Form 1 Survey Instrument for Local Agency Staff-Form B Diff

OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Prenatal Alcohol and Other Drug Exposures:

Local Agency Survey

1. Select all of the following options that best describe your current role?

(Select all that apply)

• Frontline worker

• Supervisor/manager

• Director/administrator

• Hotline/intake staff

• Child protective services/investigative staff

• Family needs assessment staff

• In-home/ongoing case management staff

• Out-of-home/foster/permanency staff

• Post-adoption staff

• Medical staff (e.g., nurse care manager)

• Behavioral/Mental Health staff (e.g., therapist, psychologist or LCSW)

• Prevention staff

• Independent living staff

• Substance abuse specialist

• Other (Please describe): __________________________________

2. How many years have you worked in at this local agency? (Select one).

• Less than 1 year

• 1 to 5 years

• 6 to 10 years

• 11 to 20 years

• 20+ years

3. How many years have you worked in child welfare? (Select one).

• Less than 1 year

• 1 to 5 years

• 6 to 10 years

• 11 to 20 years

• 20+ years

4. Please tell us about the activities you currently conduct as part of your job.

	I do this routinely as part of my job	I supervise those who conduct this activity	I manage/ direct a department where these activities are conducted
	(select the best answer in each column)
Intake/screening of allegations of child abuse and neglect	Yes No	Yes No	Yes No
Child protection investigations of screened-in reports to determine occurrence/assess for risk of abuse and neglect	Yes No	Yes No	Yes No
Family and child need assessments and referrals for voluntary services (when the child is not in foster or adoptive care)	Yes No	Yes No	Yes No
Family/child needs assessment and referrals for mandatory family services (when the child is in foster or adoptive care)	Yes No	Yes No	Yes No
Service planning and referrals during ongoing case management, when the child has been placed out-of-home	Yes No	Yes No	Yes No
Service planning and referrals during ongoing case management, while the family is receiving in-home services	Yes No	Yes No	Yes No

5. We are interested the types of information that are collected by local agencies when cases have been opened and are the subject of a family needs assessment to assess for potential child abuse/neglect. Please read the following scenarios, and then answer the questions that follow.

A report on the Davis family has been provided to your agency, and your agency has opened a case. There will be an assessment of the family using [the differential/alternative response process]. The Davis family consists of the mother (age 28) and one child Jesse (age 2) who live with the child’s grandmother. They have no prior involvement with child protective services. Police records indicate that, 3 years ago, the mother had one conviction for driving under the influence of alcohol. The grandmother reports that mom attends AA and has maintained employment for two years. The grandmother also notes that mom loses her temper, and sometimes hits Jesse out of frustration, leaving bruises. The grandmother reports that Jesse has been extremely small since birth and uses mostly gestures, with few words, to communicate. Jesse also “has too much energy” and “is hard to control;” he was recently “kicked out” of daycare as he kept biting other children. The mother has one other son (10 years old) who currently lives with his biological father.

Please answer the following questions as best you can - we understand that [differential/alternative response family assessments] might not be part of your job duties, that other important information would be collected, and that you are working with very limited information in the scenario above.

If conducted by a typical staff member at your local agency with responsibilities in family assessments, in the above scenario, please tell us:
Types of information	How often would this information be obtained during the investigation of the above scenario?						How important would this information be to inform the investigation of the above scenario?
	Always	Usually	Sometimes	Rarely	Don’t Know		Critical	Very important	Somewhat important	Not important	Don’t Know
	(Select one response for each row)						(Select one response for each row)
Mother’s history of drug use
Mother’s history of alcohol use
Mother’s current use of drugs
Mother’s current use of alcohol
Mother’s pregnancy history (e.g., prenatal care, nutrition)
Mother’s use of drugs or alcohol while pregnant with child
Child’s birth history (e.g., medical history at birth)
Child’s developmental milestones
Child’s known disabilities
Child’s mental health diagnoses

6. When answering the questions about Scenario 1 above, how might you use the types of information that you marked as critical to inform decisions about risk and possible referral for services?

____________________________________________________________________________________________________________________________________________________________________________________

6. We are also interested in the types of information collected by local agencies when assessing family and/or child needs in preparation for case planning and service referrals, when children are under care and placement responsibility of the child welfare agency. Please read the following scenario, and then answer the questions that follow.

SCENARIO TWO: Alyssa (age 13) was recently removed from her home and placed in a non-relative foster family. Alyssa’s older brother is 18 and lives outside the home. The investigation found that her mom frequently abused alcohol and it would lead to violent behavior directed towards Alyssa. In addition, Mom has a long history of past and current substance abuse.  Alyssa’s mother has biweekly visitations with Alyssa and has a goal of reunification. Alyssa’s current foster family notes that, since placement, Alyssa has kept mostly to herself and seems anxious and depressed. The foster family notes that Alyssa has difficulty following directions, though breaking instructions down into shorter phrases and keeping them simple has helped. Alyssa’s school indicated that Alyssa has learning disabilities and an IEP, and has difficulty making friends her own age.

Please answer the following questions as best you can - we understand family needs assessment and case planning might not be part of your job duties, that other important information would be sought, and that you are working with very limited information in the scenario above.

If conducted by a typical staff member with case planning responsibilities at your agency, in the above scenario, please indicate how important this information would be to inform case planning and service referrals for Alyssa and her mom.
	Critical	Very important	Somewhat important	Not important	Don’t Know
	(Select one response for each row)
Mother’s history of drug use
Mother’s history of alcohol use
Mother’s current use of drugs
Mother’s current use of alcohol
Mother’s pregnancy history (e.g., prenatal care, nutrition)
Mother’s use of drugs or alcohol while pregnant with child
Child’s birth history (e.g., medical history at birth)
Child’s history of illness and injury
Child’s developmental milestones
Child’s known disabilities
Child’s mental health diagnoses

8. When answering the questions about Scenario 2 above, which types of information that were marked as critical or very important are least likely to be available to you? Please describe how you would go about getting that information, if available.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Please think now about the same scenario (repeated below for your convenience), and consider what type of service referrals would likely be made.

SCENARIO TWO: Alyssa (age 13) was recently removed from her home and placed in a non-relative foster family. Alyssa’s older brother is 18 and lives outside the home. The investigation found that her mom frequently abused alcohol and it would lead to violent behavior directed towards Alyssa. In addition, Mom has a long history of past and current substance abuse.  Alyssa’s mother has biweekly visitations with Alyssa and has a goal of reunification. Alyssa’s current foster family notes that since placement, Alyssa has kept mostly to herself and seems anxious and depressed. The foster family notes that Alyssa has difficulty following directions, though breaking instructions down into shorter phrases and keeping them simple has helped. Alyssa’s school indicated that Alyssa has learning disabilities and an IEP.

We understand that working with ongoing cases might not be part of your job duties, that there could be more referrals than those listed below, and that you are working with very limited information. Given those limitations, please respond as best you can with the answer that most closely resembles typical agency practice.

Assuming that services are available, please indicate what kinds of referrals a typical staff member at this agency would provide to Alyssa as part of the case planning/service referral process.
	All children served by this agency are referred to this service	Would definitely refer Alyssa to this service	Might refer Alyssa to this service	Probably would not refer Alyssa to this service	Would not refer Alyssa to this service	Are these services available in your clients’ community?
Types of referrals made:	(Select one response for each row)
Medical examinations/ physical health check/ medical treatment exam?						Available Somewhat available Not available Don’t know
Initial screening to identify potential developmental or learning issues?						Available Somewhat available Not available Don’t know
Initial screening to identify potential mental health or behavioral issues?						Available Somewhat available Not available Don’t know
Initial screening to identify potential speech, physical therapy, and/or occupational needs?						Available Somewhat available Not available Don’t know
In-depth assessment/ diagnosis of mental health/behavioral issues?						Available Somewhat available Not available Don’t know
In-depth assessment/ diagnosis of intellectual, learning, developmental, and/or cognitive issues?						Available Somewhat available Not available Don’t know
In-depth assessment/ diagnosis related to speech, physical therapy, and/or occupational needs?						Available Somewhat available Not available Don’t know
Referral for specific assessment of diagnosis related to prenatal alcohol exposure						Available Somewhat available Not available Don’t know

8. In your opinion, when reviewing information to determine whether a child has been prenatally exposed to alcohol or other drugs….

	…which are the top three most commonly reviewed sources of information at your agency?	…which are the top three most accurate sources of information?
	(select three)	(select three)
a. Observations of drug or alcohol paraphernalia in the child’s home
b. Birth records (e.g., medical status at birth, positive toxicology)
c. Developmental assessments
d. Other medical records (e.g., doctors’ appointments, diagnoses)
e. Information shared by schools
f. Conversations with the mother
g. Conversations with other family members or collateral reports
h. Observations of the child’s physical symptoms or behaviors
i. Judicial review or court reports
j. Other, please describe________________________________

8. When do you think is the most ideal point to assess or identify a child’s history of prenatal substance exposure to alcohol or other drugs? (select one)

• intake/screening of allegations of child abuse or neglect

• child protection investigations of screened-in reports to determine occurrence/assess for risk of abuse and neglect

• family/child needs assessment for mandatory services

• service planning during ongoing case management,

• Other (please specify): _________________________

8. Now we’d like to ask a few questions about your training related to prenatal substance exposures of children, including alcohol. For each topic listed, please select the appropriate column to indicate any training that you have received on that topic.

TRAINING TOPICS	TRAINING/EDUCATION SOURCE
	Courses or sections of courses in undergraduate and/or graduate school	Training through State CW Agency	In-House Local CW Agency Training	Continuing Education Units	Other Source (e.g. training/TA provider)	Training not offered/ Did not receive any training on topic
	(Select all that apply, selecting at least one option for each row)
General training on prenatal alcohol exposure	☐	☐	☐	☐	☐	☐
General training on prenatal exposure to opioids and/or heroin	☐	☐	☐	☐	☐	☐
General training on prenatal exposure to other drugs (please describe drug type(s)): ________________________ ________________________	☐	☐	☐	☐	☐	☐
Effects of prenatal alcohol exposure on childhood development	☐	☐	☐	☐	☐	☐
Effects of prenatal exposure to other drugs on childhood development	☐	☐	☐	☐	☐	☐

8. How would you rate your level of understanding about the development of children with prenatal exposure to alcohol? (Select one).

• No knowledge

• Beginner

• Intermediate

• Advanced

8. How would you rate your level of understanding about the development of children with prenatal exposure to other drugs besides alcohol? (Select one).

• No knowledge

• Beginner

• Intermediate

• Advanced

8. In your opinion, what type of prenatal substance exposure do you think is most harmful? Why?

______________________________________________________________________________________________________________________________________________________________________________

8. Please select either “True” or “False” for the following statements about prenatal exposure to alcohol (As a reminder, this survey is anonymous and your responses will not affect your employment status at this agency).

1. Alcohol use during pregnancy is the leading known cause of developmental disability and birth defects in the United States. True False

2. Alcohol can harm an embryo or fetus at any time during pregnancy. True False

3. Women who drink early in pregnancy but stop drinking are not at risk for having a child with a Fetal Alcohol Spectrum Disorder. True False

4. Of all substances of abuse, alcohol produces the most serious neurobehavioral effects in the fetus. True False

5. There is no cure for Fetal Alcohol Spectrum Disorder, although treatment can mitigate some effects. True False

6. A woman can have 1 or 2 drinks a day without causing harm to her baby since she isn’t binging. True False

7. Fetal Alcohol Spectrum Disorders only occur if the mother is an alcoholic during pregnancy. True False

8. Women only need to avoid hard liquor during pregnancy, beer and wine are okay. True False

9. Most children with a Fetal Alcohol Spectrum Disorders have unusual facial features. True False

8. Please select all of the possible effects of prenatal exposure to alcohol on children.

(Select all that apply).

• Growth deficits

• Brain damage

• Intellectual disability

• Abnormal facial characteristics

• Heart, lung, and kidney defects

• Hyperactivity and behavior problems

• Attention and memory problems

• Difficulty with judgment, reasoning and self-regulation

• Learning disabilities

• Social issues

• Sleep problems

• Poor adaptive skills

• Neonatal Abstinence Syndrome (NAS)

• Other effects (please describe):_________________

8. Among the children that this local agency comes into contact with, what percentage of children would you estimate have been prenatally exposed to alcohol? ______%

8. Among the children that this local agency comes into contact with, what percentage of children would you estimate have been prenatally exposed to drugs other than alcohol? ______%

8. Please use the space provided to share any other thoughts you have about the identification, documentation, and service referrals for children in care with prenatal exposure to alcohol and other drugs.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your participation!

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