SUBSTANCE ABUSE SERVICES ACROSS THE CONTINUUM

Implications for Treatment

This webpage identifies the major literature in the field of substance abuse and child welfare practice: implications for treatment. The time frame is from January 2000 through December 2014.

Blome, W. W., Shields, J., & Verdieck, M. J. (2009). The association between foster care and substance abuse risk factors and treatment outcomes: An exploratory secondary analysis. Journal of Child & Adolescent Substance Abuse, 18(3), pp. 257-273

The child welfare and substance abuse systems are integrally linked through the children and families they both serve. There is a dearth of knowledge, however, on how children who have experienced foster care fare when they are treated for substance abuse issues as adults. This article presents an exploratory study using the Alcohol and Drug Services Study (ADSS) data set. To pursue a set of exploratory questions, adults in substance abuse treatment who were formerly in foster care were matched with a group who had not experienced substitute care. Their experiences before and after treatment were compared. This article presents the methodological and substantive findings.

Boekel, L. C., Brouwers, E. P. M., Weeghel, J., & Garretsen, H. F. L. (2014). Healthcare professionals’ regard towards working with patients with substance use disorders: Comparison of primary care, general psychiatry and specialist addiction services. Drug and Alcohol Dependence, 134(1), pp. 92-98.

In this study, healthcare professionals’ regard for working with patients with substance use disorders was examined and three sectors in which professionals are working were compared. Results show that regard for working with patients with substance use disorders was different between the three sectors. Health care professionals of specialist addiction services showed higher regard for working with patients with substance use disorders compared to professionals of general psychiatry services and general practitioners. Improvement of education and shared care models in which healthcare professionals are supported by professionals specializing in addiction might address low regard.

Forrester, D., Copello, A., Waissbein, C., & Pokhrel, S. (2008). Evaluation of an intensive family preservation service for families affected by parental substance misuse. Child Abuse Review, 17(6), pp. 410-426.

This article reports on an evaluation of an Intensive Family Preservation Service (named ‘Option 2’) aimed at families in which parents misuse substances and children are considered at risk of entering care. The study used mixed methods. A quasi-experimental element compared solely data relating to care entry (e.g. how long children spent in care and its cost) for Option 2 children (n = 279) and a comparison group of referrals not provided with the service (n = 89) on average 3.5 years after referral. Findings show that 40% of children in both groups entered care, however Option 2 children took longer to enter, spent less time in care and were more likely to be at home at follow-up. As a result, Option 2 produced significant cost savings. A small-scale qualitative element of the study involved interviews with 11 parents and seven children in eight families. The findings suggested that Option 2 was a highly professional and appreciated service. For some families it achieved permanent change. For others, particularly those with complex and long-standing problems, significant positive changes were not sustained. The implications for services designed to prevent public care, particularly where there are substance misuse issues, are discussed and recommendations for policy and evaluation made.

Goldstein, A.L., Wekerle, C., Tonmyr, L., Thornton, T., Waechter, R., Pereira, J., Chung, R. (2011). The relationship between post-traumatic stress symptoms and substance use among adolescents involved with child welfare: Implications for emerging adulthood. International Journal of Mental Health and Addiction, 9(5), pp. 507-524. DOI: 10.1007/s11469-011-9331-8

The purpose of the present study was to examine the role of posttraumatic stress symptoms (PTSS) in predicting substance use and substance-related problems in a sample of older youth and emerging adults involved with child welfare. The sample was drawn from the Maltreatment and Adolescent Pathways (MAP) longitudinal study (Wekerle et al. 2009). Participants were 253 youth and emerging adults (ages 15–20; M = 16.87, SD = 1.04; 61.4% female and 38.6% male) who were involved with child welfare. Multiple regression analyses were conducted to examine the impact of PTSS using subscales from the Trauma Symptom Checklist for Children. Outcome variables were past year alcohol, marijuana and illicit drug use, as well as alcohol and drug problems. Controlling for gender, age, child welfare status and child maltreatment, both dissociation and anger emerged as significant predictors of substance use and related problems. The implications of these findings for older youth and emerging adults exiting the child welfare system are discussed.

Grant, T., Huggins, J., Graham, J. C., Ernst, C., Whitney, N., & Wilson, D. (2011). Maternal substance abuse and disrupted parenting: Distinguishing mothers who keep their children from those who do not. Children and Youth Services Review, 33(11), pp. 2176-2185. DOI: 10.1016/j.childyouth.2011.07.001

This study further explores the complicated interplay of how maternal risk and protective characteristics and service elements are associated with reunification. The study contributes to existing literature by following mothers for three years; examining service needs as identified by the mother herself; using a summary proportion score to reflect the totality of services received to matched service needs identified; and using logistic regression to examine interactions of services received with critical maternal characteristics. The sample is comprised of 458 substance-abusing mothers enrolled during pregnancy or postpartum in the Washington State Parent–Child Assistance Program (PCAP), an evidence-based case management intervention. Participants' custody status was well distributed among four categories based on continuity of parenting. Findings indicate that at program exit 60% of the mothers were caring for their index child. These mothers had more treatment and mental health service needs met, had more time abstinent from alcohol and drugs, secure housing, higher income, and support for staying clean and sober. Among women with multiple psychiatric diagnoses, the odds of regaining custody were increased when they completed substance abuse treatment and also had a supportive partner. Mothers who lost and did not regain custody had more serious psychiatric problems and had fewer service needs met.

Green, B. L., A. Rockhill, et al. (2007). Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis. Children and Youth Services Review, 29(4), pp. 460-473.

In this statewide longitudinal study of 1,911 women who had children placed in substitute care, the authors examined the influence of three key factors in the treatment process on child welfare outcomes. Results indicated that when these women entered treatment more quickly, spent more time in treatment, or completed at least one treatment episode, their children spent fewer days in foster care and were more likely to be reunified with their parents. These findings were significant even controlling for families' levels of risk including treatment and child welfare history, substance abuse frequency and chronicity, and demographic risks. Implications of these findings for improvements in the way that treatment services are provided to women in the child welfare system are discussed.

Hohman, M. M., Shillington, A. M., & Baxter, H. G. (2003). A comparison of pregnant women presenting for alcohol and other drug treatment by CPS status. Child Abuse and Neglect, 27(3), pp. 303-317.

The purpose of this study is to describe the demographic, substance use, and treatment variables of 678 treatment seeking pregnant women and to compare these variables based on Child Protective Service (CPS) status. The authors found that pregnant women reporting CPS involvement were similar to non-CPS women on demographic variables but differed on drug use and treatment variables. CPS women were more likely to report marijuana use as their primary problem drug, be mandated to treatment, attend day treatment and be released from treatment unsatisfactorily compared to the non-CPS pregnant women. Those without CPS involvement were more likely to report cocaine or crack as their primary drug, attend outpatient treatment and be found to have a satisfactory release from treatment compared to those with CPS involvement. Significant predictors of CPS involvement were mandated status and unsatisfactory treatment release. The authors postulate that the specific demands of CPS requirements may be burdensome on pregnant women. CPS demands may include parenting classes, monitored visits, working with a social worker on concurrent planning, and adhering to specific timelines to prepare for reunification or removal. The authors state that both AOD treatment services and CPS need to examine their policies and practices with pregnant substance-abusing women, to determine if treatment needs are not being met and if burdensome expectations are being placed upon them.

Lewandowski, C. A., & Hill, T. J. (2008). The impact of foster care and temporary assistance for needy families (TANF) on women's drug treatment outcomes. Children & Youth Services Review, 30(8), pp. 942-954.

This study assesses the impact of having a child in foster care and receiving cash benefits through Temporary Assistance for Needy Families (TANF) on women's completion of a residential drug treatment program. The study's hypothesis was that drug treatment completion rates for women who had children in foster care and/or who were receiving TANF would differ from women who did not receive these services. The sample included 117 women age 19 to 54, in a Midwestern state. Findings suggest that women with a child or children in foster care were less likely to complete treatment. Women receiving cash benefits were also somewhat less likely to complete treatment than women not receiving services. Women with children in foster care had similar levels of psychological, employment, and drug and alcohol concerns as other women, as measured by the Addiction Severity Index. Future research should focus on identifying strategies that enhance retention rates of these vulnerable women. Implications for improving treatment retention are discussed in light of the Adoption and Safe Families Act of 1997 and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

Libby, A. M., Orton, H. D., Barth, R. P., Webb, M. B., Burns, B. J., Wood, P. A., & Spicer, P. (2007). Mental health and substance abuse services to parents of children involved with child welfare: A study of racial and ethnic differences for American Indian parents. Administration and Policy in Mental Health and Mental Health Services Research, 34(2), pp. 150-159.

American Indian parents of children involved with child welfare were compared to White, Black and Hispanic parents on mental health and substance abuse problems and access to treatment. Data came from the National Study of Child and Adolescent Well-Being, a longitudinal study of a nationally representative sample of children aged 0-14 years involved with child welfare. The study found that there were significant disparities in the likelihood of receiving mental health, but not substance abuse, services. Unmet need for mental health and substance abuse treatment characterized all parents in this study. American Indian parents fared the worst in obtaining mental health treatment. Parents of children at home and of older children were less likely to access mental health or substance abuse treatment.

Marsh, J. C., & Cao, D. (2005). Parents in substance abuse treatment: Implications for child welfare practice. Children and Youth Services Review, 27(12), pp. 1259-1278.

This study compares the predictive factors of post-treatment drug use in organizational, service and individual characteristics between 1237 parents and 1905 non-parents, mothers and fathers. The results show that treatment duration and the frequency of counseling available in treatment facilities are the most predictive factors for parents when other factors are controlled. Further, treatment duration, onsite service availability, and frequency of counseling available are significant factors in predicting post-treatment drug use for fathers, but not for mothers. The authors concluded that outcomes are better for parents who receive services in treatment organizations that provide counseling on a frequent schedule (once a week or more). Further, treatment duration and receipt of comprehensive services were specifically predictive for fathers but not for mothers. These findings have implications for improving substance abuse treatment services for parents in child welfare settings. For example, programs seeking to integrate substance abuse and child welfare services will be most effective when they can connect with substance abuse treatment programs that are able to (a) retain parents in treatment, and (b) tailor services to address health and social problems that typically co-occurring with substance abuse.

New Jersey uses money from child welfare system to treat addicted parents. (2008). Alcoholism & Drug Abuse Weekly, 20(21), pp. 1-7.

The article provides facts on the issue of substance abuse problems in the child welfare system in New Jersey. The city government develops alternative way to continue offering foster care program throughout the country by transferring the money from the Division of Youth and Family Services (DYFS) to the Division of Addiction Services (DAS) to assist the parent paying treatment of children in the system. The treatment program is acknowledged as part of the region's child welfare services.

Niccols, A., Milligan, K., Smith, A., Sword, W., Thabane, L., and Henderson, J. (2013). Integrated programs for mothers with substance abuse issues and their children: A systematic review of studies reporting on child outcomes. Child Abuse & Neglect. 36(4), pp. 308-322.

In this study, the authors performed a systematic review of studies published from 1990 to 2011 in order to examine the impact and effects of integrated programs for women with substance abuse issues and their children. In studies comparing integrated to non-integrated programs, most improvements in emotional and behavioral functioning favored integrated programs and, where available, most effect sizes indicated that this advantage was small.

Nishimoto, R., & Roberts, A. (2001). Coercion and drug treatment for postpartum women. American Journal of Drug and Alcohol Abuse, 27(1), pp. 161-181.

This research examined the extent to which various indicators of coercion were related to treatment retention in a gender-specific treatment program and a traditional outpatient program for pregnant and postpartum women who were mandated to enter treatment. Women who were given custody of their infant stayed in treatment longer than women who did not have custody. Women who had custody and were in the intensive day treatment program also completed treatment at a much higher rate than those in the traditional program. These findings have important implications for social work practice as the decision to place a newborn infant with a mother who has a history of or is currently abusing or dependent on substances is a serious concern for child welfare workers.

Osterling, K. L., & Austin, M. J. (2008). Substance abuse interventions for parents involved in the child welfare system: Evidence and implications. Journal of Evidence-Based Social Work, 5(1), pp. 157-189.

This structured review of the literature focuses on evidence related to two areas: (1) individual-level interventions designed to assist mothers and women in addressing their substance abuse problems, and (2) system-level interventions designed to improve collaboration and coordination between the child welfare system and the alcohol and other drug system. Overall, research suggests the following program components may be effective with substance-abusing women with children: (1) Women-centered treatment that involves children, (2) Specialized health and mental health services, (3) Home visitation services, (4) Concrete assistance, (5) Short-term targeted interventions, and (6) Comprehensive programs that integrate many of these components. Research also suggests that promising collaborative models between the child welfare system (CWS) and the alcohol and other drug (AOD) system typically include the following core elements: (1) Out-stationing AOD workers in child welfare offices, (2) Joint case planning, (3) Using official committees to guide collaborative efforts, (4) Training and cross-training, (5) Using protocols for sharing confidential information, and (6) Using dependency drug courts. Although more rigorous research is needed on both individual-level and system-level substance abuse interventions for parents involved in the child welfare system, the integration of individual-level interventions and system-level approaches is a potentially useful practice approach with this vulnerable population.

Ryan, J. P., Choi, S., Hong, J. S., Hernandez, P., & Larrison, C. R. (2008). Recovery coaches and substance exposed births: An experiment in child welfare. Child Abuse & Neglect, 32(11), pp. 1072-1079.

The objective of the current study is to evaluate the use of recovery coaches in child welfare. Methods: The current study is longitudinal and utilizes an experimental design. The sample includes 931 substance abusing women enrolled in a Title IV-E Waiver Demonstration, 261 in the control group, and 670 in the experimental group. Women in the experimental group received traditional services plus the services of a recovery coach. Administrative records are used to indicate substance exposure at birth. Of the 931 women enrolled in the waiver demonstration, 21% of the control group and 15% of the experimental group were associated with a subsequent substantiated allegation indicating substance exposure at birth. Cox proportional hazards modeling indicates that women in the experimental group were significantly less likely to be associated with a new substance exposed birth. The use of recovery coaches in child welfare significantly decreases the risk of substance exposure at birth. Integrated and comprehensive approaches are necessary for addressing the complex and co-occurring needs of families involved with child protection.

Shook, J., Goodkind, S., Pohlig, R. T., Herring, D., & Kim, K. H. (2011). Patterns of mental health, substance abuse, and justice system involvement among youth aging out of child welfare. American Journal of Orthopsychiatry, 81(3), pp. 420-432. DOI: 10.1111/j.1939-0025.2011.01110.x

Although research on youth aging out of the child welfare system has increased, there has been limited focus on how their experiences vary. In particular, there is a need to examine patterns in the involvement of these youth in other systems, which indicate constellations of challenges facing these young people as they transition out of care and into adulthood. Using administrative data from a large birth cohort of individuals born between 1985 and 1994 whose families have been involved in the child welfare system, this article presents an analysis of the mental health, substance abuse, juvenile justice, and criminal justice system involvement of youth who have aged out of child welfare. Using a 2-step cluster analysis, we identify 5 subgroups of youth. Two of these groups, accounting for almost half of the youth, have little other system involvement and have child welfare care careers of relative stability. The other 3 groups, consisting of just over half of the youth, have much more extensive other system involvement, as well as care careers marked by instability and a greater proportion of time spent in congregate care.

Straussner, S. L. (Ed). & Fewell, C. (Ed). (2011).Children of substance-abusing parents: Dynamics and treatment. Lam, W.K., & O’Farrell, T.J. (Ch.3) Dynamics of substance-abusing families and implications for treatment. Springer Publishing Company: New York, NY.

Over the past three decades, substance abuse has become widely acknowledged to be a disorder that affects not only the afflicted individual, but also affects and is substantively influenced by family members with whom the individual lives and interacts. Although some continue to view and treat substance abuse as largely an individual problem, the clinical and historical literature across disciplines have converged in recognition of the systemic impact of alcohol, and more recently, other substances, on the family. Understanding the role family members may lay in the development, maintenance, and treatment of alcoholism and drug abuse has not been limited to researchers or even the broader professional community. To wit, in the popular press, the sheer volume of texts which has appeared on the topics of codependency, adult children of alcoholics, addictive personality, enabling, and so forth, is voluminous. For example, an Internet search of large on-line book retail revealed that over 400 books were currently available for purchase on the topic of codependency alone. Moreover, self-help support groups for family members of alcoholics and drug abusers are available in virtually every community. Because relationship problems and substance use disorders so frequently co-occur, it would be very difficult to find clinicians who specialize in the treatment of substance use disorders or relationship problems that have not had to address both sets of issues concurrently for many clients seeking help (either with the client individually or in the context of the client’s larger family system).

Sun, A-P., Shillington, A. M., Hohman, M., & Jones, L. (2001). Caregiver AOD use, case substantiation, and AOD treatment: Studies based on two southwestern counties. Child Welfare, 80(2), pp. 151-178.

This article includes two separate studies: the first explores the impact of caregiver AOD use on CPS case substantiation; the second compares CPS-involved and CPS-noninvolved females in AOD treatment systems and describes what happens to AOD abusers once they enter the treatment system. By using two different approaches, the two studies presented here provide a profile of AOD-using caregivers in the child welfare and AOD systems. Results suggest that cases with indications of AOD use are more likely to be substantiated than cases without; and increasing numbers of children and younger maternal ages are risk factors for CPS involvement among AOD-using women. Both studies point to the importance of cross-training and skills in interdisciplinary work between CPS and AOD treatment field. CPS workers need to be familiar with AOD screening, identification, and assessment; AOD workers must be sensitive to the multiple problems and needs experienced by their CPS clients.

Sword, W., Niccols, A., Yousefi-Nooraie, R., Dobbins, M., Lipman, E., & Smith, P. (2013). Partnerships among Canadian Agencies Serving Women with Substance Abuse Issues and Their Children. International Journal of Mental Health Addiction, 11(3), pp. 344-357. DOI: 10.1007/s11469-012-9418-x

This study aimed to describe the partnership patterns, activities, and qualities among Canadian agencies serving women with addictions and to determine predictors of partnerships. The authors found that a number of partnerships exist, and that the extent and characteristics of these partnerships vary. Agency responsiveness to clients was predictive of sending referrals whereas friendliness predicted joint programming and consultation. The authors suggest that efforts should be made to build on the social capital inherent in these agencies to strengthen existing networks, further develop linkages to improve service delivery, and promote evidence-informed practice in a field where there is an identified research-practice gap.

Thompson, S., Roper, C., & Peveto, L. (2013). Parenting in recovery program: participant responses and case examples. Child Welfare, 92(1), pp. 139-157.

This study reports on the preliminary findings of the Parenting in Recovery program which was created to address the needs of substance-abusing mothers involved in child welfare. This manuscript describes this program and perceptions of participants concerning its effectiveness. The authors argue that intensive service provision within a collaborative setting appears to be one of the core processes needed by this population.

Westermeyer, J., L. Bennett, et al. (2007). Substance use disorder among adoptees: a clinical comparative study. American Journal of Drug and Alcohol Abuse, 33(3), pp. 455-66.

Goals of the study were to assess whether adoptees in treatment for Substance Use Disorder (SUD) (1) were over-, equi-, or under-represented in a clinical sample of patients with (SUD) and (2) differed demographically and clinically from non-adoptees with SUD. Sample consisted of 608 patients in two alcohol-drug treatment programs. Data collection included the Childhood Problems Scale, the Minnesota Substance Abuse Problem Scale, and the Minnesota Substance Abuse Treatment Questionnaire, and the Michigan Assessment-Screening Test/Alcohol-Drug. Findings showed that the prevalence of adoptees among SUD patients was 14 times higher than expected (95% Confidence Interval, 10 to 18 times). Adoptees reported childhood histories similar to those of non-adoptees with "any parental SUD", but they more closely resembled non-adoptees without parental SUD in regard to SUD severity and SUD treatment. Conclusion is that adoptees and their adoptive families should be alert to the increased risk of SUD among adoptees. Clinicians can expect that adoptees should manifest milder levels of SUD morbidity, similar to "non-heredity" SUD.

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