Blending Perspectives and Building Common Ground

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

Chapter 7

Service Delivery Models:
Approaches to Addressing Joint Substance Abuse and Child Maltreatment Problems

Addressing the problems of substance abuse and child maltreatment requires intervention at a variety of levels.  Among the clear lessons that have emerged in the decades of effort by dedicated service providers in both fields is that there are no easy answers and that what works for one family will not necessarily work for another.  Flexibility and comprehensiveness are key, and, particularly when dealing with these multi-problem clients, collaborative working relationships across agencies are essential.

A variety of documents have been written about building interagency collaborative relationships, generally (e.g., Melaville et al, 1993; Mattessich & Monsey, 1992; Gardner, in press) and specifically to address substance abuse and child maltreatment in families (Young, Gardner and Dennis, 1998; Jones and Hutchins, 1993).  Collaborative working relationships are important for several reasons:  (1) they enable service providers to meet a broader range of family needs; (2) they allow agencies to better coordinate their efforts and ensure that they neither overwhelm families with requirements nor impose conflicting demands; and (3) they enable a more efficient use of limited resources and prevent inefficient parallel program development.  Effective teamwork is difficult to achieve, however, and harder to sustain.  But it is only by working together that our agencies are likely to make progress in serving these children and families well.  No single agency can provide all the supports these families need, nor does any agency alone have the knowledge or authority upon which to make informed decisions about the strengths and needs of the family as a unit, parents and children.

The sections below describe interventions for families with substance abuse and child maltreatment issues across a spectrum of care, and, to the extent information is available, describe what is known about the effectiveness of interventions.  Generally, however, information on the effectiveness of interventions to address child maltreatment is sparse.  Few studies of child maltreatment interventions directly address the particular issue of substance abuse.  Similarly, few evaluations of substance abuse interventions directly address child maltreatment. Nonetheless, below we describe what we know about:

Valuing Prevention

An effective, comprehensive approach to addressing substance abuse among parents and its harmful effects on children must include a strong prevention component.  The maltreated children we serve now are at high risk of becoming the next generation of adults with addiction problems and/or the next generation of abusive and neglectful parents whose family, legal, and health problems will have to be addressed.  Of the population being served in SAMHSA's program of Comprehensive Mental Health Services for Children with Serious Emotional Disturbances, 60 percent of the children are from homes in which at least one parent has been identified as having a substance abuse problem.  This strongly suggests the need for early intervention services for children of parents with substance abuse and related problems.

Research regarding substance abuse prevention has developed significantly in recent years, and has begun to demonstrate clear lessons for program developers (Office of Technology Assessment, 1994; HHS/NIDA, 1997).  Among these lessons are that:  (1) interventions need to be directed at clearly defined target populations, and (2) must address the specific risk and protective factors associated with substance abuse.  Too often, broad based prevention programs fail to incorporate these and other lessons learned through research.

SAMHSA's Starting Early Starting Smart projects are leading efforts to produce new institutional approaches to collaboration in social services programs.  These projects are designed to generate new empirical knowledge about the effectiveness of integrating substance abuse prevention, substance abuse treatment and mental health services for children aged zero to seven and their families.  Grantees are integrating these behavioral health services into early child care settings such as day care facilities and Head Start Centers.  Starting Early Starting Smart programs will create partnerships among community service providers in various fields to better meet the needs of young children.

Child abuse prevention research is much less well developed than research on substance abuse prevention.  Few maltreatment prevention programs have been designed with a clear theoretical framework regarding risk and protective factors that ultimately lead to reduced abuse or neglect.  Until the early 1990s, prevention models focused almost exclusively on parental behaviors such as excessive physical discipline.  While some existing programs have been able to demonstrate some changes in parental knowledge and attitudes, they have not been shown conclusively to reduce abuse.  In addition, relatively little is known about child neglect, which is the principal issue in cases where substance abuse is significant.  As the National Research Council noted in 1993, "in designing preventive interventions, researchers have given very little attention to interactions among multiple variables in the determination of risk status for subsequent maltreatment" (National Research Council, 1993).  A key challenge in research regarding prevention programs in both substance abuse and child protection has been the difficulty in measuring behavior that does not occur.  While the crux of prevention lies in avoiding negative outcomes, decreases in what are relatively rare behaviors even among high risk groups is difficult, particularly when these behaviors are ones the subject is likely to hide.

Children of substance abusing parents generally, and children in foster care particularly, possess, almost by definition, many of the risk factors and few of the identified protective factors associated with a host of negative outcomes.  For instance, children exposed to severe substance abuse in the home often experience mental, emotional, and developmental problems, as well as severe trauma, which may result from physical or sexual abuse or chronic neglect.  These children are among the populations at highest risk of developing substance abuse disorders, including addictions.  Despite their high risk, few efforts have been made to target children and youth in foster care specifically for substance abuse prevention activities.  In most communities, substance abuse prevention is not viewed as a function of the child welfare agency, even for the children in their care.  "They'll get that in school" is the typical reaction to the subject, although few school-based prevention programs are equipped to deal with the personal and family experiences with alcohol and drug abuse and child abuse or neglect that children in foster care bring to standard drug education programs.

Reducing the emotional trauma experienced by children in foster care or who are living in abusive or neglectful families and/or with substance abusing caretakers is a significant approach to preventing substance abuse among these children as they grow up.  If substance use is in part a means of self medication to dull emotional pain and avoid trauma, it is only by providing other ways of addressing these needs that destructive behaviors, including future substance abuse, will be avoided.  An argument growing in prominence is that providing therapeutic services for children in the context of a parent's substance abuse treatment program provides a significant opportunity to prevent future maladaptive behaviors in these children (Kumpfer, 1998; McMahon and Luthar, 1998).

Strengthening Training and Identification Skills

A key factor in assuring that both substance abuse and child protection issues are addressed is making sure that workers are trained to look for and identify both problems in families served.  Yet neither child welfare nor substance abuse pre-service training typically includes information on the other field (Dore et al, 1995).  A variety of studies have shown that training for child welfare staff includes inadequate information on substance abuse and case planning skills to use with these families (Gregoire 1994; Tracy 1994).  Indeed, one study found that social workers failed to correctly identify and respond to clients' alcohol problems in 83 percent of cases (Kagel, 1987).  The 1993 Study of Child Maltreatment in Alcohol Abusing families found that only 21 percent of caretakers of maltreated children received a substance abuse assessment by an alcohol or drug abuse professional (HHS/NCCAN, 1993).  If we do not accurately identify these problems, we are unlikely to adequately assess or treat them.  Routine screening and identification systems have the potential to improve services provision.  For instance, recent HCFA demonstrations to improve medicaid-provided services to pregnant substance abusing women found that systematic screening and identification raised service enrollment rates (Howell et al, 1998).  Too often, however, CPS staff do not ask about or follow up on potential substance abuse, and substance abuse treatment providers have a similar stance toward child maltreatment.

Several studies have been identified that address substance abuse training and identification issues for child welfare staff.  It appears that less attention has been devoted to assisting substance abuse treatment staff to recognize child safety issues.  Many treatment programs have policies about reporting suspected abuse and neglect, but aside from treatment programs specializing in treating women with children, usually little attention is paid to training staff on how to recognize abuse and neglect, the effects it has on children, or how to intervene beyond making a child protective services report.  Many of the substance abuse treatment programs that provide residential treatment for women with their children or outpatient programs that have on-site services for children have paid more attention to these issues, but they are few and far between.

Training can improve the ability of workers to identify and intervene with families.  For instance, Gregoire (1994) found that following a seven-hour training on substance abuse issues, child welfare workers showed an increased awareness of the connection between alcohol and other drug abuse and child maltreatment.  In addition, workers' aversion to engaging clients with alcohol and drug problems decreased.  As a recent Child Welfare League of America publication points out, "the prerequisite to a serious commitment on training is a recognition that the great majority of workers in the child welfare system and in the treatment agencies do not know enough about the 'other side' to work effectively across systems" (Young et al, 1998, p. 18).

Both the Administration for Children and Families (ACF) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have recognized the need to improve training on these crossover issues.  In 1994, the National Center on Child Abuse and Neglect (NCCAN) issued a widely-used manual on protecting children in substance abusing families (HHS/NCCAN, 1994), and will soon complete a substance abuse training curriculum developed as a result of several communities' activities under Federal demonstration grants during the early 1990s.  SAMHSA's Center for Substance Abuse Treatment is also in the process of developing a manual for treatment programs on the implications of child abuse for substance abuse treatment programs.  In our discussions with grantees working on both sides of this issue, we were told repeatedly that joint training is an important key to effective collaboration.  Until local staff in both fields have opportunities to learn about the other's discipline and to interact constructively with respect to families' needs, they will find it difficult to meet expectations for positive outcomes.  Appendix C describes existing Federal child welfare and substance abuse treatment services and research programs, and Chapter 8 will discuss additional steps toward addressing these issues.

One community that has taken seriously the importance of training on these and related issues is Sacramento County, California.  Since 1993, the county's Department of Health and Human Services has developed an extensive, three-level training effort for its employees in order to provide child welfare workers and their partners in related agencies the knowledge and skills necessary to identify and intervene with substance abusing families.  Topics in the basic level of training include, among others, the awareness that alcoholism and drug dependence are diseases; the effectiveness of different modalities of treatment for different clients; the relevance of client measures of functioning in addition to abstinence; and an awareness of the phases of recovery as measures of parents' readiness for child custody.  Staff undergoing additional levels of training may be certified in administering the substance abuse screening instrument used in the county, and become skilled at making assessment-based referrals to the nine treatment options available in the county.  Sacramento County has struggled to implement consistent processes to identify substance abuse problems in maltreating parents so that appropriate interventions may be provided.  The county's efforts are described in more detail in the recent volume Responding to Alcohol and other Drug Problems in Child Welfare (Young, Gardner & Dennis, 1998).

In 1991, NCCAN funded 25 grants to develop and implement multi-disciplinary training programs on substance abuse and child maltreatment (HHS/NCCAN, 1995b). Evaluations of these efforts indicate that trainees:

Process evaluations of these efforts also revealed a number of lessons.  These grantees found that success required:  that professionals from various disciplines be involved early in the development of training; that needs assessments were essential in assuring curricula addressed the needs of their target populations.  In addition, evaluations indicated that outreach and recruitment of potential trainees is extremely difficult because professionals in these fields have to meet numerous time commitments and are likely to be skeptical about the quality and value of additional training.  Successful projects involved both management and line staff in training and used a variety of training strategies emphasizing interactive methods.

Enhancing Risk Assessment, Needs Assessment, and Referral Capacity

Unless workers can appropriately identify risk to children, accurately assess client needs, refer clients to appropriate services in their communities, and evaluate clients' progress, treatment plans are likely to be based on inadequate, erroneous, or useless information.  Yet many child protection risk assessments barely mention substance abuse (Dore et al, 1995).  The Child Welfare League of America recently found that 18 of 47 child protection risk assessment protocols reviewed did not address parental drug abuse, 19 did not address parental alcohol abuse and 35 did not include items about a child's potential substance abuse (CWLA, 1998).

There is further evidence that even when the issue does appear on forms, workers may be uncomfortable asking about it.  An NCCAN-funded study entitled Casework Decision-Making in CPS, based on the risk assessment model utilized in Washington State and interviews with workers there, found that substance abuse is one of the three risk factors most likely to be rated as "insufficient information to assess."  One explanation offered by the study's principal investigator is that workers are often questioned in court as to their qualifications to make substance abuse assessments and because most are not certified assessors, they tend to rate that factor as "insufficient information to assess" unless they have clear evidence of such a problem.  Washington State now requires workers to order a substance abuse evaluation in the absence of clear, sufficient information (English, 1998).

An important set of innovations regarding assessment and referral of maltreating parents to substance abuse services is occurring in the State of Delaware under a Federal demonstration project.  Under normal circumstances, Federal foster care funding under title IV-E of the Social Security Act may be used only for foster care maintenance payments on behalf of eligible children in foster care as well as for expenses related to the administration of foster care.  Delaware requested and has received a demonstration waiver allowing the State to use some of these funds for a system of substance abuse assessment and referral.  This system provides for staff from the substance abuse agency to be located in child welfare offices to do substance abuse assessments and to identify appropriate substance abuse treatment resources for those parents who need them.  While the project has not yet been operating long enough for thorough evaluation, initial results show that the demonstration is improving the engagement of clients in substance abuse treatment services.  Indications so far are that foster care costs for families participating in the demonstration will be significantly reduced in comparison to the control group (Lockwood, 1998).  The State of New Hampshire will begin a similar demonstration soon, to further test the efficacy of using substance abuse assessment and referral staff in a child welfare agency.

Outstationing substance abuse staff to child welfare agencies is also occurring in other communities using more standard financing mechanisms, most often using State or Federal substance abuse treatment funds.  Such co-location allows more timely and accurate substance abuse assessments than might otherwise be available to a child welfare agency.  Another alternative is for a child welfare agency to arrange with local substance abuse services providers to set aside several assessment appointments per week (based on the child welfare agency's typical need) that are designated as the slots for parents whose children have just been placed in foster care or on whom child abuse or neglect complaints have just been substantiated.  In this way, long waiting lists for assessments can be avoided for these parents in crisis, and the child welfare agency can quickly determine what substance abuse services should be included in a family's service plan.

Key to making appropriate service referrals is knowing the treatment providers in the local community and the services they offer.  Social service agencies are now a relatively minor source of referrals to alcohol and other drug treatment facilities.  One recent study revealed that in 1996, 7.2 percent of referrals to alcohol and drug programs were from welfare and social service agencies, including child welfare (Horgan & Levine, in press).  As ongoing working relationships are established, it is essential that substance abuse treatment providers understand what the child welfare agency is expecting treatment to accomplish, and that, in turn, the child welfare agency understands what substance abuse treatment can provide.  To the extent that these expectations are not entirely compatible initially, ongoing discussions may be needed.

As child welfare agencies become more active sources of substance abuse treatment referrals, a number of administrative procedures may be necessary to facilitate the ongoing exchange of information about joint clients.  For instance, establishing processes to get consent from the client at the time of referral for the sharing of treatment information between the child welfare and substance abuse agency can avoid considerable frustration and delays later on when the child welfare agency wants information regarding the results of an evaluation or the client's progress in treatment.  In most cases child welfare clients are willing to sign release of information forms because they are eager to cooperate in order to retain or regain custody of children.  Establishing Qualified Service Organization Agreements (QSOAs) between service providers is another way of assuring that information can be shared on behalf of clients within the scope of Federal drug treatment confidentiality guidelines.  As discussed in chapter 6, under a QSOA, in certain circumstances client-specific information may be shared between the substance abuse treatment agency and another agency providing services to the program and its clients without the consent of individual clients.

In many communities, substance abuse treatment providers routinely provide biweekly or monthly progress reports on clients to their referral sources.  Child welfare agencies may wish to work out such arrangements with their treatment agency partners to assure that they have timely and up-to-date information upon which to base case decisions.  Agreeing ahead of time on formats and content for such updates may also help assure the usefulness of information exchanged.

Increasing the Availability, Access, and Appropriateness of Substance Abuse Treatment for Families

Child welfare agencies consistently report difficulty obtaining substance abuse treatment for clients who need it, particularly programs that are designed to meet the specific needs of women with children.  The Child Welfare League of America reports that agencies can obtain timely treatment for only one-third of clients who need it, and only 10 percent of agencies report being able to find treatment within a month for most who need it.  Also disturbing is the fact that many agencies report being unaware of whether treatment is available in their communities (CWLA, 1998).  Until clients have access to treatment services it is unrealistic to expect significant improvement in problems surrounding their substance abuse.

Often a family crisis, such as a child protective services intervention, is the catalyst needed to prompt a substance abusing parent to seek treatment.  The resolve of an addicted person is often short lived, however, and unless treatment is available promptly the opportunity for intervention may be lost.  This is another issue on which different views of a problem may create misunderstanding between substance abuse and child welfare agencies.  If, for instance, half of a child welfare agency's referred clients cannot locate treatment or are placed on long waiting lists which fail to result in services, the child welfare agency may very well consider those clients as treatment failures.  The substance abuse agency, however, is likely to argue that they should not be held responsible for the "failure" of a client who has never entered their program or received a service.  In addition, some treatment programs are reluctant to accept clients who may not be entering treatment voluntarily.  Regardless, the reality is that the substance abuse has not been addressed and the client's problems continue.

Nationally there is a shortage in all varieties of publicly funded substance abuse treatment opportunities for those in need.  As noted in Chapter 4, only 37 percent of mothers with problem levels of drug use who are living with children under age 18 and 48 percent of such fathers received treatment services in the past year (SAMHSA, 1997d).  In addition, substance abuse patterns vary greatly regionally and locally.  This fact, coupled with the significant gap between available treatment capacity and current demand, often impedes the ability of the existing treatment system to respond quickly to changing needs.  Within States, the needs of a variety of treatment-seeking populations must be balanced.  Competing demands for services for criminal justice clients, HIV+ clients, and others under conditions of service scarcity often result in unpredictable and inconsistent funding for treatment programs and force treatment providers to constantly pursue new funding streams rather than concentrate on the provision of quality services.

In addition to the general problem of treatment availability, programs addressing parents' needs are in particular shortage.  The fact that parents, and in particular, mothers, have specific needs in treatment that most programs do not address has been widely observed (HHS/CSAT, 1994; Magura, 1998; Grella, 1997).  These needs may include child care, services to address parenting stress, economic and educational issues, reproductive health care services, psychological services, domestic violence services and more.  These services are generally not as applicable to male substance abuse treatment clients, but are essential for effective women's services.

Many comprehensive substance abuse treatment programs for women are the result of Federal grant initiatives from either the Substance Abuse and Mental Health Services Administration or the Administration for Children and Families, and most have very small client loads (Allen & Larson, 1998).  As demonstration projects and new Federal funds have become less available, it is unclear the extent to which these programs will survive with other funding sources.  Few States have extensive networks of substance abuse treatment programs geared toward women and children, and child welfare agencies spend little money to acquire substance abuse treatment for families.  The Child Welfare League of America's recent survey found that nearly half of States report spending no child welfare money at all on substance abuse treatment; the most active State spent 2 percent of its child welfare funds for this purpose (Child Welfare League of America, 1998).  When States were asked to identify the funding sources used for treatment for child welfare clients, State alcohol and drug agencies were such a minor funding source that they ended up in a category entitled "other," combined with a variety of funding sources that did not merit their own categories.

Funding Sources Child Welfare Agencies Report Using to Pay for Clients' Substance Abuse Treatment, 1997. See text for explanation.As Figure 7-1 illustrates, Medicaid is the funding source most often used by child welfare agencies to obtain treatment for clients.  Indeed, a majority of States cover substance abuse services through mandatory and optional Medicaid service benefits.  Medicaid coverage for substance abuse treatment is described at more length in Appendix A.  States are increasingly submitting State plan amendments to cover substance abuse services, both for children and adults, primarily using the optional rehabilitation benefit, because of its flexibility.

During our consultation process, a number of experts pointed out that a significant limitation in Medicaid's coverage of substance abuse treatment services is the prohibition on payments to certain facilities classified as institutions for mental diseases (IMDs).  As currently defined, an IMD is any facility of more than 16 beds that specializes in psychiatric care.  This includes most residential substance abuse treatment programs.  Thus, for clients aged 22 - 64 whose payment source is Medicaid, the IMD exclusion significantly limits access to the more intensive models of substance abuse treatment, which are often indicated for the most severely addicted clients.

The IMD exclusion, which dates back to the 1950s, applies to Alcohol, Drug Abuse, and Mental Health (ADM) inpatient facilities.  Since the general trend in the total system has been to outpatient or partial care since 1972, the IMD policy now limits Medicaid payment for a smaller proportion of total ADM services today than it did in years past.  The IMD statutory definition that exempts facilities of under 17 beds should further reduce this proportion.  The two types of inpatient facilities most clearly meeting the IMD criteria are State and county mental hospitals, and private psychiatric hospitals.

Despite the IMD exclusion, a number of States and localities have found ways, within the existing rules, to make residential-like substance abuse treatment services eligible for Medicaid reimbursement.  Exhibit 7-A describes a number of these methods which may be used to expand treatment access.

Exhibit 7-A:
State Methods Used to Ease the Effect of the Institutions for Mental Diseases (IMD) Exclusion

Many States looked to the following methods as a way to address treatment access and lessen the effect of the IMD exclusion in order to provide substance abuse services to their Medicaid population.

Size Limits.  Psychiatric hospitals and psychiatric nursing facilities that have fewer than 17 beds are not IMD's and are not subject to the exclusion.  Patients in facilities, such as many substance abuse treatment facilities, continue to be Medicaid funded for covered services if the facility has fewer than 17 beds.  Larger facilities are being legally divided into a number of smaller facilities with fewer than 17 beds each.

Mergers.  Psychiatric hospitals are merging with general hospitals that are somewhat larger so that the resulting entity is not an IMD, but a general hospital with a large psychiatric "wing."  This type of merger can be accomplished largely via legal paperwork and seems to be an increasingly popular way to negate IMD status.  If a psychiatric hospital is larger than the general hospital, a portion of the psychiatric hospital that is smaller than the general hospital merges with the general hospital — or just uses a general hospital for all psychiatric care.

During the 1990s, five States (MD, MA, NY, SC and WA) expanded services for pregnant substance abusing women using Medicaid waivers initiated as demonstration projects.  The demonstrations varied widely, but included the following components:

Most States chose to modify and enhance existing substance abuse treatment programs; none developed entirely new programs.  Howell and colleagues (1988) have described the projects in detail.  Each site had significant difficulty engaging clients in program services.  The experiences of these projects may be a source of insight for others considering service expansions.  The significant differences in program designs across States made the detection of cross-site results difficult.

Some States have begun to address treatment access issues by building networks of treatment programs, sometimes with services specifically designed for women and parents.  In Missouri, for instance, the State has invested in a series of programs called the Comprehensive Substance Abuse Treatment and Rehabilitation program (CSTAR).  CSTAR is a flexible model emphasizing community-based service provision in an intensive outpatient model, beginning with programming seven days per week, ten hours per day that tapers off as recovery is established.  Case management, family therapy and co-dependency counseling are among the components included in addition to more traditional substance abuse counseling.  Child care and supported housing are also available.  Using this model the State treats approximately 2,000 women and over 6,000 children annually and has achieved good recovery rates and satisfaction ratings from clients (Jordon, 1997).

Eight States have also begun using some of their funding under the Promoting Safe and Stable Families Program (formerly the Family Preservation and Support Program), authorized under title IV-B, subpart 2 of the Social Security Act, to pay for substance abuse assessment and treatment services for some clients.  While substance abuse services are among the relatively minor uses of these funds (in contrast, thirty States support parent skills training, 23 States support respite care and 17 support recreation programs using these funds), such services are a growing category of State spending under this program (Kaye and Ensign, 1998).  These funds are a flexible source of funds States use to serve families, primarily those at risk of child abuse or neglect.

Another opportunity for States to expand treatment access is through Child Welfare Demonstration Waivers.  These demonstrations are intended to allow States the flexibility to try alternative means of addressing the child welfare needs of families through use of existing foster care and related funding streams for activities that are not usually allowable under titles IV-E and IV-B of the Social Security Act.  The announcement to States soliciting applications for the Fiscal Year 1998 and Fiscal Year 1999 application cycles have included a Federal priority for addressing the substance abuse treatment needs of families in the child welfare system.  Among the initial ten States receiving Child Welfare Demonstration Waivers, only one (Delaware, described above in the section on assessment and referral) identified itself as intending to address the problem of substance abuse and its relationship to child maltreatment.  Among the Fiscal Year 1998 demonstrations, one addresses substance abuse as its main focus (New Hampshire) and one more includes it as a sub-focus (Kansas).  The remainder address it only indirectly.  States may wish to look toward the use of this demonstration waiver mechanism in the future as they seek innovative ways of addressing substance abuse in families where child maltreatment occurs.  The Department of Health and Human Services has the statutory authority to grant additional waiver demonstrations, up to ten per fiscal year.  Demonstrations may last up to five years (although under some circumstances they may be extended), must be cost-neutral to Federal child welfare programs over five years (that is, they must cost no more to these programs than would be spent under current law, although funds may be spent in alternative ways), and must have strong evaluations.

Promoting Client Retention and the Effectiveness of Services

Closely related to access and appropriateness of treatment are retention and effectiveness.  Substance abuse treatment has been found to be effective for many people in both the short and long terms as well as cost effective for taxpayers and society.  Outcomes for substance abuse treatment are closely linked to clients' length of stay and treatment completion.  Typically, the longer the client is in treatment, the better the outcomes.  Generally, few positive long term outcomes are seen unless the client is in treatment for at least three months (Hubbard et al, 1989).  Treatment may still be cost effective for shorter treatment episodes and for persons who do not maintain long term abstinence, (because of reduced crime, health care and other such costs while the person is in treatment and afterwards) but it is less likely that short stays produce long-term behavior change.

Effectiveness studies of substance abuse treatment programs consistently find positive outcomes, including reduced alcohol and other drug use, reduced criminal activity, improved health outcomes and improved employment and earnings.  For instance, the National Treatment Improvement Evaluation Study (NTIES), an examination of 4,400 clients who received treatment services in 1993-94 in programs funded at least in part by SAMHSA's Center for Substance Abuse Treatment, found that one-year post-treatment abstinence rates for 495 women seeking to regain or retain custody of children were highest for cocaine users (70-71 percent for powdered cocaine users and 52-62 percent for crack cocaine users) and were lowest for those who sought treatment primarily for alcohol problems (only 26-37 percent of these clients remained abstinent throughout the year after treatment).  Figure 7-2 shows one-year abstinence rates by treatment modality for female clients seeking to regain custody of children. 

Figure 7-2. Abstinence Rates One Year Post Substance Abuse Treatment for Female Clients Seeking to Regain Custody of Children by Treatment Modality, 1996.

Figure 7-3 shows this data by primary drug of abuse. 

Figure7-3. Abstinence Rates One Year post Substance Abuse Treatment for Female Clients Seeking to Regain Custody of Children by Primary Drug of Abuse, 1996.

Further, in addition to outcomes related to abstinence, women in these treatment programs showed improvements in other dimensions.  These included reduced crime and violence, increases in employment, and reduced mental health concerns.  For instance, among women seeking to regain child custody, the prevalence of prostitution declined from 54 percent in the year before substance abuse treatment to 17 percent in the year after treatment.  The study found that in this population, outcomes for outpatient treatment programs were generally similar to those for residential programs (Burgdorf, 1998).

Family and child custody outcomes appear to have improved for some NTIES clients following treatment, as shown in Table 7-A, although the relationship between treatment outcome and child custody outcomes was not strong.  Of female clients seeking to regain custody of children and remaining abstinent in the year post-treatment, 39 percent were living with more children after treatment than at admission.  Of female clients seeking to regain custody but who had negative outcomes, 26 percent were living with more children post-treatment.  Overall, 32 percent of the female clients who sought to regain custody of their children reported living with more children after treatment than before.  It seems likely that many of these were living with additional children because of successful reunification efforts (Burgdorf, 1998).

Table 7-A.
Relationship Between Substance Abuse Treatment Outcomes and Family Maintenance/Reconciliation Among NTIES Clients Who Entered Substance Abuse Treatment for Custody-Related Reasons, 1996
CLIENT MOTIVATION FOR SUBSTANCE ABUSE TREATMENT, GENDER, AND TREATMENT OUTCOME

NUMBER OF CLIENTS
POST-TREATMENT CHANGE IN NUMBER OF CHILDREN
(row percent)
FEWER SAME MORE
Clients seeking to regain custody
     Women:
          Positive outcome (abstinent)
          Negative outcome (not abstinent)
     Men:
          Positive outcome (abstinent)
          Negative outcome (not abstinent)


185
210

162
213


12
15

12
17


49
59

67
66


39
26

20
16
Clients seeking to retain custody
     Women:
          Positive outcome (abstinent)
          Negative outcome (not abstinent)
     Men:
          Positive outcome (abstinent)
          Negative outcome (not abstinent)


44
56

39
39


20
29

54
44


70
48

41
51


9
23

5
5

Source:  U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.  National Treatment Improvement Evaluation Study, (re-tabulations of 1996 study data by CSAT's National Evaluation Data Services).

NTIES clients who were motivated to enter substance abuse treatment by a desire to maintain custody of their children were more successful.  Of these clients, 51 percent of the male clients and 75 percent of the women reported no reduction, post-substance abuse treatment, in the number of children they were raising.  For male clients seeking to retain or regain custody there was essentially no relationship between treatment outcome and whether or not a client was living with their children.

Child welfare outcomes are rarely measured by substance abuse treatment programs, but early results from SAMHSA grantees operating substance abuse treatment programs targeting women with children report that 75 percent of their clients who successfully completed treatment remained drug free; 46 percent obtained employment following treatment; and 65 percent of clients' children in foster care were reunited with their families (HHS/SAMHSA, 1995).

Recently released findings from the Services Research Outcome Study (SROS), a five-year follow up of over 1,800 substance abuse treatment clients discharged from treatment in 1989-1990, show that substance abuse declined substantially in the five years after treatment (Figure 7-4).

Figure 7-4. Average Declines in Clients' Use of Selected Drugs at least 5 Times During the 5 Years Before and After Substance Abuse Treatment.

A minority of clients were abstinent, or nearly so, for a full five years after treatment.  Women consistently had greater declines in drug use than did men (Figure 7-5).

Figure 7-5. Declines in Clients'Use of Selected Illicit Drugs at Least 5 Times During the 5 Years Before and After Substance Abuse Treatment, by Gender.

The number of clients who reported having lost custody of children declined by 30 percent five years after treatment as compared with the five years before treatment (HHS/SAMHSA, 1998b), indicating that many had been reunited with absent children during this period.

A variety of individual evaluations of women's treatment programs have also found positive outcomes.  A study of PAR Village, a residential substance abuse treatment program for women and children in Florida, found positive outcomes such as reduced alcohol and drug use and reduced criminal behavior.  Success rates of over 80 percent were reported for those who completed treatment (Hughes, 1994).  A therapeutic community program in Arizona reports that 77 percent of treatment completers had at least one of their children living with them 6 to 12 months post treatment, as compared with 52 percent of treatment dropouts (Stevens and Arbiter, 1995).

While many treatment clients show improvements in a variety of areas, abstinence and other positive outcomes are not universal by any means, and improved outcomes are needed in several areas.  In particular, substance abuse treatment programs are known for high drop out rates that typically run upwards of 50 percent and may approach 80 percent in some instances.  A recent report from the U.S. General Accounting Office (USGAO, 1998) found that of substance abusing parents whose children have been in foster care at least one year in Illinois and California, most had either never entered substance abuse treatment (42 percent in Illinois and 40 percent in California) or had dropped out of treatment (34 percent in Illinois and 40 percent in California).  Fewer than 20 percent in each State had completed treatment or were currently enrolled in a treatment program (Figure 7-6). 

Figure 7-6. Treatment Status for Substance Abusing Parents of Children in Foster Care at Least One Year, 1997.

Along similar lines, Wobie and colleagues (1997) report a 38 percent completion rate for women entering a residential treatment program for mothers with infants.  Connecticut's Project SAFE reports that only 30 percent of clients assessed as needing treatment and referred to treatment programs actually enroll (Sheehan and Libby, 1998).  Zlotnick (1996) reports dropout rates ranging from 52 percent to 78 percent.  And Stranz and Welch (1995) report that 45 percent of their sample of mostly CPS-referred clients completed an intensive day treatment program for women with children - not ideal, but more than double the 21 percent completion rate for participants in a traditional outpatient program that served as their comparison group.  Famularo and colleagues (1989) found that 80 percent of parents failed to comply with substance abuse treatment ordered by courts in order to retain or regain child custody, and fewer than 10 percent of parents attended at least two-thirds of treatment sessions.  Clients addicted to alcohol and illicit drugs were equally non-compliant.  When looking at substance abuse treatment outcome studies it is important to understand the base group for whom outcomes are being reported.  Often outcomes are reported only for those who complete the full course of treatment.  Alternatively, data may be reported for all clients referred to treatment, even those who may have participated for as short a time as one day.

In large part because of such high drop out rates, the effectiveness of treatment is often challenged, particularly in the child welfare community.  In what are reasonably typical responses, an Ohio study found that substance abuse treatment was judged "not very effective" by more than half (53 percent) of child welfare caseworkers.  An additional 21 percent rated it as "somewhat effective," 14 percent said it was "adequate" and 12 percent thought treatment was "very effective" (The Public Child Services Association of Ohio, 1995).

Research suggests that providing child development, health care and other services to children of drug abusers promotes improved treatment outcomes for parents, including longer treatment stays (Stevens et al, 1989) and reduced frequency of relapse (Kumpfer, 1998).  The provision of child care has similarly been shown to improve treatment retention (Beckman and Amaro, 1986) and its lack has been shown to be a treatment barrier (Brown, 1992).  Studies of parent-oriented treatment programs also find improvements in family functioning.  Olsen (1995) found that a majority of mothers participating in a comprehensive, multi-agency collaborative treatment program made steady progress on goals related to substance abuse.  Families also showed improvements in housing, mental health, knowledge of child development and other related issues.  Magura and colleagues (1998), looking at intensive family treatment programs in New York City, found positive outcomes on many indicators, although not on foster care reunification rates.  Liddle and Dakof (1995) review the literature on the use of family therapy in drug treatment and conclude that several models of family intervention show promise as a means to engage and retain clients in treatment, reduce drug use and improve family functioning.  Research has also shown that parenting programs can improve parenting knowledge, attitudes, and practice of women with substance abuse problems (Camp and Finkelstein, 1997; Black et al, 1994).

Evaluations of programs funded in the early 1990s by the National Center on Child Abuse and Neglect to provide services to substance abusing families with child maltreatment issues documented a number of positive outcomes.  For instance, a number of projects were successful in getting parents to enter and remain in substance abuse treatment.  Some grantees achieved higher rates of treatment completion and longer periods of abstinence than had previously been attained.  Also reported were more effective discipline techniques among parents; better understanding of and response to meeting children's needs; more nurturing behaviors toward the children and less use of corporal punishment; and improved communications between parents and children.  Projects noted that while there were families who showed little or no progress, there were also many families who became committed to recovery and healthy parenting.  For these clients, programs became a lifeline and parents often became strongly attached both to project staff and to other clients who became a social support network to replace the unhealthy networks developed while immersed in the drug culture (HHS/NCCAN, 1995a).

In Illinois, Project SAFE and its successor, the Illinois Treatment Expansion Initiative, have for a number of years, worked hard to engage child welfare clients in substance abuse treatment services (USGAO, 1998).  Project staff have found that intensive, persistent outreach services are essential to engaging this client population in treatment.  Their efforts seem to have paid off.  Outcomes for initial clients included 81 percent treatment completion rates, with 51 percent of clients judged as having good or excellent prognosis.  More than half of clients' children in foster care (54 percent) had been reunified with their parents (White, 1995).  Others have also found that effective outreach is essential with this population (HHS/NCCAN, 1995b).

The experience of substance abuse treatment programs, particularly those geared towards parents and their children, demonstrates that many clients can and do improve their lives and many are able to resume their parenting roles.  Service providers have discovered repeatedly, however, that these clients are extremely difficult to engage and to retain in treatment programs.  However, programs geared specifically to the needs of women and their children and with highly trained outreach and treatment staff are more likely to get and keep women in treatment.  We must do a significantly better job in this regard if treatment progress is to be made within the time frames mandated by the Adoption and Safe Families Act.  Improving access to family services, psychological treatment, and other wrap-around services that have declined in recent years (Etheridge et al, 1995) may improve retention rates.  Closer collaboration with child welfare agencies may also be helpful in this regard.

Improving Time Lines and Decision Making for Children

Among the key issues in improving child welfare services is ensuring that permanency decisions are made in keeping with a child's developmental time line.  Children should not have to wait indefinitely for a permanent home, be that with their biological parents or in an alternate home with adoptive parents or relatives.  The pace of casework, court procedures, and appeals has often meant, however, that children are left in limbo far too long.  By the time many of them find permanent homes, they have spent much of their childhoods and developmental years in temporary living situations.

Among the goals of the Adoption and Safe Families Act is to speed decision making regarding permanent homes for children and avoid such delays.  Rather than only making administrative machinery work faster, many communities are trying also to work smarter.  Innovations being tried include using the leverage of child protective services involvement to require treatment participation, adapting criminal drug court models to the family court, and concurrent planning.  Concurrent permanency planning is an alternative to the traditional sequential case planning process, in which, at the same time services are being provided to achieve family reunification, alternative permanency options for the child are also being explored in the event that the child cannot be safely returned to the biological parent(s).  The goal is to expedite the permanency process for those children who may linger in foster care.

Common to the variety of innovations being developed in communities to improve outcomes for children in foster care are that: 

  1. efforts to resolve the issues which led to maltreatment must begin immediately;
  2. clients should receive up-front, clear disclosure regarding the consequences of a lack of participation or progress;
  3. appropriate intervention plans are developed with the family's involvement and are closely monitored; and
  4. lack of progress or non-compliance is dealt with swiftly. 

Whether initiated from the child welfare agency or the court, the notion of mandating treatment and closely monitoring compliance and outcomes is a relatively new concept in child welfare.  Social services generally, and reunification services specifically, have traditionally been offered on a voluntary basis.  As noted above, however, purely voluntary models have not resulted in high completion rates.  In response, particularly in light of data showing that treatment completion is higher among clients whose participation is mandated by the criminal justice system (Collins et al, 1983; Haller et al, 1993), some child welfare agencies began asking their family court judges to mandate treatment for some clients.

Pressure from a child welfare agency can be helpful for treatment retention.  Carten (1996) reports that interviews with women who successfully completed a substance abuse treatment program in New York City often said that "although they initially experienced their CPS referral as intrusive and unfair ... the ever-present threat that their children would be placed in foster care provided the external pressure to continue in drug treatment."  Similar information is reported from a Rhode Island program (Caldwell, 1998) that found most of its clients entered treatment primarily because of child welfare mandates and indicate that most clients would not have stayed in treatment without them.  Indeed, this program reports that most of those who dropped out did so shortly after such a treatment mandate ended.  A downside of mandatory treatment efforts, and particularly programs that seem to punitively jail women for refusing treatment, is that potential clients are more likely to hide from service systems, possibly placing children at greater risk.

In 1992, the National Council of Juvenile and Family Court Judges issued its Protocol for Making Reasonable Efforts to Preserve Families in Drug-Related Dependency Cases.  The protocol suggests factors judges should consider in making custody and permanency decisions regarding child protection cases involving substance abuse, suggests services that should be made available to families as part of "reasonable efforts," and discusses opportunities for judicial leadership.  Juvenile and family courts can provide initiative in mobilizing resources for families coming before them and monitoring agencies' activities and families' progress to assure the best possible outcomes for children.

Building upon the notion of treatment mandates is the swiftly growing innovation of drug courts.  Now common in the criminal court system, the use of treatment mandates with intensive follow-up procedures and strict sanctions for noncompliance is now being tried in several family court settings around the nation.  When used in criminal cases, drug courts have been found consistently to achieve much better treatment retention rates; substantially reduced drug use and criminal behavior during the participation periods; and, to a lesser but still significant extent, reduced criminal behavior following program participation (Belenko, 1998).  Drug courts are designed to improve the court's handling of cases involving substance abuse by providing:

Family drug courts were operational in only six jurisdictions nationally as of January 1998, but are expected to proliferate quickly.  Extensive information regarding these programs is available in a recent Department of Justice publication, Juvenile and Family Drug Courts:  A Profile of Program Characteristics and Implementation Issues (Office of Justice Programs Drug Court Clearinghouse and Technical Assistance Project at American University, 1998), and several family drug court programs are profiled in a recent publication of the National Center on Addiction and Substance Abuse at Columbia University (1999).

Concurrent Planning is a casework approach that has recently become popular as a tool to improve the timely achievement of permanency for children.  Traditionally, case workers have been taught to work diligently toward the singular goal of family reunification.  Only after a year or more of unsuccessful efforts could other permanency options (such as adoption) be considered.  Adoption planning from scratch could then take additional years, further prolonging uncertainty for the child.  Concurrent planning instead emphasizes working toward reunification while at the same time establishing one or more "back up" permanency plans to be implemented if reunification proves unlikely.  By considering a variety of permanency alternatives from the start and by engaging parents and other family members more effectively in early discussions of children's needs and permanency options, children's lives can be stabilized more quickly, in keeping with children's developmental time frames.

Concurrent planning provides the opportunity and the challenge for caseworkers and families to realistically face the problem(s) which prompted the child's removal, collaborate in planning interventions and following through on treatment, within the much more stringent time lines detailed in ASFA.  Agencies and families must honestly acknowledge the external constraints of the new time lines, which imply a new type of accountability.

Supporting Recovery

One of the frustrations frequently expressed by professionals working with families with substance abuse and child maltreatment problems is that significant setbacks often occur after long strides have been made, particularly in the weeks immediately following discharge.  During our consultation process, we heard from a number of sources comments such as, "we can get these clients clean and sober.  It's the longer term, after we step back, that's the problem."  Families often lack the ongoing support structures, formal and informal, that make sustained recovery possible.  Especially important in ongoing recovery efforts are that the client learns the skills to create drug-free leisure time effectively after treatment and socialize without intoxicants.

Recovery is a lifelong process, but the substance abuse treatment field has come to view chronic relapse as a preventable part of the recovery process (HHS/SAMHSA, 1996a).  There are predictable causes of relapse during each stage of recovery.  For instance, during early recovery (described in Chapter 2 and which encompasses the first year to two years of sobriety), it is the lack of effective social and recovery skills needed to build a sobriety-based lifestyle that is the major cause of relapse.  By understanding these issues and teaching clients the skills they need to successfully overcome them, substance abuse treatment programs can reduce relapse rates.  Child welfare agencies can also assist in this process by recognizing how their actions regarding custody, visitation and other family issues affect the recovery process.  Without needed support, even positive actions like the return of custody can undermine recovery.

Most of our interventions with families are designed to be short term.  Indeed, the main Federal child welfare program directed at these problems was for years called the Emergency Services Program, calling forth images of short term interventions which grantees subsequently found completely inadequate to address the complex family situations confronting them.  One of the most common themes in grantees' progress reports and process evaluation results was that intervention periods needed to be much longer than grantees anticipated (HHS/NCCAN, 1995b).  Grantees of ACF's Abandoned Infants Assistance program, intended to prevent the abandonment of drug-exposed and/or HIV+ infants, as well as SAMHSA grantees serving these clients, had similar experiences, often extending their intervention periods beyond their initial expectations.

Continuing care for this population is critical.  Without it, relapse rates are high, even after long periods of sobriety while in treatment.  It is at this point in treatment that the need for safe, affordable and sober housing is especially critical.  Also, because issues related to substance abuse, such as a client's possible history of sexual abuse or incest, may go beyond the scope of substance abuse treatment, ongoing efforts to address such issues may need to continue long after leaving formal substance abuse treatment.  For recovery to be successful, treatment counselors must help the client identify stressful areas in her life and learn to locate and use resources to deal with the stress.

Some have suggested that we may need to rethink the short term way in which we conceptualize child welfare interventions and instead provide longer term interventions for at least some families.  The current movement toward two-track child protective services systems with many families receiving non-coercive, community-based support may be an opportunity to provide such longer-term services.  Post placement support services, provided after a child returns home in order to assure the success of reunification, can also play this role.  Such services may also be developed and implemented using the Promoting Safe and Stable Families Program (formerly the Family Preservation and Family Support Program) administered by the Children's Bureau.  However they are provided, services of this sort can help assure child safety and family stability on a more ongoing basis and prevent the need either for initial foster care placements or for the re-entry of children into foster care following reunification.

Building a Stronger Continuum of Interventions

Specialized services for female substance abusers, particularly those who are parents, is a relatively new concept in substance abuse treatment, one which has developed considerably over the past decade.  During that time as well, the child welfare field has come to recognize that substance abuse is among the most pressing problems facing families who neglect or abuse their children.  While these fields have a long way to go in improving how they work together to serve their mutual clients, we have learned a great deal about what it takes to produce positive outcomes for these parents and children.  Improved efforts across a wide spectrum of activities from prevention through aftercare are needed in States and communities across our nation.  While we do not believe that any of us yet has put in place an entirely satisfactory network of interventions, the examples and research results described above demonstrate that we have solid indications of how outcomes can be improved at each stage of intervention.  Strengthened partnerships between child welfare and substance abuse professionals are key to many of these innovations.


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