cers, and collaboration 

with other national resource centers. 

CHILD ABUSE PREVENTION ORGANIZATIONS 

National Alliance of Children’s Trust and 

Prevention Funds 

address: 5712 30th Avenue, NE 

Seattle, WA 98105 

phone: (206) 526-1221 

fax: (206) 526-0220 

email: alliance@psy.msu.edu 

website: www.ctfalliance.org 

Assists State children’s trust and prevention funds in 

strengthening families and protecting children from 

harm. 

82 Appendix B—Resource Listings of Selected National Organizations Concerned 

with Child Maltreatment and/or Substance Use Disorders 
Prevent Child Abuse America
 

address: 500 N. Michigan Avenue, Suite 200 

Chicago, IL 60611 

phone: (312) 663-3520 

fax: (312) 939-8962 

email: mailbox@preventchildabuse.org 

website: www.preventchildabuse.org 

Conducts prevention activities such as public 

awareness campaigns, advocacy, networking, research, 

and publishing. Also provides information and 

statistics on child abuse. 

FOR THE GENERAL PUBLIC 

Childhelp
 

address: 15757 North 78th Street 

Scottsdale, AZ 85260 

phone: (800) 4-A-CHILD (child abuse hotline) 

(800) 2-A-CHILD (TDD child

 abuse hotline) 

(480) 922-8212 

fax: (480) 922-7061 

website: http://www.childhelp.org/ 

Provides crisis counseling to adult survivors and child 

victims of child abuse, offenders, and parents, and 

operates a national hotline. 

National Center for Missing and 

Exploited Children 

address: 	 Charles B. Wang International Children’s 

Building 

699 Prince Street 

Alexandria, VA 22314-3175 

phone: 	 (800) 843-5678 (24-hour hotline) 

(703) 274-3900 

fax: (703) 274-2220 

website: www.missingkids.com 

Provides assistance to parents, children, law 

enforcement, schools, and the community in 

recovering missing children and raising public 

awareness about ways to help prevent child abduction, 

molestation, and sexual exploitation. 

Parents Anonymous 

address: 675 West Foothill Blvd., Suite 220 

Claremont, CA 91711 

phone: (909) 621-6184 

fax: (909) 625-6304 

email: Parentsanonymous@parentsanonymous. 

org 

website: www.parentsanonymous.org 

Leads mutual support groups to help parents provide 

nurturing environments for their families. 

Protecting Children in Families Affected by Substance Use Disorders 83 
 

 

 

FOR MORE INFORMATION 

Child Welfare Information Gateway
 

address: 1250 Maryland Avenue, SW 

Eighth Floor 

Washington, DC 20024 

phone: (800) 394-3366 

(703) 385-7565 

fax: (703) 385-3206 

email: info@childwelfare.gov 

website: http://www.childwelfare.gov/ 

Collects, stores, catalogs, and disseminates information 

on all aspects of child maltreatment and child welfare 

to help build the capacity of professionals in the fi eld. 

A service of the Children’s Bureau. 

National Center for Substance Abuse 

and Child Welfare 

address: 	 4940 Irvine Blvd., Suite 202 

Irvine, CA 92620 

phone: 	 (714) 505-3525 

fax: 	 (714) 505-3626 

email: 	 ncsacw@cff utures.org 

website: 	www.ncsacw.samhsa.gov 

Disseminates information, provides technical 

assistance, and develops knowledge that promotes 

effective practice, organizational, and system changes 

related to substance use disorder and child welfare 

issues at the local, State, and national levels. 

National Clearinghouse for Alcohol 

and Drug Information 

address: P.O. Box 2345 

Rockville, MD 20847 

phone: (240) 221-4019

 (800) 729-6686 

(877) 767-8432 (En Español) 

(800) 487-4889 (TDD) 

fax: (240) 221-4292 

email: info@health.org 

website: http://ncadi.samhsa.gov 

Serves as the world’s largest resource for current 

information and materials concerning substance 

use disorder prevention and addiction treatment. A 

service of the Substance Abuse and Mental Health 

Services Administration’s Center for Substance Abuse 

Prevention. 

84 Appendix B—Resource Listings of Selected National Organizations Concerned 

with Child Maltreatment and/or Substance Use Disorders 
 

APPENDIX C 

State Telephone Numbers 

for Reporting Child 

Maltreatment 

Each State designates specific agencies to receive and investigate reports of suspected child abuse and neglect. 

Typically, this responsibility is carried out by child protective services (CPS) within a Department of Social 

Services, Department of Human Resources, or Division of Family and Children Services. In some States, police 

departments also may receive reports of child abuse or neglect. 

Many States have local or toll-free telephone numbers for reporting suspected maltreatment. Th e reporting 

party must be calling from the same State where the child is allegedly being maltreated for most of the 

following numbers to be valid. 

For States not listed, or when the reporting party resides in a different State from the child, please call Childhelp, 

800-4-A-Child (800-422-4453), or your local CPS agency. States may occasionally change the telephone 

numbers listed below. To view the most current contact information, including State Web Addresses, visit 

http://www.childwelfare.gov/pubs/reslist/rl_dsp.cfm?rs_id=5&rate_chno=11-11172. 

Alabama (AL) 

334-242-9500 

Delaware (DE) 

800-292-9582 

Indiana (IN) 

800-800-5556 

Alaska (AK) 

800-478-4444 

District of Columbia (DC) 

202-671-SAFE (7233) 

Iowa (IA) 

800-362-2178 

Arizona (AZ) 

888-SOS-CHILD 

Florida (FL) 

800-96-ABUSE 

Kansas (KS) 

800-922-5330 

(888-767-2445) (800-962-2873) 

Arkansas (AR) Hawaii (HI) 

Kentucky (KY) 

800-752-6200 

800-482-5964 808-832-5300 

Colorado (CO) Idaho (ID) 

Maine (ME) 

800-452-1999 

303-866-5932 800-926-2588 800-963-9490 (TTY) 

Connecticut (CT) 

800-842-2288 

Illinois (IL) 

800-252-2873 

Massachusetts (MA) 

800-792-5200 

800-624-5518 (TDD) 217-524-2606 

Protecting Children in Families Affected by Substance Use Disorders 85 
Mississippi (MS) 

800-222-8000 

601-359-4991 

Missouri (MO) 

800-392-3738 

573-751-3448 

Montana (MT) 

866-820-KIDS (5437) 

Nebraska (NE) 

800-652-1999 

Nevada (NV) 

800-992-5757 

New Hampshire (NH) 

800-894-5533 

603-271-6556 

New Jersey (NJ) 

877-652-2873 

800-835-5510 (TDD/TTY) 

New Mexico (NM) 

800-797-3260 

505-841-6100 

New York (NY) 

800-342-3720 

518-474-8740 

800-369-2437 (TDD) 

Oklahoma (OK) 

800-522-3511 

Pennsylvania (PA) 

800-932-0313 

Puerto Rico (PR) 

800-981-8333 

787-749-1333 

Rhode Island (RI) 

800-RI-CHILD 

(800-742-4453) 

South Carolina (SC) 

803-898-7318 

Tennessee (TN) 

877-237-0004 

Texas (TX) 

800-252-5400 

Utah (UT) 

800-678-9399 

Vermont (VT) 

800-649-5285 (after hours) 

Virginia (VA) 

800-552-7096 

804-786-8536 

Washington (WA) 

866-END-HARM 

(866-363-4276) 

800-562-5624 (after hours) 

800-624-6186 (TTY) 

West Virginia (WV) 

800-352-6513 

86 Appendix C—State Telephone Numbers for Reporting Child Maltretment 
APPENDIX D

 Diagnostic and Statistical 

Manual of Mental 

Disorders Criteria1 

Criteria for Substance Dependence 

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested 

by three (or more) of the following, occurring at any time in the same 12-month period: 

1. 	 Tolerance, as defined by either of the following: 

a. 	 A need for markedly increased amounts of the substance to achieve intoxication or desired eff ect. 

b.	 Markedly diminished effect with continued use of the same amount of the substance. 

2. 	 Withdrawal, as manifested by either of the following: 

a. 	 The characteristic withdrawal syndrome for the substance (refer to criteria A and B of the criteria sets 

for withdrawal from the specifi c substances). 

b.	 The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 

3. 	 The substance often is taken in larger amounts or over a longer period than was intended. 

4. 	 There is a persistent desire or unsuccessful efforts to cut down or control substance use. 

5. 	 A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors 

or driving long distances), use the substance (e.g., chain-smoking), or recover from its eff ects. 

6. 	 Important social, occupational, or recreational activities are given up or reduced because of substance use. 

7. 	 The substance use is continued despite knowledge of having a persistent or recurrent physical or 

psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current 

cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition 

that an ulcer was made worse by alcohol consumption). 

1

 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Text Revision (DSM-IV-TR). 

Washington, DC: Author. 

Protecting Children in Families Affected by Substance Use Disorders 87 
Specify if: 

a. 	 With physiological dependence—evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is 

present). 

b. Without physiological dependence—no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 

is present). 

Criteria for Substance Abuse 

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested 

by one (or more) of the following, occurring within a 12-month period: 

1. 	 Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 

(e.g., repeated absences or poor work performance related to substance use; substance-related absences, 

suspensions, or expulsions from school; neglect of children or household). 

2. 	 Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or 

operating a machine when impaired by substance use). 

3. 	 Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct). 

4. 	 Continued substance use despite having persistent or recurrent social or interpersonal problems caused 

or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of 

intoxication, physical fi ghts). 

The symptoms never have met the criteria for substance dependence for this class of substance. 

88 Appendix D—Diagnostic and Statistical Manual of Mental Disorders Criteria 
 

APPENDIX E 

Commonly Abused 

Substances 

This appendix presents information about some of 

the most commonly abused types of substances and 

the drugs affiliated with those types. A table provides 

additional information on commonly abused 

substances, including street names and methods of 

use. 

TYPES OF COMMONLY ABUSED SUBSTANCES 

Cannabinoids (e.g., marijuana, hashish) can 

produce feelings of euphoria, anxiety, or depression 

as well as distort perception and slow reaction time. 

Marijuana, the most commonly used illicit drug, 

has been associated with automobile and industrial 

accidents as well as physical ailments, most notably 

cancer.1

 It is usually smoked, making its health risks 

similar to those of tobacco in terms of pulmonary and 

cardiac eff ects. 

Club Drugs (e.g., GHB, ketamine, MDMA, 

fl unitrazepan, yaba) include a variety of drugs from 

other drug categories (e.g., hallucinogens, depressants). 

The name is derived from the fact these substances 

often are used by younger people at nightclubs and 

parties. Some club drugs, gamma hydroxyl butyrate 

(GHB) and Rohypnol in particular, have gained 

notoriety for use in drug-assisted sexual assault cases 

and, therefore, are referred to as “predatory drugs.” 

Certain club drugs, such as ketamine, have medical or 

veterinary uses, but are used in a signifi cantly diff erent 

quantity or by a population other than for whom they 

are intended. Yaba, which means “crazy medicine” 

in Thai, is a combination of methamphetamine and 

caffeine and is becoming increasingly available at rave 

parties. Like methamphetamine, use of yaba can result 

in a rapid heart rate and damage to the small blood 

vessels in the brain, which can lead to stroke. Its use 

also can lead to violent behavior, paranoia, confusion, 

or insomnia. 

Depressants (e.g., barbiturates) include some 

drugs that are prescribed to reduce anxiety or act as 

a sedative or anticonvulsant. Depressants are used 

illicitly to produce feelings of well-being and to lower 

inhibitions. Signs of use include fatigue, confusion, 

and impaired coordination and memory. Alcohol, 

the most commonly abused substance, is categorized 

as a depressant. 

Hallucinogens (e.g., acid, mescaline, psilocybin, 

phencyclidine) have no known medical use and are 

illegal. These substances produce altered states of 

perception and feeling. Users often are disoriented 

or inattentive. Th e effects of hallucinogens are 

unpredictable and depend on several factors, including 

the user’s personality, the surroundings in which they 

are used, the quantity taken, and the drug’s purity. 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2003). Marijuana: 

Facts for teens [On-line]. Available: http://www.nida.nih.gov/MarijBroch/Marijteens.html. 

Protecting Children in Families Affected by Substance Use Disorders 89 

1
Users may experience a “bad trip” that can include 

terrifying thoughts and feelings, fear of insanity or 

death, and deep despair. An observable, long-term 

effect for some users is persistent perception disorder, 

which is commonly referred to as fl ashbacks. 

Inhalants (e.g., aerosol sprays, nitrous oxide, 

butyl nitrate) usually are legal and readily available 

household and commercial products whose chemical 

vapors are inhaled to produce mind-altering eff ects. 

Observable effects of use include runny nose, watery 

eyes, and headaches. Users can ingest the substances 

by inhaling directly from product containers, sniffing 

a cloth saturated with the substance, or sniffing 

the substance from a plastic bag that is placed over 

the nose and mouth. Deeply inhaling vapors or 

using large amounts over a short time may result in 

disorientation, violent behavior, unconsciousness, or 

even death. High concentrations of inhalants can 

cause suffocation by displacing oxygen in the lungs. 

One of the significant factors in the use of inhalants is 

their accessibility, particularly for children. National 

surveys indicate inhaling dangerous products is 

becoming a widespread problem.2 

Opioids and Narcotic Pain Relievers (e.g., heroin, 

morphine, oxycodone, hydrocodone) are used 

illegally for their euphoric effects. Many opioids and 

narcotic pain relievers originally were developed to 

relieve pain, and doctors still prescribe some for that 

purpose. The pain of withdrawal from heroin and 

other opioids is made worse by the fact that these drugs 

medicate pain. Therefore, individuals in withdrawal 

may experience pain they did not feel while using 

opiates and may not be able to deal with pain as they 

normally would. Signs of use include needle marks as 

well as decreased pulse and respiration rates. 

Stimulants (e.g., cocaine, amphetamines, methamphetamine) can produce eff ects such as increased 

alertness, over-activity, depression, and insomnia. 

Cocaine is a powerful stimulant that primarily 

affects the dopamine system—the part of the brain 

that regulates feelings of pleasure and excitement. 

Cocaine use can cause violent or hypersexual 

behavior, paranoid thinking, and agitation or anxiety. 

Prenatal exposure to cocaine can cause premature 

labor, low birth weight, and fetal death. Studies also 

indicate that exposure to cocaine leads to problems 

in school-aged children in such areas as problem 

solving, inhibition, impulse control, and abstract 

reasoning.3

 Th e effects of methamphetamine and 

amphetamines, which are other types of stimulants, 

are similar, although methamphetamine often has 

a greater impact on the central nervous system. 

Methamphetamine is generally less expensive than 

cocaine, and because the body metabolizes it more 

slowly, its effects may last as much as 10 times longer 

Commonly Abused Commercial Products 

Adhesives: Model airplane glue, household glue, rubber cement. 

Aerosols: Spray paint, hair spray, air freshener, fabric protector. 

Anesthetics: Nitrous oxide, ether, chloroform. 

Cleaning agents: Dry cleaning fluid, spot remover, degreaser. 

Gases: Nitrous oxide, butane, propane, helium. 

Solvents: Nail polish remover, paint thinner, lighter fl uid, gasoline. 

90 

2

 UNational Inhalant Prevention Coalition. (2004). About inhalants [On-line]. Available: http://www.inhalants.org/about.htm. 

3

Lester, B. M., LaGasse, L. L., & Siefer, R. (1998). Cocaine exposure and children: The meaning of subtle eff ects. Science, 282(5389),

633–634. 

.

Appendix E—Commonly Abused Substances 
 

 

 

than a high from cocaine.4 Individuals who use aggression, violence, psychotic behavior, and potential 

methamphetamine may experience serious health coronary and neurological damage.5 

and psychiatric conditions, including memory loss, 

The types of substances used by adolescents and adults change faster than current literature can document, 

and families may mention drugs that are unknown to child protective services caseworkers. Th ree valuable 

Federal Internet resources for current information on a variety of substances are: 

• 	 The National Clearinghouse for Alcohol and Drug Information ( http://ncadi.samhsa.gov/) 

• 	 The National Institute on Drug Abuse ( www.drugabuse.gov) 

• 	 Th e Office of National Drug Control Policy ( www.whitehousedrugpolicy.gov). 

Drug Group 

Cannabinoids 

Drug 

Hashish 

Street Names 

Hash 

Method of Use 

Smoked in hand-rolled cigarettes, 

Marijuana Grass, pot, weed pipes, or water pipes (i.e., “bongs”). 

Club Drugs Gamma hydroxy butyrate GHB, “G” Mixed into drinks or injected. 

Ketamine Special K, “K,” Kit Kat, 

vitamin K 

Mixed into drinks, injected, added 

to smokable materials, snorted, or 

consumed in pill form. 

MDMA 

(3,4-methylenedioxy 

methamphetamine) 

Ecstasy, X, XTC, E Consumed in pill form, mixed into 

drinks, or injected. 

Flunitrazepan Rohypnol (commercial name), 

roofi es 

Mixed into drinks or injected. 

Yaba Crazy medicine, Nazi speed Consumed in pill form, inhaled (by 

melting tablets and inhaling vapors), 

snorted, or injected. 

Depressants Alcohol Booze, juice, hooch Swallowed in liquid form. 

Barbiturates, 

methaqualone, 

benzodiazepines 

Downers, ludes Consumed in capsules, tablet, or pill 

form; mixed into drinks; or injected. 

4	 American Council for Drug Education. (1999). Basic facts about drugs: Methamphetamine [On-line]. Available: http://www.acde. 

org/common/Meth.htm. 

5	 Otero, C., Boles, S., Young, N. K., & Dennis, K. (2004). Methamphetamine: Addiction, treatment, outcomes and implications. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 

Protecting Children in Families Affected by Substance Use Disorders 91 
Drug Group 

Hallucinogens 

Drug 

Lysergic acid 

diethylamide 

Street Names 

Acid, LSD 

Method of Use 

Swallowed in tablet or capsule form, 

or placed into thin squares of gelatin, 

paper, sugar cubes, gum, candy, or 

crackers. 

Mescaline Peyote, cactus, mesc Chewed, swallowed in capsule or pill 

form, or ground and infused in hot 

water and consumed as tea. 

Psilocybin/Psilocyn Mushrooms, shrooms Chewed, smoked, or ground and 

infused in hot water and consumed as 

tea. 

Phencyclidine Angel dust, crystal, PCP Snorted, injected, applied to leafy 

material and smoked, or swallowed in 

liquid, capsule, tablet, or pill form. 

Inhalants Airplane glue, aerosol 

sprays, gasoline, paint 

thinner 

Air blast, highball Inhaled or sniffed, sometimes using a 

paper bag, rag, gauze, or ampoule. 

Cyclohexyl, amyl nitrate, 

or butyl nitrate 

Poppers, snappers 

Nitrous oxide (N2

0) Whippets 

Opioids and 

narcotic pain 

relievers 

Heroin Smack, junk Injected, snorted, or smoked. 

Morphine M, monkey, white stuff Injected, snorted, or smoked. 

Opium Black stuff, block, gum, hop Swallowed or smoked. 

Oxycodone Oxycontin (commercial 

name), O.C. 

Swallowed, injected, or snorted. 

Hydrocodone Vicodin (commercial name) Swallowed. 

Stimulants Amphetamines Speed, uppers Swallowed in capsule, tablet, or pill 

form; injected; smoked; or snorted. 

Cocaine Coke, blow, Connie Snorted or injected. 

Crack cocaine Crack, rock Smoked. 

Methamphetamine Meth, crystal, crystal meth, 

Tina, T, crank, speed 

Snorted, injected, smoked, or 

swallowed. 

Other 

compounds 

Anabolic steroids Anadrol (commercial name), 

Oxandrin (commercial name), 

roids, juice 

Injected, swallowed, applied to skin 

Dextromethorphan 

(DXM) 

Robotripping, robo, triple C 

(Note: DXM is found in some 

cough and cold medications) 

Swallowed 

For more information on commonly used drugs and their effects and health consequences, visit http://www. 

nida.nih.gov/drugpages/drugsofabuse.html. 

92 Appendix E—Commonly Abused Substances 
APPENDIX F 

Commonly Used Screening

Instruments 

The substance use disorder treatment fi eld has 

developed and tested several screening instruments. 

The following table provides a short description 

of the more commonly used instruments that have 

been found valid when used in appropriate settings. 

It is essential to review the materials accompanying 

the instruments before using them. Th ese materials 

provide practical guidance, such as how many 

positive responses indicate that alcohol or drug use 

may be a problem, and they may suggest alternative 

wording of questions that might work better in child 

welfare settings. 

Many of these screening instruments are available 

from Federal websites, especially the National 

Institute on Alcohol Abuse and Alcoholism (http:// 

www.niaaa.nih.gov) and the National Institute on 

Drug Abuse (http://www.nida.nih.gov). Some are 

available in Spanish. For screening instruments in 

other languages, it may be necessary to work with 

a translator who is not a friend or a relative of the 

family. 

Selected Substance Use Disorder Screening Instruments 

Instrument Purpose Summary For More Information 

Adult Substance Use Survey 

(ASUS) 

(For use with the SelfAppraisal Survey) 

Screens for an individual’s 

perceived alcohol and drug 

use and abuse, mental 

health concerns, motivation 

for treatment, anti-social 

attitudes and behaviors, and 

level of defensiveness. 

• Sixty-four questions that 

can be self-administered 

or asked by another 

person. Available in 

Spanish. 

• Takes 8–10 minutes to 

administer. Training is 

required and available. A 

user’s guide is available. 

• Free for use in Colorado 

but permission is 

required. 

Kenneth Wanberg, Ph.D. 

Center for Addiction Research 

and Evaluation, Inc. 

5460 Ward Road, Suite 140 

Arvada, CO 80002 

(303) 421-1261 

Protecting Children in Families Affected by Substance Use Disorders 93 
 

Appendix F—Commonly Used Screening Instruments 

 Brown, R. L., & Rounds, L. A. (1998). Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in primary 

care practice. Wisconsin Medical Journal, 94(3), 135–140. 

Selected Substance Use Disorder Screening Instruments 

Instrument Purpose Summary For More Information 

Alcohol Use Disorders Designed to identify • Ten questions that can Th omas Babor 

Identifi cation Test individuals whose alcohol be self-administered or Alcohol Research Center 

(AUDIT)1 use has become a danger to asked by another person. University of Connecticut 

their health. Includes three • Takes about 1 minute to 263 Farmington Avenue 

subscales that assess amount complete. Farmington, CT 

and frequency of drinking, 

alcohol dependence, and • Targeted at adults. 06030-2103 

problems caused by alcohol. • Free except for training 

materials. 

CAGE Questionnaire2 Related to drinking 

behavior. 

• Four questions that can 

be self-administered or 

asked by another person. 

• Targeted at individuals 

16 years of age or older. 

• Questions can be 

incorporated into other 

questionnaires. 

Available through numerous 

publications, websites, and 

treatment and prevention 

programs, including: 

http://pubs.niaaa.nih.gov/ 

publications/Assesing%20 

Alcohol/InstrumentPDFs/16_ 

CAGE.pdf 

• Free. 

CAGE-AID3 Similar to the CAGE 

Questionnaire, but this 

expanded version includes 

questions about the use 

of illicit drugs as well as 

alcohol. 

• Nine questions that can 

be self-administered or 

asked by another person. 

• Targeted at individuals 

16 years of age or older. 

• Questions can be 

incorporated into other 

questionnaires. 

• Free. 

Available through numerous 

publications, websites, and 

treatment and prevention 

programs. 

Drug Abuse Screening Test Designed to screen for the • Twenty questions The Addiction Research 

(DAST)4 use of illegal drugs. (short version has 10) Foundation 

whose cumulative score Center for Addiction and 

indicates whether there Mental Health 

is a drug problem, 

whether the person 

should be monitored, 

or whether the person 

should be assessed 

33 Russell Street 

Toronto, M5S2S1 

Ontario, Canada 

(415) 595-6111 

further. (800) 463-6273 

1

 Babor, T., de la Puente, J. R., Saunders, J., & Grant, M. (1992). AUDIT: The Alcohol Use Disorders Identifi cation Test: Guidelines for use in 

primary health care. Geneva, Switzerland: World Health Organization. 

2

 Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism instrument. American Journal of 

Psychiatry, 131(10), 1121–1123. 

3

4

 Skinner, H. A. (1982). The Drug Abuse Screening Test (DAST). Addictive Behavior, 7(4), 363–371. 

94 
Selected Substance Use Disorder Screening Instruments 

Instrument Purpose Summary For More Information 

Michigan Alcoholism Designed to screen for • Twenty-fi ve questions Melvin L. Selzer, M.D. 

Screening Test (MAST)5 lifetime alcoholism-related 

problems. 

that can be selfadministered or asked by 

another person. Shorter 

version also available. 

• Takes 5 minutes to 

administer. 

• Targeted at adults. 

• Minor cost for original, 

then can be copied. 

6967 Paseo Laredo 

La Jolla, CA 92037 

(619) 459-1035 

Self-Appraisal Survey (SAS) Designed to screen for 

alcohol and chemical 

• Twenty-four questions 

that can be selfKenneth Wanberg, Ph.D. Center for Addiction Research 

(For use with the Adult dependency and to administered by and Evaluation, Inc. 

Substance Use Survey) determine both the extent 

of use and the effects of use 

on aspects of life. 

participants and 12 

items for caseworkers 

to complete using 

observations and other 

information. 

• Takes about 15 minutes. 

• Free in Colorado, but 

permission is required. 

5460 Ward Road, Suite 140 

Arvada, CO 80002 

(303) 421-1261 

Substance Abuse Subtle Designed to screen for • Eighty-eight questions. The SASSI Institute 

Screening Inventory 

(SASSI)6 

chemical dependency and 

efforts to fake or conceal • Takes 10–15 minutes. 201 Camelot Lane Springville, IN 47462 

problems. It has eight • Requires training to (800) 726-0526 

subscales that can assess administer, but can be http://www.sassi.com 

defensiveness and other self-administered. 

dependency characteristics. • Requires training to 

interpret and score. 

• Must be purchased. 

 Selzer, M. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 

127(12), 1653–1658. 

6 Miller, G. (1985). The Substance Abuse Subtle Screening Inventory (SASSI) manual. Bloomington, IN: Spencer Evening World. 

Protecting Children in Families Affected by Substance Use Disorders 95 

4
Triage Assessment for Designed for both drug • Th irty questions. Norman G. Hoff mann, Ph.D. 

Addictive Disorders 

(TAAD) 

and alcohol use in face-toface interviews where time 

commitment is minimal. 

• Takes 12–13 minutes to 

administer and score. 

Evince Clinical Assessments 

P.O. Box 17305 

Smithfield, RI 02917 

• 

• 

• 

Can be administered 

by anyone with good 

interviewing skills. 

Requires expertise to 

score. 

Must be purchased. 

(800) 755-6299 

http://www.evinceassessment. 

com 

TWEAK Alcohol Screen Developed and validated for 

women. Recommended by 

the California Institute of 

Mental Health. 

• 

• 

• 

• 

Five questions that can 

be self-administered or 

asked by another person. 

Takes 5 minutes to 

administer and score. 

No training is required. 

Free 

Marcia Russell, Ph.D. 

Research Institute on 

Addictions 

1021 Main Street 

Buffalo, NY 14203 

(716) 887-2507 

http://www.ria.buff alo.edu 

UNCOPE Designed to detect alcohol 

or drug problems. 

• 

• 

• 

• 

Six questions found in 

existing instruments and 

research reports. 

Can be self-administered 

or asked by another 

person. 

No training is required. 

Free. 

Norman G. Hoff mann, Ph.D. 

Evince Clinical Assessments 

P.O. Box 17305 

Smithfield, RI 02917 

(800) 755-6299 

http://www.evinceassessment. 

com/research.html 

Although screening tools are a great resource, they are their professional training and experience to help 

not meant to be the sole source of decision-making. them decide whether substance use is a problem for a 

Rather, child protective services caseworkers must specific family. 

rely on multiple sources of information as well as 

96 Appendix F—Commonly Used Screening Instruments 
 

 

 

 

 

APPENDIX G 

State of Connecticut 

Department of Children and 

Families Substance Abuse 

Screening and Information Form

Date: ______/______/_______
 

DCF Worker: _________________________________ Phone: _________________________
 

DCF Supervisor: ____________________________ __ Phone: _________________________
 

Client Name: _________________________________ SAFE #: ________________________
 

Date client referred to SAFE, if applicable: _________________________________________
 

This form shall be completed by the social worker upon return to the office. Please check every box 

either “yes” or “no,” as appropriate. If there is any “yes” box checked for questions 1-13, a referral for an

evaluation shall be made to Project Safe. 

1. Yes ‬ No ‬ Client appeared to be under the influence of drugs and/or alcohol. 

2. Yes ‬ No ‬ Client showed physical symptoms of trembling, sweating, stomach cramps, or 

nervousness. 

3. Yes ‬ No ‬ Drug paraphernalia was present in the home, i.e., pipes, charred spoons, foils, 

blunts, etc. 

4. Yes ‬ No ‬ Evidence of alcohol abuse was present in the home, i.e., excessive number of 

visible bottles/cans whether empty or not. 

5. Yes ‬ No ‬ There was a report of a positive drug screen at birth for mother and child. 

List drugs detected: ____________________________________________________ 

6. Yes ‬ No ‬ There was an allegation of substance abuse in the CPS report. 

7. Yes ‬ No ‬ The child(ren) reports substance abuse in the home. When? ___________________ 

______________________________________________________________________ 

8. Yes ‬ No ‬ The client has been in substance abuse treatment. When? ____________________ 

_____________________________________________________________________ 

Protecting Children in Families Affected by Substance Use Disorders 97 
 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

 

______________________________________________________________________ 

9. Yes ‬ No ‬ The client has used the following in the last 12 months: 

Marijuana/Hashish ‬ Heroin/Opiates ‬ Cocaine/Crack ‬

Other drugs: __________________________________________________________ 

10. Yes ‬ No ‬ Client shared that he/she has experienced negative consequences from the misuse 

of alcohol. 

DWI/DUI ‬ Domestic Fights ‬ Job Loss ‬ Arrests ‬
 

Other: _______________________________________________________________
 

11. Yes ‬ No ‬ Client shared he/she has experienced trouble with the law due to the use of alcohol 

or other drugs. 

DWI/DUI ‬ Domestic Violence ‬ Drug Possession Charge ‬
 

Other: ________________________________________________________________
 

12. Yes ‬ No ‬ There are adults who may be using drugs and/or misusing alcohol who have 

regular contact with the client’s children. 

13. Yes ‬ No ‬ The client acknowledged medical complications due to the use of substances.

 ______________________________________________________________________ 

14. Other Comments: 

______________________________________________________________________

 ______________________________________________________________________

 ______________________________________________________________________ 

Adapted from Young, N. K., & Gardner, S. L. (2002). Navigating the pathways: Lessons and promising practices in 

linking alcohol and drug services with child welfare, Technical Assistance Publication (TAP) Series 27, p. 131–132. 

(SAMHSA Publication No. SMA-02-3639). Rockville, MD: Department of Health and Human Services, Substance 

Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. 

98 Appendix G—State of Connecticut Department of Children and Families 

Substance Abuse Screening and Information Form 
APPENDIX H 

Memorandums of 

Understanding1 

What is a Memorandum of Understanding (MOU)? 

An MOU is a written agreement that serves to clarify relationships and responsibilities between two or more 

organizations that share services, clients, and resources. 

Why is it important to have an MOU? 

MOUs help strengthen community partnerships by delineating clear roles between individuals, agencies, 

and other groups. Communities with MOUs report that the strengthened partnerships resulted in enhanced 

services for children and families. 

What is actually included in an MOU? 

Generally, MOUs can address a variety of issues and topics. Content areas to consider including in an 

MOU are: 

• Clarification of agency roles; 

• Referrals across agencies; 

• Assessment protocols; 

• Parameters of confi dentiality; 

• Case management intervention; 

• Interagency training of staff ; 

• Agency liaison and coordination; 

• Process for resolving interagency confl icts; 

• Periodic review of the MOU. 

 Bragg, H. L. (2003). Child protection in families experiencing domestic violence [On-line]. Available: http://www.childwelfare.gov/ 

pubs/usermanuals/domesticviolence/. 

Protecting Children in Families Affected by Substance Use Disorders 99 

1
How do we know our community is ready to develop an MOU? 

Communities that are concerned about reducing the incidence of child maltreatment are excellent candidates 

for creating an MOU. In communities that are experiencing strained relationships between potential partners, 

the process of writing an MOU provides a unique opportunity to address misperceptions and differences and to 

work jointly to resolve gaps in service delivery. 

What strategies should we undertake as we begin the MOU process? 

Depending on existing relationships within communities, one strategy may include inviting key supporters to 

meetings to explore the feasibility of MOU development. Communities have reported that once they had the 

commitment and investment from the various agencies, the MOU process quickly crystallized and resulted in a 

written MOU. An additional strategy may include inviting an outside consultant to facilitate a partnership that 

leads to the development of an MOU. 

What are the problems that might arise during the MOU process? 

Problems may arise concerning misperceptions about each other’s goals, missions, and philosophy. Professionals 

from child welfare agencies report that the MOU meetings helped them understand each other’s language and 

history and provided a context in which to view other philosophies and missions. Additional problematic issues 

may include confidentiality policies, assessment decisions, levels of intervention, and out-of-home placement 

for children. The MOU provides an opportunity to address these critical issues to meet the needs of the 

community. 

How does the MOU actually help families and children? 

Families affected by child maltreatment report that they are reluctant to request assistance, are required to 

participate in services that do not address the underlying issues, and frequently feel misunderstood by 

professionals. Communities with existing MOUs have reported that children who are maltreated were less 

likely to be placed in out-of-home settings and that families were more motivated to work with professionals to 

reduce the risk of future child abuse and neglect. Families in communities where MOUs have been established 

reported a higher level of satisfaction in working with professionals. 

100 Appendix H—Memorandums of Understanding (MOUs) 
 

 

 

 

 

Protecting Children in Families Affected by Substance Use Disorders 101 

APPENDIX I 

Confidentiality and the 

Release of Substance 

Use Disorder 

Treatment Information 

The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (1970) 

and the Drug Abuse Office and Treatment Act (1972) regulate the disclosure of confi dential information 

by substance use disorder treatment programs that receive Federal assistance. Generally, a provider cannot 

release any information that identifies an individual in the program and cannot acknowledge the presence of 

an individual in the treatment program. The following are exceptions under which client information can be 

released: 

• 	 It will be used in internal communications between or among those with a legitimate interest who 

need the information in connection with their duties that arise out of the provision of diagnosis, 

treatment, or referral for treatment of substance use disorders if the communications are within the 

program or between a program and an entity that has direct administrative control over the program. 

• 	 It relates to a medical emergency requiring assistance. 

• 	 It relates to research or an audit of the program or service. 

• 	 It relates to a crime on the premises involving drug use or a mental condition. 

• 	 It relates to reports of suspected child abuse and neglect. 

• 	

A court order has been obtained. 

• 	 It will be used by qualified organizations providing services to the program. 

Proper consent, by way of a criminal justice consent form, has been obtained from the individual in 

the program (in the case of a minor, the consent must be obtained from the patient, the parents, or 

both). This consent must be in writing and must contain each of the following items: 

–	 The name and general description of the program(s) making the disclosure; 

–	 The name of the individual or organization that will receive the disclosure; 

–	 The name of the patient who is the subject of the disclosure; 

–	 The purpose or need for the disclosure; 

–	 How much and what kind of information will be disclosed; 
 

 

– The signature of the patient; 

102 Appendix I—Confidentiality and the Release of Substance 

Use Disorder Treatment Information 

– A statement regarding revocation of consent; 

– The date, event, or condition upon which the consent will expire; 

– The date on which the consent is signed. 1 

Adapted from U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. (2000). Legal issues. 

Juvenile Accountability Incentive Block Grants Program Bulletin [On-line]. Available: http://www.ncjrs.org/html/ 

ojjdp/jiabg_blltn_03_1_00/6.html. 
APPENDIX J 

Sample Qualified Service 

Organization Agreement 

and Consent Form 

XYZ Service Center (“the Center”) and 

(Name of the alcohol/drug program) 

(the “Program”) hereby enter into an agreement whereby the Center agrees to provide: 

(Nature of services to be provided to the program) 

Furthermore, the Center: 

(1) Acknowledges that in receiving, transmitting, transporting, storing, processing, or otherwise dealing with any 

information received from the Program identifying or otherwise relating to the patients in the Program (“protected 

information”), it is fully bound by the provisions of the Federal regulations governing the Confi dentiality of Alcohol 

and Drug Abuse Patient Records, 42 CFR, Part 2; and the Health Insurance Portability and Accountability Act 

(HIPAA), 45 CFR, Parts 142, 160, 162, and 164, and may not use or disclose the information except as permitted or 

required by this Agreement or by law; 

(2) Agrees to resist any efforts in judicial proceedings to obtain access to the protected information except as 

expressly provided for in the regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 

42 CFR, Part 2. 

(3) Agrees to use appropriate safeguards (can defi ne with more specificity) to prevent the unauthorized use or 

disclosure of the protected information; 

(4) Agrees to report to the Program any use or disclosure of the protected information not provided for by this 

Agreement of which it becomes aware (insert negotiated time and manner terms); 

(5) Agrees to ensure that any agent, including a subcontractor, to whom the Center provides the protected 

information received from the Program, or created or received by the Center on behalf of the Program, agrees to the 

same restrictions and conditions that apply through this agreement to the Center with respect to such information;* 

(6) Agrees to provide access to the protected information at the request of the Program, or to an individual as 

directed by the Program, in order to meet the requirements of 45 CFR § 164.524, which provides patients with the 

right to access and copy their own protected information (insert negotiated time and manner terms); 

Protecting Children in Families Affected by Substance Use Disorders 103 
(7) Agrees to make any amendments to the protected information as directed or agreed to by the Program pursuant 

to 45 CFR § 164.526 (insert negotiated time and manner terms); 

(8) Agrees to make available its internal practices, books, and records, including policies and procedures, relating 

to the use and disclosure of protected information received from the Program, or created or received by the Center 

on behalf of the Program, to the Program or to the Secretary of the Department of Health and Human Services for 

purposes of the Secretary determining the Program’s compliance with HIPAA (insert negotiated time and manner 

terms); 

(9) Agrees to document disclosures of protected information, and information related to such disclosures, as would 

be required for the Program to respond to a request by an individual for an accounting of disclosures in accordance 

with 45 CFR § 164.528 (insert negotiated time and manner terms);* 

(10) Agrees to provide the Program or an individual information in accordance with paragraph (9) of this agreement 

to permit the Program to respond to a request by an individual for an accounting of disclosures in accordance with 

45 CFR § 164.528 (insert negotiated time and manner terms); 

Termination 

(1) The program may terminate this agreement if it determines that the Center has violated any material term; 

(2) Upon termination of this agreement for any reason, the Center shall return or destroy all protected information 

received from the Program, or created or received by the Center on behalf of the Program. This provision shall 

apply to protected information that is in the possession of subcontractors or agents of the Center. The Center shall 

retain no copies of the protected information. 

(3) In the event that the Center determines that returning or destroying the protected information is infeasible, the 

Center shall notify the Program of the conditions that make return or destruction infeasible (insert negotiated time 

and manner terms). 

Upon notification that the return or destruction of the protected information is infeasible, the Center shall extend the 

protections of this Agreement to such protected information and limit further uses and disclosures of the information 

to those purposes that make the return or destruction infeasible, as long as the Center maintains the information. 

Executed this ______ day of ______, 20 ___. 

_____________________________________ ________________________________ 

President Program Director 

XYZ Service Center [Name of the Program] 

[address] [address] 

*Although HIPAA requires these paragraphs to be included in Business Associate agreements, 42 C.F.R. § 2.11 

requires qualified service organizations to abide by the Federal drug and alcohol regulations, which prohibit such 

organizations from redisclosing any patient-identifying information even to an agent or subcontractor. Legal 

Action Center has asked the U.S. Department of Health and Human Services for an opinion on this issue. 

Obtained from Legal Action Center. (n.d.). Sample qualifi ed service organization/business associate agreement [Online]. Available: http://www.lac.org/doc_library/lac/publications/QSO-BA%20Agreement%20Form.pdf. 

Appendix J—Sample Qualified Service Organization 

Agreement and Consent Form 

104 
_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

________________________ ______________________________ 

Sample Consent Form 

Consent for the Release of Confi dential Information 

I, __________________________, authorize ________________________________________________

 (Name of patient) (Name or general designation of program making disclosure) 

to disclose to ____________________________________________________________

 (Name of person or organization to which disclosure is to be made) 

the following information:________________________________________________________________ 

(Nature and amount of information to be disclosed; as limited as possible) 

The purpose of the disclosure authorized in this is to: 

(Purpose of disclosure, as specific as possible) 

I understand that my substance use disorder treatment records are protected under the Federal regulations 

governing Confidentiality and Drug Abuse Patient Records, 42 CFR, Part 2, and the Health Insurance Portability 

and Accountability Act of 1996, 45 CFR, Parts 160 and 164, and cannot be disclosed without my written consent 

unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at 

any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires 

automatically as follows: 

(Specification of the date, event, or condition upon which this consent expires) 

I understand that generally (insert name of program) may not condition my treatment on whether I sign a consent 

form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form. 

Date Signature of Patient 

______________________________ 

Signature of parent, guardian, or uthorized 

representative where required. 

Adapted from Legal Action Center. (n.d.). Sample consent - basic [On-line]. Available: http://www.lac.org/doc_ 

library/lac/publications/Consent-Basic.pdf. 

Protecting Children in Families Affected by Substance Use Disorders 105