What are some of the strategies being used to reunite families with substance use disorders?

In 2015, parental substance abuse was cited as a factor in more than one-third of the cases in which a child was removed from home.1 Reuniting children with their birth families as soon as possible is essential for their healthy development and ability to thrive. But for families affected by substance abuse, timely reunification can be a challenge. Recovery is a lifelong and cyclical process, with relapse often part of that process. The federal Adoption and Safe Families Act (ASFA) requires, however, that children achieve permanency within 15 months of their 22 months in care. The tension between these two timelines — the urgency for children to be reunited with their families as soon as possible versus the patience needed for recovering parents to engage in services and prepare to safely care for their children — is a challenge for child welfare systems.

Fortunately, investing in adequate and appropriate interventions for this population can lead to timely reunifications and successful recovery for parents. Child welfare leaders can use the evidence about what works to meet the complex needs of families affected by substance abuse while also complying with reunification timelines.

Considerations and Strategies

For families in treatment and recovery, reunification within federal timelines can be achieved if the proper interventions and system supports are in place. Child welfare agencies can take steps to align workforce and financial resources, as well as work across systems, in order to coordinate services. A number of key issues for child welfare leaders should be considered when developing a service continuum for families affected by substance abuse, including a range of practice strategies that have proven effective at reunifying families and keeping them together.

Parent Engagement and Early Access to Treatment

The single strongest predictor of reunification for families affected by substance abuse is completion of treatment. In fact, studies have shown that women who complete 90 or more days of treatment nearly double their likelihood of reunification.2 Specifically, women who enter early into substance abuse treatment programs are more likely to reunify than women who don’t, and their children spend less time in foster care.3 Unfortunately, no more than half of women mandated to enroll in drug treatment programs ever actually participate in them.4 Engagement strategies that help motivate parents to enter and remain in substance abuse services are critical to enhancing treatment outcomes.

Strategies

Early screening paired with recovery coaches. Given the often-conflicting timelines between AFSA and recovery, identifying the issues early is critical to the success of reunification and long-term recovery. Screening family members for possible substance abuse with the use of brief, validated, and culturally appropriate tools should be a routine part of child welfare investigation and case monitoring.

In addition, studies have shown that parents are more likely to enter treatment quickly and remain in treatment longer if they are supported by a recovery coach.5 Recovery coaches work with parents, child welfare caseworkers, and treatment agencies to remove barriers to treatment, engage parents in treatment, and provide ongoing support following reunification.

Engaging Moms (EM). This home-based 12-week intervention is designed to promote maternal enrollment and retention in substance abuse services. Program specialists address barriers to treatment (e.g., transportation, child care), and therapeutic contacts focus on validating a mother’s feelings about delivering a substance-exposed baby; highlighting losses and missed opportunities as well as competencies and strengths; helping a mother understand her life situation as a consequence of her difficult life circumstances; instilling hope; and strengthening bonds between a mother and her child, family, and other natural supports. The program has been found to increase the percentage of women who enroll in drug treatment programs and receive at least four weeks of services.6

Need for Encouragement and Frequent Feedback

Frequent and well-deserved praise has a powerful influence on adult behavior. When working with parents dealing with addiction, child welfare agencies can implement structured responses that are timely, therapeutic, and motivational instead of punitive and coercive. Institutionalizing the practice of giving parents frequent and regular feedback on their progress in treatment and recovery is essential and should be delivered in advance, scaled up gradually, and applied consistently and appropriately.

Strategies

Family Treatment Drug Courts (FTDCs). These courts bring together treatment services with case management in a supportive and rehabilitative setting and coordinate those efforts with child protective services. In general, components include substance abuse evaluation services available within the courthouse and frequently completed immediately following the initial dependency hearing; regular, often weekly, court hearings to monitor parents’ treatment compliance; provision of substance abuse treatment and wraparound services; frequent drug testing; and rewards, sanctions, and intense judicial surveillance linked to service compliance. Family reunification rates are higher and children spend less time in care when clients participate in FTDC.7

Addiction Affects the Whole Family

Treating the family as a complete system—rather than an individual child or parent in isolation—can be more effective in addressing a family’s underlying and complex issues. Parental recovery occurs in the context of family relationships, with attachment and parent-child bonding particularly important, as well as consistent discipline, boundary-setting, and consistency of care. Since improved family functioning is part of recovery, child welfare leaders may want to consider attachment-based parent-child therapy and trauma-informed services as key components to improving parent-child relationships.

Strategies

PCIT. Parent–child interaction therapy (PCIT) is an evidence-based treatment for young children with behavioral and emotional challenges that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. It uses a unique combination of behavioral therapy, play therapy, and parent training to teach more effective discipline techniques and improve the parent-child relationship.8  Research has shown that, as a result of PCIT, parents learn more effective parenting techniques, the behavior problems of children decrease, and the quality of the parent-child relationship improves.9

Celebrating Families. Celebrating Families is a family-inclusive, trauma-informed, skill-building program for families with a parent with a substance addiction. It was developed to prevent children’s future addiction and mental and physical health problems. The program combines prevention and intervention to support the healing of families in early recovery while developing skills to prevent future addiction.10

Recovery as a Process, Not an Event

Changes in parental behavior don’t happen automatically when treatment is completed. Parents rarely progress in a straight line. Instead, they often return to old habitual behaviors despite negative consequences. Significant and meaningful change develops over time as parents move through the denial of addiction, begin the process of recovery, and learn basic living and parenting skills. The process of personal growth and change is time-consuming. Children and parents may need continued support and services even after they successfully reunify. Because relapse is part of the recovery process, it should not be defined it as treatment failure. Following relapse, a short-term plan can be put in place to keep children safe. A coordinated response from treatment and child welfare professionals as well as the parent’s support network can motivate the parent to resume recovery.

Strategies

Personal recovery safety planning. Child welfare leaders can ensure that their staff are coordinating with treatment providers to implement a safety plan in the event of parental relapse. The plan may include identifying individuals who regularly check on the well-being of children. This plan can identify homes where the child can stay if the parents are unable to provide a safe environment. In addition, the plan can help the parent identify trigger behaviors that would necessitate safety planning.

Matched, Sequenced Services

Parents affected by substance abuse typically come to treatment with multiple, often co-occurring issues that need to be addressed. The best treatment programs provide a combination of therapies and other direct services tailored to meet the parent’s needs. These tailored services might include housing, transportation, child care, employment, and educational services. Studies show that treatment that provides parenting support and employment opportunities results in higher rates of reunification.11 Since substance-affected families have many issues to contend with, services should be sequenced so they do not overwhelm the family. One strategy is to make sure that case management planning includes asking the parents to identify the most pressing issues to address first so that the plan is driven by internal motivation.

Strategies

Transitional housing programs with employment/education services. After completion of treatment services (12–24 months), families can remain in their housing for a transitional period of up to 1 year and are offered intensive services, allowing for adequate time to develop vocational, educational, and/or supportive systems necessary for ongoing recovery and family maintenance.

Setting Parents Up for Success

There is no greater motivator for parents than having their children removed from their care. In fact, studies have found that almost half of parents enter treatment solely to regain custody of their children.12 However, although reunification is a motivating force for recovery, mothers also report experiencing significant stress from parenting for lengthy periods of time after they have regained custody. The emotional stress of being reunified can overwhelm coping resources and increase the risk of relapse. In addition, many parents do not have strong support networks in place to assist them after they reunify with their children. Successful reunification requires assistance in disengaging from former unhealthy relationships and forming newer, healthier ones to avoid social isolation.

Strategies

Post-reunification support. To mitigate social isolation and help build healthy support networks, child welfare agencies should provide post-permanency services to all families, including case management, support groups, crisis intervention, and group activities for at least one year after parents are reunified with their children. In some cases, the child welfare agency can engage foster family or kin caregivers to serve as supports for birth families post-reunification.

Shared family care. Shared family care involves the placement of a parent (usually the mother) and at least one child in the homes of community members who provide mentoring and support to help parents obtain the skills and resources they need to achieve their goals. Families are given comprehensive services to meet their needs, increase their social and life skills, and connect them to community supports for ongoing and future relationships.13

One Agency, Many Partners

Promoting reunification in recovering substance-abusing families requires a cross-systems commitment and coordinated approach to address the multiple and complex needs of these families. Integrated service provision with providers who are flexible and committed to the success of parents is needed. When all parties work together, studies have shown that treatment works better, faster, and produces stronger families.14

Strategies

Co-location. Co-location of substance abuse experts in child welfare offices to assess and engage parents, provide services to families, and offer training and consultation to caseworkers creates a team approach that is known to be effective.

Increased communication between treatment providers and caseworkers. Cross-system information-sharing related to screening and assessment results, case plans, treatment plans, changes in behavior, and progress toward goals can support professionals in each system in making informed decisions.

1 U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2016). The AFCARS report. http://www.acf.hhs.gov/programs/cb
2 Grella, C., Needell, B., Shi, Y. & Hser, Y. (2009). Do drug treatment services predict reunification outcomes of mothers and children in child welfare? Journal of Substance Abuse Treatment, 36, 279–293.
3 Green, B. L., Rockhill, A., Furrer, C. (2007). Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis. Children and Youth Services Review, 29, 460–473.
4 Oliveros, A. & Kaufman, J. (2011). Addressing substance abuse treatment needs of parents involved with the child welfare system. Child Welfare, 90(1), 25–41.
5 Ryan, J., Perron, B., Moore A., Victor, G., & Park, K. (2017). Timing matters: A randomized control trial of recovery coaches in foster care. Journal of Substance Abuse Treatment, 77, 178–184.
6 Dakof, G. A., Quille, T. J., Tejeda, M. J., Alberga, L. R., Bandstra, E., & Szapocznik, J. (2003). Enrolling and retaining mothers of substance-exposed infants in drug abuse treatment. Journal of Consulting and Clinical Psychology, 71(4):764–72.
7 Marlow, D., Carey, S. (2012). Research update on family drug courts. National Association of Drug Court Professionals. Retrieved from http://www.nadcp.org/sites/default/files/nadcp/Reseach%20Update%20on%20Family%20Drug%20Courts%20-%20NADCP.pdf
8 PCIT International. Retrieved from http://www.pcit.org/what-is-pcit1.html
9 Bagner, D. M., & Eyberg, S. M. (2007). Parent-Child Interaction Therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 36(3), 418–429.
10 California Evidence-based Clearinghouse for Child Welfare. (n.d.) Program registry. Retrieved from http://www.cebc4cw.org/program/celebrating-families/detailed
11 Grella, C.E, Needell, B., Shi, Y., Hser, Y. (2009). Do drug treatment services predict reunification outcomes of mothers and their children in child welfare? Journal of Substance Abuse Treatment, 36, 278-293.
12 Gerstein, D., Johnson, R. (2000). Characteristics, services, and outcomes of treatment for women. Journal of Psychopathology and Behavioral
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13 National AIA Resource Center.
(2003). Shared Family Care: Creating families through community partners. Retrieved from https://www.youtube.com/watch?v=XVg9asydzK0.
14 Green, B. L., Rockhill, A., & Burrus, S. (2008). The role of interagency collaboration for substance-abusing families involved with child welfare. Child Welfare, 87(1), 29.

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