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Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009

Prevention and Drug Treatment
Authors: Mark F. Testa Brenda Smith

Do Substance Abuse Interventions Promote Family Reunification?

Failure to engage parents in drug recovery services or to prevent the recurrence of maltreatment will usually precipitate the children’s removal from parental custody and placement into foster care. In these circumstances, attention turns to encouraging or compelling parents to attain sobriety or total abstinence so that the children can safely be restored to their care. The shock of child removal is thought to provide a sufficient incentive for parents to engage in treatment50 to avoid permanent separation from their children through continued state custody or termination of parental rights.

A statewide long-term study of substance-abusing mothers in Oregon51 found that the more quickly mothers entered treatment and the more time they spent in treatment, the fewer days their children spent in foster care. Also, children of mothers who completed at least one treatment episode were more likely to be reunified with their parents than were children whose mothers did not complete treatment.

In an effort to boost reunification rates among children taken from substance-involved parents, the Illinois Department of Children and Family Services secured federal permission to fund a randomized controlled trial of a state-funded enhanced services program that previous quasi-experimental findings suggested showed promise. The Illinois demonstration was initially implemented in Cook County (which includes the city of Chicago) in April 2000. The demonstration randomly assigned Illinois Performance-Based Contracting agencies to treatment and comparison conditions. Parents were referred on a rotational basis to these agencies and subsequently screened for drug abuse problems. Eligible parents assigned to the comparison condition received the standard substance abuse services. Those assigned to the treatment condition received the standard services plus a package of enhanced services coordinated by a “recovery coach.” The recovery coach worked with the parents, child welfare caseworker, and AODA treatment agency to remove barriers to drug treatment, engage the parents in services, provide outreach to re-engage the parent if necessary, and provide ongoing support to the parent and family throughout the permanency planning process.

The final results from the independent evaluation52 showed that assignment of a recovery coach only marginally increased parental participation in drug treatment (84 percent versus 77 percent, not significant) but that 43 percent of the treatment group managed to complete at least one level of treatment compared with 23 percent of caregivers in the comparison group. The higher rate of completion in the treatment group helped to boost the difference in reunification rates between the treatment and comparison groups by a small but statistically significant difference of 3.9 percentage points (15.5 percent versus 11.6 percent). Although this difference was compelling enough for federal officials to grant Illinois a five-year extension to expand the demonstration to downstate regions, the failure of the sizable difference in treatment completion rates to carry over to a larger difference in reunification rates prompted a closer look at some possible explanations for the shortfall.

An investigation by Jeanne Marsh and several colleagues53 found that although completing at least one level of treatment helped to boost reunification rates, only 18 percent of participants in the Illinois demonstration completed all levels of treatment. Furthermore, besides substance abuse, participants faced other serious problems, such as domestic violence, housing, and mental illness. Only 8 percent of participants had no other problem besides substance abuse; 30 percent had at least one other problem; 35 percent had two other problems; and 27 percent had three or more. Parents whose only problem was substance abuse achieved a 21 percent reunification rate, while parents with one or more other problems achieved only an 11 percent rate. Reunification rates were highest among the 5 percent of participants who completed mental health treatment (41 percent) and next highest among the 10 percent of participants who solved their housing problems (12 percent). Of the 18 percent of participants who completed all levels of drug treatment, only 25 percent regained custody of their children. The authors concluded that a service integration model designed to increase access to substance abuse treatment will not successfully promote reunification unless outreach and retention services can ensure client progress in the three co-occurring problem areas as well as in completing substance abuse treatment.

In another area, preventing subsequent substance-exposed infant (SEI) reports, assignment of a recovery coach was linked with a reduced likelihood of recurrence. At baseline, 69 percent of parents randomly assigned to the treatment group had previously delivered an infant reported for intrauterine substance exposure compared with 70 percent in the comparison group. After at least eighteen months of follow-up, 21 percent of parents assigned to the comparison group experienced a subsequent SEI report compared with 15 percent in the treatment group.54 Prior SEI reports were most strongly associated with the hazards of subsequent SEI reports. Parents with prior SEI reports were seven times more likely than those without reports to experience the birth of a child reported for intrauterine substance exposure. Parents randomly assigned to the comparison group were 1.4 times more likely than those assigned to the recovery coach treatment to have a subsequent SEI report. Despite the lowered risk in the treatment group, the fact that 15 percent of mothers assigned a recovery coach experienced a subsequent SEI report further compounds the permanency planning dilemma—whether to continue investing in the uncertain outcomes of drug recovery and family reunification or to cut the process short by terminating parental rights and proceeding with adoption or other planned permanency arrangements such as legal guardianship and long-term placement with extended kin.