19.26 Case Management Involving Substance Abuse or Use | CWS

Conduct purposeful contacts to assess the needs of the child, parent/guardian/legal custodian and other household members:

Engage children in an age appropriate manner regarding parent/guardian/legal custodian or other adult household member substance and alcohol use (see Practice Guidance: Talking to Children about Parental Substance Use).

Engage substance use treatment providers regarding the treatment if the parent/guardian/legal custodian or other adult household members is/was in treatment. Obtain substance use disorder assessments, treatment information, relevant medical records, etc.

Engage the family treatment court in accordance with policy 19.24 Case Management: Family Treatment Court, to coordinate:

Engage collateral contacts regarding their observations of physical and behavioral indications of substance and alcohol use (see policy 19.16 Case Management: Collateral Contacts).

Refer the parent/guardian/legal custodian and other adult household members for a drug screen as part of the comprehensive assessment in accordance with policy 19.25 Case Management: Drug Screens.

In conjunction with the Social Services Supervisor (SSS), analyze the information gathered to determine the need for a referral for a substance and/or alcohol use assessment and make applicable referrals in accordance with policy 19.17 Case Management: Service Provision. (Also see Practice Guidance: Warm Hand-off in policy 19.17 Case Management: Service Provision).

Assess the health and substance use disorder needs of infants and other children in the household, when prenatal abuse is alleged or confirmed:

Obtain a copy of the substance/alcohol use assessments from the provider:

Refer the parent/guardian/legal custodian and other family members for substance use disorder treatment and/or other recommended services outlined in the substance use disorder assessment, in accordance with policy 19.17 Case Management: Service Provision. This may also include clinical treatment (i.e., detoxification, crisis intervention, treatment planning, substance use counseling and education, medical care, mental health services and pharmacotherapy); clinical supportive services; and community supportive services.

Develop a Plan of Safe Care to address the health and substance use disorder needs of the infant, parent/guardian/legal custodian and affected family in accordance with policy 19.27 Case Management: Developing the Plan of Safe Care for Infants Prenatally Exposed to Substances of a Fetal Alcohol Spectrum Disorder (FASD).

Support and evaluate the parent/guardian/legal custodian’s progress towards recovery goals (see Practice Guidance: Evaluating Progress Towards Recovery and Case Plan Outcomes):

When the parent/guardian/legal custodian is not willing to submit to substance and alcohol use assessments and/or comply with treatment recommendations.

During monthly supervisor staffings discuss the parent/guardian/legal custodian’s progress on their recovery goals and any changes in family functioning and child safety (see Practice Guidance: Recovery, Recovery Supports, and Cultural Awareness and Competency.

Consider case closure when:

Ensure that prior to case closure the family is connected to services to support recovery and that a viable relapse plan is in place (see Practice Guidance: Transition Planning, Aftercare and Recovery Services).

Ensure that prior to closure of any case that involves parent/guardian/legal custodian substance use, and the parent/guardian/legal custodian(s) does not complete a recommended substance use disorder assessment and/or the treatment (see Practice Guidance: Closing a Case When SUD Treatment Recommendations Are Not Followed).

Document all activities in Georgia SHINES within 72 hours of occurrence including:

Analyze and discuss with the SSCM the assessment of family functioning to determine how to proceed. This includes review the assessment to ensure that it is consistent with the discussions with the SSCM. Provide guidance regarding the assessment findings and strategies the SSCM can use to motivate the parent/guardian/legal custodian to participate in treatment.

Discuss recommendations by the parent/guardian/legal custodian, SSCM, substance use treatment provider, and applicable medical provider, to reassess or modify the treatment plan.

Ensure that the health and substance use disorder needs of infants, parent/guardian/legal custodian(s) and family are assessed and addressed in the Plan of Safe Care when prenatal abuse is identified.

Discuss during the monthly staffing case progress, barriers to progress, case management tasks and progress, collaborative service delivery, and client response to targeted interventions (see policy 19.6 Case Management: Supervisor Staffing). Review Georgia SHINES case documentation and External Documentation to evaluate progress.

Discuss strategies to motivate parent/guardian/legal custodian(s) who are resistant to complete a substance use assessment or participate in treatment.

Provide guidance when intervention by Juvenile Court is needed to assure child safety.

Ensure that prior to case closure the following occurs:

Review and ensure all documentation completed and assessments/reports received from providers, ROIs, referral forms and plans of safe care are uploaded to External Documentation in Georgia SHINES within 72 hours of receipt.

CAGE Questionnaire: Best practice dictates asking parents/guardians/legal custodian(s) about their substance use to screen for alcohol or other substance abuse. The screening can indicate whether a full SUD assessment/evaluation is necessary. Screens should be brief and include questions about unintended use and/or desire to end use, as well as regarding consequences of use or concerns about consequences. One well-known screening tool is the four-questions:

Helpful Questions when Assessing for Substance or Alcohol Use:

Observe Behavioral and Environmental Indicators of Substance Abuse: Observing and documenting behavioral and environmental indicators (red flags, warning signs) of substance use as part of the assessment of family functioning and child safety is important in all child welfare program areas. These indicators provide critical information that can support case assessment and findings, as well as consensus building with parent/guardian/legal custodian(s) regarding the need for or continuation treatment or other services. The indicators include, but is not limited to (also refer to Forms and Tools: The Effects of Substance of Abuse on Behavior and Parenting):

Documenting Behavioral and Environmental Indicators of Substance Abuse: The SSCM should clearly document the specific indicators observed and how the indicators demonstrate the parent/guardian/legal custodian’s ability to protect his/her child(ren). The SSCM should also make every effort to get other corroborating evidence of substance use, including, but are not limited to:

Assessing Neonatal Abstinence Syndrome^[6]: Neonatal abstinence syndrome (NAS), formerly known as “withdrawal symptoms, may occur when a pregnant woman takes drugs such as heroin, codeine, oxycodone (OxyContin), methadone or buprenorphine. Because the baby is no longer getting the drug after birth, the withdrawal may occur as the drug is slowly cleared from the baby’s system. Symptoms may appear within a few hours of birth to 14 days after birth, and depend on the type of substance used, length of time used, etc. Symptoms generally include blotchy skin coloring (mottling), diarrhea, excessive crying or high-pitched crying, excessive sucking, fever, hyperactive reflexes, increased muscle tone, irritability, poor feeding, rapid breathing, seizures, sleep problems, slow weight gain, stuffy nose, sneezing, sweating, trembling (tremors), vomiting.

Drug Screens: See policy 19.25 Case Management: Drug Screens

SUD Assessment^[7]: The assessment defines the nature of the SUD, determine a diagnosis, and develop specific treatment recommendations. SUD assessments may be administered by a physician or clinician. Essentially, it involves a series of questions which help identify warning signs of substance abuse, frequency of use (i.e., daily, monthly, or yearly) or duration of use (i.e. how long abuse may have occurred). It may also involve an exploration of person’s personal history of substance abuse, health history, family history of substance abuse, age, and mental health disorders.

Assessing Levels of Drinking:

Health: overcoming or managing one’s disease(s) or symptoms, such as abstaining from use of alcohol, illicit drugs, and non-prescribed medications (if an addiction) and, for everyone in recovery, making informed, healthy choices that support physical and emotional well-being.

Home: having a stable and safe place to live.

Purpose: conducting meaningful daily activities, i.e., a job, school volunteerism, family caretaking, creative endeavors, and the independence, income, and resources to participate in society.

Community: having relationships and social networks that provide support, friendship, love, and hope.

Hope: the belief that these challenges and conditions can be overcome is the foundation of recovery. A person’s recovery is built on his or her strengths, talents, coping abilities, resources, and inherent values. The SSCM can encourage recovery by through services addresses the whole person, including community, peers, friends, and family members.

Resilience: an individual’s ability to cope with adversity and adapt to challenges or change. Resilience develops over time and gives an individual the capacity not only to cope with life’s challenges but also to be better prepared for the next stressful situation. The process of recovery is highly personal and occurs via many pathways including clinical treatment, medications, faith-based approaches, peer support, family support, self-care, and other approaches. Recovery is characterized by continual growth and improvement in one’s health and wellness that may involve setbacks. Because setbacks are a natural part of life, resilience becomes a key component of recovery.

Outpatient Treatment programs vary in the types and intensity of services offered.^[8] Such treatment is more suitable for people with jobs or extensive social supports. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient’s characteristics and needs. Some outpatient programs are also designed to treat patients with medical or other mental health problems in addition to their drug disorders. The levels of outpatient treatment are as follows:

Residential Treatment (Level III and IV): Level III provides intensive 24 hours a day, generally in non-hospital settings. Treatment is highly structured with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious and constructive ways to interact with others. Level IV offers 24-hour medically directed evaluation, care and treatment, including daily meetings with a physician. The facilities are usually equipped with the resources of general acute care or psychiatric hospitals and offer substance abuse treatment that addresses co-occurring disorders. Treatment focuses on stabilization and preparation for transfer to a less robust level of care for continued monitoring.

Individualized Drug Counseling focuses on reducing or stopping illicit drug or alcohol use and addressing related areas of impaired functioning, such as employment status, illegal activity, and family/social relations, as well as the content and structure of the patient’s recovery program. Through its emphasis on short-term behavioral goals, individualized counseling helps the individual develop coping strategies and tools to abstain from drug use and maintain abstinence.

Group Counseling capitalizes on the social reinforcement offered by peer discussion to help promote drug-free lifestyles. When group therapy either is provided with individualized counseling or is formatted to reflect the principles of cognitive-behavioral therapy or contingency management, positive outcomes are achieved.

Treating Criminal Justice-Involved Drug Users and Addicted Individuals: Individuals who abuse drugs are under legal mandate to stay in participate in intervention and treatment prior to, during, after, or in lieu of incarceration.

Family Treatment Court Common Characteristics: From Family Dependency Treatment Court: Addressing Child Abuse and Neglect Cases Using the Drug Court Model

Self-Help, Peer Support, and Consumer Groups: See Forms and Tools

Medication Assisted Treatment (MAT): MAT is the use of medications to treat alcohol or opioid dependence, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of SUDs.^[9] In the treatment of addiction to opioids such as heroin and prescription pain relievers that contain opiates, the prescribed MAT medication operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative and euphoric effects of the substance used.^[9] (See below for information on ADA and Substance Use Disorders).

That 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.

You are not the reason your parent drinks or uses drugs; you did not cause this disease and you cannot stop it.

You are not alone. In fact, there are millions of kids whose parents are addicted to substances; some are in your school.

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. (The child welfare worker can provide support as well.)

Use the 7Cs^[11] of addiction developed by the National Association for Children of Alcoholics to help children understand that addiction is not their fault.

Co-Occurring Disorders (COD)^[3]: People with CODs have at least one diagnosable mental illness along with one or more SUD (SAMHSA/CSAT, 2013; TNCODC, 2013). They typically have more episodes of relapse, inpatient hospital visits, emergency room visits, and higher rates of chronic diseases. People with a mental health issue are more likely to experience SUD than those without a mental illness. People with COD are best served when screening, assessment, and treatment planning are integrated, i.e., both substance use and mental health disorders, each in the context of the other, are addressed. It is important to:

Men: Men have unique needs that impact their engagement in SUD treatment and the child welfare system. Men tend to use alcohol and drugs more frequently and in greater quantities than women. It is important that treatment takes into special consideration the unique treatment needs of men and understanding of male psychological development and trauma. Substance abuse treatment programs for men should be both gender-responsive and trauma-informed. To reduce resistance to entering treatment^[13]:

Women: Women may respond to substances differently, e.g., they may have more drug cravings and are more likely to relapse after treatment. Women who are victims of domestic violence are at increased risk of substance use. Women with SUDs are more likely to have partners that have a SUD. Getting or retaining women in treatment is often arduous because women are usually the primary caregiver for their children and/or other family members, they are fearful they will lose their partner or custody of their children and/or be perceived as a bad parent. Cultural issues may also interfere in a woman’s help-seeking behavior. It is important to explore cultural issues to gain an understanding and work within the context of the individual and family to engage them in services. Services that need to be available for women include: medical services, health promotion, psychoeducation, gender-specific needs, cultural/language needs, life skills, family/child-related services, comprehensive case management, mental health services, disability services, and staff/program development (SAMHSA, 2013).

Pregnant Women and Post-Partum^[2]: Substance use during pregnancy can result in health concerns and risks for the woman, unborn fetus and newborn. Pregnant women with SUDs have priority admission status for SUD services in Substance Abuse Prevention and Treatment block-grant funded programs. Intervention and treatment considerations for pregnant and post-partum women include:

Older Adults/Elderly^[15]: Due to an increase in the number of grandparents caring for their grandchildren, SSCMs may encounter older parent/guardian/legal custodian(s) with substance and/or alcohol use disorders frequently. While the current proportion of older adults with SUDs is low compared with the general population, a growing number of older adults are at risk for hazardous drinking, prescription drug misuse, and illicit substance use and abuse. When assessing older adults about substance use consider:

Veterans^[16]: Veterans often encounter challenging experiences during their service and some turn to substance use to cope with those experiences (SAMHSA/CBHSQ, 2015). In addition, many veterans have a co-occurring mental health disorder. Post-traumatic stress disorder (PTSD) and SUD tend to co-occur very frequently in veterans. One of the most prevalent substance use problems for military personnel is alcohol use. Strategies for promoting positive outcomes with veterans should include educating them about their substance(s) of choice and how it affects the body. It may also be necessary to educate the veteran about the impact of substance use on treatment and the ability to achieve treatment goals.

ADA and Substance Use Disorders^{[17] [18] [19] [20]}

An individualized assessment of the individual with a disability based on reasonable judgment that relies on current medical knowledge or the best available objective evidence to ascertain the nature, duration, and severity of the risks to the child;

The probability that the potential injury to the child will actually occur; and

Whether reasonable modifications of policies, practices, or procedures, or the provision of auxiliary aids and services will mitigate the risk.

Increasing lack of cooperation/avoiding behavior;

Deterioration in daily living activities;

Unexplained financial hardship;

Mood swings;

Depression, anger, anxiety, or paranoia;

Setting expectations that are too numerous or unrealistic;

Distancing from friends who are clean and sober; and

Re-establishing old relationships with drug-using acquaintances.

Outlining who will contact the SSCM

Participation in AA or NA

Weekly telephone contact with an identified family member or friend

A temporary caregiving resource for the children

Attends and stays engaged in a substance abuse treatment program or aftercare.

Participates in community recovery support groups.

Achieves a period of abstinence.

Has established a pattern of negative results from drug tests.

Complies with the safety plan and case plan.

Has a relapse plan in place.

Is achieving parenting goals and demonstrating behaviors indicative of enhanced protective capacity.

Visits their children consistently and displays increased parental responsibility and bonding with children (if applicable).

Has changed past substance-abusing behaviors and has developed a network of sober, abstinent family members and friends.

Demonstrate financial self-sufficiency, if applicable.

Has no new reports of abuse/neglect or criminal activity, if applicable.

Takes prescribed psychotropic medications correctly (if applicable).