The Use of Hair Exposure Testing (ChildGuard®) in the Evaluation of Child Physical Neglect/Drug Endangerment

Originally published in Substance, Winter/Spring 2016.
Since 2011, Children’s Center in Oregon has utilized ChildGuard to help identify when a child has been exposed to harmful substances, and determine the next best step toward a healthier life for both child and caretaker.

by Sue Skinner, MD, FAAP

Child abuse and neglect remain a public health crisis in the United States. For FFY 2013, there were 679,000 child victims in the U.S., with an overall rate of 9.1 abuse victims per 1,000 children. In other words, nearly 1 in 100 children yearly is a victim of abuse or neglect. By the time a child reaches adulthood, he or she then has a nearly 1 in 5 likelihood of having been a victim of abuse or neglect. Nearly four-fifths of child abuse cases are the result of neglect.¹ Although many types of abuse coexist (sexual abuse, physical abuse and psychological abuse), by and large child neglect remains the most significant risk to a child.

Frequently, child neglect is not a one-time episode, but rather a pattern of circumstances where the child’s needs are not met by his or her caregivers. Fundamentally, neglect occurs when a child’s basic needs are not met.² More specifically, neglect is the failure of a parent or caretaker to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety, and well-being are threatened with harm.³

Child neglect itself is heterogeneous. However, parent or caretaker drug use is a frequent contributor to child neglect, for a variety of reasons. There is the risk of the primary presence of the drug itself, as well as the high-risk environment the child is living in as a caretaker is using and perhaps dealing in drugs. Most importantly, however, the caregiver’s ability to safely and consistently care for their child is impaired. Some professionals emphasize that parental substance abuse is associated with neglect, however, others state more directly that parental substance abuse and/or exposing children to illegal drug activity is itself actually child neglect.³ In fact, 33 states address in their criminal statutes the issue of exposing children to illegal drug activity.⁴ The National Alliance for Drug Endangered Children defines drug-endangered children as those who are at risk of suffering harm as a result of illegal drug use, possession, manufacturing, cultivation or distribution. They may also be children whose caretaker’s substance misuse interferes with the caretaker’s ability to parent and provide a safe and nurturing environment.⁵ In summary, children whose parents are actively abusing drugs, which may or may not include manufacturing or distribution, are also likely being neglected, and are at increased risk of other forms of abuse as well.

2009-2010 Federal data show the state of Oregon is one of the top 10 states for rates of drug-use in several categories (past month illicit use of drugs other than marijuana in persons age 12 and older, also age 18-25, and illicit drug dependence among young adults 18-25). 12.63% of Oregon residents reported past-month use of illicit drugs, higher than the national average of 8.82%. Oregon voters legalized medical marijuana in 1998, then legalized recreational marijuana in 2014. 2011 data shows that marijuana is the most commonly cited drug among primary drug treatment admissions in the state.⁶

DHS data from FFY Oct 2013-Sept 2014 showed there were 6,485 founded (or substantiated) allegations of child abuse and neglect in Oregon, this rate of 12 per 1,000 children demonstrates Oregon’s rates of abuse are above the national average.1 Of the child victims (founded assessments), 44.2% were due to neglect, representing the most common type of maltreatment. Alcohol and drug issues represented the largest family stress factor, when child abuse and neglect was present (46.1%). Of the 13 children who died due to abuse and neglect that year, 7 were due solely to neglect. Of children who entered foster care, 45.7% were due to parent drug abuse.⁷

Oregon’s Child Abuse Intervention Centers (CAIC) were created to minimize trauma for child abuse victims by focusing on the fundamental needs of the child. Currently there are 20 centers which collectively serve Oregon’s 36 counties, and see more than 6,700 children a year.⁸ By working in partnership with child protective services (DHS), law enforcement and other medical and mental health providers, CAICs have been designed to provide services, based on each child’s needs, in a neutral, child-focused environment and to be a resource for both the child and their caregivers. Each CAIC is uniquely suited to serve the needs of their communities. While services provided vary from county to county, generally services include medically-based evaluations, interviews regarding abuse allegations, mental health treatment and/or referrals.⁹ 

Children’s Center is one of the state’s child abuse intervention centers, located in Oregon City. It serves the 400,000 residents of Clackamas County, the third largest county in the state. Since the clinic opened in 2002, many children have been seen for concerns of physical neglect/drug endangerment. When children are seen acutely for concerns of drug exposure/endangerment, urine is frequently sent for drug testing. However, when seeing children for ongoing physical neglect/drug endangerment concerns, hair testing is more often utilized. Children’s Center began using the ChildGuard® hair exposure test in 2011. Our center sees ∼440 patients annually, of these, 21% are referred for concerns of neglect, which often also includes concerns of drug endangerment. Children’s Center is somewhat unique in this approach, as statewide only 12% of children seen at CAICs are referred for concerns of child neglect or drug endangerment.8 Over the past four years, Children’s Center has sent 486 ChildGuard® hair exposure tests, for an average of 122 a year (diagram 1). This means Children’s Center is ordering hair exposure testing on ∼28% of the patients we see. Of the 122 hair tests sent per year, on the average 55% of those are positive. Of those that were positive, 32% were positive for more than one substance.

In our evaluation of these children who are referred for physical neglect/drug endangerment, staff have noticed several things. Frequently the children we are seeing have developmental delay, in particular, speech delay. It is also fairly common that a child has dental caries and has never been to the dentist. Children’s Center medical staff note there is often immunization delay and children have not had regular ongoing care by a primary care provider. During comprehensive evaluations, staff are able to do a complete head-to-toe exam, including the anogenital exam. Height and weight are documented, as well as the developmental delays and physical findings. In addition, ChildGuard® testing is sent when history suggests drug exposure is a concern. If a child is old enough and has the verbal abilities, he/she will be transitioned to a recorded interview with a forensic interviewer, where the child can be screened for all types of abuse, including neglect. Questions are asked about discipline, drugs and alcohol, domestic violence, guns in home, as well as general questions about who watches the children, who cooks, and where people sleep. At the conclusion of the evaluation, children are referred for a mental health assessment. Where appropriate, they are also referred to a dentist and a consistent primary care provider. If a child is under 5 years old, he/she is referred to Educational Services District (ESD) for a developmental assessment. Recommendations in the completed report address all the risk factors in the child’s life, to include drug and alcohol exposure, domestic violence, physical punishment and storage of weapons. The report stresses that adult caretakers should be both physically present and not mentally impaired, in order to best safely parent their children.

Children’s Center sees a real value to assessing children for concerns of physical neglect/drug endangerment, and this is evidenced by the fact that it is 21% of our referrals. National and state data, as well as medical literature indicate this is the most common type of abuse; families often have a long standing history and there are far-reaching effects on the health and well-being of the child, if not addressed. Data obtained through the Adverse Childhood Experiences (ACE) Study, clearly demonstrates a strong relationship between household dysfunction and abuse, and multiple risk factors for leading causes of death in adults.10 Studies show that parental substance abuse is associated with a more than twofold increase in the risk of physical and sexual abuse.¹¹

Community partners who refer to Children’s Center (law enforcement, DHS, medical providers & therapists) see the value in these assessments as well, given that they make the majority of the referrals. A comprehensive evaluation for drug endangerment/physical neglect, including the ChildGuard hair exposure testing provides valuable documentation and test results to best allow work with families and other caretakers, and to engage parents in treatment they otherwise may be reluctant to address. Children’s Center data has shown that positive test results on the ChildGuard hair exposure test were associated with an increased number of founded DHS referrals, as well as improved outcomes in Dependency Court.¹²

The bottom line – at Children’s Center we consider what is best for the children, as well as their adult caretakers. Child neglect, left unchecked and unidentified, has lifelong physical and emotional consequences for children. It is imperative that advocacy centers address the needs of children in homes where illegal drug activity is taking place. Best practice includes a comprehensive medical assessment, a forensically sound interview, and lab testing, to include the ChildGuard hair exposure testing. Appropriate referrals upon completion will provide the best chance at identifying all challenges present within the family unit and hopefully moving toward a healthier and safer life for each child.

References

1. http://www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf#page=20
2. Dubowitz, Howard, H.  Neglect in children.  NIH-Public Access Author Manuscript, Pediatric Annals. 2013 April:  42(4): 73-77.
3. https://www.childwelfare.gov/pubPDFs/define.pdf
4. https://www.childwelfare.gov/pubPDFs/drugexposed.pdf
5. http://www.nationaldec.org
6. https://www.whitehouse.gov/sites/default/files/docs/state_profile_-_oregon_0.pdf
7. http://www.oregon.gov/dhs/children/child-abuse/Documents/2014%20Data%20Book.pdf
8. Oregon Network of Child Abuse Intervention Centers, Statewide Statistical Data July 2014-June 2015.
9. http://www.childabuseintervention.org
10. Felitti, Vincent et al. Relationship of Childhood abuse & household dysfunction to many of the leading causes of death in adults. Am J Prev Med 1998 14(4):  245-258.
11. Walsh, Christine et al.  The relationship between parental substance abuse and child maltreatment:  findings from the Ontario Health Supplement.  Child Abuse & Neglect 27 (2003): 1409-1425.
12. Unpublished data, CC poster presentation, APSAC national conference 2013.

Dr. Sue Skinner is the Medical Director for Children’s Center in Oregon City, Oregon. She is board certified in both General Pediatrics & Child Abuse Pediatrics. She has been working in the field of child abuse & neglect for more than 20 years. Children’s Center is a private, non-profit child abuse intervention center. For more information, visit http://www.childrenscenter.cc.