Families involved with the child welfare system are among the most troubled in our society. The child welfare system serves as the final safety net, when no other public or private institution has been able to address a family's problems successfully. It is expected to meet the family's needs and assure a permanent, safe environment for the child, either at home with the biological family or elsewhere. But even if the child welfare agency, in a particularly egregious case, responds by moving a child out of the family quickly and on to an adoptive home, unless the parents' problems are addressed, the family is likely to remain unhealthy and may reappear at a future date, with another child identified as at-risk.
In maltreating families, maltreatment is rarely the only issue. Even addiction, while among the most common co-occurring problems, is rarely the only significant one. Serious mental illness may be present, particularly among substance abusing women. Domestic violence and HIV/AIDS are also critical factors in the lives of some families. Poverty is pervasive, and inadequate or unsafe housing are very significant problems, particularly in urban areas. These serious difficulties combine in the lives of these families to produce extremely complex and dysfunctional situations and relationships that are difficult to resolve. The presence of so many serious issues also implies that addressing the substance abuse alone is not likely to produce the changes in a family that are necessary to ensure a healthy environment for a child. Unless the whole of a family's situation is addressed, substance abuse treatment is unlikely to be successful -- and even if a parent achieves abstinence, the other issues present may continue to pose safety problems for the child(ren).
The National Research Council of the Institute of Medicine, in its comprehensive volume Understanding Child Abuse and Neglect (1993), cautions against viewing substance abuse as a monolithic cause of child maltreatment. The panel notes that substance abuse and child maltreatment are "often complicated by the presence of other social and economic variables ... that confound the analysis of the contributing role of drugs themselves. At this time the literature on substance abuse and child maltreatment is not well ... developed" (National Research Council, 1993, p. 19). Mental illness, health problems, past childhood abuse and domestic violence are examples of these other variables.
Particularly among women, mental illness and substance abuse are often intertwined. Over one third of females with problem drug use have experienced a major depressive episode in the past year, and 45 percent have experienced at least one of several mental health problems including panic attacks and anxiety disorders. These rates are more than double those for men with similar levels of substance use (HHS/SAMHSA, 1997d). Chavkin and her colleagues (1993) found that most crack cocaine using women reported psychiatric symptoms, and nearly a third had histories of psychiatric medication or hospitalization. Half reported having been sexually abused as children. Merikangas and Stevens (1998) present a comprehensive review of the literature on psychiatric comorbidity in women with substance use disorders. It has been hypothesized that for many women with both substance abuse and other affective disorders, drug use may in part represent self-medication, that is, drugs are being used to alleviate psychiatric symptoms (Dackis and Gold, 1992). To the extent this is the case, abstinence alone will not solve the problem. If the underlying psychiatric problem is not addressed, the factors causing the drug problem have not gone away (at least in part) and relapse is likely to result. Dually diagnosed clients (those with both substance abuse and other mental illnesses) are known to have higher relapse rates than other clients (HHS/SAMHSA, 1994). Diagnosis of co-occurring mental and addictive disorders can be difficult but is extremely important for effective treatment and recovery. Because alcohol and drug abuse may mask other symptoms, it is often several months into sobriety before additional diagnoses can be made.
The nation's AIDS epidemic is also closely intertwined with problems of substance abuse. Two thirds of AIDS cases among women are the result of either intravenous drug use or sexual relations with an intravenous drug user (Selwyn and Gorevitch, 1998). Women with substance abuse problems are more likely both to have high risk sexual partners and to have multiple sexual partners than are women without such problems. The vast majority of women diagnosed with HIV or AIDS are between the ages of 15 and 44 (the childbearing years). Many of these women have children who may be born with HIV themselves, or are likely to be orphaned as their mothers succumb to the disease, although prenatal HIV treatments have reduced mother-infant transmission rates substantially. Between 72,000 and 125,000 U.S. children are expected to be orphaned because of parents' AIDS by the year 2000 (Levine and Stein, 1994). Women are likely to be diagnosed with HIV or AIDS at later stages than are men and are less likely to receive health care for their infections (Selwyn and Gorevitch, 1998).
The relationship between domestic violence and substance abuse is well documented (HHS/SAMHSA, 1997b) and recent consensus panels held by SAMHSA conclude that "failure to address domestic violence issues interferes with treatment effectiveness and contributes to relapse" (HHS/SAMHSA, 1997b, page 5). In up to 70 percent of all incidents of domestic violence, the victim, the batterer, or both, had been drinking. Women who are alcoholics are more likely to have been beaten than non-alcoholics and are more likely to have partners who also drink heavily. Miller (1998) reports that 88 percent of women in a drug treatment program for women had experienced severe partner violence in their lifetimes, and 26 percent had experienced such violence in the past six months. The most common forms of severe partner violence were being hit with a fist, beaten up, hit with an object, or choked. Women in substance abuse treatment had much higher rates of partner violence than women in comparative community samples -- often 2, 3, or 4 times higher depending on the specific type of violence. In these women, substance abuse may be related to victimization either because alcohol and drugs are used as a general coping mechanism, or to deal with post traumatic stress disorder resulting from the violence (Miller et al, 1997).
Women with substance abuse problems are frequently involved with men who are also substance abusers. In fact, women are often introduced to substance abuse by male partners. These men may feel threatened by their partners' efforts to get clean and may actively or tacitly undermine the goals of her treatment. A woman's efforts to separate from an abusive partner during recovery may also place her at risk for further violence. Treatment programs which fail to recognize this dynamic may inadvertently contribute to escalating violence. Child welfare agencies, too, must acknowledge these risks and recognize potential danger to the mother, as well as the children, as they intervene with families.
Women who abuse alcohol and other drugs have often been the victims of violent crimes, either as children or adults. According to several research studies, between 41 percent and 74 percent of women in treatment for alcohol and other drugs reported being childhood or adult victims of sexual abuse, including incest (Wilsnak, 1991). A number of researchers have found significantly higher proportions of histories of sexual and/or physical abuse among women in treatment as opposed to comparison groups of women (Bergman et al, 1989).
Preliminary data from a cross-site evaluation of demonstration grants funded by SAMHSA's Center for Substance Abuse Treatment finds that 76 percent of clients in treatment programs for women with children report a personal history of abuse, neglect or trauma. About a fourth report physical abuse by a parent, a third report emotional or psychological abuse by a parent, and slightly over 10 percent report sexual abuse by a parent. Many more report physical, emotional or sexual abuse by a non-parent (over three-quarters report physical and emotional abuse and about one-half report sexual abuse). Clearly, many of these women have experienced severe stress which may affect their basic abilities to function socially and emotionally and especially as a parent. (Dowell and Roberts, 1998)
Finally, substance abuse is also related to increased involvement of women in the criminal justice system. Sales of illicit drugs and drug use have contributed to the enormous 386 percent rise in the female prison population between 1980 and in 1994 (Wilsnack, 1995). The average percent of arrested women who tested positive for drugs in 20 cities in 1996 was 64 percent (U.S. Department of Justice, National Institute of Justice, 1997).
The complexity of these families often makes it difficult for child protective services workers to determine the extent to which substance abuse presents a risk to children. Again, it is important to recognize that not all those who abuse or are dependent on alcohol or other drugs abuse or neglect their children, and that danger to a child may or may not be the direct result of a parent's substance abuse. Child welfare workers struggle with trying to evaluate the role of substance abuse in the dynamics of a given family and what a child is experiencing. In many cases, while a parent's substance use may impair his or her parenting ability, these parenting deficiencies do not rise to the level of neglect or abuse at which a child welfare agency would intervene.
Substance abuse has profound effects on parental disciplinary choices and child rearing styles. Research has shown that parents with substance abuse problems employ less effective discipline than other parents (Tarter et al, 1993). Research through taped clinical observations have shown that drug abusing parents are very limited in their ability to attend to their children's emotional and social cues and to respond appropriately (Hans, 1995). As a consequence, substance abusing parents can overreact with harsh discipline or neglectful child support leading to the higher levels of child abuse and neglect in substance abusing parents (Kumpfer & Bayes, 1995). They also tend to be poor role models for the use of alcohol and drugs and effective conflict resolution and family management skills (Kumpfer, 1987). However, research also demonstrates that substance abusing parents, whether in treatment or not in treatment, can be taught through therapeutic child play and behavioral parent training to be more empathetic and effective parents. Through these family interventions child abuse and neglect and harsh and ineffective discipline can be decreased, while also decreasing the child's emotional and behavioral risk factors for later substance abuse and other adolescent problems (Egeland & Erickson, 1990; Kumpfer, Molgaard & Spoth, 1996; Kumpfer & Alvarado, 1995, 1998; Kumpfer, Williams & Baxley, 1997, Kumpfer, 1999).
Kearney and colleagues (1994) studied the parental attitudes and behaviors of drug dependent mothers. They found that these women felt a strong responsibility toward their children and were quite proud of them. Studying how these mothers try, unsuccessfully, to balance their addictions with their parenting responsibilities, they found that "the basic problem crack cocaine presented to mothers was its drain on their attentiveness, their financial resources and their efforts to be appropriate role models for their children" (p. 354). Hawley and colleagues (1995) also found that motherhood was often the only legitimate social role valued by drug dependent women and that most women in treatment were very concerned about how their substance abuse had affected their children - indeed such concern was a powerful treatment motivation. Catalano and associates (1999) have found that providing a parenting program to parents while in drug treatment, in fact, also reduces relapse after treatment. Because of the importance of being a good parent, offering effective parenting programs during outpatient or inpatient residential treatment improves recruitment, retention and outcomes for parents and children in addition to reducing relapse.
Over the past twenty years, a number of behavioral parent training, family skills training, family therapy and family support programs have been found effective in improving behavioral and emotional outcomes for both parents and children (Ashery et al, 1999; Kumpfer & Alder, in press) and with children from diverse cultures (Kumpfer & Alvarado, 1995). Over 50 effective, research-based models of parenting interventions have been identified by SAMHSA/CSAP in their expert review of the family-based intervention research literature (SAMHSA/CSAP, 1998). The Office of Juvenile Justice and Delinquency Prevention (OJJDP) also conducted two expert reviews over the past then years of their Strengthening Families Initiative and have identified 34 model parenting and family programs which are being disseminated though conferences, training of trainers, technical assistance and mini-grants. For a review of these programs see Kumpfer and Alvarado (1998), or program descriptions on their web site: www.strengtheningfamilies.org.
A number of these parenting interventions have been specifically tested in federally-funded research projects with drug abusing parents. For instance, the Strengthening Families Program for substance abusing parents has been fount to significantly improve the parent's parenting skills, parenting self-efficacy, depression, stress and drug, while also improving the children's emotional and behavioral status (Kumpfer, Molgaard, & Spoth, 1996). This program has been culturally adapted for different ethnic populations and field tested with similar positive results with five different investigators. A version for rural families has been developed and found effective in reducing alcohol use (Spoth & Redmond, 1996; Spoth, Redmond & Lepper in press).
Despite these positive research findings, few substance abuse treatment programs offer these or other research-based and effective parenting programs to their clients. A great gap exists between scientifically valid prevention and treatment programs and the commercially marketed but untested programs being implemented by practitioners. To improve the dissemination and adoption of science-based parenting and family support interventions, SAMHSA's Center for Substance Abuse Prevention is investing $10 million in grants to over 100 communities to select, implement and evaluate their choice of over 50 research-based models.
No less complex than the problems of substance abusing parents are their children's needs. A large research literature exists from epidemiological, family, adoption and twin studies concerning the genetic and environmental risks that put these children at higher risk for a variety of problems (Kumpfer, 1987; Tarter & Messich, 1997; Johnson and Leff, in press). Whether because of in utero exposure to stressors including tobacco, alcohol, or drugs, or to genetic and environmental family risks, children of substance abusers are more frequently described by their parents as being hyperactive and as having difficult temperaments. Clinical studies do not find these children to have significantly more diagnosable attention deficit disorder, but simply to be more active and have a high energy level. McMahon and Luthar (1998) report in a review of developmental issues in children of substance abusers that the two main research findings regarding such children are (1) that they have poorer developmental outcomes (physical, intellectual, social and emotional) than other children, although generally in the low-normal range rather than severely impaired; and (2) they are at risk of substance abuse themselves.
Evidence is increasing that children of substance abusers are at elevated risk for developing substance use disorders at young ages due to familial and genetic factors. Merikangas, Stolar, and their colleagues (1998) report an 8-fold increased risk of drug disorders among relatives of 299 individuals with drug disorders. These findings were reinforced in a second generation study of the children of these drug dependent research subjects (Merikangas, Dierker, et al., 1998). The strongest link was found between substance disorders in offspring (mean age 12 years) with parental substance abuse although the link for psychopathology, particularly anxiety disorders, was similar. Risks of this magnitude place a family history of drug disorder as one of the most potent risk factors for the development of the child and the child's development of drug disorders at an early age. These findings suggest that substance prevention and intervention programs should target offspring of parents with substance use disorders. In fact, children of alcohol and drug abusing parents are at the highest risk of any children for later drug use and other adolescent behavioral health and mental health problems. Research also suggests that some children of substance abusers, like other children of dysfunctional parents, can develop special resilience skills with appropriate adult support (Johnson & Leff in press; Kumpfer, Walker & Richardson, in press).
A number of good literature reviews have been published regarding developmental issues in children prenatally and environmentally exposed to substance abuse (Harden, 1998; Pagliaro and Pagliaro, 1997; Carta et al, 1997). Generally, most research finds that factors in the postnatal environment mediate prenatal factors. It is now recognized that the older a child gets, the more important the home environment is in predicting developmental outcomes, including how the environment interacts with any direct effects of prenatal drug exposure. Women who use drugs during pregnancy are at risk for delivering premature and low birth weight babies. Alcohol appears to have more profound and long-lasting effects on development than do cocaine and other illicit drugs, including serious intellectual and behavioral consequences in many children.
SAMHSA's Center for Mental Health services has found, through an evaluation of its Comprehensive Community Mental Health Services Program for Children and Their Families, that children's mental health problems are closely intertwined with parents' substance abuse, child maltreatment, and other forms of family violence. These grantees serve children with serious emotional disturbances. Evaluation results reveal that over 60 percent of families have had a history of substance abuse, and over half of the families had a history of family violence. Almost one-fourth of children were reported to have been sexually abused prior to entering services, 20 percent of children were reported to have used alcohol and drugs, and 59 percent of children served were described by their caregivers as having one or more risk factors including: physical abuse, sexual abuse, previous psychiatric hospitalization, sexual abusiveness, suicide attempts, drug and alcohol use, and a history of running away (HHS/SAMHSA, 1999).
Babies whose mothers drink alcohol during pregnancy can be born with Fetal Alcohol Syndrome (FAS) or alcohol-related birth disorders. FAS is among the leading known causes of mental retardation in the United States. Infants born with FAS have difficulties with coordination, speech and hearing impairments, and heart defects. Research indicates that there is no known safe level of alcohol consumption during pregnancy, although FAS and related problems are more likely with heavy consumption of alcohol, particularly binge drinking. According to the National Organization on Fetal Alcohol Syndrome, at least 5,000 infants are born with FAS annually and another 50,000 infants demonstrate symptoms of alcohol-related birth disorders (National Organization on Fetal Alcohol Syndrome, no date).
Consumption of illicit drugs during pregnancy also may harm the fetus and may have long-term effects on children. Babies who were prenatally exposed to cocaine or other drugs may experience a range of problems, including some that can be long-lasting and serious. However, these physical and mental deficits are not seen in infants to the extent that earlier expert warnings and media reports regarding "crack babies" had predicted (HHS/NIDA, 1994).
Some researchers have found that more subtle developmental problems, particularly in language skills, can be observed in prenatally drug-exposed children as they age. A recent meta-analysis combining results from eight studies finds that cocaine-exposed infants have, on average, IQ scores that are 3.26 points lower than other children. While the effects of cocaine exposure on IQ were small, medium sized differences (defined as those in which cocaine exposed children's scores were lower than those of other children by between 0.5 and 0.75 standard deviations) were found in receptive and expressive language functioning (Lester et al, 1998). Although the developmental effects are subtle, special education to prevent these children from failing in the school environment could cost up to $352 million per year according to the Brown University analysis.
How much of children's presenting developmental difficulties are due to prenatal injury versus postnatal deprivation continues to be a matter of some debate. In their review, Bernstein and Hans (1994) conclude that it may be the number and persistent nature of threats that best predicts developmental outcomes. That is, more risk factors in place for longer periods in a child's life are most likely to have long lasting and serious negative consequences.
Given the multi-problem nature of these clients and their families, it is no wonder that programs serving them find it difficult to meet their needs. Indeed, most evaluations of programs serving parenting substance abusers report that it is difficult to identify these women, it is difficult to engage them in services, and it is difficult to retain them in treatment. Women who are in need of treatment often do not seek it due to the social stigma of using alcohol and other drugs. Denial of her problem on the part of the woman and her family, as well as the fear of losing her partner, is another significant barrier to treatment for a substance abusing women. However, many of the grantees operating programs developed under SAMSHA's women's and children's programs have developed substance abuse treatment programs that are sensitive to the needs of women and children and have been successful in recruiting and retaining them in treatment. Programs have shown particular success if they have
The physical and mental health consequences of alcohol and other drug use for women are often different in nature and degree from those of men, as is the etiology of alcohol and other drug use. Often women arrive at substance abuse treatment later in the progression of the disease than do men. These factors require both different approaches to treatment of the drug use itself and to treatment of the consequences of use.
SAMHSA's Center for Substance Abuse Treatment has developed a model for women's substance abuse treatment services (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Administration, Center for Substance Abuse Treatment [HHS/SAMHSA], 1994) which recommends a series of 17 components that are critical for substance abuse treatment for women. The model recommends that all services planned and developed must be age appropriate, culturally relevant and gender-specific for the different populations of women and their children. The components range from substance abuse counseling to obstetrical and gynecological services, and parenting counseling through housing and legal services. These components are implemented through:
A detailed description of this model appears as Appendix B.
Working with parents and children together is generally more effective than working with children only, particularly if the children have conduct problems (Dishion & Andrews, 1995). However, a number of children of alcohol and drug abusers programs have been developed to work directly with these children primarily through educational and support groups offered through schools, community agencies, or faith-based organizations. Research suggests that these children need to be informed about their potential genetic, biological, cognitive and emotional risk factors. School-based programs such as the CASPAR program and the New York-based Student Assistance Services program (HHS/SAMHSA, 1993, HHS/SAMHSA, in press) have demonstrated significant reductions in risk factors and improved social competencies and effective problem solving skills. Services like these could be used effectively in substance abuse treatment programs to produce educational and behavioral change and ultimately reduce the risks these children face for later drug use.
Addressing families' multiple needs is a critical factor in the successful engagement and retention of clients in substance abuse treatment and related services. Often a family's basic needs (such as those for food, shelter, and safety) are so pressing that they must be addressed before a parent has the ability to focus on his or her addiction. Further, a crisis in any single area of their lives may cause a client to relapse and/or drop out of treatment. If a treatment program does not or cannot help the client to address what he or she defines as the family's most significant problem(s), the client is likely to view the program as irrelevant. Efforts to coordinate treatment with other systems are also vital to treatment engagement and retention. These program design issues will be discussed further in Chapter 7.
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