Blending Perspectives and Building Common Ground

A Report to Congress on Substance Abuse and Child Protection
April 1999

Chapter 6

The Context of Collaboration
and Overcoming Barriers to Quality Service

It becomes obvious to observers of interactions between service providers in the child welfare and substance abuse treatment fields that in most instances, agencies do not work well together and that truly collaborative relationships are rare.  This chapter will explore why this is so often the case.  Substance abuse treatment agencies and child welfare agencies both have the vision of healthy, functional families resulting from their interventions.  In moving from the family's immediate situation to that end result, however, very different perspectives and philosophies may impede cooperation, causing agencies to mistrust each other, hamper one another's efforts, and stymie progress. 

Several key differences in perspective underlie the majority of misunderstandings and frustrations child welfare agencies and substance abuse treatment agencies feel toward one another (Feig, 1998; Young et al, 1998).  These include:  different definitions of "the client," what outcomes are expected on what time lines, and how best to respond to setbacks.  In addition, interagency collaborations do not happen in a vacuum.  Factors related to the legal and policy environments in which agencies operate set a context for joint activities and affect the willingness and ability of agencies to work together.  For the substance abuse and child protection fields, these factors include the following: 

• State and Federal laws and policies regarding child abuse reporting, foster care, permanency planning, and termination of parental rights, including new time lines for decision making set forth in the Adoption and Safe Families Act.
• The sense of crisis under which many child welfare agencies operate.
• Chronic shortages of substance abuse treatment services, particularly services appropriate for women with young children.
• Confidentiality requirements of both fields that are often perceived as impediments to cooperation.

Client Identification

For many substance abuse treatment programs, the adult is the primary client and the one around whom services revolve.  The adult's relationship with the drug is the focus of the clinical intervention, and everything else in the client's life is of secondary importance.  While family relationships and other life issues are assessed, they are not the principal focus and may be de-emphasized until at least several months into the treatment process, if the client remains with the program that long.  While parents may discuss their children in group therapy sessions, most treatment programs do not consider children and other family members to be clients, do not include them in therapeutic activities, and may not know whether the client even has children or whether child protective services is involved with the family, unless the client raises the issue or the child welfare agency was the client's referral source.

For many parenting women who enter substance abuse treatment, however, concerns about their parenting and the effects of their substance abuse on their children are key reasons why they enter treatment in the first place (HHS/SAMHSA, 1996b; Gerstein et al, 1997).  Unless these issues are addressed, the women may not be getting what they seek from treatment.  This may contribute to high drop out rates for women in treatment programs that are not specifically designed to assess and treat these and related critical issues.  Lack of attention to family issues also frustrates child welfare workers who may have referred the parent for substance abuse treatment in the first place, but do not see improved parenting and child safety as a consequence of the substance abuse agency's treatment plan.

For child welfare agencies, the child is the focus of activity, and the entire family is usually defined as the client.  A variety of services may be offered to the family, with the intent of assuring the child's safety, within the family if possible.  But when a choice must be made in balancing children's needs and parents' needs, the mandates of child welfare agencies demand that the children must come first.

With both agencies viewing themselves as the primary service provider, differences may arise around who the client is, what service goals are selected, who is responsible for assuring that outcomes are achieved, what information gets shared and with whom, and myriad other day-to-day issues around working with clients.

Defining Outcomes and Success

Substance abuse and child welfare agencies have different views of what represents a successful outcome and what they seek to achieve.  Most substance abuse treatment outcome studies focus on the extent to which treatment results in decreased alcohol and drug use, decreased criminal behavior, and decreased need for and utilization of health care services.  Very few measure child- and family-related outcomes unless they are programs specifically designed for women and their children, of which there are few.  By these definitions, treatment may be successful even when child safety issues remain and may be unsuccessful even if child welfare goals have been met.  Similarly, for a child welfare agency, the child's safety, well-being and ensuring he or she has a permanent family situation in which to grow up are the primary goals.  These may be met either within the family of origin or by identifying a substitute.  But success may be achieved at a cost of separating a child permanently from his or her biological parents.  Further complicating the situation, custody decisions are made by family court judges who may hold yet another set of expectations for clients and may seek additional evidence of success.

As staff begin to work together more closely, child welfare and substance abuse agencies should talk through these issues, both institutionally and also on a case-by-case basis, seeking common ground regarding their definition of the client, mutual expectations for the client and for each other as the case develops.  Establishing joint case goals for clients may also prove helpful, particularly identifying interim goals that will allow both agencies to determine, together, the extent to which progress is being made.  Such discussion on joint goals may lead to broader interagency agreements on working together.  Involving judges in setting expectations may also help assure key players are all in agreement.

Balancing Competing Time Lines

Families involved with the child welfare and substance abuse treatment systems, and who are often involved with other service providers as well, face a variety of time constraints that may be at odds with one another and that may frustrate interagency cooperation.  These time lines have been referred to as "the four clocks" (Young et al, 1998) and include: 

Child welfare mandates for decisions regarding permanent placements for children who are in foster care.  Federal child welfare law now requires that permanency hearings to determine the long term plan for a child be held within 12 months of a child's entry into foster care, and that a petition to terminate parental rights be filed after a child has resided in foster care for 15 of 22 months, unless there is compelling reason not to do so, or other specific circumstances exist, such as that the child is in the care of a relative or the family has not received planned services.

The pace of recovery from addiction.  Addiction is a complex illness and multiple treatment attempts over a period of time may be required before significant improvement is seen.  Relapse is common, particularly in the early stages of recovery.  The long term needed for recovery for many women with multiple problems may conflict with shorter time lines associated with child welfare decision making.

Time limits associated with welfare receipt.  Some parents in substance abuse treatment are welfare recipients and subject to Federal and State work requirements and time limits on cash assistance.  The majority of female parents in publicly funded substance abuse treatment programs, for example, are welfare recipients (64 percent according to one study of California treatment clients) (Gerstein et al, 1997).  As these clients reach their time limits and can no longer depend on welfare income, or are required to participate in extensive work activities, treatment programs will need increasingly to accommodate clients' other activities.

Children's developmental time line.  Children grow up quickly and need consistent parental attention.  While several months or years is a short period to parents and service providers, to a child that time is essential developmentally.  A child cannot be put on hold during a parent's addiction and recovery without serious developmental consequences.  Children's developmental time frames are the rationale for speedy child welfare mandates discussed above.

The differences in perspective between a substance abuse treatment program's attention to the relatively long time frames of addiction and recovery and the child welfare agency's shorter time line to be attentive to children's developmental need for permanency and statutory time lines for service delivery, further sets the stage for difficult interagency relationships.

Child Protection Laws and Policies

State laws regarding child abuse reporting, foster care and termination of parental rights set a tone for the consideration of substance abuse as a factor in child protection decisions.  Mandatory child abuse reporting laws identify who must report suspected child abuse or neglect and under what circumstances.  Most State child abuse and neglect reporting laws do not explicitly mention substance abuse, but rather speak to physical abuse, sexual abuse, and neglect.  Generally these laws focus on parental behaviors toward children rather than potential conditions that may precipitate those behaviors.

Each of the seven state laws that did mention substance abuse as of the end of 1996, (California, Illinois, Iowa, Minnesota, Missouri, Oklahoma, and Utah) pertain only to infants prenatally exposed to drugs.  None of these reporting laws mention substance abuse beyond pregnancy (HHS/NCCAN, 1997b; HHS/NCCAN, 1998c) and most refer only to illicit drugs, not alcohol.  Most of these State child abuse reporting laws require that health professionals make mandatory child abuse reports regarding all infants who are known to be drug exposed at birth.  Minnesota's law includes considerable detail regarding the conduct of drug tests.  The Illinois law requires a report to the public health agency rather than the child protection agency.  California's law specifies that a positive toxicology is not in and of itself sufficient grounds for a child protection report, but requires that an assessment of the parent be conducted, and requires a child protection report if the assessment determines there is danger for the child.

These laws seek to bring particular children at risk of abuse and neglect to the attention of child protection agencies.  They also serve to emphasize prenatal exposure to illicit drugs rather than the longer-term risks (arguably more significant to a child's development) of living with a potentially neglectful or abusive substance abusing caretaker.  This factor can impede a substance abusing pregnant or post partum woman from seeking health care or substance abuse treatment for fear that admitting a problem will lead to the loss of her child(ren).

In addition to child abuse reporting laws, substance abuse is sometimes mentioned in the statutory criteria for termination of parental rights, particularly laws regarding when expedited adoptions are appropriate.  Several States have expedited adoption laws that mention substance abuse, but observers have noted that existing laws include significant flaws (Hardin and Lancour, 1996) which may include:  the degree of substance abuse that might lead to termination of parental rights is not specified; unsuccessful treatment attempts need not be demonstrated; and harm to the child need not be shown.  Some States' termination of parental rights statutes contain language describing when a parent's continued substance abuse may be considered grounds for terminating parental rights and how many treatment attempts constitute reasonable efforts to facilitate reunification (USGAO, 1998; HHS/NCCAN, 1997a).

As noted above, the Adoption and Safe Families Act (ASFA), passed in November of 1997, requires that decisions regarding permanency for children who enter foster care are to be made within 12 months of a child's entry into care.  This requirement creates a context of urgency around the provision of services to families with children in foster care that put special strains on the usual and customary course of substance abuse treatment plans.  Communities have very limited time frames within which to offer reunification services (including substance abuse treatment, as needed) before alternative plans must be made for the child.  And parents have the same limited time frames within which to demonstrate their readiness to provide a safe home environment for their children.  These factors also make it critically important that child welfare workers be able to judge accurately whether a parent is making sufficient progress in his or her rehabilitation program to reasonably expect the child could be returned to the parent within 12 months or shortly thereafter.

The Impact of Perpetual Crisis in the Child Welfare Field

Child welfare staff make complex decisions daily regarding child safety that fundamentally affect the lives of children and families.  These decisions are made in an environment of "zero tolerance" for error, in which a worker's error may become tomorrow's headline accusing an agency of overlooking "obvious" peril for a child.  The constant possibility of harm to a child following a decision that the child is not at immediate risk, or following reunification with a parent who has improved, makes workers cautious about withdrawing from the lives of families.  Child welfare professionals know that if a child is harmed following reunification with a parent who relapses, it is the child welfare agency, not the substance abuse treatment agency, that will be blamed by the media and politicians.  In this environment of high visibility in the case of error, workers are often also faced with large caseloads that make it extremely difficult to adequately attend to families' complex situations.  This combination of factors may produce a crisis orientation in which only the most pressing situations are addressed and other families' needs are given only cursory attention.

An environment of perpetual crisis also manifests its impact in high burnout and turnover rates among child welfare staff, making it difficult to assure continuity and therefore quality casework.  Workers become frustrated because services for families are in critically short supply and many are not within the caseworker's authority to provide.  The result is that too often families receive whatever services are available rather than those that may be most appropriate for their needs.  These frustrations are particularly evident when a client's key problem is substance abuse and the child welfare agency does not itself have the authority to access or pay for substance abuse treatment services.  In addition, the courts become frustrated by the apparent disconnect between clients' needs and delivered services - and it is the child welfare staff who tend to bear the brunt of this frustration.  Families, however, face the loss of their children when termination of parental rights actions are initiated in the absence of appropriate, accessible services.

Chronic Shortages of Substance Abuse Treatment

Another contextual issue that must be considered in any discussion of addressing problems related to substance abuse is that substance abuse treatment, particularly treatment tailored to the needs of women and parents, is in chronically short supply.  As illustrated in Figure 6-1, approximately 37 percent of problem drug users who are mothers with children under 18 years of age reported receiving some form of substance abuse treatment in 1994-95, significantly fewer than the 48 percent of male parents with substance abuse problems in treatment (HHS/SAMHSA, 1997d). 

Table 6-A shows trends in the demographics of substance abuse treatment clients 1980-1992.  Women make up less than a third of substance abuse treatment clients, up only slightly between 1980 and 1992.  The population of persons in treatment closely resembles the age and racial/ethnic distribution of the population of parents in need of treatment (presented in chapter 4, Table 4-B), but differs significantly from the population of parents with substance abuse problems who are clients of child welfare agencies in gender (child welfare clients are predominantly women), and race (minority and especially African American women are over represented in the child welfare system).

Source:  HHS/SAMHSA, Overview of the National Drug and Alcoholism Treatment Unit Survey (NDATUS):  1992 and 1980-1992 (Advance Report Number 9), January 1995.

Table 6-B shows the prevalence of substance abuse treatment by type of treatment and demographic group.  As shown, an estimated 3.3 million Americans, 1.5 percent of the population age 12 and older, reported receiving some form of drug and/or alcohol treatment in 1995.  The number reporting any form of substance abuse treatment was only slightly higher than the number reporting treatment for alcohol abuse (3.3 million versus 3.0 million), which suggests that the great majority of substance abuse treatment clients (upwards of 90 percent) sought treatment partly or wholly for problems with alcohol.

Additional information on substance abuse treatment supply and demand are available from State and local sources.  The National Association of State Alcohol and Drug Abuse Directors (NASADAD) reports that in on a given day in 1997 there were nearly 52,000 persons on substance abuse treatment waiting lists maintained by State agencies (NASADAD, 1997).  Further, only 10 percent of child welfare agencies report that they can find substance abuse treatment programs for most of the clients who need it within 30 days (Child Welfare League of America, 1998).  Although not everyone who receives treatment will recover, and not all those who need it will enter a treatment program even if one is available, without treatment few of those who are as severely impaired by substance abuse as are many child welfare clients will be able to address their addictions successfully and become better functioning parents.

¹ 5 or more drinks on the same occasion 1 or more days in the past 30 days.

Source:  Adapted from HHS/SAMHSA, National Household Survey on Drug Abuse, Main Findings, 1996 (1998) p. 160.

While women's specific treatment needs are slowly being recognized, recent drug treatment data demonstrate that over the past decade there have been significant declines in the delivery of a variety of services provided in conjunction with substance abuse treatment.  For instance, only 8.3 percent of patients in outpatient, drug free treatment programs (through which most persons are treated for substance abuse) had received any family services (such as parenting classes or family therapy) during the first three months of treatment according to a 1990 survey.  A similar study a decade earlier had found much more comprehensive service delivery.  In the earlier study, nearly 43 percent of outpatient clients reported receiving family services.  Clients of long term residential programs and short term inpatient programs were somewhat more likely to receive family services, but even in the most service intensive modalities fewer than 40 percent of clients received these services (Figure 6-2). 

Similar declines were reported in the provision of medical, psychological, legal, educational, vocational and financial services.  Declines were marked in all modalities but were especially severe in outpatient programs, where fewer than 10 percent received any ancillary services other than medical treatment, and over 60 percent received no services beyond basic substance abuse counseling (Etheridge et al, 1995).  Pressures from managed care may be responsible for some of the decline in comprehensive services.  The shortages of substance abuse treatment, particularly treatment with services designed specifically for women with children, mean that treatment programs do not feel the need to develop new referral sources such as child welfare agencies - their programs are full without seeking new clients.  Despite increased Federal substance abuse treatment funding over the last decade, funds to develop additional treatment capacity have not caught up with the need.

Confidentiality Issues

Confidentiality has long been central to both the substance abuse treatment and child welfare fields.  Both fields recognize a need to guard clients' rights to privacy and shield clients from outside scrutiny while they address the problems which led them to service providers' attention.  Confidentiality is especially important in both these fields because stigma may cause clients to avoid needed services if, as a consequence of receiving assistance, their problems become known to others in the community.  In the substance abuse field, confidentiality is governed by Federal law (42 U.S.C. § 290dd-2) and regulations (42 C.F.R., Part 2) that dictate under what limited circumstances information about the client's treatment may be disclosed with and without the client's consent.

In child welfare, confidentiality is governed by State laws and regulations that conform to the Federal child abuse and neglect and child welfare statutory and regulatory standards.  Title IV-E of the Social Security Act requires that States provide safeguards to restrict the use and/or disclosure of information regarding children receiving title IV-E foster care and adoption assistance (section 471(a)(8)).  Further, in accordance with 45 C.F.R. 1355.30(p)(3), records maintained under titles IV-B and IV-E are subject to the confidentiality provisions in 45 C.F.R. 205.50.  Those provisions restrict the release or use of information to certain persons or agencies that require the information for specified purposes.  The Child Abuse Prevention and Treatment Act (CAPTA) further requires that States preserve the confidentiality of all child abuse and neglect reports and records; however, it allows information to be shared in certain circumstances, for purposes related to child abuse and neglect intervention (section 106(b)(2)(A)(v)).  The only exception to those restrictions is the CAPTA provision which requires that States allow for public disclosure in cases of child abuse or neglect that result in the death or near death of a child (section 106(b)(2)(A)(vi)).  Authorized recipients of information under titles IV-B, IV-E and CAPTA are in turn subject to the same confidentiality standards as the child welfare or child protective services agency that released it.

While there are excellent reasons to guard clients' confidentiality, there are also important reasons for sharing information among programs that are working together to serve clients.  These include the need to assure full assessment and understanding of client needs, progress and case goals among varied service providers; the need to assure that agencies do not work at cross purposes, accidentally making conflicting demands of clients or undermining each other's efforts; and the desire to make an efficient use of resources, avoiding a duplication of efforts.

When child welfare and substance abuse treatment agencies begin to work together, confidentiality issues arise quickly.  One or the other agency will often claim that the information needed by the other "can't" be shared.  Most often, it is the Federal substance abuse confidentiality rules which are said to prevent collaboration.  Experts on both sides point out, however, that existing Federal confidentiality guidelines incorporate mechanisms for appropriate information sharing to take place - but agencies at the local level tend not to incorporate them into their daily activities.  For instance, Qualified Service Organization Agreements (QSOAs) may be established between a substance abuse agency and other organizations that provide services to the program and its clients (HHS/SAMHSA, 1997c).  The regulations specifically mention agencies that provide "services to prevent or treat child abuse and neglect" as being among those with whom QSOAs may be established in order to facilitate services to the client.  Under a QSOA, information about clients may be disclosed between the two agencies without the individual consent of each client (although both agencies remain bound by rules about re-disclosing information outside the agreement).  In addition, if child welfare agencies routinely requested written parental consent for the release of substance abuse treatment records early in the life of a case, many parents might readily consent.  Since the child welfare agency remains bound by prohibitions against redisclosure (again, unless consent is provided), they should be able to receive critical information from the treatment provider about the parent's participation and progress.  However, few child welfare and substance abuse agencies have entered into QSOAs.  Nor does it seem that many child welfare agencies have procedures in place to routinely request consent from clients early in the case.

Agencies that want to cooperate have been able to establish working relationships within the rules to provide child welfare agencies with updates regarding clients' progress in treatment and to ensure that treatment agencies are partners in efforts to achieve child safety.  During our consultation process we heard reports of excellent working relationships from a number of treatment agencies and child welfare agencies, which use each other's expertise to work as a team on behalf of the family.  These relationships take time to build and maintain, however, while staff learn about each other, gain an understanding of each other's role, constraints, and bottom line imperatives, gain confidence and trust in one another, and put in place policies and procedures governing the sharing of information and preventing redisclosure of confidential information.

Dealing with Setbacks

As has been noted previously, most substance abuse treatment clients will suffer relapses, no matter how great their resolve to stop using alcohol and other drugs.  Unfortunately, however, there are not reliable ways of predicting which clients will be successful.  Relapse does not necessarily indicate treatment failure.  It may instead be an indication that the treatment plan has not adequately addressed important issues, and in addition may present a therapeutic opportunity to teach the client that controlled use of substances is not possible.  Given that most clients will relapse, the questions for service providers become (a) how to prevent relapses to the maximum extent; and (b) how to respond to relapses in order to minimize their duration and consequences for the individual, his or her family, and the community.

While the substance abuse treatment community views relapse as a part of the recovery process, relapse makes it extremely difficult for child welfare professionals to determine whether the client is making appropriate progress in treatment.  Even if progress is recognized, it remains hard to determine accurately whether that progress is sufficient to assure children's safety.  To a child welfare professional, relapse indicates that the client's behavior is likely to be unpredictable and that neglect of children's needs is a significant possibility.

Responses to setbacks may cause tension between service agencies.  A brief relapse may be taken by child welfare officials as evidence of treatment failure, even if the parent makes efforts to assure adequate supervision of children during relapse, for instance by taking children to a relative.  On the other hand, a substance abuse professional is likely to view a brief relapse during which child safety precautions are taken as a significant step forward for a severely addicted client who has not before achieved significant sobriety.  Further, if the relapse is more than brief, child welfare staff are likely to conclude alternative permanency options for the child should be pursued.  Yet foreclosing the possibility of regaining custody may further undermine the client's motivation for treatment.

It is important that steps be taken to keep clients engaged in the treatment process following a relapse.  Child welfare time lines, as discussed above, do not allow for a "hands off" attitude in which treatment providers wait for clients to become "treatment ready."  If clients cannot be made treatment ready quickly, child welfare agencies and courts must expeditiously make alternative permanency decisions for children.  Child welfare and substance abuse treatment staff must become better at utilizing parental concern for children to engage and re-engage families in treatment.

While tensions on these issues are inevitable, there are a number of steps which might be taken by child welfare and substance abuse agencies to build common ground regarding appropriate relapse planning and response.  These include articulating more clearly the demonstrable signs of treatment progress that child welfare agencies and courts can use to inform child welfare decisions; assuring that substance abuse treatment programs and child welfare agencies discuss with clients safety planning for children in the event of relapse; and establishing policies regarding under what circumstances the substance abuse treatment agency should notify the child welfare caseworker of a relapse (assuming a QSOA is in place, the client has provided consent for information exchange, or the situation warrants a formal child protective services report).  Similarly, substance abuse treatment agencies are likely to be more willing to discuss clients' relapses if there is a consistent pattern of child welfare system response they can anticipate.

Striving Toward Improved Service Delivery — Together

There are real and significant barriers to productive collaborations between child welfare and substance abuse agencies.  The differences in perspectives and traditional methods of functioning are real.  But for agencies that truly want to work together to improve services to clients, these differences can and must be accommodated.  Doing so will require sustained efforts by staff in agencies in communities throughout the nation — efforts to learn about one another, to understand one another, and to establish a shared set of expectations for each other and for clients.

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