Quiz #1

Chapter 4: Child Physical Abuse

Lecture Outline

I. Scope of the Problem of Child Physical Abuse

i. U.S. Advisory Board on Child Abuse and Neglect described the level of child maltreatment in the United States as a national emergency

ii. Definitions

1. harm standard: recognizes children as CPA victims if they have observable injuries that last at least 48 hours

2. endangerment standard: recognized children as abuse victims if they were deemed to be substantially at risk for injury (endangerment)

3. any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm

4. intentional use of physical force by a parent or caregiver against a child that results in, or has the potential to result in, physical injury

5. physical punishment—use of physical force with the intention of causing the child to experience bodily pain or discomfort so as to correct or punish the child’s behavior

6. protective physical restraint—when parents must use physical force to prevent a child from hurting themselves is not a form of punishment

iii. Corporal punishment

1. children are the only group in society that may be hit legally

2. arguments against

a. when authority figures spank, they are condoning the use of violence as a way of dealing with frustration and settling disputes

b. message of acceptance of this form of violence contributes to violence in other aspects of society.

c. adults who administer punishment that reduces a behavior have modeled how, when, and why one uses violence against another

d. ineffective in achieving the anticipated results because a punisher is an event that decreases responses, therefore, punishment cannot teach new, desirable behaviors

e. harsh physical punishment has adverse effects on brain development

f. counterproductive

g. positively correlated with other forms of family violence, including sibling abuse and spouse assault

h. children judged spanking to be the least fair method of discipline

II. Prevalence of Child Physical Abuse

a. Statistics on Child Physical Abuse

i. Official estimates

1. decreased from 1992 to 2004

2. CPS substantiated the abuse for 25.1% of the cases in a year

3. 13.2% infants <1 week of age were victims of physical abuse

4. Injuries/Deaths

a. of children < 12 years of age presenting at emergency rooms for treatment, half of those treated were under 5 years of age

b. relatives inflicted 56% of the injuries; acquaintances inflicted 34.1%; and strangers inflicted 9.7%

c. 22.9% of fatalities were attributed to physical abuse

d. 69.9% of all child fatalities were caused by parents

e. male infants were more likely than female infants to become a fatality

f. 41.1% of fatality victims were white; 26.1% of victims were African American; 16.9% were Hispanic; and the remainder was other unknown

g. 52% fatalities occurred in children under 1 year of age

h. fathers/father substitutes significantly more likely to be perpetrators; mothers were significantly more likely to be deemed responsible for neglect

ii. Child Death Review Teams

1. community leaders in medicine, child services, religion, law enforcement, and other areas

2. careful scrutiny of the causes will lead to development of methods to intervene and prevent such deaths

3. Sudden Infant Death Syndrome (SIDS) and Sudden Unexpected Infant Death (SUID)

a. safe sleeping campaigns— unsafe sleeping situations caused the deaths of a number of infants

iii. Neonaticidal Mothers

1. 75% of mothers who kill newborns fit a common profile

2. not mentally ill, and they do not have a history of arrest

3. often deny their pregnancy intermittently

4. most manage to deliver the baby on their own in secret

5. most recover sufficiently to go right on with their daily routines, such as going to school or work

iv. Self reports

1. 75% of the parents acknowledged having used at least one violent act in rearing their children

2. approximately 2% of the parents had engaged in one act of abusive violence (e.g. an act with a high probability of injuring the child)

3. most frequent type of violence in either case was slapping or spanking

4. distinguishes three levels of physical assault: minor assault (i.e., corporal punishment), severe assault (e.g. physical maltreatment), and very severe assault (e.g. severe physical maltreatment)

5. 75% reported using some method of physical assault during the rearing of their children (e.g. spanking, slapping, and pinching)

6. 50% of parents surveyed said that they had engaged in behaviors from the severe physical assault subscale at some point during their parenting (e.g. hitting the child with an object such as a stick or belt)

7. less than 1% of the parents employed behaviors from the very severe physical assault scale (e.g. throwing or knocking down a child)

8. half reported having experienced at least one physical assault by an adult caretaker, with the acts of violence ranging from relatively minor forms of assault (e.g., being slapped or hit) to more serious forms (e.g., being threatened with a knife or gun)

b. Trends of Statistics on Child Physical Abuse

i. all forms of child maltreatment decreased from 40%-70%

ii. fewer teen pregnancies, teen suicides, and children living in poverty

iii. improved economic factors

iv. increased agents of social change (e.g., more social workers)

v. psychopharmacological advances

vi. child maltreatment was staying about the same, at least not increasing

vii. estimated rate of violence toward children declined

viii. most substantial decline was in the use of severe and very severe violence

III. Effects of Child Physical Abuse on Children

a. Findings on Child Physical Abuse

i. children who experience physical maltreatment are more likely exhibit physical, behavioral, and emotional impairments

ii. associations between corporal punishment and negative outcomes in childhood and into adulthood, including deficits in moral internalization, poor mental health, and increased aggression, antisocial behavior, and abusive behavior toward others

b. Types of Child Physical Abuse

i. Physical and mental health

1. head injuries, abdominal injuries, and burns are likely to have long-lasting effects

2. chronic pain on into old age

3. depression, high inflammation levels, and a clustering of metabolic risk factors including being overweight, having high blood pressure, high bad cholesterol, high blood sugar, and low oxygen consumption

4. elevated risks for allergies, arthritis, asthma, bronchitis, high blood pressure, and other problems

ii. Criminal and violent behavior

1. higher likelihood of arrests for delinquency, adult criminality, and violent criminal behavior

2. adults with histories of CPA are more likely both to receive and to inflict dating violence

3. adults (primarily males) who were physically abused as children are more likely to inflict physical abuse on their marital partners

iii. Genetics

1. variations in a gene that helps to regulate neurotransmitters in the brain that are implicated in antisocial behavior

2. maltreated children with a protective version of the gene were less likely to develop antisocial problems in adulthood

3. children who had the less protective version of the gene later became violent criminal offenders

iv. Substance abuse

1. CPA among girls led to a use of substances at age 12 which then continued onward

2. substance abuse at age 12 was related to substance abuse at ages 16 and 24

v. Socioemotional difficulties

1. adults with histories of CPA exhibit more significant emotional problems

c. Mediators/Moderators of Child Physical Abuse

i. explain the variability of effects, why some effects may be pervasive and other not

ii. Frequency, severity, and duration of the abuse

1. more severe and/or chronic maltreatment may have more negative outcomes

iii. Polyvictimization

1. greater the number of subtypes of maltreatment (e.g., physical abuse, sexual abuse, neglect) experienced by a child, the more negative the outcomes will be

iv. Prior involvement with CPS

1. prior involvement with CPS influenced the probability of a second determination of abuse

v. Child’s attributions

1. Children who tended to blame themselves for the abuse exhibited greater internalizing symptoms

vi. Family stress

1. negative effects of abuse are greatest for children in families in which there are high levels of stress and parental psychopathology or depression

vii. Sociocultural factors

1. presence of community violence can be a factor influencing the effects of CPA

viii. Child’s intellectual functioning

1. high intellectual functioning and/or the presence of a supportive parent figure have a protective influence

ix. Relationships between the victim and abuser

1. parental sensitivity, for example, has a protective influence; lack of empathy predicted symptoms following CPA victimization

x. Trauma symptoms

1. children whose abuse eventuated in the trauma symptom of avoidance coping were more likely to abuse their own child

xi. Child’s temperament

1. low fear and low sensitivity to punishment

xii. Social support

1. more likely to have received emotional support from a nonabusive adult during childhood, to have participated in therapy during some period in their lives, and to have been involved in nonabusive, stable, emotionally supportive, and satisfying relationships with mates

xiii. Medical and neurological problems

1. bruises are one of the most common types of physical injuries

2. other marks on their bodies as the result of being grabbed or squeezed or of being struck with belts, switches, or cords

3. chest and abdominal injuries

4. burns

5. fractures

6. abdominal injuries by being struck with objects, by being grabbed tightly, or by being punched or kicked in the chest or abdomen, which can result in organ ruptures or compressions

7. compromised brain development

8. deficits in language skills, memory, spatial skills, attention, sensorimotor functioning, cognitive processing, and overall intelligence

9. head injury resulting in neurotrauma

10. shaken baby syndrome

a. violently shaking an infant can result in mild to serious Traumatic Brain Injuries

b. shaking a child violently can cause the child’s brain to move within the skull, stretching and tearing blood vessels

c. damage may include bleeding in the eye or brain, damage to the spinal cord and neck, and rib or bone fractures

d. long-term neurological or mental disability may appear

xiv. Cognitive problems

1. lower intellectual and cognitive functioning on general intellectual measures as well as on specific measures of verbal facility, memory, dissociation, verbal language, communication ability, problem-solving skills, and perceptual motor skills

2. poor school achievement and adjustment, receive more special education services, score lower on reading and math tests, exhibit more learning disabilities, and are more likely to repeat a grade

3. greater concentrations of urinary dopamine, norepinephrine, and free cortisol, as well as a number of smaller specific brain regions, resulting in negative impacts on children’s ability to regulate both emotional and behavioral responses

xv. Behavioral problems

1. physical aggression and antisocial behavior

2. drinking and drug use, noncompliance, defiance, fighting in and outside of the home, property offenses, and arrests

3. bullying

a. use of power and aggression in order to distress a vulnerable person using verbal or physical actions and behaviors such as exclusion and ostracism

b. relational bullying—aggression aimed at damaging someone else’s relationship

c. relationship between parents’ harming a child physically and the child victims’ bullying behaviors; youth from violent homes often model the violence and carry out similar abusive patterns of behavior in their own relationships

d. more prevalent before age 12, and it continues during adolescence; beginning in middle school and reaching a peak during the transition from middle school to high school followed by a decline

e. black students report being victimized more than white students

f. bully only, victim only, and both victim and bully

g. physical, emotional, indirect, verbal, sexual, and relational

h. bullies rank high on antisocial behavior and aggression, associated with anger, impulsivity, and depression

i. bullies have lower quality parental attachment are significantly more likely to bully and to be bullied

j. victims are submissive/nonassertive, someone who is different because of sexual orientation, race, or disability

k. victims exhibit low self-esteem and depression, lower in prosocial behavior and girls were higher in impulsivity, intensified anxiety and depression

l. victims suffered from an escalation of symptoms of depression, anxiety, social withdrawal, and physical complaints

m. violent childhood does not mean that bullying behavior is inevitable, and interventions can change the way school children relate to others

xvi. Pathology

1. internalizing behavioral symptoms

2. Attachment problems

a. insecure attachment in infants where the parent-child relationship presents an irresolvable paradox because the caregiver is both the child’s source of safety and protection and the source of danger or harm

3. Psychiatric disorders

a. increased risk for psychiatric disorders problems (e.g. social dysfunction, somatization, revictimizations, attention-deficit/hyperactivity disorder, borderline personality disorder, bipolar disorder)

4. Posttraumatic stress disorders

a. 81% of abused children have partial PTSD symptoms

5. Depression

a. greater risk of depression

b. learned helplessness

IV. Characteristics of Children Who Are Physically Abused

a. Statistics on the Characteristics of Physically Abused Children

i. Age

1. highest report is 5.5 per 1,000 for children 6 to 8

ii. Gender

1. girls are generally more at risk for all abuse

2. boys are generally at slightly greater risk than girls for CPA

iii. SES

1. CPA occurs disproportionately more often among economically and socially disadvantaged families

iv. Race

1. black children to be the most sexually abused

2. African American families are at the greatest risk for CPA

v. Disabled

1. special characteristics of disabled children increase their risk for abuse

2. association between CPA and birth complications such as low birth weight and premature birth

3. incidence of child maltreatment was almost twice as high

4. most common disabilities noted were emotional disturbance, learning disability, physical health problems, and speech or language delay or impairment

b. Services Provided to Physically Abused Children

i. CPS is less likely to initiate an investigation of disabled children compared with nondisabled children

ii. CPS is likely to recommend services for disabled abused children instead of services for the abusive parents

V. Characteristics of Adults Who Physically Abuse Children

a. Findings on Adults Who Physically Abuse Children (Please align)

i. Age: Younger parents are more likely than older parents

ii. Gender and Parental Type

1. More adult males (62%) physically abused children than females

2. Biological parents abused more females than male children (NIS-4)

3. Nonbiological parents/partners abused more male than female children (NIS-4)

4. Others abused more male than female children (NIS-4).

5. Kaiser-Permanente study found gender differences related to type of homes (e.g., substance abuse in the home)

iii Race: Looking at child maltreatment as a whole (not just physical abuse), Whites perpetrated more abuse than their other groups (DHHS)

iii. Close to half are White

b. Relationship of Perpetrator to the Abused child

i. birth parents (0.9%) are the perpetrators of the abuse in the majority of reported cases of any type of abuse (DHHS)

ii. biological parents perpetrate 72% of physical abuse against children (NIS-4)

c. Nontraditional Parenting

i. single parents are overrepresented among abusers

ii. highest rates of child abuse occurred among single parents who had a cohabiting partner, rate of abuse was 10 times higher than children living with married biological parents

iii. children cared for by grandparents were less apt to be physically abused than cared for by parents

d. Psychological, Interpersonal, and Biological Characteristics of Adults Who Physically Abuse Children

i. Emotional and behavioral characteristics

1. Characteristics such as anger control problems, hostility, low frustration tolerance, depression, low self-esteem, deficits in empathy, and rigidity

2. Substance abuse problems are significantly related to recurrence of a CPA report

ii. Family and interpersonal difficulties of perpetrators

1. Physically abusive adults are more likely to exhibit family and interpersonal difficulties

2. Report more verbal and physical conflict among family members, higher levels of spousal disagreement and tension, and greater deficits in family cohesion and expressiveness

3. Report more conflict in their families of origin

4. Engage in fewer interactions with their children, such as playing together, providing positive responses to their children, and demonstrating affection

5. More likely both to receive and to inflict dating violence

6. Adults (primarily males) who were physically abused as children are more likely to inflict physical abuse on their marital partners

7. Adults who were victims of physical abuse as children are more likely to be perpetrators of CPA as adults

VI. Explaining Child Physical Abuse

a. Perpetrators exhibit psychological, behavioral, and biological characteristics such as anger control problems, depression, parenting difficulties, physiological hyperreactivity, and substance abuse

b. The psychiatric explanation - Only a small proportion of abusive parents (less than 10%) meet criteria for severe psychiatric disorders

c. Postpartum depression/psychosis model

i. they have problems in feeding, sleep routines, well-baby clinic visits, vaccinations, and safety practices

ii. there is a biological basis for postpartum depression

iii. few mothers actually harm their babies because of postpartum depression, many women have recurrent and disturbing thoughts of harming their babies

iv. postpartum depression is under-identified and under-treated

v. treatments are psychotherapy, antidepressant medications, stress reduction, massage therapy

d. Munchausen by Proxy – A rare type of physical child abuse

i. adult caretakers falsify to medical personnel physical and/or psychological symptoms in a child in order to meet their own (parent’s) psychological needs

ii. fabrication of symptoms such as altering laboratory specimens, and the direct production of physical symptoms

e. Difficult Child Model

i. children with certain characteristics (such as mental disabilities, aggressiveness, and young age) are at increased risk for abuse

ii. some parents may lack the skills to manage children who are annoying, defiant, argumentative, or vindictive, and their frustration may lead to child abuse

f. Parent-Child Interaction Model

i. difficult child behaviors interact with specific parental behaviors

ii. behavior of both parent and child, rather than the behavior of either alone brought about the abuse

iii. difficulties in parent-child relations develop during the abused child’s infancy, when early attachments between parent and child are formed

g. Social Learning Theory

i. abusive adults presumably learned through experiences with their own parents that violence is an acceptable method of child rearing

ii. parents who had been neglected during their own childhood, relative to those who had not, were 2.6 times more likely to neglect their own children and 2 times more likely to physically abuse their own children

iii. parents who had been physically abused during childhood, relative to those who had not, were 5 times more likely to physically abuse their own children and 1.4 times more likely to neglect their children

iv. children who observe interparental violence were likely to engage as perpetrator or victim in their own adult intimate relationship

h. Situational and Societal Conditions

i. Economic disadvantage

1. more common among low-income families and families supported by public assistance

2. fathers who are unemployed or work part-time are also at greater risk for abusing their children

ii. Social isolation - more interpersonal problems outside the family—such as social isolation, limited support from friends and family members, and loneliness

1. lack an extended family or peer support network

2. children who had grandparents were significantly less likely to be abused than those who did not, suggesting that having an extended family may have functioned to reduce isolation and abuse

i. Stress

i. parenting stress strongly influences both parenting behaviors and children’s behavioral and emotional problems

ii. abuse is associated with high numbers of stressful life events as well as stress associated with parenting

iii. stressors include a new baby, illness, death of a family member, poor housing conditions, larger-than-average family size, work-related problems and pressures, marital discord, conflicts over a child’s school performance, illness, a crying or fussy child, and military service

1. abuse doubled during the after period, the deployment period, and increased both upon deployment and upon return from deployment

2. parents of children with a deployed spouse had significantly elevated depression

j. Corporal Punishment Acceptance

i. there are no federal laws against spanking children, and only half the states ban spanking in child care settings and/or schools

ii. certain protestant religious beliefs and sociopolitical conservatism play a role in the acceptance of physical discipline but do not incorporate acceptance of child physical abuse

iii. United Methodist Church has now called for a ban on corporal punishment

k. Risk Factors for Child Physical Abuse

i. frequent spanking

ii. spanking the buttocks with an object

iii. polyvictimization

l. Protective Factors

i. Supportive family environment

ii. Nurturing parenting skills

iii. Household rules

iv. Family protective community

v. Child monitoring

vi. Parental employment

vii. Adequate housing

viii. Access to healthcare

ix. Access to social services

x. Extended family support

VII. Practice, Policy, & Prevention

a. Practice Issues Regarding Child Physical Abuse

i. Parent-Focused Treatment: improvements in parenting skills

ii. In-Home Treatments: several in-home treatments are effective for reducing CPA

1. Project SafeCare

2. parents actively acquire needed skills through techniques such as completing homework assignments and demonstrating (modeling) desirable parental behaviors

iii. Behavior-Based Treatment Programs

1. programs focus on parent’s behavior, the child’s behavior, parent-child interactive behaviors, or all three.

2. parent training based on behavioral (learning) or cognitive-behavioral principles that involve educating parents about the following elements:

a. effects of reinforcement and punishment on children’s behavior

b. appropriate methods of delivering reinforcement and punishment

c. importance of consistency in discipline

d. identification of events that increase negative emotions

e. changing anger-producing thoughts

f. relaxation techniques

g. methods for coping with stressful interactions with their children

iv. Parent-Child Interaction Therapy (PCIT)

1. eliminate parents’ physical abuse of their children, observing counselor gives the parent instructions via an electronic hearing device

2. parents learn specific skills, such as empathic listening and how to communicate the consequences for specific behaviors

v. Cognitive-Behavioral Therapy

1. psychoeducation, skills training, and application

2. manifested less parental distress, risk for child abuse, and family conflict

3. better family cohesion and a reduction in children’s externalizing behavior

vi. Combined Parent-Child Cognitive Behavioral Treatment

1. 16 therapy session, each 90 minutes long

2. therapist meets the parent and child separately and together

3. engagement strategies to motivate the parent to enter and remain in treatment

4. psychoeducational component provides information about different types of abuse and coercive behavior and their impacts on children and parents

5. teaches child development and setting realistic expectations for children’s behavior

6. children learn how to express their feelings

7. parents practice communication skills, positive parenting, and behavior management

8. whole family develops a safety plan and practices how to implement it

9. works on communicating about abuse issues

10. parent writes a letter of apology for being abusive, and the child writes about the traumatic elements of his abuse

11. outcome evaluation judged the program to be effective

vii. Therapeutic day care

1. programs that offer child care can provide relief for overly burdened parents who need a break

2. individual therapy, group therapy, and play sessions

3. group activities, opportunities for peer interactions, and learning experiences to address developmental delays

4. sharing experiences, anger management, and social skills training

5. opportunities for informal interaction between abused children and adults and/or peers

viii. The Incredible Years Teacher Training Series

1. helps children deal with externalizing behaviors

2. offered once a week

3. children in group settings learn how to empathize and behave in prosocial ways

4. children become less disruptive at home and in class and also improve their academic performance

5. parent training led to many improvements in the area of disciplining children: less harsh discipline, less physical punishment, more praise/incentive behaviors, more appropriate discipline, and positive verbal discipline

ix. Parental support interventions

1. developing social support networks made up of personal friends as well as community contacts

2. group therapy format that centers on identification of stressors common to parenting and how to cope with them

x. Treatment by CPS agencies

1. have shown only weak evidence of effectiveness, mainly because the programs are not necessarily evidence based

2. provide assistance in obtaining services for basic necessities

3. helps parents who need help in completing government forms that will allow them to obtain food stamps and other welfare assistance

x. Family preservation

1. short-term intensive and supportive interventions

2. focus on training parents in child development and parenting skills, as well as in stress reduction techniques and anger management - prevents out-of-home placement

xi. Out-of-home care

1. foster care placement, court placements with relatives, and placement in residential treatment centers and institutions

2. reaffirms the principle of family reunification but also holds paramount the concern for children’s safety

3. risk factors for foster care re-entry include

a. prior foster care placement

b. being younger than 4 years of age

c. prior placement with non-relatives

d. being neglected or maltreated physically rather than sexually

4. risk for re-entry into out-of-home care following physical abuse almost doubled and following neglect was tripled

xii. Fathers Supporting Success

1. focus on guiding fathers in methods that “help their children”

2. video presentation depicting parent-child interactions followed by a group discussion

3. fathers evaluate the interactions in the videos and eventually bring up their own issues, allowing experts to explain effective and nonviolent ways to parent

b. Policy Issues Regarding Physical Child Abuse

i. Policy Problems

1. how to define abuse in as objective a manner as possible

2. how to balance children’s rights with parental rights

3. how to apply the legal system to such a complex set of human behaviors

4. only since 2003 has CAPTA (Child Abuse and Prevention Act) provided a uniform definition of child abuse and neglect

5. each of the 50 states, and the District of Columbia, has its own legal definition of CPA (child physical abuse) and corresponding reporting responsibilities

6. there is a clash between mandatory reporting vs. confidentiality vs. best interest of the client

ii. Prosecuting Problems

1. child maltreatment offenders are still not uniformly prosecuted for their crimes

2. prosecution and conviction rates for child abuse are still very low

3. proportion of child maltreatment cases that proceed to trial is approximately 10%, which is similar to the proportion for criminal cases in general

iii. Human Rights violations

1. Human Rights protections for children clearly state that hitting children is not acceptable

2. United Nations proclaims that no violence against children is justifiable

3. 24 nations have banished corporal punishment of children

iv. Medical policies – Medical personnel need to respond to physical child abuse determinations by:

1. conducting a medical exam

2. interpreting various laboratory tests

3. taking the child’s age and developmental status into account

4. examining the child’s medical history

v. Research Issues

1. addressing parents’ social needs and providing case management are both important elements of treatment

2. understanding high therapy drop-out rates undermine findings

3. understanding male caregivers’ very low participation in child care

4. making sure studies include control groups

5. pretreatment evaluation measurement lack validity because parents minimize their parenting problems

6. most programs are psychoeducational and do not directly address parents’ psychological needs

7. safety screening should occur before all family members receive treatment

8. treatment failures do not readily appear in the literature

c. Prevention of Child Physical Abuse

i. strategies for preventing CPA must be aimed at all levels of society

1. early recognition

2. specialized programs for groups

ii. Medical setting

1. medical professionals detect and manage infant abuse

2. researchers are crafting a screening tool to identify parental risk of harsh punishment of infants and older children for use by medical workers

iii. Anticipatory guidance

1. concise discussion with parents before any children’s major health care problems occur including information about refraining from hitting, shaking, spanking, securing firearms and preventing exposure to violent media

iv. Public awareness

1. educating the public about the problem through mass-media campaigns on radio and television, in newspapers, magazines, and brochures, and on posters and billboards. The rationale behind this approach is that increasing knowledge and awareness about the problem of CPA will result in lower levels of abuse

2. dramatic increase in the number of calls received by a national child abuse hotline in the period after the campaign

v. Grandparenting

1. assistance by grandparents may play a role in preventing abuse

2. generally the presence of grandparents is associated with fewer incidents of child abuse and fewer incidents of severe child abuse

3. grandparents may suffer from stress and depression associated with providing care

4. caring for grandchildren poses an economic burden on grandparents or calls into question their legal rights

5. Latina grandmothers had the highest scores on life satisfaction

6. African American grandmothers who had custodial care of their grandchildren were more satisfied than grandmothers who had co-parenting responsibilities with the parent

7. White grandmothers had the highest negative mood about their roles; they frequently stepped in to care for grandchildren when the parents were incapacitated by drugs