A Deeper Dive Into the Toxicology Resource Guide

A Deeper Dive Into the Toxicology Resource Guide

Toxicology results can be complicated to understand. The results may or may not tell us whether the environment is safe for the children, who was exposed to a substance, or shed light on the strengths and protective capacities of caregivers and children. Even the decision to request a toxicology test is not be as straightforward as many may think–to say nothing of which test should be selected. Since research indicates that substance use is a factor in a majority of child welfare cases, caseworkers need to be prepared to work with parents, caregivers, pregnant people and youth as they navigate the complex issues surrounding substance use and child safety.

The Toxicology Resource Guide was developed by toxicology experts for Colorado child welfare professionals to provide a quick reference guide for understanding substances and possible effects, the types of toxicology tests and their use cases, and the application of application of toxicology testing in everyday practice. For these reasons, The Toxicology Resource Guide is featured as a resource in a number of Colorado Child Welfare Training System (CWTS) trainings that explore the intersection of substance use and child maltreatment.

Trainings Featuring the Toxicology Resource Guide

Marijuana, Children and Families and Building Safety when Parents Use Substances are two highly-recommended course for all caseworkers, especially those who work in family drug courts or otherwise have a primary focus on substance use and child maltreatment. Training participants are encouraged to bookmark the guide and use it in future casework to guide them as they interpret the results of UA tests. They can also draw from the guide’s information when synthesizing court reports to accurately represent an individual’s progress toward their treatment plan objectives and toward case closure.

Impacts and Implications of Prenatal Substance Exposure is another full-day CWTS training where the Toxicology Resource Guide is provided as a resource for caseworkers. This training explores toxicology testing in pregnant people leading up to the time they give birth and immediately after birth, along with testing of newborn children. As the name suggests, learners explore the impacts of prenatal substance exposure, using the guide as a reference. Learners explore a broad range of implications, from personal trauma to systemic bias.

The Toxicology Resource Guide is just one of many online resources discussed in the course, such as the CHoSEN Collaborative and its initiative to promote equity in substance use screening procedures, and the Tough as a Mother Campaign to support pregnant people and mothers in recovery. Resources such as these help remind us that testing is only one part of the puzzle when it comes to child welfare casework.

Explore the Toxicology Resource Guide on your own, and when you’re ready for a deeper dive, review the CWTS course offerings and register for an upcoming training.

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Toxicology, But Make It Understandable

Toxicology, But Make It Understandable

Have you heard about the Toxicology Resource Guide? It was developed by toxicology experts working with Illuminate Colorado, the Colorado Office of Children, Youth, & Families and Children’s Hospital.

The Toxicology Resource Guide was developed to support Colorado Child Welfare Professionals in understanding substances, possible effects, and the utility and application of toxicology testing to enhance practice.

Let’s start at the beginning.

What is toxicology, you ask? Well, according to the National Institute of Environmental Health Studies, “Toxicology is a field of science that helps us understand the harmful effects of chemicals, substances, or situations, as well as the dose-response of the chemical or substance a person is exposed to.” In other words, toxicology helps us understand the impacts that substances have on our minds and bodies.   

Okay, so what are the impacts of substance use?

Substance use increases risk not only to the user, but also to any children in their care. Effects like inattentiveness and impaired decision making that impact the caregiver also affect child safety. As a result, the misuse of substances is directly linked to adverse childhood experiences, neglect and abuse. Children of substance users are more likely to use substances themselves, so youth substance use is itself a related problem.

That seems pretty straightforward. Why do we need a resource guide?

Drug testing is just one aspect of determining how concerned we need to be about a family’s substance use and is best done in conjunction with clinical examination and/or observation of behavior, environment, and evaluation of the entire situation. That said, drug testing is particularly complicated since each drug, patient and case is different. There are no universal rules with drug testing.

The complexity of drug testing makes a reference guide like the Toxicology Resource Guide beneficial for those who work directly with children and families that may be impacted by substance use. This guide is filled with accurate, evidence-based information about substances, toxidromes, testing and signs associated with the use and misuse of substances.

Don’t know what a toxidrome is? The Glossary of Terms is a strong foundation of useful information for caseworkers who are often tasked with interpreting clinical reports despite not being trained on the basic terminology contained within them.

But the greatest strength of the guide is the insight it may provide to professionals who use urinalysis exams and other types of tests in their work. Throughout the guide, red light bulbs with critical thinking tips remind professionals that the results from a drug test must be viewed within the context of the situation, that negative results do not ensure safety for children, and that positive results do not guarantee that abuse or neglect has occurred. A drug test is just one piece of the puzzle.

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A Drug Test is Just One Piece of the Puzzle

A Drug Test is Just One Piece of the Puzzle

Professionals in child welfare, child maltreatment prevention, prenatal and neonatal care need to collaborate to improve support for families impacted by substance use disorders prior to the birth of a new baby and during those first years of a child’s life. 

 

Working together across sectors to strengthen families impacted by substance use means that it is critical that caseworkers and supervisors alike know how to read toxicology results, decipher symptoms related to substance use and know how substance use may or may not impact someone’s ability to parent children of all ages. This can be complicated and overwhelming. A Toxicology Resource Guide was developed to support Colorado child welfare professionals in understanding substances, possible effects and the utility and application of toxicology testing to enhance practice.

Accidental drug overdose is one of the leading causes of maternal death in Colorado [1], and a woman’s risk for overdose is highest at 7-12 months postpartum [2]. However, fear of losing custody of your child, stigma and lack of appropriate treatment options for parents are real challenges for families in Colorado. We need to work together to keep families together and support healthy kids.

Recent legislative changes have underscored the fact that substance use may or may not impact someone’s ability to care for a child, mandatory reporters in health care settings are still encouraged to refer a family to support from child protective services by reporting concerns to the Colorado Child Abuse and Neglect Hotline 844 -CO-4-Kids if they have a concern. These legislative changes to the Children’s Code in 2020 as a result of SB20-028 Substance Use Disorder Recovery included:

      • de-emphasized the focus on a test,
      • removed the references to the federal schedule of substances,
      • elevated impacts to the child as the main consideration, and
      • advanced a two-generation approach to keep parents and their children together during treatment.

Only around 4% of referrals to county departments of human/social in 2019 contain allegations of a substance exposed newborn, according to the Colorado Department of Human Services. However, most referrals to the Colorado child welfare system related to substance use are for children under the age of one month old. [3] The experiences of children who have been involved in a fatal, near fatal and egregious incidents of child maltreatment also underscore the importance of working together to focus on supporting and engaging with families impacted by substance use. In 2019, 31 incidents were reviewed by the Colorado Department of Human Services Child Fatality Review Team (CFRT). Of the families involved in a fatal child maltreatment incident which met criteria for review by the CFRT, 63.6 percent of families had a history of substance abuse issues. It is important to note that some incidents do not have any of the stressors identified during the review process, while others will have more than one stressor identified, 45.4% percent of families were identified to have a history of domestic violence and history of mental health issues. [4]

According to the Colorado Department of Human Services Division of Child Welfare, from August 2019 through May of 2020, 37% of referrals associated with substance exposed newborns were not screened-in and 63% were screened-in by counties.

When the referral reason is substance exposed newborn, the majority reported Marijuana (51%) as the substance used followed by methamphetamines (19%) and other opiates (8%).  These ratios remained largely the same for cases that were subsequently screened-in with methamphetamines rising to 22%.

 

WATCH VIDEO>>   Dr. Sam Wang, one of the authors of the Toxicology Guide, talks about using the tool and why each drug, each patient and each case is different. There are no universal rules with drug testing, underscoring why child welfare caseworkers and supervisors should bookmark COToxGuide.org or download the e-book today.

 

Sources

  1. Metz et al. (2016). Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstetrics & Gynecology, 128(6), 1233-1240.
  2. Schiff et al., (2018). Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts. Obstetrics & Gynecology, 132(2), 466-47
  3. Oliveros, A., & Kaufman, J. (2011). Addressing substance abuse treatment needs of parents involved with the child welfare system. Child Welfare, 90(1), 25-41.
  4. 2019 Colorado Department of Human Services (CDHS). Child Fatality Review Annual Report.

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A Practical Caseworker Field Tool: The Toxicology Resource Guide

A Practical Caseworker Field Tool: The Toxicology Resource Guide

When parents use substances, determining the safety of a child isn’t as simple as reading the results of a drug test because drug testing itself is rarely diagnostic when interpreted alone. The results of drug tests are best interpreted in conjunction with other strengths and risk factors. Caseworkers are no strangers to crucial conversations and the Toxicology Resource Guide may make those discussions more nuanced.

Anne Auld, the director of education for Illuminate Colorado, recently sat down with Becky Tolpa, the supervisor of child protection in Larimer County, to discuss the practical uses of the toxicology guide for supervisors as well as a caseworker in the field. Both Auld and Tolpa were able to offer some keen insights into the usefulness of this resource, having been instrumental in the creation of the guide in 2019.

View the video below to watch the full interview below.

Talking Toxicology 

To make this process easier, the online searchable Toxicology Resource Guide, along with eBook available for download at COtoxguide.org was created to support Colorado child welfare professionals in understanding substances, possible effects and the utility and application of toxicology testing to enhance practice. The resources were developed by Illuminate Colorado through a collaborative process with multiple contributors and by the Colorado Department of Human Services Office of Children, Youth, & Families Division of Child Welfare.

The Importance of Critical Thinking

In the field, issues are often complicated and a simple toxicology chart doesn’t always help as much as it should. The critical thinking components of the guide help to navigate the more complex situations that many caseworkers come across in their day to day job.

One of the best parts of the guide, Tolpa noted, is that it includes critical thinking sections that apply directly to a caseworker’s job. If a toddler is in the home, what considerations need to be had?  What about for a teenager?

The guide helps caseworkers think through these important areas, as well as next steps once test results come back.

“We want to empower people to come up with creative questions and think through every scenario when they’re out in the field and be able to think on their feet. And that’s a really difficult thing to do…when you have a guide like this, it gives you a jumping off point,” said Tolpa.

Engaging Families 

Planning is another important area where the guide can be helpful. Determining how to best help families is crucial, and it’s important to help families come up with a plan that keeps their kids safe. The guide can help in developing a plan for families in a way that works better for them.

The guide also helps to engage families better. Tolpa firmly believes that the more you know, the more you are able to help families. “[The guide] gives us the education to go out and have a great conversation with a family member and be transparent about our worries, and hear what they have to say in return.”

Visit COtoxguide.org to use the Toxicology Resource Guide in your work today.

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Video For Professionals: Talking Support for Families Impacted by Substance Use Disorders

Video For Professionals: Talking Support for Families Impacted by Substance Use Disorders

Substance use among parents and caregivers, particularly new parents, has been a concern to those working within the child welfare system for many years. Much has been done to support substance-exposed newborns and their families over the last twelve years; and more improvements are on the horizon thanks to multidisciplinary collaboration at the local and state levels. While only around 4% of referrals to the department in 2019 contain allegations of a substance-exposed newborn, according to the Colorado Department of Human Services, most referrals to the Colorado child welfare system related to substance use are for children younger than one month. (1)

Colorado experts in child welfare and child maltreatment prevention recently sat down with the Colorado Division of Child Welfare CAPTA and federal funding administrator Matt Holtman to talk about efforts underway to improve support for families impacted by substance use disorders prior to the birth of a new baby and those first years of a child’s life.

The panelists included:

      • Jade Woodardexecutive director of Illuminate Colorado and co-chair of the Colorado Substance Exposed Newborn Steering Committee, a subcommittee of the Colorado Substance Abuse Trend and Response Task Force;
      • Suzy Morrissubstance exposed newborn specialist with the Colorado Division of Child Welfare working to oversee practice related to substance-exposed newborn and roll-out of Plans of Safe Care for the State of Colorado; and
      • Angela Meaddeputy division manager at Larimer County Human Services and project lead for Plans of Safe Care in Larimer County.

 Over the course of the hour-long town hall with county employees, progress through a variety of collaborations and tools were covered including legislative changes to the Children’s Code in 2020 as a result of SB20-028 Substance Use Disorder Recovery. This bill:

      • de-emphasizes the focus on a test,
      • removes the references to the federal schedule of substances,
      • elevates impacts to the child as the main consideration, and
      • advances a two-generation approach to keep parents and their children together during treatment.

C.R.S. 19-1-103(1)(a)(VII) now states:

Any case in which a child IS BORN AFFECTED BY ALCOHOL OR SUBSTANCE EXPOSURE, EXCEPT WHEN TAKEN AS PRESCRIBED OR RECOMMENDED AND MONITORED BY A LICENSED HEALTH CARE PROVIDER, AND THE NEWBORN CHILD’S HEALTH OR WELFARE IS THREATENED BY SUBSTANCE USE

The purpose of this change was to:

      • increase alignment with federal law
      • reduce the emphasis on schedule I and II controlled substances
      • increase access to the most appropriate supports by reducing stigma and fear associated with seeking treatment and ensuring more holistic and meaningful assessments are done to help understand the risk and safety considerations

“This was a big change needed to bring Colorado where we needed to be to really start to make progress on the amazing systemic work happening to increase access to substance use treatment and support families in being well, together,” said Woodard during the presentation.

Plans of Safe Care is one of the systemic shifts beginning to take hold in Colorado. Most new parents leave the hospital feeling scared and nervous about now being responsible for the safety and well-being of an infant. A substance use disorder can make this challenging time significantly more difficult for parents and caregivers. Coupled with the unique needs of substance-exposed newborns in the first days and months of life at home, it is easy to understand why special attention to this period of time can produce extraordinarily positive results for parents and their baby.

Children deserve to grow up with a family and research shows this is best for newborns and new parents. When safety concerns have been identified, caseworkers strive to help a parent address those concerns while keeping the family together. In 2019, in recognition of the unique opportunity to serve substance-exposed newborns and parents together and in response to changes in federal law, Colorado launched a Plans of Safe Care pilot to send parents and babies home from the hospital with a plan for safety.

Angela Mead and Larimer County were a part of piloting this effort. She shared her experiences collaborating closely with Poudre Valley Hospital to identify substance-exposed newborns as early as possible and partnering with families to set up systems of support.

In my experience Plans of Safe Care is really a mechanism for engaging parents in caring for their infant and mitigating the risk of child abuse and neglect” said Mead. Reflecting on outcomes of the pilot, Mead shared that Larimer County had “seen an increase in our family engagement, there have been improvements in our discharge planning process, the hospital reports there has been a reduction in readmission for infants and there has been a reduction in length of stay at the hospital. In many of these cases, there has been a reduction of out of home placement and that is really the goal of Plans of Safe Care – maintaining the family unit and helping parents be successful in caring for their children.”

Other Important Tools for Professionals in the Child Welfare System Supporting Families Impacted by Substance Use Disorders Welcoming a New Baby

Reading toxicology results, as well as trying to decipher symptoms related to substance use, can be complicated and overwhelming. A Toxicology Resource Guide was developed to support Colorado child welfare professionals in understanding substances, possible effects and the utility and application of toxicology testing to enhance practice. Look for a short video and blog next week highlighting how this guide is an essential tool for child welfare supervisors and caseworkers!  

To aid multidisciplinary teams of Colorado professionals needed to implement Plans of Safe Care, the Department created a new section on the Colorado Department of Human Services website.

Multiple courses on substance use and families, including Prenatal Substance Exposures, are available through the Child Welfare Training System:

      • The Substance Use Puzzle (OnlineTraining)
      • Building Safety When Parent Use Substances (1 Day)
      • Enhancing Practice with Families Impacted by Substance Use (2 Days)
      • In Depth with Substance Use & Families (ECHO Series)
      • Fetal Alcohol Spectrum Disorders (Online Training)
      • Impacts & Implications of Prenatal Substance Exposure (1 Day)
      • Plans of Safe Care (Web Based Training)
      • Legalized Marijuana: Considerations for Child Safety (OnlineTraining)
      • Marijuana, Children, & Families (1 Day)
      • Opioids & Families (ECHO Series)

WATCH THE VIDEO of the town hall for child welfare professionals to learn more about these tools, as well as:

      • a review of the work being done through the Colorado Substance Exposed Newborn Steering Committee
      • details on the rule-making process as a result of SB20-028 Substance Use Disorder Recovery already underway
      • implementation timeline for Plans of Safe Care
      • ways to get involved to get involved in systemic changes supporting substance exposed newborns and their families

Sources

(1) Oliveros, A., & Kaufman, J. (2011). Addressing substance abuse treatment needs of parents involved with the child welfare system. Child Welfare, 90(1), 25-41.

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