Understanding the nature and dynamics of substance use disorders (SUDs) can help child protective services (CPS) caseworkers in screening for SUDs, making informed decisions, and developing appropriate case plans for families experiencing this problem.

The Continuum of Alcohol and Drug Use

Substance use, like many human behaviors, occurs along a broad continuum from no use to extremely heavy use. The likelihood of an individual experiencing problems stemming from substance use typically increases as the rate of use increases. The continuum for the use of substances includes substance use, substance abuse, and substance dependence or addiction.

Substance use is the consumption of low or infrequent doses of alcohol or drugs, such that damaging consequences are rare or minor. In reference to alcohol, this means drinking in a way that does not impair functioning or lead to negative consequences, such as violence. In reference to prescription drugs, use involves taking medications as prescribed by a physician. Regarding over-the-counter medications, use is defined as taking the substance as recommended for alleviating symptoms. Some people who choose to use substances may use them periodically, never use them to an extreme, or never experience life consequences because of their use.

Substance abuse is a pattern of substance use that leads to significant impairment or distress, reflected by one or more of the following:

• Failure to fulfill major role obligations at work, school, or home (e.g., substance-related absences from work, suspension from school, neglect of a child's need for regular meals)

• Continued use in spite of physical hazards (e.g., driving under the influence)

• Trouble with the law (e.g., arrests for substance related disorderly conduct)

• Interpersonal or social problems.⁹

Additionally, use of a medication in a manner different from how it is prescribed or recommended and use of an intravenous drug that is not medically required are considered substance abuse.

Individuals may abuse one or more substances for a certain period of time and then modify their behaviors because of internal or external pressures. Abuse is characterized by periodic events of abusive use of substances, which may be accompanied by life consequences directly related to its use. With proper intervention, an individual with substance abuse problems can avert progression to addiction. At this level of progression, the abusers often are not aware, or if they are, they may not be honest with themselves that the negative consequences they experience are linked to their substance use. With proper intervention, these individuals are able to choose to limit or to cease substance use because of the recognition of the connection between use and consequences. Other people, however, may continue abusing substances until they become addicted.

Substance dependence or addiction is the progressive need for alcohol or drugs that results from the use of that substance. This need creates both psychological and physical changes that make it difficult for the users to control when they will use the substance or how much they will use. Psychological dependence occurs when a user needs the substance to feel normal or to engage in typical daily activities. Physical dependence occurs when the body adapts to the substance and needs increasing amounts to ward off the effects of withdrawal and to maintain physiological functioning. Dependence can result in:

• The continued use of a substance despite negative consequences. The individual continues drug or alcohol use despite incidents, such as accidents, arrests, or a lack of money to pay for food because it was spent on drugs.

• An increase in tolerance to the substance. The individual requires more of the alcohol or drug to obtain the same effect.

• Withdrawal symptoms. The individual needs to consume the substance in order not to experience unpleasant withdrawal effects, such as uncontrollable shaking and tremors or intense nausea.

• Behavioral changes. The individual who is dependent:

• Uses more than intended

• Spends a majority of the time either obtaining, using, or withdrawing from the use of the substance

• Cannot stop using until the substance is gone or the individual passes out.

Criteria for diagnosing substance dependence and substance abuse as an SUD have been defined in theDiagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), the American Psychiatric Association's classification index for mental disorders. (See Appendix D, Diagnostic and Statistical Manual of Mental Disorders Criteria, for more information on this topic.)

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Appropriate and Inappropriate Uses of Substances

Certain substances, when used appropriately, have helpful and even lifesaving uses. Many individuals use various drugs to help overcome physical and psychological problems. Drugs can alleviate cold and flu symptoms, make it easier to sleep, reduce physical or emotional pain, and help overcome feelings of anxiety, panic, or depression. Some of these drugs require a prescription from a doctor to be obtained legally, while others are considered safe enough to be sold over the counter to the public. Although these drugs have many health benefits, many also can be used in a higher quantity or in combination with other substances to produce either a "high" or a numbing effect. Combining these drugs with alcohol or other drugs can intensify their effects and increase risks to the user and to those around the user. Individuals who abuse prescription medication sometimes resort to forging prescriptions, to visiting several doctors who will prescribe the same drug without asking questions ("doctor shopping"), or to buying stolen drugs. Exhibit 2-1 provides key statistics for commonly abused substances.

Other substances may not have medicinal qualities but can affect users psychologically and physically or lower inhibitions and impair judgment if misused. For instance, some individuals drink alcohol at social gatherings to feel more comfortable talking and relating to others. Being of legal age and drinking alcohol is a commonly accepted practice in the United States. Of course, alcohol often can be misused and can negatively affect events ranging from traffic safety to the ability to care adequately for children.

With respect to child protection, substance use becomes problematic when it contributes to the harm of children. This can be difficult for CPS caseworkers to identify because the distinction between "normal" alcohol use and problematic use may be blurred and subject to interpretation. (See Chapter 4, In-home Examination, Screening, and Assessment of Substance Use Disorders, for more information about identifying SUDs.)

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Characteristics of Addiction

Knowing the characteristics of addiction can help inform effective intervention and practice with individuals suffering from SUDs. Characteristics include:

• Progressive Nature. A central feature of addiction is a progressive use of a substance, whether alcohol, prescription medications, or illegal drugs. The physical, emotional, and social problems that arise from addiction typically continue to worsen unless the SUDs are treated successfully. If left untreated, addiction can cause premature death through overdose; through organic complications involving the brain, liver, heart, and many other organs; and by contributing to motor vehicle crashes, homicide, suicide, and other traumatic events.

• Denial and Concealment. Addiction can be difficult to identify, even for individuals experiencing it. People who are addicted to a substance often engage in elaborate strategies to conceal the amount being consumed and the degree to which the substance is affecting their lives. Another dimension of addiction is that individuals who suffer from it often do not perceive that their pattern of drinking or drug use creates or contributes to their problems. Additionally, the use of substances may affect their memory or perception of events or of what they have said or done. This lack of recognition commonly is identified as denial.

• Chronic Disease. The National Institute on Drug Abuse has defined addiction as a chronic disease, like heart disease, hypertension, and diabetes. Studies have shown alcohol and drug abuse treatment is about as effective as treatments required for these other chronic diseases. Lifetime management of chronic diseases in all cases requires individuals to change their habits and activities and to take precautions that prevent them from relapsing or worsening their condition.

• Lapses and Relapses. Lapses and relapses are common features of addiction. A lapse is a period of substance use after the individual has been clean and sober for some length of time. A relapse is not only using the substance again, but also returning to the problem behaviors associated with it.¹²

Addiction is difficult to deal with; many individuals lapse or relapse one or more times before being able to remain abstinent. If lapses or relapses occur, they do not necessarily mean that treatment has failed. They can point the way toward needed improvements in how those individuals are approaching recovery. Most individuals who have lapsed or relapsed can identify, prior to the lapse or relapse, certain situations, thoughts, or behaviors that contributed to the use of the substance.

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Why Some People Become Addicted

Many theories and explanations have been proposed to describe the reasons why some individuals become addicted to substances and others do not. Research on the causes of addiction is not conclusive, and multiple factors may contribute to it. Early explanations for addiction included moral weakness, insanity, demonic possession, and character pathology.¹³ These explanations, combined with the problematic behaviors that sometimes accompany addiction, have created a serious stigma. Recent research, however, indicates that substance addiction is a brain disease that changes its structure and functioning, which in turn affects an individual's behaviors. Although the initial use of a substance may be voluntary, a person's ability to control future use may be seriously impaired by changes in the brain caused by prior use.¹⁴

Some research, including adoption and twins studies, has demonstrated a biological and genetic predisposition to addiction, with scientists estimating that genetic factors account for 40–60 percent of an individual's risk of addiction.¹⁵ These studies suggest that an individual's genes play a role in vulnerability to addiction. For example, one study found that children whose parents are addicted to drugs or alcohol are three times more likely to develop an SUD later in life than children whose parents are not addicted.¹⁶ Other research emphasizes a social factor to explain that addictions appear to "run in the family." These studies suggest that children who grow up in families with SUDs may model their adult behavior on what they have seen and known in their familial experience.¹⁷ Risk for addiction can also be affected by gender, ethnicity, developmental stage, and social environment.¹⁸ In other words, both nature and nurture contribute to a person's vulnerability or resistance to substance abuse.

Many self-help groups, such as 12-step programs, consider addiction a progressive illness that is physical, spiritual, and emotional in nature. They believe that individuals who are addicted must admit that they are powerless over the substance; that is, they are unable to resolve the problem on their own and must seek help outside themselves.¹⁹

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Negative Consequences of Substance Use Disorders

Negative consequences from alcohol and drug use, abuse, and dependence generally fall into three categories: loss of behavioral control, psychophysical withdrawal, and role maladaptation.

Loss of behavioral control happens when individuals do things they normally would not do because their inhibitions and reasoning abilities are impaired. Loss of behavioral control can include passing out, having a blackout (i.e., short-term memory loss), behaving violently, leaving children unsupervised or in a potentially unsafe situation, and neglecting children's basic needs.

Psychophysical withdrawal occurs when individuals experience physical symptoms that result from withdrawing from using a substance. Indicators of psychophysical withdrawal include becoming nauseated or vomiting; feeling feverish, hot, sweaty, agitated, or nervous; and experiencing significant changes in eating or sleeping patterns. In advanced cases, withdrawal may include experiencing, seeing, or hearing things that are not there, such as having the sensation of bugs crawling on the skin or having seizures or convulsions. Physical withdrawal, particularly from alcohol and heroin, can be life threatening.

Role maladaptation occurs when individuals cannot conform to what are generally considered their expected roles (e.g., parent, breadwinner). For parents, this can mean difficulties in caring properly for their children (e.g., prioritizing a need for drugs over a child's needs for food and clothing). Other examples of role maladaptation due to SUDs include relationship problems, failure to keep a job, difficulties paying the bills, and criminal activity.

Problems in one area will not necessarily indicate or predict problems in other areas. Someone who experiences regular hangovers from drinking (defined as anxiety, agitation, nausea, and headaches) can experience these symptoms without experiencing a significant loss of behavioral control or role maladaptation. Others struggling with addiction, however, may suffer from all three consequences.

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Co-Occuring Issues

CPS caseworkers must place SUDs into context with the other problems that families may face. In general, these families have more numerous and complex issues to address than those who are not abusing or addicted to alcohol and drugs. Similarly, child abuse and neglect seldom occur in a vacuum; these families often are experiencing several layers of problems. For both SUDs and child maltreatment, common co-occurring issues include mental and physical illnesses, domestic violence and other trauma, economic difficulties or poverty, housing instability, or dangerous neighborhoods and crime.²¹ All of these challenges can constitute barriers to successful participation in SUD treatment and, when addressed, can improve an individual's chances of attaining long-term abstinence. The following sections describe some of the most common co-occurring issues experienced by families affected by child maltreatment and SUDs. The goal is to increase caseworker awareness of the variety of symptoms and factors, particularly those most likely to affect assessment and decisions regarding services for families and children involved in CPS cases.

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Mental Illness

SUDS have a strong association with mental illness. In 2007, an estimated 24.3 million adults aged 18 or older had a serious mental illness.²² (Having a serious mental illness is defined as having a diagnosable mental, behavioral, or emotional disorder during the past year that met the DSM-IV criteria.) Adults with a serious mental illness are much more likely to have used illicit drugs within the past year than those adults without a serious mental illness (28.0 percent versus 12.2 percent).²³

It is not clear why there is a high correlation between SUDs and mental illness. Three ways in which they may relate to one another are:

• The disorders may occur independently of each other.

• The mental health disorder may place an individual at greater risk for SUDs.

• Alcohol or drug intoxication or withdrawal may result in temporary mental health disorders, such as paranoia or depression.²⁴

It is common for either the SUD or the mental health issue to go undiagnosed. In addition, not all mental health problems affecting a parent necessarily will appear severe or profound. As a result, when one issue is identified, it is important to screen for the other. When both are identified, current accepted practice is to treat both disorders simultaneously, especially with individuals who have serious mental illnesses.

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Physical Health Problems

SUDs can cause or worsen physical health problems. For example:

• Alcohol abuse can cause numerous physical problems related to the function of the liver, heart, digestive system, and nervous system.

• Marijuana use is associated with ailments ranging from a burning or stinging sensation in the mouth or throat, to respiratory problems, to an increased likelihood of cancer in the throat and lungs.

• Individuals who inject drugs, such as heroin or methamphetamine, put themselves at risk of contracting infectious diseases, such as HIV/ AIDS and hepatitis C, through the sharing of syringes and other injection paraphernalia.

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Domestic Violence and Other Forms of Trauma

Trauma can take the form of a physical injury or a painful or disturbing experience that can have lasting effects. It can result from exposure to a variety of events ranging from natural disasters to violent crimes. The consequences of trauma can be significant, affecting the victim on biological, psychological, social, and spiritual levels.

Individuals who have experienced a traumatic event sometimes turn to drugs or alcohol in an effort to deal with the resulting emotional pain, anxiety, fear, or guilt. If the pattern becomes well established, it may indicate that the person has an SUD. SUDs, particularly if they are active over a period of time, increase the likelihood of further exposure to accidental and intentional acts that may result in additional trauma. In addition, individuals who have not experienced a traumatic event, but have an SUD, have an increased likelihood of exposure to events that may then result in trauma, such as being assaulted.

Studies have shown that a high percentage of women treated for SUDs also have significant histories of trauma.²⁵ Women who abuse substances are more likely to experience accidents and acts of violence, including assaults, automobile accidents, intimate partner violence, sexual abuse and assault, homicide, and suicide.²⁶

Alcohol commonly is cited as a causal factor and precursor to adult domestic violence. Research studies indicate that approximately 25 to 50 percent of domestic violence incidents involve alcohol and that nearly one-half of all abusers entering batterer intervention programs abuse alcohol.²⁷ Despite the evidence that many batterers and victims abuse alcohol, there is no empirical evidence that substance use disorder directly causes domestic violence. However, SUDs increase the severity and frequency of the batterers' violence and interfere with domestic violence interventions.²⁸ They also contribute to the increased severity of injuries among victims.²⁹

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Poverty

SUDs cross all socioeconomic lines, but studies show that there is a relationship between poverty and substance abuse.³³ People living in poverty sometimes turn to substances for relief from the anxiety and the stress associated with economic insecurity. Of course, spending money on alcohol or drugs often only contributes to economic problems. Dealing illegal drugs is viewed by some as a source of income and a means of escaping poverty. Unfortunately, some individuals suffering from economic hardship feel that they have little to lose if they get involved in drugs, no matter what the effects are on themselves or their families.

Parents who are distracted by their financial problems may have less energy and attention for parenting. In some homes, the psychological distress of poverty may be directed toward the children. Research has indicated a strong association between child maltreatment, particularly neglect, and poverty.³⁴ CPS case plans invariably need to address issues related to poverty and establish service plans for families.

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Homelessness

In some cases, extreme poverty and other factors may lead to homelessness. Homeless people typically experience several overlapping challenges, including SUDs, mental illnesses, and a variety of physical health problems. Parents with children account for approximately 11 percent of the homeless population, and this number appears to be growing.³⁵

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Crime

Crime has a strong association with drug use. In the most recent study of its kind, more than three out of every four State, Federal, or local jail inmates previously were involved seriously with drugs or alcohol in some way (e.g., convicted of a drug- or alcohol-related crime, used illicit substances regularly, were under the influence of alcohol or drugs when they committed crime).³⁶ Another study found that adults who were arrested for a serious offense were much more likely to have used an illicit drug in the prior year (60.1 percent) than those who were not arrested (13.6 percent).³⁷ In addition, many individuals in prisons and jails experience multiple, overlapping problems. For instance, research indicates that among inmates with a serious mental disorder, 72 percent have a co-ccurring SUD.³⁸ It often is challenging for these individuals to obtain appropriate services either in prison or upon their release.

Because women are generally the primary caretakers of their children, the increase in the number of incarcerated women over the past decade is particularly relevant to CPS caseworkers. The Bureau of Justice Statistics reports that the female prison population increased from 44,000 in 1990 to more than 111,000 in 2006.³⁹ One-third of incarcerated women have been convicted of drug offenses, and approximately 65 percent of women in prison report having used drugs regularly.⁴⁰ Additionally, 75 percent of incarcerated women are mothers, and two-thirds have minor children, who often are placed outside the home while their mothers are incarcerated.⁴¹

In response to problems arising from low-level, nonviolent drug offenses, many States and localities have established alternative, less putative programs, such as drug courts, to rehabilitate offenders. (For more information on drug courts, see Chapter 8, Putting It Together: Making the Systems Work for Families.)