Substance Abuse and Child Maltreatment 1 Substance Abuse among Caregivers of Maltreated Children

Objective: The purpose of this study was to measure the prevalence of substance abuse by in-home caregivers of maltreated children, and to compare the prevalence of selfreported substance abuse to child welfare worker-identified substance abuse. Method: Data from the National Survey of Child and Adolescent Well-Being, a national probability sample of children investigated for child maltreatment were analyzed. Substance abuse was measured using the Composite International Diagnostic Interview Short Form (CIDI-SF) and questions from the child welfare worker interview. The sample consisted of 4073 families whose children lived at home. Results: 9.6% of caregivers had a problem with alcohol or drugs according to the child welfare worker assessment, and only 3.9% of caregivers were alcohol or drug dependent according to the CIDI-SF. Overall, 11.1%, or 234,851, of caregivers whose children live at home with them have a substance abuse problem. Child welfare workers did not identify a substance abuse problem among 61% of caregivers who met DSM-IV criteria for alcohol or drug dependence. Conclusion: These findings suggest that substance abuse rates may not be as high in the child welfare population as often believed. Still, child welfare workers need more training in identifying substance abuse problems among their clients and methods to identify substance abuse early in the service delivery process. Substance Abuse and Child Maltreatment 4 Introduction Over the past two decades, caregiver substance abuse (i.e., abuse of substances by the child’s parent or guardian) has been considered to be at least responsible for much of the child maltreatment reported to child welfare services. There are many mechanisms that explain how caregiver substance abuse might contribute to child maltreatment. For instance, some researchers have observed that in-utero exposure to cocaine and other drugs can lead to congenital deficits in the child, which may make the child more difficult to care for and therefore more prone to child maltreatment (Black & Mayer, 1980; Magura & Laudet, 1996). Studies also have shown that parenting skills can suffer among substance-abusing parents. For example, some researchers have found that substanceabusing mothers are less responsive to their infants (Magura & Laudet, 1996). Caregivers who abuse substances also may prioritize their drug use more highly than caring for their children, which can lead to lack of attention to children’s needs for such things as food, clothing, hygiene and medical care (Black & Mayer, 1980; Magura & Laudet, 1996). Finally, some have found that violence is more likely in homes where stimulant drugs and alcohol are used (Famularo, Kinscherff & Fenton, 1992; Magura & Laudet, 1996). Studies that have examined the prevalence of substance abuse among caregivers who have maltreated their children have found widely varying rates of caregiver substance abuse. Previous estimates have ranged from 19 percent (Pierce & Pierce, 1985) to 79 percent (Besinger, Garland, Litrownik & Landsverk, 1999). One widely quoted estimate of the prevalence of substance abuse among caregivers involved in child welfare is that “...40 to 80 percent...” of caregivers have a substance abuse problem (Young, Gardner, & Dennis, 1998). Substance Abuse and Child Maltreatment 5 Indeed, many previous studies have found a strong positive association between caregiver substance abuse and child maltreatment. For example, one large community based study (namely, the Epidemiological Catchment Area study) of 4,000 noninstitutionalized parents found that 40% of respondents who reported that they had abused their child in the previous 12 months had an alcohol or drug disorder compared to 16% of respondents who did not report abusing their children in the previous 12 months (Kelleher, Chaffin, Hollenberg, & Fischer, 1994). Furthermore, 56% of respondents who had neglected their children had an alcohol or drug disorder compared to 17% who had not neglected their children. Pierce and Pierce analyzed 205 substantiated sexual abuse cases reported to a child abuse hotline in Missouri between 1976 and 1979 (1985). They found that 19% of the caregivers were described by the child abuse hotline workers as having a drinking problem. In addition, the Child Welfare League of America conducted a survey in 1992 of child welfare workers within public and non-profit child protective service agencies that were members of the league (Curtis & McCullough, 1993). They found that 37% of the children served by public agencies and 57% of children served by non-profit agencies were “...affected by problems associated with alcohol or other drugs.” Finally, in a study sponsored by the National Center on Child Abuse and Neglect, child welfare workers were asked to identify adults in their caseloads who had either suspected or known alcohol or illicit drug abuse problems (US DHHS, 1993). They found that in 29% of the cases a family member abused alcohol and in 18% of the cases at least one adult abused illicit drugs. Studies have also shown that substance abuse plays an important role among families whose children are placed in foster care. For example, McNichol and Tash studied the effect of parental substance abuse on 268 children in family foster care in southern California (2001). They found that 8% of children were placed due to prenatal exposure Substance Abuse and Child Maltreatment 6 to illegal drugs and another 14% were placed due to parental substance abuse. In addition, Besinger and her colleagues found that 79% of the 639 children who entered out-of-home care in San Diego County between 1990 and 1991 had caregivers who abused substances (1999). These studies have clearly established a positive relationship between caregiver substance abuse and child maltreatment among children in out-of-home care and among children in the general population. However, one important group of children has been omitted from previous research: children involved with the child welfare system who live at home. All of the previous studies focused on families with children living in foster care, on families with children who are at high risk of being placed in foster care, or on a mixture of families with children living at home and families with children living in foster care. It is vitally important to understand the prevalence of substance abuse among families involved in the child welfare system whose children live at home. It is particularly important to study these families because most children who become involved with child welfare services continue to live at home. Only about 19 percent of investigated reports of maltreatment result in children placed in foster care (US DHHS, 2003). Although children living with parents abusing illegal substances are probably more likely than other children to enter foster care, many of these children will remain at home (Beckwith, Howard, Espinosa, & Tyler, 1999; Suchman & Luthar, 2000). Although children living at home after a report of child maltreatment remain at high risk for repeat reports of abuse or neglect (Fluke, Yuan, & Edwards, 1999), we were unable to identify any study that examined the prevalence of substance abuse among families who are involved with child welfare services and whose children live at home. In addition, despite considerable discussion in the older literature about child welfare Substance Abuse and Child Maltreatment 7 workers’ lack of training in the addictions (Curtis & McCullough, 1993), and a general discomfort among child welfare workers in working with caregivers who have substance abuse problems (Thompson, 1990; Tracy & Farkas, 1994), less has been done recently. Further, the authors located only two previous studies that examined how well child welfare workers identified caregiver substance abuse problems (English & Graham, 2000; Kagle, 1987). Although these studies provide some indication that child welfare workers are not identifying many cases of substance abuse in families in the child protective system, the study designs were somewhat limited. One of the investigations did not use a standardized questionnaire to identify substance abuse problems, and the sample size was very small (Kagle, 1987). The other study also had a relatively small sample size of 261 children in a single geographic location in the Northwest (English & Graham, 2000). The present study seeks to expand the literature by examining the prevalence of caregiver substance abuse among children who live at home using data from the National Survey of Child and Adolescent Well-Being (NSCAW), a nationally representative sample of 5,504 families who have been investigated by Child Welfare Services (CWS) for child maltreatment. This analysis focuses on caregivers in the NSCAW sample whose children live at home with them (termed “in-home caregivers”). The in-home caregiver for the vast majority of children is their biological parent. The analysis includes both open cases (those that received some type of service beyond the CWS investigation) and closed cases (those that did not receive any services after the CWS investigation). The NSCAW sampling frame, the child welfare worker interview, and the caregiver interview were all used to determine whether the family or child received services. This study will also compare the prevalence of self-reported caregiver Substance Abuse and Child Maltreatment 8 substance abuse to the prevalence of child welfare worker identified substance abuse. There are two research questions in this study: 1. Among families involved with the child welfare system, what proportion of the children’s caregivers have substance problems based on: a. The assessment performed by the child welfare workers? b. The assessment of a standardized measure of substance dependence, namely, the alcohol and drug scales on the Composite International Diagnostic Interview (CIDI-SF)? c. The assessment of both the child welfare workers and the CIDI-SF? 2. How well do the child welfare workers’ assessments of substance dependence agree with the standardized measure of substance dependence (the CIDI-SF)?