Studies suggest a high prevalence of substance abuse among women receiving public assistance, with some studies reporting rates as high as 27-39% (CSAT, 1996; Klein et al., 1997; Sisco & Pearson, 1994). Substance abuse among parenting women has long been identified as a major public health problem (e.g. Reed, 1985). However, as states implement welfare reform attempts to address this problem take on greater urgency. Substance abuse is an important barrier to employability. In a recent national survey, welfare administrators estimated that about 20% of recipients had a substance abuse problem and ranked substance abuse as third in importance out of seven challenges to employability (CASA, 1999).
Although substance abuse among welfare recipients is thought to be a prevalent and serious problem, it is widely recognized that individuals with substance use disorders often fail to acknowledge that they have a problem or seek treatment. For example, less than 3% of welfare recipients sought treatment in New York State in 1994, despite estimated prevalence rates for substance abuse problems of 15%-25% (Cohen, 1997). Similarly, a needs assessment of pregnant low-income women indicated that 39% screened positive for a substance use problem, yet less than 14% of these entered treatment (Klein et al., 1997). Therefore, developing effective screening, identification, and referral strategies are necessary components of any state plan to address substance abuse among welfare recipients.
Models have been developed to identify substance abuse problems in settings where there is a high prevalence of such problems. Screening and case identification methods developed in medical settings have proved successful and serve as models for efforts in other settings. Typically these methods involve administering a very brief screening questionnaire 4 to 10 questions - to patients presenting for medical care. Patients scoring above a predetermined threshold are then referred for a more complete evaluation.
This model of screening and case identification would appear to have good applicability in welfare settings. A number of screening measures have been developed to screen for alcohol and other drug use problems. Paper and pencil measures could be administered to welfare recipients at relatively low cost and those screening positive could be referred for further evaluation. A number of states (e.g., California, Kansas, New Jersey, New York) who are in the forefront of addressing substance abuse among welfare recipients have adopted this model. However, experiences during the last two years across states indicate this approach to identification has not yielded the expected result (e.g., Gardner, Young & Merrill, 1999). Only a small percent of TANF recipients are being identified through such methods or seeking substance abuse treatment on their own.
This report describes the experience in NJ of implementing, evaluating, and attempting to improve screening and identification of substance abuse among TANF recipients. The initial program, labeled "generic screening", is described and identification rates are reported. An evaluation was conducted to determine the factors associated with low referral rates. Evaluation results were used to develop a new approach. This approach, labeled "specialized screening", is described and outcomes are presented.