When a little boy reportedly fell off the deck of a house in Lincoln County in July 2009 and hit his head, his mother and her boyfriend were drunk, according to a report by a state child-protection worker.
There was no food in the filthy house, but there were pill bottles, beer cans and needles lying around, and blood on the child's bed.
The mother, who allegedly had tested positive for painkillers and cocaine in late 2004 and March 2005, went missing for three days while the boy lay gravely injured with a fractured skull.
When caseworkers found her, she was drunk and apparently lied about where she was when her son was hurt, the report said.
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The boy died July 31, 2009. An autopsy showed he had bruises and bite marks that happened before his fatal injury.
"It was apparent that the child had been abused over a long period of time," the report concluded.
The case points to a troubling reality: When children are abused or neglected in Kentucky, substance abuse often plays a role.
A Lexington Herald-Leader review of files released this week on children killed or nearly killed because of abuse or neglect over a two-year period found that more than half mentioned suspected or confirmed substance abuse by parents or caregivers.
The newspaper analyzed internal reviews that the Cabinet for Health and Family Services is required by law to complete.
There were 85 such cases in 2009 and 2010. The cabinet released the files Monday under order from Franklin Circuit Judge Phillip Shepherd after the Herald-Leader and The (Louisville) Courier-Journal sued to get access to them. However, the state redacted the names of many children and their caregivers before releasing the documents.
About 59 percent of the cabinet's internal reviews mention substance abuse by parents or caregivers.
The substance abuse allegedly happened before the incident under review in some cases, but in at least 19 of the 85 deaths and near-deaths, drug or alcohol use was mentioned in connection with the incident.
The number was even higher in the 35 death cases. Of those, 29 included information about drug or alcohol use by parents or caregivers.
Examples of the link between abuse of drugs and alcohol and abuse or neglect of children in 2009 and 2010 included a mother who admitted taking an anti-anxiety drug before she rolled over on her little girl while asleep, asphyxiating her.
In another case, a man with financial problems drank all day before shooting a 3-year-old boy to death in February 2009 and then killing himself, according to the case review.
The state's review of a February 2010 beating death of a 23-month-old Powell County girl noted that after the mother's boyfriend moved in, their drug abuse "skyrocketed."
An autopsy showed the girl had a broken clavicle, a broken rib, a detached aorta, a laceration of the liver, hemorrhaging in her eye and multiple bruises. The mother, whom authorities said beat the child, tested positive for drugs, the report said.
The reports also note several cases in which adults gave children drugs or alcohol, or failed to prevent children from getting access to those substances.
In one case in May 2010, a boy nearly died after he apparently ate some of his mother's methadone, one case file said. The mother's explanation — that the 3-year-old apparently got her purse from atop the clothes dryer and opened the child-proof bottle of pills — "is unfeasible," a state caseworker concluded.
In another May 2010 case, a Northern Kentucky man acknowledged encouraging his 2-year-old stepdaughter to take sips of iced tea spiked with gin. When she was taken to the hospital, unresponsive, she had a blood-alcohol level of 0.259, the report said. That is more than three times the legal driving limit in Kentucky.
The link between substance abuse and child abuse or neglect is an issue nationwide, experts told the newspaper.
People who work in the child-welfare field have said that 75 percent or more of abuse and neglect cases across the country involve substance abuse, said Linda Carpenter, who is program director at the National Center on Substance Abuse and Child Welfare and works with practitioners nationwide.
"It plays a significant role," Carpenter said.
Research has shown the most significant factors in chronic neglect of children are mental-health issues, substance abuse and poverty on the part of caregivers, she said.
Substance abuse is a particular problem because studies have shown that maltreated children of parents who abuse drugs and alcohol are more likely to have physical, emotional and intellectual problems, according to studies cited by the National Clearinghouse on Child Abuse and Neglect Information.
Substance abuse leads to more instances of child neglect than physical or sexual abuse, according to studies and experts. The reason is simple. Adults who are impaired, or preoccupied with chasing their next high, are less likely to attend to the needs of their children, and they spend often-limited resources on drugs or alcohol.
That is a particular problem among people using methamphetamine, said Dan Smoot, deputy director of Operation UNITE, which investigates drug trafficking and provides treatment and education in southern and Eastern Kentucky.
"Every house you go in, the toilets are clogged, there's no food, the house is tossed upside down," Smoot said. "The only thing the parents care about is fueling that addiction. The kids, as always, are the biggest losers."
Robert Walker, an associate professor at the University of Kentucky and researcher at UK's Center on Drug and Alcohol Research, said there is a link between poverty and substance abuse.
Many parents using drugs don't have a good understanding to begin with about what is harmful to a child in terms of nutrition and other issues, Walker said.
"A lot of these parents come themselves from pretty limited backgrounds," he said.
One federal agency estimated that in 2007-08, Kentucky tied for the second-highest percentage of people 12 and older who had taken part in non-medical use of pain relievers.
The 2009 Kentucky Treatment Outcomes Study found that misuse of one type of painkiller, called opiates, had gone up 60 percent over five years, according to Operation UNITE.
Congress became so concerned a few years ago about the link between substance abuse and child welfare that it approved funding for states to address the issue, said Carpenter.
Kentucky got two of the grants, one for a program in Frankfort and the other for a program in the Hazard area aimed at helping people with their substance-abuse and child-welfare problems, Carpenter said. However, the money available to deal with families facing those dual issues falls far short of the need, she said.
"There's very little money that's been allocated to deal with these families," Carpenter said. "Kentucky doesn't begin to have the substance-abuse treatment services that are needed to support these families."
Kentucky cabinet officials told legislators in December that providing treatment and services for drug-addicted parents was its most pressing funding need, but three years of declining state revenue have meant no new money to expand substance abuse programs.
Legislators are set to tackle the state's two-year budget in January. Although state tax revenue has improved during the past year, there still is little or no money for new programs, legislative leaders have warned.
Rep. Jimmie Lee, D-Elizabethtown, who serves on a key health budget subcommittee, said Tuesday he would like to see the state examine its substance-abuse programs and determine what works. Lee said his legislative staff had found that the state receives a combined $145 million in federal and state money to address substance abuse, but the programs are operated by a variety of agencies.
"Right now we have no idea how effective our substance-abuse treatment programs are" he said. "We need to know how we're spending the money we already have."