Blending Perspectives and Building Common Ground. 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).