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Effective: 6/29/2020

1.15 Working with Families Affected by Substance Misuse

Legal Authority

Introduction

​​​​​​​​​​​​​​​​​​​​​​The SSW may encounter families affected by substance misuse during all phases of intervention, including during investigations and ongoing case work. This section of SOP is to be utilized for all of these phases.

To achieve successful outcomes for the family, cases related to substance misuse must be handled in an intensely collaborative setting. No single agency has the resources, the information base, or the lead role to address the full range of needs of all substance-affected newborns, children and their families.

Practice Guidance

Best practice in cases related to substance misuse requires that:

  • Decisions are made and shared timely with professional reporting sources—especially with birthing hospitals in substance-affected infant cases; 
  • Assessments (investigative and ongoing) cannot be limited to assessment of the parent's caregiving while sober, and must include the degree to which the parent is impaired in terms of day-to-day living and functioning;
  • Regular ongoing contact with services providers is vital to completing the global risk assessment;
  • The frequency of contact with clients and services providers may need to increase beyond the minimum as established in SOPs 3.10 and 4.24 depending on case circumstances; and
  • The worker must continue to make efforts to engage adult clients through the life of the case until a waiver of reasonable efforts is granted or case closure occurs.  Worker should maintain frequency and quality of contacts and work to minimize any resistance to treatment services.

It is important to recognize that in medication-assisted treatment (MAT), prescribed medication could be lifesaving and is an acceptable form of treatment but is only a piece of treatment and should be used in conjunction with additional services. 


Appropriate service matching includes, but is not limited to assessment of the following:

  • Referral of pregnant women, and mothers who have recently given birth, to appropriate and timely prenatal and follow-up postnatal medical care, including MAT or other medications as prescribed by treatment providers.  This is also a good time to discuss birth control methods to begin after the child's birth. 
  • The family is following up with post-delivery medical appointments for the infant, and follows any subsequent recommendations. 
  • The family's parenting skills and developmental expectations for the child, and referral to appropriate classes or support systems, i.e. HANDS or other local community programs.
  • Appropriate nutrition for the child, i.e. formula or breastfeeding, and referral to treatment providers for recommendations regarding breastfeeding mothers who are prescribed MAT or other medications. 
  • Substance misuse treatment is accompanied by a mental health assessment for treatment of the parent's underlying issues that resulted in the substance misuse.
  • Appropriate supports for the family, both personal and community programs that can assist, if needed. 
  • The family's basic needs are met and referral to community programs that can assist, if needed.
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Plans of Safe Care (POSC) 

For cases involving an infant born identified as substance affected, including withdrawal symptoms resulting from prenatal drug exposure or a Fetal Alcohol Spectrum Disorder (FASD), federal requirements require that the worker develop a POSC for the family (CAPTA 106(b)(2)(B)(ii) and (iii)).  The plan should go beyond immediate safety threats to address the health and developmental needs of the affected infant and the caretaker’s need for treatment related to substance misuse and/or mental health.  Additionally, it should identify the services and supports the caretaker needs to strengthen his or her capacity to nurture and care for the infant.  To ensure safety of the infant, it should also incorporate a plan of safe sleep; and a plan for the care of the infant, and any other children, in the event of a return to use.  The child welfare agency will use existing continuous quality improvement (CQI) processes, which includes collaboration with partner agencies, to monitor local development of POSC, referrals to services, and appropriate services to infants and affected family or caregivers.

The identification of a substance-affected infant may occur during any stage of involvement, including at birth or later during the infant’s development and/or as symptoms manifest.  The POSC addresses actions and services for the infant and family’s needs, and these needs must be incorporated into the safety plan, prevention plan, case plan, or aftercare plan in accordance with best practice described in SOP 7.2 CPS Safety Planning, SOP 7.4 CPS Prevention Planning, SOP 7.6 CPS Aftercare Planning, SOP 3.4 Initial In Home Case Planning Conference, SOP 3.13 Ongoing Case Planning, SOP 4.17 Preparation for and Completion of the Ten Day Conference, SOP 4.18 Ongoing Case Planning [OOHC], and SOP 4.36 Case Closure and Aftercare Planning.

Alcohol and substances cause significant changes in brain chemistry, which affects a person’s mood, thinking, behavior, and perception.  It can be difficult for a person to follow through on scheduling and keeping appointments; therefore, it is essential that SSWs assist families with making and keeping appointments or identify a responsible person, such as an appropriate family member/friend or community service provider, to assist the family.




Procedure

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The SSW ​

 
  1. Requests a signed release of information for treatment providers, as most providers require a specific form prior to disclosing information;
  2. Makes timely and direct personal contact with treatment providers prior to completing any referral for assessment or drug testing; 1
  3. When there are indicators of substance misuse, requests an initial substance use disorder (SUD) assessment/testing as well as follow up services as determined by ongoing assessment, through the life of the case; 2
  4. Refers the individual to a SUD assessment regardless of the results of a drug test;
  5. Discusses the results of the assessment, including any follow up recommendations, with the evaluator;
  6. Ensures that a safety and/or prevention plan includes specific steps related to the caregivers’ high-risk behaviors and safety of the child in the event of return to use and a plan for safe sleep for infants in the home;3
  7. Increases the frequency of contact with treatment providers and family members based on the case specific needs; 4
  8. Reports any concerns to the treatment provider regarding the caretaker’s functioning or ability to care for the child.  (i.e., the caretaker is nodding off inappropriately, slurring words, appears to be over or under-medicated, etc.);
  9. Assesses if caretaker is taking medication as prescribed (by counting pills or medication strips in the presence of SSW);
  10. Consults with any treatment or medication provider, to incorporate specific treatment information into the child welfare assessment and case planning, including but not limited to:
    1. Safety of child, (i.e., what are the effects of the medication on the caretaker’s ability to function daily and care for the child, safe storage of medications).  Do not assume the treatment provider recognizes or considers safety of the child while in the caretaker’s custody;
    2. Medication management, (i.e., what type of medication is prescribed, what phase of treatment);
    3. Recommendations for follow-up treatment, (i.e., in-patient, outpatient, AA/NA, length of treatment, etc.);
    4. Provider recommendation for mental health treatment.  Best provider practice recommends that mental health treatment accompanies medication management;
    5. Verification of medication doses, (i.e., in the office or self-administered take-home);
    6. Compliance with treatment programs;
    7. Drug test results, both positive and negative, completed through the treatment program; 5 and
    8. Treatment discharge planning, including appropriate aftercare plan if caretaker is continuing MAT after case closure.
  11. Works with service providers regarding recommendations for safe sleep and breast feeding safety, as well as tools for caretakers of neonatal abstinence syndrome (NAS) infants;
  12. Ensures that a treatment plan from any provider is incorporated into any safety plan, prevention plan, case plan, and/or aftercare plan completed for the family;
  13. Includes information from the treatment provider in the assessment and any case plans developed on behalf of the family;
  14. Relies on treatment providers for medication recommendations, and does not make medication recommendations to individuals;
  15. Does not make recommendations to the court regarding treatment;
  16. Does not take a punitive approach with regard to return to use or treatment plan infractions such as withholding parent/child visits;
  17. Does not set conditions on visitation that aren’t tied to a specific safety threat (i.e. changing unsupervised to supervised, location from out of office to in office);
  18. Does not expect tapering of the dose or an end-date of treatment;
  19. Does not require, or recommend, that the court necessitate tapering of the dose or an end-date of treatment;
  20. Recognizes that some individuals will return to use:
    1. If return to use occurs, SSW assesses the situation by talking to the individual, treatment provider, and any other collaterals;
    2. Assesses the risk to the child in the home; and
    3. Offers additional support to stabilize the situation if possible.
  21. Refers substance misusing caregivers or alternate caregivers to appropriate supportive services including, but not limited to:
    1. HANDS;
    2. KY-Moms MATR; or
    3. Other services appropriate for providing care for infants experiencing withdrawal.
  22. Ensures appropriate designation of a case involving a substance-affected infant through the use of the correct subprogram in the central intake screens to permit reporting of the number of substance-affected infants are reported, and for whom a POSC was developed, and the number of infants for whom a referral was made for appropriate services. 
  23. Reports any concerns regarding treatment providers not following guidelines, or prescribing medications inappropriately, or to a large volume of people to the Kentucky Board of Medical Licensure at (502) 429-7150 or http://kbml.ky.gov/Pages/index.aspx;
  24. Immediately consults with FSOS to discuss the discontinuation of the safety and /or prevention plan when the safety threats requiring the provisions within the safety and/or prevention plan have been mitigated prior to the fourteen (14) working day expiration of the plan, and:
    1. If it is determined that the safety plan should be discontiued prior to the expiration date on the safety plan, informs the family and other involved individuals within forty eight (48) hours, by phone call, if the safety/prevention plan will be discontinued prior to the expiration date.  If the family is not available by phone within forty eight (48) hours, SSW will send notification by mail, or conduct a home visit.  
  25. Completes a face-to-face interview with the parent/caregiver within forty eight (48) hours if the safety or prevention plan needs to be renegotiated based on safety threats or risks to the child(ren).  6


​Contingencies and Clarifications

When developing the POSC, the family, SSW, and other service providers should keep in mind that the postpartum period is a time of unique vulnerability and the risk of return to use increases for the mother due to:


    1. Increased stress associated with motherhood, newborn care, sleep deprivation;
    2. Limited social support and resource availability;
    3. Increased financial demands;
    4. Pain and physical recovery from delivery; and/or
    5. Physiologic transition from pregnant to non-pregnant state.

What to include in a plan of safe care (CAPTA 106(b)(2)(B)(ii)and (iii)):

  1. Service referrals to meet the needs of the mother (CAPTA 106 (b)(2)(B)(ii) and (iii), including but not limited to:
    1. Health care;
    2. Identification of a consistent and appropriate primary caregiver;
    3. Medication management;
    4. Pain management;
    5. Support with breast feeding;
    6. Discussion of family planning;
    7. SUD treatment and mental health services which assist the mother in identifying and accessing the appropriate assessments and treatment services, including the following:
      1. Timely access;
      2. Engagement, retention and recovery supports;
      3. Appropriate treatment (i.e. gender-specific, family focused, accessible, MAT, trauma responsive); and
      4. Depression/anxiety/domestic violence.
    8. Referrals to appropriate supportive services including, but not limited to:
      1. HANDS;
      2. KY-Moms MATR; and
      3. Other services appropriate for providing care for infants experiencing withdrawal;
    9. Appropriate alternate care, i.e. child care referral, respite care by an appropriate relative, etc.
  2. Services referrals to meet the needs of the infant (CAPTA 106(b)(2)(B)(ii) and (iii)) and other children in the home, including but not limited to:
    1. Identification of a consistent pediatrician/healthcare provider;
    2. High-risk follow-up care;
    3. Referral to specialty care, as indicated;
    4. Developmental screening and assessment;
    5. Linkage to early intervention services; and
    6. Plan for safe sleep.
  3. Services to meet the needs of secondary caregivers and other household members, including but not limited to:
    1. SUD assessment and treatment, if indicated;
    2. Mental health assessment and treatment;
    3. Medication management;
    4. Parenting skills (i.e. bonding, nurturing, understanding of the special care needs of the infant and the ability to provide it, etc.); and​
    5. Ability to demonstrate the care and protection needs of the infant and any other children living in the home.
  4. A designation of who will monitor the POSC to determine whether and how local entities are making referrals and delivering appropriate services to the infant and affected family or caregiver for cases alleging maltreatment (CAPTA 106(b)(2)(B)(ii) and (iii).
  5. Ensure that the designation for monitoring includes another responsible agency in the aftercare plan, if the child welfare case closes (CAPTA 106(b)(2)(B)(ii) and (iii)).

Related Information

Definitions

Substance Use Disorder (SUD):  Substance use disorders are patterns of symptoms resulting from use of a substance, which the individual continues to take despite experiencing problems as a result.
Substance use disorders span a wide variety of problems arising from substance use and cover eleven different criteria:


  • Taking the substance in larger amounts or for longer than the individual intended;
  • Wanting to cut down or stop using the substance but not able to do so;
    • Spending a lot of time getting, using, or recovering from use of the substance;
      • Cravings and urges to use the substance;
        • Not managing to do what the individual should at work, home or school, because of substance use;
          • Continuing to use, even when it causes problems in relationships;
            • Giving up important social, occupational or recreational activities because of substance use;
              • Using substances again and again, even when it puts the individual in danger;
                • Continuing to use, even when the individual knows they have a physical or psychological problem that could have been caused or made worse by the substance;
                  • Needing more of the substance to get the effect the individual wants (tolerance); or
                    • Development of withdrawal symptoms, which can be relieved by taking more of the substance.

                    Fetal Alcohol Spectrum Disorder (FASD):  A group of conditions that can occur in a person whose mother drank alcohol during pregnancy.  These effects can include physical problems and problems with behavior and learning.  Often, a person with an FASD has a combination of these problems. 

                    Neonatal Abstinence Syndrome (NAS):  A result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy.  This includes any of the adverse consequences in the newborn of exposure to addictive or dangerous intoxicants during fetal development.  The consequences include, but are not limited to, preterm delivery, intrauterine growth retardation, asphyxia, low birth weight, drug withdrawal symptoms after delivery, behavioral, psychiatric, and learning disabilities later in life.

                    KY-Moms MATR helps expectant Kentucky mothers who are at risk for using alcohol, tobacco and other drugs, to reduce harm to their children from their substance use, during and after pregnancy.  Call (800) 374-9146 or visit the Department of Behavioral Health, Developmental, and Intellectual Disabilities website. (See resources)

                    The Substance Exposed Infant Reporting is a guide for the SSW to use when speaking with the delivering hospital’s medical staff regarding a substance-affected infant.  The checklist can be used during any phase of interaction with the family.  (See resources)


                    Footnotes

                    1. This will ensure that the provider is aware of any case concerns, including relevant criminal charges, and the reason for referral.
                    2. Consider that SUD screening is not an all-inclusive depiction of the family's capacity.
                    3. See resources for safe sleep website.
                    4. Maintaining the minimum but increasing frequency during times of return to use, or stress that may contribute to return to use.
                    5. Note that some street drugs taken in conjunction with MAT can be fatal.
                    6. The phone call, face-to-face renegotiation (if applicable), and written notification (if applicable) are documented in the assessment and documentation tool (ADT), and the written notification (if applicable) is filed in the case file.

                    Documents

                    Revisions