1. Substance Abuse among Caregivers Involved with Child Welfare Services: Prevalence and Identification by Child Welfare Workers Presented at the Society for Social Work Research January 17, 2004 The research for this presentation was funded by the Administration on Children, Youth, and Families of the U.S. Department of Health and Human Services and the Robert Wood Johnson Foundation (RWJF).. Points of view or opinions in this presentation and accompanying documents are those of the presenter and do not necessarily represent the official position or policies of the U.S. DHHS or the RWJF. Results are preliminary. Contact information: rbarth@unc.edu Schools of Public Health¹ and Social Work ² Claire B. Gibbons¹, Richard P. Barth², Shenyang Guo² Schools of Public Health¹ and Social Work ² University of North Carolina, Chapel Hill

2. Significance  How much does substance abuse influence involvement in Child Welfare Services (CWS)?  How informed is the identification and response to substance abuse by child welfare workers?  How equitable is the response?

3. Previous Research  Child Welfare Research  Children at risk of being placed in foster care  Caregivers of children in foster care  Children in dependency caseloads  Primarily urban samples  Other Human Services Research  Substance abuse among TANF recipients

4. Limitations of Previous Research  Lack standardized measures of substance abuse  Limited generalizability  Sample sizes are small  Studies are almost all from urban areas  Prevalence among in-home caregivers  Agreement between caregiver and CWW reports not available

5. Study Questions: Prevalence  Among in-home caregivers, what is the prevalence of substance abuse according to the:  Caregiver?  Child Welfare Worker?  Both the caregiver and child welfare worker?

6. Study Questions: Agreement  What is the agreement between caregiver self-report and child welfare worker report of substance abuse?  What is the average caregiver self-report score according to the child welfare worker report?

7. National Survey of Child and Adolescent Well-Being (NSCAW)  Funded by PRWORA 1996  Longitudinal  Nationally representative sample of 5,504 children  Subjects of investigation for child abuse or neglect by CPS between October 1999 and December 2000

8.  Extended Research Team includes:  Research Triangle Institute  University of North Carolina  San Diego Children’s Hospital  Duke Medical Center, Psychiatry  National Data Archive on Child Abuse and Neglect, Cornell  Administration for Children and Families, US DHHS  92 Public Child Welfare Agencies  Children, Caregivers, Teachers National Survey of Child and Adolescent Well-Being “NSCAW”

9. Substance Abuse Measures: Risk Assessment  Child welfare worker report  Asks whether the caregiver was:  “actively abusing alcohol at the time of the investigation”  “actively abusing drugs at the time of the investigation”

10. Composite International Diagnostic Interview Short Form (CIDI-SF)  Caregiver self-report (ACASI)  Alcohol dependence in last 12 months  Drug dependence in last 12 months  Screen  Alcohol: 4 or more drinks in a day in past 12 months  Drugs: Use of any illegal drug or inappropriate use of prescription drug  Dichotomous  Sum the seven questions  3 or higher is considered dependent  Continuous  Average the seven questions

11. DSM-IV Criteria for Dependence  Tolerance  Withdrawal  Taking substance in larger amounts or for longer period than intended  Unsuccessful attempts to decrease or cease use  Time  Giving up other activities  Continuing to use even after recognizing problem

12. Scoring the CIDI-SF  Screen  Alcohol: 4 or more drinks in a day in past 12 months  Drugs: Use of any illegal drug or inappropriate use of prescription drug  Dichotomous  Sum the seven questions  3 or higher is considered dependent  Continuous  Average the seven questions

13. Child Characteristics (In-Home) % (SE) (Unweighted n= 4037) Child age 0-2 0-2 18 (1) 3-5 3-5 22 (1) 6-10 6-10 37 (2) 11+ 11+ 24 (1) Child race Black Black 27 (3) White White 47 (4) Hispanic Hispanic 19 (3) Other Other 7 (1)

14. In-Home Caregivers % (SE) (Unweighted n=4037) Female 90 (1) Caregiver age <35 <35 63 (2) 35-44 35-44 28 (2) 45-54 45-54 7 (1) 55+ 55+ 2 (<1) Caregiver education No degree No degree 30 (2) High school diploma High school diploma 46 (1) BA or higher BA or higher 24 (1)

15. NSCAW: Parental Substance Abuse (CWW Report), Urbanicity, and Service Setting In-home closed In-home open CWS OOHCTotal URBAN (77% of all Cases) SA problem 34411 No SA problem 4615566 NON-URBAN (23% of all Cases) SA problem 1113 No SA problem 154120 Total652411100 CWWs report that substance abuse is present in about 1/2 of OOHC cases; 1/5th of In- Home Open CWS cases; and 1/16 th of in- home closed cases, regardless of urban or non- urban setting

16. NSCAW: Child Age, Urbanicity, and Parental Substance Abuse (CWW Report) In-homeOut-of-home ChildAgeUrbanNon-urbanUrbanNon-urban 0-225173428 3-525261411 6-1028303637 11+21281725 Total100100100100 Amongst infants there are higher rates of substance abuse among caregivers with children in OOHC… … but this is opposite for 11+ year olds… …infants and 6- 10 year olds have the highest rates of parental substance abuse

17. NSCAW: Caregiver Report of AOD Use and Dependence CIDI-SF% Alcohol Screen 7.3 Drug Screen 18.3 Alcohol or Drug Screen 23.9 Alcohol Dependence 2.2 Drug Dependence 2.8 Alcohol or Drug Dependence 3.9

18. NSCAW: CWW Report of AOD Problems Primary Caregiver % Alcohol Abuse 8.2 Drug Abuse 9.2 Alcohol or Drug Abuse 13.8 Secondary Caregiver Alcohol Abuse 11.9 Drug Abuse 8.9 Alcohol or Drug Abuse 16.6

19. NSCAW: CWW AOD Report by Child Setting Total In-home no CWS In-home CWS Out-of- home Alcohol abuse** 8.23.312.628.7 Drug abuse** 9.23.512.137.4 Alcohol or drug abuse** 13.86.020.346.1 ** p <.001

20. Prevalence of substance abuse among in-home caregivers (CIDI-SF) %(SE) CWW report CG report Both CWW and CG report Drugs5.8(<1)2.8(<1)0.7(<1) Alcohol5.8(<1)2.2(<1)0.6(<1) Either Drugs or Alcohol 9.6(1)3.9(<1)1.4(<1)

21. Prevalence of CG reported substance abuse: open vs. closed cases % (SE) Closed (n=1690) Open to CWS at Home (n=2275) Total (n=3965) Drugs2.6(<1)3.3(<1)2.8(<1) Alcohol2.2(<1)2.1(<1)2.2(<1) Either Drugs or Alcohol 3.6(<1)4.5(<1)3.9(<1)

22. Prevalence of CWW reported substance abuse, open vs. closed cases % (SE) Closed (n=1698) Open to CWS at Home (n=2286) Total (n=3984) Drugs3.5*(<1)12.1(1)5.8(<1) Alcohol3.3*(<1)12.6(2)5.8(<1) Either Drugs or Alcohol 5.8*(1)19.8(2)9.6(1) *p<.001

23. Findings  Prevalence of substance abuse problems among in-home caregivers is much lower than previously reported  Open cases are much more likely to have CWW-reported substance abuse problems than closed cases

24. Agreement between Caregiver and CWW report (Kappa statistic) ClosedOpen Total In- home Drugs.16.20.19 Alcohol.11.11.11 Either Drugs or Alcohol.18.20.20

25. CWW identification of self-reported substance “abuse” Identified by CWW Caregiver Self-Report Closed % (SE) Open Total Alcohol screen 11 (4) 25 (5) 14 (3) Drug screen 8 (3) 23 (4) 13 (2) Alcohol or drug screen 12 (2) 32 (4) 18 (2)

26. CWW Recognition of Alcohol or Drug “Abuse” CIDI + CWW + 18%

27. CWW identification of self-reported substance dependence Identified by CWW Caregiver Self-report Closed % (SE) Open Total Alcohol dependent 22 (10) 47 (13) 29 (9) Drug dependent 17 (6) 52 (10) 27 (6) Alcohol or drug dependent 28 (7) 64 (8) 39 (6)

28. CWW Recognition of Alcohol or Drug Dependency CIDI + CWW+ 39%

29. NSCAW: Agreement Between Caregiver and CWW Report, Dependence SensitivitySpecificity In-home, no services In- home, services In-home, no services In-home, services Alcohol dependen ce 22.246.797.188.4 Drug dependen ce 16.552.196.889.2 Alcohol or drug dependen ce 30.764.494.882.0 HigherLower In-home CWS services increase AOD detection

30. NSCAW: CWW Identification of Substance Abuse  Of the caregivers who are alcohol dependent, 71% are classified by the CWW as not having an alcohol problem  Of the caregivers who are drug dependent, 73% are classified by the CWW as not having a drug problem  Of the caregivers who met alcohol screen, 86% are classified by the CWW as not having an alcohol problem  Of the caregivers who met drug screen, 87% are classified by the CWW as not having a drug problem

31. Average CIDI-SF Score by Risk Assessment Status Risk Assessment Yes mean (se) No Alcohol score 3.2 (.6) 2.5 (.3) Drug score 3.2 (.3) 2.7 (.3)

32. Findings  Overall, 39% of cases of alcohol or drug dependency were identified by CWW  CWWs missed 46,245 cases (+/- 9,476) of alcohol/drug dependent in-home caregivers, 37,944 (+/- 9,089) of those were closed  Alcohol or drug dependence is more likely to be identified among open cases (or, dependent CGs are more likely to have cases opened?)

33. Findings  The prevalence of AOD problems among in-home caregivers can now be discussed  Prevalence of AOD problems among out- of-home caregivers is lower than commonly discussed

34. Reasons for Lower OOHC Estimate  Entry cohorts may be changing  Measurement may be improving  Estimates more inclusive of in-home services populations  Early Overestimates are a common phenomena in human services  Missing children  DV among pregnant women

35. Reasons for Lower OOHC Estimate  Entry cohorts may be changing  Measurement may be improving  Estimates more inclusive of in-home services populations  Early Overestimates are a common phenomena in human services  Missing children  DV among pregnant women

36. NSCAW: Summary of Findings  CWW’s misclassify caregivers who are AOD dependent the majority of the time  CWW’s are even more likely to miss potential AOD problems among caregivers who use substances, but are not dependent  CWW’s are about twice as likely to identify an AOD problem when a case is opened

37. NSCAW: Implications  Confirms that substance abuse is a significant issue among the child welfare population  Confirms that a consistent response to substance abuse is not in operation as part of CWS  CWW’s need training regarding substance abuse detection  Risk assessment should routinely include structured, brief substance abuse assessments

38. NSCAW: Summary of Findings  CWW’s misclassify caregivers who are AOD dependent the majority of the time  CWW’s are even more likely to miss potential AOD problems among caregivers who use substances, but are not dependent  CWW’s are about twice as likely to identify an AOD problem when a case is opened

39. NSCAW: Summary of Findings  Differences in demographic characteristics between dependent, screened, and no AOD  Poverty (higher)  Recent Arrest (more often)  Another supportive caregiver present (less)  Differences in child well-beingscores:  Problem Behavior (more)  Developmental scores (no differences)

40. Limitations  Risk assessment  Broadly defines substance abuse  Not all risk assessment tools include substance abuse  Not a perfect measure of CWW knowledge  CIDI-SF  Measures dependence (very strict criteria)  Self-report  Kappa is an unweighted measure

41. Implications  Substance abuse is a significant issue, but not a predominant issue among CWS cases  CWW’s need better training  Risk assessment should include structured, brief substance abuse assessments

42. Ongoing Research  Who has substance abuse problems?  Who receives substance abuse treatment?  What is the effect of substance abuse treatment receipt on re-reports?  What is the effect of substance abuse AND child welfare services on parent and child functioning?