Figure 2-2 Direct Questions To Screen
for a History of Childhood Abuse or Neglect
The following questions can be used to help screen for a history
of childhood abuse or neglect. They can be asked as written.
However, they can also be asked in relation to developmental
stages. To do so, ask the same question with a different introductory
phrase that reflects different time periods or developmental
stages. For example, the basic question "Were you treated harshly
as a child?" can be rephrased as, "When you were 5 to 10 years
old, ..." or, "When you were 11 to 15 years old, ..."
Questions about trauma events include:
Were there any significant traumatic events in your family
while you were growing up? For example, did any of the following
events occur in your family: death of a parent or sibling, hospitalization
of a parent or sibling, incarceration of a parent or sibling,
divorce, or chronic disease?
Were you treated harshly as a child?
Did you ever experience physical, sexual, or emotional abuse
as a child?
Did you experience inappropriate physical or sexual contact
with an adult or person at least 5 years older than you while
you were growing up?
When you were a child, was there violence in your household,
such as battering of family members, involving siblings or a
parent and his or her partner?
Do you feel that your parents neglected you while you were
growing up? For example, were there ever periods during which
you did not have adequate food, clothing, shelter, or protection
by your parents?
Did your parents use alcohol or drugs frequently when you
were growing up? Did you ever use alcohol or drugs with them?
Questions about circumstances that may suggest traumatic events:
Have you or has anyone in your family ever been involved
with the child protective system?
Did you ever live away from your parents? Were you ever
in foster care? Were any of your siblings ever in foster care?
When you were a child, were there any periods when you felt
unsafe or in danger?
When you were growing up, did anyone in your family use alcohol
or drugs? How did their alcohol or drug use affect you as a
child?
Have you ever felt that abuse or neglect was justified based
on your misbehavior or shortcomings? (In other words, did the
client feel that the abuse was her fault and that she deserved
it?)
Figure 5-1
Behavioral Clues That Suggest Possible Child Abuse or Neglect
Name calling, verbal abuse, negative or belittling labeling
of the child
Stories that suggest children are living in unsafe conditions
(e.g., spoiled food, being left alone, traveling in unsafe neighborhoods)
Blaming children or directing misplaced anger on them that
may mask guilt about poor parenting
Describing children inappropriately in terms of their development
(e.g., having expectations for a 4-year-old that should be reserved
for a 12-year-old)
Giving children too much responsibility and autonomy for
their age
Sexualizing the child
Insisting that the child is just like one of the parents
(i.e., negatively describing him)
Negative behavior on the part of a new partner in the caregiver's
life
Inappropriate disciplinary measures; an inability to distinguish
between discipline (guiding) and punishment (hurting)
Figure 7-1 Linking Child Welfare
and Substance Abuse Treatment Systems
In a unique program currently being developed, the Connecticut
Department of Children and Families plans to make voluntary substance
abuse disorder assessments available to parents involved in CPS
agency investigations, thus establishing a direct link between
the child welfare and substance abuse treatment systems. Through
use of a telephone referral system maintained by a managed care
company with a network of 43 providers, child welfare workers
with questions about the severity of parental substance use can
secure appointments for evaluation on a priority basis. The
program will provide rapid reporting of results and priority
access to treatment when necessary. By directly linking the
two systems, the agency hopes to decrease the risk of continued
abuse or neglect, enhance decisionmaking about service needs,
facilitate admission to substance abuse treatment, and reduce
the need for out-of-home placement.
Consent for the Release of Confidential Information
I, ___________________________, authorize XYZ Clinic
to receive
(name of client or participant)
from/disclose to ________________________________________
(name of person and organization)
for the purpose of _______________________________________
(need for disclosure)
the following information__________________________________
(nature of the disclosure)
I understand that my records are protected under the
Federal and State Confidentiality Regulations and cannot be disclosed
without my written consent unless otherwise provided for in the
regulations. I also understand that I may revoke this consent
at any time except to the extent that action has been taken in
reliance on it and that in any event this consent expires automatically
on ____________________ unless otherwise specified below.
(date, condition, or event)
Other expiration specifications:
_________________________
Date executed
_________________________
Signature of client
________________________
Signature of parent or guardian, where required
Figure B-2
Consent Form: Criminal Justice System Referral
Consent for the Release of Confidential Information
I, _____________________________, hereby consent to communication
(name of defendant)
between __________________________________________________
and
(treatment program)
______________________________________________________________
(court, probation, parole, and/or other referring agency)
the following information______________________________________
(nature of the information, as limited as possible)
The purpose of and need for the disclosure is to inform
the criminal justice agency(ies) listed above of my attendance
and progress in treatment. The extent of information to be disclosed
is my diagnosis, information about my attendance or lack of attendance
at treatment sessions, my cooperation with the treatment program
prognosis, and
I understand that this consent will remain in effect
and cannot be revoked by me until:
_____ There has been a formal and effective termination or revocation
of my release from confinement, probation, or parole, or other
proceeding under which I was mandated into treatment or
_____
(other time when consent can be revoked and/or expires)
I also understand that any disclosure made is bound by Part 2
of Title 42 of the Code of Federal Regulations governing Confidentiality
of Alcohol and Drug Abuse Patient Records and that recipients
of this information may redisclose it only in connection with
their official duties.
____________________________
(Date)
____________________________
(Signature of defendant/patient)
____________________________
(Signature of parent, guardian, or
authorized representative if required)
Figure B-3
Qualified Service Organization Agreement
XYZ Service Center ("the Center") and the _______________________________
(name of the program)
("the Program") hereby enter into a qualified service
organization agreement, whereby the Center agrees to provide
(nature of services to be provided)
Furthermore, the Center:
(1) acknowledges that in receiving, storing, processing, or otherwise
dealing with any information from the Program about the clients
in the Program, it is fully bound by the provisions of the Federal
regulations governing Confidentiality of Alcohol and Drug Abuse
Client Records, 42 C.F.R. Part 2; and
(2) undertakes to resist in judicial proceedings any effort to
obtain access to information pertaining to clients otherwise
than as expressly provided for in the Federal Confidentiality
Regulations, 42 C.F.R. Part 2.
Executed this ____________ day of _____________________,
199_____
__________________________
President
XYZ Service Center
[address]
__________________________
Program Director
[name of program]
[address]
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