Child welfare plays a major role in the lives of families with caregivers affected by mental health (MH) and substance use disorders (SUD). Although child welfare policy typically precludes substantiation solely on the basis of caregiver MH or SUD, they are common reasons for referral and identified sources of risk in many investigations motivated by other issues. Caregiver SUD is present in 40-80% of child welfare cases and linked with more severe trajectories and worse overall case outcomes. Recent studies have parsed the relative and combined roles of caregiver MH and SUD in decisions to substantiate. Few studies have examined how workers make decisions about substantiation and risks to children in cases involving MH and SUD. This paper aims to fill that gap.
Data come from semi-structured interviews with 34 frontline child welfare workers (CWWs) in a single county in the Midwestern U.S. Interviews focused on the use of the Structured Decision Making Model Risk Assessment (RA) in case decisions. CWWs were asked to describe their use of the RA to interpret evidence and make judgements in their most recent completed case and their most recent cases involving caregiver mental health, domestic violence, child behavior, and parental discipline. CWW case descriptions included worker reasoning about how typical their examples were of each type of case. Interviews were transcribed verbatim and analyzed in accordance with grounded theory principles using Atlas.TI. In the course of the interviews, CWWs described 26 cases involving caregiver MH, 14 involving SUD, and 16 involving co-occurring MH and SUD.
CWWs described MH and SUD as typically co-occurring and attributed most caregiver SUD to untreated MH issues. MH issues were seen as difficult to document when undiagnosed. While CWW could easily order a toxicology screen, negotiating caregiver buy-in and access to a psychological evaluation posed challenges during the initial 30-day investigation period. This complicated CWW efforts to gather evidence to substantiate allegations and confirm risks. When weighing risks posted by MH and SUD, CWW sought to distinguish between historical and current issues, mild versus severe ones, and treated versus untreated conditions The RA limited CWWs’ ability to factor these nuanced clinical and contextual information into decision-making. Specifically, CWW felt unable to accurately document past and mild issues and caregiver engagement in MH and SUD recovery. Challenges related to issue identification and risk assessment had negative implications for the extension of services and supports, increasing the likelihood of re-referral for the same or similar issues.
Conclusions & Implications
Both the MH and SUD field have moved away from acute models of care and towards recovery-focused approaches, which include early intervention and provision of ongoing supports to foster long-term stability. Our results indicate approaches in the child welfare system remain embedded in an acute model. Interventions that are offered are typically limited to either MH or SUD and with minimal integration or attention to parenting, a powerful motivation for engagement. This represents a missed opportunity to make a lasting difference in child safety and wellbeing.