DEE WILSON CONSULTING

(Originally published April 2024)

​

Substance misuse is a heterogenous phenomenon, involving many different drugs, combinations of drugs and alcohol and patterns of use, as well as a wide variety of effects on users’ health, mental health and capacity for parenting. Substance misuse does not always lead to compromised child safety, but it does create challenges to reliable parenting of preschool and young school age children, which requires a predictable structure. In addition, the discussion of substance misuse as an isolated risk factor, or safety threat, among child welfare involved families is misleading. Substance misuse frequently co-occurs with chronic mental health conditions and/or domestic violence, as well as poverty, often severe poverty, i.e., annual incomes less than half the federal poverty standard. This is a complex picture,

difficult to account for in assessment guidelines, much less in an algorithm.

 

CPS investigations and family assessments are usually a response to a report of a specific incident of alleged child abuse or neglect. It is often difficult to ascertain with a reasonable degree of certainty whether an allegation of child maltreatment is valid, or understand how substance misuse contributed to the incident, e.g., alleged lack of supervision of a young child. In other cases - such as drunk driving - the misuse of alcohol is obvious, but whether a single incident reflects a pattern of parental behavior may be unclear.    

 

Research studies that treat parental substance misuse as a dichotomous variable, either “Yes” or “No,” do not reflect the ambiguity frequently present in CPS assessments. Denial of substance misuse takes various forms: a) parents may admit to a single incident of out-of-control behavior related to drug use while denying that they have a drug/alcohol problem or, b) parents may admit to struggling with drug or alcohol abuse while denying (even to themselves) that drug use or drinking has affected their parenting.  

  

Some parents have a remarkable ability to believe their children are unaware of substance misuse or recurrent interpersonal violence within the family. It is difficult for caseworkers to have a useful conversation with parents about safeguarding their child when they deny that there is any cause for concern. It is important for caseworkers to learn how to “chip away” at denial when talking with parents whose substance misuse is crystal clear. When there is genuine doubt regarding substance misuse, caseworkers will often rely on a substance abuse treatment specialist to determine the extent and characteristics of substance misuse.  However, even these specialists can be

fooled when they rely on a parent’s self-report rather than on  a history of parental behavior. 

 

Parents’ capacity for harm reduction practices

 

Consider the following differences in harm reduction practices among parents with histories of substance misuse:

 

• A parent who makes arrangements with family members or friends for the care of her/his child during a drug binge and its aftermath vs. parents who leave responsibility for child care to happenstance.

• A parent who stores drugs or alcohol out of the reach of a young child vs. parents who are careless about where they keep their drugs.

• Parents who are careful regarding the persons who have easy access to their children vs. parents who allow a wide range of extended family members, acquaintances or virtual strangers, some with histories of violence or child sexual abuse, to care for their children or be present in the home.

• A parent who, when drunk or high, does not drive vs. a   parent with a history of drunk driving with a child in the car.

• A parent with limited economic resources who buys food for their child before he/she buys drugs or alcohol vs. a parent for whom the purchase of substances always comes first.

• A parent under the influence of drugs or alcohol able to refrain from violent or emotionally ugly outbursts directed at their children vs. parents who become mean to anyone and everyone when drinking to excess or engaged in heavy drug use. 

          

It is common to encounter the implicit assumption, or explicit argument, that no parent who has a history of using cocaine, methamphetamine, heroin, fentanyl, etc., could be capable of consistent harm reduction behaviors required to maintain child safety. This idea gives too much weight to the chemical properties of various drugs rather than their psychological uses, as well as underestimating the importance of lengthy histories of substance misuse. A common reason persons engaged in substance misuse underestimate and minimize the effects of drug/alcohol use on their health and mental health is they remember a time when they could use heavily without lasting harmful effects, and without losing control of their drug use. By definition, substance misuse involves the use of increasing amounts of drugs or alcohol despite harmful consequences. The gradual evolution of substance use into substance misuse is a psychological process that can arise out of trauma histories, the use of substances to manage emotional or physical pain and/or intergenerational histories of drug/alcohol use, not just a function of brain chemistry.

 

Factors that affect harm reduction behaviors or their absence

 

A substance misusing parent’s capacity to engage in harm reduction practices is influenced by:

1) the motivation to be a good parent,

2) the extent of control over use of drugs and/or alcohol,

3) the ability to recognize safety threats, which is affected by cognitive abilities, psychiatric impairments and trauma histories and,

4) by the availability of social supports provided by extended family members, friends and community agencies.

 

Substance misuse may undermine the motivation to parent through one implacable requirement, i.e., as parents lose control over their substance use, the importance of acquiring drugs takes precedence over any and all relationships, including the parent-child relationship. Children’s needs, along with non-stop pressure to provide for basic necessities, may be deeply resented by a parent whose first and foremost need is a steady reliable supply of drugs and/or alcohol and the opportunity to use them without worrying about child care.  

 

When assessing the effects of substance misuse on child safety, it is positively dangerous for CPS caseworkers to endorse high minded sentiments such as “every parent loves their child and wants to be a good parent.” This idea is probably true most of the time, even in cases of addiction, but it is not universally true and misrepresents the extent to which substance misuse can radically alter the motivation to parent. School aged children of alcoholics and drug addicts are often painfully aware that their parents’ supposed love for them is a fiction, whatever may have been the case when they were babies or toddlers. I grew up in such a family and know whereof I speak.   

 

A parent’s “motivation to parent” is a key factor in successful reunification; two main indicators of parental motivation are a) the parent’s participation in visits and, b) the ability to recognize their child’s needs as separate from their own needs.  Substance misusing parents who are strongly motivated to retain or regain custody of their child or children will usually take steps to increase their ability to control their substance use even when they are not committed to sobriety, or fail to become clean and sober. Active participation in substance abuse treatment, support groups and/or the use of prescribed medications are ways of regaining some degree of control over use of drugs and alcohol.

 

A study, “Substance Use Disorder Treatment Penetration among Child Welfare-Involved Caregivers,” (Patton, et al, 2020) of 148,264 caregivers with child welfare involvement in Washington State from SFY 2015 to SFY 2018 found that only “39 percent received any SUD treatment in the 12 months following the CPS intake or child removal.” And, “Among caregivers with children in out-of-home placement who had SUD, 49 percent received any SUD treatment in the 12 months following the date of their child’s removal.” This study does not indicate whether the less than 40% rate of SUD “treatment penetration” during the year following a screened in CPS report was due to lack of services or lack of parental motivation to seek services, or both. However, the study suggests that a large percentage of substance misusing parents with open child welfare cases in Washington do not receive SUD services. 

 

When a parent’s lack of control of their drug/alcohol use is compounded by an inability to recognize danger resulting from psychiatric impairments, preschool children should be assessed as “unsafe,” unless there is another reliable caregiver in the home.

 

A 2011 study (Grant, et al) of mothers enrolled in Washington State’s Parent Child Assistance Program (PCAP), a three-year program for women with a substance abuse disorder, compared four groups of PCAP mothers: a) those who maintained custody of their infant or toddler throughout the program, b) mothers who lost custody of their young child but regained custody; c) mothers who lost custody of their child while in the program and had not regained custody at their exit from PCAP; d) mothers who never had custody of their infant or toddler while in PCAP.   

 

Mothers who retained custody of their youngest child throughout PCAP involvement had fewer children, higher rates of high school graduation and fewer psychiatric problems at entry into PCAP than mothers who never had custody of their infant. They also had fewer children who had died in early childhood.

 

Mothers who lost custody of their child while in PCAP and did not have custody at exit from the program had more serious psychiatric problems and were less likely to be involved in services for their multiple mental health conditions than mothers who regained custody of their child. It appears that the co-occurrence of inadequately treated psychiatric problems with substance misuse was a major factor in caseworkers’ and courts’ decision making re child custody, especially when a parent’s psychiatric conditions

were compounded by neurological impairments in cognitive functioning.   

 

A substance misusing parent’s capacity to engage in harm reduction practices is likely to be greatly influenced by the availability of social support from extended family members or friends. When substance misusing parents have alienated their entire extended family and have been abandoned by former friends, they may have no place to turn for help in caring for their children, or for economic assistance in emergencies.

 

 A 2008 study of racial disproportionality in Washington’s

child welfare system found that almost 80% of children in out-of-home care were from single parent families. In many families, the quickest way to strength child safety is to reconnect substance misusing parents with extended family members and to provide full time child care and respite care on demand. Child welfare agencies that seek to safely reduce the use of foster care for preschool children should be making large investments in these types of services.  

 

Parenting structure and the erosion of social norms

 

Substance misuse over months or years steadily undermines a parent’s capacity to reliably meet their children’s basic needs, first and foremost by making it difficult to maintain a structure for parenting, i.e., a routine time and way of feeding, bathing, supervising, interacting with, reading to, putting to bed in safe circumstances, etc. Families with young children typically organize their lives around meeting the basic physical and emotional needs of their children, a difficult if not impossible task without a predictable structure. The functional health and mental health impairments resulting from drug/alcohol misuse are likely to lead to erratic attention to children’s needs, including periodic compromises with parenting standards such as “preschool children should be supervised at all times.”

 

Initial fissures in a parenting structure develop into large cracks as social norms that guide parenting erode or collapse. Under pressure from habitual substance misuse and/or mental health conditions, small compromises with ‘taken for granted’ parenting standards will often become large compromises, leading to a shocking indifference to child safety. There have been cases in Washington of young children left without parental attention for days, or not fed for long periods of time even with food in the home. Parents who occasionally violate a parenting standard that they endorse may gradually become indifferent to parenting standards as a whole. For this reason, it is dangerous child protection practice to do nothing to protect children until there is risk of imminent harm.  Fissures in parenting structure and the gradual erosion of parenting standards are much easier to repair early in their development, before they have become embedded in chronic neglect or (worse) chronic multitype maltreatment that includes physical and/or sexual abuse, as well as pervasive neglect.       

 

Chronic neglect is characterized by the inattention to children’s basic needs across multiple child care domains, i.e. feeding, bathing, supervising, nurturing, etc. Chronic neglect develops gradually in conjunction with substance misuse, persistent mental health conditions such as depression and sometimes domestic violence as well. One goal of CPS intervention should be to stop the development of situational neglect into intermittent neglect and stop intermittent neglect from becoming chronic neglect. A wide range of family support services, including poverty related services, delivered as early as possible in a child’s life are needed to interrupt the development of chronic neglect in high-risk families. SUD services are essential but not sufficient for this purpose.   

 

Parents who have lost control of their drug/alcohol use and have begun to compromise parenting standards often experience a loss of self-efficacy in self-care, and in seeking help as needed. The loss of self-efficacy is often reflected in hopeless/helpless attitudes regarding the capacity to meet life’s challenges, benefit from help or treatment programs, or regain custody of their children in foster care. The initial challenge for caseworkers and other professionals is to engage with parents who may have given up on themselves, and who do not believe anyone or any program can help them. To this end, child welfare training programs should give the development of engagement skills the same emphasis as development of assessment skills.

 

In-home safety plans

 

I cannot emphasize too strongly that there is no science of in-home safety planning with families involved in child welfare. In-home safety planning is arguably the weakest element of child protection programs both in Washington and nationally.  A DCYF manager in a position to know recently said to me: “These (in-home) safety plans are not worth the paper they’re printed on,” the same words I heard from CPS supervisors in Florida almost a decade ago. Currently, there is no sound justification for staking the lives of children, 0-3, assessed as “unsafe,” on an in-home safety plan. This is reckless practice regardless of its ideological rationale.

 

It is urgently important that public child welfare systems develop partnerships with academic researchers to study and improve in-home safety planning during the next several years, and that public agencies develop an extensive infrastructure to support in-home safety planning.     ©

 

References

​

Grant, T., Huggins, J., Graham, J.C., Ernst, C., Whitney, N. & Wilson, D., “Maternal substance abuse and disrupted parenting: Distinguishing mothers who keep their children from those who do not,” (2011), “Children and Youth Services Review,” 33, 2176-2185.

      

Patton, D., Liu, C., Kerstein, E., Lucenko, B. & Felver, B., “Substance Use Disorder Treatment Penetration among Child Welfare- Involved Caregivers,” (2020), Office of Innovation Alignment and Accountability, Washington State Department of Social and Health Services, Olympia, Washington. Available online.  

 

“Racial Disproportionality in Washington State’s Child Welfare System,” (2008), Washington State Institute for Public Policy, Olympia, Washington.  Available online.

​

See past Sounding Board commentaries     

​

©Dee Wilson     

  

deewilson13@aol.com

    

​