The following identifies the major literature in the field of cross-system issues involving child welfare, substance use disorders, and dependency courts. It is organized in 5 topic areas, and the time frame is from January 2000 through November 2008.

1. SUBSTANCE ABUSE AND CHILD WELFARE PRACTICE
   • Child Abuse and Maltreatment
   • Foster Care, Removal, and Reunification
   • Implications for Treatment
2. FAMILY COURT AND CRIMINAL JUSTICE INVOLVEMENT
   • Family Court
   • Incarcerated Persons with Substance Use Disorders
3. PERINATAL AND FAMILY SERVICES
   • Pregnant and Parenting Women
   • Prenatal Exposure and Effect on Children
   • Children of Substance Abusers
   • Family Treatment, Evidence-Based Practices and Related Issues
   • Childhood Abuse and Trauma
4. PREVALENCE AND SYSTEMS PLANNING
   • Methamphetamine and Children
   • Systems and Policy Issues
5. SUBSTANCE ABUSE SERVICES ACROSS THE CONTINUUM
   • Prevention, Screening and Assessment
   • Treatment, Rehabilitation, and Recovery

SUBSTANCE ABUSE AND CHILD WELFARE PRACTICE

Child Abuse and Maltreatment

Barth, R.P., Gibbons, C., & Guo, S. (2006). Substance abuse treatment and the recurrence of maltreatment among caregivers with children living at home: A propensity score analysis. Journal of Substance Abuse Treatment, 30(2), 93-104.

Policy and programmatic initiatives of the last decade have focused on increased coordination of services and expansion of prompt substance abuse treatment for mothers initially involved with child welfare services (CWS). Yet, little evidence has been amassed concerning the implications of this approach on the recurrent need for CWS. This study examines data from a large national probability sample of children and their caregivers involved with CWS following an allegation of maltreatment. Data include the recurrence of maltreatment reports for this group of children who remain at home. Selected from 1,101 caregivers with an indicated substance abuse problem, a group of 224 clients who did not receive services were compared with 224 treated clients. Results showed that clients who received substance abuse treatment were nearly twice as likely to have another child abuse report within 18 months. Reasons why participation in substance abuse treatment may result in greater involvement with CWS are posited.

Connell, C. M., N. Bergeron, et al. (2007). "Re-referral to child protective services: The influence of child, family, and case characteristics on risk status." Child Abuse & Neglect 31(5): 573-588.

Introduction: This study examines child, family, and case characteristics that impact rates of re-referral to Child Protective Services (CPS) using data on all closed CPS investigations for the state of Rhode Island between 2001 and 2004. Method: A longitudinal dataset of all referrals to CPS was created using state submissions to the National Child Abuse and Neglect Data System (NCANDS). After excluding children whose initial CPS investigation resulted in removal from the home, a Cox proportional hazards model was tested to examine factors impacting the likelihood of re-referral. Results: Consistent with other research in this area, the initial 6-month period following case disposition is the period of greatest risk of re-referral. Approximately 13% of cases experienced a recurrent allegation during the first 6-month period: an additional 14% experienced a re-referral over the following 12-month period; 7% during the next 12-month period. Family poverty was the strongest predictor of re-referral, though a number of child and case characteristics were significantly related to recurrence. Cases that were substantiated at index were significantly less likely to result in a new allegation, though substantiated cases of physical abuse or those receiving post-investigation services were at higher risk. Conclusions: Children from families facing multiple stressors (e.g., low SES, parental substance abuse child disability) are at highest risk of re-referral to CPS and may benefit from the development of preventive services targeted immediately following case closings within CPS. (c) 2007 Elsevier Ltd. All rights reserved.

Duran, B., Malcoe, L.H., Sanders, M., Waitzkin, H., Skipper, B., & Yager, J. (2004). Child maltreatment prevalence and mental disorders outcomes among American Indian women in primary care. Child Abuse Neglect, 28(2), 131-145.

The prevalence of child maltreatment among American Indian families and communities is not well documented, nor is the effect of maltreatment on the mental health of individuals as they grow into adulthood. Understanding the extent and nature of exposure to child maltreatment among American Indian women presenting for primary care is important, and contributes directly to treatment availability and options for patients reporting mental health problems. The purpose of this study was to examine the prevalence, types, and severity of child abuse and neglect, and study the relationship between child abuse and neglect and lifetime psychiatric disorders among 234 American Indian women using primary care services. Approximately three-quarters of respondents reported some type of childhood abuse or neglect; over 40% reported exposure to severe maltreatment. Severity of child maltreatment was associated in a dose response manner with lifetime diagnosis of mental disorders. Severe child maltreatment was strongly associated with lifetime PTSD, and was moderately associated with lifetime substance use disorders, mood disorders, and with two or more disorders. Child abuse and neglect was common in our sample of American Indian women in primary care and was positively associated with lifetime psychiatric disorders outcomes. Screening for abuse and neglect and psychiatric disorders would enhance the treatment of patients seeking primary care services. Primary prevention of child maltreatment might reduce the high prevalence of mental disorders among American Indian women. These findings also confirm the importance of increasing funds and other resources for observation, primary prevention and treatment programs, and research of child abuse and neglect in American Indian populations.

Fuller, T.L., & Wells, S.J. (2003). Predicting maltreatment recurrence among CPS cases with alcohol and other drug involvement. Children and Youth Services Review, 25(7), 553-569.

Evidence suggests that the number of Child Protective Services (CPS) cases involving families with alcohol and other drug (AOD) problems is increasing, which presents unique challenges to CPS workers who must be able to determine how a parent's substance use affects their child's safety. Recent research has identified several factors that consistently predict maltreatment recurrence; however, these studies have assumed that the risks for recurrence are the same for all families who come to the attention of CPS. The current study examined factors predictive of short-term (e.g. within 60 days) maltreatment recurrence among CPS cases with AOD involvement. The authors found that four factors were related to an increased risk of short-term maltreatment recurrence: 1) the safety assessment factor involving caretaker AOD use checked "yes;" 2) a high risk assessment rating for caretaker criminal behavior; 3) no police involvement during the investigation; and 4) families headed by single, African-American women. The findings of the current study have several implications for CPS practice. They underscore the importance of including information on caretaker substance use in ongoing safety and risk assessment activities. Once substance use has been identified as a risk factor, investigators should have tools that help them determine the history and extent of addiction, as well as associated problems such as criminal behaviors, health problems, and mental illness. It is vital for investigators to then translate this information into an effective safety plan that addresses the risks present.

Smith, B.D., & Testa, M.F. (2002). The risk of subsequent maltreatment allegations in families with substance-exposed infants. Child Abuse & Neglect, 26(1), 97-114.

This study seeks to assess the relationship between identified prenatal substance use and the risk of subsequent maltreatment allegations among families involved with child protective services, and to compare the types of safety threats encountered by children whose parents had SEI allegations to the types of safety threats faced by children whose parents had other types of allegations. A clearer understanding of these relationships can help child welfare agencies develop family-centered protective interventions that better balance the severity of risks posed by prenatal substance use against the harms of parent-infant separation and out-of-home placement. The authors found that the risk of subsequent allegations associated with parents whose child welfare case opened following an SEI allegation was compared to parents whose case opened following other types of allegations. The authors found that the likelihood of subsequent allegations was greater among parents in the SEI group. However, the increased risk resulted almost entirely from subsequent SEI-related allegations. Parents in the SEI group were not more likely to incur other types of allegations such as physical abuse or lack of supervision. The authors concluded that an increased risk of subsequent maltreatment has been used to justify opening child protective cases on the basis of an SEI allegation alone. The results suggest that concerns about SEI allegations might be balanced with concerns about other risks facing substance-exposed and non-exposed children and that child welfare authorities might pursue the same family-centered interventions with families having an SEI allegation that are pursued with families having other types of allegations.

Street, K., Whitlingum, G., Gibson, P., Cairns, P., & Ellis, M. (2008). Is adequate parenting compatible with maternal drug use? A 5-year follow-up. Child: Care, Health & Development, 34(2), 204-206.

INTRODUCTION This prospective, cohort study compares child protection outcomes over the first 5 years of life in a group of children born to self-declared drug-using mothers recruited during pregnancy (cases) and a group of children matched for gestational age, chronological age, maternal neighbourhood and place of delivery whose mothers made no such declaration of problematic drug use (controls). METHODOLOGY We monitored local child protection registers to identify cohort members who came to the attention of the local authority. RESULTS Of the 71 original cases and 142 original controls, 55 (77%) and 96 (68%) remained in the area enrolled in local schools at 5 years of age. In total, 26 (47.3%) of the case children were subject to child protection procedures compared with 18 (18.8%) of the control children. This risk difference of 28.5% (95% CI 13.2% to 43.9%) has increased marginally since our previous report in this journal of child protection outcomes at 18 months of age (32% vs. 7%). However, the level of intervention deemed necessary to protect the child has increased significantly with six cases (compared with one control child) taken into the care of the local authority. CONCLUSIONS Despite early maternal intentions and multiple supportive interventions, 27% of children born to women with significant substance abuse problems in our area required child protection during the pre-school years. Child protection risk assessment procedures need to weigh problematic maternal drug use heavily. Intervention studies with child welfare outcomes are needed to identify the most effective harm reduction strategies and inform public debate on how we can minimize child abuse related to substance misuse. [PUBLICATION ABSTRACT]

Sun, A.-P., M. P. Freese, et al. (2007). "An Exploratory Study of Drug-Exposed Infants: Case Substantiation and Subsequent Child Maltreatment." Child Welfare 86(3): 33.

This study explores factors related to drug-exposed infants' case substantiation and subsequent child maltreatment. Child protective services computerized administrative data (from January 1998 to October 2001) were obtained from an urban Nevada county. The data included 457 drug-exposed infant cases. Chi-square, t-test, one-way ANOVA, and logistic regression were used to analyze the data. Results indicate that: (1) drug-exposed infant case substantiation was related to the type of drug exposure and the unit to which the case was assigned, but not to the mother's ethnicity; and (2) subsequent maltreatment among drug-exposed infants was related to the mother's age and prior parental alcohol abuse, but not to the type of drug exposure, nor to the initial drug-exposed infant status of case substantiation. Implications for child welfare practice and research are discussed. [PUBLICATION ABSTRACT]

Welsh, J., Precey, G., & Lambert, P. (2008). Parents of children at risk—a multi-agency initiative to address substance misuse amongst parents whose children are at risk of neglect. Child Abuse Review, 17(6), 454-462.

The article presents information about parents as substance abusers and the impact that this behavior has on young children. The authors comment on the report called "Hidden Harm" that was released in 2003 by the Advisory Council on the Misuse of Drugs. The report shows that the cities of Brighton and Hove in England have some of the highest percentages of parental drug abusers. The report also considers the needs of children affected by these circumstances and the health and developmental consequences that they face in such environments.

Widom, C.S., & Hiller-Sturmhofel, S. (2001). Alcohol abuse as risk factor for and consequence of child abuse. Alcohol Research and Health, 25(1), 52-57.

The relationship between child abuse and the use or abuse of alcohol has two aspects. First, some findings have indicated that parental alcohol abuse may be associated with the physical or sexual abuse of children. Research findings in this area remain inconsistent, however. Second, the experience of being abused as a child may increase a person's risk for alcohol-related problems as an adult. This relationship has best been demonstrated in women who had been victims of childhood abuse. Several factors most likely contribute to or influence this relationship, including coping skills; antisocial behavior; and psychological problems, such as posttraumatic stress disorder. This article review studies assessing alcohol-related and non-alcohol-related factors that might contribute to parental child abuse and presents research findings concerning the relationship between childhood victimization and subsequent adult alcohol abuse. Within this discussion, the article explores how future research may identify further characteristics that could increase a person’s risk for developing alcohol abuse as a consequence of childhood victimization.

Foster Care, Removal, and Reunification

Carison, B. E., Smith, C., Matto, H., & Eversman, M. (2008). Reunification with children in the context of maternal recovery from drug abuse. Families in Society, 89(2), 253-263.

Little is known about mothers' experiences of reunification with children in the context of recovery from drug abuse. Using a stress and coping framework, this qualitative study interviewed 6 mothers and 11 service providers from substance abuse and child welfare agencies regarding reunification experiences. Analysis of themes indicated that multiple parenting stressors and lack of resources and supports complicate women's abilities to manage parenting pressures upon reunification. Maternal readiness for reunification was an important theme; returning children prematurely heightens risk for poor outcomes, especially if insufficient services are in place to support children's return home. The stress of dealing with child protective services and multiple service systems was another theme. Implications for service provision to mothers and families are discussed. [PUBLICATION ABSTRACT]

Carlson, B.E., Matto, H., Smith, C., & Eversman, M. (2006). A pilot study of reunification following drug abuse treatment: Recovering the mother role. Journal of Drug Issues, 36(4), 877-902.

This qualitative study explored the experiences of women in recovery from drug abuse who had resumed parenting their children after child placement. Six mothers and 11 service providers from substance abuse treatment and child welfare agencies were interviewed about their perceptions of the experience of being reunified with one's children following substance abuse treatment Findings revealed that mothers have intense emotional reactions to having children placed, which can motivate recovery but also be a source of stress. A variety of supports were identified as necessary to prepare mothers for resuming care of children beyond substance abuse treatment including counseling, child care, financial support, and parenting education. Reunification, however desirable, was described as overwhelming and fraught with parenting challenges, such as effective limit setting with children. Numerous challenges and barriers to successful reunification were identified, such as stigmatization in the child welfare system. The authors state that the results suggest the need for continuity and coordination in service delivery that targets several key areas of skill development for substance-abusing mothers following initial treatment and post-reunification with children. This would require coordinated, effective collaborations between treatment providers, the child protective system, and community-based child welfare providers.

Haight, W., T. Ostler, et al. (2007). "A child's-eye view of parent methamphetamine abuse: Implications for helping foster families to succeed." Children and Youth Services Review 29(1): 1-15.

This report focuses on the experiences and perspectives of rural, Midwestern children aged 7-14 years who were involved with the public child welfare system because of their parents' methamphetamine abuse. Eighteen children participated in semi-structured, in-depth interviews focusing on their families of origin. Children reported exposure not only to their parents' and non-kin adults' methamphetamine and other substance abuse, but to a constellation of activities related to drug use or drug seeking behavior including violence within their homes and other criminal behavior. Children responded to the contexts in which they were reared in a variety of ways including accepting or actively resisting socialization messages that normalized substance abuse. The majority of children described involvement with law enforcement and child welfare as a "sad" and "scary" time in their families. Far from embracing their placement within safe and stable families, many children continued to express sadness, distress and resistance to legal and child welfare interventions even after months in foster care. Implications for facilitating the adjustment of children to foster care and beyond are discussed including providing foster parents with support and information about the contexts in which children have been reared and children's understanding of those contexts in order that they may interpret and respond to challenges that may emerge. (c) 2006 Elsevier Ltd. All rights reserved.

Hohman, M.M., & Butt, R.L. (2001). How soon is too soon? Addiction recovery and family reunification. Child Welfare, 80(1), 53-67.

This article describes the addiction recovery process and stages of recovery, the behaviors and attitudes that indicate recovery, and how recovery impacts parenting. This information is crucial for child welfare workers involved in decision making regarding family reunification. Two models of recovery, one from alcoholism and one from cocaine addiction, are reviewed. In addition, issues encountered in recovery, particularly for women for discussed. Case examples and discussion demonstrate how child welfare workers can apply these models in determining the appropriateness of reunification.

Marcellus, L. (2008). (Ad)ministering love: Providing family foster care to infants with prenatal substance exposure. Qualitative Health Research, 18(9), 1220-1230.

A significant percentage of children in foster care in North America are younger than 1 year of age and are in foster care because of parental substance use and other social challenges. Infants might present with specific health and behavioral issues that are challenging to manage within the foster family home environment; foster families require specialized skills and knowledge to manage these issues. In this article, the author describes a constructivist grounded theory of the process of becoming and providing family foster caregiving in the context of caring for infants with prenatal alcohol and/or drug exposure. The basic social process of (ad)ministering love was identified. The author further describes the three phases of this process and the core concepts within each phase. [PUBLICATION ABSTRACT]

Marsh, J.C., Ryan, J.P., Choi, S., & Testa, M.F. (2006). Integrated services for families with multiple problems: Obstacles to family reunification. Children and Youth Services Review, 28(9), 1074-1087.

Child welfare clients with co-occurring problems are recognized as clients who have difficulty achieving positive child welfare outcomes. The current study focuses on families in the child welfare system with co-occurring problems and the impact of such problems on the likelihood of reunification. The current study contributes to the literature on service integration by examining whether it is necessary to go beyond assessment and service access to insure families make progress in each co-occurring problem area to achieve reunification. The sample is comprised of 724 substance-abusing families enrolled in the Illinois Title IV-E Alcohol and Other Drug Abuse (AODA) Waiver Demonstration. Data on client progress consisted of provider ratings completed quarterly to track progress related to problems of substance abuse, domestic violence, housing and mental health. The findings indicate that progress in resolving co-occurring problem areas increases the likelihood of achieving family reunification. Thus, the provision of the child welfare service model alone is insufficient. In order for child welfare systems to increase reunification rates, services must target the specific needs of individual families and assist them in achieving progress within co-occurring problem areas. Successful integrated service programs must identify the range of specific problems that clients are dealing with and insure that they address and resolve these problems in order to increase the likelihood of family reunification.

McWey, L. M., Henderson, T. L., & Alexander, J. B. (2008). Parental rights and the foster care system: A glimpse of decision making in Virginia. Journal of Family Issues, 29(8), 1031-1050.

Using ecological theory and a mixed-methods approach, the authors examined family-court interactions for foster care decisions made in Virginia across three policy periods: 1980 to 1993, 1994 to 1997, and 1997 to present (N= 95). For the first and last policy periods, quantitative analyses revealed significant differences in the rates at which parental rights were terminated. Differences also existed in termination rates for parents with mental health issues and limited IQs but not for parents with substance abuse issues or those with special-needs children. The best-interests-of-the-child standard and clear and convincing evidence were the primary legal principles used to determine whether to terminate parental rights or to reunify families. Suggestions were made to enhance the understanding of family professionals. [PUBLICATION ABSTRACT]

Miller, K.A., Fisher, P.A., Fetrow, B., & Jordan, K. (2006). Trouble on the journey home: Reunification failures in foster care. Children and Youth Services Review, 28(3), 260-274.

This article examined parent, child, family, environmental, and service utilization factors hypothesized to be associated with reunification failure. The sample for the study included foster children who, at reunification with their birth parents, ranged in age from 4-7 years. All participants were reunified with at least one parent. Among the variables found to significantly differentiate between failed and successful reunifications were parental utilization of substance abuse treatment, child utilization of special educational services, child utilization of individual, family, or group therapy, overall parenting skill level, appropriate use of discipline, and quality of neighborhood. The authors discuss the implications of these results for policies aimed at increasing the success rate of reunifications following foster care.

Pelton, L. H. (2008). An examination of the reasons for child removal in Clark County, Nevada. Children & Youth Services Review, 30(7), 787-799.

The factors precipitating child placement were examined in two randomly selected samples of protective custody cases that were brought before the family court in Clark County, Nevada during a one-year period. Methamphetamine use, homelessness, lack of resources, and physical abuse were factors frequently prompting placement. Homelessness was as prevalent in cases not involving meth or other drug use as in those that did. Police were involved in a large proportion of the cases, and children were more frequently placed in foster care facilities when they were. In many cases, the arrest and incarceration of parents on outstanding warrants unrelated to the immediate safety of the children precipitated the need for placement. Parents frequently received counseling for their substance abuse and other issues, but were rarely offered concrete assistance or any significant help with housing. The reallocation of resources from Child Haven, the emergency placement congregate care facility in which most children were initially placed, to the provision of direct assistance with housing and other concrete services, is recommended and discussed. [PUBLICATION ABSTRACT]

Pilowsky, D.J., & Wu, L.T. (2006). Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care. Journal of Adolescent Health, 38(4), 351-358.

The purpose of this study was to ascertain the prevalence of psychiatric symptoms and substance use disorders among adolescents with a lifetime history of foster care placement, using data from a nationally representative sample of U.S. adolescents. Methods: Study subjects were adolescents aged 12-17 years in the public use file of the 2000 National Household on Drug Abuse (n = 19,430, including 464 adolescents with history of foster care placement). Psychiatric symptoms and substance use disorders were ascertained through direct interviewing of adolescents. Results indicated that adolescents involved with foster care had more past-year psychiatric symptoms, and especially more conduct symptoms, and past-year substance use disorders than those never placed in foster care. Adolescents involved with foster care were about four times more likely to have attempted suicide in the preceding 12, and about five times more likely to receive a drug dependence diagnosis in the same period The authors concluded that adolescents involved with foster care have a higher prevalence of psychiatric symptoms and drug use disorders than those never placed in foster care.

Raphel, S. (2008). Kinship care and the situation for grandparents. Journal of Child and Adolescent Psychiatric Nursing 21(2), 118-120.

Kinship care. What is it? What's needed? What's being done? A totally new swing in child welfare is before us. In 1996, 2.5 million U.S. families were maintained by grandparent(s) who had one or more grandchildren living with them. According to census records, this number increased 30% in the decade ending 2000. The grandparent(s) provide a safety net to children inside and outside the Social Welfare System in cases where parents struggle with substance abuse, incarceration, mental illness, economic hardship, divorce, domestic violence, and other issues leading to their absence as primary caregivers for their children. Although this informal, private or voluntary arrangement has many advantages for the child, there are fewer resources available to the kin caregiver. Kinship care arrangements tend to be complex. Some families find themselves in both formal and informal situations with related children. Many caregivers are still raising their own children or caring for elder parents. Evaluating the quality of kinship care involves many views. The quality indicators are appropriate behavior, school performance, happiness, and the caregiver's experience with raising other children. [PUBLICATION ABSTRACT]

Smith, B.D. (2003). How parental drug use and drug treatment compliance relate to family reunification. Child Welfare, 82(3), 335-365.

This study assesses the relationships among parental drug use, drug treatment compliance, and reunification from substitute care. Parental drug use and treatment compliance have been presented as justification for a new emphasis in child welfare policy and practice, especially due to the shorter permanency timelines. Using in-person survey data and state administrative data, the study finds that drug treatment compliance is associated with faster reunification, even when accounting for ongoing drug use and three parenting measures. The findings are consistent with a conceptual framework suggesting that certain client actions, such as drug treatment compliance, may serve as markers that substantially affect client outcomes. This study contributes to the growing body of empirical literature on the correlates of reunification, including parents’ treatment compliance.

Vanderploeg, J. J., C. M. Connell, et al. (2007). "The impact of parental alcohol or drug removals on foster care placement experiences: A matched comparison group study." Child Maltreatment 12(2): 125-136.

Research has established the coincidence of parental alcohol and other drug (AOD) use and child maltreatment, but few studies have examined the placement experiences and outcomes of children removed because of parental AOD use. The present study examines demographic characteristics and placement experiences of children removed from their homes because of parental AOD use (n = 1,333), first in comparison to the remaining sample of children in foster care (n = 4,554), then in comparison to a matched comparison group of children in foster care who were removed for other reasons (n = 1,333). Relative to the comparison sample, children removed for parental AOD use are less likely to experience co-occurring removal because of neglect and physical or sexual abuse and are more likely to be placed in relative foster care. In addition, these children remain in care longer, experience similar rates of reunification, and have significantly higher rates of adoption.

White, C. R., O'Brien, K., White, J., Pecora, P. J., & Phillips, C. M. (2008). Alcohol and drug use among alumni of foster care: Decreasing dependency through improvement of foster care experiences. Journal of Behavioral Health Services & Research, 35(4), 419-434.

The Northwest Foster Care Alumni Study examined the effects of family foster care on adult substance dependencies. The study focused on young adults ( N = 479) who were served by a private (Casey Family Programs) or public foster care agency in Washington and Oregon states. This paper describes (1) prevalence rates of alcohol dependence and drug dependence, (2) the relation between risk factors and experiences in foster care and adult substance dependencies, and (3) statistical simulations showing how adult substance dependency rates may be reduced through improvement of the foster care experience. The rate of alcohol dependence within the past 12 months (3.6%) among alumni was not significantly different from that of the general population; the rate of drug dependence within the past 12 months (8.0%) was significantly higher among alumni. Optimization of foster care experiences (i.e., improving care) was associated with significant reductions in the estimated prevalence of these two dependencies.

Implications for Treatment

Forrester, D., Copello, A., Waissbein, C., & Pokhrel, S. (2008). Evaluation of an intensive family preservation service for families affected by parental substance misuse. Child Abuse Review, 17(6), 410-426.

Parental misuse of drugs or alcohol is recognized to be an issue for a high proportion of families to known social services, and for many children who enter care. However, there is limited research on what is effective in working with such families. This article reports on an evaluation of an Intensive Family Preservation Service (named ‘Option 2’) aimed at families in which parents misuse substances and children are considered at risk of entering care. The study used mixed methods. A quasi-experimental element compared solely data relating to care entry (e.g. how long children spent in care and its cost) for Option 2 children (n = 279) and a comparison group of referrals not provided with the service (n = 89) on average 3.5 years after referral. It found that about 40 per cent of children in both groups entered care, however Option 2 children took longer to enter, spent less time in care and were more likely to be at home at follow-up. As a result, Option 2 produced significant cost savings. A small-scale qualitative element of the study involved interviews with 11 parents and seven children in eight families. The findings suggested that Option 2 was a highly professional and appreciated service. For some families it achieved permanent change. For others, particularly those with complex and long-standing problems, significant positive changes were not sustained. The implications for services designed to prevent public care, particularly where there are substance misuse issues, are discussed and recommendations for policy and evaluation made.

Green, B. L., A. Rockhill, et al. (2007). "Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis." Children and Youth Services Review 29(4): 460-473.

Although substance abuse is one of the primary reasons that parents become involved with the child welfare system, there is surprisingly little empirical research that examines the relationship of substance abuse treatment to child welfare outcomes. In this statewide longitudinal study of 1911 women who had children placed in substitute care, we examined the influence of three key factors in the treatment process on child welfare outcomes. Results indicated that when these women entered treatment more quickly, spent more time in treatment, or completed at least one treatment episode, their children spent fewer days in foster care and were more likely to be reunified with their parents. These findings were significant even controlling for families' levels of risk including treatment and child welfare history, substance abuse frequency and chronicity, and demographic risks. Implications of these findings for improvements in the way that treatment services are provided to women in the child welfare system are discussed. (c) 2006 Elsevier Ltd. All rights reserved.

Gregoire, K.A., & Schultz, D.J. (2001). Substance-abusing child welfare parents: Treatment and child placement outcomes. Child Welfare, 80(4), 433-452.

This article provides information on substance abuse interventions with child welfare parents and describes outcomes for 167 child welfare clients referred for substance abuse assessments, and when recommended, treatment. The authors found that nearly one-third of the clients did not complete the substance abuse assessment required by the agency family plan, indicating the difficulty intervening in addiction. However, those clients who completed the assessment and treatment had higher rates of post-referral sobriety, affirming the value of intervention. The authors also found that prior treatment was associated with continued substance abuse rather than sobriety indicating a higher level of severity of addiction. To meet the goals of child safety, family preservation, and permanency planning, child welfare agencies and substance abuse service providers must work collaboratively to provide timely, accessible, and effective substance abuse treatment and support services for child welfare families with substance abuse problems.

Hohman, M.M., Shillington, A.M., & Baxter, H.G. (2003). A comparison of pregnant women presenting for alcohol and other drug treatment by CPS status. Child Abuse and Neglect, 27(3), 303-317.

The purpose of this study is to describe the demographic, substance use, and treatment variables of 678 treatment seeking pregnant women and to compare these variables based on Child Protective Service (CPS) status. The authors found that pregnant women reporting CPS involvement were similar to non-CPS women on demographic variables but differed on drug use and treatment variables. CPS women were more likely to report marijuana use as their primary problem drug, be mandated to treatment, attend day treatment and be released from treatment unsatisfactorily compared to the non-CPS pregnant women. Those without CPS involvement were more likely to report cocaine or crack as their primary drug, attend outpatient treatment and be found to have a satisfactory release from treatment compared to those with CPS involvement. Significant predictors of CPS involvement were mandated status and unsatisfactory treatment release. The authors postulate that the specific demands of CPS requirements may be burdensome on pregnant women. CPS demands may include parenting classes, monitored visits, working with a social worker on concurrent planning, and adhering to specific timelines to prepare for reunification or removal. The authors state that both AOD treatment services and CPS need to examine their policies and practices with pregnant substance-abusing women, to determine if treatment needs are not being met and if burdensome expectations are being placed upon them.

Lewandowski, C. A., & Hill, T. J. (2008). The impact of foster care and temporary assistance for needy families (TANF) on women's drug treatment outcomes. Children & Youth Services Review, 30(8), 942-954.

This study assesses the impact of having a child in foster care and receiving cash benefits through Temporary Assistance for Needy Families (TANF) on women's completion of a residential drug treatment program. The study's hypothesis was that drug treatment completion rates for women who had children in foster care and/or who were receiving TANF would differ from women who did not receive these services. The sample included 117 women age 19 to 54, in a Midwestern state. Findings suggest that women with a child or children in foster care were less likely to complete treatment. Women receiving cash benefits were also somewhat less likely to complete treatment than women not receiving these services. Women with children in foster care had similar levels of psychological, employment, and drug and alcohol concerns as other women, as measured by the Addiction Severity Index. Future research should focus on identifying strategies that enhance retention rates of these vulnerable women. Implications for improving treatment retention are discussed in light of the Adoption and Safe Families Act of 1997 and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. [PUBLICATION ABSTRACT]

Libby, A.M., Orton, H.D., Barth, R.P., Webb, M.B., Burns, B.J., Wood, P.A., & Spicer, P. (2007). Mental health and substance abuse services to parents of children involved with child welfare: A study of racial and ethnic differences for American Indian parents. Administration and Policy in Mental Health and Mental Health Services Research, 34(2), 150-159.

American Indian parents of children involved with child welfare were compared to White, Black and Hispanic parents on mental health and substance abuse problems and access to treatment. Data came from the National Study of Child and Adolescent Well-Being, a longitudinal study of a nationally representative sample of children aged 0-14 years involved with child welfare. The study found that there were significant disparities in the likelihood of receiving mental health, but not substance abuse, services. Unmet need for mental health and substance abuse treatment characterized all parents in this study. American Indian parents fared the worst in obtaining mental health treatment. Parents of children at home and of older children were less likely to access mental health or substance abuse treatment.

Marsh, J.C., & Cao, D. (2005). Parents in substance abuse treatment: Implications for child welfare practice. Children and Youth Services Review, 27(12), 1259-1278.

Substance abuse treatment in parents of young children is an important element of child welfare services. Increasingly, child welfare agencies, confronted with increasing numbers of substance abusing client, seek to integrate substance abuse treatment into child welfare services. These efforts are limited by a lack of targeted information about effective substance abuse treatment for parents. This study compares the predictive factors of post-treatment drug use in organizational, service and individual characteristics between 1237 parents and 1905 non-parents, mothers and fathers. The results show that treatment duration and the frequency of counseling available in treatment facilities are the most predictive factors for parents when other factors are controlled. Further, treatment duration, onsite service availability, and frequency of counseling available are significant factors in predicting post-treatment drug use for fathers, but not for mothers. The authors concluded that outcomes are better for parents who receive services in treatment organizations that provide counseling on a frequent schedule (once a week or more). Further, treatment duration and receipt of comprehensive services were specifically predictive for fathers but not for mothers. These findings have implications for improving substance abuse treatment services for parents in child welfare settings. For example, programs seeking to integrate substance abuse and child welfare services will be most effective when they can connect with substance abuse treatment programs that are able to (a) retain parents in treatment, and (b) tailor services to address health and social problems that typically co-occurring with substance abuse.

New Jersey uses money from child welfare system to treat addicted parents. (2008). Alcoholism & Drug Abuse Weekly, 20(21), 1-7.

The article provides facts on the issue of substance abuse problems in the child welfare system in New Jersey. The city government develops alternative way to continue offering foster care program throughout the country by transferring the money from the Division of Youth and Family Services (DYFS) to the Division of Addiction Services (DAS) to assist the parent paying treatment of children in the system. The treatment program is acknowledged as part of the region's child welfare services. [PUBLICATION ABSTRACT]

Nishimoto, R., & Roberts, A. (2001). Coercion and drug treatment for postpartum women. American Journal of Drug and Alcohol Abuse, 27(1), 161-181.

Some have contended that there is a role for coercion in drug treatment and that external pressures from family and the courts are necessary factors in successful treatment, particularly regarding women who are parenting and who are in the child welfare system. This research examined the extent to which various indicators of coercion were related to treatment retention in a gender-specific treatment program and a traditional outpatient program for pregnant and postpartum women who were mandated to enter treatment. Women who were given custody of their infant stayed in treatment longer than women who did not have custody. Women who had custody and were in the intensive day treatment program also completed treatment at a much higher rate than those in the traditional program. These findings have important implications for social work practice as the decision to place a newborn infant with a mother who has a history of or is currently abusing or dependent on substances is a serious concern for child welfare workers.

Osterling, K. L., & Austin, M. J. (2008). Substance abuse interventions for parents involved in the child welfare system: Evidence and implications. Journal of Evidence-Based Social Work, 5(1), 157-189.

As child welfare systems across the country face the problem of parental substance abuse, there is an increasing need to understand the types of treatment approaches that are most effective for substance-abusing parents in the child welfare system--the majority of whom are mothers. This structured review of the literature focuses on evidence related to two areas: (1) individual-level interventions designed to assist mothers and women in addressing their substance abuse problems, and (2) system-level interventions designed to improve collaboration and coordination between the child welfare system and the alcohol and other drug system. Overall, research suggests the following program components may be effective with substance-abusing women with children: (1) Women-centered treatment that involves children, (2) Specialized health and mental health services, (3) Home visitation services, (4) Concrete assistance, (5) Short-term targeted interventions, and (6) Comprehensive programs that integrate many of these components. Research also suggests that promising collaborative models between the child welfare system (CWS) and the alcohol and other drug (AOD) system typically include the following core elements: (1) Out-stationing AOD workers in child welfare offices, (2) Joint case planning, (3) Using official committees to guide collaborative efforts, (4) Training and cross-training, (5) Using protocols for sharing confidential information, and (6) Using dependency drug courts. Although more rigorous research is needed on both individual-level and system-level substance abuse interventions for parents involved in the child welfare system, the integration of individual-level interventions and system-level approaches is a potentially useful practice approach with this vulnerable population. [PUBLICATION ABSTRACT]

Ryan, J. P., Choi, S., Hong, J. S., Hernandez, P., & Larrison, C. R. (2008). Recovery coaches and substance exposed births: An experiment in child welfare. Child Abuse & Neglect, 32(11), 1072-1079.

Objectives: Substance exposed infants present a major challenge to child welfare and public health systems. Prenatal substance exposure and continued substance abuse in the home are associated with a wide range of adverse social, emotional, and developmental outcomes. The objective of the current study is to evaluate the use of recovery coaches in child welfare. Methods: The current study is longitudinal and utilizes an experimental design. The sample includes 931 substance abusing women enrolled in a Title IV-E Waiver Demonstration, 261 in the control group, and 670 in the experimental group. Women in the experimental group received traditional services plus the services of a recovery coach. Administrative records are used to indicate substance exposure at birth. Results: Of the 931 women enrolled in the waiver demonstration, 21% of the control group and 15% of the experimental group were associated with a subsequent substantiated allegation indicating substance exposure at birth. Cox proportional hazards modeling indicates that women in the experimental group were significantly less likely to be associated with a new substance exposed birth. Conclusions: The use of recovery coaches in child welfare significantly decreases the risk of substance exposure at birth. Integrated and comprehensive approaches are necessary for addressing the complex and co-occurring needs of families involved with child protection.

Sun, A-P., Shillington, A.M., Hohman, M., & Jones, L. (2001). Caregiver AOD use, case substantiation, and AOD treatment: Studies based on two southwestern counties. Child Welfare, 80(2), 151-178.

This article includes two separate studies: the first explores the impact of caregiver AOD use on CPS case substantiation; the second compares CPS-involved and CPS-noninvolved females in AOD treatment systems and describes what happens to AOD abusers once they enter the treatment system. By using two different approaches, the two studies presented here provide a profile of AOD-using caregivers in the child welfare and AOD systems. Results suggest that cases with indications of AOD use are more likely to be substantiated than cases without; and increasing numbers of children and younger maternal ages are risk factors for CPS involvement among AOD-using women. Both studies point to the importance of cross-training and skills in interdisciplinary work between CPS and AOD treatment field. CPS workers need to be familiar with AOD screening, identification, and assessment; AOD workers must be sensitive to the multiple problems and needs experienced by their CPS clients.

Westermeyer, J., L. Bennett, et al. (2007). "Substance use disorder among adoptees: a clinical comparative study." Am J Drug Alcohol Abuse 33(3): 455-66.

Goals of the study were to assess whether adoptees in treatment for Substance Use Disorder (SUD) (1) were over-, equi-, or under-represented in a clinical sample of patients with (SUD) and (2) differed demographically and clinically from non-adoptees with SUD. Sample consisted of 608 patients in two alcohol-drug treatment programs. Data collection included the Childhood Problems Scale, the Minnesota Substance Abuse Problem Scale, and the Minnesota Substance Abuse Treatment Questionnaire, and the Michigan Assessment-Screening Test/Alcohol-Drug. Findings showed that the prevalence of adoptees among SUD patients was 14 times higher than expected (95% Confidence Interval, 10 to 18 times). Adoptees reported childhood histories similar to those of non-adoptees with "any parental SUD", but they more closely resembled non-adoptees without parental SUD in regard to SUD severity and SUD treatment. Conclusion is that adoptees and their adoptive families should be alert to the increased risk of SUD among adoptees. Clinicians can expect that adoptees should manifest milder levels of SUD morbidity, similar to "non-heredity" SUD.

FAMILY COURT AND CRIMINAL JUSTICE INVOLVEMENT

Family Court

Boles, S. M., N. K. Young, et al. (2007). "The Sacramento dependency drug court: Development and outcomes." Child Maltreat 12(2): 161-171.

Dependency Drug Courts (DDCs) are a growing method of addressing the functional status and reunification success of families involved in child welfare and affected by substance use disorders. Despite widespread interest in DDCs, few evaluations have appeared in the literature to help inform the discussion about their effectiveness. This article provides a description of various types of DDCs and reports 24-month reunification rates from the Sacramento DDC. Results indicated that DDC participants had higher rates of treatment participation than did comparison participants. In addition, at 24 months, 42% of the DDC children had reunified versus 27.2% of the comparison children. There were no differences in treatment completion or child reunification rates by parent's primary drug problem. Rates of recidivism were extremely low for both the DDC and comparison groups and did not differ significantly. The results of the present study are encouraging and suggest that rigorous, controlled studies are merited to further evaluate the effectiveness of DDCs.

Dice, J.L., Claussen, A.H., Katz, L.F., & Cohen, J.B. (2004). Parenting in dependency drug court. Juvenile and Family Court Journal, 55(3), 1-10.

This article discusses the underlying approach and philosophy of the Miami-Dade Dependency Drug Court (DDC), which addresses the needs of families affected by substance abuse through a comprehensive and therapeutic approach. The DDC works with community agencies to provide services that effectively treat the family as a unit. The DDC provides a model approach to addressing risk factors associated with substance abuse in families and a model approach to collaboration with community stakeholders. This article discusses the process of adapting a parenting program to meet the needs of families in the DDC.

Edwards, L.P., & Ray, J.A. (2005). Judicial perspectives on family drug treatment courts. Juvenile and Family Court Journal, 56(3), 1-27.

Family Drug Treatment Courts are a specialized calendar or docket that operates within the juvenile dependency court. These courts provide the setting for a collaborative effort by the court and all the participants in the child protection system to come together in a non-adversarial setting to determine the individual treatment needs of substance-abusing parents whose children are under the jurisdiction of the dependency court. This article is intended to give judges and others a judicial perspective on FDTCs, and to offer some assistance for those who are operating or who are considering creating one.

Family court and outpatient treatment hoped to lead to more reunification. (2008). Alcoholism & Drug Abuse Weekly, 20(20), 1-6.

The article reports on the joint effort of the Department of Human Resources (DHS) and the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) to improve parent reunification in the state. The two agencies believe that the problems in the state's foster care system could be solved by expanding the family court program, which aims to reunify parents who are substance-dependent. They funded the assessment and treatment for these parents. [PUBLICATION ABSTRACT]

Green, B.L., Furrer, C., Worcel, S., Burrus, S., & Finigan, M.W. (2007). How effective are family treatment drug courts? Outcomes from a four-site national study. Child Maltreatment, 12(1), 43-59.

Family treatment drug courts (FTDCs) are a rapidly expanding program model designed to improve treatment and child welfare outcomes for families involved in child welfare who have substance abuse problems. The present study examines the effectiveness of the FTDC in improving treatment and child welfare outcomes for parents. This study compares outcomes for 250 FTDC participants to those of similar parents who did not receive FTDC services in four sites. Results show that FTDC parents, compared to comparison parents, entered substance abuse treatment more quickly, stayed in treatment longer, and completed more treatment episodes. Furthermore, children of FTDC parents entered permanent placements more quickly and were more likely to be reunified, with their parents, compared to children of non-FTDC participants. Finally, the FTDC program appears to have a "value added" in facilitating positive child welfare outcomes above and beyond the influence of positive treatment experiences. The authors note that one important aspect of the FTDC context that has been seen as important to its success is the increased information sharing between treatment, child welfare, the courts, and the regular contact between judges and participants. The study also suggests that FTDCs are supporting parents who may struggle with treatment.

Malbin, D.V. (2004). Fetal alcohol spectrum disorder (FASD) and the role of family court judges in improving outcomes for children and families. Juvenile and Family Court Journal, 55(2), 53-63.

The purpose of this article is to support increased recognition and efficacy of services for people with Fetal Alcohol Spectrum Disorder (FASD) in the legal system. FASD is under-reported, under-diagnosed, and over-represented in juvenile justice. Prenatal alcohol and other drug exposure causes brain damage that affects behaviors, e.g., poor judgment, impulsivity, difficulty learning from experience, and difficulty understanding consequences, leading to multiple diagnoses such as Attention Deficit Disorder, Conduct Disorder, Oppositional Defiant Disorder and Emotionally Disturbed. FASD is an invisible physical disability; most people with FASD have no observable physical characteristics. The courts are in an important position to increase awareness of this problem by simply asking whether FASD is a factor that needs to be considered. This article includes: (1) an overview of FASD diagnostic criteria and current terminology; (2) exploration of FASD as a physical disability with behavioral symptoms; (3) a case example illustrating common patterns of behaviors in children and adults with FASD without identification and improved outcomes following identification and implementation of appropriate treatment; and (4) recommendations for family court judges. The courts are in an important position to increase awareness of this problem by encouraging advocates and professionals to learn more about FASD and to take it into account when making recommendations to the court.

Rittner, B., & Dozier, C.D. (2000). Effects of court-ordered substance abuse treatment in child protection cases. Social Work, 45(2), 131-140.

Courts often play active roles in the lives of families supervised by child protective services (CPS). Judges adjudicate dependency, mandate services, determine placements of children, and order continued supervision or termination of parental rights or services. This study examined the effects of court orders in preventing recurrence of substance abuse in the cases of 447 children in kinship care while under CPS supervision. In addition, the effects of court orders on duration of service and on numbers of placements were studied. Results suggested that court interventions had mixed outcomes. Levels of compliance with mandated substance abuse and mental health treatment did not appear to influence rates of re-abuse or duration of service. Court orders appeared to affect both the number of caretakers and placements the children experienced. Children adjudicated dependent were more likely to have multiple caretakers than those under voluntary supervision. This study suggests that further research is needed to determine how compliance with court-ordered treatment should be used by workers in making decisions about continued supervision. In addition, the authors highlight the importance of adequate substance use and abuse screening in good case planning.

Somervell, A.M., Saylor, C., & Mao, C.L. (2005). Public health nurse interventions for women in a dependency drug court. Public Health Nursing, 22(1), 59-64.

There are an increasing number of children placed in foster care due to abuse and neglect. Parents of these children often have difficult drug abuse problems leading to the removal of their children. The cost of caring for these children is staggering, reaching an estimated $24 billion. One program in Northern California that has been created to assist parents is dependency drug court. This research utilized qualitative and quantitative data to identify the perceived needs of women who have graduated from this dependency drug court (n = 50) and what they think the public health nurse (PHN) could do to intervene in the difficult process of going through dependency drug court and reunifying with their children. In addition, select interviews were conducted with former drug court recipients who were functioning as "mentor moms" (n = 4). Themes relating to successful strategies emerged from the interviews. They included respect, validation, empowerment, understanding, and support. Common barriers such as overwhelming feelings of anger, denial, and hopelessness contributed to stress during recovery. Among strategies recommended by the mentor moms was a suggestion for PHNs to bridge the information gap through regular reports on the development and health of their children during the time they reside in foster care.

Worcel, S., Furrer, C., Green, B.L., & Rhodes, B. (2006). Family treatment drug court evaluation final phase I study report. Portland, OR: NPC Research.

This report presents the final analysis of Phase I of the Family Treatment Drug Court (FTDC) Evaluation. The FTDC Evaluation, funded by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment, is a 4-year study conducted by NPC Research aimed at investigating the short- and long-term child welfare and treatment outcomes for families involved with these innovative programs. There are four study sites participating in this evaluation: San Diego County, CA; Santa Clara County, CA; Suffolk County, NY; and Washoe County, NV. The Phase I design collected archival administrative data on past participants in the FTDCs and similar comparison group cases, and included information about placement changes, types of placements, treatment services and outcomes, case lengths and resolutions, and demographic and background information about the families involved with the cases. Results indicated that rapid entry into drug court and treatment services appear to be related to a number of positive outcomes, including more treatment completion, shorter times to permanent placement, and shorter case closure. In addition, parents who entered treatment faster, stayed in treatment longer, and completed treatment were more likely to graduate from drug court and were more likely to have faster time to permanent placement.

Worcel, S. D., Furrer, C. J., Green, B. L., Burrus, S. W. M., & Finigan, M. W. (2008). Effects of family treatment drug courts on substance abuse and child welfare outcomes. Child Abuse Review, 17(6), 427-443.

This paper presents results from the first large-scale outcome study of American Family Treatment Drug Courts (FTDCs)—specialized courts designed to work with substance-abusing parents involved with the child welfare system. The paper examines whether court, child welfare and treatment outcomes differed for 301 families served through three FTDCs as compared to a matched sample of 1,220 families with substance abuse issues who received traditional child welfare services. Propensity score weights were used to account for measured differences between the FTDC and comparison groups. Child welfare outcomes were analyzed using analytical techniques that controlled for these inherently nested data (i.e. children within a family). Overall, the study found that FTDC mothers had more positive treatment outcomes than similar mothers who were not served by the FTDC. FTDC mothers were more likely to enter substance abuse treatment services than were non-FTDC mothers, entered treatment more quickly after their initial court petition than did non-FTDC mothers, spent twice as much time in treatment than did non-FTDC mothers and were twice as likely to complete at least one treatment episode than non-FTDC mothers. In addition, data from the study indicate that FTDCs influence a key child welfare variable of interest: FTDC children were significantly more likely to be reunified with their mothers than were unserved children.

Incarcerated Persons with Substance Use Disorders

Hanlon, T.E., O’Grady, K.E., Bennett-Sears, T., & Callaman, J.M. (2005). Incarcerated drug-abusing mothers: Their characteristics and vulnerability. American Journal of Drug and Alcohol Abuse, 31(1), 59-77.

Although the number of mothers with histories of drug addiction who are incarcerated has grown substantially in recent years, there is little information on their unique characteristics and vulnerability. This study provides treatment-relevant information on the early life circumstances and developmental experiences of incarcerated substance-abusing women; examines the extent to which risk and protective factors derived from these early circumstances and experiences were associated with the adjustment and functioning of the mothers as adults; and contributes to an understanding of the general emotional adjustment of the mothers and their perceptions of themselves as parents. The subjects were 167 incarcerated drug-abusing mothers from Baltimore City who had volunteered for a parenting program offered at a Maryland correctional facility. Results revealed significant relationships between higher risk levels (i.e., lack of a structured, nurturing home environment during adolescence, association with deviant peers), and less favorable current adjustment. There was a high level of emotional attachment between the mothers and their children, yet many of the incarcerated mothers lacked confidence in their parenting skills. The authors also found that despite the potential disruption stemming from their mothers’ drug use and incarceration, many of the children in the sample were protected to some extent from the negative consequences of these circumstances by a strong kinship environment. The above considerations must be taken into account in planning interventions targeting incarcerated addicted mothers. The first priority in assisting these mothers should involve the provision of a drug abuse treatment intervention, both prior to and following their release from custody that highlights the incompatibility of drug abuse and successful parenting practices. In addition, in this and/or supplemental clinical services, the mothers should be given specific assistance in developing their parenting skills, in reestablishing relationships with their children, and in addressing present family circumstances having a direct bearing on her reintegration within the family that includes input from both the current caretakers and the children

Smith, A., Krisman, K., Strozier, A.L., & Marley, M.A. (2004). Breaking through the bars: Exploring the experiences of addicted incarcerated parents whose children are cared for by relatives. Families in Society, 85(2), 187-195.

Although research on addictions, incarceration, and kinship care has attracted the interests of social workers, little research is available that provides insight into the unique experience of incarcerated parents who are receiving substance abuse treatment and whose children are being raised by relatives. The present study sought to clarify the issues encountered by incarcerated parents, their children, and relative caregivers in an attempt to develop recommendations for a multidisciplinary, wraparound approach to designing services for these families during and after incarceration. To do so, researchers conducted a series of open-ended semistructured interviews with 25 incarcerated men and women who received substance abuse treatment while their children were being cared for by relatives. Respondents in this study were asked questions designed to explore issues such as parent-child bonding, relationships with caregivers, and the impact of drug abuse and incarceration on the family. The results revealed that many children had continuously resided with relative caregivers for a long period of time beginning before the parent’s incarceration and that many of the incarcerated parents had not seen their children since being incarcerated. Results of this study indicate that there is a need for a multidisciplinary, wraparound approach to designing services for affected parents, children, and caregivers. Professionals working in substance abuse treatment, child welfare, and corrections can benefit from gaining a better understanding of incarcerated parents’ feelings and concerns about being separated from their children and the resulting impact on the children and relative caregivers. This awareness can contribute to treatment relationships that encourage an improved sense of self, more support for substance abuse recovery, and stronger familial relationships for incarcerated parents. It is recommended that social workers include the biological parent in family decision making and facilitate visitation with all members of the kinship family system in order to help strengthen the parent’s self-perception as well of their understanding of the children and relative caregiver.

PERINATAL AND FAMILY SERVICES

Pregnant and Parenting Women

Chang, J. C., Dado, D., Frankel, R. M., Rodriguez, K. L., Zickmund, S., Ling, B. S., et al. (2008). When pregnant patients disclose substance use: Missed opportunities for behavioral change counseling. Patient Education & Counseling, 72(3), 394-401.

Objective: The first obstetric visit is an opportunity to provide counseling to women with substance abuse risks, including smoking, drug use, and alcohol use. Little is known about how obstetric care providers and patients discuss these issues. Our objective was to examine patient–provider communication about substance use behaviors during these visits. Methods: We audio-taped and transcribed verbatim first prenatal visits in an outpatient hospital clinic, then qualitatively analyzed them for content and process of communication using modified grounded theory methods. Results: Twenty-nine providers (21 residents, 5 midwives, 3 nurse practitioners) and 51 patients participated. Twenty-five patients were smokers, 4 used alcohol, and 11 used drugs. Provider responses to smoking disclosures included discussions of risks, encouragement to quit-cut down, affirmation of attempts to quit-cut down, and referral to smoking cessation programs. Responses to alcohol or drug disclosures included only a general statement regarding risks and referral to genetics. Conclusion: Providers were less attentive to alcohol and drugs than smoking where they had pre-established patterns of response. Practice implications: Providers should discuss behavioral change strategies and motivations with pregnant patients who use drugs and/or alcohol as well as those who smoke.

Clark, H.W. (2001). Residential substance abuse treatment for pregnant and postpartum women and their children: Treatment and policy implications. Child Welfare, 80(2), 179-198.

In FY 1993 and FY 1995, the federal government awarded 27 five-year grants that supported 35 residential treatment projects for substance-abusing pregnant and postpartum women (PPW) and their children. The impetus for the PPW program came not only from legislation, but from an increasing focus on research corroborating the significant consequences of substance abuse for women and their children. These projects provided comprehensive, culturally competent, and gender-sensitive treatment. Preliminary findings indicate that comprehensive residential treatment in which infants and young children live with their mothers is a promising approach for alleviating the women’s substance abuse and other problems, improving birth outcomes, and helping these mothers become more competent parents. These programs were also found to help the women reduce substance use, avoid criminal activity, and become responsible wage earners. The findings from the PPW program demonstrate the importance of treatment services for these families and it appears that intensive, comprehensive, and prolonged residential services are effective for women with multiple, serious needs, with benefits for both mothers and children. Future cost data are expected to demonstrate the efficiencies and benefits of these projects compared to no treatment.

Goler, N. C., Armstrong, M. A., Taillac, C. J., & Osejo, V. M. (2008). Substance abuse treatment linked with prenatal visits improves perinatal outcomes: A new standard. Journal of Perinatology, 28(9), 597-603.

Objective: To evaluate the impact of Early Start, an obstetric clinic-based prenatal substance abuse treatment program, on perinatal outcomes. Study Design: Subjects were 49 985 women who completed Prenatal Substance Abuse Screening Questionnaires at obstetric clinics between 1 January 1999 and 30 June 2003, had urine toxicology screening tests and either live births or intrauterine fetal demises (IUFDs). Four groups were compared: women screened/assessed positive and treated by Early Start (‘SAT’, n=2073); women screened/assessed positive without treatment (‘SA’, n=1203); women screened positive only (‘S’, n=156); controls who screened negative (n=46 553). Ten neonatal and maternal outcomes were studied. Result: SAT women had either similar or slightly higher rates than the control women on most outcomes but significantly lower rates than S women. SA women generally had intermediate rates to the SAT and S groups. In multivariate analysis, the S group had significantly worse outcomes than the SAT group: preterm delivery (odds ratio (OR)=2.1, 1.3 to 3.2), placental abruption (OR=6.8, 3.0 to 15.5) and IUFD (OR=16.2, 6.0 to 43.8).Conclusion: Substance abuse treatment integrated with prenatal visits was associated with a positive effect on maternal and newborn health.

Grella, C.E., Hser, Y.-I., & Huang, Y.-C. (2006). Mothers in substance abuse treatment: Differences in characteristics based on involvement with child welfare services. Child Abuse & Neglect, 30(1), 55-73.

Greater awareness of the role of parental substance abuse in child maltreatment makes it imperative that the substance abuse treatment and child welfare systems coordinate services for these parents. Yet little is known about the characteristics of child-welfare involved parents (primarily mothers) who enter into substance abuse treatment. This paper compares the characteristics of mothers in substance abuse treatment who were and were not involved with child welfare services, and discusses the treatment implications of these differences. Data were obtained from a statewide treatment outcome monitoring project in California. Clients were assessed at treatment admission using the Addiction Severity Index. The authors found that mothers who were involved with child welfare were younger, had more children, and had more economic problems. They were more likely to be referred by the criminal justice system or other service providers, to have a history of physical abuse, and to be treated in outpatient programs. They had lower levels of alcohol severity, but did not differ with regard to psychiatric severity or criminal involvement. Primary users of methamphetamine were disproportionately represented among this group and had a distinct profile from primary alcohol- and opiate-users. The authors conclude that mothers involved with child welfare enter substance abuse treatment through different avenues and present a clinical profile of treatment needs related to exposure to physical abuse, economic instability, and criminal justice involvement.

Harris, M. S. (2008). Alcohol, child maltreatment, and parenting stress in the lives of birth mothers. Journal of Human Behavior in the Social Environment, 18(2), 129-150.

This exploratory study examines the potential relationship between parenting stress, child maltreatment, and alcoholism in a pilot data set. Twenty-four participants (six African-American, six European-American, six Mexican-American, and six Native-American) completed four questionnaires (Parenting Stress Index, Conflict Tactics Scale Parent-Child, Michigan Alcoholism Screening Test, Chemical Dependency Assessment Profile [PSI, CTSPC, MAST, and CDAP]). Through principle component analyses and multiple regression analyses, it was suggested that self-perceived parenting strength or competence directly affect a parent's tactics to deal with parent-child conflicts. Results indicated that self-confidence as a competent parent was related to the frequency of using verbal degrading and physical punishment. Parents who reported that the child's temperament bothers them a lot were more likely to physically abuse the child. Though all the participants could be categorized as alcoholic by the MAST, parents' alcoholic abuse did not appear to elevate the severity of child maltreatment, as measured by the CTSPC.

Hser, Y.I., & Niv, N. (2006). Pregnant women in women-only and mixed-gender substance abuse treatment programs: A comparison of client characteristics and program services. Journal of Behavioral Health Services & Research, 33(4), 431-442.

This study compared characteristics of pregnant women treated in women-only (WO) and mixed-gender (MG) substance abuse treatment programs and compared services provided by these two types of programs. Participants were 407 pregnant women who were admitted to 7 WO programs and 29 MG programs in 13 counties across California during 2000-2002. Pregnant women treated in WO programs demonstrated greater severity in drug use, legal problems, and psychiatric problems than those treated in the MG programs. They were also less likely to be employed and more likely to be homeless. Women-only programs were more likely to offer child care, children's psychological services, and HIV testing. The greater problem severity of pregnant women treated in WO programs suggests that these specialized services are filling an important gap in addiction services, although further expansion is warranted in psychiatric, legal, and employment services.

Jones, H. E., Martin, P. R., Heil, S. H., Kaltenbach, K., Selby, P., Coyle, M. G., et al. (2008). Treatment of opioid-dependent pregnant women: Clinical and research issues. Journal of Substance Abuse Treatment, 35(3), 245-259.

This article addresses common questions that clinicians face when treating pregnant women with opioid dependence. Guidance, based on both research evidence and the collective clinical experience of the authors, which include investigators in the Maternal Opioid Treatment: Human Experimental Research (MOTHER) project, is provided to aid clinical decision making. The MOTHER project is a double-blind, double-dummy, flexible-dosing, parallel-group clinical trial examining the comparative safety and efficacy of methadone and buprenorphine for the treatment of opioid dependence in pregnant women and their neonates. The article begins with a discussion of appropriate assessment during pregnancy and then addresses clinical management stages including maintenance medication selection, induction, and stabilization; opioid agonist medication management before, during, and after delivery; pain management; breast-feeding; and transfer to aftercare. Lastly, other important clinical issues including managing co-occurring psychiatric disorders and medication interactions are discussed.

Kerwin, M.E. (2005). Collaboration between child welfare and substance-abuse fields: Combined treatment programs for mothers. Journal of Pediatric Psychology, 30(7), 581-597.

This article provides a review of collaboration between child welfare and drug-abuse fields in providing treatment to mothers who abuse drugs and maltreat their children. A literature review of studies examining effects of maternal drug abuse on parenting skills and outcomes of interventions for both maternal drug abuse and parenting skills is provided. Results indicate that parenting skills differ between mothers who do and do not abuse drugs, but these studies are primarily limited to mothers of infants and preschoolers. The author finds that the evidence base for interventions to address both substance use and parenting in these mothers is growing, but more well-controlled studies are needed. Opportunities for improved collaboration between fields are presented. The author concludes that progress has been made toward collaboration to address drug abuse and parenting skills of mothers who abuse drugs, but more integrated strategies are needed, especially for mothers who use drugs and maltreat their children.

Kettinger, L.A., Nair, P., & Schuler, M.E. (2000). Exposure to environmental risk factors and parenting attitudes among substance-abusing women. American Journal of Drug and Alcohol Abuse, 26(1), 1-11.

This study examined the amount of exposure to negative environmental risks and their association with parenting attitudes among a group of 198 inner city substance-abusing women. Mothers were recruited at delivery and were part of a randomized longitudinal intervention study for substance-abusing women and their infants. When the infants were 18 months old, a cumulative environmental risk score was calculated for each mother based on nine factors: violence (both domestic and environmental), depression, homelessness, incarceration, number of children, life stress, psychiatric problems, and absence of significant other. Based on their cumulative scores, mothers were placed in a low or high environmental risk group. Mothers in the high-risk group had fewer years of education, were younger when their first child was born, and had significantly worse scores on parenting attitude scales. Given the current state of welfare reform, it is important to determine which factors besides maternal substance abuse place these mothers at risk for poor parenting.

Knight, D.K., Logan, S.M., & Simpson, D.D. (2001). Predictors of program completion for women in residential substance abuse treatment. American Journal of Drug and Alcohol Abuse, 27(1), 1-18.

Although there is increasing emphasis on providing drug treatment programs for women that address their specific needs (including parenting and childcare), some women still fail to complete treatment. Because of the limited information about the barriers involved, this study examines pretreatment characteristics as predictors of program completion for 87 women who were pregnant or who entered residential treatment with their children. Women who completed program requirements were more likely to have a high school degree or equivalent, no arrests in the 6 months before admission, and friends who were less deviant. These findings support the need for specialized education and services that address social deviancy of pregnant and/or parenting women.

Kovalesky, A. (2001). Factors affecting mother-child visiting identified by women with histories of substance abuse and child custody loss. Child Welfare, 80(6), 749-768.

The influence of maternal substance abuse upon the placement of children in out-of-home care increased significantly in the 1980s and 1990s, affecting mother-child visiting in numerous ways. The present study sought to identify factors that affect mother-child visiting when maternal substance abuse is a contributing reason to the placement of a child in out-of-home care. Content analysis of interview data from 15 mothers with histories of illegal drug use and child custody loss provides insight into five major factors that can promote or inhibit visiting: (1) mother's drug use and health status, (2) effects of visits on the child, (3) transportation, (4) scheduling/visit settings, and (5) support of others. The authors conclude that if treatment for the mother’s substance abuse problem is not imminently available following child custody loss, the mother may find it difficult to maintain her abstinence for visits with her child. In addition, the visits themselves can elicit such strong emotional responses regarding custody loss that a relapse can occur following a visit. The authors state that ready access to a counselor, 12-step sponsor, substance abuse treatment program, or other source of support is essential to promoting mother-child visiting.

Lam, W.K.K., Wechsberg,W., & Zule, W. (2004). African-American women who use crack cocaine: A comparison of mothers who live with and have been separated from their children. Child Abuse & Neglect, 28(11), 1229-1247.

This study examined factors that influenced caregiver status for African-American mothers who use crack cocaine but are not receiving drug treatment and participated in an HIV prevention study in North Carolina. Given that many mothers who use illicit drugs may retain care of their children, understanding the contexts in which these mothers and their children live is important for advancing research and practice in the fields of substance abuse and child welfare. This study fills an important gap of the literature by examining factors that affect whether mothers retain care of their children among a rarely studied sample of African American women who actively abuse drugs but are not connected to formal service or welfare systems. Caregiver mothers who were living with at least one of their children were compared with non-Caregivers who were separated from all of their children. Non-Caregivers were more likely to be older, to have been physically abused as children, to trade sex more frequently, to be homeless, to have no health insurance, report higher frequencies of drug use, risky sex practices, psychological distress, and victimization experiences. Findings that socio-environmental factors were more strongly associated with caregiver status than crack use underscore the importance of contextual issues such as housing, victimization history, and resources in serving maternal crack users. This article suggests that community outreach and interventions that engage mothers who use drugs and live with their children may be more effective strategies than formal office-based services to link mothers who use crack and their children to needed drug treatment and family and child services.

May, P. A., Miller, J. H., Goodhart, K. A., Maestas, O. R., Buckley, D., Trujillo, P. M., et al. (2008). Enhanced case management to prevent fetal alcohol spectrum disorders in Northern Plains communities. Maternal & Child Health Journal, 12(6), 747-759.

Women proven to be extremely high risk for drinking during pregnancy were provided case management (CM) enhanced with strategies derived from motivational interviewing (MI) as a part of a comprehensive Fetal Alcohol Syndrome (FAS) epidemiology and prevention program in four American Indian communities in Northern Plains states. Data on the first women enrolled ( n = 131) revealed that they have extreme issues with alcohol abuse to overcome. Sixty-five percent of these women have experienced extensive alcohol use within their immediate family. At intake, 24% of CM clients reported binge drinking one or more days in the preceding week. Heavy drinking resulted in estimated blood alcohol concentrations (BAC) as high as .576 using the BACCUS methodology. Project staff has attempted to actively engage each of these women in CM. Clients have been in CM an average of 17.2 months ( SD = 16.6). The mean number of significant contacts (face-to-face or telephone MI sessions) was 19. Thirty-one percent of the women entered some type of formal alcohol or drug treatment while in CM. Data were collected at 6 month intervals from 6 to 72 months after enrollment. Consumption of alcohol, as measured by both quantity and frequency measures, was reduced at 6 months. Thirty-eight percent of enrolled women reported complete abstinence from alcohol use at 6 months, and the number of binges while drinking in CM declined significantly from 15 at baseline to 4.3 at 6 months. However, mean peak BACs for the heavy drinking sessions were still problematic for those who continued to drink. They ranged from .234 to .275 from baseline to 12 month follow-up, but the total number of binges was reduced substantially at 12 months as well. Furthermore, the most important outcomes are the status of the children born while in CM. [PUBLICATION ABSTRACT]

Mayet, S., Groshkova, T., Morgan, L., Maccormack, T., & Strang, J. (2008). Drugs, alcohol and pregnant women—changing characteristics of women engaging with a specialist perinatal outreach addictions service. Drug & Alcohol Review, 27(5), 490-496.

Pregnant substance misusers present an increased risk to themselves and the unborn child. The aim of this study was to investigate changes in the characteristics of women referred to a specialist perinatal addictions outreach service (1989-1991 versus 2002-2005). A cross-sectional audit of health records was conducted. Information was gathered for each woman who contacted the service (2002-2005). Data were compared to an earlier study in the same locality (1989-1991). A total of 167 pregnant substance-using women were referred between 2002 and 2005, of whom 126 made contact. The mean age was 30.2 years at 20.8 weeks' fetal gestation, with 76% not in addictions treatment, 32% from black or minority ethnic (BME) communities, 49% polysubstance users and 29% homeless. The primary substance used was illicit heroin (38%), followed by cocaine (24%). Compared to 1989-1991, there were significantly more pregnant women presenting at an older age, later gestation, with increased polysubstance use and a higher percentage of women from BME communities. This service was able to access vulnerable substance-abusing women with an altered pattern of substance use compared to over 10 years previously. However, improvements are needed for engaging all referred women and accessing women at an earlier gestation. [PUBLICATION ABSTRACT]

Metsch, L.R., Wolfe, H.P., Fewell, R., McCoy, C.B., Elwood, W.N., Wohler- Torres, B., et al. (2001). Treating substance-using women and their children in public housing: Preliminary evaluation findings. Child Welfare, 80(2), 199-220.

Demonstration research and service programs have been initiated to verify that comprehensive, long-term residential treatment services for women will decrease alcohol and drug use, reduce reliance on social and health welfare programs, and improve functioning in specific life-skill and vocation areas. The article reports on one such program, SafePort, a residential substance abuse treatment program within public housing to provide drug treatment to parenting women. All family members-women, children, and significant others-receive comprehensive assessments to determine appropriate therapeutic interventions to resolve their problems. Preliminary evaluation findings suggest that women who participate with their children are more likely to remain drug free than are those who participated without their children. This model suggests that providing women and their children with a home as well as treatment for substance abuse and related issues facilitates women’s abstinence from drug use after treatment.

O'Connor, M.J., & Whaley, S.E. (2006). Health care provider advice and risk factors associated with alcohol consumption following pregnancy recognition. Journal of Studies on Alcohol, 67(1), 22-31.

This study examined the extent to which pregnant women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were counseled by their health care providers to stop drinking alcohol during pregnancy. A second purpose was to identify characteristics associated with alcohol consumption postrecognition of pregnancy. The sample consisted of 279 women who continued to drink after learning they were pregnant. Measures of provider advice on alcohol consumption, demographic characteristics caffeine intake, smoking, other drug use, alcohol risk (using the TWEAK scale), and depressive symptoms on the Center for Epidemiological Studies Depression Scale (CES-D) were collected. The authors found that 62% of women had significantly high TWEAK scores, and 60% scored within the clinical range for depression. Sixty percent of sample women had been advised by their care providers not to drink alcohol during pregnancy. Women who were most likely to receive advice were black non-Hispanic and Hispanic, were Spanish speaking, were less educated, were on public assistance, and had a higher number of alcohol-related risk behaviors. Advanced age, public assistance, caffeine use, smoking, and elevated TWEAK and CES-D scores predicted elevations in alcohol consumption rates. The authors concluded that although advice to stop drinking during pregnancy was provided to 60% of this sample, women continued to drink following pregnancy recognition, with alcohol consumption rates highly associated with sociodemographic and psychological factors, namely maternal depression. Because elevations in alcohol consumption during pregnancy are associated with poorer developmental outcomes for children, further efforts are needed to better address social and mental health factors that influence consumption.

Perreira, K.M., & Cortes, K.E. (2006). Race/ethnicity and nativity differences in alcohol and tobacco use during pregnancy. American Journal of Public Health, 96(9), 1629-1636.

The authors examined race/ethnicity and nativity correlates of prenatal substance use. Using data on a nationally representative cohort of pregnant women in US cities (N = 4185), the authors evaluated the relative importance of socioeconomic status, paternal health behaviors, social support, and maternal stress and health history in explaining variations in prenatal substance use by race/ethnicity and nativity. The authors found that maternal stress and health history appeared to fully explain differences in alcohol use by nativity, but these and other factors could not explain differences in prenatal smoking. For all races/ethnicities, paternal health behaviors were most strongly associated with maternal substance use. Except among Black women, socioeconomic background bore little relation to prenatal substance use after adjustment for more proximal risk factors (e.g., paternal and maternal health behaviors). Social support was most protective among Hispanic women. The authors concluded that foreign-born immigrant women are at equal risk of prenatal alcohol use compared with similarly situated US-born women and should not be overlooked in the design of interventions for at-risk women. Furthermore, the inclusion of fathers and the development of social support structures for at-risk women can strengthen interventions.

Pregnancy-related drinking reduction varies between white, black women.(2008). DATA: The Brown University Digest of Addiction Theory & Application, 27(10), 3-4.

The article presents a study on the pregnancy-related changes in alcohol consumption between Black and White women. Daniel S. Morris and colleagues found that White women appear more likely to reduce drinking and binge drinking upon becoming pregnant than Black women. Other predictors of differences in drinking levels include age, education and smoking. Authors highlight the need for alcohol education programs and interventions for pregnant drinkers in the Black community.

Reid, C., Greaves, L., & Poole, N. (2008). Good, bad, thwarted or addicted? Discourses of substance-using mothers. Critical Social Policy, 28(2), 211-234.

This paper examined discourses of mothers who use substances. Focus groups were conducted at two different treatment programs with diverse women who identified as mothers challenged by substance use. Real scenarios were presented to the participants and feedback was sought about how the women within the scenarios managed their situations and the actions taken by legal, media, and health authorities. Through the use of three lenses - rights, risks, and evidence - we identified four major discourses in the participants' talk. The 'good mother', 'bad mother', 'thwarted mother' and 'addicted mother' discourses revealed the multiple and at times contradictory ways the women made sense of their lives. Within all of the discourses the mother-child bond and the importance of providing necessary supports to mothers with substance-use problems were central. The women's discourses highlighted the challenges of negotiating the prevailing attitudes, practices and stigmas of being a substance-using mother while trying to do the right thing for their children. [PUBLICATION ABSTRACT]

Sarkola, T., H. Kahila, et al. (2007). "Risk factors for out-of-home custody child care among families with alcohol and substance abuse problems." Acta Paediatr.

Aim: To study the risk of children to mothers with alcohol and/or substance abuse related problems for early childhood out-of-home care in Finland. Methods: A population-based cross-sectional retrospective analysis of 526 pregnant women attending special outpatient clinics during 1992-2001 and their 626 offspring, with out-of-home care data until 2003 provided by the National Child Welfare Register. Results: Fifty percent (95% confidence interval 46-54%) were at some point and 38% (34-42%) by the age of two years, in out-of-home care. Out-of-home care was associated with maternal care for substance abuse after delivery, nonemployment, housing, daily smoking during pregnancy, increasing number of previous births, mother in custody in her childhood, maternal education, previous child in custody, drug in urine during pregnancy, unplanned pregnancy, partner with significant abuse, regular health-care contact for abuse, daily alcohol consumption before and/or during pregnancy, newborn not discharged with mother, neonatal abstinence symptoms (NAS), intensified perinatal surveillance or NICU, and delayed discharge from hospital. Conclusions: There is a substantial risk of children born to mothers with significant alcohol and/or substance abuse related problems for out-of-home care during early childhood. Factors identified during the pre- and perinatal period are associated with this risk.

Schilling, R., Mares, A., & El-Bassel, N. (2004). Women in detoxification: Loss of guardianship of their children. Children and Youth Services Review, 26(5), 463-480.

Conducted in hospital-based clinics in New York City, this study depicts the living circumstances of children of women in detoxification for heroin or crack cocaine. Structured interviews were conducted with 160 African American and 96 Latina female patients who had at least one child under age 18. High-risk drug use was common, including injection, frequenting crack houses, overdosing and trading sex for drugs. Fewer than half of the mothers had a high school education, and few received income from wages or child support. Mothers, with a mean age of 36, reported an average of 2.84 minor children. Only 34% of children were in the guardianship care of their mothers alone or mothers and their partners. Only 21% of mothers indicated that they were the guardians of all of their minor children. Rates of guardianship and custody were somewhat higher for Latina mothers compared to African American mothers. The most important sources of care for the children were grandparents, other relatives and foster parents. Of the children of detoxifying mothers, 21% were living with a non-relative, whereas in a national comparison sample of African American and Latino households, only 2% of children were living with non-relatives. The study also found that women who did not live in their own home, had less education and used multiple drugs were more likely to have lost guardianship of one or more children. Study findings expand understanding of the detrimental effects of parental drug abuse on children's life opportunities.

Sharpe, T. T., & Velasquez, M. M. (2008). Risk of alcohol-exposed pregnancies among low-income, illicit drug-using women. Journal of Women's Health (15409996), 17(8), 1339-1344.

Objectives: Poor women of childbearing age who use crack, cocaine, marijuana, and heroin may be at risk for having an alcohol-exposed pregnancy because of concurrent alcohol use. Women who use illicit drugs may not know the harmful effects of fetal alcohol exposure. Fetal alcohol exposure is a leading cause of developmental disabilities and mental retardation. Methods: We report findings of a survey administered to 2672 women 18–44 years of age in settings serving low-income women, including an urban jail, a drug treatment facility, and healthcare facilities in Florida, Virginia, and Texas. We compared women who reported using more than one illicit drug (drug users) and women who reported never using illicit drugs (nonusers) for frequent alcohol consumption, binge drinking, failure to use contraception, unplanned pregnancies, and drinking during pregnancy. Results: Of women interviewed, 75% (2000) reported using more than one illicit drug. Drug users were more likely to report frequent drinking (33%, relative risk [RR] 12.73, 95% confidence interval [CI] 7.9-20.4, binge drinking (39%, RR 5.7, 95% CI 4.9-7.6), and drinking during pregnancy (37%, RR 2.10, 95% CI 1.75-2.53) compared with nonusers (3%, 7%, 17%, respectively, p < 0.0001). Greater proportions of drug users (27%, RR 2.20, 95% CI 1.75-2.53) also failed to used contraception compared with nonusers (19%, p < 0.05). Notable proportions of both groups, drug users (91%) and nonusers (82%), reported unplanned pregnancies. Conclusions: The findings suggest that poor women who reported ever using more than one illicit drug were at greater risk for having an alcohol-exposed pregnancy. Unplanned pregnancies in both groups surpassed national averages. Poor women likely require enhanced education about the hazards of drinking during pregnancy and methods to reduce unplanned pregnancies.

Suchman, N., Mayes, L., Conti, J., Slade, A., & Rounsaville, B. (2004). Rethinking parenting interventions for drug-dependent mothers: From behavior management to fostering emotional bonds. Journal of Substance Abuse Treatment, 27(3), 179-185.

Mothers who are physically and/or psychologically dependent upon alcohol and illicit drugs are at risk for a wide range of parenting deficits beginning when their children are infants and continuing as their children move through school-age and adolescent years. Behavioral parent training programs for drug-dependent mothers have had limited success in improving parent-child relationships or children’s psychological adjustment. One reason behavioral parenting programs may have had limited success is the lack of attention to the emotional quality of the parent-child relationship. Research on attachment suggests that the emotional quality of mother-child relationships is an important predictor of children’s psychological development through school-age and adolescent years. In this paper, the authors present a rationale and approach for developing attachment-based parenting interventions for drug-dependent mothers and report preliminary data on the feasibility of offering an attachment-based parenting intervention in an outpatient drug treatment program for women.

Suchman, N., Pajulo, M., DeCoste, C., & Mayes, L. (2006). Parenting interventions for drug-dependent mothers and their young children: The case for an attachment-based approach. Family Relations, 55(2), 211-226.

Maternal substance abuse is the most common factor involved when children come to the attention of the child welfare system. Although there is a clear need for clinical trials to evaluate parenting interventions for drug-dependent women, few studies to date have systematically examined the efficacy of interventions for this population. The authors review six published reports of outpatient interventions that aimed to enhance the caregiving skills of substance-abusing mothers caring for children between birth and 5 years of age. Following a discussion of the implications of these studies, the authors describe an attachment-based intervention that addresses these implications and has demonstrated preliminary feasibility in a pilot trial.

Suchman, N.E., McMahon, T.J., Zhang, H., Mayes, L.C., & Luthar, S. (2006). Substance-abusing mothers and disruptions in child custody: An attachment perspective. Journal of Substance Abuse Treatment, 30(3), 197-204.

Using an attachment framework, the authors examined (1) whether substance-abusing mothers' perceptions of how they were parented were related to the severity of their substance abuse and psychological maladjustment and (2) whether these two factors mediated the association between mothers' perceptions of how they were parented and their children's placement out of home. The sample included 108 mothers of 248 children who completed interviews upon admission to a methadone maintenance program for women. Measures included lifetime risk composite scores derived from the Addiction Severity Index, the Parental Bonding Instrument, and a demographics questionnaire. The authors found that out-of-home placement of substance-abusing children appeared to be linked with risks at multiple levels of influence (e.g., sociodemographic, family/social, individual maternal adjustment, and child characteristics). In addition, mothers who perceived their own mothers as uncaring and intrusive were more likely to have developed severe substance abuse problems and psychological maladjustment and to have lost custody of a minor child. The authors suggest that the findings are consistent with an attachment perspective on parenting suggesting that the internal psychological processes of a parent play a critical role in the continuity of parenting.

Sun, A-P. (2004). Principles for practice with substance-abusing pregnant women: A framework based on the five social work intervention roles. Social Work, 49(3), 383-394.

The author discusses components essential to pregnancy-specific substance abuse treatment, based on a review of the literature. Elements and issues related to substance abuse during pregnancy are identified under the five social work intervention roles: teacher, broker, clinician, mediator, and advocate. These five roles are used as a framework and integrate relevant literature. The concepts and approaches presented in this article can be applied by social workers in residential or outpatient substance abuse treatment programs; hospital prenatal, labor, and delivery units; the child welfare system; public health districts; or community family service centers.

Velez, M.L., Jansson, L.M., Montoya, I.D., Schweitzer, W., Golden, A., & Svikis, D. (2004). Parenting knowledge among substance abusing women in treatment. Journal of Substance Abuse Treatment, 27(3), 215-222.

The purpose of this study was to assess parenting knowledge and beliefs among drug abusing pregnant and recently postpartum women engaged in a comprehensive substance abuse treatment program. In addition, this study examined the effects of a parenting skills training program incorporated into a maternal substance abuse treatment program. Seventy-three pregnant and drug-dependent women received a manualized 8-week training program on parenting instruction. Preliminary results obtained from this clinic-based sample suggest that these substance abusing mothers lacked important parenting knowledge and held misconceptions about basic parenting practices. This knowledge improved after comprehensive substance abuse treatment that included parenting training. This study demonstrated that parenting skills training, as a component of drug treatment, was associated with at least short-term improvements in parenting knowledge. Parenting knowledge and practices are particularly important for this group of women, as their children are at high risk for developmental and other difficulties. Therefore, systematic evaluation of parenting knowledge among women of childbearing age entering substance abuse treatment is recommended. Substance abuse treatment for drug-dependent pregnant and postpartum women should include a parenting skills training component with the ultimate goal of improving the overall development of the drug-exposed child.

Winhusen, T., Kropp, F., Babcock, D., Hague, D., Erickson, S. J., Renz, C., et al. (2008). Motivational enhancement therapy to improve treatment utilization and outcome in pregnant substance users. Journal of Substance Abuse Treatment, 35(2), 161-173.

Pregnant substance users can benefit significantly from substance abuse treatment, but treatment retention can be challenging. Two hundred pregnant substance users entering outpatient substance abuse treatment at one of four treatment programs were randomized to receive either three individual sessions of Motivational Enhancement Therapy for pregnant substance users (MET-PS) or the first three individual sessions normally provided by the program. All participants were encouraged to participate in all other treatment offered by the program. Outcome measures included treatment utilization according to clinic records, qualitative urine toxicology measures, and self-report of substance use. One hundred sixty-two (81%) participants completed the 1-month active phase. Participants attended 62% of scheduled treatment on average and reported decreased substance use during the first month of treatment, with no differences between MET-PS and treatment-as-usual (TAU) participants. There was some evidence that the efficacy of MET-PS varied between sites and that MET-PS might be more beneficial than TAU in decreasing substance use in minority participants. These results suggest that MET-PS is not more effective than TAU for pregnant substance users in general but that there might be particular subgroups or treatment programs for which MET-PS might be more or less effective than TAU.

Winklbaur, B., Kopf, N., Ebner, N., Jung, E., Thau, K., & Fischer, G. (2008). Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. Addiction, 103(9), 1429-1440.

Aims Through a novel synthesis of the literature and our own clinical experience, we have derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants. Methods PubMed literature searches were carried out to identify recent key publications in the areas of pregnancy and opioid dependence, neonatal abstinence syndrome (NAS) prevention and treatment, multiple substance abuse and psychiatric comorbidity. Results Pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Applying multi-disciplinary treatment as early as possible, allowing medication maintenance and regular monitoring, benefits mother and child both in the short and the long term. However, there is a need for randomized clinical trials with sufficient sample sizes. Recommendations Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication. Conclusion Methodological flaws and inconsistencies confound interpretation of today's literature. Based on this synthesis of available evidence and our clinical experience, we propose recommendations for further discussion.

Prenatal Exposure and Effect on Children

Barth, R.P., Freudlich, M., & Brodzinsky, D. (Eds.). (2000). Adoption and prenatal alcohol and drug exposure: Research, policy and practice. Washington, DC: Child Welfare League of America.

As professionals become aware of the impact of prenatal substance exposure on children in the adoption process or who are available for adoption, there is a heightened need for understanding the range of issues connected with prenatal alcohol and drug exposure. This book addresses many of these issues, providing important information on: the impact of prenatal substance exposure on children’s immediate health and well-being; the long-term implications for the health and development of substance-exposed infants; the role that a positive postnatal environment can play in remediating the effects of prenatal substance exposure; counseling suggestions for prospective adoptive parents regarding the effects of prenatal substance exposure; and the ongoing services and supports that are needed for adoptive families and their substance-exposed children to maximize positive outcomes.

Barth, R.P. (2001). Research outcomes of prenatal substance exposure and the need to review policies and procedures regarding child abuse reporting. Child Welfare, 80(2), 275-296.

Research on the outcomes of drug-exposed children evinces elevated developmental risks from the interaction of subtle biological vulnerabilities and compromised parenting. States, however, have generally not reviewed the procedures and policies they developed in the early 1990s when there was less research and experience with these children. At that time the gravest risks related to perinatal substance exposure seemed to be excessively punitive treatment of mothers by overzealous criminal justice prosecutors. This article discusses primary and secondary risks of prenatal drug exposure. The author also clarifies policy options for reporting and serving children who are born testing positive for controlled substances and calls for strengthening existing state policies regarding child abuse reporting and response.

Bauer, C.R., Langer, J.C., Shankaran, S., Bada, H.S., Lester, B., Wright, L.L., et al. (2005). Acute neonatal effects of cocaine exposure during pregnancy. Archives of Pediatrics & Adolescent Medicine, 159(9), 824-834.

The purpose of this study was to identify associations between cocaine-exposure during pregnancy and medical conditions in newborn infants from birth through hospital discharge. A total of 717 cocaine-exposed infants and 7442 nonexposed infants participated in a multi-site, prospective, randomized study. The authors examined results of physical examination and conditions observed during hospitalization. The study found that cocaine-exposed infants were about 1.2 weeks younger, weighed 536 g less, measured 2.6 cm shorter, and had head circumference 1.5 cm smaller than nonexposed infants. Results did not confirm previously reported abnormalities. Central and autonomic nervous system symptoms were more frequent in the exposed group: jittery/tremors, high-pitched cry, irritability, excessive suck, hyperalertness, and autonomic instability. No differences were detected in organ systems by ultrasound examination. Exposed infants had more infections, including hepatitis, syphilis, and human immunodeficiency virus exposure; were less often breastfed; had more child protective services referrals; and were more often not living with their biological mother. The authors conclude that central and autonomic nervous system symptoms were more frequent in the exposed cohort and persisted in an adjusted analysis. They were usually transient and may be a true cocaine effect. Abnormal anatomic outcomes previously reported were not confirmed. increased infections, particularly sexually transmitted diseases, pose a serious public health challenge. Exposure increased involvement of child protective services and out-of-home placement.

Belcher, H.M.E, Butz, A.M., Wallace, P., Hoon, A.H., Reinhardt, E., Reeves, S.A., & Pulsifer, M.B. (2005). Spectrum of early intervention services for children with intrauterine drug exposure. Infants and Young Children, 18(1), 2-15.

Intrauterine illicit drug exposure may lead to a variety of adverse neurobehavioral and neurodevelopmental outcomes. Providing early intervention to reduce the impact of maternal substance abuse on the developing fetus may have significant benefits for the child and family. This article highlights three different approaches utilized by programs to provide early intervention and improve the well-being of parents for parents who have a history of drug dependence and their children. The initiation of these programs spans from pregnancy through early childhood. All three programs are community-based, using comprehensive culturally relevant developmental models. The first program, Project STRIVE (Support, Trust, Rehabilitation, Initiative, Values, and Education), provided onsite comprehensive substance abuse treatment, intensive center- and home-based social work, and parent education care for pregnant women with drug dependence and their newborns. The second program, the Early Infant Transition Center, enrolled newborns with a history of neonatal abstinence syndrome and their mothers and provided 24-hour nursing care, oncall physicians and nurse practitioners, social workers, parent education, and onsite sleeping accommodation for parents during their infant’s recovery. The third program, Home-U-Go Safely, used community-based nurses to give home-based health monitoring, education, and support to new mothers with a history of cocaine and/or opiate dependence. Data collected from these programs showed significant improvements in maternal/caregiver and child outcomes such as improved parent knowledge, decreased parental stress and better perceptions of their children’s behavior, improved neonatal birth growth parameters including weight and head circumference. The authors point out that interventions for children with intrauterine drug exposure require a comprehensive culturally relevant family-oriented approach. Intervention strategies which address the multiple needs of the drug-dependent mother and the child have the greatest promise in improving overall outcomes.

Berger, L.M, & Waldfogel, J. (2000). Prenatal cocaine exposure: Long-run effects and policy implications. Social Service Review, 74(1), 28-54.

This article reviews the literature regarding prenatal cocaine exposure and child development. The authors reexamine current child welfare policies in light of that literature, paying particular attention to laws that mandate reporting substance-exposed newborns and substance use during pregnancy as well as policies that view such reports as prima facie evidence of child maltreatment The authors also reassess the utility of such policies, given the current knowledge of the long-term effects of prenatal exposure, and consider alternative approaches to protecting children who are born to parents who are using crack cocaine.

Burry, C.L., & Wright, L. (2006). Facilitating visitation for infants with prenatal substance exposure. Child Welfare, 85(6), 899-918.

Permanency planning for infants with prenatal substance exposure is challenging due to characteristics of the infants and the ongoing substance use or relapse of the parents. Visitation is a primary mechanism through which child welfare workers determine and support permanency planning. This article addresses the use of visitation as a child welfare intervention when a child with prenatal substance exposure is in out-of-home care, and discusses special issues in providing such intervention. Productive use of visitation for permanency planning for infants with prenatal substance exposure is described, along with strategies for skillfully focusing visits on issues and needs relevant to this population. The authors suggest that although substance use is a critical factor in planning, it cannot be the deciding factor in decision making about permanency. The authors state that the child welfare service of visitation is the primary mechanism through which workers normally deal with issues such as psychological or emotional reactions to separation, improvement of parenting skills, sharing information, and determining and supporting permanency planning. The authors conclude that visitation is no less important when substances are involved and the productive use of visitation for permanency planning depends on workers understanding of how substance use affects the dynamics of visitation and skillfully focusing visits on issues and needs that are particularly relevant to this population.

Chasnoff, I. (2001). The nature of nurture: Biology, environment, and the drug-exposed child. Chicago: National Training Institute Publishing.

The health consequences for children exposed to alcohol, cocaine, and other drugs are enormous, but the implications for behavior and learning are even greater. This book explores the biological and environmental factors that impact the ultimate development of drug-exposed children and presents practical strategies for helping children reach their full potential at home and in the classroom. In particular, this book addresses risk and protective factors in the life of a child; fetal alcohol syndrome; drugs, pregnancy, and the growing child; understanding children’s behavior; a theoretical basis for behavioral change; developing an intervention strategy; and the problem-solving process for behavior management.

Davies, J.K., & Bledsoe, J.M. (2005). Prenatal alcohol and drug exposures in adoption. Pediatric Clinics of North America, 52(5), 1369-1393.

Families choosing to adopt domestically or internationally are faced with the possibility of prenatal substance exposure for their child. As more families turn to medical providers for consultation before adoption, the challenge of accurately identifying risk factors (such as prenatal substance exposure) for poor medical or cognitive outcomes becomes paramount. Although accurate data from the pregnancy history are crucial to helping medical professionals assess the risk of adverse neurodevelopmental outcomes in waiting children, these data are frequently not available at the time of a preadoptive medical review. Even with prenatal history available, it is extremely difficult to disentangle the consequences of prenatal substance exposure from the frequent comorbidities of prematurity, malnutrition, neglect, abuse, multiple placements, or institutional deprivation as discussed elsewhere in this issue. In addition, prenatal exposure to potentially harmful substances often occurs in the context of social dysfunction: poverty, parental addiction, impaired parenting, and poor access to services. A family history of mental illness or learning disabilities is often present, which can carry additional genetic risk for adoptees. This article addresses the major potential prenatal substance exposures for children joining families by adoption or, indeed, by birth: alcohol, opiates, tobacco, marijuana, cocaine, and methamphetamines. For each substance, the authors review the teratogenicity of the exposure and identify the spectrum of neurodevelopmental issues that can present in children exposed to this substance. Diagnosis of the spectrum of fetal alcohol outcomes is also discussed. When possible, the authors provide country-specific statistics on exposure risks for adopted children.

Day, N.L., Goldschmidt, L., & Thomas, C.A. (2006). Prenatal marijuana exposure contributes to the prediction of marijuana use at age 14. Addiction, 101(9), 1313-1322.

The purpose of this study was to evaluate the effects of prenatal marijuana exposure (PME) on the age of onset and frequency of marijuana use among 14-year-olds. In this longitudinal cohort study, women were recruited in their fourth prenatal month from a hospital-based prenatal clinic. Women and children were followed throughout pregnancy and at multiple time-points into adolescence. The women ranged in age from 18 to 42, half were African American and half Caucasian, and most were of lower socio-economic status. The women were generally light to moderate substance users during pregnancy and subsequently. At 14 years, 580 of the 763 offspring-mother pairs (76%) were assessed regarding socio-demographic, environmental, psychological, behavioral, biological and developmental factors. A total of 563 pairs (74%) were included in this analysis. Outcomes were age of onset and frequency of marijuana use at age 14. PME predicted age of onset and frequency of marijuana use among the 14-year-old offspring. This finding was significant after controlling for other variables including the child's current alcohol and tobacco use, pubertal stage, sexual activity, delinquency, peer drug use, family history of drug abuse and characteristics of the home environment including parental depression, current drug use and strictness/supervision. The authors conclude that prenatal exposure to marijuana, in addition to other factors, is a significant predictor of marijuana use at age 14.

Derauf, C., L. L. LaGasse, et al. (2007). "Demographic and Psychosocial Characteristics of Mothers Using Methamphetamine During Pregnancy: Preliminary Results of the Infant Development, Environment, and Lifestyle Study (IDEAL)." The American Journal of Drug and Alcohol Abuse 33(2): 281.

This study describes the psychological characteristics and caretaking environments of 131 women enrolled in the first longitudinal study of prenatal methamphetamine (MA) exposure and child development. Prenatal MA use was associated with lower maternal perceptions on quality of life, greater likelihood of substance use among family and friends, increased risk for ongoing legal difficulties, and a markedly increased likelihood of developing a substance abuse disorder. Our preliminary findings suggest that MA using women are more likely to have multiple, intertwined psychosocial risks that may result in maladaptive parenting and caregiving. These factors may impact the developmental outcomes of affected children. [PUBLICATION ABSTRACT]

Effects of prenatal alcohol exposure on hippocampal volume, verbal learning, and verbal and spatial recall in late childhood. (2008). Journal of the International Neuropsychological Society, 14(6), 1022-1033.

Children with prenatal alcohol exposure (PAE) show deficits in verbal learning and spatial memory, as well as abnormal hippocampal development. The relationship between their memory and neuroanatomic impairments, however, has not been directly explored. Given that the hippocampus is integral for the synthesis and retrieval of learned information and is particularly vulnerable to the teratogenic effects of alcohol, we assessed whether reduced learning and recall abilities in children with fetal alcohol spectrum disorders (FASDs) are associated with abnormal hippocampal volumes. Nineteen children with FASDs and 18 typically developing controls aged 9 to 15 years were assessed for verbal learning and verbal and spatial recall and underwent structural magnetic resonance imaging. Images were analyzed for total intracranial volume and for right and left hippocampal volumes. Results revealed smaller left hippocampi and poorer verbal learning and verbal and spatial recall performance in children with FASDs than controls, as well as positive correlations between selective memory indices and hippocampal volumes only in the FASD group. Additionally, hippocampal volumes increased significantly with age in controls only, suggesting that PAE may be associated with long-term abnormalities in hippocampal development that may contribute to impaired verbal learning and verbal and spatial recall.

Hyter, Y. D. (2007). "Understanding children who have been affected by maltreatment and prenatal alcohol exposure." Language Speech and Hearing Services in Schools 38(2): 93-98.

This prologue introduces an important topic for multiple disciplines involved with children and their families. This introduction includes a review of some of the current literature on the effects of maltreatment and prenatal alcohol exposure on child development, an explanation of why this topic is essential learning for communication professionals, prevalence figures for the occurrence of these effects, and a summarization of the articles that have been contributed by a cross section of researchers from various disciplines.

Minnes, S., Singer, L. T., Humphrey-Wall, R., & Satayathum, S. (2008). Psychosocial and behavioral factors related to the post-partum placements of infants born to cocaine-using women. Child Abuse & Neglect, 32(3), 353-366.

OBJECTIVE One objective was to determine if cocaine-using women who did not maintain infant custody (NMC) would report more psychological distress, domestic violence, negative coping skills, lower social support and more childhood trauma than cocaine-using women who maintained custody (MC) of their infant. A second objective was to evaluate the relative contribution of psychosocial factors to infant placement. METHODS Psychosocial profiles of MC women (n = 144) were compared with NMC (n = 66) cocaine-using women. Subjects were low income, urban, African-American women who delivered an infant at a county teaching hospital. The Brief Symptom Inventory (BSI), an assessment of coping strategies (COPE), Multidimensional Scale of Perceived Social Support (MSPSS), Conflict Tactics Scale (CTS) and Childhood Trauma Questionnaire (CTQ) were administered. The associations of infant placement status to demographic factors, drug use and psychosocial measures were evaluated. RESULTS The NMC group reported greater overall psychological distress, psychoticism, somatization, anxiety and hostility than the MC group. The NMC group had more childhood neglect and physical abuse and used more negative coping strategies than the MC group. Lack of prenatal care [OR = .83, CI (.75–.91), p < .0001], heavier prenatal cocaine use [OR = 2.55, CI (1.13–4.34), p < .007], greater psychological distress [OR = 2.21, CI (1.13–4.34), p < .02] and a childhood history of emotional neglect [OR = 1.10, CI (1.02–1.19), p < .02] were associated with increased likelihood of loss of infant custody after control for other substance use and demographic variables. CONCLUSIONS NMC women have more negative psychological and behavioral functioning post-partum than MC women. Less prenatal care and greater cocaine use, psychological distress and maternal childhood emotional neglect are associated with the post-partum placement of infants born to cocaine-using women. PRACTICE IMPLICATIONS Results of this study indicate that poor, urban women who use cocaine prenatally display several measurable differences on psychosocial and behavioral risk factors based on child placement status. Among these risk factors heavier cocaine use, lack of prenatal care, more severe psychological symptoms and early childhood experiences of emotional neglect increase the likelihood of loss of infant custody. Routine, objective assessments of psychosocial and behavioral characteristics of women who use cocaine during pregnancy can aid Child Protective Service workers and clinicians by providing baseline data from which to tailor interventions and set improvement criteria for mother-child reunification. [PUBLICATION ABSTRACT]

Nordstrom Bailey, B., Sood, B.G., Sokol, R.J., Ager, J., Janisse, J., Hannigan, J.H., et al. (2005). Gender and alcohol moderate prenatal cocaine effects on teacher-report of child behavior. Neurotoxicology & Teratology, 27(2), 181-190.

Prenatal cocaine exposure has been associated with behavior problems at school age. Cocaine use during pregnancy is often associated with alcohol use, making it difficult control for the effects of multiple substances. In addition, child gender-specific effects are not typically reported. Thus, the purpose of the current study was to determine the degree to which gender-specific effects of prenatal cocaine exposure on teacher-reported child externalizing behavior problems were evident when evaluated in relation to prenatal alcohol exposure. Subjects were single birth infants of mothers who were prospectively evaluated during pregnancy. At age seven, 499 children (214 exposed prenatally to cocaine) were evaluated in our laboratory and teacher reports were solicited. Results revealed that among boys with prenatal alcohol exposure, co-occurring prenatal cocaine exposure was associated with increased levels of teacher reported externalizing behavior, particularly delinquent behavior. Boys with any prenatal cocaine exposure were twice as likely as unexposed boys to have clinically significant externalizing behavior scores. For girls, prenatal cocaine exposure only was associated with increased levels of externalizing behaviors and aggressive behavior. In contrast, the authors found no evidence of a externalizing behavior effect for girls with prenatal alcohol exposure only. The current findings support gender- and alcohol-moderated effects of prenatal cocaine exposure on school-age teacher-reported child behavior problems. These findings are consistent with other studies that have suggested that behavior of boys is more likely to be negatively impacted by prenatal and postnatal environmental influences than the behavior of girls.

Riley, E.P., & McGee, C.L. (2005). Fetal alcohol spectrum disorders: An overview with emphasis on changes in brain and behavior. Experimental Biology and Medicine, 230(6), 357-365.

Fetal alcohol spectrum disorders constitute a major public health problem. This article presents an overview of important issues that surround these disorders and emphasizes the structural and neurobehavioral consequences associated with prenatal exposure to alcohol. Diagnostic criteria are discussed, and possible moderating factors for the range of outcomes are mentioned. In addition, the prevalence of fetal alcohol spectrum disorders is described, and estimates of the financial impact of these disorders are given. Heavy prenatal alcohol exposure can severely affect the physical and neurobehavioral development of a child. A wide range of neuropsychological deficits have been found in children prenatally exposed to alcohol, including deficits in visuospatial functioning, verbal and nonverbal learning, attention, and executive functioning. These children also exhibit a variety of behavioral problems that can further affect their daily functioning. Children exposed to alcohol prenatally, with and without the physical features of fetal alcohol syndrome, display qualitatively similar deficits. Determining the behavioral phenotypes that result from heavy prenatal alcohol exposure is critical, because the identification of these children is crucial for early interventions. In addition, knowing which brain areas are involved might enable the development of better intervention strategies. However, intervention needs to go beyond the affected individual to prevent future cases. As evidenced by the staggering financial impact these disorders have on society, prevention efforts need to be aimed at high-risk groups, and this issue needs to be made a high priority in terms of public health.

Schiller, C., & Allen, P.J. (2005). Follow-up of infants prenatally exposed to cocaine. Pediatric Nursing, 31(5), 427-436.

Maternal cocaine use during pregnancy continues to be of great concern for health care professionals. Research in this area has increased as investigators examine the effects of prenatal cocaine exposure in the infant/young child. This paper reviews the literature, identifies the primary care needs of infants and young children with a known history of prenatal cocaine exposure, and presents guidelines for the primary care practitioner to monitor the infant's physiologic and developmental sequelae during the first 3 years of life. Findings in the literature demonstrate inconsistencies in regard to the physiologic and developmental outcomes of infants/young children prenatally exposed to cocaine. The authors conclude that further research is warranted, as it is evident from studies that not all investigators are controlling for confounding variables such as poly-drug use, which is necessary in isolating cocaine's effects. Subtle effects, however, have been reported from well-controlled studies and, thus, particular attention needs to be paid to early identification and interventions by primary care practitioners to prevent negative health outcomes. The guidelines proposed assist the practitioner with a thorough and focused approach to assessing the physiologic and developmental effects that are currently known to occur in the infant/young child prenatally exposed to cocaine.

Shankaran, S., Lester, B.M., Das, A., Bauer, C.R., Bada, H.S., Lagasse, L., & Higgins, R. (2007). Impact of maternal substance use during pregnancy on childhood outcome. Seminars in Fetal Neonatal Medicine, 12(2), 143-150.

The impact of maternal substance abuse is reflected in the 2002-2003 National Survey on Drug Use and Health. Among pregnant women in the 15-44 age group, 4.3%, 18% and 9.8% used illicit drugs, tobacco and alcohol, respectively. Maternal pregnancy complications following substance use include increases in sexually transmitted disorders, placental abruption and HIV-positive status. Effects on the neonate include a decrease in growth parameters and increases in central nervous system and autonomic nervous system signs and in referrals to child protective agencies. In childhood, behavioral and cognitive effects are seen after prenatal cocaine exposure; tobacco and alcohol have separate and specific effects. The ongoing use of alcohol and tobacco by the caretaker affects childhood behavior. Therefore, efforts should be made to prevent and treat behavioral problems as well as to limit the onset of drug use by adolescent children born to women who use drugs during pregnancy.

Smith, L.M., LaGasse, L.L., Derauf, C., Grant, P., Shah, R., Arria, A., et al. (2006). The Infant Development, Environment, and Lifestyle Study: Effects of prenatal methamphetamine exposure, polydrug exposure, and poverty on intrauterine growth. Pediatrics, 118(3), 1149-1156.

Methamphetamine use among pregnant women is an increasing problem in the United States. Effects of methamphetamine use during pregnancy on fetal growth have not been reported in large, prospective studies. This study examined the neonatal growth effects of prenatal methamphetamine exposure in the multicenter, longitudinal Infant Development, Environment and Lifestyle (IDEAL) study. The IDEAL study screened 13 808 subjects at 4 clinical centers: 1618 were eligible and consented, among which 84 were methamphetamine exposed, and 1534 were unexposed. The authors found that the methamphetamine exposed group was 3.5 times more likely to be small for gestational age than the unexposed group. Mothers who used tobacco during pregnancy were nearly 2 times more likely to have small-for-gestational-age infants. In addition, less maternal weight gain during pregnancy was more likely to result in a small-for-gestational-age infant. Birthweight in the methamphetamine exposed group was lower than the unexposed group. These findings suggest that prenatal methamphetamine use is associated with fetal growth restriction after adjusting for covariates. Continued follow-up will determine if these infants are at increased risk for growth abnormalities in the future.

Sood, B.G., Nordstrom Bailey, B., Covington, C., Sokol, R.J., Ager, J., Janisse, J., et al. (2005). Gender and alcohol moderate caregiver reported child behavior after prenatal cocaine. Neurotoxicology & Teratology, 27(2), 191-201.

The concurrence of prenatal alcohol exposure with other drug exposure, low socioeconomic status and environmental risk factors may obscure associations, if any, between prenatal cocaine exposure and child outcomes. This study evaluates the effects of prenatal cocaine exposure on child behavior in a sample of 506 mothers and their children. Maternal alcohol, cigarette, and illicit drug use were assessed pre- and postnatally. Caregiver report of child behavior was assessed with the Achenbach Child Behavior Checklist. The authors found girls prenatal exposed to cocaine only had higher rates of adverse behavioral outcomes on caregiver reported child behaviors, such as externalizing (i.e., aggression), internalizing, and attention problems. No differences were found for boys prenatally exposed to cocaine only. Girls and boys with both prenatal cocaine and alcohol exposure had higher scores on delinquent behavior. Maternal age, cigarette and alcohol exposure during pregnancy, and current drug use were increased with prenatal cocaine exposure. In addition, children with any prenatal cocaine exposure were less likely to have consistently been in the custody of their biologic mother. These results emphasize the need for collection of longitudinal data to follow the effects of prenatal exposure in children. The manifestations of prenatal cocaine exposure are likely to change with the development of the child and are probably different in adolescents.

Wobie, K., Eyler, F.D., Garvan, G.W., Hou, W., & Behnke, M. (2004). Prenatal cocaine exposure: An examination of out-of-home placement during the first year of life. Journal of Drug Issues, 34(1), 77-94.

This paper presents basic placement issues for infants at risk for out-of-home placement by describing the postnatal living arrangements of a group of cocaine-exposed infants and a matched control group of nonexposed infants during their first year of life. Descriptions of birth mothers include demographic data, substance use, social support, life events, and other psychosocial measures as reported by the mothers during the prenatal period, and obstetrical history and outcomes, including birth outcomes of the infants. Risk factors for infant placement outside of the maternal home are identified. Of this predominantly African-American, low socioeconomic status, multiparous cohort, 46% of the women who used cocaine prenatally had infants in out-of-home placement at some time during the first year of life. More positive life experiences and higher education significantly improved the potential of retaining custody. Depression had a small but significant negative effect on the possibility of maintaining custody. The prenatal and post-partum period is an important time to provide services that encourage substance abuse recovery and associated factors of stability that facilitate an intact mother-infant dyad. This study reinforces the idea that the pregnancy and postpartum period presents an opportunity for physicians and other medical practitioners to engage in more extensive interviewing of at-risk patients in order to identify and refer users as early as possible to substance abuse treatments and services. This proactive approach creates an opportunity for more women to receive help for their substance use and psychosocial problems and may decrease the likelihood of mother-infant separation.

Children of Substance Abusers

Conners, N.A., Bradley, R.H., Mansell, L.W., Liu, J.Y., Roberts, T.J., Burgdorf, K., et al. (2004). Children of mothers with serious substance abuse problems: An accumulation of risks. American Journal of Drug and Alcohol Abuse, 30(1), 85-100.

The purpose of this study was to offer some insight into the life circumstances and experiences of a large group of children affected by maternal addiction. The study addresses the characteristics of their caregivers, the multiple risk factors faced by these children, their health and development, and their school performance. Data were collected from mothers at intake into 50 publicly funded residential substance abuse treatment programs for pregnant and parenting women. Findings from this study suggest that children whose mothers abuse alcohol or other drugs confront a high level of risk and are at increased vulnerability for physical, academic, and social-emotional problems. Children affected by maternal addiction are in need of long-term supportive services. Programs are needed to fully address the fully array of immediate, transitional, and long-term needs of these children as individuals or members of a family. Treating the complex needs of children requires a team of professionals that extends well beyond the kind of team found in a traditional treatment setting.

Harwin, J. (2008). Focusing on parental and young people's substance misuse: Exploring the links. Child Abuse Review, 17(6), 365-370.

The author reflects on the issue of parental substance misuse and the effect that it has on young children. The author argues that this is an important subject to look into for a number of reasons, including the growth of research in the field, the types of harm that parental substance misuse has on childhood development and the impact this issue has on child welfare services. The article references various changes that have taken place in the fields of health and social services in order to integrate parental substance misuse.

Office of Applied Studies (2003, June). The NHSDA report: Children living with substance-abusing or substance-dependent parents. Rockville, MD: Substance Abuse and Mental Health Services Administration. Available online at: http://www.oas.samhsa.gov/2k3/children/children.cfm

This brief report is based on SAMHSA’s National Household Survey on Drug Abuse, which is the primary source of information on the prevalence, patterns, and consequences of drug and alcohol use and abuse in the general U.S. civilian non institutionalized population, age 12 and older. This report focuses on biological, step, adoptive, and foster children younger than 18 years of age who were living with one or both parents at the time of the survey interview. This report found that in 2001, more than 6 million children lived with at least one parent who abused or was dependent on alcohol or an illicit drug during the past year. Past year substance abuse or dependence by parents involved approximately 10 percent of children aged 5 or younger. Among parents who lived with one or more children, fathers were more likely than mothers to abuse or be dependent on alcohol or an illicit drug.

VanDeMark, N.R., Russell, L.A., O’Keefe, M., Finkelstein, N., Noether, C.D., & Gampel, J.C. (2005). Children of mothers with histories of substance abuse, mental illness, and trauma. Journal of Community Psychology, 33(4), 445-459.

Children exposed to parental substance abuse, mental illness, and violence face profound challenges, including increased risk for emotional and behavioral problems, substance abuse, and victimization. In this article, the authors describe the characteristics of a sample of children of women entering treatment. The children had been exposed to domestic violence, frequent child welfare involvement, and residential instability. Parental entry into treatment affords treatment providers an opportunity to intervene early with these children, enabling them to offer supportive and preventive services and to help children build skills to avoid problems later. Treatment providers are encouraged to offer assessment and services to children of parents entering treatment, capitalizing oil the opportunity to intervene early with a group of children who are at risk for problems with significant individual and social consequences.

Family Treatment, Evidence-Based Practices and Related Issues

Center for Substance Abuse Treatment. (2004). Substance abuse treatment and family therapy. Treatment Improvement Protocol (TIP) Series, No. 39. DHHS Publication No. (SMA) 04-3957. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Family therapy has a long and solid history within the broad mental health field. Substance abuse treatment, on the other hand, developed in considerable isolation. This TIP represents advice on how both fields can profit from an understanding and incorporating the methods and theories of the other field. The primary audience for this TIP is substance abuse treatment counselors; family therapists are a secondary audience. This TIP addresses how substance abuse affects the entire family and how substance abuse treatment providers can use principles from family therapy to change the interactions between family members. Basic information about family therapy for substance abuse treatment professionals and basic information about substance abuse for family therapists is provided. The TIP presents the models, techniques, and principles of family therapy, with special attention to the stages of motivation as well as to treatment and recovery. Discussion also focuses on clinical decision-making and training, supervision, cultural considerations, special populations, funding, and research. The TIP concludes with policy and program issues for administrators and trainers to consider for effectively joining family therapy and substance abuse treatment.

Diamond, G., & Josephson, A. (2005). Family-based treatment research: A 10-year update. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9), 872-887.

This article provides an update on the state of the art of family-based treatment research. The authors reviewed randomized clinical trials conducted in the past 10 years that included parents as a primary participant in treatment of child and adolescent psychiatric problems. Studies were identified from major literature search engines and current significant pilot work was identified in the National Institute of Mental Health Computer Retrieval of Information on Scientific Projects Web page or from the authors themselves. The results indicate that family treatments have proven effective with externalizing disorders, particularly conduct and substance abuse disorders, and in reducing the comorbid family and school behavior problems associated with attention-deficit/hyperactivity disorder. In addition, several new studies suggest that family treatments or treatment augmented by family treatments are effective for depression and anxiety. The authors conclude that for many disorders, family treatments can be an effective stand-alone intervention or an augmentation to other treatments. They state that engaging parents in the treatment process and reducing the toxicity of a negative family environment can contribute to better treatment engagement, retention, compliance, effectiveness, and maintenance of gains. Lastly, recommendations for the next decade of research and some implications of family-based treatment for child and adolescent psychiatry are explored.

Jackson., V. (2004). Residential treatment for parents and their children: The Village experience. NIDA Science & Practice Perspectives, 2(2), 44-53. Available at: http://www.drugabuse.gov/PDF/Perspectives/vol2no2/05Perspectives-Residential.pdf

The Village South, Inc., in Miami, Florida, offers comprehensive substance abuse treatment and prevention services to adults, adolescents, and children. The Village’s Families in Transition (FIT) program, launched in the early 1990s as one of the Nation’s first 11 federally funded programs for women with children, has provided services to nearly 800 parents and approximately 2,000 children. This article discusses the philosophy behind FIT’s family focused residential treatment program, characterizes its participants, describes its challenges and successes, and points out research needs that have come to light through experience with mothers and children in treatment.

McComish, J.F., Greenberg, R., Ager, J., Essenmacher, L., Orgain, L.S., & Bacik, W.J. (2003). Family-focused substance abuse treatment: A program evaluation. Journal of Psychoactive Drugs, 35(3), 321-331.

Until recently, few programs were available for children whose mothers are in recovery. A refinement of the gender-specific model of substance abuse treatment, the "family-focused" approach, has placed increased emphasis on the needs of children and other family members. However, because these programs are relatively new, little is known about the effectiveness of this type of treatment for either the mother or her children. This article presents findings from a three-year evaluation of a family-focused residential treatment program for women and their children. Longitudinal assessment of the mothers indicated that their psychosocial status and parenting attitudes improved over time. Additionally, the mothers remained in treatment longer. At intake, as a group, the children who were birth to three years of age did not exhibit developmental delay. However, developmental concerns were identified for some children in the areas of motor and/or language development. The results reported here provide beginning evidence that family-focused treatment improves retention, psychosocial functioning, and parenting attitudes of pregnant and parenting women. They also support the evidence that having children on site improved retention in treatment for pregnant and parenting women, as well as self-esteem, depression, and parenting. This study also provides a mechanism for early identification and intervention for children.

Moore, J., & Finkelstein, N. (2001). Parenting services for families affected by substance abuse. Child Welfare, 80(2), 221-238.

This article describes the development, implementation, and replication of a group-based parenting program for families affected by substance abuse, the Nurturing Program for Families in Substance Abuse Treatment and Recovery. Developed as a result of a federally funded demonstration project for pregnant and parenting women in substance abuse treatment, this program represents significant changes in substance abuse treatment services and increases the ability of child welfare and substance abuse service systems to coordinate service planning. Preliminary results indicate that this program improves parenting, as measured on objective scales; enhances parents' satisfaction and competence, as measured by participant reports; and is based on principles demonstrated to be effective in reducing risk of both child abuse and neglect and substance abuse for both parents and children. The Nurturing Program for Families in Substance Abuse Treatment and Recovery was designed to be easily adapted to the needs of different agencies and client populations. The development of a parenting program specifically for families affected by substance abuse enhances opportunities for substance abuse and child welfare systems to work together for the families they both serve. This leads to not only greater understanding of each other’s missions and how they are often seen as conflicting with one another, but to the building of more trusting, collaborative relationships across systems.

O'Farrell, T. J., Murphy, M., Alter, J., & Fals-Stewart, W. (2008). Brief family treatment intervention to promote aftercare among substance abusing patients in inpatient detoxification: Transferring a research intervention to clinical practice. Addictive Behaviors, 33(3), 464-471.

Two earlier studies showed that a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification increased aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member with whom the patient lived to review aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Based on the earlier research results, we trained a newly hired staff person to continue providing BFT. We monitored key process benchmarks derived from the earlier research studies to ensure ongoing fidelity in delivering BFT. This method proved successful in transferring BFT from delivery in a research study to ongoing delivery in routine clinical practice after the research ended. It also ensured that a high proportion of patients had their families contacted and included in planning the patients' aftercare. [PUBLICATION ABSTRACT]

Suchman, N., DeCoste, C., Castiglioni, N., Legow, N., & Mayes, L. (2008). The Mothers and Toddlers Program: Preliminary findings from an attachment-based parenting intervention for substance-abusing mothers. Psychoanalytic Psychology, 25(3), 499-517.

The authors examined pilot data from an attachment-based parenting intervention for substance-abusing mothers of toddlers (ages 12-36 months). The Mothers and Toddlers Program (MTP) is a 20-week individual therapy intervention that aims to help mothers develop more balanced representations of their children and improve their capacity for reflective functioning (i.e., recognition of the intentional nature of children's behavior). The authors hypothesized that improvement in maternal representational balance and maternal capacity for reflective functioning would correspond with improvements in maternal behavior with toddlers (e.g., sensitivity to cues, responsiveness to distress, and social-emotional growth fostering) and reduction in maternal psychiatric distress and substance abuse. Eight mothers who completed MTP showed moderate improvements in representational balance and reflective functioning, and these changes corresponded with significant improvements in maternal behaviors with toddlers. The authors also compared MTP completers and noncompleters on sociodemographic and psychosocial indexes and examined the validity of the intervention's proposed mechanisms of change. Preliminary findings support the importance of attachment mechanisms and indicate that attachment-based interventions may strengthen substance-abusing mothers' capacities to foster their toddlers' socioemotional development. [PUBLICATION ABSTRACT]

Worley, L.L.M., Conners, N.A., Crone, C.C., Williams, V.L., & Bokony, P.A. (2005). Building a residential treatment program for dually diagnosed women with their children. Archives of Women's Mental Health, 8(2), 105-111.

The epidemic of drug and alcohol abuse in our nation impacts millions of women, mothers, and children. Addicted mothers with complex problems and numerous co-morbidities present unique treatment challenges. This intergenerational cycle of abuse and addiction is difficult to stop. Arkansas CARES (Center for Addictions Research Education and Services, referred to in this article as CARES) initially was created to treat addicted pregnant and postpartum women and their infants. CARES evolved into a residential treatment program for dually diagnosed mothers with their children. The purpose of this study is to share a glimpse inside the treatment program and lessons learned along the way in an effort to assist others who are interested in building treatment programs for addicted women with their children.

Childhood Abuse and Trauma

Boles, S.M., Joshi, V., Grella, C., & Wellisch, J. (2005). Childhood sexual abuse patterns, psychosocial correlates, and treatment outcomes among adults in drug abuse treatment. Journal of Child Sexual Abuse, 14(1), 39-55.

This study reports on the effects of having a history of childhood sexual abuse (CSA) on treatment outcomes among substance abusing men and women (N = 2,434) in a national, multi-site study of drug treatment outcomes. A history of CSA was reported by 27.2% of the women and 9.2% of the men. Patients reporting CSA were younger at entry into the current drug treatment, were more likely to be White, were more likely to have a comorbid mental disorder, be alcohol or cocaine dependent, had higher levels of criminal activities, had a higher level of problem recognition, and had a more negative peer influence than patients without CSA. A history of abuse was also related to a lower likelihood of post-treatment abstinence. High concentrations of adults with abuse histories indicate that drug treatment represents an opportunity for targeted intervention strategies to address the often traumatic experiences associated with abuse, and the link between these abusive strategies and drug use.

Brems, C., Johnson, M.E., Neal, D., & Freemon, M.. (2004). Childhood abuse history and substance use among men and women receiving detoxification services. American Journal of Drug and Alcohol Abuse, 30(4), 799-821.

The current study was designed to shed additional light on the link of childhood victimization and subsequent substance use and psychological adjustment among men and women receiving detoxification services at a large, comprehensive substance abuse treatment center in the Northwestern United States. Specifically, this study assesses the link between childhood sexual and physical abuse and subsequent life adjustment via the following variables: type and severity of substance use, psychological symptoms, and criminal behavior. Results revealed 20% of men and more than 40% of women reported childhood physical or sexual abuse. Sexual or physical abuse had negative sequelae, regardless of gender. Individuals with abuse history reported earlier age of onset of drinking, more problems associated with use of alcohol/drugs, more severe psychopathology, and more lifetime arrests, arrests related to substance use, and arrests related to mental health. Given their high reported rates of both types of abuse, especially among women, it appears crucial to screen for abuse histories among individuals seeking detoxification services. Early intervention may be made possible by identifying consumers with such histories early on in their contacts with the substance abuse treatment system and more appropriate treatment planning will ensue. In addition, they will most likely benefit from additional mental health counseling because they have greater psychological distress than individuals without abuse histories. Criminal activity also increases among individuals with abuse histories, making prevention plans in this regard necessary to serve this population appropriately. This is particularly true with regard to criminal activity that occurs under the influence of drugs or alcohol or in the presence of symptoms of mental illness.

Center for Substance Abuse Treatment. (2000). Substance abuse treatment for persons with child abuse and neglect issues. Treatment Improvement Protocol (TIP) Series, No. 36. DHHS Publication No. (SMA) 00-3357. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Research and clinical evidence indicates that physical, sexual, and emotional abuse and neglect during childhood can increase a person’s risk of developing substance abuse disorders. This TIP examines treatment issues for both adult survivors of child abuse and neglect and adults in treatment who may be abusing or neglecting their own children. This TIP does not, however, address the treatment needs of children who are currently being abused or who are abusing substances. Definitions and rates of child abuse and neglect are provided for the general population and among those in substance abuse treatment. There is also a review of the literature on links between childhood abuse and subsequent substance abuse. Screening and assessment tools that can be used to determine whether a client has a history of childhood abuse or neglect are included and guidelines on treating clients with histories of child abuse or neglect are provided. The TIP also discusses the personal issues that counselors may encounter when working with clients with histories of abuse or neglect and offers suggestions for addressing them. Treatment guidelines and an overview of the legal issues that counselors should be aware of as mandated reporters are provided. Also included is an overview of continuing and emerging trends such as fast-track adoption and welfare reform.

Eiden, R.D., Foote, A., & Schuetze, P. (2007). Maternal cocaine use and caregiving status: Group differences in caregiver and infant risk variables. Addictive Behaviors, 32(3), 465-476.

This study examined differences between cocaine and non-cocaine-using mothers, and between parental and non-parental caregivers of cocaine-exposed infants on caregiver childhood trauma, psychiatric symptoms, demographic, and perinatal risks. Participants included 115 cocaine and 105 non-cocaine mother-infant dyads recruited at delivery. Approximately 19% of cocaine mothers lost custody of their infants by 1 month of infant age compared to 0.02% of non-cocaine mothers. Mothers who used cocaine during pregnancy had higher demographic and obstetric risks. Their infants had higher perinatal risks. Birth mothers who retained custody of their infants had higher demographic risks and perinatal risks, higher childhood trauma, and higher psychiatric symptoms compared to birth mothers who did not use cocaine and non-parental caregivers of cocaine-exposed infants. Results highlight the importance of addressing childhood trauma issues and current psychiatric symptoms in substance abuse treatment with women who engaged in substance use during pregnancy.

Felitti, V.J. (2002). The relation between adverse childhood experiences and adult health: Turning gold into lead. The Permanente Journal, 6(1), 44-47. Available online at: http://xnet.kp.org/permanentejournal/winter02/goldtolead.pdf

This article reports on the Adverse Childhood Experiences Study, a long term, in-depth analysis of over 17,000 adult Americans, matching their current health status against adverse childhood experiences that occurred on average a half-century earlier. The study found that adverse childhood experiences are quite common although typically concealed and unrecognized; that they still have a profound effect a half century later, and that they are the main determinant of the health and social well-being of the nation. The findings are of direct importance to the everyday practice of medicine and psychiatry because they indicate that much of what is recognized as common in adult medicine is the result of what is not recognized in childhood. The ACE Study challenges as superficial the current conceptions of depression and addiction, showing them to have a very strong dose-response relationship to antecedent life experiences.

Hyman, S.M., Garcia, M., & Sinha, R. (2006). Gender specific associations between types of childhood maltreatment and the onset, escalation and severity of substance use in cocaine dependent adults. American Journal of Drug and Alcohol Abuse, 32(4), 655-664.

The authors examined associations between types of childhood maltreatment and the onset, escalation, and severity of substance use in cocaine dependent adults. Results indicated that, in men (n = 55), emotional abuse was associated with a younger age of first alcohol use and a greater severity of substance abuse. In women (n = 32), sexual abuse, emotional abuse, and overall maltreatment was associated with a younger age of first alcohol use, and emotional abuse, emotional neglect, and overall maltreatment was associated with a greater severity of substance abuse. There was no association between childhood maltreatment and age of nicotine or cocaine use. However, age of first alcohol use predicted age of first cocaine use in both genders. All associations were stronger in women. Findings suggest that early intervention for childhood victims, especially females, may delay or prevent the early onset of alcohol use and reduce the risk for a more severe course of addiction.

Libby, A.M., Orton, H.D., Novins, D.K., Spicer, P., Buchwald, D., Beals, J., & Manson, S.M. (2004). Childhood physical and sexual abuse and subsequent alcohol and drug use disorders in two American-Indian tribes. Journal of Studies on Alcohol, 65(1), 74-83.

The purpose of this study was to examine the relationship of childhood physical and sexual abuse to subsequent lifetime alcohol or drug use disorders among two American Indian tribes. A sample of 3,084 American Indians participated in a large-scale, community-based study. Participants were asked about traumatic events and family history and were administered standard diagnostic measures of substance use disorders. Prevalence of childhood physical abuse was approximately 7% for both tribes, and childhood sexual abuse was 4%-5%, much higher for females. Childhood physical abuse had a stronger effect than childhood sexual abuse on lifetime substance dependence. Childhood sexual abuse, on the other hand, was more associated with lifetime substance abuse. Females more commonly experienced childhood abuse but were less likely than males to develop substance use disorders. The results provide clinical guidance to constellations of risk factors and expand the population at risk to include males. This study is unique in that it is one of the few that examines tribal and cultural variations among American Indians. The authors provide several observations that would be helpful when developing interventions for this population.

Liebschutz, J., Savetsky, J.B., Saitz, R., Horton, N.J., Lloyd-Travaglini, C., & Samet, J.H. (2002). The relationship between sexual and physical abuse and substance abuse consequences. Journal of Substance Abuse Treatment, 22(3), 121-128.

This study examines the relationship between past physical and sexual abuse and drug and alcohol related consequences. Three hundred fifty-nine male and 111 female subjects were recruited from an urban inpatient detoxification unit. Eighty-one percent of women and 69% of men report past physical and sexual abuse, starting at a median age of 13 and 11, respectively. Physical and sexual abuse was significantly associated with more substance abuse consequences for both men and women. This study reinforces the high rate of physical and sexual abuse among both men and women admitted for detoxification. Thus, future research should develop interventions to lessen the substance abuse consequences of physical and sexual abuse. There is a need for trauma and PTSD assessments among substance abuse clients, and battered women’s shelters should be aware of substance abuse issues among its clients.

Pederson, C. L., Vanhorn, D. R., Wilson, J. F., Martorano, L. M., Venema, J. M., & Kennedy, S. M. (2008). Childhood abuse related to nicotine, illicit and prescription drug use by women: Pilot study. Psychological Reports, 103(2), 459-466.

A sample of 811 women ages 18 to 59 (M=26.0, SD=6.5) responded to an advertisement by telephone. Inquiries were made about childhood abuse status and adult use of alcohol, nicotine, and prescription and illicit drugs. Significant associations were noted for reported sexual, physical, and emotional childhood abuse with use of nicotine, marijuana, and antidepressants in adulthood. Reported childhood physical and emotional abuses were also significantly associated with use of cocaine and anxiolytics, and sexual abuse with antipsychotic use in adulthood. Only childhood emotional abuse was associated with the use of sleeping pills. Number of types of abuse was significantly related with use of nicotine, marijuana, cocaine, antidepressants, antipsychotics, and anxiolytics. Alcohol use was not related to any type of abuse. The long-term effects of childhood emotional abuse may be just as severe as physical or sexual abuse.

Pirard, S., Sharon, E., Kang, S.K., Angarita, G.A., & Gastfriend, D.R. (2005). Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes. Drug and Alcohol Dependence, 78(1), 57-64.

More than half of substance abusers entering addiction treatment report a history of physical or sexual abuse. It is unclear if such a history impacts treatment outcomes. This one-year follow-up study of 700 substance abusers sought to clarify the relationship between lifetime physical and/or sexual abuse and addiction treatment outcome to help address the specific needs of this population. This study found that abused subjects, predominantly women, were significantly more impaired at baseline on clinical dimensions including family/social severity and psychiatric severity as measured by the Addiction Severity Index, and general level of functioning than non-abused subjects. In addition, the abused group less frequently endorsed heroin and cocaine in favor of alcohol and polydrug use. Abused subjects reported more prior medical and psychiatric treatments. Abuse history was not a predictor of no-show for treatment. Over the 1-year follow-up, lifetime physical and/or sexual abuse was significantly associated with worse psychiatric status and more psychiatric hospitalizations and outpatient treatment despite receiving similar intensive addiction treatment. These findings indicate that substance abuse patients with lifetime physical or sexual abuse have worse treatment outcomes than their counterparts. The development of programs that would specifically address the needs of substance abusers with histories of abuse might improve the efficacy and lower the costs of treatment for this population.

Robertson, A. A., Baird-thomas, C., & Stein, J. A. (2008). Child victimization and parental monitoring as mediators of youth problem behaviors. Criminal Justice and Behavior, 35(6), 755-771.

This study examines the effects of family characteristics, parental monitoring, and victimization by adults on alcohol and other drug (AOD) abuse, delinquency, and risky sexual behaviors among 761 incarcerated juveniles. The majority of youth reported that other family members had substance abuse problems and criminal histories. These youth were frequently the victims of violence. Relationships between victimization, parental monitoring, and problem behaviors were examined using structural equation modeling. Monitoring was negatively related to all problem behaviors. However, type of maltreatment was related to specific problem behaviors. The effects of family substance abuse and family criminal involvement on outcomes were mediated by monitoring and maltreatment. The study underscores the need to provide family-focused and trauma-related interventions for juvenile offenders. [PUBLICATION ABSTRACT]

Sprang, G., Staton-Tindall, M., & Clark, J. (2008). Trauma exposure and the drug endangered child. Journal of Traumatic Stress, 21(3), 333-339.

This study examines the differences in trauma exposure and the response to those events between drug endangered children (DEC) and non-drug endangered children involved in the child welfare system. This data represents the experiences of 1,127 children randomly selected from the state's child protective service database and represents 20% of all open cases during 2005–2006. Archival data were analyzed to determine the presence of exposure using DSM-IV-TR posttraumatic stress disorder (PTSD) Criterion A1, and whether or not the child's response to exposure met PTSD Criterion A2. Results reveal high rates of trauma exposure in the DEC group and indicate that trauma exposure and trauma response did significantly vary across groups. Implications for the assessment and treatment of child welfare-involved children are drawn. [PUBLICATION ABSTRACT]

Widom, C.S., Schuck, A.M., & White, H. R. (2006). An examination of pathways from childhood victimization to violence: The role of early aggression and problematic alcohol use. Violence and Victims, 21(6), 675-691.

Using prospective data from a cohort design study involving documented cases of child abuse and neglect and a matched control group, the authors examine two potential pathways between childhood victimization and violent criminal behavior: early aggressive behavior and problematic drinking. Results revealed different pathways for men and women. For men, child maltreatment has direct and indirect (through aggressive behavior and problematic alcohol use) paths to violence. For women, problematic alcohol use mediates the relationship between childhood victimization and violence, and, independent of child maltreatment, early aggression leads to alcohol problems, which lead to violence. The authors suggest that interventions for victims of childhood maltreatment need to recognize the role of early aggressive behavior and alcohol problems as risk factors for subsequent violence.

PREVALENCE AND SYSTEMS PLANNING

Methamphetamine and Children

Asanbe, C. B., Hall, C., & Bolden, C. D. (2008). The methamphetamine home: Psychological impact on preschoolers in rural Tennessee. Journal of Rural Health, 24(3), 229-235.

A growing number of children reside with methamphetamine-abusing parents in homes where the illicit drug is produced. Yet, the effects of a methamphetamine environment on psychological child outcome are still unknown. Purpose: To examine whether preschoolers who lived in methamphetamine-producing homes are at increased risk for developing psychological problems. Methods: The participants were 58 white children between the ages of 4 and 5 years; 31 with a history of living in methamphetamine-producing homes and 27 children who live in non-methamphetamine producing homes in rural Tennessee. The groups were similar in age, gender, and socioeconomic background. The groups were compared for behavioral and emotional adjustment using the behavior assessment system for children-parent rating scale-preschool (BASC-PRS-P) form. Biological or custodian parents completed a rating on their preschoolers that provided information about the children's pattern of behavior and feelings. Findings: Preschoolers from the methamphetamine-producing homes showed more externalizing problems than their peers, but were comparable on internalizing problems. On specific behaviors, the data indicate that preschoolers in the methamphetamine group showed higher aggression symptoms than their peers from non-methamphetamine-producing homes. Conclusions: These findings, if replicated, point to the need for mental health screening when a child is removed from a methamphetamine-producing home. [PUBLICATION ABSTRACT]

Carnevale Associates. (2004, October). Children endangered by methamphetamine: Drug endangered children. Darnestown, MD: Author. Available online at: http://www.carnevaleassociates.com/CAPolBrief-DEC.pdf#search='Carnevale%20Associates%20and%202004%20and%20Children%20endangered'

The growth in methamphetamine production and use has grown significantly over the past decade. As a result significant numbers of children have been endangered due to direct or indirect exposure to methamphetamine or living in a dwelling where methamphetamine is used or manufactured. This policy brief examines the scope of the drug endangered children, damaging effects of methamphetamine lab exposure, the effects on prenatal development, federal help available, State legislative actions, and the National Alliance for Model State Drug Laws. This brief also identifies the need for policies to improve medical protocols, medical research, and awareness and intervention.

Connell-Carrick, K. (2007). "Methamphetamine and the Changing Face of Child Welfare: Practice Principles for Child Welfare Workers." Child Welfare 86(3): 125.

Methamphetamine use and production is changing child welfare practice. Methamphetamine is a significant public health threat (National Institute of Justice, 1999) reaching epidemic proportions (Anglin, Burke, Perrochet, Stamper, & Dawud-Nouris, 2000). The manufacturing of methamphetamine is a serious problem for the child welfare system, yet child welfare has not addressed the needs of children living in homes where methamphetamine is manufactured (U.S. Department of Justice, 2002; DOJ, 2003; Altshuler, 2005). This article presents key issues for child welfare workers related to the use, production, and effects of methamphetamine on children and families, and identifies practice principles for child welfare workers in order to ensure safety for victims, parents, and workers themselves. [PUBLICATION ABSTRACT]

Haight, W., Jacobsen, T., Black, J., Kingery, L., Sheridan, K., & Mulder, C. (2005). “In these bleak days": Parent methamphetamine abuse and child welfare in the rural Midwest. Children and Youth Services Review, 27(8), 949-971.

This report describes the impact of parent methamphetamine abuse on the development and wellbeing of school-aged children, and considers implications for culturally appropriate child welfare services. Thirty-five adult informants from several, adjacent rural Midwestern counties in the United States were interviewed as part of a larger ethnographic study. Child welfare workers, other community professionals (educators, counselors, law enforcement personnel, and substance abuse treatment providers), and foster caregivers described their experiences with families involved with methamphetamine. Overall, informants described that children are brought by their methamphetamine-abusing parents into a rural drug culture characterized by distinct, antisocial beliefs and practices. Children's experience of this culture includes environmental danger, chaos, neglect, abuse, loss, and isolation. Informants believed that children develop antisocial beliefs and practices such as lying, stealing, drug use, and violence through direct teaching by their parents and, indirectly, through observing parents' own antisocial behavior. Informants described children as displaying psychological, social, and educational disturbances. They also described individual variation in functioning across children that they attributed, in part, to individual (e.g., temperament, intelligence), familial (e.g., extended family), and community (e.g., school) characteristics. Informants noted a need for effective child mental health services in the area, and for ensuring a positive environment for children's future development through education of the children, foster parents and other community members. The authors discuss four strategies for enhancing the development of school-aged children whose parents abuse methamphetamine: (1) enhancing education in schools and communities; (2) enhancing timely, child welfare involvement with children of methamphetamine abusers; (3) providing timely access to quality mental health services focused on adequate assessment, trauma, and socialization; and (4) employing culturally and developmentally sensitive intervention practices

Hohman, M., Oliver, R., & Wright, W. (2004). Methamphetamine abuse and manufacture: The child welfare response. Social Work, 49(3), 373-381.

Methamphetamine abuse is on the rise, particularly by women of childbearing age. This article describes the history of methamphetamine, the effects of methamphetamine use, treatment for methamphetamine abuse, and the effects of exposure to methamphetamine during pregnancy. The authors examine the ways exposure to the manufacture of this drug affects clients and social workers in the course of their work. Because children are frequently found at the scene of a manufacturing laboratory, the child welfare system often becomes involved, and child protective services and other social work agencies need protocols on how to recognize home laboratories and on how to address the needs of these children and their parents. In 1997, California created and implemented Drug-Endangered Children's units in seven counties to address the needs of children from families that manufacture methamphetamine; these units involve collaborative efforts among child protective workers, district attorneys, physicians, and police officers. A case example provides information about the role of social workers and their collaboration with these multiple systems.

Ostler, T., W. Haight, et al. (2007). "Case Series: Mental Health Needs and Perspectives of Rural Children Reared by Parents Who Abuse Methamphetamine." Journal of the American Academy of Child and Adolescent Psychiatry 46(4): 500.

Objective: This case-based, mixed-methods study was undertaken to understand the perspectives and mental health needs of rural children exposed to parental methamphetamine abuse. Method: Participants were 23 children involved with a state child protective agency because of parental methamphetamine abuse. A semistructured interview provided information on children's perspectives of their families. Information on children's mental health needs was obtained from the Child Behavior Checklist and Trauma Symptom Checklist. Case records and caseworker reports provided information on children's family experiences. Results: Children described emotional pain; few social resources for coping with emotions, problem solving, or talking about their experiences; and avoidant or passive coping skills. Sixty-five percent of children evidenced significant dissociative or posttraumatic symptoms on standardized assessments; 57% had other significant emotional and behavioral problems. Challenges to understanding children's perspectives included children's perceptions that talking about methamphetamine abuse was taboo and underreporting of significant symptoms on the Trauma Symptom Checklist. Conclusions: The high rate of mental health problems suggests the need for nontraditional strategies for services delivery in rural areas that are targeted toward these vulnerable children. Early identification and treatment of mental health problems should be a priority. Clinicians should be alert to the complexities in assessing children's mental health needs. [PUBLICATION ABSTRACT]

O'Brien, A. M., Brecht, M., & Casey, C. (2008). Narratives of methamphetamine abuse: A qualitative exploration of social, psychological, and emotional experiences. Journal of Social Work Practice in the Addictions, 8(3), 343-366.

Clinicians are increasingly confronted with treating the dramatically growing numbers of methamphetamine (MA) abusers. However, scant research documents the internal experience of MA abuse. This study uses data from ethnographic interviews to describe the development of MA abuse across users' lives. Results show drug initiation emerging from abuse during childhood and parental drug abuse. Respondents entered drug-using peer groups that paradoxically offer both protection from and vulnerability to violence and other problems. Consequences of MA abuse include economic instability and concern with only the acquisition and use of MA, instead of MA-related problems. Understandings of "problematic" drug use emerge as respondents stigmatize users who lack basic resources and hurt others for the sake of money or drugs, and parents whose use interferes with parenting. Respondents describe barriers and alternatives to treatment. Results provide insight into the experience of MA abuse. Theoretical considerations and implications are discussed.

Systems and Policy Issues

Albert, V., Klein, D., Noble, M., Zahand, E., & Holtby, S. (2000). Identifying substance abusing delivering women: Consequences for child maltreatment reports. Child Abuse & Neglect, 24(2), 173-183.

The major objective of this study was to determine how and the extent to which SB2669, which requires the identification of substance abusing delivering women, affected the number of children reported for abuse or neglect in seven high prevalence California counties. The results suggest that the effects of SB2669 on the number of child maltreatment reports are mixed. On an aggregate level, SB2669 is associated with a decrease in child maltreatment reports in two of the participating counties. This decrease may be due to conscientious implementation of the legislation in these counties. This mixed finding is expected mainly because SB2669, although mandated, was never enforced. Moreover, from the process component of the study we learned that the implementation practices of this legislation vary substantially between and even within counties’ hospitals. A decrease in maltreatment reports in the presence of SB2669 is not necessarily the most desirable outcome in the light of what we know about the relationship between substance abuse and child maltreatment. Law makers need to rethink the purpose of the law and provide the necessary language, tools and training to ensure that the goals of identifying substance abusing mothers and their families are met. Provisions also need to be made that somehow enforce this legislation. These provisions could lessen county-level and hospital-level variability in implementing the law.

Arria, A.M., Derauf, C., LaGasse, L.L., Grant, P., Shah, R., Smith, L., et al. (2006, January). Methamphetamine and other substance use during pregnancy: Preliminary estimates from the Infant Development, Environment, and Lifestyle (IDEAL) Study. Maternal and Child Health Journal, 1-10.

Methamphetamine use is a continuing problem in several regions of the United States and yet few studies have focused on prenatal methamphetamine exposure. The purpose of this study was to estimate the prevalence and correlates of alcohol, tobacco, and other substance use-including methamphetamine-during pregnancy. Methods: The sample consisted of the first 1632 eligible mothers who consented to participate in a large-scale multisite study focused on prenatal methamphetamine exposure. This unselected screening sample included both users and nonusers of alcohol, tobacco, methamphetamine, and other drugs. Substance use was determined by maternal self-report and/or GC/MS confirmation of a positive meconium screen. Results indicated that 5.2% of women used methamphetamine at some point during their pregnancy. One quarter of the sample smoked tobacco, 22.8% drank alcohol, 6.0% used marijuana, and 1.3% used barbiturates prenatally. Less than 1% of the sample used heroin, benzodiazepines, and hallucinogens. Tobacco smokers and illicit drug users were more likely to be single and less educated, have attended less than 11 prenatal visits, and utilize public financial assistance. The authors concluded that his is the first large-scale investigation to report the prevalence of methamphetamine use during pregnancy in areas of the United States where methamphetamine is a notable concern and that follow-up research is ongoing to investigate the outcomes associated with prenatal methamphetamine exposure. The authors also concluded that given that this research extends and confirms previous findings showing that high-risk groups of pregnant women can be identified on the basis of basic demographic characteristics, targeted interventions are greatly needed to reduce serious adverse outcomes associated with prenatal alcohol and tobacco use.

Brecht, M.L., Anglin, M.D., & Dylan, M. (2005). Coerced treatment for methamphetamine abuse: Differential patient characteristics and outcomes. American Journal of Drug and Alcohol Abuse, 31(2), 337-356.

Policymakers have responded to the increase in the prevalence of methamphetamine (MA) use and the associated social costs (such as crime and child abuse and neglect) by mandating a growing number of MA users to substance abuse treatment via the criminal justice system (CJS) and/or child protective service (CPS) agencies. However, empirical evidence remains sparse about treatment outcomes specifically for MA users who report that their treatment admission occurred under such pressures. This article assesses the relationship of perceived legal pressure for treatment entry to treatment outcomes for a sample of 350 MA-using clients from a large county publicly-funded substance abuse treatment system. Approximately half the clients reported legal pressure to enter the index treatment episode. Those reporting pressure were younger, less likely to have received residential treatment, and had longer treatment episodes than those not reporting pressure. Outcomes did not differ significantly in simple comparisons between the pressured and nonpressured groups; however, when client and treatment characteristics were controlled, the short term outcome of relapse within 6 months was worse for those reporting legal pressure. Outcomes did not differ by source of pressure. Such results offer optimism for individuals and socially-beneficial outcomes of the growing policy emphasis for substance abuse treatment of MA and other drug users through drug court and other CJS jurisdictions.

Child Welfare Services Stakeholders Group. (2003, September). CWS Redesign: The future of California's child welfare services. Sacramento, CA: California Department of Social Services. Available online at: http://www.cwsredesign.ca.gov/res/pdf/CWSReport.pdf

The Child Welfare Services (CWS) Redesign is the long-term strategic plan that sets in motion a series of actions across the state of California to bring the new vision of child welfare services to every county. The Redesign represents an unprecedented effort to proactively examine what works and what needs improvement about California’s child welfare system. The CWS Redesign objectives include: partnering to prevent child abuse and neglect; acting early to preserve and strengthen families; broadening efforts to restore family capacity; strengthening alternatives to rebuild permanent families for children; systematically preparing youth for success in adulthood; affecting change through workforce excellence; strengthening interagency partnerships at the State and Local levels; expanding and restructuring child welfare financing; and achieving better outcomes through accountability. The Redesign also recognizes that substance abuse has profound effects on child abuse and neglect. In relation to AOD issues, the Redesign proposes strengthening community partnerships, having a differential intake system, workforce investments including cross-training, accountability, and funding reforms. This document includes important information on the implementation of the Redesign, particularly in relation to developing evidence-based AOD practices, and progress on its implementation to date.

Christian, S. (2004, September). Substance-exposed newborns: New Federal law raises some old issues. Washington, DC: National Council of State Legislatures. Available in PDF at http://www.ncsl.org/print/cyf/newborns.pdf.

This paper describes the new federal law, provides an overview of existing state reporting laws, discusses the role of child protective services, and highlights the importance of prevention. State legislators who are called upon to enact legislation to comply with the new CAPTA notification requirement will have an opportunity to re-examine their states’ response to drug and alcohol use by pregnant women, including efforts to identify and treat such women as soon as possible after conception and to provide appropriate services to children who are born exposed to substances in utero. An appendix contains the text of state laws that require reporting of substance-exposed newborns.

Dohan, D., Schmidt, L., & Henderson, S. (2005). From enabling to bootstrapping: welfare workers' views of substance abuse and welfare reform. Contemporary Drug Problems, 32(3), 429-442.

In the United States, a trope of "deservingness" shapes policy related to public aid and substance abuse. In recent decades, poor people with substance use problems have increasingly been seen as "undeserving." Federal welfare reform, passed in the mid-1990s, is an important exemplar of this trend. Welfare reform empowered line workers to directly and indirectly withhold aid from people with substance use problems. This paper uses in-depth interviews with workers to explore their views of these new policies. Results indicated that workers generally applauded welfare reform's renewed attention to deservingness, including program emphases on client self-sufficiency and personal accountability and policies that time-limited cash aid and mandated working. They felt that these changes allowed them to stop "enabling" substance abuse and to encourage clients with alcohol and drug problems to bootstrap their way into jobs. Workers' embrace of these policy changes appears likely to shape how substance abuse problems are addressed within the welfare system.

Drabble, L. (2007). Pathways to collaboration: Exploring values and collaborative practice between child welfare and substance abuse treatment fields. Child Maltreatment, 12(1), 31-42.

Although recent research has highlighted the importance of "bridging the gap" between child welfare and substance abuse treatment delivery systems, few studies examine specific factors that may facilitate such collaboration. This study examined similarities and differences in values and perceived capacity for collaboration between substance abuse and child welfare fields based on survey data from more than 350 respondents in 12 California counties. Results indicated that although respondents across disciplines held similar values in some areas, such as priorities for services, significant differences between respondents from child welfare and substance abuse fields were found in other areas, including values and beliefs about drug use and drug-using parents, funding; and planning and measurement of outcomes. Respondents from counties with a strong history of collaboration were more likely to report institutionalized collaborative practices in several areas, from use of multidisciplinary teams for case planning to use of multiyear budgeting to plan for integrated services. The author concludes that areas of commonality between child welfare and alcohol and drug treatment fields may provide a rich opportunity for building on a sense of shared purpose and identifying problems to be overcome in the process of collaboration.

Drake, B., Jonson-Reid, M., & Sapokaite, L. (2006). Re-reporting of child maltreatment: Does participation in other public sector services moderate the likelihood of a second maltreatment report? Child Abuse & Neglect, 30(11), 1201-1226.

This study uses administrative data to track the first re-reports of maltreatment in a low-income, urban child welfare population (n = 4957) while controlling for other public service involvement. Service system involvement is explored across the following sectors: Child Welfare, Income Maintenance, Special Education, Juvenile Court, and various forms of Medicaid-reimbursed medical or mental health care. This study builds knowledge by adding the services dimension to an ecological framework for analyses and by following recurrence for a longer period of time than prior investigations (7.5 years). Key results included a lower rate of re-reporting among children with parents who were high school graduates and/or permanently exited from the first spell on AFDC; and for children in families that received less intensive in-home services compared to those not receiving services, receiving intensive in-home, or foster care services. Higher rates of re-reporting were found for children with Medicaid mental health/substance abuse treatment records and special education eligibility for emotional disturbance. The authors conclude that caretaker characteristics and non-child welfare service use patterns had a strong association with the likelihood of a child being re-reported to the child welfare agency and should be more heavily attended to by child welfare workers. High rates of service sector overlap suggest that interagency ties and cooperation should be strengthened. The lower risk associated with less intensive in-home services compared to un-served cases may indicate under-identification of in-home service eligibility following a first report of maltreatment.

General Accounting Office. (2003). Foster care: States focusing on finding permanent homes for children, but long-standing barriers remain. Testimony of Cornelia M. Ashby, Director of Education, Workforce, and Income Security Issues presented before the Subcommittee on Human Resources Committee on Ways and Means. Washington, DC: Author. Available online at: http://www.gao.gov/new.items/d03626t.pdf#search='Foster%20care:%20States%20focusing%20%20and%20GAO'

In response to concerns that some children were languishing in temporary foster care, Congress enacted the Adoption and Safe Families Act of 1997 (ASFA) to help states move children in foster care more quickly to safe and permanent homes. Representative Wally Herger, Chairman of the House Ways and Means Subcommittee on Human Resources asked the Government Accounting Office to review (1) changes in outcomes for children in foster care since ASFA was enacted, (2) states' implementation of ASFA's fast track and “15 of 22” provisions, (3) states' use of two new adoption related funds provided by ASFA, and (4) states' initiatives to address barriers to achieving permanency. In her testimony, Director Ashby provided background information on foster care and AFSA. She also reported that limited data are available to measure changes in the outcomes and characteristics of children since AFSA, other than their being an increase in adoptions. Director Ashby also discussed that some states have reported court-related issues that hinder the use of the fast track provision for more children and that some states do not file termination of parental rights on many children. New AFSA adoption-related funds were most commonly used to recruit adoptive families and provide post adoption services. States are also developing practices in response to long-standing barriers (i.e., a lack of adoptive families, placing children across jurisdictions, poor access to services) that continue to hamper efforts to promote permanency for foster children.

Green, B.L, Rockhill, A., & Burrus, S. (2002, November). What helps and what doesn't: Providers talk about meeting the needs of families with substance abuse problems under AFSA: Summary of findings. Portland, OR: NPC Research, Inc.

This report presents results from a research study designed to understand how child welfare; substance abuse treatment; and the legal system including judges, referees, lawyers, and others are (or are not) working together to meet the needs of substance-abusing families involved with child welfare. Features of the systems themselves that were seen as particularly helpful included Family Decision Meetings; cross-system trainings; outreach workers and other means of providing wraparounds services; having appropriate substance abuse treatment available to clients; appropriate judicial and child welfare authority to mandate services; and frequent judicial monitoring. Several other issues also emerged as areas of effective practice that were remarkably consistent across the three systems: having positive, supportive relationships with families; advocacy for parents; communicating clearly and frequently with parents; collaboration across the three systems; and knowledge and experience with substance abuse issues and with AFSA. When these elements are in place, parents are better able to make timely progress.

Heflinger, C. A., & Hoffman, C. (2008). Transition age youth in publicly funded systems: Identifying high-risk youth for policy planning and improved service delivery. Journal of Behavioral Health Services & Research, 35(4), 390-401.

Youth with Serious Emotional Disturbances (SED) face many challenges as they approach the transition to adulthood and adult services. This study examines publicly funded transition-age youth in order to describe the numbers and type of youth in need of policy and service planning in one state. Using Medicaid enrollment and claims/encounter data, youth with high risk of transition difficulties were identified in the following groups: SED, state custody/foster care or risk of custody, users of intensive or frequent mental health services, or having diagnoses of major mental disorders, conduct disorders, or developmental disabilities. Almost one quarter of all enrolled 14 to 17-year olds met criteria for at least one of the high risk groups, and three-quarters of these were youth with SED. High risk youth are described, with greater detail on those with SED, and implications for policy, services, and research are discussed.

Howell, J.C., Kelly, M.R., Palmer, J., & Magnum, R.L. (2004). Integrating child welfare, juvenile justice, and other agencies in a continuum of services. Child Welfare, 83(2), 143-156.

This article presents a comprehensive strategy framework for integrating mental health, child welfare, education, substance abuse, and juvenile justice system services. The comprehensive framework consists of a continuum of six levels of prevention programs, interventions, and sanctions, moving from least to most restrictive, followed by aftercare. The authors propose an infrastructure of information exchange, cross-agency client referrals, a networking protocol, interagency councils, and service integration models. The authors also provide information on financing integrated service delivery. Information contained in this article can assist community planning teams with developing an infrastructure and formulating a long-term strategic plan to improve integration of all youth-serving systems.

Jones, L. (2005). The prevalence and characteristics of substance abusers in a child protective service sample. Journal of Social Work Practice in Addictions, 4(2), 33-50.

The purpose of this research was to identify characteristics of substance abusers in a child protective services caseload. The random sample of 443 children was drawn from an urban county from all children with a substantiated abuse case. Files of children were reviewed to derive data. Sixty-eight percent of the children had mothers who abused alcohol or drugs, and 37 percent of them had mothers who abused both. Substance abuse, service contacts, public assistance, homelessness, and household conditions in the service plan were all associated with child removal from the home. These findings suggest that the risks associated with substance abuse are not necessarily ameliorated with social work intervention.

Jones, D., Macias, R. L., Gold, P. B., Barreira, P., & Fisher, W. (2008). When parents with severe mental illness lose contact with their children: Are psychiatric symptoms or substance use to blame? Journal of Loss & Trauma, 13(4), 261-287.

This study compared parental psychiatric symptom severity, and the absence or presence of severe substance abuse, as predictors of contact with minor children for a representative sample of adults with diagnoses of serious mental illness (N = 45). Child contact and psychiatric symptom severity were measure ed during regularly scheduled 6-month research interviews over a total 30-month period following each participant's entry into the project. Severe substance abuse was documented as present or absent for the 6-month interval preceding each interview. Results revealed that incidence of severe substance abuse was repeatedly associated with less frequent parent-child contact, even after controlling for psychiatric symptoms, diagnosis, gender, age, ethnicity, and socioeconomic status. Neither psychiatric diagnosis nor symptom severity predicted frequency of child contact when substance abuse was taken into account. Mental health agencies offering parenting classes for adults with serious mental illness should incorporate substance use interventions to reduce loss of child custody and strengthen parent-child relationships. [PUBLICATION ABSTRACT]

Legal Action Center. (2003). Safe and sound: Models for collaboration between the child welfare and addiction treatment systems. Washington, DC: Author.

This report examines policy and practice issues affecting the child welfare and treatment systems. A background on the problem of addiction in the child welfare system is provided, including resources and effectiveness of the treatment system. This report also includes a discussion of the Adoption and Safe Families Act (ASFA), in particular making “reasonable efforts”, permanency hearings, and termination of parental rights. Implications for families at risk for involvement or involved in the child welfare system because of parental addiction is included. The report presents case studies of how two localities (Cook County, Illinois, and Cuyahoga County, Ohio) are addressing addiction in their child welfare systems, and also presents a model for addressing the needs of addicted parents involved in the child welfare system based on case study findings.

Lester, B.M., Andreozzi, L., & Appiah, L. (2004). Substance use during pregnancy: Time for policy to catch up with research. Harm Reduction Journal, 1(1), 5-50.

The purpose of this review is to summarize policy research findings in the area of maternal prenatal substance abuse to: 1) inform and advance the field; 2) identify future research needs; 3) inform policy making; and 4) identify implications for policy. This review is a systematic analysis of existing data findings on maternal drug use during pregnancy for determining the best policy among the alternatives for dealing with drug using mothers and their children. This article address the issues of efficacy (which policies work), economics (cost), and politics. New policies are also examined for their fit with existing policies and laws, the social impact, ethical issues, and the feasibility of implementation and administration. Several general policy recommendations are offered here addressing the critical issues. The authors hope that by focusing on these fundamental issues and ultimately detailing statistics, policymakers throughout the United States will consider the course of action that views both pregnant mother and fetus/child as humanely as possible.

Libby, A.M., Orton, H.D., Barth, R.P., Webb, M.B., Burns, B.J., Wood, P., & Spicer, P. (2006). Alcohol, drug, and mental health specialty treatment services and race/ethnicity: A national study of children and families involved with child welfare. American Journal of Public Health, 96(4), 628-631.

The authors used data on a national sample of children involved with child welfare systems to compare American Indian caregivers with White, Black, and Hispanic caregivers in their need for, and receipt of, specialty alcohol, drug, and mental health treatment. The authors found that American Indian caregivers were significantly less likely to receive services than were Hispanic caregivers but not significantly less likely than were White or Black caregivers. Child placement, child age, and caregiver psychiatric comorbidity were significantly associated with service receipt. The authors suggest that racial and ethnic disparity exists in referral to, and receipt of, specialty services for alcohol, drug, and mental health problems.

Lundgren, L.M., Schilling, R.E., & Peloquin, S.D. (2005). Evidence-based drug treatment practice and the child welfare system: The example of methadone. Social Work, 50(1), 53-63.

This article examined the extent to which methadone maintenance is discussed in the child welfare and social work literature and the extent to which child welfare policies mention and recommend this treatment method as a treatment alternative for drug-dependent parents. Since heroin is used by some maltreating parents and is unique in terms of its favorable response to pharmacological treatment, it is particularly important to examine how social work views methadone maintenance for heroin-dependent parents. Findings were derived from a review of 15 social work journals published from 1996 through 2002, and from a review of child welfare policies in 27 states to determine the extent to which methadone maintenance is mentioned as a treatment for women with minor children. The social work literature illustrated the following themes: the need to better integrate child welfare and substance abuse treatment services; the need to provide gender-specific treatment; the need for social workers to be better educated about substance abuse issues; the common occurrence of relapse among drug-using populations; and different types of treatment available. Missing from these journals were discussions of the merits of methadone maintenance as a substance abuse treatment option for heroin-dependent individuals, including parents. The review of state policies indicated that methadone maintenance is not specified or recommended as a treatment approach for child welfare workers to consider for opiate-using parents. The authors believe that methadone maintenance improves the welfare of children and reduces parental drug use and that failure to mention its potential utility appears to contradict current substance abuse treatment practices and policy recommendations by organizations such as the World Health Organization and the National Institutes of Health.

McAlpine, C., Marshall, C.C., & Doran, N.H. (2001). Combining child welfare and substance abuse services: A blended model of intervention. Child Welfare, 80(2), 129-149.

Service integration is critical to working effectively with substance abusing parents and providing intensive time-limited reunification services to children and families. Based on this premise, the local child welfare services and adult addiction service agencies in Montgomery County, Maryland developed an initiative to address the requirements of the Adoption and Safe Families Act (ASFA) while meeting the needs of families and the community of providers. A blended model of intervention was determined to be the best strategy to achieve the dual mandates of child welfare and the treatment providers. Drawing from criminal justice, systems theory, social work, and addiction treatment, the approach made use of graduated sanctions or levels of intensity in providing services, engaging client participation, and engendering motivation. This article proposes strategies at client and organizational levels to understand the process of adaptation to ASFA and to guide planning for blending services.

McCrystal, P., Percy, A., & Higgins, K. (2008). Substance use among young people living in residential state care. Child Care in Practice, 14(2), 181-192.

Existing empirical evidence on substance use among young people living in residential state care during adolescence is comparatively limited. This paper reports on substance use trends of young people living in residential state care during three annual data-sweeps when aged 14, 15 and 16 years. A repeated cross-sectional research design was utilized in the research. The findings suggest some similarities for lifetime prevalence rates for tobacco and alcohol use for those living in residential state care with a group of same-age young people not living in residential state care who participated in the research. However, solvent abuse and cannabis use was higher among those living in care. More frequent substance use was reported by the residential care sample for all substances at each stage of the study. These findings suggest that young people living in state care continue to merit higher levels of vigilance from researchers and policy-makers in order to fully understand this behaviour and develop appropriate prevention initiatives to meet their needs regarding potential drug problems. [PUBLICATION ABSTRACT]

McFarland, B.H., Gabriel, R.M., Bigelow, D.A., & Walker, R.D. (2006). Organization and financing of alcohol and substance abuse programs for American Indians and Alaska Natives. American Journal of Public Health, 96(8), 1469-1477.

Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. The authors used national data from 1997-2002 to describe recent trends in organizational and financial arrangements. Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, the authors estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. The authors compared expected and observed IHS expenditures. Results indicated that half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal. The authors concluded that many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

McNichol, T., & Tash, C. (2001). Parental substance abuse and the development of children in family foster care. Child Welfare, 80(2), 239-256.

The purpose of this study was to examine the impact of parental substance abuse on the development of 268 children in family foster care and to document their verbal and nonverbal skills and behavioral characteristics. In addition, this study analyzed changes in these skills and characteristics after a period of time in family foster care and examined where the children were subsequently placed. As a group, the children in family foster care presented with low average cognitive skills and made significant improvement in cognitive functioning during placement. The children with prenatal exposure to drugs scored significantly lower in cognitive skills at the beginning of placement but made significantly more progress than the other children during placement. Behavior ratings by the foster parents and teachers revealed that 29% of the children had scores in the significant range, and the children exposed prenatally to drugs had a higher incidence of behavior problems at school compared to family foster care peers. Policy implications focus on selection, training, and support of foster families, increased mental health services, early identification of needs, individualization of intervention programs to nurture hidden cognitive potential and address specific acting-out behavior problems, comprehensive planning that includes the child’s functioning and behaviors at school, and additional funding of research on the causes and treatment of substance abuse and methods of improving outcomes for children in family foster care.

National Association of State Alcohol and Drug Abuse Directors, Inc. (2005, August). Alcohol research on prenatal alcohol exposure, prevention, and implications for state AOD systems (State Issue Brief No. 2). Washington, DC: Author.

This is the second in a series of State Issue Briefs prepared by the National Association of State Alcohol and Drug Abuse Directors primarily for distribution to State Alcohol and Other Drug (AOD) Agencies through support from the National Institute on Alcohol Abuse and Alcoholism. This Brief is not intended to be a comprehensive review of the science around the topic but rather a compilation of selected findings in the area of prenatal alcohol exposure, prevention, and an exploration of the implications for administrators of AOD treatment systems. This Brief includes a the following areas: definitions and diagnoses, prevalence, effects of prenatal alcohol exposure, prevention approaches and their effectiveness, implications for State AOD prevention and treatment systems, and future research.

Noble, A., Klein, D., Zahnd, E., & Holtby, S. (2000). Gender issues in California's perinatal substance abuse policy. Contemporary Drug Problems, 27(1), 77-120.

This article examines gender issues that arose when California created and passed a law related to substance -exposed infants in 1990. The law intended to clarify whether prenatal alcohol and drug use was a reportable form of child abuse. The authors conducted 32 interviews with those who created the law and those who implemented part of the law, creating a model protocol. The authors also collected documents related to the overall project, such as the final report, the model protocol itself and comments on a draft protocol, and then minutes of meeting. Three gender issues arose in interviews with the law's framers and the protocol developers. First, the discourse about the law and the process of the law's creation was a divisive one. Members took sides as being either "pro-woman" or "pro-child" These positions were also respectively aligned with a further division: one was either "pro-treatment" or "pro-protection." Second, there were issues related to drug testing and the purposes of such testing. Drug test results were, and continue to be, turned over to child welfare agencies. Child welfare workers have the difficult task of balancing parents’ and children’s interests within the legal guidelines.

Rockhill, A., Green, B.L., & Furrer, C. (2007). Is the Adoption and Safe Families Act influencing child welfare outcomes for families with substance abuse issues? Child Maltreatment, 12(1), 7-19.

The Adoption and Safe Families Act (ASFA) was designed to promote more timely permanent placements for children in the child welfare system. To date, however, available data have said little about whether ASFA is meeting its intended goals. This study looks at the impact of ASFA on parents struggling with substance abuse issues. The authors compared child welfare outcomes, pre- and post-ASFA, for children of more than 1, 900 substance-abusing women with some treatment involvement. After the implementation of ASFA, children in this study spent less time in foster care, were placed in permanent settings more quickly, and were more likely to be adopted than remain in long-term foster care. The portion of children who were reunified with their parent or parents stayed the same. These outcomes were apparent even controlling for case and family characteristics. The authors conclude that the outcomes suggest that ASFA was able to accelerate (at least to a limited degree) the permanency process for children who might have otherwise remained in foster care, while at the same time, it did not unduly hinder the efforts of substance-abusing parents to have their children returned to them.

Ryan, J.P., Marsh, J.C., Testa, M.F., & Louderman, R. (2006). Integrating substance abuse treatment and child welfare services: Findings from the Illinois Alcohol and Other Drug Abuse Waiver Demonstration. Social Work Research, 30(2), 95-107.

Alcohol and other drug abuse is a major problem for children and families involved with public child welfare. Substance abuse compromises appropriate parenting practices and increases the risk of child maltreatment. A substantial proportion of substantiated child abuse and neglect reports involve parental substance abuse. Once in the system, children of substance-abusing families experience significantly longer stays in foster care and significantly lower rates of reunification. To address these problems, child welfare systems are developing service integration models that incorporate both substance abuse and child welfare services. This study provides an initial examination of the effectiveness of one service integration model that emphasizes the provision of intensive case management to link substance abuse and child welfare services. The authors used an experimental design and focused particular attention on two outcomes: access to substance abuse services and family reunification. The findings indicate that the families assigned to the experimental group used substance abuse services at a significantly higher rate and were more likely to achieve family reunification than were families in the control group.

Semidei, J., Radel, L.F., & Nolan, C. (2001). Substance abuse and child welfare: Clear linkages and promising responses. Child Welfare, 80(2), 109-128.

Parental substance abuse is a significant factor in many of the families served in the child welfare system. This article examines: the prevalence of substance abuse among families involved with the child welfare system; the impact of substance abuse on child welfare practice; and how both the Adoption and Safe Families Act of 1997 and welfare reform legislation intensify the need to address parental substance abuse effectively. The article also includes promising strategies for addressing substance abuse among child welfare clients, such as Delaware’s Title IV-E Waiver Demonstration and Family Drug Courts.

Stahmer, A.C., Leslie, L.K., Hurlburt, M., Barth, R.P., Webb, M.B, Landsverk, J., & Zhang, J. (2005). Developmental and behavioral needs and service use for young children in child welfare. Pediatrics, 116(4), 891-900.

The purpose of this study was to determine the level of developmental and behavioral need in young children entering child welfare (CW), estimate early intervention services use, and examine variation in need and service use based on age and level of involvement with CW by using a national probability sample in the United States. As part of the National Survey of Child and Adolescent Well-Being, data were collected on 2813 children under 6 years of age for whom possible abuse or neglect was investigated by CW agencies. Results indicate that both toddlers (41.8%) and preschoolers (68.1%) in CW have high developmental and behavioral needs; however, few children are receiving services for these issues (22.7% overall). Children that remain with their biological parents have similar needs to those in out-of-home care but are less likely to use services. Children under 3 years of age are least likely to use services. Children referred to CW have high developmental and behavioral need regardless of the level of CW involvement. The authors conclude that mechanisms need to be developed to address disparities in access to intervention.

Twomey, J.E., Soave, R., Gil, L., & Lester, B.M. (2005). Permanency planning and social service systems: A comparison of two families with prenatally substance exposed infants. Infant Mental Health Journal, 26(3), 250-267.

This article introduces an innovative program developed to work with families in which substance use during pregnancy leads to Child Protective Services involvement. The Vulnerable Infants Program of Rhode Island (VIP-RI) was established to facilitate permanency planning for substance-exposed infants by focusing on the interface of social service systems with one another and with the families affected by perinatal substance use. Permanent placement within the time frame mandated by federal legislation places increased pressures on parents and the social service systems designed to provide them with assistance. The Vulnerable Infants Program of Rhode Island promotes collaboration, coordination, and communication among social service systems engaged with families of substance-exposed infants. The Vulnerable Infants Program of Rhode Island works to increase the efficacy of social service systems in order to optimize the resources that are available to a family in their attempts at reunification with their infant. Case examples illustrate the complexities of the families of substance-exposed infants, the breadth of social service systems that become involved with these families, and the vastly different placement outcomes that substance-exposed infants may experience.

Young, N. K., S. M. Boles, et al. (2007). "Parental substance use disorders and child maltreatment: Overlap, gaps, and opportunities." Child Maltreat 12(2): 137-149.

There are relatively few empirically sound studies or nationally representative data on the number of children in Child Welfare Services (CWS) who are affected by their parents' substance abuse or dependence. The two systems that could systematically monitor this population, CWS and substance abuse treatment, are not required to capture the data elements that would identify families in both systems. The studies that are based on CWS populations or parents in treatment indicate that there is a substantial overlap in client populations. This review provides a summary of the available data; provides estimates of the overlap between populations, including the number of infants born each year with prenatal substance exposure; and suggests important opportunities to close the data gap between the systems. The findings underscore both the need for obtaining accurate data within the systems and the opportunities for states to improve their cross-system data efforts as part of their outcome monitoring.

Zimmer, M.H., & Panko, L.M. (2006). Developmental status and service use among children in the child welfare system: A national survey. Archives of Pediatrics & Adolescent Medicine, 160(2), 183-188.

This study estimated the prevalence of developmental delay and service use among children in the child welfare system and identified factors that influence developmental delay and use of these services. Subjects were children aged 0 to 10 years (n = 4324) and their caregivers, who were interviewed within 60 days of a report being made to the child welfare system. The sample was part of the National Survey of Child and Adolescent Well-Being. Children's development was measured directly using standardized assessment tools. Three questions from the caregiver interviews estimated receipt of developmental services. Prevalence of developmental delay and service use by age group, type of maltreatment, type of placement, race, sex, and income were reported. The authors found that younger children aged 0 to 2 and 3 to 5 years had higher rates, 33% and 36%, respectively, of developmental delay than school-aged children (13%). Despite their high prevalence of developmental delay, children aged 0 to 2 years were less likely to receive developmental services than preschool-aged children or school-aged children. The authors conclude that rates of developmental delay are high and developmental services are underused, particularly by young children in the child welfare system. In addition, the authors suggest that strategies for overcoming barriers to using early intervention services should be implemented.

SUBSTANCE ABUSE SERVICES ACROSS THE CONTINUUM

Prevention, Screening and Assessment

Berger, L.M. (2002). Estimating the benefits and costs of a universal substance abuse screening and treatment referral policy for pregnant women. Journal of Social Service Research, 29(1), 57-84.

Prenatal substance exposure poses a significant public health problem in terms of both its economic costs to society and the health and development of those children affected. While substance abusing pregnant women and their children could benefit from early identification and appropriate interventions, drug testing of infants is controversial, and there is currently no national policy regarding the drug testing of infants, nor substance abuse screening for pregnant women. This paper provides a cost-benefit analysis of a universal substance abuse screening and treatment referral policy for pregnant women. The results indicate that mothers and children are likely to benefit economically from a universal substance abuse screening and intervention policy. The extent to which society and non-participants would incur economic costs or reap economic benefits from such a policy, however, is dependent on CPS reporting practices and investigation rates, as well as foster care entry rates. Results suggest that the monetary benefits of such a policy will only outweigh its costs if it does little to increase post-birth child protective services reporting and/or foster care placement rates. Thus, additional policies regarding the ways in which screening results are utilized may be important factors in determining the effects of a universal substance abuse screening policy for pregnant women.

Chasnoff, I.J., McGourty, R.F., Bailey, G.W., Hutchins, E., Lightfoot, S.O., Pawson, L.L., et al. (2005). The 4P’s Plus screen for substance use in pregnancy: Clinical application and outcomes. Journal of Perinatology, 25(6), 368-374.

The purpose of this study was to evaluate the performance of a new screening instrument in five diverse populations of pregnant women enrolled in prenatal care. The 4P’s Plus is a five-question screen specifically designed to quickly identify obstetrical patients in need of in-depth assessment or follow-up monitoring for risk of alcohol, tobacco, and/or illicit drug use. Those women with a positive screen underwent an assessment for substance use through a follow-up structured clinical interview conducted at the same prenatal visit. Among 7818 women in five communities, 2555 (32.7%) had a positive screen for substance use in pregnancy. Four of the communities conducted a follow-up assessment on all women with a positive screen (n = 1548). Among these women, 717 (15% of the total population) had continued use after learning of the pregnancy. Overall, 21% of the pregnant women used alcohol prior to recognition of the pregnancy, and 11% continued use after knowledge of the pregnancy. Among the 512 women who continued to use alcohol, 2% were drinking daily, 7% were drinking 3 to 6 days per week, 27% were drinking 1 to 2 days per week, and 63% were drinking less than 1 day per week. The rates of marijuana use and other illicit drug use among the women were 7 and 2%, respectively, prior to knowledge of pregnancy and dropped to 3 and 1% after learning of the pregnancy. The results indicate that the 4P's Plus identifies not only those pregnant women whose drinking or drug use is at a high enough level to impair daily functioning, but provides an opportunity for early intervention for the much larger group of women whose pregnancies are at risk from relatively small amounts of substance use.

Cheon, J. W. (2008). Best practices in community-based prevention for youth substance reduction: Towards strengths-based positive development policy. Journal of Community Psychology, 36(6), 761-779.

Substance use among youth remains a major public health and safety concern. One fundamental way to address youth substance use prevention is to keep young people on a positive trajectory by engaging them in positive activities from early years of their childhood. In this article, the author offers a best practice analysis of systematic review about 12 selected community-based preventions, and proposes policy changes towards incorporating a strengths perspective. A substantive, methodological, and value-based critical analysis of the strongly effective preventions was conducted. A strengths-based positive youth development perspective is specified as one feasible needed improvement and subsequent policy changes in the school district as well as in the local, state, and federal levels are proposed along with the suggestion of a mandated community youth participation strategy. [PUBLICATION ABSTRACT]

Floyd, R.L., O'Connor, M.J., Bertrand, J., & Sokol, R. (2006). Reducing adverse outcomes from prenatal alcohol exposure: A clinical plan of action. Alcoholism-Clinical and Experimental Research, 30(8), 1271-1275.

Fetal alcohol spectrum disorders (FASDs) are among the leading preventable causes of developmental disorders in the United States; however, recognition and prevention of these conditions cannot be achieved without informed and educated health providers. This commentary addresses the importance of recognition and prevention of FASDs through the use of well-established standardized practices of diagnosis, screening, and brief alcohol reduction counseling. This article includes diagnostic guidelines for FAS, prevention strategies, methods for establishing alcohol use, and brief interventions. The authors suggest that routine formal screening for alcohol use should be conducted with all women of child bearing age and that screening can be done in both physicians’ offices and in community health settings.

Kerker, B.D., Horowitz, S.M., & Leventhal, J.M. (2004). Patients' characteristics and providers attitudes: Predictors of screening pregnant women for illicit substance use. Child Abuse and Neglect, 28(2), 209-223.

This study's aim was to determine how patients' and providers' characteristics affect hospital providers' decisions to screen pregnant and postpartum women for illicit substances. Participants included low-income women (N = 1, 100) who delivered at an urban teaching hospital over a 12-month period and the providers (N = 40) who provided prenatal and delivery care for these women. Medical records were abstracted to obtain demographic, medical, social, and substance use information. Providers were interviewed to obtain data on their attitudes. Results indicated that women who were single, Black, received prenatal care at the prenatal clinic, saw fewer providers, or had a placental abruption, preterm labor, inadequate prenatal care, a history of involvement with Child Protective Services, a high social/Mental Health Risk Factor Score, a past or present history of illicit drug use, or a present history of tobacco use were more likely to be screened than women without these characteristics. Women whose providers scored medium or high on the Professionalism Scale were more likely to be screened than women whose providers scored low on this scale. This study indicates that providers' decisions to screen pregnant women for illicit substance use are influenced by both patients' characteristics and providers' personal attitudes. Universal hospital protocols might help reduce the potentially biased impact of attitudes on screening decisions.

McNamara, T.K., Orav, E.J., Wilkins-Haug, L., & Chang, G. (2005). Risk during pregnancy - Self-report versus medical record. American Journal of Obstetrics and Gynecology, 193(6), 1981-1985.

This study was undertaken to compare the frequencies with which physicians and patients report medical and behavioral risk factors during pregnancy, with particular attention to identification of women at risk for prenatal alcohol use. The sample included 278 women, drawn from a randomized trial of T-ACE (alcohol screening questionnaire) positive pregnant women receiving obstetric care. Medical records and participants' self-reports were available for comparison. Results indicated that physicians identified only 10.8% of women recognized as at risk for alcohol consumption by the T-ACE screening measure. In contrast, the physicians' records were more inclusive for medical risk factors than the participant's self-reports. Physicians were significantly more likely to correctly identify nonwhite participants as being at risk for prenatal alcohol use, compared with their white counterparts. The authors concluded that self-report on the T-ACE questionnaire is more effective than medical records in identifying women at risk for prenatal alcohol use.

Treatment, Rehabilitation, and Recovery

Brecht, M.L., Greenwell, L., von Mayrhauser, C., & Anglin, M.D. (2006). Two-year outcomes of treatment for methamphetamine use. Journal of Psychoactive Drugs, Suppl 3, 415-426.

While evaluation research supports the general effectiveness of substance abuse treatment, there is not a comprehensive literature on treatment effectiveness for methamphetamine (MA) use. The authors consider three outcome measures - MA use, criminal activity, and employment-compared across three periods: 24-months pretreatment, during treatment, and 24-months post-treatment. Data are from an intensive natural history interview conducted two to three years after treatment for 349 randomly selected admissions to treatment for MA abuse in a large publicly-funded county treatment system. Results showed reduction in MA use and crime during and following treatment and increased employment following treatment over pretreatment levels. Analyses showed higher levels of education and more time in treatment related to more positive post-treatment outcomes for all three measures. Lower percentage of post-treatment months with MA use also was related to more pretreatment MA-related problems, lower pretreatment MA use, and residential (compared to outpatient) treatment modality. Lower post-treatment criminal activity was also related to gender (being female), lower pretreatment criminal activity, and residential modality. Higher percentage of post-treatment months with employment also was related to gender (being male), ethnicity (not African-American), and higher pretreatment employment. The authors conclude that the study results for all three outcome measures showed benefits of treatment for MA users, a pattern of findings that is consistent with results of general large-scale treatment outcomes studies of community-based treatment of other substances.

Cattapan, O., & Grimwade, J. (2008). Parental illicit drug use and family life: Reports from those who sought help. Australian & New Zealand Journal of Family Therapy, 29(2), 77-87.

Family histories of abuse and neglect are common among persons with substance addictions. Clearly such family backgrounds impact on future lifestyle choices. How this early life experience then impacts on the substance user as a parent and on their children has not been considered in the literature in any detail. Clients of local community drug services were invited to participate in a study evaluating the family life of parents who were dependent on illicit substances. Fifteen parents participated in a qualitative, longitudinal study about their family life, treatment and drug of choice. Four aspects of parental perception of family life were examined: the perceived impact of the family of origin on the parent drug user, self-perception, the impact of parental illicit drug use on the family environment, the impact of parental illicit drug use on children. For parents struggling with a substance addiction, it would seem that recovery has much to do with differentiation and gaining a sense of agency. [PUBLICATION ABSTRACT]

Claus, R.E., Orwin, R.G., Kissin, W., Krupski, A., Campbell, K., & Stark, K. (2007). "Does gender-specific substance abuse treatment for women promote continuity of care? Journal of Substance Abuse Treatment, 32(1), 27-39.

Research has stressed the value of providing specialized services to women and suggests the importance of treatment duration. This quasi-experimental retrospective study reports on the continuity of care for women with children who were admitted to long-term residential substance abuse treatment. Women were admitted to 7 agencies offering specialized, women's only treatment (SP, n = 747) or to 9 agencies that provided standard mixed-gender treatment (ST, n = 823). Client and treatment data were gathered from administrative sources. The authors hypothesized that women in specialized treatment would demonstrate higher continuing care rates after controlling for treatment completion and length of stay. Results indicated that women in SP programs (37%) were more likely than those in ST programs (14%) to continue care. Analyses revealed that SP clients who completed treatment with longer stays were most likely to continue care. The authors conclude that the findings show that specialized treatment for women promotes continuing care and demonstrate the importance of treatment completion.

Conners, N.A., Grant, A., Crone, C.C., & Whiteside-Mansell, L. (2006). Substance abuse treatment for mothers: Treatment outcomes and the impact of length of stay. Journal of Substance Abuse Treatment, 31(4), 447-456.

This article examines the treatment outcomes of 305 women enrolled in a comprehensive, residential substance abuse treatment program for pregnant and parenting women and their children. The women were assessed at intake and three times in the year after discharge. Analyses focused on change in client functioning over time, and investigating the impact of length of stay in treatment on client outcomes. Comparisons of clients' functioning before and after treatment suggest significant improvements in a number of domains, including substance use, employment, legal involvement, mental health, parenting attitudes, and risky behaviors. Longer treatment stays were associated with abstinence from AOD, reductions in cigarette use, employment and higher income, a reduced likelihood of being arrested, a reduction in symptoms of depression, and more positive parenting attitudes.

Evans, E., Spear, S.E., Huang, Y.C., & Hser, Y.I. (2006). Outcomes of drug and alcohol treatment programs Among American Indians in California. American Journal of Public Health, 96(5), 889-896.

The authors examined differences in substance abuse treatment outcomes between American Indians and their non-American Indian counterparts in California, during 2000 to 2002. A total of 368 American Indians and a matched sample of 368 non-American Indians from 39 substance abuse treatment programs in 13 California counties were assessed at multiple time points. Records on arrests, driving while under the influence of alcohol or drugs, and mental health care were obtained 1 year before and 1 year after treatment entry. Differences in pretreatment characteristics, services received, treatment satisfaction, treatment completion and retention, and outcomes were examined. The results indicated that pretreatment problems were similarly severe among American Indians and non-American Indians. About half in both groups either completed treatment or stayed in treatment more than 90 days; American Indians in residential care had significantly shorter treatment retention. American Indians received fewer individual sessions and out-of-program services, especially for alcohol abuse, but were nevertheless generally satisfied with their treatment. Both groups improved after treatment, with American Indians demonstrating greater reductions in arrests than non-American Indians. The authors suggest that American Indians benefit from substance abuse treatment programs, although the type and intensity of services offered could be improved.

Grella, C.E., Scott, C.K., & Foss, M.A. (2005). Gender differences in long-term drug treatment outcomes in Chicago PETS. Journal of Substance Abuse Treatment, 28, S3-S12.

Few long-term follow-up studies of substance abusers have examined gender differences. In the current study, gender differences were examined at 36 months following residential or outpatient drug-free treatment among 951 participants in the Chicago Target Cities Project, the majority of whom were female (62%) and African American (93%). There were no differences in the proportion of men and women who reported any alcohol or drug use at the 36-month follow-up, with an overall reduction of 41% from intake. Greater proportions of men were incarcerated or employed, whereas greater proportions of women had returned to treatment, lived with their children, lived with a substance user, or had interpersonal problems. Women, as a group, had greater increases over time in self-help participation, free time spent with family, non-using family/friends, and employment. Although both men and women showed significant improvements following treatment, gender differences persisted in several areas of psychosocial functioning related to recovery. This study confirms significant reductions in substance use following treatment and corresponding improvements in psychological functioning, social, and family relationships. This study also demonstrates that gender differences persisted in domains of functioning that are relevant to drug treatment processes and outcomes. These findings have implications for treatment provides and program planning.

Greenfield, S.F., Brooks, A.J., Gordon, S.M., Green, C.A., Kropp, F., McHugh, R.K., Lincoln, M., Hien, D., & Miele, G.M. (2007). Substance abuse treatment entry, retention, and outcome in women: A review of the literature. Drug and Alcohol Dependence, 86(1), 1-21.

This article reviews the literature examining characteristics associated with treatment outcome in women with substance use disorders. A search of the English language literature from 1975 to 2005 found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. The authors conclude that gender-specific predictors of outcome do exist, however, and individual characteristics and treatment approaches can differentially affect outcomes by gender. The authors state that while women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field.

Hser, Y.I., Evans, E., & Huang, Y.C. (2005). Treatment outcomes among women and men methamphetamine abusers in California. Journal of Substance Abuse Treatment, 28(1), 77-85.

This prospective longitudinal study examined treatment outcomes among 1,073 methamphetamine-abusing patients (567 women, 506 men) from 32 community-based outpatient and residential programs in 13 California counties. Data were collected at intake and at 3 months and 9 months after admission. With one exception, improvements from baseline to follow-up were observed in all areas measured by the Addiction Severity Index for both women and men in either modality. Compared to men, women demonstrated greater improvement in family relationships and medical problems, and similar improvement in all other areas, despite the fact that more women were unemployed, had childcare responsibilities, were living with someone who also used alcohol or drugs, had been physically or sexually abused, and reported more psychiatric symptoms. Study findings confirmed that these meth abusers were a highly troubled group with problems in multiple key life areas, most noticeably employment, legal/criminal, parenting, and psychological distress. Improved intervention strategies should target both substance use and other related needs that are necessary for rehabilitation. Women in the sample, most of whom were of childbearing age or had children, demonstrated more severe problems than did men. Developing and delivering adequate services to address the problems and needs of women will undoubtedly improve treatment outcomes.

McMahon, T.J., Winkel, J.D., Luthar, S.S., & Rounsaville, B.J. (2005). Looking for poppa: Parenting status of men versus women seeking drug abuse treatment. American Journal of Drug and Alcohol Abuse, 31(1), 79-91.

Research on drug abuse and fathering has been hampered by inadequate documentation of parenting responsibilities within samples of drug-abusing men and the status of men as fathers if rarely noted in published studies of the general population or in individuals seeking treatment. Thus, this study was designed to document the parenting status of drug-dependent men seeking methadone maintenance treatment and to clarify ways their status as parents differs from that of drug-dependent women. Data concerning demographic characteristics, drug abuse history, and parenting status were systematically coded from the medical records of 362 men and 162 women seeking methadone maintenance treatment during a 12-month period. Results indicated that, although a greater proportion of women were the parent of at least one biological child, there were actually more fathers than mothers seeking treatment. Among the parents, fathers were more likely to have been abusing opioids when they first became a parent, and they were more likely to be living away from their children. There were no significant gender differences in the number of children or the average age of children. The results suggested that fathering may be an important, but largely neglected, treatment issue for drug-abusing men, one which requires clinical interventions to support them in their role as fathers. These results indicate a need to better document the ways the parenting behavior of drug-abusing men differs from both that of drug-abusing women and men with no history of drug and alcohol abuse. Lastly, there is a need to better document ways the parenting behavior of drug-abusing fathers affects the cognitive, emotional, and social development of their children.

Mullins, S.M., Suarez, M., Ondersma, S.J., & Page, M.C. (2004). The impact of motivational interviewing on substance abuse treatment retention: A randomized control trial of women involved with child welfare. Journal of Substance Abuse Treatment, 27(1), 51-58.

Previous studies have supported the efficacy of Motivational Interviewing (MI) in increasing treatment engagement and retention among people with substance abuse disorders. However, few studies have assessed the impact of MI with coerced populations, particularly women referred to drug abuse treatment by child welfare due to prenatal drug use. This study sought to examine the impact of individual MI sessions on treatment retention and engagement in a treatment program serving clients under heavy child protective services pressure to participate. Seventy-one such women who used drugs during pregnancy were randomly assigned to either receive three MI sessions or to watch two educational videos and participate in a home visit. Treatment retention group attendance and random urine analysis results were evaluated in these women during the first 8 weeks of treatment. No differences were found between the two conditions on these variables. Possible reasons for these negative findings are discussed, including the possibility that MI may not provide any additional benefit when the population is coerced or when they are concerned that specific information about their progress will be shared with the court and with their child welfare worker.

Mullins, S.M., Bard, D.E., & Ondersma, S.J. (2005). Comprehensive services for mothers of drug-exposed infants: Relations between program participation and subsequent child protective services reports. Child Maltreatment, 10(1), 72-81.

It is unclear whether intensive services for women using drugs during pregnancy can reduce child maltreatment. This article sought to address this question by evaluating the association between dose of program participation and subsequent reports to CPS in a sample of 142 women whose infants tested positive for illicit drugs at birth. The authors found that simply attending the program without exhibiting behavior changes was not sufficient to avoid future child maltreatment reports. The women’s termination status, however, was strongly related to follow-up CPS reports; such that those with higher participation in all aspects of the program had significantly lower risk of re-report. The findings suggest that program effects may be detectable using a treatment process-- based index that combines dose, duration, and quality of program involvement. In addition, the findings suggest that comprehensive interventions for mothers of drug-exposed infants may be efficacious, particularly when participant enthusiasm for a particular treatment approach is considered when conducting treatment planning.

Ondersma, S.J., Chase, S.K., Svikis, D.S., & Schuster, C.R. (2005). Computer-based brief motivational intervention for perinatal drug use. Journal of Substance Abuse Treatment, 28(4), 305-312.

Computer-based brief motivational interventions may be able to reach a high proportion of at-risk individuals and thus have potential for significant population impact. The present studies were conducted to determine the acceptability and preliminary efficacy of a computer-based brief motivational intervention (the motivation enhancement system, or MES). The goal of MES is to facilitate self-change, treatment engagement, and/or motivation to change via a single intervention session. In Study 1, quantitative and qualitative feedback from 30 postpartum women and 17 women in treatment for drug use were used to modify the software. In Study 2, 50 urban postpartum women who reported drug use in the month before pregnancy completed the intervention and provided repeated within-session ratings of state motivation. In Study 3, 30 women were randomly assigned to intervention or control conditions with 1-month follow-up. Overall, women rated the MES as highly acceptable and easy to use and reported significant increases in state motivation at postintervention and at 1-month follow-up. These preliminary results are encouraging and suggest that further work in this area is warranted.

Roberts, A.C., & Nishimoto, R. (2006). Barriers to engaging and retaining African-American post-partum women in drug treatment. Journal of Drug Issues, 36(1), 53-76.

Little is known about barriers to engaging and retaining African-American women in drug treatment. This study examines (a) what barriers made it difficult for a sample of 221 African-American women to participate in treatment, (b) the extent to which those barriers differed by program modality, and (3) the extent to which those barriers were related to length of time in treatment and treatment completion. Findings revealed that barriers considered to be internal in nature (i.e., drug severity, did not feel like going, and felt I could manage on my own) were most frequently reported. Only a few program-related barriers were found to be related to length of time in treatment and both internal and programmatic barriers had an effect on treatment completion. Implications for policy decisions, future research, and clinical competence in addressing barriers to treatment for African-American women are discussed.

Smith, B.D., & Marsh, J.C. (2002). Client-service matching in substance abuse treatment for women with children. Journal of Substance Abuse Treatment, 22(3), 161-168.

This article addresses the relation between services matched to client-identified needs and substance abuse treatment outcomes for women with children. The study uses data collected for a program evaluation of an enhanced substance abuse services program for mothers involved with the child welfare system. In-person surveys were conducted with 183 women who were currently attending, or had recently completed substance abuse treatment. Matched counseling services (domestic violence services, family counseling) were associated with reports of reduced substance use; matched ancillary services (housing, job training, legal services) were associated with clients' satisfaction with treatment. However, the total number of services clients received had a stronger relationship to treatment outcomes than did services matched to client-identified needs. This study suggests that the substance abuse treatment clients have many service needs and that few of these needs were addressed by their treatment programs. Substance abuse treatment services are effectively enhanced when health and social services are also provided.

Somov, P. G. (2008). A psychodrama group for substance use relapse prevention training. Arts in Psychotherapy, 35(2), 151-161.

The article reviews utilization of psychodrama group therapy in the context of drug and alcohol treatment and introduces a specific application of psychodrama group therapy for the purposes of relapse prevention. The proposed psychodrama group format features facilitator guidelines for directing relapse prevention behavioral role plays, substance-use specific role plays, and a format for post-role-play processing of group participants’ experiences. [PUBLICATION ABSTRACT]

Vaughn, M. G., Shook, J. J., & McMillen, J. C. (2008). Aging out of foster care and legal involvement: Toward a typology of risk. Social Service Review, 82(3), 419-446.

The article focuses on the study that shows the treatment models with the strongest evidence base for treating adolescent substance abuse. Researchers Sara J. Becker and John F. Curry reveals that the treatment models are ecological family therapy, brief motivational interventions, and cognitive behavioral therapy (CBT). The study evaluated 31 peer-reviewed randomized trials of outpatient interventions for adolescent substance abuse on 14 attributes of trial quality.

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