ALCOHOL AND OTHER DRUG ABUSE (AODA) OVERVIEW
What can the Department do to assist parents with alcohol and other drug involvement address these problems and learn to safely care for their children in their own home?
Recent external forces have impacted both the child welfare and AODA treatment systems in Illinois. Permanency initiatives adopted in 1997 shortened the time frames for making child placement decisions by child welfare workers and the courts. AODA providers treating parents involved with the child welfare system see themselves faced with cost controls and other limits on service delivery from external managed care entities and renewed efforts to standardize clinical assessment, placement, and treatment decisions.
Even while these external factors create a need for close collaboration between the two systems, child welfare and AODA providers find themselves farther apart on the core issues than ever before. AODA providers are perceived by their child welfare counterparts as unaccountable for client retention and treatment success and non-responsive to the courts requests for information. They are also perceived as focusing solely on the needs of the addicted parent and not concerned with the safety or welfare of the child involved. AODA providers see state child welfare workers and private agency staff as uniformed about the dynamics of AODA relapse and recovery and unwilling to get involved in the treatment and recovery of the substance abusing parents.
The impact of parental alcohol and other drug abuse (AODA) on children has been demonstrated both nationally and in Illinois through numerous studies. Estimates from the U.S. General Accounting Office indicate that nationally as many as two-thirds of all children in foster care had at least one parent who abused drugs or alcohol ( Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers. United States General Accounting Office; GAO/HEHS-98-182; September, 1998) (Figure 1). In Illinois, most of these parents abused hard drugs and had been doing so for at least five years.
The generational impact of parental AODA on child welfare has also been documented. The National Household Survey on Drug Abuse (Substance Abuse among Women in the United States. 1979-1995 National Household Survey on Drug Abuse (NHSDA). Substance Abuse and Mental Health Services Administration (SAMHSA); Office of Applied Studies; September, 1997.) estimates that 29.8% of female and 18.2% of male adult problem drug users live with children under age 18. As many as two thirds of all people in treatment for alcohol and other drug abuse report that they were physically, sexually, or emotionally abused during childhood (NIDA Notes 13:2. National Institute on Drug Abuse; 1998). Even though hard data from research studies do not exist, according to NIDA?s Women's Health Coordinator, "the sheer weight of the many reports over the years certainly implicates child abuse as a factor in drug abuse for many people." ("Exploring the Role of Child Abuse in Later Drug Abuse." NIDA Notes 13:2. National Institute on Drug Abuse; 1998.)
Pre-natal exposure to drugs can be an indicator of subsequent cases of abuse. In a study of more than 500 infants who were exposed prenatally to illicit substances, reports of abuse were subsequently filed for close to one-third of the children and two-thirds of those reports were substantiated (Jaudes, et. Al. 1995)
AODA's impact can be felt throughout the child welfare system. A survey conducted by the Child Welfare League of America reported child welfare agencies estimate that parental chemical dependency was a contributing factor in the out of home placement of at least 53% of child protection cases. (Child Welfare League of America (CWLA). 1997)
In Illinois a needs assessment study conducted jointly by OASA and DCFS found that over 46% of women involved with DCFS met the clinical criteria for substance abuse or dependence. Over 80% of these women reported using illicit drugs in their lifetime and over half (60.8%) had used them in the past year. Furthermore, nearly half (49.3%) reported drug use as the reason for their involvement with DCFS. (Alcohol, Tobacco and Other Drug Abuse by Women in the Illinois Child Welfare System. Illinois Department of Alcoholism and Substance Abuse; 1997). Almost three-fourths of Illinois children in foster care on June 1, 1997 had at least one parent who was required to undergo AODA treatment as part of the family?s service plan for reunification (Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers. United States General Accounting Office; GAO/HEHS-98-182; September, 1998).
OASA supported providers in FY98 reported a total of 11,231 duplicated admissions of individuals referred by DCFS. ( OASA FY-97 Data Book. Illinois Office of Alcoholism and Substance Abuse; 1998) Each individual served by OASA providers may have more than one treatment admission per year. Typically each person served by OASA averages between 1.9 and 2.1 admissions per year. This would translate to roughly half the number of admissions are actual individuals. This figure includes individuals served in the OASA/DCFS Initiative and other OASA supported programs (Figure 2). Of this total 3,319 admissions were reported by the OASA Initiative programs established specifically to serve DCFS referrals. In FY97, DCFS had 25,549 open female head-of-household cases. Using the relatively conservative 46.6% need for treatment estimate, over 11,000 DCFS involved women would be in need of AODA treatment.
CURRENT AND FUTURE STEPS
Despite these disconcerting statistics, both the child welfare and AODA systems have previous efforts they can point to as successes and promising approaches for the future. The DCFS/OASA collaboration on Project SAFE (Substance and Alcohol-Free Environment) developed a program that successfully addressed child neglect and parental substance abuse. The evaluation of Project SAFE in 1988 found that only 6% of participants had subsequent child abuse and neglect indications as compared to 92% in a control group of substance abusing non-SAFE participants.(Project Safe Final Evaluation Report. Lighthouse Institute; September, 1988.)
OASA and DCFS also jointly worked on development of programs specifically targeting pregnant and parenting substance abusers. In addition to providing residential treatment, these programs provided support for the pregnant and parenting women, including housing for the woman?s children in the program during residential treatment. While the main goal of these programs was to reduce barriers to treatment and improve outcomes, an additional benefit has been the literally hundreds of drug-free infants born to program participants.
The effectiveness of AODA treatment is still being debated today. Much of the recent debate however has focused on the various study methodologies employed to measure effectiveness and the extent to which treatment ?works? rather than if treatment works.
Major national studies of treatment effectiveness, conducted by independent evaluators, have documented treatment effectiveness. The National Treatment Improvement Evaluation Study
(NTIES) found that individuals receiving treatment in publicly funded treatment programs reduced their drug use, and criminal activity twelve months after receiving AODA treatment when compared with twelve months prior to treatment (National treatment improvement evaluation study. U.S. Center for substance abuse treatment; September, 1996). In a review of treatment effectiveness the U.S. General Accounting Office found that clients receiving treatment report reductions in drug use and criminal activity. Better outcomes were associated with longer stays in treatment. The GAO review found that across recent national studies clients who stay in treatment longer have better outcomes (GAO July, 1998). In the Drug Abuse Treatment Outcome Study (DATOS) fewer clients in treatment longer than three months reported continuing drug use than those in treatment for less than three months. Drug clients with the most positive outcomes were those in treatment for at least twelve months ("Overview of One Year Follow-up Outcomes in DATOS." Psychology of Addictive Behaviors, 1997). In fact results from the Drug Abuse Reporting Program (DARP) evaluation found that treatment lasting 90 days or less was no more effective than no treatment at all in facilitating abstinence from drug use during the year following treatment ( Drug Abuse Reporting Program (DARP). U.S. General Accounting Office; March, 1998.)
An Illinois evaluation of the DCFS Initiative treatment programs conducted by the University of Illinois and the University of Chicago found that participation in the DCFS Initiative treatment program reduced the likelihood of subsequent drug use. The more service components of the Initiative program that individuals used, the less likely they were to subsequently use drugs. (DASA/DCFS Initiative: Evaluation of Integrated Services for Substance Abusing Clients of the Illinois Public Child Welfare System. Marsh, Jeanne C.; D'Aunno, Tom; Smith, Brenda D.; University of Chicago, School of Social Services Administration; July, 1998) The evaluation also showed however that at the time of the follow-up interview, participation in the Initiative was unrelated to improvements in health, family, and parenting related outcomes.
Additional studies conducted in Illinois and elsewhere have identified promising approaches in AODA treatment. These could be applicable to improving both treatment and child safety outcomes for DCFS involved families. Case management services for AODA clients that include aggressive outreach have shown to improve drug use outcomes and also to enhance related factors including employment, residential stability, family environment, and stress. Improving these outcome areas can impact child safety as well as subsequent AODA use ("Case Management in Alcohol and Drug Treatment: Improvement Client Outcomes." Journal of Contemporary Human Services; April, 1992.).
A separate study of case management services provided to Medicaid recipients in public AODA treatment showed better outcomes than the control group six months following treatment (Supplemental Social Services Improve Outcomes in Public Addictions Treatment. Treatment Research Institute, University of Pennsylvania, and Coordinating Office for Drug and Alcohol Abuse Programs; Philadelphia, Pennsylvania, 1997).
The case managers added to the standard outpatient treatment program coordinated access to and delivery of medical screenings, housing assistance, parenting classes, and employment referrals.
Coercion to motivate individuals into AODA treatment has been utilized by a number of social and criminal justice service systems. Research has shown that while these efforts are sometimes controversial, the outcomes of individuals coerced into treatment are as good or better than those of voluntary treatment clients (Coerced Addiction Treatment: Research and Policy Recommendations. Miller, N.S.; Bruni, M.A. Illinois Office of Alcoholism and Substance Abuse, 1997.). Coercion has also been shown to be effective among individuals involved with the child welfare system. The Options for Recovery program in California offered AODA treatment and case management to women involved with the child welfare system. Evaluation findings showed that when this treatment was offered as an alternative to incarceration or losing child custody, women mandated to the Options for Recovery program were more likely to successfully complete treatment than the voluntarily enrolled clients ("Options for Recovery: Promoting Success among Women Mandated to Treatment." Journal of Psychoactive Drugs; 28(1): 31-38, 1996.).
Even with the successes and promising approaches chronicled above, recent Illinois data illustrate the pervasive and persistent nature of AODA and the impacts of AODA on the ability to parent. A recent study by the U.S. General Accounting Office (GAO) looked at parental AODA as a barrier to securing permanent homes for foster children (Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers. United States General Accounting Office; GAO/HEHS-98-182; September, 1998.) The study examined the parents of foster care children in California and Illinois as of June, 1997. Findings from the draft report are summarized below.
In Illinois 74% of children in foster care had at least one parent required to undergo AODA treatment as part of their service plan. This broke out to approximately 40% of fathers and over 90% of mothers. Among mothers with AODA problems whose children had been in foster care for over 12 months, just over twenty percent had either completed AODA treatment (10.6%) or were enrolled in treatment (9.6%) at the time of the survey. Almost forty percent (39.1%) had failed to complete treatment and more than one-third (34.1%) had never even been in treatment, even though AODA problems were identified in their case file (Figure 3).
There appears to be a consensus that child welfare and AODA treatment need to be integrated into a more seamless system for serving DCFS involved AODA parents and their families. Agreement on the degree to which this has been accomplished varies across systems. Given this situation, a listing of issues and needs from the child welfare and AODA systems is provided below along with issues and needs currently common to both systems.
Issues and Needs Related to the Current AODA Treatment System
Issues and Needs Related to the Current Child Welfare System
Issues and Needs Common to Both Systems
While the issues and needs related to alcohol and other drug abuse in the DCFS system appear daunting, much progress has been made and plans for further improvements to the system are in process. At DCFS, overall responsibility for AODA policy has been placed with the Department's Office of Health Policy to improve AODA planning and coordination.
The Office of Health Policy has prepared a Policy Guide for all DCFS workers and POS staff that provides guidance on serving substance affected families. A training video and a DCFS Handbook for Services to Substance Affected Families will be distributed with the Policy Guide during the spring and summer of 1999.
The Department's Clinical and Training Divisions have prepared a comprehensive training package on services to substance affected families. The training will be presented statewide to over 7,000 DCFS and POS staff in five half-day training modules, starting in the fall of 1999. In developing the Policy Guide and training described above, DCFS has also taken steps to implement all of the AODA related recommendations provided in the most recent report of the DCFS Inspector General (Report to the Governor and General Assembly. Office of the Inspector General, DCFS; January, 1999.). A number of new service initiatives have also been put in place or are in development.
A court based AODA assessment program was implemented in February, 1999 at the Cook County Juvenile Court. Judges can now refer DCFS involved parents for an AODA assessment and recommendation for treatment. Results of the assessment and referral for treatment are provided within 24 hours of the judges? request. Along with this project, an AODA treatment support project for DCFS involved families is scheduled to come on-line in May, 1999 at the Juvenile Court. The project will provide a Recovery Coach for AODA involved DCFS parents to engage and support them throughout the AODA treatment and recovery process.
The Department has also submitted in June 1999, a IV-E waiver request to the U.S. Administration for Children and Families. The waiver request specifically seeks to improve child welfare services to families impacted by AODA by providing an improved integration and interface between the child welfare and AODA treatment systems in Illinois. The goal will be to develop better child welfare and AODA outcomes while spending less IV-E funds than otherwise would be spent on DCFS AODA involved cases.
LONG RANGE GOALS AND OBJECTIVES
The federal Adoption and Safe Families Act and the Illinois Permanency Initiative at the state level have changed the environment and structure of foster care and family reunification strategies. The role of DCFS in the process has already changed greatly, and the AODA treatment system will also need to change its philosophy, strategies, and tactics to remain effective and relevant to the child welfare system.
Permanency requirements establish safety of the child as the paramount consideration. Child welfare and juvenile court decisions must be made within a time-limited process. Parents are now required to show progress toward correcting the condition which led to the removal of their child (e.g. AODA) within nine months of adjudication.
This is the current environment where AODA providers as well as child welfare workers now operate. Consideration of these new parameters and time frames is critical if AODA treatment is to remain relevant and significant to the child welfare system and reunification of families. In the next five years the Department needs to move forward to act on the needs discussed above by addressing the obstacles described below.
The overall management of the OASA/DCFS Treatment Initiative needs to be redesigned to better meet the clinical needs of the families served and the administrative needs of DCFS and the Courts. Illinois commits over $10 million in general revenue funds to the OASA/DCFS Initiative plus additional funding from the Medicaid program. The funds are currently allocated by OASA to AODA treatment providers participating in the Initiative.
The level of accountability by the AODA providers, particularly to DCFS, needs to improve if the current funding strategy is to continue. The services provided need to be better targeted toward the specialized needs of clients involved with DCFS, including:
In addition, DCFS must begin to receive on a regular basis information on clients served in the Initiative, the use of Initiative funds by providers, and program performance and client outcome measures. This information is needed to monitor the Initiatives success as well as to better inform the Court regarding client progress. DCFS staff are still working with OASA staff to address these accountability and information issues.
The Permanency Initiative in the child welfare field and managed care, welfare reform, and other financing initiatives in the AODA field are requiring the nature of AODA treatment to change. AODA treatment providers must find ways to do more with their clients quicker and in shorter overall time frames than ever before. OASA and DCFS should focus whatever efforts are necessary to assist AODA providers to make this change.
OASA and DCFS need to more clearly delineate the roles and responsibilities AODA providers have in child safety and welfare and, conversely, those child welfare case workers have in serving substance affected families. A best practice guide on the proper relationships, roles, and responsibilities needs to be developed, adopted, and implemented by both departments.
A paradigm shift is needed in the thinking of AODA providers concerning the confidentiality of patient information, especially when release of the information impacts permanency and child safety decisions. AODA treatment providers cannot continue to be perceived as hiding behind confidentiality regulations. DCFS also needs to continue to find ways to share relevant information, such as CANTS and LEADS data appropriately with AODA providers.
Information flow from OASA providers to DCFS and the Courts needs to be improved so DCFS and the Courts can meet the new Permanency Initiative requirements and make better informed child safety decisions. OASA treatment providers have to be more responsive to this need and also become more involved in assessing the child safety risks of children returning to an AODA involved parent.
The concept of success in AODA treatment is an elusive one. There is no standard agreement on what constitutes treatment success between or even within the two systems. OASA and DCFS have to agree on what defines treatment successes and how treatment outcomes will be measured and reported. Performance measures must become an integral component of the OASA/DCFS Initiative providers? contracts.
An automated system to track individual referrals from DCFS/POS agencies to OASA providers needs to be built and implemented. Currently, neither DCFS nor OASA can be sure of the number of assessment referrals, treatment referrals, the status or location of individual referrals as they move through the system(s), or drop out of the treatment system.
The assertive outreach and case management model has a proven success record with the AODA child welfare population, but the use of this style of ?in your face? outreach and case management has been de-emphasized and diluted in recent years. DCFS and OASA need to develop, adopt, and implement a best practice model for these services in the OASA/DCFS Initiative.
Both systems (child welfare and AODA) need a better understanding of each other?s environments, systems, procedures, and players. Current training efforts by DCFS must continue and be further expanded. AODA providers have identified POS child welfare agencies as in the greatest need for immediate training.
Coercion to enter and stay in treatment has been shown to be an effective motivator for AODA clients. OASA and DCFS need to make better use of the time pressures presented by the Permanency Initiative to leverage individuals into entering and completing treatment. When the courts are better and more frequently informed of an individual treatment progress, they can participate in motivating and supporting the gains made in treatment. Judges and court personnel are also in an excellent position to set and enforce consequences for lack of treatment progress.
The pilot and demonstration projects referenced above are in various stages of development at DCFS. If replication or expansion of these projects is contemplated, an evaluation component needs to be built in. The evaluation at the least should give some indication of the success of the projects and the cost feasibility of expansion and/or replication as the IV-E AODA waiver request plans to do.
To make AODA treatment a workable and relevant option for DCFS referrals, DCFS needs to increase the number of AODA screens on DCFS involved family members that are conducted by DCFS workers and POS staff. In addition to conducting more screens, DCFS/POS staff need to perform the screens as early in their contact with the family members as possible. (With the relatively high numbers [equal or greater than 50%] of DCFS involved adults with AODA problems, DCFS/POS staff should error on the side of referring for an assessment if/when there is any doubt about the existence of an AODA problem.)
DCFS caseworkers and their POS counterparts need to become more directly and continuously involved throughout the treatment process of parents on their caseloads. AODA treatment providers need to design or modify their treatment and case staffing processes to enable child welfare workers to easily participate. Specifically, child welfare caseworkers need to be actively involved in collaborative service planning for the DCFS involved client shortly after the start of the treatment process. When significant changes in the service plan or changes in the level of care are considered, child welfare workers need to be involved in the process staffing. To close the loop, child welfare workers should participate in the case staffings around discharge planning.
AODA provider's experience with Project SAFE and reports from OASA/DCFS Initiative providers indicate that safe and drug free housing is a critical component of the recovery process. For many individuals this has meant changing their living arrangement or location at some point during the treatment process. The OASA/DCFS Initiative needs to have the capability to assist individuals in accessing safe and drug free housing as part of the treatment process.
While much of the efforts to date have focused on the need to provide AODA treatment for DCFS involved parents, the Department also needs to develop more and better screening, referral, and treatment resources for DCFS wards with AODA problems.