By listening to partners, reviewing what has been learned through decades of research in both the child welfare and alcohol and drug fields, and conducting additional focused analyses of the data collected by HHS, the agencies involved in producing this report have begun to understand the complex interactions among substance abuse, child maltreatment, and other problems within families, and among the service providers and policy makers in these and related fields who struggle to make a difference in the lives of children and families. Available information indicates that while the nation is a long way from having in place an effective, smoothly functioning service network to address these issues, there are clear indications of how services must be refocused in order to generate better outcomes: safety, stability and improved developmental outcomes for children; healthier, sober, and more productive parents; and better-functioning families.
Nationally and in many States and communities, mutual lack of knowledge, understanding, and trust creates barriers that hinder effective collaboration between child welfare and substance abuse treatment agencies and professionals, as well as with other services systems and judges and court personnel. These barriers ultimately prevent effective service delivery to families with substance abuse and related problems, further placing their children at risk, or preventing their healing. The most critical problem is the scarcity in many communities of available, appropriate services designed to address the multiple problems these clients face. The preceding chapters have detailed the parameters of the problem and have explored isolated promising efforts in communities across the nation. This chapter suggests steps that might be taken to improve the situation more broadly. It is important to note that there is not currently a consensus in the field as to how to solve these problems effectively. Yet finding common ground is imperative if these fields are to "do right" by the families who are clients of both systems. To the extent that the differences between the child welfare and substance abuse treatment fields prevent collaboration and quality service delivery, service systems will continue to fail these families.
While the Congress has asked Federal agencies within the U.S. Department of Health and Human Services to prepare this Report to Congress, much of the difficult work of building effective collaboration between these fields must happen at the local and State levels. In discussions with practitioners, their national associations and advocates, several themes emerged regarding steps the Federal Government could take that would assist agencies to improve their working relationships and ultimately the services delivered to families. A number of these are discussed below. It must be acknowledged, however, that neither the child welfare system nor the substance abuse treatment system is nationally operated, and while the Federal government provides significant funding and related structure to both fields, the day-to-day relationships which ultimately determine effective service provision are primarily local. Therefore it is not sufficient to discuss what the Federal government should do to address these issues. There are significant roles for service providers, program administrators and policy makers at all levels, from front line social workers and treatment counselors to agency administrators, political leaders and judges at the community and State levels as well as in Federal agencies.
With the implementation of the Adoption and Safe Families Act, child welfare agencies are required under most circumstances to make decisions about permanent living arrangements for children within 12 to 15 months of the time they enter foster care. Equally, agencies are required to make reasonable efforts to prevent foster care placement and reunify families, so long as children can be kept safe. It is hard to argue that these reasonable efforts for a substance abusing parent do not include substance abuse treatment. Yet it is clear that case plans for many parents of children in foster care do not include substance abuse assessment and, as needed, treatment, even when substance abuse is identified or suspected. Even if a case plan requires a parent to attend substance abuse treatment, in many instances there is not an available treatment slot in a program with services designed for women and parents, or outreach and engagement efforts are insufficient to secure clients' participation. Finally, it is clear that substance abuse is rarely the only serious problem in families whose children are neglected or abused and it cannot be expected that abstinence alone will produce healthy, functioning families.
While discussions of improving the situation usually focus on funding, addressing the problem is not just an issue of funding. Rather, service providers on both sides of the divide, child welfare and substance abuse treatment, must change how they do business, and especially how they deal with each other. As McMahon and Luthar (1998, p. 147) recently observed, "regardless of how difficult the clients might be and how easy it may be to blame them when things do not go well, provider-provider interaction is often the critical and rarely acknowledged factor in many of our service delivery failures."
Below, five topics are described on which important actions must occur in order to improve outcomes for these vulnerable children and families. Strengthening both fields' activities on these issues will improve the ability of front line staff to achieve, whenever possible within a reasonable time frame, safe and well-functioning families, and, when family preservation or reunification is not possible, other permanent living arrangements for children. Whether or not the children can return home, there must be a continuing commitment to parents' recovery as well as to the well being of their children. No agency can be complacent or claim that the burden of action is solely on another system or another level of government. Progress is possible only if approaches are adapted at all points in the process to focus, in a collaborative manner, on achieving client outcomes.
Building Collaborative Working Relationships
The first step toward improved services and ultimately better outcomes for these families is to begin working together more effectively. Partnerships are essential for progress. No single agency's services are adequate. Until agencies work together to assist families move toward healthy lifestyles, they risk an expensive and futile tug of war in which families are torn apart between conflicting imperatives as staff argue over whose problem it is. In order to build relationships successfully that can address the complex needs of substance abusing parents with children in the child welfare system, ongoing interdisciplinary training is required as well as training in effective parenting, family support and family skills training models. Cross disciplinary training is a powerful vehicle for sharing values, skills and knowledge. Such training is necessary to reach the common goals implicit in partnership building.
HHS intends to lead the field toward improving communications and developing common ground between the child welfare and substance abuse treatment fields. We began by sponsoring, through ACF's Child Maltreatment Resource Center, a conference in June of 1998 focusing on the nexus between these fields and models of collaborative professional activities. In addition, we are increasing the collaborative activity between ACF and SAMHSA, as well as with NIDA, NIAAA and HCFA, beginning with the production of this report. We expect further joint activities among these agencies over the next several years, including:
- Developing a framework for cross system collaboration and 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.
- Preparing and disseminating information 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.
- 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 in effective parenting and family interventions, treatment retention, relapse management and post-treatment support.
- Exploring ways in which improved interagency cooperation can result in more effective substance abuse assessment and treatment referrals.
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. These 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
Parents must be provided with opportunities for treatment and recovery. Addiction is a treatable disease. With high quality care, many addicted parents can and will take control over their lives, enter recovery, and provide safe and loving homes for their children. Unfortunately, however, few of the parents who come to the attention of the child welfare system ever receive such care.
There are currently several important opportunities for States and local communities to expand substance abuse treatment for child welfare clients.
The Fiscal Year 1999 appropriations includes a significant increase in substance abuse treatment funding, particularly an increase of $225 million over last year's funding level for the Substance Abuse Prevention and Treatment Block Grant, the Federal block grant to States that provides funds for substance abuse prevention and treatment services.
Treatment for women with children was last year and will again this year be a priority population for applications under SAMHSA's Targeted Capacity Expansion Program. This program allows State and local government agencies to apply for funds to enhance treatment capacity for populations for which local treatment capacity is insufficient. In Fiscal Year 1999, a total of $55 million will be available for the program, and $110 million has been requested for this program in the President's Budget for Fiscal Year 2000, doubling the size of the program with a significant investment of new resources. SAMHSA's Center for Substance Abuse Treatment (CSAT) will also continue to support a number of long-term residential substance abuse treatment programs for women with children that enable women to bring their infants and children into treatment with them.
Further opportunities for States and local governments to improve treatment for parents include making increased use of Medicaid to fund substance abuse treatment services. Many child welfare clients are Medicaid-eligible. As described in Appendix A, most substance abuse treatment services for adults, with the exception of services provided in large residential facilities, can be paid for under Medicaid. A number of States have expanded their provision of substance abuse treatment services through Medicaid in recent years, and additional States may wish to consider this option as a way of expanding treatment capacity.
Finally, many substance abuse services could be paid for under the Temporary Assistance For Needy Families (TANF) and Welfare-to-Work Programs. Many families with substance abuse problems who come to the attention of the child welfare system are families receiving welfare benefits. If these parents' substance abuse problems are interfering with their ability to care for their children, it is likely that the substance abuse is also compromising employment. States and counties may wish to consider writing substance abuse treatment services into these clients' employment plans. Under these circumstances, TANF funds, and funds under the Welfare-to-Work program, could be used for non-medical aspects of substance abuse treatment, if such treatment is not otherwise available to the participant. Non-medical services include services performed by those not in the medical profession such as counselors, technicians, social workers and those services not provided in a hospital or clinic. The Welfare-to-Work Program, operated by the U.S. Department of Labor and implemented through local Private Industry Councils (PICs) and/or State and local Workforce Investment Boards (WIBs), specifically targets individuals who require substance abuse treatment for employment and allows non-medical substance abuse treatment as an allowable activity under job retention and support services.
State and local leaders are urged to consider these options as they plan to address the treatment needs of child welfare clients. It is essential that communities provide substance abuse treatment services to these clients so as to allow as many parents as possible to establish sobriety and provide safe homes for their children. 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. If the utilization of these resources can be shaped in a collaborative way that builds on the knowledge and expertise of both systems and the needs of families, the stage can be set for more effective use of future resources.
Improving Our Ability to Engage and Retain Clients in Care and to Support Ongoing Recovery
Assuring adequate treatment capacity is not sufficient to produce significant changes in families' behavior unless clients engage in the recovery process and stick with programs long enough for learning to occur and behavior to change. Too often, clients fall through gaps between agencies before intervention begins, as relapses occur, and after treatment programs end. A clear lesson shown by research is that engagement and retention is an extremely difficult process with this client population. It is precisely during these transition periods that contact with clients is likely to be lost, and with it the opportunity for constructive intervention.
In order to assist service providers to implement effective engagement and retention strategies, ACF and SAMHSA, with other agency partners, will:
- Expand our research in this area to build knowledge and develop effective program strategies.
- Utilize our technical assistance mechanisms to assure materials on effective approaches are available to the field. In ACF this will include updating materials on substance abuse and child welfare that are available through its clearinghouse and resource centers. In addition, materials will be developed for the field regarding assessing progress in treatment and on decision making for families of children in foster care. SAMHSA/CSAT is also exploring the development of a technical assistance publication or publications for use by child protective services agencies that will answer questions about substance abuse treatment services.
- The Children's Bureau within ACF will make particular efforts to work with the Court Improvement Projects (State grantees working to improve courts' capacity to deal with dependency proceedings) to share information on effective programs, assessing treatment progress, and on the application of drug court methods to juvenile and family courts.
- SAMHSA/CSAT will continue to focus on increasing opportunities for family reunification and improved child safety though the Family Drug Court Program. Since 1997, SAMHSA/CSAT has funded this pilot program to evaluate the use of family drug courts as a strategy for reducing the cost and trauma that result from foster care in neglect and abuse cases.
We encourage child welfare and substance abuse treatment providers at the local level to design programs with a recognition that the recovery from addiction is an ongoing process that is characterized by the risk of relapse and that clients are prone to dropping out of treatment. To mediate against the likelihood of these events and to respond to them, services need to be structured in ways that promote retention and provide relapse prevention and supportive services.
Enhancing Children's Services
As substance abuse treatment programs design services for parents, children's needs must also be addressed. Services for infants and children are designed to foster healthy development, linking primary health care, prenatal, hospital inpatient and postnatal care, and mental health and social services. Activities and services may be provided for the children either on-site or through linkages with other appropriate and qualified community service providers. Whenever possible these services should include extensive joint parent-child activities focused on improving substance abusing parents' ability to avoid emotional or physical abuse and neglect. These include interventions such as therapeutic play, family skills training or family therapy. 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 risky behaviors among children in foster care. A family history of drug disorder is one of the most potent risk factors for the development of the child and the child's development of drug disorders at an early age. This suggests that substance abuse prevention and intervention programs should target offspring of parents with substance use disorders.
ACF intends to focus new attention on issues of preventive services. These activities will include:
- Highlighting opportunities to address substance abuse within the Independent Living Program.
- Developing training materials for foster parents on working with the children they care for to prevent future substance abuse.
- Focusing attention on substance abuse issues within the Community Based Family Resource and Support (CBRFS) Program (Title II of the Child Abuse Prevention and Treatment Act), which provides services in every State for the prevention of child abuse and neglect and coordinates a Statewide network of family resource services. Agencies supported by the CBFRS Program offer a variety of training programs that help all parents reduce stress, teach basic child development and parenting skills, and support adults in creating safe and stable environments for their children.
SAMHSA has in recent years significantly expanded its attention to early childhood issues. These efforts include:
- SAMHSA's three Centers in collaboration with the Health Resources and Services Administration, The Administration for Children and Families, the Department of Education, the National Institutes of Health and the Casey Family Program support the Starting Early Starting Smart (SESS) Program which is a child-centered, family-focused, and community-based initiative designed to test the effectiveness of integrating behavioral health services within primary care and early childhood service settings for children age 0 - 7.
- SAMHSA's Center for Substance Abuse Prevention (CSAP) has funded 15 community sites for three years to field test effective, research-based models of prevention interventions for children of substance abusers from diverse cultural populations. Some of these children and their older siblings are already in the child welfare system due to neglect and/or abuse or from the need for temporary placement while their mothers are in treatment.
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 own homes. Efforts should be made to work with prevention service providers to identify maltreated children as a priority for such services.
Filling Information Gaps
Our fields' understanding of the interrelated issues of substance abuse and child maltreatment has progressed significantly over the past decade. Research and demonstration programs sponsored by SAMHSA, ACF, NIDA and NIAAA have been instrumental in exploring these issues and testing intervention approaches. For instance, CSAT's demonstration programs for women with children have helped build model substance abuse treatment programs that also serve children and which provide parenting training to treatment clients. While our understanding of these issues has improved, it has also become clear that significant gaps in the knowledge base remain. These gaps must be addressed in the coming years to ensure programs and approaches are well grounded in research findings.
As noted above, there are significant gaps in knowledge about the interrelationships among substance abuse, child maltreatment, and related problems. The discussion below describes a number of the gaps that became clear as we developed this report.
Regarding the extent and scope of the problem, much better information is available nationally on the prevalence and severity of substance abuse among child welfare clients than there is about the prevalence and severity of child welfare and parenting issues in families with substance abuse problems. In the child welfare system, the new Adoption and Foster Care Analysis and Reporting System (AFCARS) will soon provide more accurate information nationally about the extent to which substance abuse has contributed to children's placement in foster care. There is currently no data being collected through Federal substance abuse data systems, however, about clients' children. The National Household Survey on Drug Abuse does collect information about whether respondents have children in their households, although in depth analysis of this information is not often conducted.
That these clients have complex needs has become a familiar refrain among service providers in both the substance abuse and the child protection systems, and it is the truth. However, while many sources list a multitude of problems often affecting these clients, there exists little information on the relationships between various needs, and virtually no information on causal relationships among co-existing problems. In addition, there is considerably more information on the small population of infants prenatally exposed to illicit drugs and alcohol than on the much larger population of children living in households with ongoing alcohol and illicit drug abuse.
Barriers to service are a common subject of research, often as evaluators try to determine why programs have been unsuccessful in meeting their goals. Programs in the substance abuse and child welfare fields often list many of the same barriers to service, generally relating to the complexity of child and family needs. Less has been written, however, about cross-system efforts to address barriers, their results, and why such efforts have been difficult to establish and maintain.
For some years now, communities have sought approaches to addressing the joint problems of substance abuse and child maltreatment. But while there is considerable information about single system approaches, there are only a few studies documenting cross-system approaches to these problems. Most of those that do exist were conducted under the auspices of demonstration grants initiated by the Administration for Children and Families or the Substance Abuse and Mental Health Services Administration. State- and community-generated activities have not generally been evaluated. In addition, while these grantees have learned a great deal about developing and implementing comprehensive services for these families, what has been produced thus far are a series of consensus-based "lessons learned" and "promising strategies." To date there is little effectiveness data to guide practice in this area.
In order to address knowledge gaps,
- ACF has proposed that these issues be the subject of the next annual Federal Forum on Child Abuse and Neglect Research, to take place in the Spring of 1999. ACF will urge the variety of research agencies within HHS and elsewhere in the Federal Government to consider these issues as they formulate their future research agendas.
- 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. Studies and research are needed on the links between physical and sexual abuse and substance abuse. In addition, studies of co-occurring and/or predisposing factors to substance abuse and child maltreatment, such as mental disorders, are urgently needed. While our knowledge base is quite thin, it nonetheless is clear that successful intervention with substance abuse and child maltreatment will necessitate treatment of such comorbid conditions as mental disorders.
- SAMHSA's Center for Substance Abuse Prevention (CSAP) has two new Knowledge Development and Application (KDA) programs, Children of Substance-Abusing Parents (COSAPs) and Initiatives on Welfare Reform and Substance Abuse Prevention for Parenting Adolescents (Parenting Adolescents), which are designed to develop new knowledge about ways to improve the prevention of substance abuse aimed at children of substance abusing parents or parenting teens. The knowledge generated from the SAMHSA KDA grants will be used to work with State and local governments as well as providers, families, and consumers to improve or develop comprehensive systems of care which address the issues of substance abuse and child welfare.
- SAMHSA's/CSAP has implemented a new Family Strengthening cross-site grantee program in over 100 communities across the country in order to increase our knowledge about how to better disseminate research-based models currently available and how to convince practitioners in the field to adopt models that have proven effective and to adapt them to diverse populations.
- The National Association of Children of Alcoholics has conducted a call for program submissions from the field to determine what types of prevention services are being provided to children of substance abusing parents in schools, treatment and youth program settings. SAMHSA/CSAP will support the analysis of these prevention programs to determine those that are the most cost-beneficial and promote their adoption with block grant and local prevention funding.
Researchers in the substance abuse field are urged to consider parenting issues as they develop research on the consequences of substance abuse and the effects of substance abuse treatment. Similarly, child maltreatment researchers are urged to consider the role of substance abuse in the dynamics of maltreating families.
Other Activities Across Action Areas
Several ongoing activities cut across the service areas described above. These activities will involve efforts to work across fields to improve the capacity of child welfare and substance abuse agencies to work together and serve families effectively. They include:
Technical Assistance and Training Activities. In the coming year, ACF will be examining its child welfare technical assistance strategy. The current cooperative agreements for five Child Welfare Resource Centers will be expiring, and new resource centers or other technical assistance mechanisms will be put in place to continue our efforts to assist the field in adapting to child welfare challenges. As this strategy is developed, ACF intends to assure that substance abuse issues are given adequate attention and that technical assistance providers have expertise to assist agencies in developing improved procedures for addressing families' complex needs. ACF will also be considering the need to develop specific resource materials on targeted topics such as confidentiality issues; establishing effective procedures for making substance abuse assessments and treatment referrals; using non-traditional resources for the purchase of substance abuse services; and judging progress in substance abuse treatment. ACF also expects to produce a series of "promising practices" documents highlighting emerging models of serving these families in a collaborative fashion.
In Fiscal Year 1997, ACF funded 11 Child Welfare Training Grants to schools of social work to develop competency-based interdisciplinary training curricula and training plans to enhance and strengthen the capacity of child welfare workers to respond to the complex family problems of child abuse and neglect resulting from substance abuse, mental illness and domestic violence. These three-year grants will soon be completed. The National Clearinghouse on Child Abuse and Neglect Information will disseminate information regarding the availability of training materials resulting from these projects.
SAMHSA's technical assistance is provided primarily through 14 Addiction Technology Transfer Centers (ATTCs) located throughout the United States. Among the goals of the ATTCs is the cultivation of an interdisciplinary consortium of health care and related professionals to address effective approaches to substance abuse treatment and recovery. As part of these efforts, fostering collaboration between child welfare and substance abuse treatment agencies has been and will continue to be an ongoing focus of the ATTCs. In addition, SAMHSA's Center for Substance Abuse Treatment also funds a number of grant programs involving substance abuse treatment for women and children and provides technical assistance on child welfare issues to these grantees.
Child Welfare Demonstration Waivers. As noted in Chapter 7, HHS has the authority to grant demonstration waivers of legal and regulatory provisions of Federal child welfare programs (especially the Title IV-E Foster Care and Adoption Assistance programs) in order to allow States to test innovative child welfare service models. As was the case last year, the Department will again this year give priority consideration to demonstration approaches designed to improve the child welfare system's response to families with substance abuse problems. ACF encourages States to consider whether such demonstration waivers would be helpful to the implementation of improved service approaches.
To date, 18 States have received approval for demonstration projects which aim to improve child welfare outcomes through:
- subsidized guardianship programs;
- more flexible use of foster care funds;
- fixed-cost funding arrangements;
- increasing the availability of services for specific sub-populations of children or families;
- efforts to increase adoption opportunities for children for whom reunification is unlikely.
As discussed in Chapter 7, two States are using demonstration waivers to provide specialized services for caretakers with substance abuse problems.
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 the recovery process.
Families often come with serious problems to service systems which are fragmented, and as such are 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 providers of service. Those of us who work in the areas of substance abuse and child welfare services 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.
By embarking on efforts to collaborate toward better outcomes for families and children and to increase service providers' understanding, identification, and responsiveness to the dual problems of maltreatment and substance abuse, we will not only enable families to address their own issues, but will improve our systemic ability to prevent and treat addictions that compromise children's care.
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.