Vol. 4, No. 4
September 1999

Substance Abuse and Child Welfare

There's no question: if you are a child welfare social worker, you work with people who use drugs. And all the relevant research shows that substance abuse is an added stress for families, another obstacle for social workers and clients, and a risk factor in almost every area, from child abuse, domestic violence, and mental illness to employment, family reunification, and cognitive and emotional development (Ray & Ksir, 1993).

Every child welfare practitioner should know about and understand substance abuse. Receiving professional training, taking a class, attending an inservice workshop, speaking with colleagues and supervisors, and reading books and journals can help you learn about this extremely complex behavior.

As a supplement to such training, this article provides you with some of the fundamentals of drug and alcohol abuse and dependence, their effect on individuals and families, how abuse and dependence may be recognized, and their implications for child welfare practice.

Who Uses Drugs?

According to the Alcohol and Drug Council of North Carolina, there are nearly 700,000 people addicted to drugs in North Carolina. Another 700,000 have a problem with alcohol (Alcohol/Drug Council of NC, 1998).

Among them are parents and children, athletes and actors, homeless men and women, and lonely adolescents. Some just drink alcohol, others smoke pot and sniff cocaine. People abuse prescription drugs like valium, codeine, and dilaudid, and people sniff gasoline. They inject heroin ("smack, dope") and amphetamines ("crank, speed, meth") and they smoke crack-cocaine ("rock"), speed, and marijuana ("pot, grass, weed").

People who abuse drugs can be loving parents, hard workers, next-door neighbors, bank tellers, janitors, students, lawyers, nurses. Only one thing is certain--no matter what role a person who abuses drugs may play, substance abuse and dependence always add complications and obstacles to successful interventions (Smyth, 1995).

Use, Abuse, & Dependence

It is important to understand the difference between use, abuse, and dependence (also called "addiction"). Use simply means drinking, smoking, inhaling, injecting, or swallowing a chemical substance. If one drinks a beer with dinner, one is using alcohol, but not necessarily abusing it. Some professionals consider any illegal drug use to be "abuse", while others use the stricter definition provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the instrument most professionals use to assess substance abuse.

According to the DSM-IV, abuse is "a maladaptive pattern of substance use leading to clinically significant impairment or distress". In other words, if the use of a drug or alcohol causes serious problems--at work, in school, within the family, with the law, or with physical or mental health--then it is probably substance abuse. Abuse can occur over a period of hours, days, months, or years.

Abuse is not dependence. Dependence, or addiction, according to the DSM-IV, has two main characteristics: tolerance and withdrawal. Tolerance means that larger and larger amounts of the substance are needed to achieve the same level of intoxication, or "high". Tolerance can be very dangerous because as more and more of a drug is taken, the risk of overdose--that is, illness or death from toxic levels of the drug--increases. An experienced user may not feel "high" but may still be close to overdose.

Withdrawal is the syndrome caused when a dependent person stops taking the drug to which he or she is addicted. Certain drugs--especially alcohol, amphetamines, cocaine, and opiates (e.g., heroin, morphine)--create a physical dependence so severe as to cause a risk of severe pain, illness, mental disturbance, and even death if the dependent person quits using or is unable to obtain enough of the drug to get intoxicated. Alcoholics who go for even a few hours without drinking may experience delirium, black-outs, tremors, nausea, seizures, and hallucinations. Heroin users who stop taking heroin often experience intense muscular pains, uncontrollable shaking, diarrhea, and high fever. For people struggling with substance dependence, quitting without treatment can be as risky as continuing to use.

Nicotine and caffeine may be the two drugs that cause the most dependence. However, because they do not cause severe intoxication and are not linked with violent or anti-social behavior in the way that alcohol and other drugs are, we will not focus on them here.

Addiction is an Illness

An important point to understand is that regardless of the substance involved, addiction is a mental illness just like depression, schizophrenia, or an anxiety disorder. These conditions are diseases, not so different from cancer or diabetes.

People who abuse substances are suffering from a debilitating illness, not from a flaw in their character or a moral shortcoming. This does not mean they are not responsible for their actions. But it does mean that they are entitled to the same respect, the same services, and the same treatment as anyone else.

Substance Abuse and Child Maltreatment

The evidence linking alcohol and drug abuse to child maltreatment makes it clear that there is an increased risk of neglect and abuse in families where substance abuse occurs.

Several studies have indicated that a quarter of all child welfare cases involve families where substance abuse is occurring (Kropenske & Howard, 1994); one study place the number closer to 40 percent (National Committee to Prevent Child Abuse, 1997). Several studies conducted in Boston found that, of the most severe instances of child maltreatment, as many as nine out of ten caretakers abused drugs or alcohol (Murphy, et al., 1991; Kowal, 1990).

Drugs, Alcohol & TPR. One of these studies showed that of the parents referred to CPS who abused "hard" drugs, such as cocaine and heroin, 90 percent eventually had parental rights terminated. Those who abused alcohol had parental rights terminated only 60 percent of the time (Murphy, et al.). These findings demonstrate the key role substance abuse can play in child welfare.

However, they may also demonstrate a bias among social workers against illegal drugs as opposed to alcohol, which, despite being legal, is still extremely dangerous. One study found that children of mothers characterized as "problem drinkers" had more than double the risk of serious injury (Bijur, et al., 1992).

Effects on Children. Children living in homes where a caregiver abuses substances suffer from a variety of physical, mental, and emotional health problems at a greater rate than the general population (Prevent Child Abuse, 1996). For example, as a group, children of alcoholics tend to experience feelings of low self-esteem and failure and struggle with depression and anxiety (Children of Alcoholics, 1992).

Later on, many of these children succumb to the same patterns exhibited by their parents; they are more likely to abuse substances, and, if they were abused, they are more likely to abuse their kids (Prevent Child Abuse, 1996).

Treatment is Critical. When families are struggling with substance abuse and child maltreatment, both problems must be addressed to ensure the safety of children. Ending the drug dependency will not automatically end child maltreatment, but parenting skills will improve little until this step is taken (Prevent Child Abuse, 1996). For more about treatment, see "More Information: Resources on Substance and Alcohol Abuse".

A Final Caution. It is important to keep in mind that even though a great number of maltreatment cases involve substance abuse, most people who use or abuse drugs do not abuse children. One study found that less than two percent of drug abusers have abused or neglected their children (Egami, et al., 1996). Other studies have produced similar results.

References

Alcohol and Drug Council of North Carolina. (1998). North Carolina doesn't have an alcohol/drug problem or does it? Durham, NC: Author.

Anderson, S. (1995). Alcohol abuse. In Richard Edwards (ed.). 19th Encyclopedia of Social Work. Washington, D.C.: NASW.

Bijur, P., Kurzon, M., Overpeck, M., & Scheidt, P. (1992). Parental alcohol use, problem drinking, and children's injuries. Journal of the American Medical Association, 267(23), 3166-3171.

Brissett-Chapman, S. (1995). Child abuse and neglect: Direct practice. In Richard Edwards (ed.) 19th Encyclopedia of Social Work. Washington, D.C.: NASW Press.

Children of Alcoholics Foundation, Inc. (1992). Help for inner-city children of addicted parents. New York: Author.

Diagnostic and Statistical Manual of Mental Disorders IV. (1994). Washington, D.C.: American Psychiatric Association.

Egami, Y., Ford, D., Greenfield, S., & Crum, R. (1996). Psychiatric profile and sociodemographic characteristics of adults who report physically abusing or neglecting children. American Journal of Psychiatry, 153(7), 921-927.

Kowal, L. (1990). Visualizing help for children living with family violence and substance addicted parents. Protecting Children, 6(4), 9-10.

Kropenske, V. & Howard, J. (1994). Protecting children in substance-abusing families. U.S. Dept. of Health and Human Services: Administration for Children and Families.

Mason, J. (1996). Reporting child abuse and neglect in North Carolina. Chapel Hll: Institute of Government of the University of North Carolina at Chapel Hill.

Murphy, J., Jellinek, M., Quinn, D., Smith, G., Poitrast, F., & Goshko, M. (1991). Substance abuse and serious child maltreatment: Prevalence, risk, and outcome in a court sample. Child Abuse and Neflect, 15, 197-211.

National Committee to Prevent Abuse. (1997). Memorandum IV (3). Unprecedented public engagement campaign plans to alert public to the importance of the first three years of life.

Oakley, R. & Ksir, C. (1993). Drugs, society, and human behavior. Baltimore: Mosby.

Prevent Child Abuse America. (1996). The relationship between parental alcohol or other drug problems and child maltreatment. On-line. <http://www.childabuse.org/fs14.html> [Aug. 31, 1999}. (Web address no longer functional.)

Smyth, N. (1995). Substance abuse: Direct practice. In Richard Edwards (ed.). 19th Encyclopedia of Social Work. Washington, D.C.: NASW.