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NASADAD
"The Link Between Substance Abuse and Child Welfare: Promising Partnerships"
June 3, 2003
Thanks and Greetings
Thank you, Luceille, for that friendly introduction, and good afternoon, ladies and gentlemen. I am pleased to be with you at this Annual Meeting of NASADAD and the National Prevention Network. I want to begin by offering my congratulations to all of the award winners and thanking them for the work they do. This is a world in which the real heroes often go unsung, so it's always tremendously satisfying to see excellence receive its due. Again, congratulations.
The Link - Story and Stats
The heroes and heroines who I see close up, day after day, are the professionals who work to make life better for neglected and abused young people, and especially our 1100 CWLA member agency executives. Luceille is a fine representative of this magnificent group of people - who, increasingly, come from the worlds of behavioral health, juvenile justice, and education, as well as our traditional child welfare constituency. As of course, I myself came to the Child Welfare League from the federal Office of Juvenile Justice and Delinquency Prevention…. No one system has all the answers. The hardened silos where we all spent our time just a few decades ago are giving way to collaborative organizations and approaches for one obvious reason: the multiple, increasingly complex, inter-related needs of children and families.
Last month, CWLA hosted a Congressional briefing on Capitol Hill, sponsored by Senators Frist, Kennedy, and Snowe, to highlight the needs of families separated by substance abuse and the effectiveness of treatment. Dr. Jim Herrell of the federal Center for Substance Abuse Treatment reported on his recent findings research findings. And Connie Brooks, a mother of seven who is in recovery after years of being addicted to crack cocaine, spoke honestly about the horror and desperation of her addiction, her life on the street, and the many ways she had failed her children and herself.
She told us at the briefing, "As a mom seeking recovery, I found that the needs particular to a parent weren't addressed in the 60- to 90-day treatment programs that I tried. Consequently, I relapsed. It wasn't until I entered a comprehensive family treatment center that I finally gained hope that my family's condition could improve, and that hope fueled my recovery." Ms. Brooks now works as a drug counselor for other families.
Everyone in the room that day was moved by Connie's story, and inspired by her transformation. We live in a world full of complex, astonishing human beings - full of human pain and human possibility. I want to cite just a few, selected statistics that illustrate both the depths of the pain and the height of the possibilities, before I move into a discussion of what we can do together to minimize one and maximize the other.
Last year, reports of abuse and neglect were confirmed for 903,000 U.S. children - nine-tenths of a million. That number rose between 2001 and 2002, the last year for which we have statistics. Of the families involved in the child welfare system because of abuse and neglect, 80% have problems with alcohol and other drugs. Children whose parents abuse substances are almost three times more likely to be abused and more than four times more likely to be neglected than other children are.
Of these families who clearly need treatment, the child welfare system is able to obtain treatment for only about one-third. And even for that third, the services may not be effective, culturally appropriate, or of sufficient intensity and duration. And so the cycle repeats itself. Thomas Kirk, Connecticut's Deputy Commissioner of Mental Health and Addiction Services, maintained in Congressional testimony a few years ago that 75% of women in residential drug treatment reported having been sexually abused as children.
It's a vicious cycle indeed. However, when effective treatment is made available, we see results that illustrate the miracle of human resilience.
When pregnant women receive high quality residential treatment, according to an ongoing study of 50 federal grantees, their rates of adverse birth outcomes are not only lower than for other drug users, but actually lower than for the population at large. The percentage of low birthweights among women served by the 24 CSAT Pregnant and Postpartum Women grantee programs was about half that for black women in the general population: 6.7% versus 13%.
In a SAMHSA five-year follow-up study, women reported a rate of reduction in drug use that was twice that for men in the same treatment programs.
When mothers received high quality treatment while their children were in foster care, 65% in one study and 75% in another were able to be safely reunited with their children.
Only 6% of the participants in Illinois' comprehensive SAFE Program had subsequent reports of abuse or neglect. That rate compared to 52% for clients with AOD involvement who did not receive treatment, and 21.5 for the general child welfare population.
And, finally, when children were able to participate in treatment with their mothers, 84% measurably improved their performance in school. These results also come from the CSAT Pregnant and Postpartum Women Program.
CW and AOD: Common Ground
This sampling, along with many other statistics, shows the clear link between substance abuse and child maltreatment, on the one hand, and between substance abuse treatment and happier outcomes for children, on the other. In the light of this evidence, a partnership between CWLA and NASADAD, between child welfare and behavioral health, is hardly optional. We're all in this together.
Now if we lived in a world, and in a nation, where children were a priority, the way out would be simple. We would provide services for everyone who needs them, beginning with prevention and moving through early intervention to treatment, as individual needs indicated.
Unfortunately, the substance abuse treatment services that do exist are not nearly adequate for families in the child welfare system. Nationally, there is a shortage of places in all types of substance abuse treatment, but especially in programs geared to women with children. All the states report long waiting lists.
Substance abusing parents have multiple and complex problems. Many mothers face poverty, depression and other mental illness, domestic violence, and health problems like HIV/AIDS, as well as patterns of abuse or neglect. All of these pose special challenges for substance abuse treatment and recovery. Engagement and retention strategies require close attention to ensure completion of treatment. Extended family connections and cultural connections must be respected. We need excellent programs, not just any programs.
So, why is successful substance abuse treatment for families so important to child welfare? Obviously, it's because we care about kids. On the most practical, everyday level, it's important for CWLA members because while thousands of families who need substance abuse treatment are unable to obtain it, child welfare agencies must nevertheless comply with the Adoption and Safe Families Act, which mandates early decision-making to keep children safe and in permanent families.
The Adoption and Safe Families Act (ASFA, for short) was enacted in 1997 to promote safety and permanence for children by expediting the timelines for decision-making. That law requires that a court review plans for a child's permanent living arrangement within 12 months of the date that a child enters foster care. It also requires that if a child is in foster care for 15 of the most recent 22 months, a petition to end a parent's rights to the child must be filed, unless certain exceptions apply.
In order to make early permanency decisions for children whose families have substance abuse problems, agencies must find a way to begin services for the family, including treatment for the parent or parents, immediately upon a child's entry into foster care. Studies show that keeping or regaining custody of their children is a primary motivator for mothers to enter treatment and succeed in treatment.
This is where our two worlds collide: our need to keep children safe by making decisions in a timely manner; AND the lack of appropriate substance abuse treatment for women and families. Beyond this, we have clocks that run at different speeds: the time frame of addiction, as a chronic relapsing condition; the developmental timetable of children, which requires that needs be met as they arise; and the time limits ASFA mandates.
Clearly, our two systems have a great deal in common. Let me just run through some of the facts that constitute our common ground… and our common challenges.
First, as we all know, both child abuse and addiction are intergenerational, UNLESS the cycle is interrupted.
We all agree that an ounce of prevention is worth a ton of cure, so we try to engage children and families as early as possible.
But we also know, and this is a key point, that both child abuse and substance abuse respond to treatment. According to one breakdown I've seen,
- Nearly one-third of substance abuse treatment clients get clean and stay clean after their first attempt at recovery.
- Another third go through relapses, but eventually achieve sustained abstinence.
- And a final third remain beyond our reach. That means that programs are able to work with a good two-thirds of the people who come to us for help to turn their lives around.
I've never seen a breakdown that neat for child maltreatment, but I do know that only about a quarter of all confirmed reports lead to the removal of children from the home, and that many, many families with histories of maltreatment are able to parent successfully once they are helped to develop the parenting skills and life skills that they lack.
For one thing, in spite of the potential for healing, "polite" society distances itself from our clients in both systems, too often creating an "us vs. them" mindset, and prefers to know as little as possible about their issues. It follows rather logically from this distancing and isolation that shame and secrecy surround clients in both child welfare and addiction services.
Poverty plays a key role in bringing clients into public systems in both areas. Let's face up to it. Affluence provides a cushion that can absorb much of the impact of dysfunction. Otherwise, since 11% of all U.S. children have at least one parent with AOD issues, the child welfare system would be dealing with one child in 10. Poor people wind up in our systems because they have very few cushions, and no place else to go. Poverty, racism, and social injustice are facts that play a large role in this picture---and they're unpopular facts, like addiction and child maltreatment.
Partly because of this convergence between shame and willful ignorance, funding patterns force both systems to under-emphasize prevention and treatment and hugely over-emphasize what CASA calls "shoveling up the wreckage." CASA demonstrated in an intensive study, not long ago, that for every dollar of AOD-related state spending, 96 cents is spent on shoveling up---courts, prisons, hospitals, child welfare, and special education---and less than 4 cents on prevention, treatment, and research combined. Research is a minuscule proportion of the 4%--it doesn't even exist in some state budgets. When all the AOD-related children's programs are totaled, states spend 113 times more on programs that shovel up than on those that prevent or treat.
Because of the way our funding streams operate, child welfare systems also spend relatively little on prevention, though that percentage has increased in recent years. We do somewhat better with treatment, but it isn't early intervention as often as it should be.
This chronic under-supply of resources, perhaps coupled with the sense that we're doing undervalued work nobody else wants to do, has led both systems, in the past, to be unable, unwilling or simply unmotivated to document our practice and demonstrate positive outcomes as often as we should. We've been too busy and too stressed. There's been an attitude of "Trust us, we're the good guys."
The culture of poverty may characterize our professional lives as much as it does the lives of our clients, so it could infect us with the same kind of fatalism that bedevils some of them. But this lack of resources does not leave us powerless, any more than the challenges our clients face render them powerless to help themselves. We can all learn and grow and change.]
Since our ability to command resources, especially in this era of tightened purse-strings, may depend on our ability to demonstrate effectiveness, we simply have to get good at it. And we are getting better, in both our practice and our ability to tell our story. More research has been funded, more outcomes are being measured, and a more effective case is being made for investment. But more needs to be done - in both areas: research and advocacy.
This brings me to what CWLA is doing to meet these challenges. How can we do a better job, together, of delivering AOD services to kids and families in the system?
For CWLA, it starts with a holistic vision, then moves to strategic partnerships, evidence-based practice, and advocacy - which leads us back to practice. Let me tell you first about the vision.
What CWLA Can Do
The Vision
A team of CWLA's most able staff members has been engaged for the last several years in developing a document we call Making Children a National Priority: A Framework for Community Action. The framework articulates a vision that links our many various initiatives together, across divisions like Child and Family Services, Behavioral Health, and Juvenile Justice, and also links our local, state, and national policy agendas.
This document begins by inviting the reader to imagine an America where every child can succeed. To imagine what this great nation could accomplish, if the well-being of ALL its children was truly a national priority. To imagine what could happen if parents, relatives, professionals, citizens, corporations, and governments worked together to support and strengthen ALL our children and families.
We know it can happen, because it's already happening in pockets of excellence around the U.S. But this is an enormous country, and many children, young people, and families still struggle alone. The core of the Framework, the foundation on which it rests, is a statement of the five universal needs of children. They are
- The basics, such as food, clothing, shelter, and education
- Nurturing relationships,
- Opportunities to succeed,
- Safety from harm, and
- Healing, when harm has already occurred.
Obviously, no one family or one system can meet all these needs. It takes wide, deep, and coordinated collaboration at many levels. CWLA's Framework monograph contains many examples of such collaboration, and our Community Implementation Guides, the first of which is due for release this summer, will feature still others. You can read an Executive Summary of the National Framework document on line, as well as installments of our Community Implementation Guide, with examples of successful programs and practical help for building and connecting them.
Strategic Partnerships
And that brings us to partnerships. The spectrum of needs I have just outlined in its barest form requires a wide array of responses, so CWLA needs an array of partners to begin making children a national priority. On the state and local level, our partners are our members, and the parallel systems that they engage become our partners too. Our consulting division, the Center for Field Consultation, has been facilitating collaborations for children at the community level for decades, so we're deeply immersed in this work - and of course, we're still learning. At the national level, we are developing closer and more effective partnerships with organizations like NASADAD and NPN and many others.
We are proud of our partnership with SAMHSA, CSAT, the Children's Bureau's Office on Child Abuse and Neglect, the Center for Children and Family Futures, NASADAD, and other partners in the National Center on Substance Abuse and Child Welfare. The Center was launched in September 2002 and is envisioned as a five-year effort. Others partners include the American Public Human Services Association, the National Indian Child Welfare Association, the National Council of Juvenile and Family Court Judges, the Federation of Families for Children's Mental Health, and the American Association for Child and Adolescent Psychiatry. This group represents a remarkable diversity of interests and perspectives, and we're optimistic about what we can accomplish together. The National Center offers technical assistance, convenes conferences, functions as a clearinghouse for information, and will develop guidelines and standards for coordinated practice.
We're also engaged in a project, sponsored by the Robert Wood Johnson Foundation, to develop guidelines and strategies for effective collaboration across child welfare, juvenile justice, and AOD. Please visit our web site, at www.cwla.org, to learn more about these and other CWLA programs and partnerships.
Evidence-Based Practice
Another major CWLA initiative is the one we call R2P, for Research to Practice. I spoke earlier about a tendency to undervalue documentation as characteristic of both our systems, especially until recent times. Today, with resources shrinking and challenges growing by leaps and bounds, we cannot afford anything but the best. We have to put our money and our efforts into interventions that are known to work.
For this compelling reason, CWLA has tripled its staff commitment to research and evaluation over the last several years. Our primary objective is to identify well-researched and "proven" methods or practices. If a sufficient body of rigorous research does not exist in CWLA priority areas, we initiate original inquiries, working with the vast, but often undocumented knowledge base that exists among our members. This process is guided by a consistent focus on the needs of the field. In the most elementary terms, Research to Practice is an ongoing effort to answer the question, "What do I need to know to do my job well?" from the multiple perspectives of the people, organizations, and systems that carry community responsibility for protecting children and ensuring their access to opportunity. CWLA is establishing standards for evaluating the quality of research that underlies specific content areas.
I have already cited some of the research that demonstrates the benefits of effective treatment, and alluded to some of the qualities that make it effective. Let me quickly review those elements. Because resources are scarce, because demands for accountability are coming from every counter and, most of all, because human lives are much too precious to experiment with, we have to be sure that the programs we do provide have all the hallmarks of effectiveness. I can think of at least five:
- They are comprehensive,
- They are focused on the family as a unit
- They are culturally relevant,
- They are intensive and sustained, and
- They are consistently documented and evaluated.
First, they are comprehensive. Comprehensive systems are built on the holistic, wraparound model rather than on the silo. The most effective treatment is comprehensive family treatment that provides an array of services for both mothers and their infants or children.
When child abuse and AOD abuse co-exist, it's likely the family is also facing stresses around housing, or health and mental health, or domestic violence, and sometimes around basic survival issues, like safety or food. Successful systems create a customized wraparound of residential, in-home, and close-to-home services for each family. They combine substance abuse treatment with prenatal and pediatric medical care, mental health care, vocational services, parenting classes, legal help, nurseries and preschools, transportation, and still other services. Probably the most successful programs, research has shown, are those that take children into care along with their parents, so the whole family can learn new ways of being and doing.
To address multiple needs, comprehensive models require collaborative local policy planning and follow-through. They require protocols for sharing information across systems, and they require ongoing cross-systems communication. And in every case I know, this requires new resources.
Privatization
Many policymakers have been convinced for the last several decades that private, for-profit systems are by definition more efficient than public systems, and that privatization is the answer to the many challenges that social service systems face. CWLA recently published a study that tested that assumption. It is called Privatization of Child Welfare Services: Challenges and Successes. The authors are Madelyn Freundlich and Sarah Gerstenzang
The authors studied six jurisdictions where privatization has run its course, four states and two counties, and found that none of them could document either cost savings or greater efficiency. In Wayne County, MI, the one jurisdiction that may have achieved heightened efficiency, the experiment was definitely not cost neutral.
Especially at the beginning of a collaboration, the authors emphasized, there has to be a significant investment in information systems, training, and other essential infrastructure. And of course, the programs that are going to enter into collaboration each need to be strong and healthy on its own, like partners entering a marriage. Otherwise, instead of one well-functioning coordinated system, all you get are coordinated bad programs -- plus a lot of bad feelings caused by fierce competition for inadequate resources.
The study had four conclusions, two about the programs it studied:
- Privatization rarely achieves cost savings, and
- Privatization rarely yields greater efficiency
and two about what might have made them successful:
- Successful privatization requires strong leadership at the highest level, and
- Successful privatization requires setting a small number of simple outcome measures and performance targets.
We may have known, or suspected some of these things all along, but now the evidence is in. Privatization is not a panacea, and neither is collaboration - though it's totally essential.
Second, successful programs are focused on the family as a unit. They are not looking just at what is good for the AOD system's client, which is usually the parent, or the child welfare system's client, which is usually the children. They focus on strengths as well as needs, and on extended families and informal systems as well as the formal ones. And they do their work WITH families, not just for them. They empower family members of all ages to be active participants in their own success.
Third, research demonstrates that successful programs are culturally relevant. They respect the strengths of larger cultural contexts as well as the strengths of families, and they draw on them to promote healing. This may well include spiritual traditions, including Native spiritual traditions, and the abiding strength they can provide.
Fourth, they are intensive and sustained. As Connie Brooks told participants in our Capital Hill briefing, lives are not transformed in 60 days or 90 days. Even an intensive, family-focused residential program needs to include a realistic aftercare component, so a relapse is not the end of recovery, and if a relapse does occur, the children are provided for.
Fifth and last, at least in this short and cursory survey of the evidence, effective programs are consistently documented and evaluated. This enables us both to identify anything that doesn't work, so it can be remediated, and to provide evidence of success that can be shared and leveraged. Sharing information is one of the things that CWLA does best. The breadth of our membership and the credibility we have gained over many decades of leadership both position us to get good information out there where it can make a difference.
We disseminate information about successful programs to our own and allied fields, and we disseminate information to the media, both proactively and in response to constant inquiries. We believe that facts matter, and that over time they will have an impact. In fact, one of the things that research demonstrates is the utility of good research - especially when it's coupled with true stories and real voices, like those of the courageous Connie Brooks.
CWLA will be disseminating the evidence for good practice through its nationwide consultation and training, through its publications and its website, through its conferences, through its task forces and advisory groups, and through its standards and guidelines for agency practice. As we implement our National Framework, making children a national priority in one community after another, we will be carrying the evidence for best practice with us. But good practice requires good policy, and good policy requires advocacy. And that brings me to CWLA's fourth major contribution: advocacy.
Advocacy
One area of collaboration between NASADAD and CWLA has been our advocacy on the federal level for the passage of S. 614, the Child Protection/Alcohol and Drug Partnership Act. This bill promotes safety and permanency for children and recovery for their parents.
The Child Protection and Alcohol and Drug Partnership Act, S. 614, would provide $1.9 billion over five years to state child welfare and substance abuse agencies that agree to join together to increase treatment and services.
All activities must be directed to families with substance abuse issues who come to the attention of the child welfare system. These funds may be used to increase treatment capacity to meet these families' needs in a timely way, so precious family bonds can be preserved.
We are grateful to Senators Olympia Snowe of Maine, Jay Rockefeller of West Virginia, Mike DeWine of Ohio, and Chris Dodd of Connecticut for introducing this legislation. These Senators know how important collaboration between child welfare and substance abuse treatment agencies is for families. They have been working with NASADAD, CWLA, the Children's Defense Fund, and others to secure funding that encourages new partnerships - between child welfare and substance abuse agencies and with other service providers, courts, community leaders, and family members.
We continue to urge Congress, advocates, and community leaders to help children and families by working with the Child Welfare League, NASADAD, and others to advocate for:
- Comprehensive, high-quality prevention, early intervention, and family treatment services;
- Collaboration across agencies-particularly child welfare and substance abuse;
- Expansion of model programs and sharing of successful practices; and
- Funding for collaborative programs through bills like S. 614, which addresses the multiple needs of children, parents, and communities on the local, state, and national levels.
CWLA is asking the Administration and our representatives to make a strong commitment, in the budget for 2004 and the coming years, to keeping children and young people safe from harm, and to helping them realize their full potential. But our legislators need to hear from you too. They need to hear the real stories of the young people who you serve. You can equip yourself with more information, and even send letters with very little effort, by visiting CWLA's web site, www.cwla.org, and going to Kids Advocate Online.
Policymakers may tell us that times are hard, but that is precisely why we need these programs. Good treatment is cost-effective. For every $1 spent on treatment, society saves $3 in lost productivity, health expenses, care for children, and other remedial costs. I know you'll help us carry that message. Perhaps, together, we will prevail.
I am happy to report one recent legislative success. We've been urging Congress for many months to enact state fiscal relief. As part of the tax cut package, Congress passed significant measures to assist the states, and last week the President signed that measure. Virginia, for just one example, will receive $418.2 million, all told. We will need to advocate strongly to see that some of this money goes into treatment programs for families in the child welfare system.
Challenge and Hope
Let me conclude then, by encouraging you to add vigorous advocacy to your job description, if it's not already there. Please don't be discouraged by the many challenges that we see around us.
WE AND OUR CLIENTS HAVE TREMENDOUS STRENGTHS.
Both child welfare and behavioral health are staffed by smart, caring, and dedicated people, and neither system is new to this work. We have some solid resources to draw on: commitment, professionalism, and proven models. Both systems can draw strength from powerful national organizations: NASADAD, NPN, CSAT and CSAP, CWLA, CDF, CASA, and many others. At their best, both systems can engage volunteers, advocates, and other community members to bolster their effectiveness.
I spoke before of the membership I deal with as the executive directors of CWLA agencies. It goes without saying, however, that we cannot accomplish our goal of healthier families and communities unless we first empower our staff members. Workers with heart and hope can motivate clients to change their own lives, and then to change their communities - to be part of the solution. Change begins with the conviction that change is possible. As Steve Hornberger, CWLA's Behavioral Health Unit Director, has been heard to say, "Our workers can be lacking a lot of things and still be effective, but they cannot lack hope."
Let's be sure they don't catch discouragement from us. Let's hold onto hope, and hold onto our common bonds. Our difficult work is easier when we're all pulling together. Thank you for being my partners. And thank you for being champions for children, young people, and families. You are all my heroes.
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