The language authorizing this Report to Congress specifically required that we describe the extent and scope of the problem of substance abuse among families involved with the child welfare system. In this chapter we review data available from a variety of sources. The data available represent different and often conflicting numbers and patterns. These differences are largely the result of the differing methodologies by which they were obtained, differences in the populations studied, and differences in how the researchers defined both what represented a substance abuse "problem" and what threshold of conduct represented child maltreatment. In addition, the figures presented below examine the problem from a variety of standpoints: the prevalence of substance abuse among the child welfare population; the prevalence of child maltreatment and other parenting problems among substance abusing parents; and the prevalence of children residing in families with substance abuse problems, regardless of whether specific maltreatment issues have been identified.
Our basic conclusions are as follows:
The child welfare system serves children who come to its attention as the result of abuse and neglect reports. These children, however, are a small fraction of those who live in households in which a parent has a serious alcohol or drug problem. Data from the 1996 National Household Survey on Drug Abuse (NHSDA) reveal that an estimated 8.3 million children in the United States, 11 percent of all children in the U.S., live in households in which at least one parent is either alcoholic or in need of substance abuse treatment.
As shown in Figure 4-1, 2.1 million of these children live in families in which the predominant problem is illicit drugs; 3.8 million live in families in which the primary problem is alcohol, and 2.4 million of these children live with parents who abuse both alcohol and illicit drugs in combination. The children living in substance abusing households are evenly spread across the age spectrum, from infants to teenagers, as shown in Figure 4-2.
The substance abuser is the mother in about half these families, and the father in the other half. These figures include only those children residing with their parent(s) at the time of the survey and do not include children who had been removed to foster care (Huang et al, 1998). Figure 4.3 and Table 4-A illustrate the number of children living in families with varying levels of substance abuse problems.
| TABLE 4-A. Children1 Living With Parents Who Use Alcohol or Other Drugs, 1996 | ||
|---|---|---|
| Definition of Substance Abuse | Number of Children Less than or Equal to 17 Years Old
Living With One or More Parents With This Level of Use (in millions) |
Percentage of Children Less than or Equal to 17 Years
Old in the U.S. Population Living With One or More Parents With This Level
of Use (in percent) |
| Parent is in need of treatment for illicit drug abuse | 4.5 | 6.0 |
| Parent is dependent on illicit drugs | 2.8 | 3.8 |
| Parent is dependent on alcohol | 6.2 | 8.3 |
| Parent is dependent on alcohol and/or illicit drugs | 7.5 | 10.0 |
| Parent is dependent on alcohol and/or in need of treatment for illicit drugs | 8.3 | 11.1 |
| Parent used an illicit drug in the past month | 8.4 | 11.2 |
| Parent used an illicit drug in the past year | 10.6 | 14.3 |
1 Includes biological, step, adoptive or foster children.
2 For definitions of dependence and "in need of treatment" used in this analysis, see Huang et al, 1998.
Source: Huang et al, 1998, based on the 1996 National Household Survey on Drug Abuse.
Additional data on the characteristics of alcohol and drug using parents from the 1994 and 1995 National Household Surveys on Drug Abuse reveal that there were an estimated 649,000 women and 645,000 men with problem levels of illicit drug use who were living with children younger than 18 years of age. Problem drug users living with children represent 30 percent of all women with this level of drug problem and 18 percent of such men (SAMHSA, 1997d). As shown in Table 4-B, parents with problem levels of drug use look remarkably like parents without such problems demographically, particularly with regard to race.
| TABLE 4-B. Percentage Distribution of Demographic
Characteristics Among Population Aged 18 or Older Who Lived with Children Under Age 18 by Gender and Problem Drug Use1: 1994-1995 |
||||
|---|---|---|---|---|
| Parents with Problem Drug Use | Parents without Problem Drug Use | |||
| Men | Women | Men | Women | |
| Age Group (Years) | ||||
| 18 - 25 | 12.2* | 18.7 | 5.5 | 11.8 |
| 26 - 34 | 43.0 | 41.9 | 28.2 | 32.8 |
| 35 and older | 44.8* | 39.9* | 66.3 | 55.3 |
| Total | 100.0 | 100.0 | 100.0 | 100.0 |
| Race/Ethnicity | ||||
| White | 64.9 | 71.7 | 73.0 | 68.2 |
| Black | 14.9* | 20.0 | 9.9 | 14.4 |
| Hispanic | 10.5* | 7.4* | 12.6 | 12.6 |
| Total | 90.3 | 99.1 | 95.5 | 95.22 |
| Education | ||||
| Less than high school | 33.0 | 28.3 | 17.0 | 17.1 |
| High school graduate | 44.3 | 40.2 | 31.0 | 34.5 |
| Some college | 12.9 | 21.3 | 21.3 | 25.1 |
| College graduate | 9.7 | 10.1 | 30.6 | 23.2 |
| Total | 100.0 | 100.0 | 100.0 | 100.0 |
| Current Employment Status | ||||
| Full-time | 74.9 | 31.3 | 81.5 | 45.7 |
| Part-time | 3.6 | 12.1 | 4.6 | 17.6 |
| Unemployed | 14.9 | 12.9 | 4.2 | 5.0 |
| Other | 6.5 | 43.6 | 9.6 | 31.7 |
| Total | 100.0 | 100.0 | 100.0 | 100.0 |
| Marital Status | ||||
| Married | 78.2 | 47.4 | 91.3 | 75.2 |
| Divorced or Separated | 11.3 | 31.4 | 4.9 | 12.5 |
| Never married | 10.1 | 21.1 | 3.0 | 9.7 |
| Total | 99.6 | 99.9 | 99.2 | 97.43 |
| Family Member Participated in Welfare Programs | ||||
| Yes | 19.8 | 40.9 | 5.9 | 12.3 |
| No | 80.2 | 59.1 | 94.1 | 87.7 |
| Total | 100.0 | 100.0 | 100.0 | 100.0 |
Footnotes:
1 Problem drug users are defined as respondents who needed treatment
for drug use in the past year. This includes respondents who were dependent
on any illicit drug using criteria similar to those of the DSM-IV; past-year
injection drug users; past-year frequent drug users (marijuana use daily
or almost daily, or weekly use of cocaine, hallucinogens, inhalants, analgesics,
sedatives, tranquilizers, or stimulants); those who had used any heroin in
the past year.
2 Total is not 100, because the category "other" for racial /ethnicity
is not included.
3 Total is not 100, because the category "widow" for marital status
is not included.
* Low precision for reported estimates.
Source: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. National Household Survey on Drug Abuse, 1994-B, 1995. This table originally appeared in HHS/SAMHSA, 1997d, Substance Use Among Women in the United States.
Nearly three-quarters (72 percent) of problem drug using mothers and 65 percent of problem drug using fathers are white, 20 percent of these mothers and 15 percent of these fathers are black, and 10 percent of these fathers and 7.4 percent of these mothers are Hispanic. Figure 4-4 shows the racial/ethnic distribution of mothers with problem levels of illicit drug use.
As a group, parents with substance abuse problems have somewhat less education, are somewhat less likely to be employed full time, and are much less likely to be married and much more likely to participate in welfare programs than are other parents. Seventy-five percent of fathers with substance abuse problems are employed full time, as are nearly one-third of such mothers.
Prenatal drug abuse has been a particular focus of media, policy and research attention. Some 221,000 infants (5.5 percent) are born each year prenatally exposed to illicit drugs. Most of these have been exposed to marijuana (2.9 percent or 119,000 children), while 1.1 percent (45,000) are exposed to cocaine and 1.5 percent (61,000) pregnant women used prescription medications during pregnancy without physician direction (U.S. Department of Health and Human Services, National Institute on Drug Abuse [HHS/NIDA], 1994). In addition, some 140,000 pregnant women (3.5 percent of all pregnant women) each year drink heavily, placing their children at risk for Fetal Alcohol Syndrome and Fetal Alcohol Effects (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention [HHS/CDC], 1997). Figure 4-5 shows the number of women who use illicit drugs or drink heavily during pregnancy.
Table 4-C shows the numbers of women using illicit drugs by pregnancy and child rearing status. Substance abuse rates are considerably lower among women who have children in the home than among women who are not raising minor children, and pregnant women report lower substance use rates than non-pregnant women. Particularly notable, and encouraging, are the very low reported rate of binge drinking and of heavy drinking among pregnant women.
| TABLE 4-C. Past-Month Substance Use by Women Age 15-44, by Pregnancy and Child-rearing status, 1996-1997 | ||||||||
|---|---|---|---|---|---|---|---|---|
| INDEX | WOMAN'S PREGNANCY AND CHILD-REARING STATUS (NUMBER IN THOUSANDS) |
|||||||
| Pregnant | Raising Child(ren) <2 Years Old | All Children Are 2+ Years Old | No Children | |||||
| N | % | N | % | N | % | N | % | |
| Population N (thousands) |
2,400 | 100 | 7,500 | 100 | 25,000 | 100 | 26,000 | 100 |
| Any illicit drug | 59 | 2.5 | 385 | 5.5 | 981 | 4.1 | 2,579 | 10.4 |
| Any, excluding marijuana | 28 | 1.2 | 147 | 2.1 | 417 | 1.7 | 1,150 | 4.6 |
| Cocaine | 4 | 0.2 | 33 | 0.5 | 151 | 0.6 | 353 | 1.4 |
| Heroin | 4 | 0.2 | 5 | 0.1 | 19 | 0.1 | 41 | 0.2 |
| Binge drinking1 | 30 | 1.3 | 622 | 9.2 | 2,395 | 10.3 | 4,009 | 16.7 |
| Heavy drinking2 | 6 | 0.3 | 133 | 2.0 | 532 | 2.3 | 1,100 | 4.6 |
Footnotes:
1 5 or more drinks on the same occasion 1 or more days in the
past 30 days.
2 5 or more drinks on the same occasion 5 or more days in the
past 30 days.
Source: Adapted from Preliminary Results from the 1997 National Household Survey on Drug Abuse (1998c), p. 94-95. Annual averages based on 1996 and 1997 samples.
With respect to drug use by pregnant women and by parents, African American women have higher rates of illicit drug use and particularly cocaine use than do white women (HHS/SAMHSA, 1997d). However, there are many more white women, including white pregnant women and white parents, who use illicit drugs than there are minority women in these categories who use illicit drugs (HHS/SAMHSA, 1998a). The number of African American women who use cocaine during pregnancy, (30,000 in 1992) far exceeds the number of white and Hispanic women who used that drug prenatally (HHS/NIDA, 1994). Studies have shown, however, that African American children prenatally exposed to illicit drugs are much more likely than white children to be both reported to child protective services (Chasnoff, 1989) and to be placed in foster care, even after taking into account factors such as the family's previous child welfare involvement, the physical health of the child, and other related factors (Neuspiel et al, 1993).
Rates of both alcohol and illicit drug abuse are even higher among Native Americans than among other ethnic groups in the U.S., although most national data on substance abuse have insufficient samples to separately analyze data for Native Americans (HHS/SAMHSA, 1998a).
Child welfare agencies tend to focus their attention on infants and very young children of substance abusers, particularly children who have been prenatally exposed to illicit drugs. But as Figure 4-2 illustrated, children of all ages reside in substance abusing families, and prenatally exposed infants represent a very small proportion of children in such households. These data also illustrate how closely intertwined and inseparable alcohol and illicit drug abuse are.
For decades child welfare staff have recognized that substance abuse is common in the families they serve (Fanshel, 1975). Studies have long shown that parents with substance abuse problems are more likely than other parents to maltreat their children (Famularo et al, 1986; Jaudes et al, 1995; Kelleher et al, 1994). The wide variety of figures cited in the literature, however, makes it difficult to sort out how the numbers fit together. Several issues drive the differences in the statistics:
Despite these issues, it is clear that substance abuse is a significant factor in the lives of families served by the child welfare system.
In 1996, child protective services (CPS) agencies received more than 2 million reports of alleged child abuse and neglect involving more than 3 million children. CPS staff conducted approximately 1.6 million investigations of these reports and found evidence to substantiate that more than 970,000 children had been victims of child abuse and neglect that year. While a great many child abuse reports are received and investigated annually, studies show that most children recognized by community professionals as having experienced injury-causing child abuse or neglect (72 percent) had not been reported to (or, if reported, had not been investigated by) the local CPS agency (U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect [HHS/NCCAN], 1996).
Most studies report that between one-third and two-thirds of substantiated child abuse and neglect reports involve substance abuse. Substance abuse is more likely to be a factor in reports regarding younger children, particularly infants, than older children. In addition, substance abuse is much more likely to be a factor in child neglect than in child abuse (Herskowitz et al, 1989; HHS/NCCAN 1993; Walker et al, 1991). In a recent survey of State child welfare administrators, the Child Welfare League of America (CWLA) found that at least 50 percent of substantiated child abuse and neglect reports involve parental abuse of alcohol or other drugs, and fully 80 percent of States reported that substance abuse and poverty are the top two issues contributing to abuse and neglect in their States (CWLA, 1998). The Indian Child Welfare Association estimates that 90 percent of Indian child welfare neglect cases and 60 percent of abuse cases involve families in which drinking or drug abuse is a major problem (Cross, 1997).
The National Child Abuse and Neglect Data System (NCANDS), operated by the Children's Bureau within HHS, compiles data voluntarily supplied by States regarding child abuse and neglect reports. In addition to aggregate data, a number of States (twelve in 1996) participate in the Detailed Case Data Component (DCDC) of the system which describes individual cases. Among the data elements in the DCDC, States are invited to report whether the parent or child has an alcohol or drug problem that contributed to the abuse or neglect report. Currently only two of the twelve States participating in the DCDC supply this information (New Jersey and South Carolina), and even in these States the information supplied appears to be incomplete. New Jersey reports that 20.3 percent of child abuse and neglect reports in 1996 involved caretaker drug abuse, and 7.3 percent involved caretaker alcohol abuse. South Carolina's figures were 10.9 percent caretaker alcohol abuse and 8.6 percent caretaker drug abuse. Each State also reports a handful of cases in which the child's alcohol or drug abuse were factors in the maltreatment allegation. In some cases these child drug abuse problems were in infants (presumably prenatally exposed), while in others the child in question was a teenager who was a drug user himself or herself. For the most part, the low substance abuse figures in NCANDS and some other tracking systems is related to the fact that agencies usually categorize cases by the type of maltreatment (e.g. physical neglect) rather than the reason(s) behind the maltreatment.
The 1993 Study of Child Maltreatment in Alcohol Abusing Families, based on a national probability sample of children with substantiated maltreatment reports, found that substance abuse was part of the presenting problem for 42 percent of children found to be victims of child abuse and neglect in 1989. Among the caretakers with substance abuse problems, alcohol was a problem substance for 77 percent, and, as shown in Figure 4-6, it was the primary (most harm-causing) substance for 64 percent. Cocaine was the primary problem substance for most of the rest (23 percent overall).
This study found that maltreatment cases involving alcohol and drugs had distinctive profiles (HHS/NCCAN, 1993). In particular:
In addition to national data and State reports to Federal information systems, several State-level reports contain data regarding substance abuse and child protection. In Illinois, where health professionals are required to report all substance exposed infants to child protective services, between 1985 and 1992 nearly 12,000 such reports were filed. Of these, 87 percent were indicated (similar to the "substantiated" category used by most States), and of indicated cases, 11 percent were taken into foster care immediately, while a total of 30 percent had child welfare cases opened. Many of these open cases involved children being served while remaining at home (Goerge and Harden, 1993). New York has reported that in 1990, 40 percent of substantiated child abuse reports involved a caretaker's drug abuse, and an additional 15 percent involved alcohol abuse (NYDSS 1992, cited in Magura et al, 1998). An early study in Massachusetts found that excessive alcohol or drug use was a factor in 64 percent of all substantiated child abuse and neglect reports and was even more common in reports of infants, where 89 percent were alcohol or drug related (Herskowitz et al, 1989).
If a child and family is to be monitored by or receive services from the child welfare system following an investigation, the child welfare agency opens a child welfare case with the family. About half the children with open child welfare cases are in foster care, while the other half receive services while remaining in their parents' care (HHS/CB, 1997). Most studies that look at children in the child welfare system look only at foster care rather than the broader population of children with open child welfare cases. The one recent national study that did look at a sample of open child welfare cases, the National Study of Protective, Preventive and Reunification Services Delivered to Children and Their Families, found parental substance abuse to be a problem in 26 percent of child welfare cases (see Figure 4-7).
An additional 5 percent of cases involved a child's own substance abuse (HHS/CB, 1997). This study looked at a representative sample of cases nationally and interviewed the child's caseworker about the family and provided services. There may have been additional substance abuse than is reflected in these data, but if so the caseworker was unaware of it.
This study found that the typical open child welfare case in which there was a substance abusing caretaker involves a young child (median age 5 years at case opening) probably being served in foster care (54 percent). The family is somewhat likely to be from a large metropolitan area (42 percent) and from a neighborhood with safety problems (63 percent). The caretaker is very likely single (71 percent) almost certainly a mother (95 percent) and probably over age 30 (median age 31). The family is probably enrolled in one or more government assistance programs such as Medicaid, welfare or food stamps. The typical child has been in foster care for almost a year (median time in care, 11 months) (U.S. Department of Health and Human Services, unpublished tables produced for this report). As compared with maltreating families without identified substance abuse, families with substance abuse problems are much more likely to be from a large urban area and from a neighborhood with safety problems. Families with substance abuse problems are more likely on welfare, have child welfare cases opened at younger ages, are twice as likely to be in foster care, and have been in foster care an average of six months longer.
Most lay persons equate child welfare with foster care, although only a small minority of families with substantiated or indicated child abuse or neglect complaints have children placed in foster care -- 16 percent in 1996 (HHS/CB, 1998d). The remainder either are served while remaining at home, or child welfare workers have determined that no services are necessary to keep the child safe (for instance if the perpetrator has left the home). Because foster care is provided to the most troubled families and provides the most intensive (and therefore most expensive) services to children, it is often the focus of public attention. Foster care is also the focus of Federal child welfare policy. There were approximately 520,000 children in foster care on March 31, 1998, a figure that has been rising steadily for a decade (Adoption and Foster Care Analysis and Reporting System, 1998).
The U.S. General Accounting Office (USGAO) in a recent report (USGAO, 1998) found that approximately two-thirds of foster care cases reviewed in urban counties in two States involved parental substance abuse (Figure 4-8).
Substance abuse was noted in 65 percent of cases in California and 74 percent of cases in Illinois. The problem was usually abuse of cocaine or methamphetamine (Figure 4-9), was usually noted in the mother or in both parents of the child, and was in most cases a longstanding problem of at least 5 years duration.
In 80 percent of substance abuse related cases, the child's entry into foster care was the result of severe neglect. In a related study conducted several years ago, the USGAO had found 78 percent of children in foster care had parents with substance abuse problems (USGAO, 1994). These figures have remained remarkably consistent, particularly in studies that look at cases in urban locations.
The Child Welfare League of America's 1998 survey on alcohol and drug issues found that only 8 States could provide information regarding the proportion of foster care cases involving alcohol or other drugs. Even if not able to report specific numbers of cases, States were asked to report whether the proportion of child welfare cases involving substance abuse was up or down in recent years. Thirteen of 47 States reported that more cases than in the past involved substance abuse (CWLA, 1998). The remaining states lacked information on trends in substance abuse in their caseloads.
In preparing this report, we reviewed data reported by States under the Adoption and Foster Care Analysis and Reporting System (AFCARS), a new reporting system under which States provide semi-annual information about all children in foster care or who have been adopted from the public child welfare system. While reporting under AFCARS is mandatory, these requirements are still in the implementation stage and not all States are yet reporting complete data. For the purposes of this report we analyzed data regarding children in care on March 31, 1998. Regarding substance abuse, AFCARS contains the following data elements for each child: yes/no fields indicating whether the parent had an alcohol problem that contributed to the child's placement; whether the parent had a drug problem that contributed to the child's placement; whether the child had an alcohol problem; and whether the child had a drug problem. Child alcohol and drug problems could represent either their own use of substances (primarily in adolescents) or a prenatal exposure to substances (seen in infants).
In the reporting period examined, only 32 States plus the District of Columbia reported any data in the four alcohol and drug fields, and many of these data are incomplete and under-reported. Reports of caretaker alcohol and/or drug problems ranged from less than 1 percent to 62 percent in the States reporting data for these elements (Figure 4-10).
Most of the large States, including New York and Illinois, were not yet reporting these data. We expect reporting for AFCARS to improve considerably over the next several reporting periods. As compared with many of the other required data elements, however, we expect information about substance abuse to be problematic for some time. Whereas elements such as the child's placement setting, case goal, or characteristics have long been part of States' own administrative data systems and transfer reasonably well to AFCARS, documentation of the problems that led to the child's foster care placement has not traditionally been included in automated child welfare information systems. Because reporting these items is not familiar to State and local agencies, it will take them longer to report these data reliably. In addition, it will be difficult to make cross-state comparisons because States may use varying thresholds to decide when substance abuse "contributes" to the foster care placement. Some States may be reporting only drug exposed infants under these data elements, while others report any case in which substance abuse is either part of the allegation or is documented. In States where at least some alcohol and drug data are being reported in AFCARS, there was no consistent pattern regarding either child and family characteristics or the child's experiences in the child welfare system. In most States, substance abuse-related cases looked quite similar to other cases, although under-reporting of substance abuse could have diluted any differences which might exist.
A few smaller studies in particular localities have also examined parental substance abuse as a factor in families with children in foster care. Walker and her colleagues in a study of children in foster care in 1986 found that substance abuse was noted in the case files for 18 - 52 percent of African American children in foster care, varying by city. In general, just over one-third of the children in foster care in New York, Miami, Seattle, Detroit and Houston had a parent with a substance abuse problem that was mentioned in the case file (Walker, et al, 1991; Walker et al, 1994).
While most analyses of data regarding children in foster care look at individual children rather than sibling groups, we must also recognize that many children in foster care are from larger families. Recent analyses of data from California find that of 1,600 newborns entering foster care in that State because of neglect or abandonment, nearly 60 percent had siblings already in care, totaling over 2,500 siblings (Barth, 1997).
As discussed above, there are approximately 1.3 million parents with problem levels of illicit drug use (and many more alcoholic parents) who are living with children younger than age 18. These figures do not include children in foster care (because children in foster care are not living in their parents' households and are thus not picked up in a household survey). Most alcohol and drug using parents do not come into contact with the child welfare system, although they are more likely to do so than other parents. HHS's 1993 Study of Child Maltreatment in Alcohol Abusing Families reported that child maltreatment was three times as likely in alcohol abusing families compared with non alcohol abusing families. It also found that once child maltreatment was substantiated, children in alcohol or drug abusing families were more likely to enter foster care than were children in other maltreating families (30 percent versus 17 percent). Where child welfare cases were opened, 97 percent of cases involving drug abuse and 87 percent of cases involving alcohol abuse were closed within four months, indicating that the child welfare agency was satisfied that the safety issues had been resolved (HHS/NCCAN, 1993).
Other researchers found that child abuse occurred in 27 percent of families with an alcoholic parent and 19 percent of families with an opiate addicted parent. Serious neglect occurred in nearly a third of both alcoholic and opiate addicted families, and children in all families with an alcoholic or drug addicted parent experienced some degree of neglect (Black and Meyer, 1980).
The Maternal Lifestyles Study, a longitudinal study following 1,400 cocaine and/or opiate exposed children and a matched comparison sample in several cities, found that 42 percent of the drug exposed infants were reported to child protective services at the time of the child's birth. Reporting rates varied substantially among study sites depending on the State reporting policies. Of the drug exposed children, 82 percent were living with the biological mother at the time of hospital discharge and virtually all of those were still living with the mother at one month of age. Of the children not discharged to the mother, at one month of age 13 percent were back in the mother's care, 32 percent were in the care of relatives, 41 percent were in non-relative foster care, and 14 percent were in some other living arrangement (Maza et al, 1998).
The Center for Substance Abuse Treatment, within SAMHSA, is currently evaluating a grant initiative to provide residential substance abuse treatment for pregnant women and women with children. Early data show that about one-fifth of women in these programs were referred to treatment by a child welfare agency, probably because of issues related to child abuse or neglect. Far more had children living in foster care. Overall, 40 percent of women in the programs had at least one child living primarily in foster care during the 30 days prior to admission. Crack cocaine, methamphetamine, and alcohol were the most common drugs of abuse for these clients (Dowell and Roberts, 1998).
Studies of women in particular substance abuse treatment programs also show high rates of child welfare system involvement. Kearney reports that in a sample of heavy cocaine users, 69 percent had lost or given up custody of a child at some time (Kearney, 1994). Evaluators of a program in Arizona report that 33 percent of clients were involved with child protective services at the time of admission, although only 11 percent admitted to being the aggressor in a violent incident toward their children (Steven and Arbiter, 1995). A residential treatment center for women with children reports that only 37 percent of women enrolling in the program had custody of a child at intake (indicating that most clients' children were either in foster care or with relatives) (Wobie, 1997). And Brindis reports from another treatment program that for the mothers entering the program she studied, of the parents' youngest child under three years old, 43 percent were living with the mother, 19 percent lived with relatives, and 38 percent lived in foster care or other living situations outside the family (Brindis et al, 1997). The high rates of child welfare system involvement in these studies is in part due to the target client populations of these treatment programs and the recruitment techniques used.
Other studies have shown high protective service needs among families with substance abuse problems (Kelley, 1992). For instance, one study found that teachers have reported a need for protective services three times more often for children being raised by someone with an addiction than for other children (Hayes and Emshoff, 1993).
Few studies directly compare child welfare clients with substance abuse problems to other child welfare clients. Analyses of the Children's Bureau's National Study of Protective, Preventive and Reunification Services conducted expressly for this report found significant differences between child welfare clients with substance abuse problems and other clients of the child welfare system. This study was based on a national sample of children with open child welfare cases in 1994 (for the report's previously published findings and a full description of the study's methodology, see HHS/CB, 1997). The 26 percent of families with identified substance abuse problems were significantly more troubled than other families in the child welfare system as measured by the frequency with which substance abuse problems were seen in tandem with a variety of other family problems. As shown in Figure 4-11, alcohol was the primary drug abused by 25 percent of substance abusing families in the child welfare system, illicit drugs were the problem for 40 percent, and in 35 percent both alcohol and drugs were abused.
Children from substance abusing households were much more likely than others to be served in foster care rather than in the home (54 percent in foster care versus 23 percent of children in non-substance abuse cases), spent longer periods of time in foster care than other children (median 11 months versus 5 months for others in foster care) and were less likely to have left foster care within a year than other children (55 percent versus 70 percent). Families with substance abuse problems were equally likely to be white or African American (47 percent), while only 6 percent were Hispanic.
Children in foster care from families with substance abuse problems were more likely than others to have a case plan of adoption (9 percent versus 3 percent) and were less likely to have a case plan of emancipation or independent living (3 percent versus 11 percent), both likely linked in part to having entered care at younger ages and being younger at the time of the study (i.e. a two-year-old is more likely than a 16-year-old to have an adoption case plan, while a 16-year old is more likely to have a plan of emancipation). Substance abusing families and others were equally likely to have a case plan goal of reunification (54 percent versus 56 percent). Children from substance abusing families were an average of 5 years old at the time of case opening, versus average age 7 for other children.
The services most commonly offered to substance abusing parents were employment training (82 percent), substance abuse treatment (70 percent), parenting training (59 percent), psychological assessment (22 percent) or household management services (22 percent). As shown in Figure 4-12, far fewer actually received the offered services -- in the case of substance abuse treatment approximately half of families with identified substance abuse problems received any substance abuse treatment services. In 23 percent of cases, substance abuse treatment services were offered but not provided, and services were not offered to another 23 percent of cases.
"Offered" services might not be delivered for a variety of reasons including clients' refusal, mismatches between available services and client needs, or ineffective referral processes. Although many of these women have multiple drug-exposed children, only 8 percent were offered family planning services. Chapter 7 includes additional information on the substance abuse treatment status of parents.
Substance abusing families were more likely than others to have had multiple caseworkers while involved with the child welfare system. Only 35 percent of families with substance abuse problems had a single caseworker, versus 59 percent of other families, and 41 percent had three or more caseworkers (versus 21 percent). This is likely due in part to the fact that cases involving substance abuse were open for longer periods of time, making multiple caseworkers more likely.
Another study, this one focusing on African American children in foster care, also found that families with substance abuse problems had more problems overall than other families, were more likely than other families to be neglectful rather than abusive, and children from these families entered care younger and stayed in care longer than other children in foster care (Walker et al, 1991; Walker et al, 1994). Researchers looking at children reported to child protective services in one California county found that 35 percent of such children were not removed from the home; 29 percent were removed from the home on an emergency basis but were returned to the parent's custody within a few days; 12 percent were removed but returned home within 18 months; and 24 percent were removed and were not expected to return home (Sagatun-Edwards et al, 1995). Ellwood and colleagues (1993) found that 25 percent of drug-exposed infants born to women on Medicaid spent most of their first two years of life in foster care, while the remainder continued in their families' care.
Data from SAMHSA's evaluation of grant initiatives to provide residential substance abuse treatment for pregnant women and women with children indicate that female substance abuse treatment clients who have ever had children removed from the home by child protective services tend to be older than other clients, have more children, and have more other problems such as having been homeless and unemployed, than do other clients entering these substance abuse treatment programs (Dowell and Roberts, 1998).
Among substance abuse treatment clients who are parents, child custody issues are a major reason for treatment entry. In the National Treatment Improvement Evaluation Study (NTIES), 44 percent of female clients with children under 18 (and 15 percent of male clients with such children) reported that they entered substance abuse treatment in order to keep and/or regain custody of their children (Figure 4-13).
Of female clients who entered treatment within a year of their most recent birth, two-thirds did so because of custody concerns and 86 percent of these women had already lost custody of this child (HHS/SAMHSA, 1996). Findings from a California study of substance abuse treatment outcomes further confirm that parenting and custody issues are an important motivation for treatment entry (Gerstein et al, 1997).
The child welfare system most commonly perceives substance abuse as causing abuse or neglect of children. However, research is also beginning to show that child abuse, particularly sexual abuse, is a common precursor of substance abuse (Dembo et al, 1997; National Research Council, 1993). The early initiation of substance use is a risk factor for addiction, and may in part represent a child's attempts to escape the unresolved emotional trauma of abuse or neglect (National Research Council, 1993). This suggests the need for improved attention to the emotional health of children in foster care, and to the need for substance abuse prevention activities focused on children involved with the child welfare system. Without intervention, the child victims we seek to protect today may become the next generation of abusive or neglectful parents.
McCauley and colleagues (1997) found that women with a history of childhood physical or sexual abuse were nearly 5 times more likely to be current users of street drugs and over twice as likely to have a history of alcohol abuse than were other women. In addition, a study of alcohol and other drug dependent persons in Iowa found that a third of dependent persons reported physical abuse as children (as compared with 11 percent in the general population), and 13 percent reported sexual abuse as children (compared with 6.3 percent in the general population) (Lutz et al, 1995).
Figures regarding the extent to which abusive and neglectful families also have substance abuse problems, and vice versa, are complex and confusing. While specific studies vary considerably for methodological and other reasons, the bottom line is that a very significant portion of the child welfare caseload involves families with substance abuse disorders. But these are far from the only problems these families face. In addition, we must recognize that while substance abuse impairs parental functioning and has negative impacts on children, most substance abusing parents do not engage in behaviors that rise to the child protective services definitions of abuse or neglect. In addition, it is clear that alcohol as well as illicit drugs may place children at risk, and that parental substance abuse is a problem for children of all ages.
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