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Nov/Dec 2007

Social Work With Children of Alcohol- and Drug-dependent Parents
By Catherine L. Herzog, PhD, MSW, and Linda Kaplan, MA
Social Work Today
Vol. 7 No. 4 P. 30

An organization offers guidelines on how to identify and assist children in families with alcohol and drug dependence who often fade into the background of emotional chaos.

One in four U.S. children under the age of 18 lives in a family affected by alcohol abuse or dependence (Grant, 2000). This statistic does not include children who may be living in households with drug-dependent parents. Parental alcohol and drug dependence affect these children’s physical and mental health, as well as their cognitive development.

This article describes the work of a cadre of experts in the social work profession together with leaders from the National Association for Children of Alcoholics (NACoA). The ultimate mission of this group is to identify a set of tools, or core competencies, as the equipment to effectively address the daily conflicts faced by children of alcohol- and drug-addicted parents (COAs). This is an invitation for social workers to become a significant source of advocacy for this population and bring a high level of knowledge and skills that will provide these children with opportunities for hope and healing.

The Hidden Impacts on Children Living With an Addicted Person
There are many ways in which economic and human costs are incurred when the needs of COAs are not identified. For example, COAs are more likely than other children to enter foster care (Reid, Macchetto, & Foster, 1999). School records reveal poor performance for many COAs, as well as encounters with the law (Sher, 1997; Moss, Vanyukov, Majumder, Kirisci, & Tarter, 1995). COAs are also more likely to experience depression, conduct disorders, or anxiety (Dube et al., 2001; Earls, Reich, Jung, & Cloninger, 1988). They have a higher risk of abusing alcohol or drugs, specifically for the purpose of self-medication (Anda et al., 2002; Kumpfer, 1999).

In a recent study of medical costs and utilization by Ray, Mertens, and Weisner (2007), a comparison was made between families with and without a member diagnosed with alcohol or drug problems. The findings suggest that families with an addicted member have higher healthcare costs and utilization rates. They also had a higher probability of being diagnosed with one or more of 10 serious childhood illnesses.

COAs in Adulthood
The Adverse Childhood Experiences Study is a 10-year retrospective study conducted under the aegis of the Centers for Disease Control and Prevention (Anda, n.d.). Adults enrolled in the study were asked whether they had experienced any of nine adverse childhood experiences (e.g., physical, verbal, and sexual abuse; domestic violence; exposure to suicide; criminal behavior; or mental illness). This study found that COAs were more likely to have endured adverse childhood experiences. In addition to an increased likelihood of depression and alcoholism in adulthood, COAs had a high probability of suffering a host of other physical illnesses and disabilities.

Development of Core Competencies for Social Workers
Previous to the current process, there were several initiatives for social workers that focused on substance use disorders (SUDs). However, these initiatives did not focus on COAs. The Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention (SAMHSA/CSAP) contracted with the NACoA to facilitate the development of competencies for social workers focusing on COAs.

The NACoA convened two panels of leading social work educators and clinicians with the following three major tasks:

1. To delineate core competencies social workers need to address COA issues.

2. To articulate strategies to disseminate core competencies to social workers.

3. To create a training model for infusion of these competencies into social work education.

The product of these meetings was “Core Competencies for Social Workers in Addressing the Needs of Children of Alcohol and Drug Dependent Parents,” which is deemed essential for social workers to master to effectively assist COAs. These core competencies were sent to several key academics and clinicians around the country for field review before being finalized. In addition, a curriculum module for social workers interested in mastering the core competencies and a report of the panel meetings were produced. These documents are also available on the NACoA’s Web site at www.nacoa.org in the section marked Social Work.

Practical Application of the Social Work Core Competencies
There are 15 core competencies preceded by a preamble. The competencies are intended to provide social workers with a working knowledge of SUD issues in a context in which to understand the functioning of many millions of families and individuals when alcohol or other drugs are involved. Mastering these core competencies has the potential to significantly improve many aspects of social work practice because being aware of these issues can sharpen the accuracy and completeness of case management, assessment, and diagnostic processes.

These core competencies can be categorized into three major domains: a working knowledge of SUD issues; skills in screening and identification; and appropriate skills, interventions, and strategies to use in social work practice to address the needs of COAs.

The first five competencies cover the knowledge base needed to possess a clear understanding of SUDs and their impact on families. This includes the genetic, psychological, and social factors that set the stage for the quality of life for all members of a given family with an addicted member. A basic understanding of addiction provides the foundation on which social workers can build a comprehensive skill base for providing appropriate prevention strategies and interventions to help COAs. A major goal of prevention activities is to help COAs gain coping skills and increase their resilience (Werner & Johnson, 2004).

The competencies developed to help social workers identify a child struggling with an addicted parent are critical because COAs are often not recognized by the professionals around them. COAs’ suffering is most often hidden because of the “no talk” rule created by the family in an effort to avoid the stigma and shame associated with addiction. If a child does not exhibit behavioral or academic problems, clinicians can easily overlook the specific nature of a child’s struggle to cope with his or her unhealthy environment.

An excellent example of an informal screening tool used to identify COAs is presented by Price and Emshoff (2000). They recommend using the four-question Family CAGE to identify COAs. The CAGE was designed to pick up whether a child has a concern about a parent’s drinking. It can also be used to decide if further intervention for the child should take place. The questions are the following:

1. Do you think your parent needs to CUT down on his/her drinking?

2. Does your parent get ANNOYED at comments about his/her drinking?

3. Does your parent ever feel GUILTY about his/her drinking?

4. Does your parent ever take a drink early in the morning as an EYE opener?

The remaining core competencies address the skills social workers need to provide direct service to COAs and their families. COAs encounter a host of difficulties while growing up, but early intervention increases a child’s resilience, improves his or her physical and mental health, and mitigates the deleterious potential of the risk factors they bear each day. In this context, we know there are important messages that COAs need to hear, including the following:

• Alcoholism is a sickness.

• You can’t make it better.

• You deserve help for yourself.

• You are not alone.

• There are people and places that can help.

• There is hope (Moe, n.d.).

Services for COAs range from awareness messages for all children to more intensive individualized therapy for children with serious issues. Morehouse (2000) describes a basic continuum of services which include the following types of activities:

• Awareness, which includes printed materials and public service announcements or other audio/visual announcements, allows COAs to learn they are not alone and reduces the feelings of stigma and isolation.

• Education providing age-appropriate information about alcoholism and drug dependence is important to helping children understand aspects of the disease and that they are not to blame for their parents’ actions. This information can be provided as part of ongoing health and alcohol education activities for all children or in groups specifically for COAs.

• Support groups for COAs, such as Alateen (a 12-step program for youth aged 11 and older) can help children learn to talk about their feelings and develop coping strategies.

An excellent resource for social workers interested in implementing support groups for children from kindergarten through high school is The Children’s Program Kit developed by the NACoA in 2003 at the request of the SAMHSA. The kit is available at no cost at www.ncadi.samhsa.gov under Publications.

In addition to the continuum of services previously described, there is a model used in schools across the country called student assistance programs (SAPs). These are cost-effective, comprehensive, school-based programs for students from kindergarten through high school. For students who are unsuccessful in school, SAPs provide identification, early intervention, referral, and support groups for those who may be COAs or are struggling with other difficulties. For more information about SAPs and how to start one, go to the NACoA Web site and click on the Student Assistance button to find the book Help Is Down the Hall: A Handbook on Student Assistance. This handbook was developed by the NACoA for the CSAP, and it contains many practical tools that can be used to create and maintain SAPs.

A Challenge for Social Workers
Social workers are often at the vanguard of needed social change. As such, social workers can play a key role in helping children overcome the shame, stigma, and silent struggles that play a prominent role in the lives of COAs. In addition, social workers can repair and rebuild the infrastructure of communities and families in several ways: connecting COAs with needed resources; educating COAs with age-appropriate materials about the disease of addiction; teaching them coping and self-care strategies to help them stay safe; helping them build healthy and trusting relationships with others; and organizing communities behind the needs of COAs by advocating for systemic change and resources needed to provide support groups and other supportive services. The purpose of all of these efforts is to promote resilience for communities, families, and individuals.

Given the wide reach of social workers employed in the human services community, they are uniquely positioned to support and help children impacted by SUDs in their family. Armed with the core competencies, social workers can help halt the intergenerational cycle of alcoholism and thereby enhance the development of social capital in communities across the country.

— Catherine L. Herzog, PhD, MSW, worked for many years in the Waterford (MI) School District as a social worker, director of student assistance programs, and director of instructional service and special education. She now works as a consultant.

— Linda Kaplan, MA, has worked in the substance abuse field for many years and was the executive director of the National Association of Alcoholism & Drug Abuse Counselors for 10 years. She currently works as a consultant for the National Association for Children of Alcoholics.

Anda, R. (n.d.). The health and social impact of growing up with alcohol abuse and related adverse childhood experiences: The human and economic costs of the status quo. Paper presented at the National Association for Children of Alcoholics Forum on October 19, 2006. Retrieved May 10, 2007 here.

Anda, R.F., Whitfield, C.L., Felitti, V.J., Chapman, D., Edwards, V.J., Dube, S.R., et al. (2002). Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatric Services, 53(8), 1001-1009.

Dube, S.R., Anda, R.F., Felitti, V.J., Croft, J.B., Edwards, V.J. & Giles, W.H. (2001). Growing up with parental alcohol abuse: Exposure to childhood abuse, neglect and household dysfunction. Child Abuse & Neglect, 25(12), 1627-1640.

Earls, F., Reich, W., Jung, K.G., & Cloninger, C.R. (1988). Psychopathology in children of alcoholic and antisocial parents. Alcoholism, Clinical and Experimental Research, 12(4), 481- 487.

Grant, B. 2000. Estimates of US children exposed to alcohol abuse and dependence in the family. American Journal of Public Health, 90(1) 112-114.

Kumpfer, K.L. (1999). Outcome measures of interventions in the study of children of substance-abusing parents. Pediatrics, 103 (5 Pt 2), 1128-1144.

Moe, J. (n.d.). To walk with one child. Retrieved May 10, 2007 here.

Morehouse, E.R. (2000). Matching services and the needs of children of alcoholic parents: A spectrum of help. In S. Abbott (Ed.) Children of Alcoholics: Selected Readings (Vol. II, pp.95-117) Rockville, MD: National Association for Children of Alcoholics.

Moss, H.B., Vanyukov, M., Majumder, P.P., Kirisci, L. & Tarter, R.E. (1995). Prepubertal sons of substance abusers: Influences of parental and familial substance abuse on behavioral disposition, IQ, and school achievement. Addictive Behaviors, 20(3), 345-358.

Price, A. W. & Emshoff, J.G. (2000). Breaking the cycle of addiction: Prevention and intervention with children of alcoholics. In S. Abbott (Ed.). Children of Alcoholics: Selected Readings (Vol. II) Rockville, MD: National Association for Children of Alcoholics.

Ray, G.T., Mertens, J.R., & Weisner, C. (2007). The excess medical cost and health problems of family members diagnosed with alcohol or drug problems. Medical Care, 45(2) 116-122.

Reid, J., Macchetto, P., & Foster, S. (1999). No safe haven: Children of substance-abusing parents. New York: Columbia University Center on Addiction and Substance Abuse.

Sher, K.J. (1997). Psychological characteristics of children of alcoholics. Alcohol Health and Research World, 21(3), 247-254.

Werner, E.E. & Johnson, J.L. (2004). The role of caring adults in the lives of children of alcoholics. Substance Use & Misuse, 39(5), 699-720.

Core Competencies for Social Workers
1. Understand substance use disorders (SUDs), including the causes, prevention, progression, consequences, and recovery.

2. Understand the biopsychosocial, cultural, and spiritual ramifications of SUDs as they impact COAs [children of addicts] and their families from neonatal development through all stages of life.

3. Understand the impact that SUDs have on parenting abilities and the consequences for children.

4. Understand the intersection of SUDs and other family, health, and social problems, including:

a. family violence (intimate partner violence and child maltreatment)

b. mental health disorders

c. physical health

d. crime (vulnerability to victimization and risk for criminality)

e. poverty, unemployment, and homelessness

f. educational and vocational opportunities

g. social/cultural biases (including, but not limited to, race, ethnicity, class, sexual orientation, and disability)

5. Value the importance of early intervention and prevention of SUDs and prevention of mental health and social problems for COAs and their families.

6. Ability to engage COAs in a manner that is respectful and nonjudgmental of their parents.

7. Ability to screen and assess COAs using developmentally appropriate assessment tools and methods.

8. Ability to identify, evaluate, and utilize existing research relevant to COAs and their families.

9. Ability to use developmentally appropriate and empirically supported interventions with COAs and their families and evaluate the effectiveness of the interventions being used.

10. Understand the concept of resiliency and how risk factors can be diminished and protective factors can be facilitated in COAs.

11. Ability to help children identify developmentally appropriate formal and informal supports in their lives and work with them to enhance their resiliency and mitigate the impact of parental SUDs.

12. Knowledge of how to access formal and informal community resources on behalf of COAs and their families.

13. Ability to provide referrals for appropriate services and supports to COAs and their families.

14. Knowledge of social policies pertinent to COAs and their families.

15. Ability to advocate for individual clients, as well as to identify and advocate for appropriate policies to help COAs and their families.