Accurate Detection of Problematic Alcohol and Drug Use By Caregivers in the Child Welfare System

Background/Purpose: Highly prevalent among families involved with child protective services (CPS), caregiver problematic alcohol use (PAU) and problematic drug use (PDU) are associated with numerous negative outcomes for children. In practice, CPS caseworker perception of PAU/PDU frequently steer decision making rather than caregiver self-report. Yet, it is unknown if CPS workers are able to accurately detect PAU/PDU.  If PAU/PDU are not identified then appropriate services cannot be provided to caregivers.  This paper examines CPS caseworkers’ ability to identify PAU/PDU in a national probability sample of caregivers investigated by CPS.

Methods: Using sensitivity and specificity analyses and chi-squares, data from the National Survey of Child and Adolescent Well-Being II were analyzed to examine the relationship of CPS caseworker report of PAU/PDU with caregiver self-report of PAU/PDU in a sample of families investigated by CPS whose children remained in the home at baseline (n=3289). CPS caseworker report of PAU and PDU were assessed separately with two questions: At the time of the investigation was there active alcohol abuse (drug abuse) by the primary caregiver? Caregiver self-report of PAU was assessed dichotomously with the Alcohol Use Disorders Identification Test (AUDIT) and a cut-point of ≥5 for female caregivers and ≥8 for males. Caregiver self-report of PDU was assessed with the Drug Abuse Screening Test-20 (DAST-20) and a cut-point of ≥6 for all caregivers. For the sensitivity and specificity analyses, self-report was utilized as the true presence or absence of PAU/PDU.  Analyses were conducted in STATA/SE 10.0 and accounted for stratification, clustering, and weighting.

Results: Caseworkers accurately identified PAU in only 17.65% of the caregivers who self-reported PAU.  Among caregivers identified as engaging in PAU by caseworkers, 57.75% of these caregivers did not self-report PAU and 42.45% did self-report PAU.  Caseworkers accurately identified PDU in 37.59% of the caregivers who self-reported PDU.  Among caregivers identified as engaging in PDU by caseworkers, caregivers very rarely self-reported PDU.  Of the 591 cases of caseworker reported PDU, 13.01% of the caregivers self-report PDU.  Sensitivity and specificity for the detection of PAU were 21.53% and 94.76%, respectively. Sensitivity and specificity for the detection of PDU were 65.27% and 83.67%, respectively.

Conclusions/Implications: Caseworkers did not accurately detect the majority of caregiver self-reported PAU/PDU.  With accurate detection rates of 17.65% for PAU compared to 37.59% for PDU, it was harder for caseworkers to detect PAU.  In practice, caseworker perception of PAU/PDU should be corroborated with some form of biological assay and caregivers should be given PAU/PDU screeners to aid in self-reporting with the goal of providing necessary services to support families.  Future research should look at differences in cases of self-reported problematic substance use comparing those where caseworkers were able to detect PAU/PDU compared to those where they were not.  The majority of caregivers identified by caseworkers as engaging in PAU (57.75%) and PDU (86.99%) did not self-report PAU/PDU.  Further analysis is needed to determine if these caregivers are engaging in sub-threshold levels of PAU/PDU or if caseworkers are misidentifying other factors as PAU/PDU in this population.