Module 5: Case Planning, Family Strengthening, and Planning for

Module 5: Case Planning, Family Strengthening, and Planning for Safety for Families with a Substance Use Disorder Child Welfare Training Toolkit

Acknowledgment A program of the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Administration for Children and Families (ACF), Children’s Bureau www.ncsacw.samhsa.gov [email protected]

Learning Objectives After completing this training, child welfare workers will be able to: Recognize assessment as a process, not an event, and understand the importance of ongoing assessment Identify the effects of parental substance use disorders on child safety Develop a case plan to meet the needs of families with a substance use disorder that integrates ongoing planning for safety Implement strategies for monitoring progress Identify and build on family strengths for successful outcomes

Collaborative Values Inventory Strongly Disagree Disagree Neutral or Unsure Agree Strongly Agree Parents with substance use disorders (sometimes called addiction) can be effective parents Parents should not be allowed visitation with children removed from their care until they demonstrate abstinence from alcohol or drugs A parent’s relapse should result in the child’s removal from a parent or a change in the case plan goal if reunification efforts are in place Parents should be reunified with their children only if they abstain from using alcohol and/or drugs (Children and Family Futures, 2017)

Key Processes How are families identified, assessed and referred? How are families supported and served? How are cases and outcomes monitored? New Event in the Family Family Stabilizes

A Closer Look at What Works Early Identification, Screening Assessment, and Timely Access to Treatment

Screening and Assessment Presence and Immediacy Is there a concern regarding a parent’s use of drugs or alcohol? Does this present a safety issue to the child?

Early Identification Know what to look for. Common signs and symptoms of substance use or misuse in the home environment may include: Physical appearance: slurred speech, nodding off, disorientation, tremors, cold or sweaty palms, dilated or constricted pupils, bloodshot or glazed over eyes, needle marks, bruises, poor personal hygiene Behavioral signs: agitated behavior or mood, excessive talking, paranoia, depression, manic behavior, lack of motivation, criminal activity, financial challenges, missed appointments Physical environment: signs of drug paraphernalia (such as straws, rolling papers, razor blades, small mirrors, glass pipes, aluminum foil, lighters, needles, syringes, tourniquets, belts, shoelaces, spoons), unusual smells, reluctance to allow home visits, unexplained visitors in and out of the home Note: This is not a complete list of possible signs and symptoms.

Early Identification Engage the parent about your observations or concerns using an approach that is supportive and not stigmatizing or judgmental. Use “person first” language and avoid using labeling terms such as “addict.” Use a conversational tone with open-ended questions such as the following: “Tell me more about . . .” “As part of our work with families, we ask all families about . . .” “I’m noticing that . . .” “How can I help you with . . .” “I’m concerned about you because . . .”

Use of a Screening Tool Gather information from a variety of sources including corroborating reports, observation of signs and symptoms, drug testing results, and results from a valid screening tool such as the UNCOPE, AUDIT, AUDIT-C, or ASSIST. The purpose of substance use disorder screening is to determine the presence of substance use and identify the need for a further clinical substance use disorder assessment. If the parent shows signs or symptoms of substance misuse or screens positive for a potential substance use disorder, a clinical assessment by a substance use disorder professional is needed.

Group Exercise Question To Consider How does the use of alcohol or drugs affect the parent’s ability to make decisions regarding the safety of the child?

Case Study A child welfare investigator following up on a report arrives at Lisa’s home to conduct an investigation. The referral came from Lisa’s sister. Lisa’s sister reported that the kids were frequently unsupervised and their mother, Lisa, is always asleep on the couch and not watching the kids. Dan, who is Lisa’s husband, is not currently residing in the home. Dan was recently arrested for a violation of probation but is expected to be released from the county jail soon. Lisa’s sister is also concerned because the kids have been ill and have not seen a doctor—one of the children was supposed to be seen regularly by a physician. Lisa’s sister reported that Lisa has frequent male visitors coming in and out of house and that she uses drugs. The sister also said that Lisa was previously investigated by child welfare in another state but that she did not follow through with services.

Case Study When the investigator arrives at Lisa’s home, she finds the family home filthy and struggles to find a pathway through the clutter. The living room floor and surfaces are covered with empty pizza boxes, and dirty dishes are piled high in the kitchen sink and on the stove. There is no food in the refrigerator. Soda and beer cans litter the house, and clothes are strewn throughout the home’s two small bedrooms. The investigator finds dirty diapers in many rooms. The investigator notes that the two boys are dressed in clothes that they have outgrown and that are filthy and worn out. Both boys appear to have upper respiratory infections, and the older boy, 6year-old Johnny, states that they have not eaten that day. When the social worker meets with the 9month-old boy, Ryan, she notices that he appears to be small for his age and developmentally behind. Lisa appears to have been napping when the investigator arrives. The child welfare services investigator asks Lisa direct questions about her substance use pattern and the adverse consequences that have resulted from her alcohol and drug use. Lisa denies having a problem with alcohol or drugs, but she does admit that she is using marijuana more than she used to. Lisa indicates that her family members have said she drinks too much.

Effect of Parental Substance Use Disorders on Parenting Parents’ use of alcohol or drugs can affect their ability to safely care for their children by decreasing their ability to: Provide a safe home environment Assess appropriate caregivers or visitors to the home Appropriately discipline their children Have realistic expectations of their children

Effect of Parental Substance Use Disorders on Parenting Parents’ use of alcohol or drugs can affect their ability to safely parent their children by decreasing their ability to: Adequately supervise their children Meet their child’s educational or medical needs Provide a daily structure and routine for a child Provide for a child’s basic needs

Areas to Consider When Assessing Safety When you are concerned about a parent’s substance use disorder and assessing a child’s safety, consider the following factors: Related to the child: Age of the child Child’s visibility in the community Special needs of the child Parent/child interaction

Areas to Consider When Assessing Safety When a child welfare worker is concerned about a parent’s substance use disorder and assesses a child’s safety, they should consider the following: Factors related to the parent or community: Current engagement in treatment History of seeking help or treatment Past recovery time Level of parent’s insight into risk factors Strong support system Another adult living in the home Strengths of the family

Assessment Throughout the Life of the Case Assessment happens along a continuum to determine: Presence and Immediacy Is there a concern regarding a parent’s use of drugs or alcohol? Does this present a safety issue to the child? Nature and Extent What is the nature of the issue? What is the extent of the issue?

Preparing Parents for a Referral to Treatment A referral is not about only handing the parent a list of resources or telling the parent that part of the case plan is to seek treatment. A successful referral includes: Explaining the concern to the parent Engaging the parent in a conversation about his or her concerns Asking the parent about what helped in the past Working with the parent to determine the best treatment options, which often begin with a clinical substance use disorder assessment

Help Parents Prepare: Referrals and Expectations Provide recommendations and contact information Assist with referrals and setting up the initial appointment Convey information so parents know what to expect Help the parent overcome any challenges or barriers to making the appointment

Help Parents Prepare: Know the Resources Treatment resources available in your community Characteristics of local treatment programs Services that the programs provide Requirements, expectations, and conditions for participating in treatment Importance of family-centered treatment

Partnerships With Treatment Professionals Learn about each other’s agency Share information regarding jointly served children, adults, and families Understand requirements for: 42 Code of Federal Regulations (CFR) Part 2 Health Insurance Portability and Accountability Act (HIPAA) Informed consent

Assessment Throughout the Life of the Case Assessment happens along a continuum to determine: Presence and Immediacy Is there a concern regarding a parent’s use of drugs or alcohol? Does this present a safety issue to the child? Nature and Extent What is the nature of the issue? What is the extent of the issue? Developing & Monitoring Change, Transitions & Outcomes of Treatment and Case Plans What is the response to the issue? Are there noticeable changes in the issue? Is the family ready for transition? Did the interventions work?

Case Planning for Families Affected by a Substance Use Disorder Identify and address the safety needs of the child Establish a plan that will support parents with a substance use disorder to get treatment Help parents find an appropriate treatment professional Address other identified needs of the child or parent

What Goes Into a Case Plan Strengths and needs Goals and objectives Services and supports Achievement dates Persons responsible Success indicators

Culturally Competent Case Planning Culture lives at the family level but also exists in individuals and organizations Culture includes beliefs, traditions, and values Beliefs, traditions, and values must be the platform on which solutions are built

Helping Parents Meet Their Case Plans In-Home Services: Provide opportunities to improve parenting skills and interactions with children Help set up a household with stability and continuity for the children Develop safety plans for children whose parents may become unavailable to them Establish a support network in the community, including connecting families to peer support services Foster Care: Support parents' participation in treatment so that they can meet dependency court requirements and participate fully in visitation rights Help parents set up a household once treatment is underway and they are meeting dependency court requirements Work with treatment providers to address relapse

Elements of Successful Visitation Plans Parenting time should occur: Consistently and frequently For an appropriate period of time In a comfortable and safe setting With therapeutic supervision when appropriate In normal parenting situations, such as during doctor visits and appointments with therapists (when appropriate)

Collaborative Case Planning Incorporate objectives in the child welfare case plan related to a parent’s treatment and recovery Ensure that child welfare case plans and treatment plans do not conflict Conduct joint reviews of case plans with treatment staff and family Share case plans with treatment providers Regularly review a parent’s progress to meet goals in the case plan, especially after critical events Identify indicators of a parent’s capacity to meet the needs of his or her children and outcomes of the case plans Regularly monitor progress and share it with treatment staff

Joint Case Planning and Case Management Focus initially on "one day at a time" steps pertaining to the child welfare requirements until the parents are able to address longer range issues Use family group conferencing strategies so key family participants understand the goals for the parent and can work on supporting these goals Specify responsibilities of all agencies involved in the case plan

Working with Providers to Support Parents Keep treatment professionals informed about: The dependency court schedule of hearings and their outcomes Information needed by the court about parental progress in treatment Problems the judge is addressing throughout this process When possible and appropriate, invite treatment counselors to hearings to offer testimony or have the provider send information about the parent’s progress in treatment

Measuring Progress Social workers should seek information from the family and other helpers about progress towards goals and objectives identified in the case plan Progress, or lack of progress, should always be noted Lack of progress means something is not right about the plan—if it is not working, change it Do not automatically assume lack of progress means the person is not doing enough or is not capable of changing

Measuring Progress Substance use disorder treatment professional’s view: Increased periods of recovery and decreased periods of relapse—as a result of treatment Scope and durability of changes in other areas of life to maintain recovery

Measuring Progress Child welfare worker’s view: Parent participation and progress in treatment within the deadlines established by the court Assessment of permanency, family strengths, and protective factors Shared views: Parental participation and progress in treatment Parental motivation to achieve the conditions that will result in retaining or reuniting with their children

Drug Testing Drug testing: What does it mean? How should it be used to measure progress?

Sharing Information in a Service Delivery Team Changes that might create stress for parents or affect their participation in treatment: Increased visitation or unmonitored visits with children Meetings scheduled with social workers Transfer of a family's case to a new child welfare worker or to a different unit Unanticipated changes in any services in the case plans Schedule of court hearings or in the court calendar

Collaboration Necessities Communication: People receiving treatment need information, and multiple helpers need to share information Coordination: Multiple efforts from helping professionals must be coordinated to benefit everyone Consultation: Helpers with one kind of expertise need input and advice from helpers with other expertise **Service is more effective when professionals talk** (Center for Substance Abuse Treatment, 2005)

Working Together: Tasks for Counselors, Child Welfare Workers, and Judges Treatment Counselor Help parents end denial and envision a positive life without substance use or mental disorder Help parents understand how their substance use disorder has affected their lives and the lives of their children, families, and friends Help parents understand how their mental health disorder has affected their lives and the lives of their children, families, and friends

Working Together: Tasks for Counselors, Child Welfare Workers, and Judges Child Welfare Worker Conduct assessments to evaluate and monitor the safety of children Help parents provide a nurturing environment for children, heal themselves, and develop capacities to care for their children

Working Together: Tasks for Counselors, Child Welfare Workers, and Judges Dependency Court Judge and Staff Assess information and make decisions leading to permanency for children in the child welfare system Follow procedures and timetables specified in state and federal statutes (e.g., Adoption and Safe Families Act) Preside over hearings to see whether the child welfare agency made reasonable efforts to provide needed services that prevent removal and/or achieve reunification

Benefits of Information Sharing Ensures that children are safe Determines whether parents are meeting dependency court requirements Provides appropriate supports for parents

Helping Parents Prepare for Recovery Parents may need help with: Maintaining sobriety Maintaining psychological medication regimen (if there is a co-occurring diagnosis) Avoiding situations that contribute to substance use or other symptom emergence Finding services to help them re-establish their lives Connecting with new support systems and resources in the community

Building on Family Strengths: Moving Toward Family Recovery

Moving Toward Child Welfare Case Closure Encourage the use of community-based supports 12-Step participation Peer support services Identify individualized services Maintain a directory of local community organizations/social supports Gather contact information, service hours, and referral requirements Establish relationships with service organizations

Moving Toward Child Welfare Case Closure: Support Linkages with community-based organizations and resources—initial visits and follow-up Relationships with family members, friends, churches or temples, or other social support groups Health insurance and other resources

Moving Toward Child Welfare Case Closure: Safety Planning Safety planning with the family: Build on the family’s strengths Establish a network of support Collaborate with other helping professionals Include a parent’s relapse prevention plan Include the children in the planning

Strengthening Families Using a protective factors approach can be a positive way to engage families because it focuses on families’ strengths and what they are doing right Focusing exclusively on risk factors with families can leave families feeling stigmatized or unfairly judged Using a protective factors approach can provide a strong platform for building collaborative partnerships with other service providers, like child care, that are not as familiar or comfortable with a risk paradigm as a basis for engaging families (Center for the Study of Social Policy, n.d.; Child Welfare Information Gateway, 2014)

5 Protective Factors Build on the five protective factors, identified in the research literature, that are associated with lower rates of child abuse and neglect, and with optimal child development: Parental resilience Social connections Knowledge of parenting and child development Concrete support in times of need Social-emotional competence of children (Center for the Study of Social Policy, n.d.; Child Welfare Information Gateway, 2014)

What is Recovery? SAMHSA’s Working Definition A process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. Access to evidence-based substance use disorder treatment and recovery support services are important building blocks to recovery (Substance Abuse and Mental Health Services Administration, 2012)

Rethinking Family Recovery Parents’ recovery occurs in the context of family relationships Services that strengthen families and support parent-child relationships help keep children safe

Recovery Occurs in the Context of the Family A substance use disorder is a disease that affects the whole family Adults (who have children) primarily identify themselves as parents The parenting role and parent–child relationship cannot be separated from treatment Adult recovery should have a parent–child component, including services for the child that help prevent a future substance use disorder (Ghertner et al., 2018; Radel et al., 2018)

A Family Focus Parent Recovery Child Well-Being Parenting skills and competencies Family connections and resources Parental mental health Medication management Parental substance use Domestic violence Well-being/behavior Development/health School readiness Trauma Mental health Adolescent substance use At-risk youth prevention Family Recovery and Well-Being Basic necessities Employment Housing Childcare Transportation Family counseling Specialized parenting (Werner, Young, Dennis, & Amatetti, 2007)

A Program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment and the Administration on Children, Youth and Families Children’s Bureau Office on Child Abuse and Neglect www.ncsacw.samhsa.gov [email protected]

References

References Center for the Study of Social Policy. (n.d). About Strengthening FamiliesTM and the protective factors framework. Retrieved from https://cssp.org/wp-content/uploads/2018/11/About-Strengthening-Families.pdf 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 and Mental Health Services Administration. Retrieved from https://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons-With-Co-Occurring-Disorders/SMA13-3992 Child Welfare Information Gateway. (2014). Protective factors approaches in child welfare. Washington, DC: U.S. Department of Health and Human Services. Children and Family Futures. (2017). Collaborative values inventory. Retrieved from http://www.cffutures.org/files/cvi.pdf Ghertner, R., Baldwin, M., Crouse, G., Radel, L., & Waters, A. (2018). ASPE research brief: The relationship between substance use indicators and child welfare caseloads. Retrieved from https://aspe.hhs.gov/system/files/pdf/258831/SubstanceUseCWCaseloads.pdf Partners for Our Children. (2014). Family time visitation in the child welfare system. Retrieved from https://partnersforourchildren.org/sites/default/files/Visitation%20Brief%2012-31-14.pdf Radel, L., Baldwin, M., Crouse, G., Ghertner, R., & Waters, A. (2018). ASPE research brief: Substance use, the opioid epidemic, and the child welfare system: Key findings from a mixed methods study. Retrieved from https://aspe.hhs.gov/system/files/pdf/258836/SubstanceUseChildWelfareOverview.pdf Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://store.samhsa.gov/product/SAMHSA-s-Working-Definition-of-Recovery/PEP12-RECDEF Werner, D., Young, N. K., Dennis, K., & Amatetti, S. (2007). Family-centered treatment for women with substance use disorders: History, key elements and challenges. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/sites/default/files/family treatment paper508v.pdf

Resources

Resources Center for Substance Abuse Treatment. (2010). Drug testing in child welfare: Practice and policy considerations. HHS Pub. No. (SMA) 10-4556 Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://ncsacw.samhsa.gov/files/DrugTestinginChildWelfare.pdf Child Welfare Information Gateway. (2014). Issue brief: Protective factors approaches in child welfare. Retrieved from https://www.childwelfare.gov/pubs/issue-briefs/protective-factors/ Child Welfare Information Gateway. Cultural competence. Retrieved from https://www.childwelfare.gov/topics/systemwide/cultural/ Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://store.samhsa.gov/product/SAMHSA-s-Working-Definition-of-Recovery/PEP12-RECDEF Substance Abuse and Mental Health Services Administration and the Office of the National Coordinator for Health Information Technology. Disclosure of substance use disorder patient records: Does part 2 apply to me? Retrieved from https://www.samhsa.gov/sites/default/files/does-part2-apply.pdf Substance Abuse and Mental Health Services Administration and the Office of the National Coordinator for Health Information Technology. Disclosure of substance use disorder patient records: How do I exchange part 2 data? Retrieved from https://www.samhsa.gov/sites/default/files/how-do-i-exchange-part2.pdf Young, N. K., Nakashian, M., Yeh, S., & Amatetti, S. (2006). Screening and assessment for family engagement, retention, and recovery (SAFERR). DHHS Pub. No. 0000. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://ncsacw.samhsa.gov/files/SAFERR.pdf