Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues
Treatment Improvement Protocol (TIP) Series 36

Family Preservation and "Fast-Track" Adoption

The Federal government has established a series of programs to fund and support States' efforts to help children and their families in crisis. These programs include Family Support and Family Preservation Services to strengthen family stability and facilitate the safe reunification of a child who has been removed from the home and Foster Care and Adoption Promotion and Support Services that support both the maintenance of foster care and encourage more adoptions out of the foster care system.

These programs provide funding to States, but they also require States to adopt a number of important policies, timetables, and restrictions, including a significant emphasis on children's health and safety, permanent placement, prompt development, and frequent review of service plans; time limits on family reunification services; and speedier termination of parental rights. In effect, the 1997 amendments to the Family Preservation and Support Services Act changed the emphasis from family preservation to child health and safety. This means that ensuring the child's developmental stability now takes precedence over extending "reasonable efforts" to reunify the family. For a more detailed explanation of this law and recent welfare reform laws, see Appendix C.

Consequences of Losing Public Assistance

Parents whose public assistance is reduced or terminated (e.g., because of changes in welfare law) may have difficulty providing their children with basic levels of food, clothing, shelter, and medical care. Will they find themselves charged with child neglect or abuse as a result? Most States prohibit a finding of child abuse or neglect if parents fail to provide the necessities of life because of poverty; however, it is not clear what will happen if their inability to provide is due to their failure to comply, for example, with welfare-to-work requirements. Treatment clients who lose public assistance may also lose their eligibility for Medicaid, which in some States pays for treatment.

The child welfare system provides Medicaid benefits for all children in its care. Some States also provide Medicaid benefits for children living at home but in open CPS cases. In many States, however, parents are not eligible for Medicaid. Advocacy for entitling Medicaid benefits to those parents who are involved in the CPS system would benefit such parents who are seeking, or seeking to complete, treatment.

The Combined Impact of Welfare Reform and Changes in Child Welfare Laws

The combined effect of new welfare reform requirements and changes in child welfare laws may place great pressure on parents involved with CPS agencies. To avoid losing their children, parents may be required to enter treatment, achieve sobriety, or meet other expectations from the CPS agency, all within a limited time period. Similarly, under TANF, welfare authorities may impose work requirements and sanction those who fail to comply.

Those with substance abuse disorders, minimal work experience, and a lack of parenting skills can feel overwhelmed by these growing demands. Staying sober, by itself, is a difficult achievement for many. If they have to comply with work requirements and assume new parenting responsibilities, they may see all of this as impossible. For some, the response will be denial of the reality that the system has changed. Others may be overcome by hopelessness and be inclined to give up. Other parents will relapse. With the States placing greater emphasis on children's health and safety and permanent placement, any one of these responses could mean loss of parental rights. Moreover, States that choose to test welfare recipients for drug abuse may quickly detect a relapse, which could result in the reduction or elimination of benefits. Or a child welfare agency might conclude that a relapse means that reasonable efforts to preserve or reunite the family are no longer consistent with the goal of a safe and stable environment for the child.

As welfare reform and changes in child protection laws are implemented, counselors will see increasingly stressed parents in need of supportive counseling and a web of other services. In these changed times, however, support will not suffice. If the parent in treatment is to emerge with her family intact, the counselor must combine support with a firmness rooted in the understanding that the rules in this area have changed and become less forgiving. The continuing challenge for counselors in the years ahead will be to provide support to clients while conveying to them the urgency of attaining or maintaining sobriety.

Managed Care

More persons entering treatment are paying for their services through managed care systems that place limitations on the type and amount of treatment provided. Medicaid, Medicare, and welfare benefits, once provided through private insurance, are all being allocated to managed care. Accountants and other nonhealth professionals who may have limited health care background often are making treatment decisions. Typically, clients are receiving authorizations for fewer sessions at less intensity. A client who required safe detoxification once was funded for 21 days; now, limited funding allows for only 2 days. In the late 1970s, a pregnant substance-dependent mother could stay in the hospital for 5 days. Now, she is discharged almost immediately after giving birth.

The amount of time most agencies must spend on the telephone with managed care representatives is staggering. Services a doctor or counselor believes are medically necessary are frequently denied (Rabasca, 1998). Programs once referred clients freely to appropriate services; now, additional services with lengthy justifications must be preapproved. Rather than taking into account the individual's circumstances, insurance representatives use reference manuals, such as the American Society of Addiction Medicine's (ASAM) Patient Placement Criteria for the Treatment of Substance-Related Disorders, 2nd edition (ASAM, 1996) or the Green Spring Health Services Medical Necessity Criteria for Utilization Management(Nyman et al., 1992), to determine the appropriate level of care.

Clients with childhood abuse and neglect issues as well as a substance abuse disorder may face managed care restrictions on the number of visits they can make to mental health services. Managed care often will not pay for sexual abuse or physical abuse assessments and evaluations if the State is involved, often looking to the State to provide them; this complicates access to services. These restrictions may mean that both problems cannot be adequately addressed, particularly given the fact that abuse issues often do not surface until late in treatment, when the allotted number of visits may be nearly exhausted. Often by the time additional visits are approved, the continuity of therapy needed for the best chance of success may have been lost. Managed care may also deny treatment to clients with childhood abuse and neglect issues because they are not sufficiently motivated to deal with these problems.

In several surveys of members of the American Psychological Association (APA), respondents reported that managed care created ethical dilemmas in which they were required to report confidential patient information as a condition of reimbursement (Clay, 1998). Clearly, such dilemmas are of particular concern in cases of substance abuse disorder because they may also involve issues of child abuse and neglect. (See TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians [CSAT, 1997a], for more information on the legal and ethical issues involved in sharing information with insurers and other third-party payors.)

The strong backlash against such policies has recently resulted in legal actions at both State and Federal levels. Legislation is also under consideration at the State and Federal levels to increase accountability for the health outcomes of managed care agencies. In 1996, five States passed laws protecting consumers from managed care abuses; in 1997, 17 more States took such actions (Clay, 1998).

Implications for providers include the following:

• Know how to "work the system" and speak the language of managed care. Some counseling agencies hire an individual specifically to perform this task. It is especially important to know a company's stated placement criteria. In cases of current child abuse, counselors should be aware that when a CPS agency is involved, the capitation rate might be higher because it is expected that more services will be used. Because the managed care company is allocating more money per client, there should be a greater capacity to support substance abuse treatment that will benefit the entire family.
• Consider innovative strategies. In Florida, for example, five major substance abuse treatment programs combined and created their own managed care company so that they could compete with other managed care companies.
• Develop the capacity for different modalities of treatment. For example, a managed care caseworker refuses to authorize residential treatment for a person who has a history of substance dependency, is currently using, and has no motivation for treatment. The counselor as provider may set up smaller goals to work within the system, proceeding with low intensity motivational counseling once or twice a week. At the end of the authorized treatment period, the counselor may be able to report increased motivation and succeed in having a higher level of care authorized.
• Have proof that the treatment program or agency is successful and ultimately saves money. A treatment program can demonstrate its contributions by maintaining data on quality assurance and program evaluations that the program manager can use when he works with the managed care administrator. Counselors should also be prepared to provide factual data to demonstrate problems that have arisen from system constraints.

Although counselors and treatment program administrators often focus on the negative impact of managed care, this trend can benefit clients by providing incentives for developing interagency collaborations and satellite clinics in different settings. In the not too distant past, few counseling programs would have been enthusiastic about locating a treatment program within a primary care clinic or a satellite child guidance clinic within a methadone maintenance treatment program. Today, although these ideas are still novel, they are by no means unthinkable. Since no one agency is likely to be able to meet all the needs of a family affected by substance abuse, particularly one in which child abuse or neglect has occurred, closer collaboration among services may result in more effective, family-oriented approaches to intervention.

As legislators address managed care issues, counselors can be effective advocates, working to ensure that the care their clients need is available. By working proactively with others to raise systemic issues, counselors can ensure their concerns are represented in the legislative process. Vocal, clear, factual communication can help hold State and managed care agencies accountable for the results of their policies. (For more information on managed care, see TIP 27, Comprehensive Case Management for Substance Abuse Treatment [CSAT, 1998a].)

Increased Accountability

Increasingly, funders are holding CPS agencies, health care services, and substance abuse treatment programs accountable for demonstrating specific outcomes. Programs must be prepared to demonstrate their effectiveness using objectively verifiable outcome measures. Failure to meet established goals may result in a loss of funding or in mandated systemic changes. The individual counselor may be asked to provide both qualitative and quantitative data (such as case histories) to demonstrate the quality of care she is giving. Such evaluations can be expensive.

Clients who are in treatment counseling and also receiving services from other agencies (which is often true of those involved in allegations of child abuse and neglect) may be assessed repeatedly through interviews and questionnaires. The counselor can help prepare clients for this invasive mandated reporting by emphasizing its potential benefits. Although time consuming to collect, such data provide a valuable opportunity to streamline programs and improve services.

Class action suits have been filed in Federal courts against child welfare agencies in several States, resulting in many of them being placed under some form of Federal supervision. The mechanisms in place to hold the agencies accountable could affect substance abuse counselors in these States, who may receive increased requests for case and outcome data from agencies that must report to the court. A counseling agency that has a contract with a CPS agency should be prepared to demonstrate that the services provided are likely to affect the outcome positively or risk losing funding.

Concerning accountability, some jurisdictions are moving to open family court hearings. (The Adoption and Safe Families Act now requires that foster parents be notified of all hearings and be given the opportunity to testify.) Clients will be affected because their cases, along with their substance abuse, are being made public. CPS agencies will be held more accountable because their work will be open to public scrutiny.

Interagency Collaboration

From the Federal to the community level, changes are being made that influence the way substance abuse treatment agencies deliver services. Increasingly, agencies must communicate and collaborate to meet a client's needs under the constraints posed by funding limitations, applicable laws, and managed care policies. Some counseling agencies have merged with other service agencies in order to deal with administrative burdens such as reporting requirements and the need to work intensively with managed care representatives. Many Federal grants require public-private partnerships and multidisciplinary treatment strategies formalized through memoranda of understanding.

As agencies become more accustomed to working together, their attitudes toward collaboration also are changing. Agencies increasingly cross borders that were once sacrosanct. Practitioners are more aware that research and experience have demonstrated the importance of a wide range of support services (such as transportation, housing, and day care) for increasing the effectiveness of counseling (Feig, 1998). As a consequence, the role of the treatment provider is changing from one who works in relative isolation to one who is a partner within an integrated system.

Many traditional treatment agencies are expanding their practice to incorporate mental health services. By doing so, they make treatment more accessible for clients with coexisting disorders. For example, an adult survivor who has mental health issues and is also a substance abuser may receive treatment for both needs at the same location. Such close partnerships provide a more cohesive approach to meeting clients' needs. In addition, this approach may provide a more solid funding base for agency services. The U.S. Department of Health and Human Services (DHHS) is committed to leading efforts to improve collaborative working relationships between the child welfare and substance abuse treatment fields and to supporting States' efforts to do the same. The Department's recent report to Congress, Blending Perspectives and Building Common Ground, describes several programs that can assist States and local communities in expanding substance abuse treatment for clients in the child welfare system, including the Substance Abuse Prevention and Treatment Block Grants, the Targeted Capacity Expansion Program, and Medicaid (DHHS, 1999).

An innovative program in Connecticut by the Department of Children and Families (DCF) called Project SAFE (Substance Abuse Family Evaluation) directly links CPS agencies with substance abuse treatment (see Chapter 5). The experience over the past 3 years has led to more than 20,000 unduplicated referrals from CPS agencies to a statewide network of substance abuse treatment providers. Project SAFE provides priority access to substance abuse evaluations, drug testing, and various outpatient substance abuse services to clients identified by the CPS agency. Referrals are coordinated from the beginning through a statewide network that also coordinates other payment responsibilities. The Project has led to communication and a definition of roles and response guidelines between CPS agencies and the substance abuse treatment system.

Connecticut's DCF recently created Supportive Housing for Recovering Families, which will provide drug-free housing assistance and case management for families who are reunifying and making a transition to the community after successful residential substance abuse treatment. DCF is working on outreach approaches once the CPS agency and Project SAFE identify a client as needing substance abuse treatment. DCF is also collaborating with the academic community to pilot motivational enhancement training and approaches to both the CPS and substance abuse treatment system as well as case management services.

In the current environment, traditional funding sources are drying up, and many traditional programs are going out of business. Moreover, many Federal grants and contracts are now aimed at collaborative efforts. Once there were many funding streams; now there are only a few State-subsidized funding sources. Persistent, creative fundraising is essential, and success almost always depends on proactive strategies to form collaborations. Agencies must clearly define their responsibilities and nurse the relationships they will need to seek funding in innovative partnerships. Program funding may come from drug courts or from CPS agencies, which now have the flexibility to use a portion of their funding to support substance abuse treatment (see Figure 7-1).

Changing Demographics Of Drug Use

Over the past 20 years, the number of people over 35 years of age using illicit substances has increased significantly ( Substance Abuse and Mental Health Services Administration [SAMHSA], 1996). The 1995 National Household Survey on Drug Abuse indicates there is a large cohort of aging substance-abusing parents:

In general, the aging of people in the heavy drug-using cohorts of the late 1970s, many of whom continue to use illicit drugs, has diminished any observable reductions in use among the 35+ age group and has resulted in an overall shift in the age composition of drug users... For example, in 1985, 19 percent of cocaine-related episodes involved persons age 35 or older. By 1995, this percentage had increased to 42 percent (SAMHSA, 1996).

Epidemiological surveys indicate that actual substance dependence occurs most frequently during early to middle adulthood, when a substantial proportion of the general population is parenting minor children (Anthony et al., 1994). Consequently, treatment providers should continue to expect to find many parents of minor children in their caseload, with the attendant possibility of substance-related child abuse or neglect.

Gender Issues

Some research now suggests that gender differences are an important factor in addiction and recovery (Magura and Laudet, 1996). When counseling clients whose families are affected not only by substance abuse but also by child abuse and neglect, research suggests that counselors can best meet the clients' needs by taking these gender-specific factors into account (Coletti et al., 1997).

Women who are pregnant or parenting need "family-oriented services providing comprehensive care as well as parenting and family skills training, all of which usually remain unaddressed in traditional drug treatment" (Magura and Laudet, 1996, p. 203). In the opinion of many researchers, the absence of such specialized interventions may well result in an increased incidence of child abuse and neglect, as well as increased out-of-home placement (Magura and Laudet, 1996). Programs that meet such needs can help engage pregnant and parenting women and improve treatment for them, but such services are still not widely available (see Chapter 6).

Men's roles as fathers also should not be ignored in providing substance abuse treatment. It is true that among clients who are parents, women are more likely to have children in their care and men more likely to be estranged from their children. But surveys of representative samples indicate that in the general population far more fathers than mothers have substance abuse disorders (DHHS, 1994) and men consistently outnumber women in all types of treatment (Gerstein et al., 1997). Consequently, though it is true that a greater proportion of women entering treatment are mothers and are more likely to have minor children in their care, the numbers of men and women seeking help who are parents are about the same (DHHS, 1999).

Changes in welfare laws now require a mother receiving welfare to identify the father of her children. Consequently, fathers who seemed nearly irrelevant in the recent past have regained visibility. Legal changes in welfare laws also allow fathers to be present in the home without the loss of financial support. Historically, in an abuse or neglect situation, CPS agencies have worked to keep the mother and children together but assumed that an abusing father should leave the family; this view, however, appears to be changing. Fathers are increasingly recognized and supported, with resulting benefits for children. Courts are discovering the value of paternal relatives as placement options for children. As substance abuse among women rises and women continue to be disproportionately affected by the AIDS epidemic, fathers in treatment may become viable placement options for children whose mothers cannot care for them.

Fathers are increasingly motivated to assume a greater share of parenting responsibilities. Over the past 20 years, a number of social forces have converged to create new definitions of fatherhood. If these trends continue, more men who enter treatment may see parenting as part of their identity as men, and more of them may be distressed about their inability to function effectively as fathers because of substance abuse. Paternal substance abuse (most commonly paternal alcoholism) has been associated with spousal abuse, parental neglect, and failure to provide financial support (Chassin et al., 1996; Dion et al., 1997; Dukma and Roosa, 1995; Egami et al., 1996; Ichiyama et al., 1996). Because many fathers today show an increased willingness to work toward change for the benefit of their children, the treatment provider would be well advised to use this information to help motivate male clients.

More practitioners in other settings are now actively concerned with the client as father and are conducting research to define associated issues and needs.

On a limited basis, some substance abuse researchers are engaged in developing interventions to build parenting skills that are offered to both men and women (Luthar and Walsh, 1995). Prisons sometimes offer courses in parenting to male inmates. Specialized interventions have also been designed for teenage fathers, fathers with newborn infants, newly divorced fathers, and fathers with families on welfare. However, gender-specific interventions targeting the specific needs and concerns of fathers with substance abuse disorders still need to be developed and tested.