1. Domestic violence, chemical dependency, and Mental health problems in child welfare

2. Learning Objectives
Identifying C/D, MH & DV concerns in the families we work with
Teasing out the relationship between these issues and child safety within each individual family
Some specifics regarding C/D, MH, and DV, that are particularly important to child welfare work
Understanding our relationship with community experts - how they help us (and the family) and how we help them (and the family).

3. A two parent family had their three children removed because they were chronically failing to supervise them. Both parents used drugs and alcohol. One parent has been engaging in treatment for 6 months and has clean UA’s since the start of treatment. The other parent has engaged less frequently in treatment and provided few UA’s. Are the children safe to return home? Scenario 1

4. An intake is called in by a school, after a 9 year old disclosed to his teacher that last night his parents were fighting and his father hurt his mother by punching and kicking her. The child was very upset and said that he would not let his mother get hurt again. He has two siblings, who are 6 and 4. Is this child safe in the home? Are the younger kids safe? Scenario 2

5. An adolescent was removed from his father after he was physically attacked by him. His father has suffered from bi-polar disorder and PTSD for 20 years and the youth has at many times resided with others when his dad was “totally crazy.” At the FTDM the father reports that he disassociated during the assault and doesn’t remember it. He has an appointment to have medication re-evaluated and to resume counseling next week, and wants his son to come home. What would need to happen for this child to return to the home? Scenario 3

6. An intake identifies concerns about the care of two school aged children, who appear to be unsupervised and marginally cared for a good portion of the time. Upon visiting the home, the worker finds that the parents are both taking prescription medications for injuries, and have prescriptions for medical marijuana. Pill bottles are in a variety of places within the home and drug paraphernalia is laying on the coffee table, along with lighters and several full ashtrays. Are these children in present danger? Is the parents use of these substances making their children unsafe? Scenario 4

7. After being involved with a family for several months, the FVS worker meets with a single mother to discuss closing her case. She has maintained her home in an adequately sanitary fashion and engaged in outpatient treatment for alcohol abuse. The mother discloses that she’s pregnant, and is very afraid of her boyfriend. She states that he has threatened her and her child, and that she doesn’t know what to do. Should the case be kept open? How can the child, and the parent, be protected? Scenario 5

8. Why it’s confusing GOT HIT HIT Victim Advocacy Programs
Batterer Intervention Programs
People who need
help & resources,
but are not
being battered
Victim Defendant
People who are SURVIVING
Classic Victim
Legal Definition
Legal System
Other Systems
People who
HIT
a family or
HH member
People who
GOT HIT
by a family or
HH member
People who are
BATTERING
System Manipulator
Classic Perpetrator
Why it’s confusing

9. It feels like this GOT GOT HIT HIT ??
They all need help and resources tailored to their situation and circumstances
SURVIVING
HIT
GOT
BATTERING
Classic Perpetrator
Victim Defendant
System Manipulator
Classic Victim
and for the people involved in the relationship, and for their friends and families…
GOT
HIT
SURVIVING
BATTERING
It feels
like this ??
DV is a complex problem with no single solution. Everyone has a role to play in ending abuse AND in helping people learn healthy relationship skills.
By Mette Earlywine/WSCADV
with thanks to the NW Network

10. Screening and Identification
Activity: The Nuts and Bolts of Screening
When DV is occurring we want to know as soon as possible
Required to screen for DV with every family and again “periodically” as a case progresses
We want to screen in a way that does not decrease anyone’s safety
How might we figure out that DV is occurring, beyond talking to the caregivers or others about the family?
Documents! –in ACES, in the criminal history or individual criminal incident reports, within CA records, asking local LE about whether law enforcement has gone to the address and why
How do we approach these interviews so that the safety of everyone is protected?
Present screening as routine, required
ALWAYS interview people separately and privately – that includes outside the presence of children who may be “used” to gain information by an abuser
Explain more about the CA case process and how that information will be used
Help people understand the limits of confidentiality – it might be better if they didn’t disclose certain things (particularly when the abuser is also a parent, and will have a right to an unredacted copy of the file)
Don’t demand “proof” of the DV or that allegations are true – we gather information and do our own assessment about what may be happening, but questioning a victim’s statement is a great way to ensure they don’t disclose anything more
Don’t confront the perpetrator with victim’s/kids’ statements – use any documentation, phrase concerns based on disclosures generally, use the batterer’s own statements when possible
Don’t try to force a disclosure – accept and expect that many batterers will not be honest and forthright upon first contact. Identify discrepancies between the batterer's statement and other information you have, as you would when working with other issues, but avoid outright confrontation. Ratcheting up the pressure may have lots of negative consequences on the adult victim and child.

11. How Do We…
How might we figure out that DV is occurring, beyond talking to the caregivers or others about the family?
How do we approach these interviews so that the safety of everyone is protected?
What if there is a disclosure of intent to harm?

12. Accurately identifying the victim
Who is afraid?
Who is controlled?
Who experiences repeated negative consequences?
Who acts to protect the children when incidents happen?
Page 30
Although DV can occur in any intimate relationship (hetero- or homo- sexual), and can be perpetrated by both men and women, the vast majority of DV is perpetrated by men against women in the context of heterosexual relationships.
It’s important that in every case we accurately assess to determine who the victim is and who the perpetrator is. Getting this wrong has very, very serious consequences.
It’s not uncommon that both partners have used violence, been arrested, reported that the other has been abusive, etc. How are we to sort this situation out? By using these types of questions – which help us focus on the why of the behavior (power and control, self defense, etc.) and the result of the behavior (being diminished, terrified, limited, isolated – or, being temporarily injured but maintaining the rest of your power and agency)

13. Specialized DV Assessment
Guides what information to gather
(not a form or tool in FamLink)
Informs conclusions about the impact of DV on the family
Critical in determining if DV makes a child unsafe
Documented in a case note specifically presenting information and conclusions
Summarized on p. 34
Section 4, p
Required by policy:
Screen every family for DV
Identify victim and perpetrator
Specialized DV ASSESSMENT
planning and engagement tailored to the specific safety threats and dynamics in the family
SPECIALIZED DV ASSESSMENT helps us analyze what is going on, - ultimately, helps us assess child safety
Remember that with DV we actually do the assessment, we don’t send clients out to community professionals

14. GAIN-SS Other approaches Screening for MH and CD
Both state law and policy require that every adult we work with be screened for C/D and MH concerns
RCW requires all DSHS administrations to use the same screening tool for substance abuse, mental health, and co-occurring disorders – the GAIN-SS was selected to be this tool
Required unless the client is currently engaged in MH or CD services, or it’s been completed in the last 6 months by someone in CA
Follow the directions for referral – but may refer even if the GAIN-SS threshold isn’t met if there are other indicators of a problem
The suicide question may require immediate action – either contacting local crisis line or DMHP’s
???How else are you going to find out whether these issues may be occurring within a family?
Documentation within a variety of systems, Collaterals, Observation of behavior and environment, child interviews, ROI to healthcare provider, other

15. Chemical Dependency Assessments
Making a referral
Providing necessary information
Understanding the report
How are clients referred to a chemical dependency assessment in your office?
How are you able to provide additional information to the agency doing the assessment? Why might this be a good idea?
ADATSA Assessment Centers -

16. UA’s Exactly when a drug was used How much of the drug was used
What they can’t
What they tell us
Exactly when a drug was used
How much of the drug was used
A particular drug or class of drugs was used
General time frame this happened
UA’s test for the body’s reaction to the drug – the metabolite. They don’t test for the drug it’s self
UA’s come back “positive” if the urine has an amount of metabolite for a particular substance that’s equal to or greater than the cutoff threshold. The amount of metabolite is not particularly telling in most drugs – that is, higher numbers don’t necessarily indicate more frequent or heavier use.
UA’s are only helpful if the specimen provided actually belongs to the person we’re testing – for that reason most UA’s are requested to be observed. For obvious reasons, clients aren’t going to be excited about this.
Many products are available to “clean” urine and allow an individual to pass a drug test – most of these are also tested for
If an individual’s urine is too diluted, the sample will indicate that rather than indicating “negative”
Whenever there are questions about a UA’s results, or a client provides a story about why their UA is positive that you are not sure about, you are always able to call Sterling Labs and discuss this possibility.
A significant amount of information about understanding results is available on the website. The document “Understanding the Drugs of Abuse” has great information including whether “passive” exposure might result in a positive and a significant amount of information about results for marijuana.
CA UA site:
Go to : and use CAstaff as the user name and UAtest as the password

17. Legal drugs
How does our assessment change if a client is using or abusing a legal drug? Alcohol Medical Marijuana Recreational Marijuana Prescription drugs
Doesn’t matter other than possible issues around abstaining/reducing access
Our concern remains how the use impacts their ability to parent
Treatment addresses these substances as well as illegal substances – clients can still access treatment

18. Prescription Drug Abuse
Managing chronic problems
Stabilizing or improving functioning
Creating care team
Connecting to substance abuse treatment

19. Opiate Replacement Therapy
Typically Methadone
Addresses physical impacts of addiction
Lowers risks associated with illegal use
Highly monitored – program compliance required
Particularly common for pregnant mothers
Replacement therapy uses a more stable, long acting drug to eliminate physical symptoms associated with stopping use (people aren’t getting high and coming down, they are receiving enough opiate to not get sick and it lasts all day)
When those addicted to opiates are able to have their needs addressed via replacement therapy – they reduce all sorts of physical/health risks that they took on when they were using
Provided as part of a medically managed treatment program – participants are typically working with programs to address many aspects of their addiction and regain social and life skills their addiction has compromised
When women are pregnant, detoxing from opiates will often cause spontaneous abortion. For that reason, pregnant women are generally monitored on methadone and when they deliver their babies may have to detox

20. Substance Exposed Newborns
Creating a plan of safe care
CAPTA requires us to develop a “Plan of Safe Care” whenever we are notified that a child was born substance exposed. This plan must include:
Medical care for the child
Safe housing
Childcare if the parent plans to work or attend school
Emergency and community contacts for the parents
Referrals to drug/alcohol services and other services that are needed
Because these are our most vulnerable children, and their mother’s are almost always addicted, this often means a safety plan of out of home care, or an in-home safety plan with a responsible adult (the other parent or a family member) monitoring or providing daily care and supporting the addicted parent in managing their addiction and their parenting tasks
In each case, we do an individualized assessment of the situation to determine the best way to ensure that the child has his or her needs met and the family experiences the least intrusion possible
There are several treatment centers in our state that accept women with their infants and these clients are high priority for admissions into treatment – so it’s a good idea to take advantage of any indication that they are interested in treatment ASAP

21. Assessment and Treatment
Mental health
Assessment and Treatment

22. Intake/Assessment by community Mental Health provider vs
Intake/Assessment by community Mental Health provider vs. Psychological Evaluation

23. Depression

24. PTSD

25. An array of treatment approaches
While some individuals with mental health disorders will need to participate in treatment for the rest of their lives to manage their illness, others will see their illness lift on its own with little or no “formal” treatment
No single approach to treating mental illness works for everyone or for every disorder, but there is a strong evidence base supporting certain approaches for certain concerns
Often, particularly in cases where mental illness has significant impacts in a variety of life spheres – a combination of therapeutic work with a counselor and psychotropic medication may have the best chance for producing significant and long lasting positive changes
Life changes can also have a significant impact on mental illness
Circumstances like living in poverty, living with a chronic illness, and living in a violent context have significant impacts on people’s mental health. Significant evidence exists that addressing these contexts (providing concrete resources, getting a chronic condition under control, helping someone get safe housing or escape a violent relationship) has a significant impact on mental health functioning. Further, there is good evidence that regular exercise is as effective at treating mild depression and anxiety disorders as is medication.

26. Psychotropic Medications
Medications have greatly increased quality of life for many people – particularly those suffering from psychotic and mood stabilization disorders
Psychotropic medications are not a panacea – they carry possible benefits as well as risks.
Some medications may lose their effectiveness over time, and others can be used indefinitely with good results
In most cases, psychotropic medications don’t restore functioning, they improve functioning. Much work may still have to be done by the person living with mental illness to gain skills and coping mechanisms to deal with the impact of the mental illness that isn’t addressed/mitigated by the medication.

27. Effectively serving this large population
Co-ocuring disorders
Effectively serving this large population

28. What works with this population?
Employ a recovery perspective
Adopt a multi-problem viewpoint
Develop a phased approach to treatment
Address Specific Real-Life Problems early in Treatment
Plan for the client’s cognitive and functional impairments
Use support systems to maintain and extend treatment effectiveness
Employ a recovery perspective
Taking the long view of recovery, recognizing the importance of settings other than the treatment milieu for gradual progress, building and reinforcing connections to these ongoing support systems (self-help groups, positive peer support systems, extended family, cultural, spiritual or civic groups)
Adopt a multi-problem viewpoint
Many people with co-occurring disorders have significant gaps in life skills, concrete resources, healthy relationships, emotional self-regulation and employment skills, as well as outstanding medical problems. All of these areas must receive attention in order for long term recovery to be supported. Programs which have built in components focusing on these, or which allow staff to focus on these areas as part of the overall treatment approach, have better outcomes.
Develop a phased approach to treatment
Again, a long view to treatment where everything from initial experiences with the counselor/agency which build trust and prove helpful through supports and continued aftercare when a client is not receiving ongoing services from the agency are included in the model. In this way clients are widely conceived as “eligible” for services and as benefiting from an array of supports that treatment can offer.
Address Specific Real-Life Problems early in Treatment
Housing, legal, and family matters have often been identified by clients as the most pressing issues they currently face. Programs that address these areas early, when a client identifies that they are at a crisis point, are able to retain clients in treatment at greater rates than those programs that use a “recovery first” model.
Plan for the client’s cognitive and functional impairments
Clients with co-occurring disorders often, and particularly initially, present with functional impairments that impact their ability to comprehend information and complete tasks. Generally, relatively short and highly structured treatment sessions work best. Gradual pacing, visual aids, and repetition can also be key in impacting clients’ retention of information and skills.
Use support systems to maintain and extend treatment effectiveness
Counselors within programs serving these clients may offer some services to an entire family system, and often also helps the client identify new systems/groups where membership can be achieved and healthy support attained.
(Figure 3-1. In SAMSA publication TIP #42 – Substance Abuse Treatment for Persons with Co-Occurring disorders ncbi.nlm.nih/gov/books/NBK64197/)
SAMSA publication TIP #42 – Substance Abuse Treatment for Persons with Co-Occurring disorders

29. The intersection of Chemical Dependency, Mental Health, and Trauma
Experiences of trauma increase the likelihood that a person will experience a mental health disorder
Because people with mental health disorders and chemical dependency issues are often quite vulnerable, both of these increase the likelihood that a person will have a traumatic experience
Among high risk groups (those who have experienced rape or family violence, military combat, and immigrants fleeing ethnic/political persecution) the percentage of people qualifying for a PTSD diagnosis ranges from 1/3 to ½.
It’s estimated that at least 55% of women in substance abuse treatment have had a traumatic experience (most commonly childhood physical/sexual abuse, domestic violence or rape). Women with substance abuse disorders are about twice as likely as men to qualify for a PTSD diagnosis.
Of women in substance abuse treatment who have a past traumatic experience, 33-59% are experiencing current symptoms of PTSD.
Becoming abstinent from substances DOES NOT generally improve symptoms of PTSD (though it does reduce the likelihood of future traumatic experiences), and clients should receive concurrent or integrated help for these symptoms in order to improve long term odds for sobriety
Teaching specific coping skills for PTSD symptoms early in treatment is often associated with better outcomes in substance abuse treatment
(all the above from SAMSA publication TIP #42 – Substance Abuse Treatment for Persons with Co-Occurring disorders ncbi.nlm.nih/gov/books/NBK64197/)