In a field where difficult decisions are made every day, child welfare workers face particular dilemmas when working with the extremely troubled families whose complex and multiple problems include both substance abuse and child maltreatment. Central to their challenge is that addiction to alcohol and other drugs can be a chronic, relapsing disorder and recovery can be a long term process. At the same time, children have an immediate need for safe and stable homes in which to grow up.
Substance abuse (including both licit and illicit drugs) can impair a parent's judgment and priorities, rendering the parent unable to provide the consistent care, supervision and guidance children need. For child welfare workers it is difficult to determine what level of functional improvement will enable a parent with substance abuse problems that have precipitated child maltreatment to retain or resume his or her parental role without jeopardizing a child's safety, particularly as relapse remains a significant possibility. With the implementation of the Adoption and Safe Families Act (ASFA, P.L. 105-89) and renewed emphasis on achieving permanency for children in the child welfare system, finding effective ways to address concurrent substance abuse and child maltreatment problems in families takes on renewed importance.
Section 405 of ASFA requires that the Secretary of Health and Human Services prepare a Report to Congress on substance abuse and child protection, describing: (1) the extent and scope of the problem of substance abuse in the child welfare population; (2) the types of services provided to this population; (3) the effectiveness of these services; and (4) recommendations for legislative changes that might be needed to improve service coordination. This document fulfills this legislative mandate. Although intended for Congress, the report will also be of interest to other national, State, and local policy makers concerned with the interrelationships between substance abuse and child maltreatment.
Understanding Addiction, Substance Abuse Treatment, and Recovery
Substance abuse is a major public health problem that affects millions of people and places enormous financial and social burdens on society. Addiction can be a chronic, life-threatening condition. Most people whose use has progressed to addiction cannot simply stop using alcohol or drugs, no matter how strong their inner resolve, without one or more courses of structured substance abuse treatment. Like virtually any other medical treatment, addiction treatment cannot guarantee lifelong health. Relapse, often part of the recovery process, is always possible. Even if a person never achieves perfect abstinence, addiction treatment can reduce the number and duration of relapses, minimize related problems such as crime and poor overall health, reduce the impact of parental addiction on children, and improve the individual's ability to function in daily life. Nearly one-third of substance abuse treatment clients achieve sustained abstinence from their first attempt at recovery. An additional one-third have a period of relapse episodes but eventually achieve long-term abstinence. The remaining third have chronic relapses that result in eventual death from complications of their addiction.
The Nature of Child Maltreatment
Child abuse and neglect is also a widespread problem in American society. Child maltreatment is commonly divided into four categories:
- physical abuse, characterized by physical injury resulting from beating, kicking, burning, or otherwise physically harming a child;
- neglect, which includes the failure to provide for the child's basic needs;
- sexual abuse, comprising a variety of sexual behaviors toward children; and
- emotional maltreatment, such as acts of commission or omission by the parents or other persons responsible for the child's care that have caused serious behavioral, cognitive, emotional or mental disorders.
The majority of all child protection reports (61 percent in 1996) involve the neglect of children. Neglect is especially predominant in child maltreatment reports in which the parent has a substance abuse problem.
Extent and Scope of the Problem
While parents abuse alcohol and other drugs at lower rates than do persons without children, 11 percent of U.S. children, 8.3 million, live with at least one parent who is either alcoholic or in need of treatment for the abuse of illicit drugs. Of these, 3.8 million live with a parent who is alcoholic, 2.1 million live with a parent whose primary problem is with illicit drugs, and 2.4 million live with a parent who abuses alcohol and illicit drugs in combination. These children are distributed relatively evenly across the childhood age span, although child welfare agencies are more likely to encounter younger children. While they have received the majority of attention, children prenatally exposed to drugs and alcohol represent only a small proportion of the children affected and potentially endangered by parental substance abuse.
Few of the children living with parents who have substance abuse problems come into contact with the child welfare system. Of children prenatally exposed to drugs, most studies find that approximately 10 to 20 percent enter foster care around the time of birth and that about a third do so within a few years. Others are cared for by relatives who may or may not have legal custody. Most remain in their parent(s)' care for all or most of their childhoods.
Parents who are alcoholic or are in need of treatment for the abuse of illicit drugs are demographically quite similar to the U.S. population as a whole. They are as likely to be fathers as mothers, although mothers with substance abuse problems are much more likely than fathers to be reported to child protective services. African American women with substance abuse problems are more likely to be involved with child welfare agencies than are similar women of other races. Many parents, especially mothers, who enter substance abuse treatment are motivated to do so out of concerns about their parenting and how their substance abuse is affecting their children.
For many children who are reported to the child welfare system, parental substance abuse is a critical factor. While figures vary for methodological reasons, most studies find that for between one-third and two-thirds of children involved with the child welfare system, parental substance abuse is a contributing problem (lower figures tend to involve child abuse reports and higher findings most often refer to children in foster care). Children with open child welfare cases whose parents have substance abuse problems are younger than other children in the child welfare system, are more likely to be the victims of severe and chronic neglect, are from families with more problems overall, and are more likely than other children to be placed in foster care rather than served while remaining at home. Once in foster care, children whose parents have substance abuse problems tend to remain in care for longer periods of time than other children.
The Complexity of Child and Family Needs
Families involved with the child welfare system are among the most troubled in our society. In maltreating families, child abuse and neglect are rarely the only issues. Even addiction, while among the most common of the co-occurring problems, is rarely the only serious problem. Mental illness is often present, as are domestic violence and HIV/AIDS. Most families involved with child welfare agencies have very low incomes, and inadequate or unsafe housing are very significant issues, particularly in urban areas. These difficulties combine in the lives of these families to produce extremely complex situations and relationships that are challenging to resolve. The presence of so many serious problems 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 family 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.
No less complex than the problems of substance abusing parents are their children's needs. The two main research findings regarding children of parents with substance abuse problems are that (1) these children 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. Prenatal abuse of alcohol appears to have more severe and long-lasting effects on development than do cocaine and other illicit drugs, including serious intellectual and behavioral consequences in many children. Babies who were prenatally exposed to cocaine or other drugs may experience a range of problems, however, including some that can be long-lasting and serious. These physical and mental deficits are not seen in infants to the overestimated extent that earlier expert warnings and media reports regarding "crack babies" had predicted . 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 outcome, including how the environment interacts with any direct effects of prenatal drug exposure.
The Context of Collaboration and Overcoming Barriers to Quality Service
While both the substance abuse treatment and the child welfare fields have the vision of healthy, functional families resulting from their interventions, in moving from the family's immediate situation to that end result, different perspectives and philosophies sometimes impede cooperation, engender mistrust, and can cause agencies to hamper one another's efforts and stymie progress. Several key differences in perspectives underlie the majority of misunderstandings and frustrations child welfare agencies and substance abuse treatment agencies feel toward one another. These include different definitions of who "the client" is; what outcomes are expected on what time lines; and potentially conflicting responses to setbacks. In addition, factors related to the legal and policy environments in which agencies operate set a context for joint activities and affect the willingness and ability of agencies to work together. These include State and Federal laws regarding child abuse and neglect and child welfare; the sense of crisis under which many child welfare agencies operate; chronic shortages of substance abuse treatment services, particularly services appropriate for women with young children; and confidentiality requirements of both fields that are often perceived as impediments to cooperation.
There are real and significant barriers to productive collaborations between child welfare and substance abuse agencies. But these differences can and must be accommodated. Doing so will require sustained efforts by Federal, State and local staff in the child welfare, substance abuse, and related fields throughout the nation - efforts to learn about one another, to understand one another, and to establish a shared set of expectations for each other and for clients.
Service Delivery Models Approaches to Addressing Joint Substance Abuse and Child Maltreatment Problems
Addressing the problems of substance abuse and child maltreatment requires interventions at a variety of levels. Among the clear lessons that have emerged from the decades of effort by dedicated service providers in both fields are that there are no easy answers and that what works for one family will not necessarily work for another. It is only by working together that agencies are likely to make progress in serving these families well. Efforts to address the dual problems of substance abuse and child maltreatment must include the following:
Valuing Prevention. 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 or neglectful parents. An effective approach to addressing substance abuse among parents and its harmful effects on children must include a strong prevention component.
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 identify both problems in families served. Training can improve the ability of workers to identify and intervene effectively with families.
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.
Increasing the Availability, Access and Appropriateness of Substance Abuse Treatment. 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. Until clients have access to quality substance abuse treatment services, it is unrealistic to expect significant improvement in problems surrounding their substance abuse.
Promoting Client Retention and the Effectiveness of Services. The experience of substance abuse treatment programs, particularly those geared toward 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 it is extremely challenging to engage and retain these clients in treatment programs.
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. Common to the variety of innovations being developed in communities to improve outcomes for children in foster care are that efforts to resolve the issues which led to maltreatment must begin immediately; appropriate intervention plans are developed with the family's involvement and are monitored closely; and lack of progress or non-compliance with the treatment plan is dealt with swiftly.
Supporting Ongoing 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. While recovery is a lifelong process, most interventions are designed to be short term. For this population, however, short term interventions may not be sufficient and continuing care is critical.
While the substance abuse and child protection fields have a long way to go toward improving how they work together to serve their mutual clients, a great deal has been learned about what it takes to produce positive outcomes for these parents and children. Improved efforts across a wide spectrum of activities are needed throughout our nation. While no community has yet put in place an entirely satisfactory response network, the examples and research results described in this report demonstrate that there are solid indications of how outcomes can be improved at each stage of intervention.
Where Do We Go From Here?
There are significant roles for service providers, program administrators and policy makers at all levels in order to improve services and achieve better outcomes for families with substance abuse and child maltreatment problems. Chapter 8 discusses actions the U.S. Department of Health and Human Services (HHS) will take in several areas to improve service provision to families affected by both substance abuse and child maltreatment, and also challenges service providers in the field to take steps to better address families' needs.
Building Collaborative Working Relationships. HHS intends to lead the field toward improving communications and developing common ground between the child welfare and substance abuse treatment fields. Our activities will include: (1) conducting leadership meetings that will convene national and regional discussions among agency leaders, service providers, and consumers of our services to begin the process of working through our different perspectives to build common ground; (2) preparing informational materials regarding substance abuse screening and assessment tools that can be used in child protective services contexts, and child safety assessments that may be useful for substance abuse treatment providers; and (3) funding a series of small grants to States and communities that will support the planning and implementation of joint strategies for service delivery, staff development and training, treatment retention, relapse management and post-treatment support.
We challenge State and community leaders in the child welfare and substance abuse fields, in consultation with the juvenile and family courts, to initiate discussions on these issues within their own jurisdictions. Such discussions should focus on an analysis of the way in which these service systems and the court currently operate and interact with one another, and the impact of these operations on child safety and family functioning. These deliberations should also identify shared goals, gaps in service, and innovations applicable to their community that can improve the outcomes for children and families.
Assuring Timely Access to Comprehensive Substance Abuse Treatment Services. There are currently several important opportunities for States and local communities to expand substance abuse treatment for child welfare clients. Specific opportunities within the Substance Abuse Prevention and Treatment Block Grant, the Targeted Capacity Expansion Program, Medicaid, and the Temporary Assistance for Needy Families and Welfare to Work Programs are discussed in Chapter 8. The availability of new resources can promote the building of capacity at the State and local levels to provide services in ways that promote safety and permanency for children and sobriety for families. State and local leaders are urged to consider the variety of options available to address the substance abuse treatment needs of child welfare clients.
Improving Our Ability to Engage and Retain Clients in Care and to Support Ongoing Recovery. In order to assist service providers to implement effective strategies for these clients, the Administration for Children and Families (ACF), the Substance Abuse and Mental Health Administration (SAMHSA) and other partner agencies will: (1) expand our research in this area to build knowledge and develop effective program strategies; (2) utilize our technical assistance mechanisms to assure materials on effective approaches are available to the field; and (3) make particular efforts to work with the Court Improvement Projects to share information on effective programs, assessing treatment progress, and on the application of drug court methods to juvenile and family courts. We urge service providers to design programs with a recognition that recovery from addiction is an ongoing process and to structure services in ways that promote retention and provide relapse prevention services.
Enhancing Children's Services. As substance abuse treatment programs design services for parents, children's needs also must be addressed. For children in foster care, increased attention to children's healthy emotional, social, and cognitive development is needed. In addition, program models are needed to address the particularly high risk of substance abuse and other problematic behaviors among children in foster care. Among ACF's planned activities in this area are (1) highlighting opportunities to address substance abuse within the Independent Living Program; and (2) developing training materials for foster parents on working with the children they care for to prevent future substance abuse. In addition, in recent years SAMHSA has significantly expanded its attention to early childhood issues, particularly through the Starting Early Starting Smart Program, which, in conjunction with several partner agencies, funds a child-centered, family-focused, and community-based initiative designed to test the effectiveness of integrating behavioral health services with primary care and early childhood service settings for children age 0-7. SAMHSA's Center for Substance Abuse Prevention is also planning a new SAMHSA-wide effort focusing on outreach to the children of substance abuse treatment clients. We challenge State and local service providers to identify opportunities for prevention and treatment services for children who are in foster care and for those under protective supervision in their homes.
Filling Information Gaps. Gaps in our knowledge base must be addressed in the coming years to ensure programs and approaches are well grounded in research findings. A discussion of specific information gaps appear in Chapter 8. In order to address knowledge gaps, ACF has proposed that these substance abuse issues be the subject of the next annual Federal Forum on Child Abuse and Neglect Research, to take place in the Spring of 1999. In addition, the National Institutes of Health, in partnership with ACF, other HHS agencies and the Department of Justice, will soon issue a grant announcement soliciting research proposals addressing child neglect. It is expected that a number of the proposals will address alcohol and drug abuse as factors in child neglect. SAMHSA's Center for Substance abuse prevention is in the process of implementing two new Knowledge and Application programs, one aimed at children of substance abusing parents and the other aimed at parenting adolescents, which are designed to develop new knowledge about ways to improve substance abuse prevention with these populations.
Moving Forward, Together
The congressional request for a report on substance abuse and child protection has provided a unique opportunity for HHS to focus on the maltreatment of children where substance abuse is a contributing factor. This report documents what we know about substance abuse treatment and recovery and its relationship to maltreatment. It further documents both systemic and individual factors that contribute to or minimize our ability to protect children and assist families in recovery.
Families often come with serious problems to service systems which are fragmented, and as such limited in their ability to facilitate safety, permanency, and sobriety. The Adoption and Safe Families Act recognizes the importance of time to children and establishes an expectation of urgency in decision making regarding their welfare. The imperative for timely decisions for children and the time frames necessary for recovery should also create a sense of urgency for policy makers and service providers. Those of us who work in these fields must recognize the immediate need to eliminate barriers to effective treatment. This report sets the stage for a number of actions which can improve the nation's capacity to serve families whose children are at the greatest risk.
The challenge before us is substantial. However, we believe that there is a broad recognition of the issues we face and a willingness to make the changes necessary at all levels of government to reach our goal.
1. Due to space limitations, citations are not included in the Executive Summary. Full citations may be found in the main report.