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. Balancing these factors, as parents make sincere efforts to provide safe and loving homes for their children, represents a key challenge for the child welfare field and for judges making critical custody decisions.
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 often difficult to determine what level of functional improvement will enable a parent with substance abuse problems to resume or retain his or her parental role without jeopardizing child safety, particularly as relapse remains a significant possibility. As child welfare workers address safety concerns, substance abuse treatment counselors work to ensure that the treatment process promotes recovery while addressing parents' concerns about their children's safety and their fear of losing their children to the child welfare system.
An important challenge facing both the child welfare and substance abuse fields is to take a comprehensive view of families' situations and to understand the contributions of various problematic behaviors to child maltreatment. The relationship between substance abuse and child welfare is complicated by the presence of other personal, health, environmental, social and economic factors. These factors, in many cases, contribute to the development of addiction and confound both the process of securing safe, stable homes for children and the treatment process. For this reason, although this report concentrates on the relationship between substance abuse and child maltreatment, it is important to note that all major family problems must be addressed to achieve substance abuse treatment success and child safety.
Many in the child welfare field have recognized for a number of years that substance abuse is central to child welfare issues (Child Welfare League of America North American Commission on Chemical Dependency, 1992). But 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. As the Adoption and Safe Families Act was developed, the Congress debated potential Federal policies that would allow child welfare agencies and partners in the substance abuse treatment field to better address the needs of parents whose substance abuse problems rendered them unable to care for their children. After considerable debate on a variety of measures, Congress asked for more information. Section 405 of ASFA required that the Secretary of Health and Human Services (HHS) prepare a Report to Congress on Substance Abuse and Child Protection Services. In particular, the law required the Department to submit a report that:
"describes the extent and scope of the problem of substance abuse in the child welfare population, the types of services provided to such population, and the outcomes resulting from the provision of such services to such population. The report shall include recommendations for any legislation that may be needed to improve coordination in providing such services to such population."
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 substance abuse and child maltreatment. Over the past year, staff from several agencies within HHS have worked together to gather information from the fields of child welfare and substance abuse prevention and treatment regarding the needs of families in which both substance abuse and child maltreatment are present. Along the way we have consulted with practitioners and researchers in both fields regarding their views of how efforts could be improved to better meet the needs of the children and families we serve. In conversations and focus groups we solicited input on several topics, including:
- What are the most important themes and messages that the report should address?
- What are the most significant problems in current relationships between child welfare agencies and substance abuse treatment agencies?
- What are the most important issues that agencies need to consider in establishing partnerships between substance abuse and child protection agencies?
- What are the most promising approaches to addressing concurrent substance abuse and child protection issues in families?
- What are the most important ways in which the Federal Government could assist in the improvement of practice in this area?
In conducting research for this report, it became clear that the child welfare and substance abuse fields have different definitions of "the client," different training and education which lead to different perspectives in defining families' problems, and often see each other as at fault when conflicts arise. Our professions have a long way to go in learning about one another, blending perspectives, and developing ways to work together more effectively. The lack of understanding, different and often conflicting frameworks and priorities, as well as a lack of communication and collaboration among the providers of care in the child welfare and substance abuse fields must be addressed if we are to better serve the children and families who most need our help.
Substance Abuse is a Critical Child Welfare Issue
Parental substance abuse, with its related physical and mental health problems and its social and economic facets, is a critical factor in many families who come to the attention of the child welfare system. While data will be discussed in detail in Chapter 4, it is clear that throughout the child welfare system, but especially with respect to children in foster care, alcohol and other drug abuse is recognized as a major contributing factor to child neglect and abuse and as one of the key barriers to family reunification. Parental substance abuse is among the factors that have fueled the rising number of abuse and neglect reports and has contributed to the rising number of children in foster care. It remains a key barrier to reunification for many of the children who reside in foster care for extended periods.
Because substance abuse is so often intertwined with a family's maltreatment of their children, the availability of effective, substance abuse treatment must become a priority for child welfare agencies seeking to address families' needs. When substance abuse treatment includes a well-coordinated service delivery system designed to address the variety of family needs, it does work for many families, allowing the addicted individual to regain control over his or her life and keep his or her family intact. Providing effective substance abuse treatment services will be discussed in Chapter 7. While child welfare agencies are rarely the providers of substance abuse treatment services, they must become knowledgeable about treatment and recovery (including its potential and limitations), should be active referral sources for treatment programs, and must be active partners in the treatment process.
Furthermore, while substance abuse treatment is often effective, appropriate, high quality treatment designed for parents, especially women with young children, is not easily available in many communities. Most providers are not prepared or equipped to address the complex physical, mental, social, and economic issues facing these women and their children. Moreover, they often lack the resources to provide the level of comprehensive, gender-specific care that is required. Even where such programs exist, child welfare agencies too often have not established effective links with treatment providers that facilitate referral and follow up. Until treatment access for child welfare system clients is ensured, it is difficult to argue that parents are being afforded the opportunity to address the barriers to successful family life. Child welfare agencies must become advocates in their communities for the establishment and provision of the types of services their clients need.
Even with adequate treatment services, not all substance abusing parents will be able to improve sufficiently to function in their parental roles. In order to make appropriate and realistic decisions about child safety, reunification, and family preservation, and termination of parental rights, increased attention must be given to appropriate assessment of the family's needs, to individualized treatment plans for these parents and their children, to the progress clients make in treatment, and to the length of time required in treatment to address major issues -- all of which relate to effective parenting. In addition, if new time lines are to be adhered to while providing realistic opportunities for recovery, it will be important to provide joint parent-child services that address parenting and other priority issues while working on recovery. Recovery is a lifetime journey, not an event. As a result, success in treatment is not likely to mean complete, permanent abstinence immediately, though progress in treatment can be observed and documented. Child welfare staff and judges, however, often do not know how to identify whether or not such progress is taking place, nor do they have the skills to determine the extent to which progress on substance abuse treatment goals is likely to translate to children's safety.
Timely Substance Abuse Services Are Key to Achieving Permanency for Children
Child welfare agencies throughout the U.S. have long recognized that every child needs a safe and permanent home, whether that home is with a birth parent, a relative, or an adoptive parent. The goal that permanency decisions be made promptly, while giving parents the opportunity and support to make the changes in their lives necessary to address safety concerns, has not been adequately realized. The Adoption and Safe Families Act of 1997 (ASFA) emphasizes timely decision making, requiring that permanency decisions be made on a 12-month time line, and requiring that agencies move to terminate parental rights once a child has been in foster care for 15 of the previous 22 months, unless there is a compelling reason not to initiate termination. These new time lines make it essential that agencies ensure that services for parents, including appropriate substance abuse treatment, be provided promptly.
For substance abuse treatment to be successful, the types, settings, and duration of treatment must be tailored to the individual client based on the severity of the addiction and other disorders that may exist. Even in the best situations, substance abuse treatment takes time and relapses are part of the recovery process, as with other diseases, particularly in the early stages of treatment. The new time lines provide sufficient opportunity for parents to take important steps into the recovery process, but only if treatment is available quickly. However, recovery is likely to be successful in the long term only if appropriate, quality substance abuse treatment services are provided promptly, and include aggressive outreach, retention, and monitoring as integral service components.
Collaboration Between Child Welfare and Substance Abuse Treatment Agencies is Challenging
The complexities within child welfare agencies and substance abuse treatment agencies, coupled with different perspectives and world views, make cooperation and collaboration between service systems difficult to establish and harder to maintain. But now more than ever, collaboration between these agencies is essential if families are to be given real opportunities for recovery and children are to have the chance to grow up in healthy family situations. As will be discussed more fully in Chapter 6, the differences between agencies are real and there are good and important reasons staff find it difficult to work together. Yet to the extent we let these differences block communication between agencies and prevent caseworkers and staff at all levels from working together, we cannot serve families effectively and we sabotage the goals both systems strive for: healthy, well-functioning families. Our clients come to us with needs for both substance abuse treatment and family intervention and are unlikely to succeed unless both are addressed.
Consider a typical case in which an addicted mother gives birth to a child who is soon taken into foster care. Handed a list of local treatment agencies (whose programs are likely to be full), the mother is told to "get clean" if she wants her child back, but is given little or no further assistance in securing treatment. Meanwhile, the child welfare agency places the child in a foster home with adoption potential. If the mother happens to be successful (without help from the child welfare agency), reunification is a possibility. If not, the child may be adopted relatively quickly. Many would consider this standard practice and adequate performance. Yet, while the child welfare agency may secure a permanent home for the child, the birth mother is likely to have received little or no treatment and thus may be reported again in 12 to 18 months with a new infant. The problem has not been solved, for either the mother or her children, often because inappropriate or very short-term treatment was the woman's only option. Unless we successfully intervene with the addicted parent (who may be a father rather than or in addition to a mother, although fewer addicted fathers are reported to child welfare agencies), we will never be able to make real progress. Improved collaboration, as well as understanding and responding to the need for high quality and appropriate treatment, are essential to these efforts.
Improved Practice and Outcomes are Possible and Essential
While effective collaboration between substance abuse and child welfare agencies is often difficult, it is possible and is the only way to address successfully the needs of the families we serve. Chapter 7 contains examples of efforts being made around the country to bring our disciplines closer together. While no easy recipe exists for putting together a comprehensive plan for addressing the problems of substance abusing families whose children suffer from maltreatment, effective pieces of the puzzle are in place in many communities. Our challenge is to learn from these efforts in order to build an effective system of care for families. While full solutions are not at hand, solid, practical next steps are clearly discernible.
Resource issues quickly arise whenever we discuss improving services for families. These issues are real and important. But we believe the issues faced in improving services for these families are not just about having additional treatment funding, but also about how we do business together. Changing the ways these systems relate to one another will do more to improve outcomes for these children and families than will simply spending significantly more money under current circumstances. Better use of current resources will allow agencies and communities to determine to what extent additional resources are needed and will demonstrate how such resources may be deployed most effectively.
Organization of the Report
The next two chapters of this report provide a brief overview of the nature of addiction, substance abuse treatment, and recovery (Chapter 2), and the nature of child maltreatment (Chapter 3). These are followed by information regarding the co-occurrence of these two serious problems (Chapter 4) and a discussion of the complexity of child and family needs (Chapter 5). The final three chapters of the report discuss overcoming barriers to collaboration (Chapter 6), provide examples of successful service delivery (Chapter 7), and lay out next steps for the Federal Government and our partners at the national, State, and local levels (Chapter 8). Three appendices provide information on Medicaid coverage of substance abuse treatment services, the Center for Substance Abuse Treatment's comprehensive treatment model for substance abusing women and their children, and current programs of the Department of Health and Human Services directed at substance abuse and child maltreatment.