When parents with substance use disorders (SUD) who are involved in the child protective service (CPS) system present in SUD treatment, children’s well-being is at risk. Ideally, parental participation in SUD treatment could help children be maintained safely with their parents, but when children must be removed, CPS must abide by time limits imposed by the Adoption and Safe Families Act (ASFA) of 1998. Parents who cannot achieve stable recovery within 15 to 22 months may permanently lose custody of their children. It is urgent that families affected by addiction get the help they need, and quickly.
The family may be caught up in the cycle of substance abuse and child maltreatment. Abuse or neglect in childhood may trigger substance abuse problems in adulthood,1 and when coupled with poverty and mental health problems that often co-exist, the now adult parents may have problems forming attachments with their own children.2 Intervention is needed to interrupt an intergenerational cycle of substance abuse and child maltreatment that could worsen over time. How can we help these families?
The Sobriety Treatment and Recovery Teams (START) model, an integrated program between CPS and SUD service providers, incorporates a number of strategies to engage families with parental substance abuse and child maltreatment in SUD treatment. Those strategies include peer recovery supports; quick access to CPS services and SUD treatment (including treatment for co-occurring disorders); a high level of collaboration between CPS and SUD treatment; engagement of both parents in services; and repeated efforts to engage families in treatment.
START was initiated in 2006 in Kentucky based on the model developed in Ohio3,4 and in response to compelling state statistics showing that almost 90% of children age 3 and younger in state custody were at risk in terms of their safety because of parental substance abuse. The program is directed and funded by the state CPS department (the Kentucky Department for Community Based Services) in partnership with the state behavioral health office that oversees contracts with local treatment providers (the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities).
The project could not operate without both CPS and SUD service providers at the table. But because CPS has to implement specific strategies, the initiative must have strong leadership within the CPS system.
START in Kentucky currently operates in two urban, one rural and one Appalachian site. While the model was developed in an urban setting, it also has been effective with adaptations in rural and Appalachian settings.
Based on work with 322 families, 531 adults and 451 children, this integrated program has produced twice the rates of sobriety and less than half the rates of placement of children in state custody (20% or less, vs. 41%) than typical practice.5
Specifically, 66% of women and 40% of men achieved sobriety at closure of their child welfare case, including clean drug tests and progress in both CPS and SUD treatment, compared with a 37% favorable discharge rate overall for CPS-involved clients served in publicly funded SUD treatment programs. These results reflect a cost offset of foster care expenses for CPS of $2.52 for every dollar spent on START substance use disorder treatment and family mentors.
Although this research found that 40% of parents with both child maltreatment and substance abuse lost custody of their children, national figures and rates of long-term permanent loss of custody are not known and are inconsistently tracked among states. We know that the risks to the child remain throughout childhood until age 18; even when reunited, children of substance-abusing parents are more likely to re-enter foster care, with the parents likely to lose custody again.6
Each START team includes a specially trained CPS social worker paired with a family mentor; the team works together on up to 15 cases. Family mentors are individuals with at least three years of sustained recovery from addiction, as well as experiences that sensitize them to child abuse and neglect. Family mentors also might be called “peer support specialists” or “recovery coaches,” and have backgrounds similar to those hired within SUD treatment facilities.
The family mentor meets the family very quickly after the report of child abuse/neglect is made and investigated, to offer hope that the START program can help and that recovery is possible. Amid a sea of professionals, the family mentor can be a friendly face while “keeping things real” with parents. With “been there, done that” knowledge, the family mentor often can see through evasions of the START clients to help guide them toward the honesty necessary for recovery.
Family mentors help parents engage in treatment by accompanying them to their first four treatment appointments with a warm handoff. They also guide parents into recovery supports and provide coaching on relapse prevention, sober parenting and daily living skills. If a parent does not show up for treatment even one day, the family mentor locates the parent to re-engage him/her in the treatment process.
Contact with the family is often very intensive early on and then tapers off as the parents stabilize. Cases are typically open for 14 months, and the family mentors spend an average of 52 hours in direct contact with clients during that time.