Understanding Substance Abuse 

and Facilitating Recovery: 

A Guide for Child Welfare Workers 
Understanding Substance Abuse

and Facilitating Recovery:

A Guide for Child Welfare Workers
                             

                       

                             

                           

                               

                           

   

                                 

                                 

                             

                                 

                               

                               

           

                         

                   

                       

                           

                           

              

                         

                       

Acknowledgments 

This document was prepared by the National Center on Substance Abuse and Child Welfare (NCSACW)

under Contract No. 270‐027108 for the Substance Abuse and Mental Health Services Administration

(SAMHSA) and the Administration for Children and Families (ACF), both within the U.S. Department of

Health and Human Services (HHS). Elizabeth M. Breshears, M.S.W., M.Ed., developed the document with

assistance from Shaila Yeh M.S.W., and Nancy K. Young, Ph.D. Sharon Amatetti, M.P.H., served as the

government project officer from SAMHSA (CSAT); Irene Bocella, M.S.W., served as the project officer

from ACF.

Disclaimer 

The views and opinions expressed in this publication are those of the author and do not necessarily

reflect the views, opinions, or policies of SAMHSA, ACF, or HHS. Resources listed in this document are

not all‐inclusive; inclusion as a resource does not constitute an endorsement by SAMHSA, ACF, or HHS.

Public Domain Notice 

All material appearing in this document is in the public domain and may be reproduced or copied

without the permission of SAMHSA, ACF, or HHS. Citation of the source is appreciated. However, this

publication may not be reproduced or distributed for a fee without the specific, written authorization of

the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication 

This publication may be downloaded or ordered at www.samhsa.gov/shin. Or, please call SAMHSA's

Health Information Network at 1‐877‐SAMHSA‐7 (1‐877‐726‐4727) (English and Español). In addition,

this publication can be ordered from the Child Welfare Information Gateway at 1‐800‐394‐3366.

Recommended Citation 

Breshears, E.M., Yeh, S. & Young, N.K. Understanding Substance Abuse and Facilitating Recovery: A

Guide for Child Welfare Workers. U.S. Department of Health and Human Services. Rockville, MD:

Substance Abuse and Mental Health Services Administration, 2009.

Originating Office 

Office of Program Analysis and Coordination, Center for Substance Abuse Treatment, Substance Abuse

and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 05‐3981

Printed 2005

Reprinted 2006 and 2009
     

       

               

                 

               

                 

       

                       

     

     

             

           

       

           

                 

     

     

                 

       

       

           

       

         

               

                 

                 

                 

               

   

   

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Contents 

Introduction 1
 

Understanding Addiction 2
 

Alcohol abuse and dependence 2
 

Women and substance abuse 4
 

Co‐occurring substance abuse and dependence and mental illness 5
 

Determining an alcohol or drug connection to child welfare 5
 

Impact of parents’ substance abuse on children 8
 

How to talk to children about parental substance use 8
 

Cultural and ethnic sensitivity 9
 

Co‐dependence 9
 

Substance Abuse Treatment: Developing and Implementing a Plan for Management of a

Lifelong Disease............................................................................................................................

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11
 

What is treatment? 11
 

What is recovery? 13
 

Treatment and recovery issues specific to women 13
 

How effective is treatment and recovery? 14
 

Self‐help or 12‐step groups 15
 

Interventions for substance‐using, but non‐addicted parents 15
 

How to Motivate Parents into Treatment and Enhance Treatment Readiness 16
 

Readiness for change 16
 

Motivation to change 17
 

How to Support and Facilitate Recovery and Enhance Treatment Effectiveness 19
 

Relapse and relapse prevention ................................................................................................

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19
 

Self‐help groups and recovery 20
 

Culture as a factor in recovery 20
 

Supporting recovery for women 20
 

Ways to Facilitate Cross‐System Communication and Collaboration 22
 

Why should I partner with local treatment programs? 22
 

Why should the substance abuse agency partner with me? 22
 

How do I partner with my substance abuse colleagues? 23
 

What issues and services should be included in the collaboration? 24
 

How to increase the chance of a successful collaboration 26
 

Resources 27
 

Federal resources: 27
 

Other resources: ........................................................................................................................ 28
 

Endnotes....................................................................................................................................... 30
 
1

Introduction 

The abuse and neglect of children are a serious social issue in the United States. During 2002, each day,

an average of 2,454 children were found to be victims of abuse or neglect.1 During that same year,

532,000 children lived in foster homes because they could not safely remain in their own homes.2 One

of the major reasons children enter foster care is abuse or neglect associated with parental alcohol or

drug abuse.3,4

The abuse of alcohol and drugs is considered a serious risk factor for child

safety.5 Whether the substance abuse is by a parent or by another adult

caregiver in the home, the behaviors of adults while under the influence

of alcohol or drugs can have life‐long effects on children.   

As a consequence, it is important for child welfare workers to recognize when alcohol or drug abuse is a

factor in the case of child abuse or neglect; to help parents obtain appropriate treatment; and to

understand the concept of recovery in the context of child safety. A working knowledge of alcohol and

drug services can help child welfare workers meet the Adoption and Safe Families Act timelines and

fulfill the child welfare commitment to child safety, permanency, and well‐being.  

The Adoption and Safe Families Act requires a permanency plan within 12 months after a child enters

foster care and requires states to initiate proceedings to terminate parental rights if a child has been in

foster care for 15 of the most recent 22 months. While 12 or 15 months is a long time in the life of a

child, it is a relatively short time in the recovery process of a parent with years, or even decades, of

alcohol and/or drug abuse. It is critical that the 15‐month time period be well spent, and that when

substance abuse is an issue, the parent’s treatment needs be assessed and appropriate alcohol and drug

services accessed without delay. To be effective, child welfare workers must understand substance use

disorders. Workers should always screen for substance abuse and feel comfortable asking questions on

a routine basis about substance use, abuse, treatment, and recovery while the case is open.  

  

To help accomplish permanency for children, child welfare workers need to partner with local alcohol

and drug abuse professionals and programs. An effective partnership between the child welfare and the

alcohol and drug treatment systems can help parents with substance use disorders retain or regain a

parental role with their child, while not putting the child at risk of harm. Thus, the child welfare‐alcohol

and drug services partnership becomes a cornerstone for long‐term child protection, a key issue for

child welfare workers.

  

The purpose of this guide is to help child welfare workers:  

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Understand the relationship of alcohol and drugs to child welfare, and recognize when substance

use is a factor in cases;  

Most states identify

substance abuse as one

of the top two factors in

child abuse and neglect.

6

Enhance collaboration with substance abuse treatment partners; and,

Improve outcomes for children of parents with substance use disorders.

Understand addiction and how to support and facilitate treatment and recovery;

The National Center on Substance Abuse and Child Welfare offers online training courses for child

welfare workers available at http://www.ncsacw.samhsa.gov/tutorials/index.asp.
2

What is physical dependence?

Understanding Addiction 

Alcohol and drug use occur along a continuum. Not everyone who uses substances is addicted. Levels of

use generally are identified as use, abuse, and dependence. Child welfare workers will want to

determine whether or not alcohol or drugs may be a factor in the reported abuse or neglect. If

substance use is a factor in the abuse or neglect, an assessment should be conducted to determine a

parent’s status on the use, abuse, dependence continuum.

Addiction to alcohol and drugs may be physical or

psychological. Physical dependence refers to physical

changes in the body, such as tolerance or withdrawal. The

symptoms of physical dependence vary by type of drug

used. Psychological dependence refers to the perceived

need for the alcohol and drugs to feel good, function, or to

keep from feeling bad. Parents who use substances may use

alcohol only, one drug only, a combination of drugs, or a

combination of alcohol and drugs. Poly‐drug use (more than

one drug, or alcohol and drugs combined) is a common

pattern of use among substance abusers.  

Alcohol abuse and dependence 

In many States, the number of people treated for alcohol

problems equals the number treated for all drugs combined.

The amount of alcohol consumed and symptoms of

dependence are discussed below and should be considered

in child safety and risk assessments. It is important to stress

that, even when alcohol use is below the level that suggests

“dependence,” the child welfare worker should assess

parental alcohol use or abuse as an indicator of risk to

children. 8

How much is too much? 

A child welfare worker should be concerned about the risk

of alcohol addiction if a woman drinks more than seven

drinks a week or three drinks at a time. For men, the level is

14 drinks per week, or four per occasion.9 The American

Psychological Association, Diagnostic and Statistical Manual

of Mental Disorders, 4th Edition, Text Revision (DSM‐IV/DSM‐

IV‐TR) gives the definitions of substance abuse and

dependence found on the following page.

Physical dependence refers to

physical changes in the body, such as

tolerance or withdrawal. The

symptoms of physical dependence

vary by type of drug used.

What is psychological dependence?

Psychological dependence refers to

the perceived need for the alcohol

and drugs to feel good, function, or to

keep from feeling bad.

What is addiction?  

Alcohol and drug addiction are

diseases that, while treatable, are

chronic and relapsing.7

What does this mean?  

This means that over time, the

disease of addiction causes changes in

the person’s body, mind, and

behavior, and that a person is unable

to control his or her substance use,

despite the harm that results.8

Chronic and relapsing mean that the

addiction is never “cured,” and that

substance use may persist or

reappear over the course of an

individual’s life.
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Alcohol and Drug Use Continuum Implications for Child Welfare/ Examples of Risk

to Children

Use of alcohol or drugs to socialize and feel effects; use

may not appear abusive and may not lead to

dependence, however the circumstances under which a

parent uses can put children at risk of harm

Use during pregnancy can harm the fetus

Use of prescription pain medication per the

instructions from a prescribing physician can

sometimes have unintended or unexpected effects—

a parent caring for children may find that he or she is

more drowsy than expected and cannot respond to

the needs of children in his or her care

Abuse of alcohol or drugs includes at least one of these

factors in the last 12 months:  

Recurrent substance use resulting in failure to

fulfill obligations at work, home or school

Recurrent substance use in situations that are

physically hazardous

Recurrent substance‐related legal problems

Continued substance use despite having

persistent or recurrent social or interpersonal

problems caused by or exacerbated by the

substance

Dependence, also referred to as addiction, is a pattern

of use that results in three or more of the following

symptoms in a 12 month period:

Tolerance—needing more of the drug or alcohol

to get “high”

Withdrawal—physical symptoms when alcohol or

other drugs are not used, such as tremors,

nausea, sweating, and shakiness

Substance is taken in larger amounts and over a

longer period than intended

Persistent desire or unsuccessful efforts to cut

down or control substance use

A great deal of time is spent in activities related to

obtaining the substance, use of the substance or

recovering from its effects

Important social, occupational, or recreational

activities are given up or reduced because of

substance use

Substance use is continued despite knowledge of

persistent or recurrent physical or psychological

problems caused or exacerbated by the substance

The American Psychological Association, Diagnostic and

Statistical Manual of Mental Disorders, 4th Edition, Text

Revision (DSM‐IV/DSM‐IV‐TR)

Driving with children in the car while under the

influence

Children may be left in unsafe care—with an

inappropriate caretaker or unattended—while

parent is partying

Parent may neglect or sporadically address the

children’s needs for regular meals, clothing, and

cleanliness

Even when the parent is in the home, the parent’s

use may leave children unsupervised

Behavior toward children may be inconsistent, such

as a pattern of violence then remorse

Despite a clear danger to children, the parent may

engage in addiction‐related behaviors, such as

leaving children unattended while seeking drugs

Funds are used to buy alcohol or other drugs, while

other necessities, such as buying food, are neglected

A parent may not be able to think logically or make

rational decisions regarding children’s needs or care

A parent may not be able to prioritize children’s

needs over his or her own need for the substance
Substance dependence—is a pattern of use

that results in at least three of seven

dependence criteria: 1) tolerance; 2)

withdrawal; 3) unplanned use; 4) persistent

desire or failure to reduce use; 5) spending a

great deal of time using; 6) sacrificing

activities to use; or, 7) physical or

psychological problems related to use.  

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Substance abuse—is a pattern of substance

use that results in at least one of four

consequences: 1) failure to fulfill role

obligations; 2) use placing one in danger (e.g.,

driving under the influence); 3) legal

consequences; or, 4) interpersonal/social

problems.  

Blackouts, which begin in the early stage of

alcoholism, are not the same as passing out. A

blackout is a type of amnesia or memory loss in

which the person cannot remember what they did

or said. Some people cannot remember how they

got home or where they parked their car. A parent

may say he or she does not remember an episode

of abuse or neglect of the child. The abuse may

have occurred during a blackout.

Research has shown that chronic alcohol use

makes changes in the brain’s chemistry, affecting

fundamental brain functions.10 Functions involved

in initiation of motor activity and integration of

behavior, intellect, and emotion are particularly

susceptible to alcohol‐induced changes.11Alcohol

may impair attention, information processing,

learning, and memory. Alcohol influences two of

the brain’s neurotransmitters, dopamine and

serotonin, affecting stress levels, mood, and

feelings of pleasure or pain. Serotonin depletion

through alcohol or drug use also can lead to

depression. Alcohol‐induced changes to the brain

are complex, serious, and may be permanent. It is

important that a parent receive a medical

evaluation, and that assessments of future risk

and permanency planning for the child realistically

address parental capacity.  

Women and substance abuse 

Substance use and abuse issues must be

addressed for both parents, as well as other

members of the household. However, this section

emphasizes treatment needs for women because

so many mothers are the primary family

caretakers. Generally, it takes less alcohol for a

woman to get intoxicated.12

In addition, some studies have indicated that

women progress to addiction in less time than

men.  Further, the life experiences that can lead to

substance abuse often are different for women

than for men.13A range of issues that are unique

to women have been found to be important when

designing and delivering treatment for women.  

A high percentage of women who access

substance abuse treatment have experienced

physical or sexual abuse in childhood. Many have

a history of family dysfunction or addiction. In

addition, women who abuse substances may have

experienced physical or sexual victimization as

adults (e.g., domestic violence). Some women use

alcohol or drugs to self‐medicate for depression or

another mental health disorder, or to help cope

with emotions or memories of trauma. As a result

of their childhood or adult experiences, they may

suffer from post traumatic stress disorder (PTSD).  

Post Traumatic Stress Disorder (PTSD) is an

anxiety disorder resulting from exposure to a

traumatic event in which both of the following

were present:

 The person experienced, witnessed, or was

confronted with an event or events that

involved actual or threatened death or

serious injury, or a threat to the physical

integrity of self or others

 The person’s response involved intense fear,

helplessness, or horror

The American Psychological Association, Diagnostic and Statistical

Manual of Mental Disorders, 4th Edition, Text Revision.
           

               

           

             

             

         

             

         

         

               

           

               

           

               

             

               

             

               

                 

               

           

               

       

     

                 

                 

           

             

               

           

               

                 

             

             

                

           

             

         

  

             

         

               

               

             

               

           

                 

           

             

             

           

               

       

                 

               

               

           

           

           

   

             

             

   

           

         

             

         

         

   

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Historically, substance abuse treatment has been

geared toward men, and fewer women had access

to substance abuse treatment services. However,

in recent years additional emphasis and funding

have begun to address women’s treatment needs.

Gender‐specific treatment is becoming more

available to women with substance abuse or

substance dependence.

Co-occurring substance abuse 

and dependence and mental 

illness 

The co‐occurrence of substance abuse and

substance dependence with mental illness is

estimated to affect between seven and 10 million

adults each year.14 In individuals with these co‐

occurring disorders it is not uncommon for one

disorder to go unrecognized. These individuals

often do not realize they need services or

minimize the existence of their disorders. When

they do come to the attention of service

providers, symptoms of one disorder may mask

the symptoms of the other. Service providers may

not realize that what appears to be a mental

health disorder may be the product of substance

abuse and visa versa.15 Child welfare workers

should be aware of the prevalence and complexity

of co‐occurring substance abuse and dependence

and mental illness.

Determining an alcohol or drug 

connection to child welfare 

How can a child welfare worker tell whether or

not substance abuse is a factor in abuse or

neglect? Every emergency response by a

protective services or child welfare worker should

consider alcohol or drug involvement as part of

the child protective services investigation. If

alcohol or drug abuse is indicated, addressing the

substance abuse issues should be part of the child

welfare case plan. Child welfare workers should

use two processes to gather information regarding

child safety and future potential risk of harm.

These activities should occur during the

investigation phase and when working with the

family:

In‐home examination for alcohol or drug
 

involvement, and
 

Screening the parent or caretaker for alcohol

and drug use or abuse.

In-home examination 

By observing the environment and persons in the

home, important indicators of alcohol or drug use

may become apparent. Check for the following

indicators of alcohol and drug involvement as part

of every child welfare worker’s on‐site

investigation.16

A report of substance use is included in the

child protective services call or report

Paraphernalia is found in the home (syringe

kit, pipes, charred spoon, foils, large number

of liquor or beer bottles, etc.)

The home or the parent may smell of
 

alcohol, marijuana, or drugs
 

A child reports alcohol and or other drug use

by parent(s) or other adults in the home

A parent appears to be actively under the

influence of alcohol or drugs (slurred

speech, inability to mentally focus, physical

balance is affected, extremely lethargic or

hyperactive, etc.)

A parent shows signs of addiction (needle

tracks, skin abscesses, burns on inside of

lips, etc.)

A parent admits to substance use

A parent shows or reports experiencing

physical effects of addiction or being under

the influence, including withdrawal (nausea,

euphoria, slowed thinking, hallucinations, or

other symptoms)

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6

In addition, workers should observe persons who

frequent the home since actions of a parent’s

friends or associates can be indicators of

behaviors and practices.

Screening the parent for alcohol 

and drug involvement 

Alcohol and drug use often are under‐recognized

as a factor in child welfare cases. Most studies

indicate that between one‐third and two‐thirds of

substantiated child abuse and neglect reports

involve substance abuse, and that nationally, at

least 50% of substantiated cases of child abuse

and neglect involve parental substance abuse.17

Best practices dictate that child welfare workers

should always ask parents and adult caretakers

about their substance use to screen for alcohol

and drug abuse. Substance abuse screening alone

is never diagnostic, but screening can indicate

whether a comprehensive assessment or

evaluation is needed.

Screens should be brief and should include

questions about unintended use and/or desire to

end use, as well as some question regarding

consequences of use or concerns about such

consequences.

One well‐known screening tool available for child

welfare worker use is the four‐question CAGE.

These are quick screens that should be used in

conjunction with other information and

observations. Answering “no” to all questions on

either the CAGE or the UNCOPE does not rule out

the possibility of an alcohol or drug‐related

problem.

Another screen that may be used is the UNCOPE.

Ask the UNCOPE questions

U – Have you continued to use alcohol or drugs

longer than you intended? Or, 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 wanted to stop using alcohol or

drugs but couldn’t? (cut down)

O – Has your family, a friend, or anyone else ever

told you they objected to your alcohol or drug

use?

P – Have you ever found yourself preoccupied

with wanting to use alcohol or drugs? Or,

Have you frequently found yourself thinking

about a drink or getting high?

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 need for further assessment.

The UNCOPE can be obtained from Evince Clinical

Assessments at

http://www.evinceassessment.com/UNCOPE_for_web.pdf.

The most important questions to ask are, “How

does drinking affect the person’s ability to

make sound judgments regarding the welfare

of the child?” and ”What behaviors are

resulting or have resulted from the parent’s

alcohol use that may put the child at risk?”

Ask the CAGE questions (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 parent should receive a formal alcohol

and drug assessment. “Yes” to one or two questions

may indicate alcohol and drug‐related problems. “Yes”

to three or four questions may indicate alcohol or drug

dependence.

The CAGE can be obtained through a number of

Internet sites or by accessing the original American

Journal of Psychiatry article—Mayfield, D., McLeod, G.,

Hall P. The CAGE questionnaire: validations of a new

alcoholism screening instrument. Am J Psychiatry

1974; 131: 1121‐1123.
                 

               

         

             

         

       

           

               

           

               

             

           

           

         

        

           

             

               

               

         

             

               

             

             

       

             

         

             

                 

             

                     

           

       

      

               

             

             

          

         

   

                   

                 

               

               

               

                   

             

                       

               

               

                       

               

       

                       

                   

         

           

               

               

         

                   

               

             

         

               

         

                 

                 

           

                 

               

             

                 

           

             

     

             

             

         

           

     

         

               

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Who should be screened? 

It may be obvious to a child welfare worker

that all adults in the household should be

screened. In addition, other individuals

connected to the case also should be

screened. Substance abuse is an

intergenerational disease; other family

members may have alcohol or drug

involvement. For example, if a child is placed

with relatives, the kinship care provider(s)

should be screened for the child’s safety. The

child welfare worker should look for and

screen a child’s other non‐parent caregivers

and any nontraditional or extended “family”

caregivers, including caregivers not formally

identified as family members.

Older children in the home, including pre‐

teens, should be asked about their own

alcohol or drug use. If the answer indicates

use, the child or teen should receive a

comprehensive assessment by a qualified

professional. Youths who have been abused or

neglected are at greater risk of developing an

alcohol or drug problem. For families involved

with the child welfare system, alcohol and

drug experimentation by family members

(including children) or others in the household

calls for early screening and intervention.

What to do when alcohol or 

drug abuse may be present 1819 

If either the home inspection or screening

indicates that alcohol or drug use may be a

factor in child abuse or neglect, three

important next steps are available to the child

welfare worker: 20 21 22

1. The parents should receive alcohol and

drug assessments from a qualified

substance abuse counselor.

2. If alcohol or drug abuse is present, the

substance use should be addressed in the

case plan. The child welfare and drug

treatment plans should be coordinated.

Methamphetamine use, production and impact

on children

Methamphetamine use is on the rise in the U.S. Once

concentrated on the West Coast, it has now spread

throughout most of the country’s metropolitan areas and

into rural communities as well.18,19 The National Household

Survey on Drug Abuse shows an increase in

methamphetamine use over the last 10 years with 2.3% of

the population having reported using methamphetamine at

least once in their lifetime in 1996, 4% in 2000, 5.3% in

2002, 4.9% in 2004 and 5.8% in 2006.20,21,22

Increased use of methamphetamine across the U.S. resulted

in an escalation in the severity of child abuse crimes and an

increase in child abuse homicides, according to law

enforcement reports and research.23 Methamphetamine

use is known to trigger violence in a way that many other

drugs do not due to the body’s increased production of

dopamine and adrenaline. Children of methamphetamine

users become victims of their parents’ drug‐focused

lifestyles, which are often characterized by neglect, physical

or sexual abuse, domestic violence, and other criminal

activities.24,25,26,27

Because methamphetamine is relatively inexpensive and

fairly easy to make, many children are exposed to dangers

of home‐based labs. According to one source, 30‐35% of

seized methamphetamine labs are in homes where children

reside.28 Children who live in home‐based

methamphetamine labs are exposed to the toxic chemicals,

waste, and filth associated with methamphetamine

production, as well as to the highly psychoactive stimulant

itself. Exposure to the chemicals involved in the production

of methamphetamine can include poisoning, burns, lung

irritation, damage to the liver, kidneys, heart, brain, and

immune system, cancers such as lymphoma and leukemia,

bone marrow suppression resulting in anemia and

increased risk of infections, as well as developmental and

growth problems.29,30,31 Lack of parental supervision often

contributes to children ingesting spoiled, rotten, or

chemically contaminated food, as methamphetamine

solutions may be stored in real food containers.32,33

For more information on methamphetamine use, production

and impact on children see:

Substance Abuse and Mental Health Services Administration

http://www.samhsa.gov

Methamphetamine Treatment Project

http://www.methamphetamine.org

Drug Endangered Children Resource Center

http://www.nationaldec.org/resourcecenter/

resourcecenterhome.html

National Center on Substance Abuse and Child Welfare

http://www.ncsacw.samhsa.gov/resources‐

methamphetamine.asp
                  

               

                   

           

               

  

  

                 

           

                     

             

               

            

    

               

               

         

           

       

           

       

         

         

               

         

                   

             

             

           

                 

                

               

           

             

           

             

               

     

               

                 

               

               

         

             

             

                 

               

           

                 

         

                   

               

               

                     

               

           

                 

               

             

                

             

                 

           

               

             

               

           

               

   

         

         

           

         

         

               

         

         

  

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3. The child should be assessed by a qualified

professional for the impact of parental use and

for the possibility of his or her own use of

alcohol or drugs. Treatment or counseling

needs also should be addressed in the case

plan. 23

Impact of parents’ substance 

abuse on children 24 25 26 

In some families involved with the child welfare

system, children themselves have alcohol and

drug issues. In cases in which a child has begun to

experiment with alcohol or drugs, the child

welfare worker should ensure that the child is

assessed and if indicated, receives treatment. 27 28

However, whether or not children in the family

use substances, parental alcohol or drug use has

significant impact. Children from homes

characterized by parental substance abuse often

experience considerable chaos and an

unpredictable home life. They may receive

inconsistent, emotional responses and

inconsistent care from substance‐using adults.

Issues of abandonment and emotional

unavailability are themes one finds in children of

substance‐abusing parents. The parental alcohol

or drug use may be treated as a family secret;

children may feel guilt, shame, and self‐blame.

2930313233

Children respond in different ways to their

parental substance abuse. Teachers and others

may see a child as withdrawn and shy. Conversely,

a child may be explosive and express rage.

Some children strive to be perfect. Others become

family caretakers by assuming responsibility for

other siblings and by “parenting” their parents.

Emotionally and developmentally, an abused or

neglected child of parents with substance use

disorders is likely to develop issues with trust,

attachment, self‐esteem, and autonomy.

If a mother used substances during pregnancy, the

child could be affected in a variety of ways,

depending on the type of substance used, the

amount used, and the stage of pregnancy during

which the substance use occurred.

The Child Abuse Prevention and Treatment Act

(CAPTA) requires States to refer children under

the age of three who are involved in a

substantiated case of child abuse and neglect to

receive early intervention services. These services

are funded under Part C of the Individuals with

Disabilities Education Act (IDEA). 34

For the reasons stated, it is important for the child

welfare worker to ensure that such children are

evaluated and treated for the impact of parental

alcohol or drug abuse. If a child has been placed in

foster care, the child welfare worker can promote

better foster‐parenting if the foster parents are

cognizant of the specific issues and needs of the

child, and if the foster parents have received

specialized training in working with children from

families in which parents abuse alcohol or drugs.

How to talk to children about 

parental substance use 

The child welfare worker’s role may include

talking with a child about his or her parent’s

substance use. Equally important, the child

welfare worker can help a foster parent or

kinship‐care provider talk with the children in

their care about the parents’ substance use or

dependence. Case workers and caregivers can

provide support and discuss a number of issues

with children:

The Children’s Program Kit: Supportive

Education for Children of Addicted

Parents

This helpful resource is a multimedia

education kit geared towards substance

abuse treatment staff, community groups,

and schools. It can be obtained through the

National Clearinghouse for Alcohol and Drug

Information at (800) 729‐6686 or

http://www.ncadi.samhsa.gov.
                   

                 

                 

                 

           

                 

                 

       

                     

             

                 

         

               

             

           

               

             

               

                   

                   

                 

           

           

                 

             

         

        

        

        

          

      

        

     

           

     

               

               

            

         

           

               

             

             

                 

             

             

                   

             

             

               

             

               

                   

               

             

           

           

             

           

             

   

             

                 

               

               

               

             

             

                       

               

         

             

9

 Addiction is a disease. Your parent is not a bad

person; he or she has a disease. Parents may

do things that are mean or stupid when they

drink too much or use drugs, but this doesn’t

mean that they don’t love you.

 You are not the reason your parent drinks or

uses drugs; you did not cause this disease and

you cannot stop it.

 There are a lot of kids like you. In fact, there

are millions of kids whose parents are

addicted to drugs or alcohol; some are in your

school. You are not alone.

 You can talk about the problem. You don’t

have to feel scared or ashamed or

embarrassed. Find someone you can trust.

Most towns have groups of kids that meet

and talk, such as “Alateen.” A counselor,

teacher, foster parent or other adult you trust

may be able to help you find one of these

groups.35

One way to help children deal with addiction is to

use the 7 Cs of addiction developed by the

National Association for Children of Alcoholics.

Child welfare workers, foster parents, and

relatives can use the 7 Cs to help children

understand that addiction is not their fault.

The 7 Cs of addiction

I didn't Cause it.

I can't Cure it.

I can't Control it.

I can Care for myself

By Communicating my feelings,

Making healthy Choices, and

By Celebrating myself.

Source: National Association for Children of

Alcoholics, on‐line at http://www.nacoa.org

Cultural and ethnic sensitivity 

Only a small percentage of children from homes

with serious alcohol and drug problems come in

contact with the child welfare system. However,

minorities are involved disproportionately with

the child welfare system.36 For example, African‐

American women are more likely to be child

welfare involved than white or Hispanic women

who abuse substances, despite studies that reflect

similar rates of alcohol and drug use. 37, 38 Child

welfare workers must be careful to avoid

assumptions about alcohol and drug use (or non‐

use), type of drugs used, or patterns of use based

on racial or ethnic stereotypes. Substance abuse

professionals commonly refer to alcohol and drug

addiction as an “equal opportunity disease” as it

crosses all racial, ethnic, social, and economic

groups.

Co-dependence 

There are times when one parent abuses alcohol

or drugs and the other parent does not. When a

child welfare worker finds this dynamic, it is

helpful to assess the relationship between the

drug‐abusing parent and the non‐abusing partner

or non‐abusing child. Co‐dependency is a term

used to describe an unhealthy relationship or

unhealthy interactions that may occur between

family members and friends, and alcohol or drug‐

abusing individuals.

Those in a co‐dependent role may assume

responsibility for the alcohol and drug use by the

other family member. Children may think that if

they made better grades, were not naughty, or

were better children, their parent would not use.

Similarly, spouses may attempt to control the

environment to prevent their partner from alcohol

or drug abuse, and may believe it is their fault if a

spouse or partner drinks or uses drugs. The

substance‐abusing parent may reinforce this

flawed thinking and blame the non‐using parent.
             

                 

           

                 

                 

         

   

               

             

               

               

                     

         

                     

                 

         

                   

                 

           

             

   

A co‐dependent parent often has a family history

of substance abuse by one or more parent or

relative. As a result of the intergenerational

nature of the disease of addiction, children in the

family are more likely to continue the cycle by

becoming co‐dependent or alcohol or drug

dependent themselves.

It is important for non‐using parents to receive

support and counseling about ways to make

healthy and safe choices for themselves and their

children. A goal for a non‐substance using parent

is to accept that he or she cannot change a spouse

or partner’s addiction. A non substance‐using

parent only can effect change in his or her own life

and can take action to enhance the safety and

well‐being of their children. When co‐dependency

is an issue, it should be addressed in the child

welfare case plan. At the end of this document,

several self‐help resources are presented for

family members of individuals who abuse alcohol

or drugs.

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11

Substance Abuse 

Treatment: Developing and 

Implementing a Plan for

Management of a Lifelong

Disease 

This section provides an overview of substance

abuse treatment. It presents treatment principles

and special treatment considerations. Most

important, the difference between treatment and

recovery is discussed.

Detoxification is a process of treating

individuals who are physically dependent on

alcohol or drugs, and includes the period of

time during which the body’s physiology is

adjusting to the cessation of substance use.

In some cases detoxification may be a

medical necessity; untreated withdrawal

may be medically dangerous or even fatal.

Source: TIP 19: Detoxification From Alcohol and

Other Drugs. DHHS Publication No. (SMA) 95‐

3046 available through the National

Clearinghouse for Alcohol and Drug Information

at (800) 729‐6686 or

http://www.ncadi.samhsa.gov

What is treatment? 

A number of alcohol and drug treatment models

are used successfully; treatment can include a

variety of services and activities. Levels of

treatment can range from outpatient, day

treatment, and short‐ and long‐term residential

programs, to inpatient hospital‐based programs.

Prior to beginning treatment, some individuals

require detoxification and stabilization.  

Other individuals may need outreach services to

help overcome barriers to treatment. Treatment

may involve a single service or a combination of

therapies and services. A partial list of treatment

services includes:

Assessment and treatment planning

Prescription of certain drugs, such as

antabuse for alcohol dependence, or

methadone and buprenephrine for heroin

addiction

Crisis intervention

Case management to coordinate among the

treatment provider, child welfare agency,

and other services needed

Individual and group counseling and

psychotherapy

Alcohol and drug abuse recovery education

Medical assessment and care

Acupuncture, diet, physical exercise, and

other nontraditional services

Self‐help groups or 12‐step programs, such

as Alcoholics Anonymous (AA) or Narcotics

Anonymous (NA)

Trauma‐specific services and mental health

services

Other specialized services also may be needed as

part of a comprehensive treatment plan,

depending on a child’s or parent’s other medical or

psychological needs. Specialized services may

address domestic violence, mental illness,

childhood trauma, multi‐drug use, HIV/AIDS, or

other issues linked to the parent’s substance

abuse.  

The duration of treatment can range from weeks

or months to years. The type, length, and intensity

of treatment are determined by the severity of the

addiction, type of drugs used, support systems

available, personality, and other behavioral,

physical, or social problems of the addicted

person. It is important to think about treatment as

management of a lifelong disease such as diabetes

or high blood pressure, rather than crisis

intervention such as emergency treatment for a

broken leg.  
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The treatment plan should be developed based on

information gathered in the substance abuse

assessment process.

Matching substance‐abusing parents to treatment

involves matching the severity of substance use to

intensity of service.39 Among the issues to

consider are the following:

Acute intoxication and/or withdrawal

potential—What risk does the parent’s level of

intoxication or withdrawal present?

Biomedical conditions and complications—
 

Does the parent have illnesses or chronic
 

conditions that affect treatment?
 

Emotional/behavioral conditions and
 

complications—Does the parent have
 

psychological or other problems that need
 

specific mental health services?
 

Treatment acceptance/resistance—Does the

parent object to treatment or disagree with

the substance abuse diagnosis? If the parent

agrees to treatment, is the compliance to

avoid a negative consequence, or is the parent

internally motivated to address their alcohol or

drug problems?

Relapse/continued use potential—How aware is

the parent of relapse triggers and what skills

does he or she have to cope with cravings or life

stresses and the impulse to use?

Recovery environment—Does the parent have

family relationships and friendships that

support treatment and recovery? Conversely,

are there family members, significant others,

relationships, or living situations that may

sabotage or threaten treatment engagement

and success?

12
 

National Institute on Drug Abuse (NIDA)

Treatment Principles (excerpt)—NIDA has

developed 13 research‐based treatment principles

that are important to the recovery process. An

abbreviated list is included here. For a complete

listing in English or Spanish, please access

http://www.nida.nih.gov/podat/PODATIndex.html

No single treatment is appropriate for all

individuals. Treatment and services should

be matched to the person’s problems and

needs.

Treatment needs to be readily available.

Parents and children who need treatment

need it now.

Effective treatment attends to multiple

needs of the individual, not just his or her

drug use. Medical, psychological, social,

vocational, and legal problems must be

addressed, in addition to substance

addiction.

Remaining in treatment for an adequate

period of time is critical for treatment

effectiveness. A child welfare worker can

help prevent a parent from leaving treatment

prematurely.

Treatment does not need to be voluntary to

be effective. Court‐ordered treatment, an

employment mandate, or family insistence

can increase treatment entry, retention, and

success.

Possible drug use during treatment must be

monitored continuously. Monitoring can

help reduce the desire to use and provide

early warning of use if a slip or relapse

occurs.

Treatment programs should provide

assessment for HIV/AIDS, hepatitis B and C,

tuberculosis and other infectious diseases,

and counseling to help patients modify or

change behaviors that place them or others

at risk of infection. Counseling can help

parents avoid high‐risk behavior and help

those who are already infected manage their

illness.

Recovery from drug addiction can be a long‐

term process and frequently requires

multiple episodes of treatment. Relapses

often occur during or after successful

treatment episodes. Relapse prevention

plans, self‐help groups, and other supports

can help minimize relapse and support

abstinence.
             

               

           

                 

           

           

                 

               

             

           

               

           

               

           

             

         

                 

           

                   

         

               

                   

               

               

               

           

           

                         

                                 

     

         

       

           

                     

           

             

           

                     

                   

         

             

       

               

               

               

         

             

               

           

               

               

         

             

           

         

             

          

           

               

             

                  

             

               

       

             

   

                           

                         

  

  

             

                         

                 

             

       

               

           

         

  

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What is recovery? 

Treatment does not equal recovery. Treatment is

an important part of recovery, but recovery is

much more than obtaining sobriety. “Recovery

from alcohol and drug problems is a process of

change through which an individual achieves

abstinence and improved health, wellness and

quality of life.” 40 Recovery is a process of making

lifestyle changes to support healing and to regain

control of one’s life. Recovery involves being

accountable and accepting responsibility for one’s

behavior. It is the process of establishing and re‐

establishing patterns of healthy living. Individuals

talk about being “in recovery” as opposed to

having “recovered,” because recovery is viewed as

an ongoing process. Persons in recovery monitor

their feelings, physical changes, and relationships

to make healthier choices and to reduce the risk

of relapse. Hence the Alcoholics Anonymous

adage, “Recovery happens one day at a time ... for

the rest of your life.”

There are different stages of recovery. A parent

who has been drug‐free for a week and one who

has been drug‐free for a year experience different

issues. Recovery is complicated. It may be helpful

to view recovery as a developmental process. The

developmental model of recovery describes stages

and tasks as part of recovery:

Transition—Parent recognizes that her or his
 

attempts to “control” substance use are not
 working
 

Stabilization—Parent goes through physical

withdrawal and begins to regain control of her

or his thinking and behavior

Early recovery—Parent changes addictive
 

behaviors and develops relationships that
 

support sobriety and recovery
 

Middle recovery stage—Parent builds a more

effective lifestyle and repairs lifestyle damage

that occurred during substance use

Late recovery stage—Parent examines his or

her childhood, family patterns, and beliefs that

supported a dysfunctional lifestyle; the parent

learns how to grow and recover from

childhood and adult traumas

Maintenance stage—Parent learns to cope in a

productive and responsible way without

reverting to substance use 41

Treatment and recovery issues 

specific to women 

Just as gender‐specific issues arise in addiction,

gender‐specific considerations are important in

treatment and recovery. While there is still much

to learn about effective treatment for women and

how it differs from treatment for men, research

studies have begun to identify gender‐specific

components and issues to address in treatment.

Research indicates that women are more likely to

complete treatment in women‐only programs and

that women have different needs than men in

treatment (such as dealing with a history of

victimization). Women’s treatment success may

depend on meeting those needs. For example:

Often women in treatment have low self‐

esteem, little self‐confidence, and feel

powerless. It is important to address these

issues to improve treatment effectiveness.

Since women appear to become addicted

more rapidly than men, by the time they

enter treatment, their addiction may be more

severe, which affects the level and intensity of

treatment needed.

Use of support groups may have greater

benefits for women. In a study of pregnant

addicted women, support group participation

resulted in better outcomes for mothers and

their infants.42

Participation in group counseling appears to

influence a lower rate of relapse for women.

In addition more intense participation in

treatment is related to lower rates of

relapse.43

In the general population, women have twice

the rate of depression as men,44 and one‐third

of women who enter substance abuse

treatment have experienced clinical

depression in the past year.45

Between 50‐75% of persons in treatment have

a co‐occurring mental disorder, including

panic attack and other anxiety disorders; it is

critical that women’s treatment identify and

incorporate mental health services as

needed.46

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A continuing relationship with the treatment

provider, particularly for women, is important

in the recovery process.

Research shows women receive the greatest

benefit from alcohol and drug treatment

programs that provide comprehensive

services.

When child welfare workers seek treatment for a

substance‐abusing mother, gender‐specific

components are important considerations. It may

be helpful to think in terms of a comprehensive

treatment model with the following three levels of

services for women with substance abuse: 47

1.	 Clinical treatment services: Outreach and

engagement, screening, detoxification, crisis

intervention, assessment, treatment planning,

case management, substance abuse counseling

and education, trauma specific services,

medical care, mental health services, drug

monitoring, and continuing care.

2.	 Clinical support services: Primary health care

services, life skills, parenting and child

development education, family programs,

educational remediation and support,

employment readiness services, linkages with

legal system and child welfare system, housing

support, advocacy, and recovery community

support services.

3.	 Community support services: The following,

when available in the community, support

long‐term recovery: Recovery management,

recovery community support services, housing

services, family strengthening, child care,

transportation, Temporary Assistance for

Needy Families (TANF) linkages, employer

support services, vocational and academic

education services, and faith‐based

organization support.

In addition to being gender‐specific, treatment

should be culturally relevant. Roles, values, and

beliefs should be respected, and the treatment

milieu should be compatible, whenever possible.

For example, some cultures have healing practices

and traditions that are important to families.

The traditional healing practices may be important

tools in treatment and recovery. Effective

treatment programs routinely examine and

remove potential barriers to treatment and

address language needs, when indicated.

Treatment also must be geographically accessible.

The child welfare and alcohol and drug services

programs may need to collaborate on

transportation, visitation with children and other

issues related to distance. Last, for individuals

involved with the child welfare system, treatment

must be family‐focused. Issues of

intergenerational substance abuse, family

relationships and dynamics, and parenting are

among concerns to be addressed.

How effective is treatment and 

recovery? 

Decades of research have demonstrated that

treatment works. Studies of publicly supported

treatment programs show a savings of $7 or more

in other societal costs for each dollar invested in

treatment.48 Studies indicate drug treatment

reduces use by 40‐60% and significantly lowers

criminal activity. However, treatment must be

available, accessible, and individualized. The

importance of a holistic approach to treatment

effectiveness cannot be overemphasized. The

parent must be matched to the appropriate

treatment program in terms of intensity, duration,

and treatment content. To improve effectiveness,

the parent must complete all or most of

treatment.

It is not enough to treat only the addiction. For

recovery to occur, the child welfare and alcohol

and drug services partnership must identify and

treat other co‐occurring psychological, physical,

and social problems. Similarly, it is important to

identify other issues to determine their impact on

substance use and to address these issues in

treatment. For example, alcohol consumption may

result in aggression, but it may also result in

increased victimization. It is important to identify

and work with either or both issues as they affect

parents and children involved with the child

welfare system.

An important role of the child welfare worker is to

support treatment and to help reduce barriers to

that treatment. Even if a parent does not achieve

complete abstinence, substance abuse treatment

14
 
   

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can reduce the number and length of relapses,

lessen related problems such as crime and poor

physical and mental health, minimize the impact

of parental substance use on children, and

improve individual and family functioning.49

Self-help or 12-step groups 

One common addition to treatment is

participation in self‐help or 12‐step groups, such

as Alcoholics Anonymous (AA) or Narcotics

Anonymous (NA). Some areas have Cocaine

Anonymous and Crystal Meth Anonymous groups,

as well. Most alcohol or drug self‐help groups are

based on 12‐steps originally developed by AA,

which begin: “I admit that I am powerless over my

addiction and that my life has become

unmanageable.” The self‐help groups can

complement treatment and often are

recommended during and after treatment. Self‐

help groups augment treatment but are not in and

of themselves treatment.

Interventions for substanceusing, but non-addicted parents 

Some parents involved with the child welfare

system may abuse alcohol or drugs, but are not

clinically diagnosed as

dependent. Alcohol and

drug use without

dependence still can lead

to serious concerns about

parenting and the safety

and welfare of children.

Because treatment may

be indicated, it is important to address effective

interactions between the child welfare worker and

parent under these circumstances.

Conversation about the reality of substance abuse

and the connection to child safety should be

initiated regularly and routinely by the child

welfare worker. Initiating and continuing the

dialogue about alcohol and drug abuse is

important. Even if the parent or family is

uncomfortable or attempts to minimize the

Every contact

between the child

welfare worker

and parent is an

opportunity for

intervention.

substance use, the child welfare worker should

not shy away from talking about the substance

abuse. An open, direct, and “matter‐of‐fact”

approach by the child welfare worker to address

the parent’s alcohol or drug use can be an

important step to facilitate motivation and entry

in treatment.

Social workers and other child welfare

professionals can improve their skills by using

techniques from a substance abuse treatment

approach known as “brief interventions.” The goal

of a brief intervention is to reduce the risk of

alcohol and drug use by motivating a person to act

to change their substance use.  

Substance abuse counselors may choose a brief

intervention model to work with persons with

mild‐to‐moderate substance use. Brief

interventions also have been used by treatment

providers on an interim basis for those on

treatment waiting lists or to engage someone

needing specialized treatment.

Components of brief interventions—Six

components (using the acronym FRAMES) offer

techniques that may be helpful to child welfare

workers when involved with substance abusing

parents.

F—Feedback regarding the parent’s impairment or

risk behavior

R—Responsibility for change is the parent’s

A—Advise on possibilities for change

M—Menu of treatment and self‐help alternatives

is offered to the parent

E—Empathic and non‐blaming style is used by the

social worker

S—Self‐efficacy or positive empowerment is

facilitated in the parent

For more information on FRAMES and other brief intervention

techniques, see TIP 34 Brief Interventions and Brief Therapies for

Substance Abuse available through the National Clearinghouse for

Alcohol and Drug Information at http://www.ncadi.samhsa.gov.
16

How to Motivate Parents 

into Treatment and 

Enhance Treatment 

Readiness 

Parenting and custody of one’s children are

powerful motivating factors for women to seek

treatment and maintain recovery. When a parent

has a positive screen or an in‐home investigation

suggests alcohol and/or drugs are a factor in

abuse or neglect, it is important to communicate

the gravity of the circumstances.

Parents need to be

told about the time

requirements for

compliance with

the Adoption and

Safe Families Act,

and why it is

critical that an

alcohol and drug

assessment and

treatment, if indicated, must occur in a timely

manner. The child welfare worker should explain

that the child welfare system is built on the belief

that each child deserves a safe, stable, and loving

home. The parent(s) always should be asked to

help accomplish the goals of safety, permanency,

and child well‐being. If possible, parents should be

engaged as partners in working toward

reunification or another permanent living

arrangement for the child.

An appropriate goal for a child welfare worker

working with an alcohol or drug‐involved family is

to understand and help create conditions that

lead to change. Motivation is not a personality

trait, rather it is a dynamic state that can be

modified. One way that child welfare workers can

enhance their own effectiveness is to operate

from the philosophy that “lack of motivation to

change is a challenge to therapeutic skills, not a

fault for which to blame the parent.” 50  

The child welfare worker

should be direct, without

threatening, when

communicating with the

parent about his or her

alcohol and drug abuse

and the need for child

safety and permanency.

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Readiness for change 

Child welfare workers can collaborate with their

alcohol and drug services colleagues to facilitate a

parent’s readiness to change his or her substance

use and related high‐risk behaviors. As part of the

change process, it is important to identify the

extent to which the parent recognizes problem

behaviors and is ready to change. Some parents

may feel ambivalent about change. Among the

reasons for such ambivalence are: current

behaviors seem to work; parents view their

behaviors as normal; they are comfortable with a

passive role (someone else must fix it for me); or it

seems too hard or overwhelming to change.

Ambivalence is viewed as positive because it

opens the door to examination of other options.

Ambivalence should not be confused with

rationalizations intended to justify and maintain

the status quo.

Ambivalence about change allows exploration

of costs of status quo, and benefits of change

versus costs of change and benefits of status

quo.  

Readiness to change factors:

Perception of need to change

Belief that change is possible and can be

positive

Sense of self‐efficacy to make the

change

Stated intention to change

Several “readiness to change” questionnaires are

available,51 and the alcohol and drug services

program may assess readiness to change as part

of its evaluation process.
       

           

             

               

                 

               

                 

               

           

                 

             

           

                   

                 

           

                 

         

               

               

           

         

             

         

Motivation to change 

Motivation to change and motivational

interventions go hand‐in‐hand with readiness to

change and the change process. Prochaska &

DiClemente described a model of the series of

changes a person must go through in order to

change or resolve a problem. They suggest that

change can be visualized as a circle with segments

of the circle representing stages in the change

process, as represented in the graphic below.52

During the process of change, it is normal to

fluctuate between stages. One reason why this

model of change is helpful for alcohol‐ and drug‐

abusing parents is that relapse is built‐in as part of

the process and is not viewed as treatment failure.

The child welfare worker, substance abuse

counselor, and significant persons in the life of a

substance‐abusing parent can promote and

support motivation to change. The table on the

following page describes the stages of change and

identifies motivational tasks for the child welfare

worker to address with the substance‐abusing

parent. The child welfare professional should work

in collaboration with the substance abuse

counselor.

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18

Parent’s Stages of Change Motivational Tasks for Child Welfare Worker

Pre‐

contemplation

Motivational interviewing is a technique in which the clinician becomes a

helper in the change process and expresses acceptance of the individual

he or she is working with. The role of the clinician in Motivational

Interviewing is directive, with a goal of eliciting self‐motivational

statements and behavioral change. The five general principles to be

practiced by a clinician using motivational interviewing include:

No perception of having a

problem or need to change

Increase parent’s perception of the risks and problems

with their current behavior; raise parent’s doubts about

behavior

Contemplation Initial recognition that

behavior may be a problem

and ambivalence about

change

Foster and evoke reasons to change and the risks of not

changing; tip the balance toward change

Decision to

change

Makes a conscious decision

to change. Some motivation

for change identified

Help parent identify best actions to take for change;

support motivations for change

Action Takes steps to change Help parent implement strategy and take steps

Maintenance Actively works on sustaining

change strategies and

maintaining long‐term

change

Help parent to identify triggers and use strategies to

prevent relapse

Lapse or

relapse

Slips (lapses) from change

strategy or returns to

previous problem behaviors

patterns (relapse)

Help parent re‐engage in the contemplation, decision, and

action stages

Motivational interviewing is a practice technique used by many alcohol and drug services professionals.

Motivational interviewing assumes that people are comfortable with their drug‐related behaviors and

that those behaviors serve some functional purpose in their lives. Part of this technique includes

exploring what they see as the positive and negative aspects of their drug‐related behaviors. The goal of

motivational interviewing is to help parents to develop self‐motivational positions to change their use

and related behaviors.

Child welfare workers

can use motivational

interviewing as a

strategy to help parents

improve their self‐

esteem and feelings of

competence. It is critical

that a parent feel he or

she has the ability to

change.

Express empathy through reflective listening.

Develop discrepancy between clients’ goals or values and their

current behavior.

Avoid argument and direct confrontation.

Adjust to client resistance rather than opposing it directly.

Support self‐efficacy and optimism.

Source: U.S. Department of Health and Human Services. (1999). Enhancing Motivation for

Change in Substance Abuse Treatment. Publication No. SMA 02‐3629. Rockville MD:

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services

Administration.
19

How to Support and

Facilitate Recovery and 

Enhance Treatment 

Effectiveness 

Just as recovery is much more than achieving

sobriety, sustaining change is much more than

achieving short‐term change. Retention in

treatment is a critical factor in recovery, and child

welfare workers can be sensitive to and help

parents address issues that can enhance or hinder

their retention in treatment and recovery. Part of

recovery is learning to pay attention to stressors

and “triggers” that put parents at risk of alcohol

and drug use. For example, substance use may

have served an anesthetic function as a way to

avoid dealing with feelings or trauma. For parents

Child welfare workers, in collaboration

with substance abuse counselors, can

assist parents to view substance use or a

relapse episode as a means for learning to

identify what triggers desire or cravings to

use.

not in tune with their feelings, learning to pay

attention to physiological and emotional states

can help them recognize potentially stressful

situations and take action to reduce the impact of

those situations. Common stressors include

returning home to a substance‐using environment

after treatment, or being with friends or family

members who use drugs or alcohol. Supporting

recovery may include assisting the parent in

finding drug‐free housing and encouraging the

parent’s efforts to develop new friendships and

relationships that support sobriety.  

  

Relapse and relapse prevention 

Relapse is not the same as treatment failure.

Recurrence of substance use can happen at any

point during recovery. When a parent relapses, it

is important to help the parent recognize the

difference between a lapse (a period of substance

use) and relapse (the return to problem behaviors

associated with substance use), and to work with

the parent to re‐engage him or her in treatment

as soon as possible. It also important to note that

a urine toxicology screen will not tell you whether

the individual has had a lapse versus a relapse.

Relapse prevention includes: “What can a

parent do differently?” For example, if

emotions around holidays spent with family

members result in high stress and a desire

to use, what can be done differently to

minimize stress? Or what can the parent do,

to minimize the emotional impact of alcohol

and drug use on the child? For example,

one mother arranged for her daughter to

participate in a weekly support group of

teens with addicted parents, as the mother

struggled (sometimes unsuccessfully) to

maintain sobriety.

Part of effecting long‐term change includes

working with parents to identify the specific

factors that preceded their substance use—What

were the emotional, cognitive, environmental,

situational, and behavioral precedents to the

relapse?

Child welfare workers can help a parent plan for

the potential of relapse and for ensuring safety of

the child. Parents who learn triggers can become

empowered to plan proactively for the safety of

their children and to seek healthy ways to

neutralize or mitigate the trigger. One element in

the process of recovery is to develop a relapse

prevention plan and strategies.
               

               

             

                   

             

             

                 

                   

                   

                 

             

         

             

               

             

               

               

       

                 

             

               

               

               

             

               

       

       

         

           

             

           

             

               

             

             

           

               

                 

   

               

               

           

           

             

       

             

             

                 

                  

                 

               

           

               

             

               

             

       

               

               

               

               

           

                 

           

               

                 

               

             

             

               

                   

                 

                 

                 

                 

           

               

         

             

           

               

               

Self-help groups and recovery 

Support of self‐help groups can help maintain a

clean and sober lifestyle. Participation in a 12‐step

program gives a parent a “sponsor”—a group

member in recovery who serves as a mentor. It is

appropriate for the child welfare worker to

support a parent’s participation in self‐help groups

and for the child welfare worker to ask questions,

such as: Does the parent have a sponsor? How can

the sponsor have a role in planning for the safety

of the child? Self‐help groups also exist for family

members of addicts, and some groups are

specifically for children. Examples include: Al‐

Anon, Alateen, and Nar‐Anon (see resources listed

at the end of this document). These groups

provide support for family members, help them

learn about addiction, and that they are neither

responsible for the addiction nor can they cure

the addicted family member.

Culture as a factor in recovery 

One factor in relapse may be that the treatment

plan did not adequately address cultural, ethnic,

or language issues. Both child welfare and alcohol

and drug services programs should work to recruit

staff with backgrounds similar to those of parents

receiving services. Staff should be trained in

cultural issues, and be able to identify and

eliminate discriminatory language and behaviors.

Agencies should offer specialized programming

and bilingual counselors. The therapeutic

environment should provide sensitivity to spiritual

beliefs and values. Recovery can often be

enhanced and sustained by incorporating healing

and support systems from the parent’s culture.

Supporting recovery for women 

Just as the etiology and physiology of addiction

may differ between men and women, the

recovery process also appears to differ. For

example, women in treatment relapse less

frequently than men do; while in treatment they

are more likely to engage than men, particularly in

group counseling.53

One study of women cocaine users found that

when women relapse, they were more likely than

men to report negative emotions or interpersonal

problems before the relapse. Women also

appeared more impulsive in their return to use.54

Additional psychotherapy may help women

manage these issues to help reduce the

occurrence or duration of relapse. Men were

more likely to report positive feelings and a belief

they could control their drug use prior to

relapse.55

As discussed previously, it is important to use a

holistic approach with women in treatment and to

avoid an assumption that retention problems

reflect a lack of cooperation. Women experience a

variety of barriers that interfere with treatment

participation. Hence, it is critical to examine and

address issues that can create barriers to

treatment success, among them: transportation,

childcare, health, and support or sabotage from a

partner or other family member. The child welfare

worker can help a mother identify and coordinate

the various services she needs to help reduce

barriers to recovery and treatment success.

While family members can play a key role in

supporting the treatment and recovery process,

significant others can also sabotage treatment. If a

spouse continues to use alcohol or drugs, it is

much more difficult to make the lifestyle changes

necessary for recovery; the accessibility of a

partner’s drugs can exacerbate cravings. A woman

may benefit from drug‐free safe housing. If family

violence is an issue, a woman may be at higher

risk of domestic violence when she begins to make

treatment progress or if she takes steps to leave

an abusive partner. Children in the home at this

time also may be at increased risk from the

abusive partner. Research findings reveal that

between 30‐60% of men who batter their female

partners also abuse their children. 56

Important actions by the child welfare worker

during treatment and recovery include regular

contact with a mother and recognizing risks and

potential of danger to the mother and children.

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Helping develop aftercare step‐down services also

is a valuable support that the child welfare worker

can facilitate to help sustain recovery.

If children have been removed from the home, a

mother’s regular and frequent visitation with her

children and planning for their return are factors

that can motivate continued abstinence. However,

some treatment programs prohibit visitations

during early stages of treatment. Restricted

visitation between a mother and her children by

the treatment program creates a conflict with the

child welfare expectation of frequent parent‐child

visits as part of the reunification plan. Child

visitation should be addressed by child welfare

and substance abuse treatment providers in the

development of a collaborative case plan. Rather

than a blanket rule regarding visitation between

parent and child, it may be more appropriate to

look at the factors affecting a specific case to

make an individual determination.

The freedom and stability of recovery are benefits

that persons in recovery have identified as

important. Helping a parent understand how his

or her life is better is an important support for

recovery. Many recovering individuals also talk

about a new appreciation of everyday tasks, such

as reading a story with their child, having a family

meal together, or going to a park with their

children.

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Ways to Facilitate CrossSystem Communication 

and Collaboration 

Collaboration between child welfare and

substance abuse treatment professionals is more

than networking or cooperation. It means forming

a partnership. Collaboration is a mutually

beneficial and well‐defined relationship, entered

into by two or more entities to achieve common

goals. For those concerned about the welfare of

children, collaboration provides the opportunity

to improve child safety and support the recovery

of parents.

When considering the development of a

collaborative relationship, child welfare workers

may want to ask themselves:

Why should I partner with local treatment
 

programs?
 

Why should the substance abuse agency

partner with me (i.e., what do I have to offer)?

How do I partner with my substance abuse

colleagues?

What issues and services should be included

in the collaboration?

How can I increase the chances for a
 

successful collaboration?
 

Each question is discussed on the following

pages.

Why should I partner with local 

treatment programs? 

Shared planning and service delivery lead to

practices that better meet the needs of children

and families. Through collaboration, multiple

agencies working with the same family can reduce

confusion and fragmentation for the family

members and improve coordination of services.

Collaboration with local treatment programs can

provide the expertise that is needed for a family in

the child welfare system.

If the protective services on‐site investigation and

screening of parents suggest that alcohol or drug

abuse is a factor in the abuse or neglect,

substance abuse treatment providers are needed

to:

Conduct a substance abuse assessment or
 

evaluation;
 

Help identify the level and type of treatment

program that is needed;

Provide treatment and aftercare services; and

Participate in case management and
 

monitoring.
 

In addition, substance abuse treatment agencies

may be able to provide crisis intervention, trauma‐

related services, or other services needed by the

parent.

Provisions of the Child Abuse Prevention and

Treatment Act require that substance‐exposed

births be reported to the child protective services

agency. The substance abuse treatment

community can provide invaluable assistance to

their child welfare partners in the development of

appropriate responses and services under the new

requirements.

Why should the substance abuse 

agency partner with me? 

The first goal of a substance abuse counselor for

clients is generally to “help them stop using

substances and maintain abstinence.” 57 This goal

is not easily accomplished. Substance abuse and

dependency, treatment, and recovery are complex

and multi‐faceted. By working collaboratively with

the child welfare worker, the substance abuse

counselor may be able to provide more effective

treatment for persons involved with both systems

and incorporate a more holistic approach.

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Parenting issues tend to be a significant factor in

recovery, particularly in women’s treatment.

When the substance abuse counselor works in

concert with the child welfare worker, the

motivation for change and treatment

effectiveness may be enhanced. Parenting skills

and child safety in the family are areas in which

the child welfare worker has expertise that may

be useful in development of the treatment plan.

In addition, the child welfare worker can play an

important role in educating the substance abuse

treatment provider, and reminding parents in

treatment, about the Adoption and Safe Families

Act timelines and case plan requirements where

failure to comply could lead to termination of

parental rights.

How do I partner with my 

substance abuse colleagues? 

Research on effective collaborations provides a

series of principles that can serve as a guide for

developing partnerships to improve services to

vulnerable children and families:

Mutual respect, understanding, and trust;

Open and frequent communication;

Partners see collaboration in their interest;

A mutual sense of ownership;

Formal and informal communication; and

Concrete, attainable goals and objectives. 58, 59

Steps child welfare workers can take toward

collaborating with substance abuse treatment

providers include:

Understand that different values do not

preclude collaboration or the development of

joint goals for systems or for individual cases.

Learn about your potential partner. Locate or

create an inventory of treatment programs.

You can start with the Substance Abuse and

Mental Health Services Administration

treatment locator website at

http://www.findtreatment.samhsa.gov.

Many areas have local directories available

through organizations such as the United

Way, a service agency, or county government.

Find out: Are women’s treatment programs

available? What intensity of treatment is

offered—day treatment, residential, a

therapeutic community? Are children’s

services also on‐site?

Establish relationships. Look for what you

have in common, not just the areas that

divide you. Learn about the treatment

program’s philosophy, the goals of treatment,

and the services provided. What are the child

welfare and alcohol and drug services

agencies each trying to accomplish? Where is

the common ground between the two

systems?

Understand and value substance abuse

counselors and the contributions each of you

makes to the community. What roles do child

welfare and substance abuse professionals

play in the community? It is important for

child welfare workers to be open and

communicative about the child welfare

agency, and to respect and try to understand

your alcohol and drug services partner’s

framework. Conversely, it is important for

substance abuse counselors to be open and

communicative about the substance abuse

treatment program, and to respect and try to

understand the child welfare framework.

Most importantly, how can the child welfare

worker and substance abuse counselor work

together to do a better job? Openness and

communication are building blocks for trust.

Acknowledge and learn about each other’s

boundaries. Workers in all systems work

within boundaries and parameters. Generally,

the parameters and current practice are

intended to enhance ethical and effective

services. Sometimes system and practice

requirements are perceived as barriers by

those in other agencies. Workers need to look

for ways to improve communication.

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Both child welfare and alcohol and drug

services workers improve their ability to

navigate each others systems when they

begin to understand and accept the

limitations, parameters, issues, and practices

of their partner.

Ask your supervisor for help. Your supervisor

may know if cross‐training is available

between child welfare and substance abuse

agencies, or if inter‐agency agreements exist

between the two systems. To be most

effective, collaboration should occur at all

levels of your organization, not just at the

level of direct services. However, even if the

child welfare and alcohol and drug services

agencies lack a formal memorandum of

agreement, partnerships can be created

between service units and between workers

in the two systems.

Identify specific areas for collaboration.

When you are ready to collaborate, define the

subset of tasks and responsibilities in each

area, and determine who will be responsible

for each task. The result is a roadmap of

shared responsibility, ownership, and

outcomes for a family served by both

agencies.

What issues and services should 

be included in the collaboration? 

This section has three parts:

1.	 What information about substance abuse

treatment will help a child welfare worker

work with families? What do I need to learn

from the treatment counselor?

Confidentiality—Treatment for alcohol and

drug abuse is the only client counseling area

governed by Federal confidentiality

regulations (as opposed to State laws).

Alcohol and drug services programs use

consent forms specifically designed to

incorporate Federal requirements. The form

must address the purpose of disclosure and

how much and what types of information are

being disclosed. It must explain that

redisclosure is prohibited unless expressly

permitted in the signed consent. Child welfare

workers and child welfare agencies should use

consent forms designed or approved by the

alcohol and drug services provider. Different

consent forms are used to release alcohol and

drug treatment information to courts, with

the primary difference being that the criminal

justice form does not permit revocation,

unlike the consent to release information to

the child welfare agency which permits

revocation of consent at any time. A court

order or consent is required even when a

parent is mandated into assessment or

treatment. “Confidentiality of Alcohol and

Drug Abuse Patient Records” requirements

are found in Volume 42 of the Code of Federal

Regulations, Part 2 (42 C.F.R. Part 2). The

Health Insurance Portability and

Accountability Act (HIPAA) also protects use

and disclosure of certain health information

through national standards available at

http://www.hhs.gov/ocr/hipaa.

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Cycle of addiction—The collaboration should

ensure that child welfare workers have an

understanding of the nature and progression

of the disease of addiction.

Relapse is an opportunity for intervention

and may be part of enhancing recovery—

When child welfare workers share this

understanding of relapse, they can work with

their alcohol and drug services partner and

parents to create plans to address child

safety.

Longer time in recovery is positive—

Successful treatment outcomes are related to

length of time in treatment. Therefore, it is

important to connect a person in need of

treatment to a treatment program as soon as

possible. This is especially important for

individuals involved with the child welfare

system due to the timelines of the Adoption

and Safe Families Act.

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2.	 What information about child welfare will

help substance abuse counselors work with

parents in treatment? Or, what does the

treatment counselor need to learn from me?

Understanding and navigating through the child

welfare system is a challenge even to those who

work within it. For those outside the system, it is

even more difficult to understand. The rules are

neither intuitive nor obvious. Child welfare

workers can help demystify the child welfare

system.

Explain the role of a child welfare worker.

Help the substance abuse counselor

understand that child welfare actions are

driven by a priority for immediate child safety,

the need to prevent future risk, and that

safety and risk must be assessed throughout

the period that the case is active.

Help the substance abuse services provider

understand your timelines under the

Adoption and Safe Families Act. The substance

abuse counselor should be aware of the

applicable Adoption and Safe Families Act

rules and court processes and how they affect

the child welfare case plan.

Share specific child welfare parameters for

each case receiving alcohol and drug services.

For example, is this an in‐home case or has

the child been removed from the home? Have

one or more children been removed, while

one or more children remain in the home? Is

it a voluntary case or is the court involved?

What are the court dates and case plan

requirements? Explaining the child(ren)’s

placement and the voluntary or involuntary

nature of the case can also be used by the

substance abuse counselor to facilitate

treatment.

Explain the development of court reports,

including the types of information needed to

show progress on the child welfare case plan,

hearings schedule and procedures, and

importance of including information regarding

the parent’s treatment and recovery progress.

 Share permanency plans. What is the

permanency goal for the child? Is there a goal

of reunification? What is the optimum parent‐

child visitation schedule? Is there a concurrent

plan? Discussing permanency, concurrent

planning (if applicable) and how the parent’s

progress will be determined in the case plan is

important to the child welfare‐alcohol and

drug services partnership; it impacts the child

welfare case plan and the alcohol and drug

services treatment plan.

3.	 What specific areas should be included in the

collaboration?

The partnership between a child welfare worker

and substance abuse counselor works best when

both parties share mutual ownership. Both

professionals have resources they can bring to

bear on a family’s needs. Areas to consider for

child welfare‐substance abuse treatment

collaboration include:

In‐depth assessment of parents’ and

children’s needs, including a substance abuse

assessment.

Services to be provided if there is a waiting

list for treatment. For example, regular and

frequent contact with the parent, brief

interventions with the parent, or other

strategies while the parent waits for the

desired level of treatment to become

available should be designed and arranged.

Case planning.

Integration of case plans or a joint
 

treatment/child welfare case plan.
 

Engagement of parent and retention in
 

treatment.
 

Identification and inclusion of other potential

partners and needed services, such as:

income support, mental health, domestic

violence services, childcare, employment

training, health care, and housing programs.

Child visitation.

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26

Supportive or counseling services for the

child, including services for the child’s alcohol

or drug experimentation or use.

Coordinate case management.

Treatment monitoring and recovery progress.  

Joint system of follow‐up with parents who

miss treatment appointments or drop out of

treatment.

Deciding how to handle slips and relapses.

Collaborative intervention by the child welfare

and alcohol and drug services agencies to re‐

engage a parent in treatment and reassess

child safety.

Ongoing assessment of child safety and risk

of harm.

How to increase the chance of a 

successful collaboration 

Collaborations can be like families—there are

times when everyone gets along and everything

works smoothly; there are other times when there

are disagreements and unclear communications.

Child welfare and alcohol and drug services

professionals generally are passionate and

committed; emotions may be strong and feelings

may run high. You will disagree about some

things. Collaborations and partnerships can

weather these times. A key ingredient for

continued collaboration is communication.  

You can foster a culture of collaboration. One

expert has identified seven rules of successful

collaboration that can be tailored to a child

welfare‐substance abuse partnership.60 These

rules are simple, but not always easy to carry out.

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An important rule of

collaboration—Make the

commitment to stay at the

table, and continue to talk.  

Believe in the value of the work you do every

day.

See your community as a place of abundance

rather than scarcity.

Recognize that the needs of children and

families in your community are greater than

one organization can meet.

Focus on child and family needs rather than

on organizational needs.

Understand the strength of what you have in

common with collaborators.

Value diversity and synergy; there is often

another way that is more effective than my

way or your way.

Reject the notions of turf and territory.

Remember, you are standing on common

ground.

In collaborations personalities matter. Important

qualities include: flexibility, openness, patience,

interpersonal sensitivity, the willingness to extend

trust, and the willingness to do things in a new

way.61 Our most vulnerable children and families

will benefit when you bring these traits to your

child welfare‐substance abuse partnership.
       

             

             

             

           

     

           

             

           

             

           

           

       

           

       

             

           

               

           

           

             

               

                 

           

  

           

           

             

             

             

           

             

          

           

               

             

               

             

           

         

  

   

     

             

           

           

               

         

         

           

               

           

         

         

           

         

         

           

         

             

               

     

Resources 

Federal resources: 

Administration for Children and 

Families 

The Administration for Children and Families

(ACF), within the Department of Health and

Human Services (HHS) is responsible for federal

programs that promote the economic and social

well‐being of families, children, individuals, and

communities. http://www.acf.hhs.gov/index.html

ACF’s Child Welfare Information Gateway

promotes the safety, permanency, and well‐being

of children and families by connecting child

welfare, adoption and related professionals as

well as concerned citizens to timely, essential

information. http://www.childwelfare.gov

National Institute of Health 

The National Institute on Alcohol Abuse and

Alcoholism (NIAAA) provides leadership in the

national effort to reduce alcohol‐related

problems. Its research programs include genetics,

neuroscience, epidemiology, health risks and

benefits of alcohol use, prevention and treatment.

http://www.niaaa.nih.gov

The National Institute on Drug Abuse (NIDA)

leads the national scientific effort to address drug

abuse and addiction. The website provides

information for students and young adults,

parents and teachers, and researchers and health

professionals. http://www.nida.nih.gov

This NIDA website provides a list of commonly

abused drugs, how they are ingested or used, and

intoxicating effects of types of drugs.

http://www.drugabuse.gov/DrugsofAbuse.html

Substance Abuse and Mental 

Health Services Administration 

The Substance Abuse and Mental Health Services

Administration (SAMHSA) administers and funds a

portfolio of grant programs and contracts that

support States’ efforts to expand and enhance

prevention programs and to improve the quality,

availability and range of substance abuse

treatment and mental health services in local

communities. http://www.samhsa.gov/index.aspx

SAMHSA’s/ACF’s National Center on Substance

Abuse and Child Welfare (NCSACW) provides

assistance to local, State, and tribal agencies to

improve systems and practice for families with

substance use disorders who are involved in the

child welfare and family judicial systems. NCSACW

provides on‐line courses for child welfare,

substance abuse treatment and court

professionals. http://www.ncsacw.samhsa.gov

(714) 505‐3525

SAMHSA’s National Clearinghouse for Alcohol

and Drug Information (NCADI) is the Nation's one‐

stop resource for information about substance

abuse prevention and addiction treatment. NCADI

distributes a wide range of free or low‐cost

materials, including fact sheets, brochures,

pamphlets, monographs, posters, and video tapes.

Information specialists are available to answer

questions about alcohol and drug abuse 24 hours

a day, 7 days a week.

http://www.ncadi.samhsa.gov (800) 729‐6686

SAMHSA’s treatment program locator Web site

includes more than 11,000 addiction treatment

programs, including residential treatment centers,

outpatient treatment programs, and hospital

inpatient programs for drug addiction and

alcoholism. Listings include treatment programs

for marijuana, cocaine, and heroin addiction, as

well as drug and alcohol treatment programs for

adolescents, and adults.

http://www.findtreatment.samhsa.gov

27
 
                   

           

               

            

                 

             

   

               

             

                 

         

                     

           

             

             

  

             

               

                 

               

               

                   

               

             

  

       

               

               

           

               

         

   

    

               

                 

             

               

         

               

           

                 

               

             

             

           

   

       

             

               

         

             

           

             

     

   

             

                 

             

                 

               

   

   

   

         

         

               

             

               

           

Other resources: 

The following is a sampling, not a complete list, of

available resources for family members. Inclusion

on this list does not imply endorsement by

SAMHSA. All States and most local governments

have an office on substance abuse issues that can

be an excellent resource; consult your local

telephone book.

Alcoholic Anonymous 

Alcoholics Anonymous (AA) is a fellowship of men

and women who share their experience, strength

and hope to help each other to recover from

alcoholism. The only requirement for membership

is a desire to stop drinking. There are no dues or

fees, AA is self‐supporting through member

contributions. AA’s primary purpose is to stay

sober and help other alcoholics to achieve

sobriety. http://www.alcoholics‐anonymous.org

(212) 870‐3400

Al-Anon and Alateen 

Al‐Anon and Alateen are organizations to help

families and friends of alcoholics recover from the

effects of living with the problem drinking of a

relative or friend. Whether the alcoholic is still

drinking or not, Al‐Anon offers hope and recovery

to all people affected by the alcoholism of a loved

one. Alateen is the recovery program for young

people. Alateen groups are sponsored by Al‐Anon

members.

http://www.al‐anon.alateen.org (888) 4AL‐ANON

Adult Children of Alcoholics 

Adult Children of Alcoholics is a twelve step,

twelve tradition program of women and men who

grew up in alcoholic or otherwise dysfunctional

homes. Members meet with each other in a

mutually respectful, safe environment and

acknowledge common experiences.

http://www.adultchildren.org (310) 534‐1815

Cocaine Anonymous 

Cocaine Anonymous (CA) is open to all persons

who state a desire to stop using cocaine, including

"crack" cocaine, as well as all other mind‐altering

substances. There are no dues or fees for

membership. Expenses are supported by

voluntary contributions of members. CA uses

the 12‐step recovery method, which involves

service to others as a path towards recovery from

addiction. CA believes that one addict talking to

another can provide a level of mutual

understanding and fellowship that is hard to

obtain through other methods. http://www.ca.org

(310) 559‐5833

Co-Dependents Anonymous 

Co‐Dependents Anonymous, a program of

recovery from codependence, is a fellowship of

men and women whose common purpose is to

develop healthy relationships. The only

requirement for membership is a desire for

healthy and fulfilling relationships. The twelve

steps and twelve traditions are used for

knowledge and wisdom.

http://www.codependents.org (602) 277‐7991

Families Anonymous 

The Families Anonymous (FA) purpose is to

provide mutual support, and to offer a safe place

to share experiences and concerns for relatives

and friends of those who have alcohol, drug or

behavioral problems. FA is a 12‐step fellowship of

support groups.

http://www.familiesanonymous.org

(800) 736‐9805

Narcotics Anonymous 

Narcotics Anonymous (NA) is an international,

community‐based association of recovering drug

addicts with more than 31,000 weekly meetings in

over 100 countries worldwide. Meeting sites are

online, as well as, recovery literature in English

and Spanish. http://www.na.org (818) 773‐9999

28
 
             

         

               

             

         

             

             

          

        

National Association for Children 

of Alcoholics 

The National Association for Children of Alcoholics

(NACOA) is a national nonprofit membership

organization whose mission is to advocate for all

children and families affected by alcoholism and

other drug dependencies. NACOA’s website

provides access to research, books, videos and

other resources to help families, raise public

awareness and advance professional knowledge.

http://www.nacoa.org (888) 554‐COAS

29
 
                                                      

Endnotes                                                                                   

30
 

1   U.S. Department of Health and Human Services

(2004). Child Maltreatment 2002. Washington,

DC: U.S. Government Printing Office.

2   U.S. Department of Health and Human Services

(March, 2003). The AFCARS Report [Electronic

version].

http://www.acf.dhhs.gov/programs/cb/publicati

ons/ afcars/report8.htm.

3   U.S. General Accounting Office (1994). Foster

Care: Parental Drug Abuse Has Alarming Impact

on Young Children. GAO/HEHS‐94‐89.

4   U.S. Department of Health and Human Services

(1999). Blending Perspectives and Building

Common Ground. A Report to Congress on

Substance Abuse and Child Protection.

Washington, DC: U.S. Government Printing

Office.

5      U.S. Department of Health and Human Services

(1999). Ibid.

6   Child Welfare League of America (1998). Alcohol

and Other Drug Survey of State Child Welfare

Agencies. Washington, DC: Author.

7   U.S. Department of Health and Human Services

(1999). Ibid, p. 14.

8   U.S. Department of Health and Human Services

(1999). Ibid., p. 12.

9   U.S. Department of Health and Human Services

(1999). Brief Interventions and Brief Therapies for

Substance Abuse. DHHS Publication No. SMA 99‐

3353. Rockville, MD: Center for Substance Abuse

Treatment, Substance Abuse and Mental Health

Services Administration.

10   National Institute on Alcohol Abuse and

Alcoholism (July, 2003). Alcohol Alert, 60

[Electronic version]. http://www.niaaa.nih.gov/

publications/aa60.htm.

11   U.S. Department of Health and Human Services

(2000). 10th Special Report to the U.S. Congress

on Alcohol and Health [Electronic version].

http://www.niaaa.nih.gov/publications/

10report/chap02.pdf., p. 136‐137.

12   National Institute on Drug Abuse (2000). Gender

Differences in Drug Abuse Risks and Treatment.

Research Findings (15) 4. Rockville, MD: Author.

13   The National Center on Addiction and Substance

Abuse (CASA) at Columbia University (2003). The

Formative Years: Pathways to Substance Abuse

Among Girls and Young Women Ages 8‐22

[Electronic version]. Retrieved April 1, 2003, from

http://www.casacolumbia.org

14   U. S. Department of Health and Human Services

(1999). Mental Health: A Report of the Surgeon

General. Substance Abuse and Mental Health

Services Administration, Center for Mental

Health Services, National Institutes of Health,

National Institute of Mental Health.

15   U.S. Department of Health and Human Services

(2002). Report to Congress on the Prevention and

Treatment of Co‐Occurring Substance Abuse

Disorder and Mental Disorders. Substance Abuse

and Mental Health Services Administration.

16   Young, N.K. and Gardner, S.L. (2002). Navigating

the Pathways: Lessons and Promising Practices in

Linking Alcohol and Drug Services With Child

Welfare. SAMHSA Publication No. SMA‐02‐3639.

Rockville, MD: Center for Substance Abuse

Treatment, Substance Abuse and Mental Health

Services Administration, p. 132.

17   Young, N.K., Boles, S.M., & Otero, C. (2007).

Parental substance use disorders and child

maltreatment: Overlaps, gaps, and opportunities.

Child Maltreatment, 12(2), 137‐149.

18   Office of National Drug Control Policy (2003).

Drug Facts: Methamphetamine,

http://www.whitehousedrugpolicy.gov/

drugfact/methamphetamine/index.html
                                                                                            

19   National Institute on Drug Abuse (2002).

Research Report Series: Methamphetamine

Abuse and Addiction,

http://www.drugabuse.gov/Research Reports/

Methamph/methamph2.html

20   National Institute on Drug Abuse Info Facts (June,

2004).  http://www.drugabuse.gov/Infofax/

methamphetamine.html

21   National Institute on Drug Abuse (2002).

Research Report Series: Methamphetamine

Abuse and Addiction,

http://www.drugabuse.gov/Research

Reports/Methamph/methamph2.html

22   Office of National Drug Control Policy (2003).

Drug Facts: Methamphetamine,

http://www.whitehousedrugpolicy.gov/

drugfact/methamphetamine/index.html

23   The social and economic effects of the

methamphetamine epidemic on America’s child

welfare system. US Senate Committee on

Finance, 109th Cong.  (2006) (testimony of Nancy

K. Young)..

24   Hampton, R.L., Senatore, V., & Gullota, T.P.

(1998).  Substance Abuse, Family Violence, and

Child Welfare: Bridging Perspectives. Sage

Publications: Thousand Oaks, CA.

25   Shillington, A., Hohman, M. & Jones, L. (2001).

Women in Substance Use Treatment: Are Those

Involved in the Child Welfare System Different?  

Journal of Social Work Practice in the Addictions,

1(4), 25‐46..

26   Rosas, A. (2003a). Child Sexual Abuse.  In Child

Abuse and Neglect: Guidelines for the

Identification, Assessment, and Case

Management, Durfee, M. and Peterson, M.

(Eds.). Volcano Press: Volcano, CA.

27   Rosas, A. (2003b).  Sexually transmitted diseases.  

In Child Abuse and Neglect: Guidelines for the

Identification, Assessment, and Case

Management, Durfee, M. and Peterson, M.

(Eds.).  Volcano Press: Volcano, CA.

28   Colorado Drug Endangered Children, Inc.,

http://www.colodec.org.

29    Drug Endangered Children (2000). Drug

Endangered Children Health and Safety Manual.

(Previously available from the Drug Endangered

Children Resource Center, 14622 Victory Blvd.,

Van Nuys, CA 91411).

30    Irvine, G.D. & Chin, L. (1997). The Environmental

Impact and Adverse Health Effects of the

Clandestine Manufacture of Methamphetamine.

Substance Use and Misuse, 32 (12 & 13), 1811‐

1812.

31    National Institute on Drug Abuse, Research

Report Series (1998). Methamphetamine, Abuse

and Addiction (NIH 98‐4210).

32    Department of Justice Information Bulletin

(2002). Children at Risk (No. 2002‐L0424‐001).

33    Manning, T. (1999). Drug Labs and Endangered

Children.  FBI Law Enforcement Bulletin, 10‐14.

34   U.S. Department of Health and Human Services

(2008). Child Welfare Policy Manual. Retrieved

October 30, 2008 from

http://www.acf.hhs.gov/j2ee/programs/cb/

laws_policies/laws/cwpm/policy_dsp.jsp?citID=3

54

35   National Association for Children of Alcoholics

(n.d.). Facts 4 You. Retrieved September 28, 2003

from http://www.nacoa.org

36   The 1999 Report to Congress, Blending

Perspectives and Building Common Ground,

noted that 11% (8.3 million) of U.S. children live

with at least one parent who is an alcoholic or in

need of treatment for the abuse of illegal drugs.

37   Green, M. Y. (2002, November/December).

Minorities as Majority: Disproportionality in Child

Welfare and Juvenile Justice [Electronic version].

Children’s Voice. http://www.cwla.org/articles

/cv0211minorities.htm

38   Goldstein, A. (2001). Addiction: From Biology to

Drug Policy (2nd ed.). New York: Oxford University

Press, p. 263.

31

                                                                          
                                                                                  

              

     

     

                                                                                  

39 Mee‐Lee, D. (n.d.). Placement Criteria and

Patient‐Treatment Matching. Retrieved

September 24, 2003,

http://www.adoctorm.com/docs/match.htm

40   Center for Substance Abuse Treatment. (2006).

National Summit on Recovery Conference Report.

DHHS Publication No. (SMA) 06‐xxxx. Rockville,

MD: Substance Abuse and Mental Health

Services Administration.

41   Gorski, T.T. and Kelley, J.M. (1996) Counselor’s

Manual for Relapse Prevention with Chemically

Dependent Criminal Offenders. Technical

Assistance Publication Series 19. Rockville, MD:

U.S. Department of Health and Human Services,

Public Health Service, Substance Abuse and

Mental Health Services Administration.

42   U.S. Department of Health and Human Services,

National Institute on Drug Abuse (2003). A

Collection of Articles that Address Women and

Gender Differences research [Electronic version].

NIDA Notes.

http://www.drugabuse.gov/NIDA_Notes/NN001

3.html

43   U.S. Department of Health and Human Services,

National Institute on Drug Abuse (n.d.). Ibid., p.

56.

44   National Institute of Mental Health (2005). Men

and Depression. Retrieved July 21, 2009 from

http://www.nimh.nih.gov/health/publications/m

en‐and‐depression/men‐and‐depression.pdf

45   National Institute of Mental Health. Co‐

Occurrence of Depression with Medical,

Psychiatric, and Substance Abuse Disorders.

Retrieved July 21, 2009 from

http://www.mhacolorado.org/file_depot/0‐

10000000/30000‐

40000/31946/folder/76324/Depression$2C+Co‐

Occurring+with+other+illnesses.pdf

46   Center for Substance Abuse Treatment. (2005).

Substance Abuse Treatment for Persons With Co‐

Occurring Disorders. Treatment Improvement

Protocol (TIP) Series 42. DHHS Publication No.

(SMA) 05‐3922. Rockville, MD: Substance Abuse

Mental Health Services Administration.

47   Center for Substance Abuse Treatment (2003).

CSAT’s Comprehensive Substance Abuse

Treatment Model for Women and their Children.

Unpublished manuscript.

48   The National Center on Addiction and Substance

Abuse (CASA) at Columbia University (2001).

Shoveling Up: The Impact of Substance Abuse on

State Budgets http://www.casacolumbia.org

49   U.S. Department of Health and Human Services

(1999). Ibid., p. 13.

50   Miller, W. R., and Rollnick, S. (1991). Motivational

Interviewing: Preparing People to Change

Addictive Behavior. New York: Guilford Press.

51   U.S. Department of Health and Human Services

(1999). Enhancing Motivation for Change in

Substance Abuse Treatment. Publication No. SMA

02‐3629. Rockville MD: Center for Substance

Abuse Treatment, Substance Abuse and Mental

Health Services Administration, Appendices B

and C, 185‐237.  

52   Prochaska, J.O., & DiClemente, C.C. (1982).

Transtheoretical Therapy: Toward a More

Integrative Model of Change. Psychotherapy:

Theory, Research, and Practice, 19, 275‐288.

53   Stocker, S. (1998, November). Men and women

in drug abuse treatment relapse at different

rates and for different reasons. National Institute

on Drug Abuse Research Findings (13), 4, p. 56.

54   Stocker, S. (1998, November). Ibid p. 57.

55   Stocker, S. (1998, November). Ibid p. 56.

56   Findlater, J. E. and Kelly, S. (1999). Child

Protective Services and Domestic Violence. The

Future of Children Domestic Violence and

Children (9), 3. (pp.  84‐96). Los Altos, CA: The

David and Lucile Packard Foundation.

32
 
                                                                                  

57   U.S. Department of Health and Human Services

(2000). Substance Abuse Treatment for Persons

with Child Abuse and Neglect Issues. DHHS

Publication No. SMA 00‐3357. Rockville MD:

Center for Substance Abuse Treatment,

Substance Abuse and Mental Health Services

Administration, p. 57.

58   Sussman, T. (2000, January). Interagency

Collaboration and Welfare Reform. Welfare

Information Network Issue Notes (4), 1.

59   Hogue, T. (n.d.). Community Based Collaboration:

Community Wellness Multiplied. Retrieved

December 5, 2003, from

http://crs.uvm.edu/nnco/collab/ wellness.html.

60   Sturm, P. (2000). The Seven Rules of Successful

Collaboration. Nonprofit World, 18, (2), p. 33‐36.

61   Hoel, J.L. (1998). Cross‐System Collaboration:

Tools that Work. Washington, D.C.: Child Welfare

League of America.

33
 
HHS Publication No. (SMA) 05-3981
 

Substance Abuse and Mental Health Services Administration
 

Printed 2005
 

Reprinted 2006 and 2009