Best Practices for Drug Testing in Child Welfare

Dr. Margaret H. Lloyd, University of Connecticut

31st Annual Research & Policy Conference on Child, Adolescent and Young Adult Behavioral Health

March 7, 2018

Tampa, Florida

Presentation Overview

• Prevalence of Parental SUD in Foster Care

• Policy-Driven Rationale for Drug Testing in Child Welfare

• Literature Review

• Recovery-Oriented Approach to Drug Testing

• Evidence-Based Drug Testing

• Considerations for a Child Welfare-Involved Population

Prevalence and Trajectories

through CWS• The percentage of children removed due to parental drug use has increased

nearly 8% since 2009 (Young et al., 2016)

• Children removed due to parental drug use less likely to reunify, more likely

to re-enter care compared to children without drug removals (Brook et al.,

2010; Brook & McDonald, 2009)

• Young children (ages 0-3) with parental drug removals least likely to achieve

permanency vs. ages 0-3 without drug removals and ages 4+ (Lloyd et al.,

2017)Prevalence of Parental SUD

12%

88%

Parental SUD Affected

Children in Gen. Pop.

SUD

Non-SUD

79%

21%

Parental SUD

Affected Children in

Foster Care

SUD

Non-SUD

Rationale for Drug Testing in Child

Welfare• Untreated SUD can threaten a parent’s ability to safely care for their child

(Wood et al., 2011)

• No reified threshold exists for “safe drug use” (Wood et al., 2011)

• Self-reported substance use is unreliable (Hunt, et al., 2015)

• Biological specimen testing is objective (Moeller et al., 2008)

• Drug testing is a common practice in mandated (i.e., substance abuse

treatment, criminal justice) and voluntary (i.e. workplace) settings (Moeller et al.,

2008)

Reasonable Efforts Clause

• The state is required to make reasonable efforts to avoid foster care

placement and, if placement occurs, reunify the child with their biological

parent before moving for termination of parental rights (ASFA; Pub. L. 105-89)

• Reasonable efforts include providing services to address issues that

threaten child safety (ASFA; Pub. L. 105-89; Edwards, 2014)

• Given the prevalence of parental SUD among child welfare-involved

families, establishing that reasonable efforts have been made, and have

failed, frequently rests on two factors:

– Completing substance abuse treatment; and

– Establishing a pattern of abstinence using biological specimen drug

tests

Drug Testing Is A Common Practice

• 79% of parents required to submit to drug testing, while only 75% had

substance abuse as an issue (D’Andrade & Chambers, 2012)

– 24% were ordered to testing once per week

– 73% were ordered twice per week

– 4% were ordered three times per week

Drug Testing Is An Effective

Practice• Newmark (1995) compared 169 parents tested for drug use in child welfare

cases to 159 parents who were not tested.

• Testing initially conducted on a weekly basis

• Parents who participated in drug testing were more likely to experience

shorter case processing times

• Children in drug testing group more likely placed in kinship care

• Parents received more referrals to available services

• Parents were more cooperative with referrals to diagnostic services

• However, groups were not randomly assigned

Drug Testing Influences Case

Outcomes• Drug screens were identified as one of six key factors affecting

professionals’ decisions to reunify families with parental SUD (Karoll & Poertner,

2001), and the importance of drug screens did not differ between judges,

caseworkers, and substance abuse professionals (Karoll & Poertner, 2003)

• When probed regarding number of months of clean drug screens necessary

for safe reunification, these professionals’ median response was 8 months

and 12 consecutive clean drug screens (Karoll & Poertner, 2001)

• Drug use (positive drug tests) and addiction were found to be the most

common termination factors in 48 TPR cases (Vesneski, 2012)

Grounds for Terminating Parental

Rights

24 states include environmental AOD use as grounds for TPR 4 states include prenatal AOD exposure as grounds for TPR

Texas:Used a controlled substance in a manner that endangered the health or safety of the child and failed to complete a court-ordered substance abuse treatment program or after completion of a treatment program, continued to abuse a controlled substance.

(Child Welfare Information Gateway, 2016)

Treatment Compliance vs.

Abstinence• Smith (2003) found that treatment completion was the strongest predictor of

reunification for parents with SUD, even if the parent reported continued

substance use (self-report, not drug test)

Compliance Not Predictive of Re-

Abuse• Rittner & Dozier (2000) rated case records for SUD caretaker case plan

compliance as “good”, “fair”, or “poor”.

• “Good”, defined as >= 50% of treatment + no positive drug tests

• “Fair”, defined as < 50% of treatment; dropped out of treatment after a

“Good” rating, or positive drug tests despite >50% of treatment attendance

• “Poor”, defined as no treatment, positive drug tests plus no treatment, or

additional substance-exposed newborn

• Over time, rates of non-compliance stayed consistent

– At 6- to 12-month review, 40% of moms “good”, 12% “fair”, 48% poor

– At 13- to 18-month review, 39% of moms “good”, 11% “fair”, 49% “poor”

Compliance with substance abuse treatment not associated with rates

of re-abuse

Literature Review Summary

• Untreated SUD is one factor that increases risk of harm to children

• SUD are prevalent among families with children in foster care and are

associated with repeat maltreatment

• Drug testing is one of the most common child welfare responses to SUD

• Drug test results may influence decision making, although treatment

compliance/completion is a critical factor as well

• Treatment compliance rates & substance abstinence are low, typically less

than 50%, and treatment completion rates are even lower (~25% or less)

• Treatment compliance is not a good metric for reduced repeat maltreatment

A Recovery-Oriented Approach

• The rationale for testing in treatment settings is not to “catch people doing

something bad”, but to gauge whether the type and dosage of treatment is

effective and make treatment adjustments

• This recovery-oriented approach to drug testing has been adopted in family

drug treatment courts (Young et al., 2013)

Evidence-Based Drug Testing:

Drug Court Perspective• SUD diagnosis is a requirement for drug court participation (Young et al., 2013)

• Behavior modification program outcomes improve when substance use

detection is likely AND when participants receive incentives for abstinence

and treatment adjustments for positive test results (Schuler et al., 2014; Hawken

& Kleiman, 2009)

• Self-disclosure is an unreliable, and treatment adverse, approach to

monitoring (Peters et al., 2015; Nirenberg et al., 2013)

Random Drug Testing

• Drug testing must be random (Carey et al., 2012)

• Participants should have equal likelihood of being tested every day (2 in 7

days; 28% chance of being tested on a given day)

• Odds of testing on weekends and holidays should be the same as every

other day (Marlowe, 2012)

Testing Timelines

Client notified of drug test

Frequent (2x week) random drug testing should occur throughout duration of case (Carey et al., 2012; Marlowe, 2011; 2012)

Negative drug tests for 90 days before case closure (Carey et al, 2012)

Client provides specimen

Client notified of

results

Treatment adjustment

made

Notification should be

random (Carey et al 2012)

Specimen provided

within 2-3 hours (Cary

2011)

Notified of results within

48 hours (Carey et al.,

2012)

Treatment adjustments

made immediately (Carey et al.,

2012)

Type of Testing

• Testing should cover more than a standard five- or eight-range panel (Mee-Lee,

2013)

• Drug testing must be witnessed by trained and experienced staff person

(Mee-Lee, 2013) and tested for validity using temperature, creatinine and specific

gravity (Mee-Lee, 2013)

• Testing for cannabinoids: excretion is slower than other substances, but a

positive cannabinoid test is unlikely to occur greater than 10 days after

cessation of chronic usage (Cary, 2005)

Methods of Testing: Pros and Cons of Different Specimen Sources (from CSAT, 2010)Specimen Window of Detection Pros Cons

Urine Up to 2-4 days Most accurate results

Least expensive

Most flexibility for testing different drugs

Most likely to withstand legal challenge

Specimen can be adulterated, substituted, or diluted

Limited detection window

Collection can be invasive or embarrassing

Specimen handling and shipping can be hazardous

Oral Fluid Up to 48 hours Collecting the oral fluid specimen can be observed

Minimal risk of tampering

Noninvasive

Can be collected easily in virtually any environment

Can be used to detect alcohol use

Can be used to detect recent drug use

Drugs and drug metabolites do note remain in saliva as long as in urine

Less efficient than other testing methods for detecting marijuana use

pH changes can alter specimen

Moderate to high cost

Sweat FDC cleared for 7 days Relatively noninvasive

Sweat patch worn for 7 days

Quick application and removal of sweat patch

Patch seal tampering minimized

Longer window of drug detection than urine or blood

Relatively resistant to specimen adulteration

No specimen substitution possible

Only a few laboratories offer sweat patch testing

Those with sensitive skin may react to the patch

Possible time-dependent drug loss from the patch

Possible external drug contamination from improper skin cleansing prior to application

For marijuana, current use by a native user may not be detected

For marijuana, positive sweat results are possible in current abstinent, but previously

chronic high dose users

Sweat production dependent

Moderate to high cost

Hair Up to 4-6 months Collecting the hair specimen can be observed

Long detection window

Does not deteriorate

Can be used to measure chronic drug use

Convenient shipping and storage; needs no refrigeration

Noninvasive

More difficult to adulterate than urine

Moderate to high cost

Cannot be used to detect alcohol use

Cannot be used to detect drug use 1-7 days prior to drug test

Not effective for compliance monitoring

External contamination

Breath Up to 12-24 hours Minimal cost

Reliable detector of presence and amount of alcohol

Noninvasive

Very limited detection window for alcohol

Can only be used to detect presence of alcohol

Blood Up to 12-24 hours Can be used to detect presence of drugs and alcohol

Test produces accurate results

Invasive

Moderate to high cost

Meconium Up to 2-3 days after

birth

Can be used to detect long-term use

Can be used to detect presence of drugs and alcohol

Easy to collect and highly reliable

Short detection window after infant’s birth

Drug Testing Research from Family

Drug Courts• Frequent, random drug testing is a standard in family drug courts (Young et al.,

2013)

• More frequent urinalyses associated with greater time in treatment and

increased likelihood of completing treatment (Worcel et al, 2007)

• Relapse most likely to occur in the first three weeks of court involvement,

and between weeks 15-19 (Haack et al, 2004)

Other Considerations for Child

Welfare• Drug tests and the 4th amendment:

– Results not shared with law enforcement without parental consent to

testing;

– The interests of the state/child must outweigh the privacy expectations

of the parent;

– “Probable cause” must exist, i.e., the parent has a substance use

disorder that threatens child safety (Coleman, 2005)

• Drug use status should not impact visitations (Leathers, 2002)

– Use of supervised visitation at mother’s home if safety is a concern

• Child welfare professionals need education on addictions (Young et al., 2013)

• Parental substance use does not in itself constitute a threat to child safety (CSAT, 2010)

Objections to Drug Testing in Child

Welfare• One-time testing provides little information (CSAT, 2002; Wood et al., 2011)

• A positive drug test result does not indicate a substance use disorder, a

threat to child safety, or parent or family dysfunction (CSAT, 2002; Wood et al., 2011)

• Drug test results must be considered in concert with other factors:

– repeated frequent, random drug tests

– substance use disorder assessment

– comprehensive assessment of parent and family strengths and needs

• Positive drug tests should be confirmed by a second testing technique (Wood

et al., 2011; Mee-Lee, 2013; Cary, 2011)

Summary of Drug Testing Best

PracticesFamularo et al (1988) outlined four questions related to drug testing in child

welfare that remain salient:

1. Will the program aid in detection of substance abuse?

2. Will testing motivate the parent to engage in substance abuse

treatment?

3. Will testing aid in the treatment process?

4. Will testing increase the chances of a favorable outcome for the child?

Practice & Research Agenda for

Drug Testing in Child Welfare• Approximately 370 family drug treatment courts exist across the country

(Young et al., 2013)

• For several reasons, FDTCs are only serving 7-10% of families with

parental SUD (Young et al., 2013)

• Best practices on drug testing should not be reserved for parents with cases

in FDTCs

• Several unanswered research questions remain:

– Relationship between positive drug tests at specific times in case

process and case outcomes (reunification, re-entry)

– Compliance versus abstinence and likelihood of maltreatment re-reports

QUESTIONS & DISCUSSION

margaret.lloyd@uconn.edu

References

• Brook, J., & McDonald, T. (2009). The impact of parental substance abuse on the stability of family reunifications from foster care.31, 193-198. Retrieved from http://www.sciencedirect.com/science/article/pii/S0190740908001801

• Brook, J., McDonald, T., Gregoire, T., Press, A., & Hindman, B. (2010). Parental substance abuse and family reunification.10, 393-412.

• Carey, S.M., Mackin, J.R., & Finigan, M.W. (2012). What works? The ten key components of drug court: Research-based best practices. Drug Court Review, 8(1), 6–42.

• Cary, P. (2005). The marijuana detection window: Determining the length of time cannabinoids will remain detectable in urine following smoking: A critical review of relevant research and cannabinoid detection guidance for drug courts. Drug Court Review, 5(1), 23–58.

• Cary, P. (2011). The fundamentals of drug testing. In D.B. Marlowe & W.G. Meyer (Eds.), The drug court judicial benchbook (pp. 113–138). Alexandria, VA: National Drug Court Institute. Available at http://www.ndci.org/sites/default/files/nadcp/14146_NDCI_Benchbook_v6.pdf

• Center for Substance Abuse Treatment. (2010). Drug testing in child welfare: Practice and policy considerations. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncsacw.samhsa.gov/files/DrugTestinginChildWelfare.pdf

• Child Welfare Information Gateway. (2017). Grounds for involuntary termination of parental rights. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau.

• Coleman, D. L. (2005). Storming the castle to save the children: The ironic costs of a child welfare exception to the fourth amendment.47, 413.

References

• D'Andrade, A. C., & Chambers, R. M. (2012). Parental problems, case plan requirements, and service targeting in child welfare reunification.34, 2131-2138. Retrieved from http://www.sciencedirect.com/science/article/pii/S0190740912002824

• Edwards, L. (2014). Reasonable efforts: A judicial perspective. United States: Leonard Edwards.

• Famularo, R., Spivak, G., Bunshaft, D., & Berkson, J. (1988). Advisability of substance abuse testing in parents who severely maltreat their children: The issue of drug testing before the juvenile/family courts.16, 217-223.

• Haack, M., Alemi, F., Nemes, S., & Cohen, J. B. (2004). Experience with family drug courts in three cities.25, 17-25. Retrieved from http://search.proquest.com/docview/621023676?accountid=14556

• Hawken, A., & Kleiman, M. (2009). Managing drug involved probationers with swift and certain sanctions: Evaluating Hawaii’s HOPE (NCJRS No. 229023). Washington, DC: National Institute of Justice. Available at http://www.ncjrs.gov/pdffiles1/nij/grants /229023.pdf

• Hunt, D.E., Kling, R., Almozlino, Y., Jalbert, S., Chapman, M.T., & Rhodes, W. (2015). Telling the truth about drug use: How much does it matter? Journal of Drug Issues, 45(3), 31–329.

• Karoll, B. R., & Poertner, J. (2001). Judges', caseworkers', and substance abuse counselors' indicators of family reunification with substance-affected parents.81, 249-269.

• Karoll, B. R., & Poertner, J. (2003). Indicators for safe family reunification: How professional differ.30, 139.

• Leathers, S. J. (2002). Parental visiting and family reunification: Could inclusive practice make a difference?

References

• Lloyd, M. H., Akin, B. A., & Brook, J. (2017). Parental drug use and permanency for young children in foster care: A competing risks analysis of reunification, guardianship, and adoptiondoi:https://doi.org/10.1016/j.childyouth.2017.04.016

• Marlowe, D.B. (2011). Applying incentives and sanctions. In D.B. Marlowe & W.B. Meyer (Eds.), The drug court judicial benchbook (pp.139–157). Alexandria, VA: National Drug Court Institute. Available at http://www.ndci.org/sites/default/files/nadcp/14146_NDCI_Benchbook_v6.pdf

• Marlowe, D.B. (2012). Behavior modification 101 for drug courts: Making the most of incentives and sanctions. NDCI Drug Court Practitioner Fact Sheet, 7(3), 1–11.

• Mee-Lee, D. (2013). The ASAM criteria: Treatment for addictive, substance-related, and co-occurring conditions. Chevy Chase, MD: American Society of Addiction Medicine.

• Moeller, K. E., Lee, K. C., & Kissack, J. C. (2008). Urine drug screening: Practical guide for clinicians doi:https://doi.org/10.4065/83.1.66

• Newmark, L. (1995) Parental Drug-testing in Child Abuse and Neglect Cases: The Washington D.C. Experience, December 1995, The Urban Institute: Washington D.C.

• Nirenberg, T., Longabaugh, R., Baird, J., & Mello, M.J. (2013). Treatment may influence self-report and jeopardize our understanding of outcome. Journal of Studies on Alcohol and Drugs, 74(5), 770–776.

• Peters, R.H., Kremling, J., & Hunt, E. (2015). Accuracy of self-reported drug use among offenders: Findings from the Arrestee Drug Abuse Monitoring-II Program. Criminal Justice and Behavior, 42(6), 623–643.

• Rittner, B., & Dozier, C. D. (2000). Effects of court-ordered substance abuse treatment in child protective services cases.45, 131-140.

References

• Schuler, M.S., Griffin, B.A., Ramchand, R., Almirall, D., & McCaffrey, D.F. (2014). Effectiveness of treatment for adolescent substance use: Is biological drug testing sufficient? Journal of Studies on Alcohol, 75(2), 358–370.

• Smith, B. D. (2003). After parental rights are terminated: Factors associated with exiting foster care.25, 965-985. Retrieved from http://www.sciencedirect.com/science/article/pii/S0190740903001051

• Vesneski, W. M. (2012). Judging parents: Courts, child welfare, and criteria for terminating parental rights

• Wood, E., Mattick, R. P., Burns, L., & Shakeshaft, A. (2011). The costs and utility of parental drug-testing in child protection: A review of the available literature and commentary. ( No. Technical Report Number 242). Sydney, Australia: National Drug and Alcohol Research Centre, University of New South Wales.

• Worcel, S. D., Green, B. L., Furrer, C. J., Burrus, S. W. M., & Finigan, M. W. (2007). Family treatment drug court evaluation. Portland, OR: NPC Research. Retrieved from http://www.npcresearch.com/Files/FTDC_Evaluation_Final_Report.pdf

• Young, N. K. (2016). In Affairs,Committee on Homeland Security and Governmental (Ed.), Written testimony of Nancy K. Young, Ph.D.: Examining the impact of the opioid epidemic. Lake Forest, CA: Children and Family Futures.

• Young, N. K., Breitenbucher, P., & Pfeifer, J. (2013). In Programs,Prepared for the Office of Juvenile Justice and Delinquency Prevention (OJJDP) Office of Justice (Ed.), Guidance to states: Recommendations for developing family drug court guidelines Retrieved from http://www.cffutures.org/files/publications/FDC-Guidelines.pdf