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Home > Protecting Children in Substance-Abusing Families > Protecting Children in Substance-Abusing Families : Innovative Approaches to Intervention: Improving the Odds
Protecting Children in Substance-Abusing Families
Innovative Approaches to Intervention: Improving the Odds
Since the 1960's, the scope of the problem of substance abuse and its devastating consequences for families have become increasingly apparent. However, our understanding of the phenomenon of chemical dependency and what constitutes effective treatment for substance abusers and their children remains limited.26 Better information is needed about what treatment efforts are most successful in helping mothers and fathers to stop abusing alcohol and other drugs, what supportive services are most effective in helping chemically involved families stay together, and what approaches are most effective in promoting family reunification. We also need to learn more about how to best intervene to help children whose health and development have been compromised by their parents' substance abuse, how to better support and encourage extended family care, and how to recruit and retain appropriate foster homes for children unable to remain with their parents. Many of the model programs and interventions described in this chapter were developed in the attempt to find solutions for these as yet unanswered questions. These programs represent innovative and hopeful approaches for dealing with the complexities of parental substance abuse and demonstrate that chemically involved families can indeed be helped to become more functional with appropriate interventions and adequate resources. It is important to remember that chemically dependent families may benefit from many of the services that are described in companion manuals in this series, such as A Coordinated Response to Child Abuse and Neglect: A Basic Manual. However, because of their unique needs, substance-abusing parents and their children often also require additional services or adaptations of conventional service delivery approaches. The purpose of this chapter is to provide examples of model programs and innovative strategies that have been developed to more effectively meet the special needs of this population in the areas of substance abuse treatment, child welfare services, foster care, health care, and education. For communities without such specialized programs, the chapter also provides suggestions for developing collaborative and coordinated services at the local level. Comprehensive Treatment Approaches Programs for Pregnant and Parenting Women with Children
Innovative day treatment programs have been developed to address the specific and unique needs of pregnant and parenting women caring for young children. These programs commonly provide health care, social services, and substance abuse treatment as well as a continuum of rehabilitative and case management services that focus on both the mother and the child. In general, programs for pregnant and parenting women differ from traditional treatment modalities in several respects. First, key services are integrated and colocated to reduce the fragmentation that commonly occurs when families are involved with multiple agencies. Second, in contrast to conventional approaches that tend to emphasize the treatment needs of single males and use confrontational methods, programs for pregnant and parenting women commonly use a supportive approach that is family focused. For chemically involved women, the supportive approach is more effective in addressing their backgrounds, which often include physical and sexual abuse, as well as their shared feelings of low self-esteem and powerlessness. Programs for pregnant and parenting women also provide a wide range of ancillary services, including transportation and child care, to further reduce the logistical barriers that are known to prevent women from seeking treatment. Unlike conventional programs, model projects provide aggressive community outreach that commonly includes home visits and enhanced after-care to reduce recidivism. The range of services typically provided by model programs includes:
Residential Treatment
Residential treatment facilities designed specifically for pregnant women and women with children allow mothers and children to remain together during the course of the family's treatment. As an intensive intervention modality, residential programs serve those chemically involved families with the most severe substance abuse problems and the fewest social supports as well as those for whom outpatient treatment has proven unsuccessful. For families involved with the child welfare system, residential treatment may offer an alternative to the children's out-of-home placement. Model programs vary in length from 9 to 24 months and commonly provide a range of psychological, social, medical, educational, and vocational services for parents as well as counseling and developmentally appropriate play and educational activities for children. Through highly structured programming, residential treatment facilities attempt to promote lifestyle changes that support sobriety and healthier patterns of family interaction. Although this intensive treatment approach is costly, in comparison with outpatient programs, residential care offers several important advantages for families. These include a consistent, safe, and supportive environment for children, drug-free housing, and removal of the family from the destructive environments that may have contributed to or supported parental addiction. Specialized Child Protective Services (CPS) Units
CPS units that work only with chemically involved families provide knowledgeable and intensive case management services designed to avoid out-of-home care by immediately linking the family with needed and appropriate community resources. To adequately address the complex and special needs of this high-risk population, these CPS caseworkers commonly have low caseloads that allow for frequent home visits, heightened involvement with families, and close collaboration with treatment agencies. Other characteristics of specialized CPS units include extensive training on topics related to alcohol and other drug abuse and vertical case management. Vertical case management promotes continuity of services with a single caseworker handling emergency response, family maintenance, family reunification, and permanency planning services for a given family. An intensive, generic approach by CPS has several advantages. Parents are usually better supported and assisted in addressing their substance abuse. Additionally, specialized units may enhance CPS caseworkers' ability to document that reasonable efforts were made to keep families together or achieve family reunification. Finally, this intensive approach also may promote earlier implementation of alternative permanent plans for children in cases where family preservation or reunification cannot be achieved. Family Preservation Programs
Innovative family preservation programs that target substance-abusing families provide intensive in-home interventions with the goal of reducing the need for foster care placement. Typically, although family preservation services are generally provided only on a short-term basis (2 to 5 months), these services are intensive because treatment staff caseloads are extremely small, with experts available for consultation on a 24-hour basis. Staff in such units may at times work in teams to provide mutual consultation and support. In contrast to traditional service delivery models, family preservation programs use the family home as the primary site for intervention. The services provided by treatment staff can range from concrete "hands-on" assistance with household tasks and child care to more conventional interventions that include individual and family counseling, parent education, and advocacy and referrals for assistance with needed health care, substance abuse treatment, and community services. Family preservation programs typically provide intervention for the family as a unit rather than focusing only on the parent or child. As we gather more data from family preservation programs serving substance-abusing families, we may find that this model will need to be modified to better serve some families. Innovations in Out-of-Home Care Transitional Group Care for Foster Children
Transitional group care centers have been developed as an alternative to children waiting in hospitals until more permanent foster placements can be found (the so-called "boarder babies") and as a resource for children whose medical, developmental, and familial needs make locating a suitable foster home difficult. Model group care centers typically provide a range of diagnostic and therapeutic services for children as well as intensive clinical and social services for parents. To diminish the impact of the institutional setting, such programs commonly are designed so that children are cared for by a limited number of consistent caregivers in small family like groupings. Because the children cared for in such settings are likely to have special medical concerns, pediatric and ancillary health care services generally are an integral part of the range of services provided for the children. In addition, model transitional group care programs also offer enhanced reunification services for parents. Typically this includes individual, family, and group therapy as well as parent education. In order to strengthen the relationship between parents and children, model programs also encourage parents to visit frequently, and centers commonly are open for parental visits on a daily basis. Many centers also conduct extensive outreach activities by phone and through home visits to promote parental visitation and parent participation in reunification efforts. Specialized Foster Homes
Specialized foster homes have been developed in many communities as a new approach to caring for those drug-affected infants who have complex needs and who otherwise might require institutional settings. Such children include those with HIV infection (AIDS), children with chronic medical problems requiring complex medical regimens, and children who are equipment-dependent. With intensive training and supportive services, caregivers in specialized foster homes have proven able to provide excellent physical care while still maintaining children within a family environment. In many programs, foster parents who care for these medically fragile children have had experience as foster caregivers. However, several programs have successfully recruited nontraditional foster families, including single parents and homosexual couples. Other programs have been successful in attracting nurses or other individuals with health care backgrounds. Once recruited, foster parents are supported and placements sustained through provision of specialized training, intensive in-home services, and financial incentives. In model programs, preplacement and ongoing training are routinely provided not only for the foster parents, but also for all adult family members who may be involved in the children's care. Furthermore, home visits by health care professionals such as visiting nurses and physical therapists are provided to reduce the need for clinic and hospital visits. In addition, frequent visits and telephone contacts from agency social workers are encouraged to help families cope with the stress of caring for a chronically ill child and to provide practical assistance with obtaining needed equipment, supplies, and community services. Finally, sponsoring agencies also often provide increased reimbursement rates to appropriately compensate caregivers, funds for respite care, or "respite foster homes" to relieve caregivers. Foster Parent Training
Even experienced foster parents often find themselves poorly prepared to care for drug- and alcohol-affected children. Burnout is common among the foster families who care for this high-risk population, and substance-exposed children are at increased risk for multiple failed placements. To help ensure that children from chemically involved families are placed with foster parents who are equipped to accommodate the child's special needs, specialized foster parent training curricula have been developed to better educate caregivers. Typically, training takes place over a period of several weeks. It is designed to increase the foster parents' knowledge and enhance caregiving skills as well as to better acquaint foster parents with relevant community agencies. The training also encourages empathy for the chemically involved parent and the family's circumstances. Model curricula typically address the following areas:
Successful completion of training programs generally is linked with increased foster care payments. Grandparent Support Groups
Increasingly, grandparents are caring for grandchildren whose parents, because of their abuse of alcohol and other drugs, are unable to provide for their children's needs. In many instances, those grandparents are elderly or have health problems that limit their stamina or restrict their mobility. Many also live on fixed incomes and have few resources for providing for their grandchildren's special needs. Even middle-aged grandparents, however, frequently find themselves overwhelmed by the responsibility of assuming full-time care for a young child. For some grandparents, a child's placement may necessitate early retirement. For others, it may mean deferring lifelong plans that were made in anticipation of the time when their own children would be raised and gone from the home. To enable these caregivers to cope with this inordinate burden of responsibility, grandparent support groups have been developed specifically for grandparents caring for drug- and alcohol-affected children. Typically, such programs provide a range of services designed to assist grandparents in caring for their dependent grandchildren while still maintaining their own physical and psychological health. Such services generally include education about addiction, codependency, and stress management, and information related to child development, nutrition, and parenting. Grandparent programs also offer specific training to help grandparents acquire skills to care for grandchildren who may have special medical or behavioral needs. In addition, programs typically provide information about community resources and practical help with such things as how to obtain legal custody of grandchildren and how to apply for extra food stamps. Grandparent support groups also serve as advocates for caregivers and assist them in dealing with complex and unfamiliar bureaucracies. Finally, these support networks provide mutual assistance and peer counseling that can help decrease grandparents' isolation and thus better support them in times of personal and family crisis. Meeting Health and Educational Needs Comprehensive Health Care Clinics for Substance-Affected Children
The multiple medical and developmental problems of some substance-exposed infants and children require a wide range of health care services. To address this growing need, specialized pediatric clinics have been developed in many communities to provide these children and their caregivers with high-quality, "one-stop" medical and developmental services. Such clinics are staffed by specially trained interdisciplinary teams of physicians, nurses, social workers, and psychologists. These facilities provide well-baby and pediatric care; psychosocial, developmental, and educational assessments; and coordination of subspecialty medical care when needed. In addition to services for children, model clinics also often provide a range of supportive and case management services for parents as well as relative and foster caregivers. These services may include individual counseling, parenting education, group counseling and peer support, advocacy, and referral assistance. Many clinics also have an aggressive outreach component that helps ensure adequate medical followup through home visits and frequent phone calls to families. Early Childhood Programs
Infant, toddler, and preschool programs for drug- and alcohol-affected children have been developed to more effectively address the unique developmental and educational needs of substance-exposed children and the parenting concerns of their caregivers. Model programs offer children a consistent, nurturing, and safe environment on a daily basis and help caregivers acquire the skills needed for providing more appropriate and effective parenting. Typically, specialized programs are staffed by an interdisciplinary team of teachers, social workers, psychologists, and health care professionals who work with both the children and their caregivers as well as with siblings or other children in the home. Classroom activities reflect this population's heightened need for predictable routines and structured environments. Active parent involvement in the classroom and in parent groups is required by most programs, and in some programs, such parental involvement may be court-ordered. In many projects staff routinely make home visits to reach out to caregivers and to better ensure that classroom curricula are meeting the needs of both children and parents. In many cases, these specialized programs have served as pilots in order to identify components that can be incorporated into more inclusive settings, such as Head Start, child care, and public school-funded preschool settings. Support Programs for Parents Twelve-Step Programs
All 12-step programs are based on the principles and traditions of the original 12-step program created by Alcoholics Anonymous (AA). AA is, to use the program's own language, "a fellowship of men and women who share their experience, strength, and hope with each other that they may solve their common problem and help others to recover from alcoholism." AA is a peer support program with a strong spiritual foundation. It uses the strength of the group and the wisdom of the 12 steps to encourage the kinds of behavioral and cognitive changes that can support the acquisition and maintenance of a sober lifestyle for both fathers and mothers. The original 12-step programs for alcoholics have been adopted and adapted to the purposes of various other populations grappling with addictions, both their own and those of loved ones. Other 12-step programs include:
Each of these programs is autonomous, but all share the same 12 steps and traditions, and all rely on the fellowship of the group and a commitment to anonymity as fundamental to recovery. For parents who are not comfortable with the spiritual aspects of the 12-step philosophy, a number of alternative self-help support groups, such as Rational Recovery (RR), Secular Organization for Sobriety (SOS), and Women for Sobriety (WFS) provide peer support without a spiritual emphasis. There are 12-step programs in almost every community, and no membership dues or charges are associated with attending meetings. Because the social characteristics of individual groups vary, professionals are encouraged to attend open meetings to become familiar with the membership of the various 12-step groups within their local areas. Programs for Adolescents Programs for adolescents generally involve the public school system or school staff. These programs may provide support groups for adolescents who come from substance-abusing families or who use alcohol and/or other drugs themselves. Another model is Project PALS (Positive Adolescent Life Skills), a research demonstration program at the University of California, San Diego, funded by the National Institute on Drug Abuse. This after-school project serves pregnant adolescents who are using drugs or who are at risk for using drugs and nonpregnant adolescents who are either using drugs or at risk for using drugs and who are at risk for pregnancy. At-risk status is determined if an adolescent has problems in any two of the following areas: peer relations, family relations, mental health, or aggressive behavior/delinquency. In addition to standard medical care, enrolled teens participate weekly in a 16-week educational program addressing the consequences of alcohol and other drug use, child and adolescent development, and sexual responsibility. Followup support groups are conducted at 3 and 12 months following program completion. Programs for Incarcerated Women
Most correctional facilities lack the technology and trained personnel needed to appropriately manage high-risk pregnancies, and substance abuse treatment is rarely provided within correctional institutions. Thus, in order to improve outcomes for incarcerated substance-abusing pregnant women and substance-abusing women with children, the criminal justice system has developed a number of innovative programs to assist mothers in their recovery from alcohol and other drug abuse and promote the birth of healthier infants. Model programs developed within institutions provide expanded health care as well as educational and social services for women. Typically, programs offer comprehensive prenatal care either on-site or through collaborative arrangements with local medical centers; substance abuse treatment (including supervised detoxification, counseling, and 12-step peer support); health education related to pregnancy, nutrition, sexually transmitted diseases (including AIDS), and birth control; and parent education. To better ensure appropriate linkages with community services upon the mothers' release, some programs also assign pregnant women to specially trained probation and parole officers. These officers are knowledgeable regarding community resources and can help women make needed connections with essential medical and social service programs. Another approach to dealing with the growing population of incarcerated pregnant and parenting substance-abusing women has been the development of innovative residential programs. Such programs allow incarcerated women to live with their children in a residential setting while serving the remainder of their sentences. In general, these programs are limited to women who have been convicted of nonviolent crimes, women whose sentences are short-term, and women whose children are preschoolers or younger. Typically, residential programs are highly structured and are specifically designed to address the issues of substance abuse, domestic violence, and lack of employment that often contribute to a woman's incarceration. Such programs commonly are staffed by specially trained correctional personnel and are located in or near a community where the mother will reside upon completing her sentence. The services offered by model residential programs generally include comprehensive medical care, substance abuse treatment, and mental health and family counseling. Programs generally require mothers to participate in educational or vocational training, and a strong emphasis is placed on developing skills needed for the family's subsequent community reintegration and independent living. Day Treatment Programs for Pregnant Women and Their Husbands/Partners As more programs have been developed to serve substance-abusing mothers and their children, fathers have become involved in these programs through home- and center-based components. For example, the FOCUS Project at UCLA, funded by the National Institute on Drug Abuse, enrolls pregnant substance abusers and provides comprehensive services for women and children for a period of 2 years. Although they are referred to other community agencies for substance abuse treatment if needed, husbands and significant others are involved during home visits with FOCUS staff and are also invited to attend center-based parent education sessions. The entire family benefits when both caregivers work together in learning effective parenting practices, and when both receive coordinated supportive services. Interagency Approaches Interagency Coordinating Councils
In the absence of an umbrella agency capable of providing the continuum of services needed by substance-exposed children and their parents, communities across the country have developed local coordinating bodies to promote collaboration among professionals and the development of needed services for chemically involved families. County-based interagency perinatal councils are one example of a successful organizational strategy that has been used in California to effectively mobilize community resources and develop interagency cooperation around issues of parental substance abuse. Perinatal councils are currently active in 29 California counties, and members on each council include representatives from local departments of health, public social services, CPS agencies, drug and alcohol treatment services, and education. Public and private hospitals, private treatment agencies, and interested community members also are represented. In bringing together the local public and private agencies that serve chemically involved families, these councils have provided a catalyst for the development of coordinated policies and services among member organizations. Councils also have sponsored community awareness and training programs, developed locally relevant educational materials, and served as conduits for collaborative, interagency funding requests. Interagency, Interdisciplinary Training
Interdisciplinary training for the various professionals who serve chemically involved families within local communities represents another strategy used successfully to improve services for substance-affected children and their caregivers. Commonly, the goals of interagency training are threefold:
To maximize the impact of cross-training ventures, experts recommend that programs target professionals from across the service delivery spectrum, including hospital-based physicians, nurses, and social workers; CPS caseworkers; judges and attorneys; public health nurses; substance abuse treatment specialists; educators; developmental disabilities counselors; and law enforcement personnel. Model programs frequently use an interdisciplinary training staff. Curricula address the medical, developmental, and psychosocial characteristics of chemically involved families; the special service needs of this population; effective approaches for addressing the family's complex health, social, and educational problems; community resources; and strategies for developing interdisciplinary and interagency collaboration in case planning and management efforts. Interagency Service Teams
Chemically involved families often require simultaneous services from a variety of health care, child welfare, and substance abuse treatment agencies. Interagency service teams that include public health nurses, CPS caseworkers, and chemical dependency counselors have proven to be another very successful strategy for promoting a unified treatment approach across agencies. Such teams help coordinate and integrate social, medical, and substance abuse treatment services and reduce service fragmentation for families. Commonly, these "teams" make joint home visits for the purpose of assessment and planning with birth and foster families, meet on a regular basis for formal staffing and sharing of information and ideas, and participate in ongoing joint training to enhance the team's overall knowledge of substance abuse and to develop common approaches for assessment and intervention with families. To support the team case management approach, collaborating agencies in some communities have developed interagency agreements that describe each agency's role and responsibilities, specify guidelines for the exchange of information, and clarify issues of confidentiality. Appendix II contains an adaptation of such a model agreement. In rural areas or in communities that lack a comprehensive intervention program, the team case management approach can help ensure appropriate health care, substance abuse treatment, and social services for family members as well as promote continuity and coordination of the various services provided through multiple agencies. Summary Substance abuse can devastate families. However, alcohol and other drug abuse is treatable, and appropriate interventions can protect children as well as help parents better care for themselves and their offspring. Because of the complex needs of chemically involved families, it is clear that a multitude of services is needed to achieve recovery and rehabilitation. Further, even individuals who are already in recovery commonly require ongoing support because new stressors as well as contact with substance-abusing friends and family members can interfere with maintenance of a sober lifestyle. Although there remain many unanswered questions about the types of intervention that are most effective, our understanding of substance abuse and the needs of families suggests we are most successful when we provide programs that are family-focused, nonpunitive, and supportive in orientation. It also is important that programs are sensitive to cultural and language issues and that staff are well-trained with respect to the special needs of this high-risk population of parents and children. Furthermore, we have a greater chance of being successful when we use an interdisciplinary approach and insist on collaboration among professionals and agencies.42 Substance abuse among families with young children has increased during the past decades, and service providers need to keep in mind the fact that effective treatment strategies are just beginning to emerge. Long-term effects have not yet been reported, and, likewise, we know very little about interventions that can be beneficial over time for older children and adolescents from substance-abusing families. However, we do know that chemical dependency is a chronic, relapsing problem, and that a long-term commitment to supporting families by reducing stresses, enhancing overall family health, providing opportunities for learning, and improving the family and community environment can make a difference. Such carefully crafted, multidisciplinary interventions can improve the odds that all members of a family affected by parental substance abuse will more fully realize their potential. Patterns of intergenerational substance abuse and child abuse that are a tragic part of many parents' histories need not be written into the futures of their children.
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