The Substance Abuse Challenge in Child Welfare
(Originally published October 2014)
Whenever public child welfare agencies begin to receive greatly increased numbers of CPS reports that include allegations of child maltreatment related to parental substance abuse, both practitioners and policymakers are led to reconsider their approach to these families. Substance abuse epidemics often involve widespread use among low income groups of a single dangerous drug or poly-drug use which has devastating effects on the parenting of substance dependent persons and addicts. Child deaths resulting from unsafe sleeping practices, lack of supervision, grossly inadequate care or physical abuse frequently occur which anger concerned citizens and legislators. Babies and toddlers with symptoms of drug withdrawal or with seriously compromised health and development are likely to enter an inadequately resourced and unprepared foster care system in large numbers.
In these circumstances, policymakers are likely to consider imposing severe criminal penalties for some types of substance abuse, for example, on use of illegal drugs during pregnancy. Child welfare practitioners and managers may reconsider their commitment to supporting and assisting substance abusing parents with maintaining custody of children, or with anything more than token efforts toward reunification.
Substance abusing parents are a challenge to a social work ethos in any organizational setting and especially in child welfare agencies, whose mission is to protect children from abuse or neglect. Resistance to offers of help, denial of a drug problem or its impact on parenting, lying whenever necessary, finding ways to beat drug tests, manipulation and/or exploitation of professionals and family members, misuse of limited resources to support a drug habit, repeated failed attempts at treatment, self-sabotage on the verge of a successful reunification process, selling drugs as well as using drugs or other criminal behavior, compromised physical health, chronic co-occurring mood disorders, relationships with violent partners, limited education and employment potential, alienation of extended family members fed up with addicts’ behavior – these are formidable challenges to say the least. In addition, when a parent’s behavior indicates without question that “drugs come first”, and children are a distant second (or third) priority in the parent’s life there is an understandable tendency of professional helpers and courts to throw in the towel (so to speak) and terminate parental rights at the first opportunity.
I remember a time in Washington State during the 1990s after methamphetamine manufacture and distribution led to massive family breakdown and an increase in the state’s foster care population when many child welfare practitioners and other professionals believed that it was impossible to help methamphetamine addicts absent at least 6 months of in-patient drug treatment, a scarce resource at the time. Reunifications declined while termination actions and adoptions increased greatly in many of the state’s child welfare offices. At this point, some interesting developments occurred:
Research studies conducted by ORDA (the DSHS research entity) found that methamphetamine abusers had recovery rates similar to abusers of other drugs.
Implementation of family treatment drug courts led to at least a doubling of reunification rates in some communities.
Creation of the Parent Child Assistance Program (PCAP) demonstrated that paraprofessionals could effectively engage and support substance abusing pregnant women and mothers of babies and toddlers, 0-3.
Pregnant and Parenting Women (PPW) programs which provided residential treatment in which mothers could retain physical custody of and proximity to young children were developed in a number of communities.
In some other areas of the country, parent mentoring programs increased rates of entry into and completion of treatment programs.
Within a few years, a critical mass of child welfare practitioners and other professionals in Washington State evolved from deep pessimism to a guarded optimism regarding the possibility of helping methamphetamine abusers in a recovery process. This is not to say that the challenges described above vanished or were rendered null and void, but that the commitment to a compassionate response to parental substance abuse was reignited by on-the-ground examples of effective non-punitive approaches to drug dependence and addiction and to insuring the safety of children in substance abusing families.
Some Rational Considerations
It is understandable that professionals, foster parents and citizens who observe the devastating effects of parental substance abuse on children’s safety and well-being often become angry and want to punish the parents. Nevertheless, it is useful to think rationally before adopting foolish and injurious policies and practices:
Research studies have found that the drugs which do the most damage to a developing fetus are alcohol and tobacco, not illegal drugs. Furthermore, criminalizing drug/alcohol use during pregnancy is likely to discourage pregnant substance abusing women from seeking help.
Substance abusing women who lose custody of children and have their parental rights terminated are likely to have additional children; and in fact what women often say to PCAP advocates is “I’ll keep having children until I’m allowed to keep one.” Even when parental rights are terminated due to continuing substance abuse, it makes sense to invest in substance abuse treatment programs on behalf of unborn children.
Substance abuse has many costs to states and communities other than the costs of child welfare and judicial interventions. Criminal justice systems, prisons, programs for the homeless, emergency room visits, hospitalizations, family violence, disabilities and reduced productivity are costly to states and communities. Policymakers capable of enlightened self-interest on behalf of the communities and organizations they represent will seek ways of limiting these costs.
Rational arguments are unlikely to change the minds of persons whose belief in
punitive approaches to drug offenders is based on something deeper than policy considerations and research. However, the great majority of child welfare practitioners and helping professionals are not motivated by the desire to punish substance abusing parents, but rather by an urgent need to protect children (often babies and toddlers) from harm. First and foremost, these professionals need effective programs and practices, and in their absence no amount of rhetoric will reduce entry-into-care rates or increase reunifications.
Some major research findings and their implications
Several studies published in the 1990s found low rates of entry into and completion of treatment programs even when mandated by courts. In some studies, not more than 20-25% of parents completed court ordered substance abuse treatment programs. Child welfare agencies do not need to be punitive to increase the likelihood parents will not enter and complete substance abuse treatment programs. Lack of concrete support and emotional support, or superficial token support, will lead to low rates of compliance with court ordered treatment plans for two main reasons: (1) many parents have already had failed treatment episodes and don’t believe in their ability to overcome drug dependence or addiction and (2) parents who belong to groups that have experienced generations of oppression and/or who themselves have histories of trauma (including child maltreatment and DV) will frequently not believe the assurance of decision makers that children will be returned to their custody if they become clean and sober and otherwise demonstrate their ability to parent children in safe and nurturing ways. Parents may not believe in their potential for recovery, and they don’t trust authority figures to follow through on promises.
For this reason, a main goal of policymakers and practitioners should be to increase rates of substance abusing parents’ entry into and completion of treatment programs. A number of initiatives/programs around the country (for example, recovery coaches in Illinois, Engaging Moms in Florida and PCAP in Washington State) have been able to at least double treatment completion rates by providing concrete support and emotional support to parents over extended periods of time. Motivational Interviewing (MI) techniques are useful, but the idea that a single interview or two conducted by MI trained staff will prove to be an effective alternative to ongoing support for child welfare involved families is an illusion.
Family teams which are part of family treatment drug courts or convened in other ways and/or professional or para-professional mentors can provide the regular feedback (much of it positive) and encouragement which are essential in what is likely to be an up and down recovery process.
Drug dependent persons and addicts are remarkably creative at fooling and manipulating caseworkers and treatment professionals, even those professionals with
an excellent understanding of the dynamics of addiction. One important study published over a decade ago found that at least half of parents who entered a substance abuse treatment program never stopped using drugs and alcohol. The idea that periodic drug tests can accurately track whether parents continue to use drugs and alcohol or have relapsed is a deeply felt wish among caseworkers and judges, but it is a naïve view. This is not to deny that occasional drug tests are valuable, but to depend on them almost exclusively to track parents’ progress in recovery, or to make decisions regarding child safety, is a foolish practice.
It is important for professionals involved in safety planning and implementation of in- home safety plans to understand that there is little or no research regarding the effectiveness of in-home safety plans, and only a limited amount of agreed upon practice wisdom regarding safety planning. The single most important agreement regarding in-home safety among practitioners and experts at the current time is that an active parental partner is required for safety plans to be effective. When substance abusing parents are in denial about risks and safety threats to children resulting from their drug/alcohol abuse, or if they are avoiding contact with caseworkers and other professionals whenever possible, an in-home safety plan cannot control danger to young children. Furthermore, it should go without saying that entry into a treatment program does not mean that children are immediately safe from child maltreatment. One of the most sobering research findings of the past two decades is that brief lengths of stay in foster care are associated with high rates of re-entry, in part because until substance abusing parents are well established in a recovery process they are unlikely to be capable of the reliable parenting that children need.
Poverty Related Services
About half of parents with open child welfare cases are not just poor but severely poor (incomes below $11-12,000 per year); and the income of parents has been found to affect both the likelihood of reunification and time to reunification. Substance abusing parents who have made a good start at recovery often have an urgent need for affordable housing, a difficult need to meet in many communities where low income housing is at a premium. In addition, parents about to be reunified with their children will need assistance in furnishing an apartment, purchasing school clothes, affording transportation, etc. When young children remain in the custody of substance abusing parents, or following reunification, they should be placed in high quality child care settings both to monitor their safety and stimulate their development.
A common distressing scenario in child welfare goes as follows
Michelle, an 18 year old young woman, was separated from one or both parents during adolescence for months or years due to physical abuse or sexual abuse, or family conflict. This young person experiences chronic depression and possibly PTSD symptoms (such as meltdowns). She begins to use drugs in adolescence, in part because drug use is common among her friends and later because she discovers that drugs make her feel less depressed and less out of control. Michelle becomes pregnant during her senior year in high school and does not graduate. She returns home to live with her mother and stepfather both of whom she dislikes. Her mother is both controlling and emotionally abusive. Soon after giving birth to a daughter, Michelle moves in with her boyfriend, her daughter’s father. Two months later an argument between Michelle and her boyfriend leads to a violent altercation in which Michelle is seriously injured. Police are called who arrest the boyfriend. Michelle returns to her mother’s home while she considers her options.
In this situation, a young mother lacking a high school degree or any vocational training and who has an incipient substance abuse problem is forced to choose between dependence on an emotionally unsupportive birth family or a violent boyfriend. She may be eligible for welfare but is probably not able to parent a child without a great deal of emotional and concrete support which is not readily available. Young women in this situation need programs which will widen their horizons and choices and which help them remedy educational deficits. Involvement in drug /alcohol treatment programs is often needed, and an aggressive law enforcement response to family violence may provide short term protection for both mother and baby. However, something more is needed: a realistic hope of a decent future (which includes employment opportunities) and a support system for mother and baby that lasts more than a few weeks or months. Absent such support and opportunity, it is easy to imagine events that would lead to the baby’s placement in foster care and eventual termination of parental rights.
Choi, S. & Ryan, J. (2007), “Co- occurring problems for substance abusing mothers in child welfare: Matching services to improve family reunification,” Children, Youth and Services Review, 29 (11), 1395-1410.
Dakof, G., Cohen, J., Henderson, C., Durate, E., Boustani, M., Blackburn, E. & Hawes, S., (2010) “A Randomized Pilot of the Engaging Moms Program for Family Treatment Drug Court,” Journal of Substance Abuse Treatment, 38, 263-274.
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, 2176-2185.