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Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009

Prevention and Drug Treatment
Authors: Mark F. Testa Brenda Smith

Children's Exposure to Parental AODA

The prevalence of children’s exposure to parental AODA refers to the proportion of abused and neglected children who are affected by parental alcohol and other drug use at a given time. Estimates vary depending on the definition of AODA used to classify cases, the segment of the child population examined, and the method of data collection used to count the cases. Prevalence estimates are best generated through carefully conducted studies using uniform definitions that rely on samples of cases drawn at random or using some other statistically valid method of selection to generate an estimate within some margin of error, for example, plus or minus a few percentage points.

Because “substance abuse” is defined differently and measured more precisely by drug professionals than by ordinary folks, an important element of the estimation process is the definition of substance abuse that is used for classifying and counting. AODA is variously measured in terms of current use, lifetime use, abuse, or dependence. Current or lifetime use of illicit substances or large amounts of alcohol (often defined as four or more drinks in one day) is best measured using uniform screening questions such as those in the Composite International Diag-nostic Interview-Short Form (CIDI-SF).4 In such diagnostic interviews, respondents are asked a series of questions such as, “In the past 12 months did you ever use… [insert name of substance]”?5

Substance abuse and dependence are distinct concepts and refer to detrimental or debilitating use. They can be systematically measured with criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).6 The manual lists seven potential dependency symptoms and suggests that dependence is indicated when at least three of the seven are present. The DSM-IV defines substance abuse in narrower terms, as a pattern of substance use that is “maladaptive”7 without meeting the criteria for dependence. The manual specifies four characteristic symptoms of substance abuse and specifies that at least one must be present to indicate a diagnosis of substance abuse.

The National Survey of Drug Use and Health (NSDUH; formerly known as the National Household Survey of Drug Abuse) conducts in-home surveys with probability samples of the population to estimate prevalence rates of alcohol and drug use within the past year. It uses DSM-based criteria to assess substance abuse and dependency. In 2002, the NSDUH found that among married women aged twenty-one to forty-nine living with children under the age of eighteen, 14.5 percent engaged in binge drinking and 4 percent used illicit drugs in the past month.8 The 2003 NSDUH found that among women aged eighteen to forty-nine, 5.5 percent abused or were dependent on alcohol or any illicit drug.9

These prevalence estimates suggest that between 6 million10 and 9 million11 children live in households in which a caregiver abuses alcohol or drugs. These numbers far exceed the number of children who become involved in the child welfare system for any reason. Of the approximately 900,000 children with substantiated maltreatment allegations of any kind in 2005, about 300,000 (33 percent) were placed in foster care, leaving about 600,000 children with substantiated allegations at home with their parents.12 Even if all of these substantiated cases with children in the home involved parental substance abuse, the number would conservatively reflect only about 10 percent of the estimated number of children living with a parent who abuses substances.

It is equally challenging to identify the prevalence of AODA among families already involved with the child welfare system.13 Just as substance abuse can be measured differently in general population studies, so can exposure to parental AODA in the child welfare population be defined and counted in a variety of ways. In the child welfare research literature, measures of AODA range from the impressions of state administrators elicited in phone surveys, to references in case files, to caregivers’ scores on standardized measures such as the CIDI-SF.14 As described below, when substance abuse is measured with standardized and validated measures, the resulting prevalence estimates tend to be lower than those of phone surveys and case records.

An added complication is that the child welfare population can also be defined in a variety of ways. The definitions range from the total number of children involved in CPS investigations to the fraction having a substantiated maltreatment report to the smaller number who are removed and placed into foster care. Prevalence rates vary not only across these different population groupings but also by geographical location and time period. Child welfare jurisdictions have different policies and norms regarding when substance abuse triggers child welfare involvement, and those policies and norms change over time. Hence, even if the same child welfare subpopulations are assessed using the same substance abuse measures, prevalence rate estimates may vary depending on the specific location and time period examined.

In light of the range of possibilities, it is easy to see how specific choices of substance abuse definitions and child welfare subpopulations can affect prevalence estimates. The most reliable prevalence estimates come from studies that meet generally accepted criteria of sampling rigor and measurement precision. Studies with unspecified response rates, response rates of less than 50 percent, or those that use only impressions as an indicator of substance abuse tend to produce unreliable estimates. The best estimates derive from studies with well-defined indicators of substance abuse and clearly specified samples. The best studies will also differentiate between samples that focus on the smaller foster care subpopulation and those that focus on the larger population of abused and neglected children.

Evidence meeting the above criteria suggests that caseworkers and investigators report substance abuse in about 11 to 14 percent of investigated cases15 and in 18 to 24 percent of cases with substantiated maltreatment.16 Of the cases that are opened for in-home services following a maltreatment investigation, 24 percent screen positive for alcohol abuse or illicit drug use in the past year.17 This figure is a nationwide average. In an urban sample with no specification about timing, 56 percent of such caregivers had a notation of illicit drug or alcohol abuse in their case files or self-reported as having engaged in drug or alcohol abuse.18

The prevalence of substance abuse runs higher for children taken into foster care, with estimates meeting the above criteria ranging from 50 to 79 percent among young children removed from parental custody.19 Although few studies meeting the specified criteria have assessed the prevalence of DSM-defined substance abuse or dependency in child welfare populations, those that do suggest that 4 percent of families having contact with the child welfare system20 and 16 percent of families having a child in foster care21 meet DSM criteria for substance abuse or dependence. Comparing reports of prevalence of substance abuse or current use to more standardized measures of drug abuse and dependency suggests that approximately one-fourth of users of alcohol and other drugs who come to the attention of CPS authorities present serious enough problems to warrant a DSM designation.

Two key generalizations may be drawn from the research about the prevalence of children’s exposure to parental AODA. First, when detection methods and measures of substance abuse are more precise, prevalence estimates tend to be lower. Prevalence rates generated from impressions (from administrators, state liaisons, or caseworkers) or from wide-ranging references in case files (such as reports of past substance abuse or a past referral to substance abuse treatment) are substantially higher than are estimates generated through individual parent assessments or professional diagnosis. A clearer picture of links between substance abuse and child maltreatment will require greater attention to definitions of substance abuse and the timing and method of assessment. Second, the prevalence of parental substance abuse is lower among children who are subjects of a CPS investigation than among those who are indicated for maltreatment and substantially lower than among those placed into foster care. These distinctions are important because, as noted, only about one-third of substantiated maltreatment allegations result in out-of-home care.22 Prevalence estimates derived from a foster care subpopulation should not be generalized to the larger child welfare populations of abused and neglected children.