Responding to Alcohol and Other Drug Problems in Child Welfare:
Weaving Together Practice and Policy

Nancy K. Young

Sidney L. Gardner

Kimberly Dennis

Office of Juvenile Justice and Delinquency Prevention

CWLA Press • Washington, DC

CWLA Press is an imprint of the Child Welfare League of America. The Child Welfare League of America (CWLA) is a privately supported, nonprofit, membership-based organization committed to preserving, protecting, and promoting the well-being of all children and their families. Believing that children are our most valuable resource, CWLA, through its membership, advocates for high standards, sound public policies, and quality services for children in need and their families.

© 1998 by the Child Welfare League of America, Inc. All rights reserved. Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher. For information on this or other CWLA publications, contact the CWLA Publications Department at the address below.

CHILD WELFARE LEAGUE OF AMERICA, INC. 440 First Street, NW, Third Floor, Washington, DC 20001-2085 e-mail: books@cwla.org

CURRENT PRINTING (last digit) 10 9 8 7 6 5 4 3 2 1

Cover design by Shelley Furgason

Printed in the United States of America

ISBN # 0-87868-736-X

This project was supported by Grant No. 98-JN-FX-K001 from the Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice.

Points of view or opinions in this document are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice.

Preface

The epidemic of drug and alcohol abuse that threatens our nation has many economic and social costs, but its cost to families is our greatest national deficit. Increasing numbers of Americans are living on the outskirts of hope and opportunity, with hundreds of thousands of children and adolescents feeling the devastating effects of abuse and neglect, homelessness, violence, and economic erosion. The widespread use of alcohol and other drugs by parents and other family members intensifies these social ills. Families should be on the front line of defense in the nation's war on drugs, but in many cases, alcohol and other drugs have broken through the line. Many children and youth stand unprotected. The child welfare community cannot carry out its mandate to protect children unless there is a dialogue among professionals and caregivers from such disciplines as child welfare, substance abuse prevention and treatment, mental health, juvenile justice, public assistance, and domestic violence. It is through collaboration that effective innovations in policies, programs, and practices evolve.

The Child Welfare League of America is especially grateful for the energy, talent, vision, and commitment of Nancy Young, Sid Gardner, and Kimberley Dennis, the authors of this guidebook. We believe that Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy will be a valuable resource to guide the important work that must be done to protect children and strengthen families.

David S. Liederman  
CWLA Executive Director

Acknowledgments

This report is based upon the work of an extraordinary group of people who have designed and staffed the innovative model projects that we have summarized. They are the real pioneers in this field, working on behalf of children and families in areas where there are few well-blazed trails. Some of them have taken risks; all of them have made a difference. Among them we would like to single out Toni Moore from Sacramento County and Katherine Wingfield of the CWLA staff.

We would like to offer special thanks to two people without whom this guidebook could never have been completed: Dr. Robert Caulk of Sacramento and Angela Young of Irvine. It was Bob's vision of CWS-AOD links and his deep commitment to doing something about AOD issues that created the Sacramento model. And it has been our niece Angela's generous caring for our two youngest children that made it possible for us to devote the intensive time that this project has required.

We would also like to acknowledge support from the following organizations in the compilation of materials from which this guidebook was developed: The Annie E. Casey Foundation, the Edna McConnell Clark Foundation, the Stuart Foundation, and the Center for Collaboration for Children of California State University, Fullerton.

We are especially grateful to the federal Office of Juvenile Justice and Delinquency Prevention, whose generous support helped to make this publication possible. We extend our deep appreciation to Shay Bilchik, Ellen Shields-Fletcher, and Gina Wood of the Office of Juvenile Justice and Delinquency Prevention, as well as staff from the Office of National Drug Control Policy and the Center for Substance Abuse Prevention of the U.S. Department of Health and Human Services for their continued commitment to improve the quality of life for vulnerable children and their families.

Introduction

Many parents coming into contact with the child welfare system are users and abusers of alcohol and other drugs (AOD), the effects of which impair their parenting skills and threaten the safety of their children. (This guidebook cites estimates of 40 to 80% of all the families in the child welfare system as AOD users/abusers.) In addition to problems with substance abuse, these parents also face difficulties due to their status in the Temporary Assistance for Needy Families (TANF) program (or welfare system), the behavior of their adolescent children, family violence, and mental health issues. As a result, a paradox is driving the future of the child welfare system: decisions and resources outside the child welfare system will determine how well that system can serve some of its most important clients—those who are in the caseloads of other agencies, as well as child welfare.

Drawing on the experience of several models of child welfare practice, this guidebook sets forth a policy framework that can assist child welfare agencies in responding to these overlapping problems. Throughout the guidebook, the experience of the Sacramento County Alcohol and Other Drug Treatment Initiative is used as a case study of building bridges between the child welfare and substance abuse treatment systems.

The policy framework focuses on the underlying values of these systems of services, the daily practices of workers in these systems, training, budget issues, outcomes and information systems, and service delivery methods. The guidebook describes several barriers that constrain cooperation between child welfare and AOD treatment agencies, including timing barriers that are summarized as "the four clocks": child welfare deadlines for permanency planning, TANF time limits, the different timetable for AOD treatment and recovery ("one day at a time for the rest of your life"), and the developmental timetables that affect younger children as they bond with adults.

Within daily practice, the most important recommendation—the keystone in the bridge needed between child welfare and substance abuse treatment agencies—is the assessment used by agencies to identify the needs and monitor the treatment of these parents with multiple problems served by multiple systems. We present options for blending assessment instruments that are now administered separately by each set of agencies, resulting in "layered assessments" that make the tasks of line workers more difficult and that force clients to go through repeated, overlapping assessment of their problems. This guidebook also makes a case for screening and assessment of AOD problems in much greater depth within the child welfare system, so that resources from the AOD treatment system can be matched with the known needs of parents.

We describe several models where agencies have been able to develop effective ways of linking child welfare services and AOD treatment and set forth the pros and cons of these models with a matrix that summarizes all nine models. The text reviews innovative practices in both the child welfare and substance abuse treatment fields, including changes in approaches to families, in interviewing techniques, in community partnerships, and in using treatment outcomes to determine which programs are most effective for which clients.

The guidebook reviews evidence of the demonstrated effectiveness of treatment for parents in the child welfare system, and makes a case that treatment has a significant payoff in costs that can be avoided if only a portion of the parents are able to reunify with their children. The report discusses the differences between parents who can be treated successfully after one episode of treatment, those who return for additional treatment episodes and eventually succeed, and those who do not succeed in treatment.

Because of the co-occurrence of AOD problems with clients affected by welfare reform, juvenile justice, family violence, and mental health, the report asserts that the CWS-AOD linkage is not enough, and goes on to describe models of stronger connections between child welfare clients and these other populations.

We draw nine lessons from the models, outline innovative practices, and present our recommendations based on these lessons. Addressing values issues that underlie policy disagreements is a major recommendation, along with active involvement of line workers whose support is essential to the success of innovation at front lines of the organization. The recommendations include urging use of several policy tools that are available to communities working in collaboratives, including resource mapping, budget analysis, annual spending inventories, a collaborative values inventory, and data matching to identify overlapping clients. Recommendations also call for the development of a "theory of resources" to ensure that pilot projects can expand beyond their initial areas of operation to tap the substantial funding for AOD treatment already available to communities.

In closing, the guidebook proposes several federal responses, including upgrading data collection, supporting blended funding experiments, and capitalizing on a requirement for a report to Congress from the Department of Health and Human Services on CWS-AOD issues in the new Adoption and Safe Families Act of 1997.

Appendix A includes a questionnaire used for assessing a community or collaborative's relative consensus on values concerning alcohol and other drugs, and Appendix B includes a dialogue among community participants, which illustrates some of the practice and policy choices discussed in the report. Appendix C lists members of the Review Panel, and Appendix D is the CWLA's Chemical Dependency and Child Welfare Task Force.

In conclusion, the report recalls the strong recommendations of the 1992 report of the North American Commission on Chemical Dependency and Child Welfare, which called for challenging the policies and practices of national and state efforts—and called for continued efforts to keep such challenges alive, building on the lessons of the model projects described in the report.

1 Facing the Problem

Introduction

Many parents coming into contact with the child welfare system are users and abusers of alcohol and other drugs (AOD), the effects of which can impair their parenting skills and threaten the safety of their children. Every child welfare agency in the nation has struggled with AOD problems among its caseload, and many have attempted to build more effective bridges between child welfare services (CWS) and AOD abuse treatment services. Those agencies that have been most active in addressing substance abuse have recognized that it is not a "stand- alone" issue, but rather is linked with delinquency, family violence, welfare reform, mental health, and the need for a stronger community role in supporting families. This guidebook focuses on understanding and improving approaches to AOD problems among child welfare clients, but also calls for a recognition of the several other problems beyond substance abuse that afflict many families.

Evidence drawn from numerous studies across the nation produces estimates that 40 to 80% of families in the child welfare system have problems with alcohol and other drugs and that those problems are connected with the abuse and neglect experienced by their children. Children are affected by their parents' alcohol and drug use in several ways, as illustrated in the chart on the following page. While prenatal exposure has received a great deal of attention in recent years, Table 1 shows that many more children can also be exposed through the behavior of their parents and through the environment in which they grow up. The underlying premise of this guidebook is that all of these forms of exposure to children are harmful and that child welfare agencies and AOD treatment agencies must increasingly work together to reduce this harm.

The Scope of the Problem

Problems related to the use of alcohol and other drugs impact the child welfare system in a number of ways—by increasing CPS caseloads, contributing to the number of children entering foster care, and interfering with the ability of families on welfare, some of whom are also in the child welfare system, to secure employment.

The Overlap: Parents in the Child Welfare System with AOD Problems

With an estimated 13 million children living with a parent who reportedly has used illicit drugs in the past year and some 28.6 million children living in alcoholic households [Colliver et al. 1994], a significant number of children may be at risk of maltreatment. But not all of these children will become victims of child abuse or neglect and, obviously, not all of those who are victims will be reported to public agencies.

insert table

Though researchers have yet to accurately document the prevalence of substance abuse problems among families within the child welfare system, most have come to agree that 40 to 80% of parents with children in the child welfare system have AOD-related problems serious enough to affect their parenting. Below are just a few of the studies documenting the overlap:

• Of the nearly 1 million children found to be substantiated victims of child abuse and neglect in 1995, at least 50% had chemically involved caregivers [CWLA 1997].
• For two consecutive years, more than three-fourths of states (76% in 1996 and 80% in 1995) reported that substance abuse is one of the top two conditions assessed as problems for families reported for maltreatment [Wang & Daro 1997].
• Famularo and his colleagues found that more than two- thirds (67%) of child maltreatment cases involved a substance-abusing parent [Jaudes et al. 1995].

In addition, studies indicate that parental substance abuse is associated with recurrent reports of child abuse and neglect. Wolock and Magura concluded that parental substance abuse of any kind results in an increased likelihood of a subsequent report to CPS, and the effect of drugs and alcohol combined is particularly strong. Here are some additional findings:

• Children who are prenatally exposed to drugs are two to three times more likely to be abused than other children. In their study of more than 500 infants exposed prenatally to illicit substances, reports of abuse were subsequently filed for close to one-third (30%) of the children, two-thirds of which were substantiated. Of the substantiated cases, 51% were abused once, 37% twice, and 12% three or more times [Jaudes et al. 1995].
• A study of families reported to CPS who were followed for an average of two years found that in 55% of the families, one or both caretakers were identified as having a substance abuse problem. One or more recurrent reports were reported in just over half of these families [Wolock & Magura 1996].

What does "best interests of the child" mean in AOD cases? There seem to be three levels of answers to the question:

• What the child needs in terms of immediate safety: who is competent right now to serve as caretaker on a daily basis?
• What the child needs him/herself: what level of intervention or treatment will best strengthen the protective factors needed to break the cycle of AOD abuse for that child?
• What the child needs in the longer term: what is the best possible relationship with his/her birth parents that will lead to family stability in later life?

The Effect of Substance Abuse on the Foster Care System

As Cole and her colleagues point out: "Whatever the prevalence of children exposed to drugs and alcohol in the general population, there can be little doubt that the vast majority of children entering foster care are affected by living in substance-abusing families" [Cole et al. 1996]. And the number of children entering foster care continues to skyrocket—in 1996, the figure topped 500,000, a 47% increase from the 340,000 cases in 1988 [DHHS 1997].

It is estimated that substance abuse is a factor in three-fourths of all placements. Children under 5 are the most vulnerable to abuse or neglect by a substance-abusing parent and represent the fastest growing population in out-of-home care [Day et al. 1998]. Several studies highlight the prevalence of AOD-problems among foster care cases:

• The U.S. General Accounting Office recently found that parental substance abuse was a factor for 78% of the children entering foster care in Los Angeles, New York City, and Philadelphia County [GAO 1994].
• In a recent CWLA survey, state child welfare agencies estimated that parental chemical dependency was a contributing factor in the out-of-home placement of at least 53% of the child protection cases [CWLA 1997].
• In that same survey, more than two-thirds (67%) of state child welfare agencies said that AOD-involved families are "much more likely" or "more likely" to reenter the child welfare system over a five-year period, compared to non- AOD-involved families [CWLA 1997].
• In Washington state, 41% of infants placed in out-of-home care in 1995 were born to mothers who abused alcohol or other drugs during their pregnancy.

Effects of Alcohol and Other Drug Abuse on a Parent's Ability to Care for Children

Use of alcohol and other drugs can seriously compromise a parent's capacity to protect a child, and such use interferes with the individual's general functioning in a number of ways. Bays [1990] stated that up to 90% of drug abusers have mental, emotional, or personality disorders that can compromise their ability to care for their children and influence poor parenting skills. More specifically, AOD use, abuse, and dependence can have the following effects [Besharov 1992]:

• Interfere with thought processes and thus consistent parenting processes—a parent's mental functioning, judgment, inhibitions, and protective capacity may become impaired.
• Interfere with the ability to respond consistently and sensitively to a child—a parent may be less sensitive, responsible, and accessible to infants. This can decrease the development of secure attachments between mother and child.
• Leave the parent emotionally and physically unavailable to a child—caseworkers may have difficulty getting a parent to focus on needs of the child.
• Lower a parent's threshold of aggression toward children.
• Result in a parent spending household money needed for food, clothing, and other basic needs on alcohol and other drugs.
• Be associated with criminal activity that may jeopardize a child's health and safety.
• Lead to the neglect of a child's routine health care needs, including well-baby checkups and immunization schedules.

Changing Practice and Policy

In recognition of the growing scope of this problem, policy reflected in recent federal and state legislation and in innovative practice in several communities shows a new emphasis on working with AOD services and agencies to help achieve the goals of the child welfare system. Efforts to strengthen the connections between these agencies have taken several forms:

• Set-asides from each system to work with children and families served by both systems,
• Federal waivers in one state (Delaware) to work with AOD- affected families in CWS^* caseloads,
• State efforts to develop new and blended AOD-CWS risk assessments,
• State action to include AOD treatment in supportive services for welfare clients under Temporary Assistance for Needy Families (TANF),
• Proposals (in federal legislation not yet passed) to expand the use of CWS funding for treatment services, and

* Throughout this document, we refer to CWS (child welfare services). This is intended to mean the full range of child welfare agencies that address issues of out-of-home care, including foster care, adoption, and other forms of permanency planning. Child protective services (CPS) are mandated to address child safety issues, while CWS agencies have larger concerns with child well-being and family functioning. When we are discussing the narrower concern within CPS units for risk assessment and the actions taken by CPS units to ensure child safety, we will shift the focus of the guidebook from the larger CWS arena to the CPS units within it.

• An in-depth, federal study of how child welfare and AOD treatment services can connect more effectively (required by the Adoption and Safe Families Act of 1997).

Efforts by several prominent organizations, including the Child Welfare League of America (CWLA), have spotlighted these issues in the past few years.* CWLA's Chemical Dependency and Child Welfare Task Force, first convened in 1990, was reestablished in 1997 and continues its work at present. With funding from the U.S. Office of Juvenile Justice and Delinquency Prevention and as part of Secretary Shalala's National Initiative on Youth Substance Abuse Prevention, the CWLA task force is developing several projects to strengthen services for children and families experiencing AOD problems in child welfare. (This guidebook is one of those projects.)

At the same time, in several innovative sites around the nation, child welfare practice has been changing through new training curricula, out-stationing staff in such other settings as schools and family resource centers, links with juvenile justice agencies and the courts, community partnerships that bring AOD and CWS staff together with neighborhood residents in decentralized service models, and negotiated agreements for referral to and assessment by treatment agencies.

* Some of these organizations include the Children's Defense Fund, the American Humane Association, Drug Strategies, the American Public Welfare Association, the National Association of State Drug and Alcohol Directors, Legal Action Center, and the Center for Substance Abuse Treatment in the U.S. Department of Health and Human Services. Funding for AOD-CWS demonstration projects has come from the Edna McConnell Clark Foundation, the Robert Wood Johnson Foundation, the Annie E. Casey Foundation, the Stuart Foundation, and others.

In recent years, the concern for the children affected by substance abuse has broadened well beyond the most visible examples of the need for connection between CWS and AOD: infants born with evidence of prenatal drug exposure. While tragic, these children represent fewer than 5% of all the children significantly affected by their parents' substance abuse [Young 1997]. Many of the innovations described in this guidebook began with a focus on prenatal drug exposure but moved to embrace the full range of problems among children and youth affected by alcohol and other drugs.

There has also been a growing recognition of the cumulative effects on children of the combination of AOD abuse and child abuse or neglect [Levoy et al. 1990]. The juvenile justice system has devoted particular attention to the relationships between child abuse and delinquency, focusing in several recent studies on the correlations between earlier child abuse and later delinquent behavior. Some studies have concluded that parents' AOD problems are especially powerful risk factors for youth, making it more likely that they will have problems in adolescence and later life [Rivinus 1991]. Several demonstration projects are targeting children who are most likely to "age into" the juvenile justice system from their earlier exposure to the CWS system, or those who have already become known to both systems.

The Sacramento County Case Study. In 1993, Sacramento County's Department of Health and Human Services (DHHS) responded to the growing number of child protective cases in the County that involved AOD-related problems. With an estimated 2,000 drug-exposed infants born annually and requests for AOD services accounting for nearly 30% of all Family Preservation service requests, the DHHS leadership assessed the agency's capacity to meet these needs and concluded that at best it could respond to no more than 25% of the need. The Department, under the leadership of then-Director Robert Caulk, developed a multifaceted initiative focused on changing the child welfare and other systems through training and making AOD assessment and intervention part of the responsibility of every worker. The clear and ambitious goal: to provide "direct AOD treatment on demand." The Department developed three levels of training for more than 2,000 employees, providing core information on chemical dependence in the first level, teaching advanced assessment and intervention skills in the second level, and building group treatment skills in the third level.

A rich set of lessons is emerging from several years of demonstration projects supported by private foundations as well as by state and federal governments. These include the Community Partnerships of the Clark Foundation, the Family to Family Projects of the Casey Foundation, demonstration projects sponsored and funded by the National Committee on Child Abuse and Neglect, studies funded by the U.S. Office of Juvenile Justice and Delinquency Prevention, and the "Starting Early/Starting Smart" project, a joint effort of the Casey Family Program and the Substance Abuse and Mental Health Administration, which includes grants for programs addressing the needs of children age 0-7 who are at high risk of developing problems related to the AOD or mental health problems of their parents.

This guidebook draws on the lessons from several of these demonstration projects. In many ways, however, some of the most instructive lessons emerge from a single case study: Sacramento County's four-year (and ongoing) initiative, which has addressed CWS-AOD issues in a larger context of other systems, including welfare, criminal justice, and health services. Thus, the Sacramento case study of CWSAOD connections is featured throughout this guidebook, illustrating many lessons for other projects and other communities.

Interaction with Other Systems: TANF, Juvenile Justice, Family Violence, and Mental Health

Some of the urgency in recent bridge-building efforts stems from the potential impact on child welfare agencies of the 1996 federal legislation that created the Temporary Assistance for Needy Families (TANF) program. While we lack comprehensive data as to how many clients are enrolled concurrently in TANF, child protective services caseloads, and AOD treatment, numerous studies have documented that these multiproblem families are the highest risk clients in each of these systems [Young & Gardner 1997].

Although this guidebook will focus primarily on CWS-AOD linkage, it will also examine the emerging models of TANF-AOD connections, since welfare reform changes are certain to affect child welfare caseloads in years to come. Substantial CWS impacts are predicted both by the welfare reform optimists (who believe that children will be much better off in families with parents working and free of welfare dependence), and by the pessimists (who believe that neglect cases will increase substantially as parents who are removed from welfare find they cannot hold jobs). Which of these proves true, and for which children and families, will depend upon implementation decisions made in communities throughout the nation. Understanding the impacts of welfare reform will also require that communities make serious efforts to monitor the effects of reform beyond simple measures such as caseload reduction.

Three other systems need to be considered in the process of enhancing the connections between CWS and AOD services: (1) the related areas of juvenile justice, delinquency prevention, and youth development; (2) family violence; and (3) mental health. In addition to TANF, these are the parallel systems, combined with the indispensable roles of parents and the wider community, that have the resources to promote family stability. If these separate systems cannot forge closer links, each will be forced to work within its own limited resources, when it is clear that the resources of more than one system are needed to address the needs of families with multiple problems. The practices and policies of other systems play crucial roles in the future of the child welfare system, leading to a powerful paradox: the well-being of many children and the future of child welfare is heavily dependent on decisions made outside the child welfare system, in the form of both daily practice and public policy.

The Need for a Policy Framework

In recent work in this area, a six-part framework has proven a useful way to organize discussion of the policy issues raised when CWS and AOD agencies and programs are brought together.* The policy framework includes values, daily practice, training, outcomes and information systems, budgets, and service delivery. The elements serve as a template for developing and assessing initiatives that go beyond pilot projects to attempt system-level change. It should not be applied as a simple checklist, however. These six elements are interdependent, as revealed in the Sacramento initiative described below and in several other model projects. Although it is obviously possible to launch projects that feature innovations in only one or two of these dimensions, the most important premise of the framework is that working solely within a single area will ultimately fail, because the other ingredients are missing or not addressed in depth. Innovation has to begin somewhere, and carefully choosing the correct entry point in each policy setting is the first step, which must be followed by working across all six areas.

These elements also help us understand why it is difficult to link CWS and AOD services, despite the excellent efforts undertaken by those agencies and communities (described on page 27 and following). In each of these areas, there are formidable barriers to connecting the two systems—and to working with other systems as well.

The Importance of Bridging the Practice-Policy Gap

The policy framework proposed in this guidebook is based on a conviction that the worlds of policy and practice remain too far apart in both CWS and AOD arenas. Attempts to change daily practice necessarily require policy change, or they become isolated pilot projects that cannot be sustained or expanded. Practice can raise important questions about the lack of CWS-AOD connections, but it requires a policy process to respond to these problems with more than ad hoc, crisis-driven, temporary fixes. At the same time, without changes in practice, the policy process often operates to ratify and protect the status quo, which is always the least disruptive policy to implement.

* This framework draws upon a 1997 report that the authors prepared for the Stuart Foundation, Bridge Building: An Action Plan for State and County Efforts to Strengthen Links between Child Welfare Services and Services for Alcohol and Other Drug Problems. Irvine, CA: Children and Family Futures.

So, practice and policy must be considered together when attempting to effect meaningful change. But the usual relationship between the two worlds ranges from benign ignorance to outright disdain. Those more familiar with the policy world may perceive hands-on practitioners as too overwhelmed by their work to see "the big picture" of resources and legislation, while practitioners may regard those from the policy sector as hopelessly unrealistic, far removed from the realities of daily practice and the dynamics of working with challenging clients in troubled communities.

A closer, mutually respectful relationship is needed between the world of the "hands-on" line staff and the world of the policymakers and budget staffs. Bringing together these two worlds is essential to build the bridges between CWS and AOD, since many policy issues that cut across the two sectors need action in both policy and practice realms:

• The impact of state and local budget decisions about CWS staffing and caseloads;
• The need to develop a resource strategy that breaks out of the pilot project mentality to create and carry out a design for going to full scale—redirecting significant core agency budgets and neighborhood assets, rather than relying solely on external grants;
• The concentration of resources on specific neighborhoods in ways that may affect overall citywide or countywide allocations;
• The impact of assessment practice in changing policy to direct resources to clients who need help; and
• The potential for securing new resources from other agencies that can support community partnerships with AOD services, family violence services, child care, and school- linked services.

These are all policy issues, in the sense that policy consists of choosing a course of action and putting resources behind it. But these choices can and must be informed and shaped by the realities of daily practice undertaken by skilled professionals, helpers, and parents. Practice needs to inform policy; policy needs to provide a framework for rational decisions that support the best kinds of practice. Policy can institutionalize best practices, ensure that they can be sustained, and provide the resources to assess their effectiveness in helping clients and communities. Practice changes are unlikely to survive unless policy supporting those changes is put in place prior to their expansion.

Why Values Matter

It is impossible to think and work effectively on issues of child abuse, substance abuse, and poverty without understanding how deep- seated our underlying values are on these issues. Our attitudes about how to treat children are learned and taught in our cultures from the earliest days of family life. Our attitudes toward legal and illegal drugs are the product of centuries of public opinion in this nation, going back to Prohibition, the Puritan era, and beyond. And the ways we think about the causes of poverty are at least four centuries old, dating from the Elizabethan Poor Laws and coming down to the intense debates over welfare reform in the mid-1990s. Sometimes we stereotype when we think and talk about these difficult issues.* When we do, it becomes more difficult to make policy or change practice, because the ingrained ways of thinking about these issues in polarized language force the middle ground options out of the debate.

* Children and Family Futures believes that the values framework in which we discuss these issues is so important that it must be addressed as a critical part of any community's efforts to work collaboratively. We have developed a Collaborative Values Inventory as a neutral tool used to reveal the underlying values that collaborations often submerge in their desire to avoid conflict. This tool is attached as Appendix A.

As we noted in the Winter 1998 issue of Public Welfare [Young & Gardner 1998], some individuals and some workers believe that society should take children away from their parents if the parents are abusing drugs. The subject becomes more difficult, however, when we recognize that millions of children live in middle-income homes where substance use—and substance abuse—are common occurrences that do not come to the attention of protective services agencies. The distinctions among use, abuse, and chemical dependence are crucial to understanding the interplay among dependence, neglect, child abuse, poverty, and a lack of job skills. Our ability to decide accurately when AOD abuse and dependence endanger children has not grown as fast as our recognition that millions of children are undeniably affected by their parents' AOD problems.

We believe that there is a middle ground in which both sets of underlying values—child safety and family stability—can be endorsed while designing systems that achieve a balanced set of obligations:

• Placing the responsibility on parents to do everything they can to provide a safe and supportive home for their children, and
• Placing the responsibility on society and its service systems to provide parents with the resources they need to end their chemical dependence and its harmful effects on their children.

Children's needs will not be met by either a strict demand for abstinence or, at the other extreme, the too-frequent practice of ignoring substance abuse problems until they become severe enough to move toward terminating parents' custody rights. Yet the public debate over these issues tends to swing from pole to pole, rarely confronting the hard choices necessary to ensure that parents are given a fair chance to recover and that children are given a fair chance to live in nurturing homes with loving caretakers.

The recent legislative history of AOD issues in social welfare and child welfare is instructive, revealing the preoccupation of some law- makers with sanctioning clients who abuse drugs and punishing those with past drug felonies. In the TANF legislation, references to drug testing and prohibitions aimed at clients convicted of drug felonies were the only AOD issues addressed in the law. But the federal law was silent on what to do about the estimated 1 million women who may need treatment to enable them to perform effectively at new jobs. In some states, however, more in-depth approaches to the issue included set-asides of specific resources for treatment of TANF clients.

The Adoption and Safe Families Act of 1997 signed by the President last November originally included detailed provisions and funding for building closer ties between child welfare and AOD agencies. But unable to agree on how to respond to overlapping substance abuse and child abuse issues, Congress removed all provisions to providing AOD treatment with child welfare funding and charged DHHS with conducting a study of the issue.

Daily Practice

Ensuring the competence and thoroughness of daily practices of line CWS and AOD workers is critical to making lasting change. Some training initiatives have encountered problems because they did not recognize that without new incentive systems, newly trained workers would have little reason to use new practices in their day-to-day work with clients. The fundamental connection between client and worker is at the heart of AOD diagnosis and treatment, and different approaches to that all-important relationship are described below. Assessment, the process at the core of how workers make judgments about their clients, is discussed in Chapter 5, since it constitutes and influences much of daily practice in both the CWS and AOD systems.

Training

Training is a crucial element in system innovations, but training alone cannot achieve system reform. Furthermore, most training today is categorical, operating as though the system in which it operates were the only system in which workers function. We frequently hear complaints by workers and supervisors in both CWS and AOD systems who state that they know far too little about the other systems with which they should be working more closely. (After the new training of more than 1,000 Sacramento County health and human services staff and others from community agencies and other county departments, workers strongly expressed their positive responses, as quoted later in this report.)

Outcomes and Information Systems

For good practice to lead to better outcomes, it must be accompanied by a move toward results-based accountability. The use of defined outcomes as client-level measures of a program's impact, rather than measuring the units of services provided or the number of clients served, has accelerated in the past decade as a critical management trend affecting both child welfare and the treatment field. Under pressure from managed care in general and behavioral health firms specifically, outcomes-based evaluation has progressed further in the AOD field than in the CWS arena. But to date, funding organizations (both government agencies and private foundations) have not fully adopted results-based evaluation or results-specific budgeting for either CWS or AOD agencies [Gardner 1996]. Agencies are collecting and using outcomes, but budget decisions are not linked to outcomes in any sustained way in most child welfare or AOD treatment agencies. Some of the most basic information about what happens to clients is not collected by child welfare agencies or by many treatment agencies.

Comprehensive Training. Sacramento implemented its training based on the fundamental belief that "department members from every level...must have the capacity to address alcohol and other drug issues." This basic premise should underlie all such efforts. The prerequisite to a serious commitment to training is a recognition that the great majority of workers in the child welfare system and in the treatment agencies do not know enough about "the other side" to work effectively across systems.

As CWLA summed up in 1997: "...a majority of state child welfare agencies are not equipped to deal with chemically involved clients. Many agencies do not have data collection processes, assessment protocols, policies, or programs that are responsive to youths' AOD needs" [CWLA 1997].

Budgets

Connecting CWS and AOD agencies must happen in a world of categorical funding. Despite growing familiarity with "wraparound funding," new legislation that enables blended funding, and the success of some well-funded demonstration programs in tapping dozens of sources from different state and federal agencies and private foundations, the world of daily practice remains a world of categorical policy making and categorical funding streams. That context eventually constrains all efforts to link programs funded from different sources and makes it far more difficult to assemble resources, train workers, and refer and treat clients across the boundaries of these separate systems.

Service Delivery

The final element of the policy framework is how services are actually delivered, whether through the efforts of CWS workers, nonprofit contractors, behavioral health firms operating managed care contracts, faith-based organizations, or neighborhood-based family support organizations. The shift to expanded use of both managed care and community-based networks of agencies needs to be taken into account in describing recent changes in the ways these services are delivered.

Barriers to CWS-AOD Links

The barriers to CWS-AOD connections loom large in each area of the policy framework. Potential conflicts in values and philosophies held by each domain occur over such fundamental issues as, "Who really is the client, the parent or the child?" There are many other differences between the CWS and AOD systems that make it difficult to develop links, including differences in the style of daily practice by line staff, how they screen and assess clients' needs, the education and background of workers, how each system measures and defines success for its clients, what data it collects about its clients, the funding streams and the financial assumptions of the two systems, and ways in which the two systems are moving toward both managed care and neighborhood-based service delivery.

One AOD practitioner summarized the barriers between the two systems in strong language:

I don't believe the substance abuse system has wanted to embrace responsibility for assisting in the determination of child placement and operationalizing the role of addiction and recovery in child protection ... I also think that most child protection workers don't believe that treatment works, and when added to the issues around difficult access, relapse, sequential case planning, treatment is just another variable to deal with in disposition of the case ... This results in consecutive and incompatible case management rather than concurrent planning . . . As the substance abuse field has been able to assist the criminal justice system in making determinations between incarceration and treatment, so we must become more adept in assisting the child welfare system in the determinations for which they are responsible, when substance abuse is a factor [personal communication 1998].

All of these pose major challenges to the effort needed to bridge the gap between the two systems. Considering the many obstacles to coordination of CWS-AOD agencies, the achievements of states, communities, and agencies that we describe in Chapter 2 are all the more impressive; the models show how innovative practices and policies can work together to overcome barriers.*

Timing Barriers: The "Four Clocks"

A key barrier that needs specific attention is what we term the "four clocks problem"—the four completely different timetables that can affect children and parents in an AOD-abusing family:

• The child welfare system timetable of six-month reviews of a parent's progress, which the new federal legislation accelerates to a requirement for a permanency hearing at 12 months.
• The timetable for treatment and recovery, which often takes much longer than AOD-based funding allows, and which is often incompatible with child welfare deadlines for parents who may have relapsed but are still working at their recovery; some have summarized the AOD timetable as "one day at a time, for the rest of your life."
• The timetable now imposed for TANF (former AFDC) clients who must find work in 24 months. (This is the federal maximum; some states have lower limits and thus some clients are already reaching the cutoff point.)
• The developmental timetable that affects children, especially younger children, as they achieve bonding and attachment—or fail to—as they pass through the period of the first 18 months, which new research on brain development has shown to be a critical period of time in a young child's life.

* A full discussion of the barriers between the systems can be found in several previous works, including the following: Child Welfare League of America (1992). Children at the front. Washington, DC: Author; Gardner,  
S. L., & Young, N. K. (1997). Bridge building; and Gardner, S. L., & Young, N. K. (1996). The implications of alcohol and other drug-related problems for community-wide family support systems. Cambridge, MA: The John F. Kennedy School of Government, Harvard University.

Barriers in Defining the Client

A further basis for the problems between the two systems arises in the competing demands for AOD services for populations other than children and families. In part due to the improving information base about what kinds of treatment are most effective for which kinds of clients, demands for AOD support services have multiplied from the criminal justice system, the mental health system, and now, notably, the overlapping welfare/TANF system. Treatment for inmates has been an area of increasing emphasis, given the number of drug offenders in state prisons and local jails. Resources in the AOD system are scarce in the short run, and the call for expanded responsiveness to the special needs of children and families in the CPS system conflicts in important ways with these other demands. With waiting lists for different kinds of clients, those with special claims in the eyes of their sponsoring agencies may not meet the same priorities in other agencies.

For a CPS worker, the client is both the child and the family, with the risk to the child as the primary short-term concern and the safety of the child the longer range priority. But for a worker in the AOD treatment system, clients are addicts and alcoholics, usually adults, and their status as a parent is generally irrelevant unless they are in one of the few perinatal programs or a special program for mothers and their children. In most treatment programs, the children of clients may not be seen as important; they may be cited as an incentive for recovery, but are usually not involved in any active way themselves. The AOD worker also may identify with the client because she/he is likely to be recovering from addiction and more readily understands the client's problems and the mechanisms of denial and avoidance.

In contrast, a CPS worker dealing with a known substance abuser is generally frustrated and sometimes even angry at such a parent, because of the risks to the child. Depending upon the worker's own attitudes, the client may be seen as suffering from a powerful disease for which treatment must be sought—but is more typically viewed as a selfish, thoughtless parent with no regard for her or his child. Judges and the court system can accentuate these attitudes when they adopt a "zero-tolerance" approach that emphasizes solely punitive measures and reflects little understanding of AOD treatment or parental functioning.

The differences between the CPS and AOD systems' responses to licit and illicit drugs are also important barriers at times. Practitioners have pointed out how CPS focuses on illegal substances and overlooks alcohol abuse and its consequences on the family, despite the much greater overall damage done to children both prenatally and environmentally by alcohol.

Differences in agency perspectives on who is the client also lead to issues of confidentiality, which are discussed at greater length in Chapter 6.

Barriers of Different Training and Education

Workers in the two systems are trained differently and tend to have different educational backgrounds. The content of training in the two systems rarely addresses the connections between the systems or methods that could be used to work across systems in identifying and assessing AOD-related problems.

A recent review of CWS training in universities documented the lack of emphasis upon addiction issues as they affect children and the complexities of working across the two systems. Most of what is included focuses on perinatal substance abuse and the issues of the positive toxicology screen at birth. These "doses" of exposure to AOD issues appear disproportionately small, compared to the importance of these issues in CWS work. As one trainer put it, while working in a program that provides an in-service orientation to addiction for health and human services professionals who work across CPS-AOD agency lines, "What we are doing here is remedial—they should have gotten all this in their preservice programs."

Workers in the AOD system are trained in a wide variety of fields. A significant percentage of them have come through the treatment system themselves. While some have advanced degrees in counseling and other fields, many frontline workers have little formal training. This is especially true when mutual aid programs are factored into the spectrum of AOD treatment programs. In these self-help oriented systems, the "helpers" are lay people who draw heavily on their own experience rather than on formal education.

Funding Barriers

The funding barriers that impair CWS-AOD connections include the complexity of categorical funding, the barriers to reimbursement for many of the treatment needs of parents and adolescents, and a tendency of each "side" of the CWS-AOD relationship to protect its own funding sources and seek allocations from the other. Representatives of the two groups would doubtless add a fundamental resources gap in total spending to the list of funding barriers. Waiting lists in some states and communities provide evidence of this barrier, despite the absence in most communities of any total inventory of AOD spending. Federal earmarks are cited by some AOD providers as funding barriers to working with CWS clients, although the national allocation of approximately 27% of all publicly funded treatment slots to women reflects state priorities for providing treatment to men, especially those in prison, rather than federal requirements for such a division of funding.

The funding barriers also lead to problems caused by the inability of either CWS or AOD agencies to control their own resources, due to two major external forces: the decisions of courts and the decisions of managed care firms in the behavioral health field. In both cases, resource decisions are significantly out of the hands of the CWS or AOD agencies, which means that when the two sets of agencies do seek to cooperate, outside mandates may make it more difficult because of a requirement set by a court or a regulatory burden of proof created by a managed care firm that makes it difficult to arrange appropriate treatment for some clients. Without education and training aimed at these key external decision makers who affect CWSAOD links, barriers from outside the two sets of agencies will continue to affect bridge-building efforts launched from within these agencies. Is a Policy Framework Realistic?

It can be argued that policy making on issues as difficult as child abuse, substance abuse, and family violence is unavoidably crisis- driven, episodic, and incremental at best. In such an environment, innovation is difficult to launch and even more difficult to sustain beyond the level of pilot projects. But there are a sufficient number of states and communities that have developed such sustained innovation in recent years, under the pressures of rising caseloads and greater understanding about the problems of substance abuse, to justify the attempt to set forth and refine a framework that could better guide policy making in a more comprehensive, less fragmented fashion.

The quest is not for rigidly coordinated, fully rationalized policy; it is rather for policy that goes beyond reacting to symptoms and crises to address the underlying forces that affect child abuse. Such policy can emerge from a framework, as described in this guidebook, that views inevitable crisis as an opportunity for reform, rather than a demand for quick fixes with more regard for media spin than the lives of children.

References

Anderson, M., Elk, R., and Andres, R. (1997). Social, ethical, and practical aspects of perinatal substance use. Journal of Substance Abuse Treatment, 14 (5), 481-86.

Bays, J. (1990). Substance abuse and child abuse impact on addiction on the child. Pediatric Clinics of North America, 37 (4), 881-905.

or AOD agencies, which means that when the two sets of agencies do seek to cooperate, outside mandates may make it more difficult because of a requirement set by a court or a regulatory burden of proof created by a managed care firm that makes it difficult to arrange appropriate treatment for some clients. Without education and training aimed at these key external decision makers who affect CWSAOD links, barriers from outside the two sets of agencies will continue to affect bridge-building efforts launched from within these agencies. Is a Policy Framework Realistic?

It can be argued that policy making on issues as difficult as child abuse, substance abuse, and family violence is unavoidably crisis- driven, episodic, and incremental at best. In such an environment, innovation is difficult to launch and even more difficult to sustain beyond the level of pilot projects. But there are a sufficient number of states and communities that have developed such sustained innovation in recent years, under the pressures of rising caseloads and greater understanding about the problems of substance abuse, to justify the attempt to set forth and refine a framework that could better guide policy making in a more comprehensive, less fragmented fashion.

The quest is not for rigidly coordinated, fully rationalized policy; it is rather for policy that goes beyond reacting to symptoms and crises to address the underlying forces that affect child abuse. Such policy can emerge from a framework, as described in this guidebook, that views inevitable crisis as an opportunity for reform, rather than a demand for quick fixes with more regard for media spin than the lives of children.

References

Anderson, M., Elk, R., and Andres, R. (1997). Social, ethical, and practical aspects of perinatal substance use. Journal of Substance Abuse Treatment, 14 (5), 481-86.

Bays, J. (1990). Substance abuse and child abuse impact on addiction on the child. Pediatric Clinics of North America, 37 (4), 881-905.

Besharov, D. (1992). When drug addicts have children. Washington,

DC: American Enterprise Institute and Child Welfare League of America

Child Welfare League of America. (1997). Alcohol and other drug survey of state child welfare agencies. Draft report, unpublished. Washington, DC: Author.

Cole, E., Barth, R., Crocker, A., & Moss, K. (1996). Policy and practice challenges in serving infants and young children whose parents abuse drugs and alcohol, Boston, MA: Family Builders Network.

Day, P., Robison, S., & Sheikh, L. (1998). Ours to keep: Building a community assessment strategy for child protection. Washington, DC: Child Welfare League of America; see also National Center on Addiction and Substance Abuse at Columbia University, http://www.casacolumbia.org.

Gardner, S. L. (1996). Moving toward outcomes: An overview of the state of the art and key lessons for agencies. Honolulu, HI: The Hawaii Community Services Council.

Gregoire, T. (1994). Assessing the benefits and increasing the utility of addiction training for public child welfare workers: A pilot study. Child Welfare, 73(1), 69-81.

Jaudes, P., Ekwo, E., & Voorhis, J. (1995). Association of drug abuse and child abuse. Child Abuse and Neglect, 19(9), 1065-1075.

Levoy, D., Rivinus, T.M., Matzko, M., & McGuire, J. (1990). Children in search of a diagnosis: Chronic trauma disorder of childhood. New York: Brunner/Mazel Publishers.

Reid, G., Sigurdson, E., Wright, A., & Christianson-Wood, J. (1996).

Risk assessment: Some Canadian findings. Protecting Children, 12, 24-31.

Rivinus, T.M. (Ed.) (1991). Children of chemically dependent parents: Multiperspectives from the cutting edge. New York: Brunner/ Mazel Publishers.

U.S. Department of Health and Human Services. (September 17, 1997).

HHS invests in America's children. Fact Sheet available online at http://www.os.dhhs.gov.

U.S. General Accounting Office. (1994). Foster care: Parental drug abuse has alarming impact on young children. Washington, DC: Author.

Wolock, I., & Magura, S. (1996). Parental substance abuse as a predictor of child maltreatment re-reports. Child Abuse and Neglect, 20(12), 1183-93.

Young, N. K. (1997). Effects of alcohol and other drugs on children.

Journal of Psychoactive Drugs, 19(1), 23-42. The 5% estimate is based on the percentage of all prenatally exposed cases that were referred to the county CPS agency in Los Angeles County in 1993, compared with estimates of the wide incidence of effects on children affected by drugs and alcohol by family and environmental sources, using national figures drawn from a variety of sources.

Young, N. K., & Gardner, S. L. (1997). Implementing welfare reform: Solutions to the substance abuse problem, Washington, DC: Drug Strategies and Irvine, CA: Children and Family Futures.

Young, N. K. & Gardner, S. L. (1998). Children at the crossroads.

Public Welfare, 56(1), 3-10.

2 Seeking Solutions

Models of Current CWS-AOD Links

To understand how child welfare agencies are responding to AOD problems, we need to examine the progress made in each of the five core areas of the policy framework. The successes and impressive pilot projects described in this section represent a substantial body of work in the decade or more since the interrelatedness of CWS and AOD problems first attracted national attention. We have sought to distill the essential knowledge from hundreds of practitioners, policymakers, and advocates; their voices can be heard throughout this guidebook.

Based on the policy framework that we have described and on nine model strategies, the matrix shown in Table 2 (on page 28) summarizes the state of the art in efforts to address AOD problems among child welfare cases [Young & Gardner 1998]. Some sites that have employed a particular model have been operational for three or four years, while others are in the early demonstration stages. But the range of options shows how different states and communities have approached the tasks of building new links across systems and with communities.

The noted sites are examples of programs based on these models; these are not the only sites where these approaches are being pursued. Some of the innovative projects and initiatives described in this chapter focus on only one of the features included in the matrix, while others have been designed as comprehensive initiatives and incorporate more than one facet of the framework.

Following our discussion of these model approaches that work across CWS and AOD systems, we turn to several innovative practices within the child welfare field and examine how these innovations interact with the growing effort to respond to AOD problems. Because of the great importance we attach to assessment practice as the process that bridges the CWS and AOD systems and that promotes interaction among and across all five of the framework elements, we also include a separate section that discusses innovation in screening and assessment of AOD problems as they affect referral of CWS parents to treatment.  

Characteristics of the Models: Strengths and Concerns

Nine model strategies are included in the matrix. Salient features and issues of each model are summarized below:

Paired AOD Counselor and CWS Worker. The model relying on an AOD counselor paired with a CWS worker has the advantage of multiple staff resources, which is also its obvious disadvantage—its cost. The model also operates from an assumption which some practitioners question—that a specialist orientation is essential to working effectively with the family, rather than teaching each professional enough about the other set of functions to be able to make connections without dedicated specialized staff.

AOD Counselor Out-stationed at a CWS Office as Technical Assistance. The model based on AOD staff out-stationing brings the advantage of line staff expertise immediately available to work on a case, which may reduce the pressures felt by CWS workers or neighborhood workers dealing with substance abuse for the first time. However, AOD out-stationing by itself doesn't change the home institution from which the worker is out-stationed. Moreover, out- stationed workers can become isolated from the "home office," unable to command its resources beyond token levels.

AOD Screener in CWS/Welfare Office. When an AOD screener is added to the service unit, the screener functions as a gatekeeper for current AOD resources and may trigger more slots for CWS clients. CWS staff still function as intake screeners for referrals. AOD workers then screen clients, but they may refer on to an unchanged AOD system in which no new priority for CWS parents has been negotiated. In an interesting variation on this approach, Oregon has placed CWS and welfare staff on loan to the AOD office to deal with policy issues. This puts CWS and welfare expertise inside the AOD agency, rather than vice versa.

Multidisciplinary Team for Joint Case Planning. Multidisciplinary teams are perhaps the most thorough staff-level reform possible. But implementing this reform at more than pilot project levels demands a "theory of resources" (discussed in Chapter 3), since it is difficult to sustain such teams beyond the pilot project phase which may become a "Cadillac model" that is hard to support. Such pilot projects tend to drift into a system maintenance role because they are so costly, in contrast to promoting system change that permanently redirects staff resources toward institutionalizing such teams as a part of the normal staffing pattern.

Paired CWS Worker and Person in Recovery. Staffing a team with a recovering person provides strong rapport and access to clients, enabling the CWS worker to perform the sanctioning role while the recovering staff member can play a more supportive role. Relying on the unique expertise of a peer from the community can reduce the client's denial and avoidance problems, as the worker both empathizes with and challenges the client. The risk of this approach is role confusion and the difficulties of building an effective partnership with an uncredentialed lay person who may face the problems of adjusting to a system that does not value lay experience as much as professional credentials and time in service.

Infusion of AOD Strategies Through Training. The AOD infusion approach (used by Sacramento County and other sites) is, in our view, by far the most appropriate way to achieve genuine reform, working across the five core elements of the framework and going outside the CWS system to other systems, such as criminal justice and public health. But it is hard to sustain and is susceptible to external events and leadership changes. It is also difficult to get workers under normal or greater pressures to adopt new behaviors, especially new assessment tools, without careful advance planning and strong topand mid-level leadership. Infusing the AOD perspective in a CWS agency requires a level of information systems and results-based accountability that many agencies are unlikely to have yet achieved. The infusion approach also expands the capacity of the AOD treatment system by moving away from treatment services narrowly defined as residential treatment, broadening the base of services to pre-treatment and community support models. This approach can and should be combined with networks at the neighborhood level.

Community Partners of Recovery and Treatment Staff with CWS. The community partners approach draws community support in the form of active buy-in from local residents, but it is not clear that it seeks to change the system. In some sites, it has led to system changes to the extent that informal community support and interim care- giving have reduced the need for formal CWS filing, enabling the placement of children in safe environments while parents are enrolled in treatment.

Community Partnerships for the Protection of Children. The advantages of community partnerships include all the advantages of the prior approach, plus the advantage of a new governance entity that can address the need for a broad constituency base for systems change. However, decentralized pilot projects often reflect an initial preference by neighborhood groups for a gradual community-building effort that focuses primarily on "microprojects." Such projects may provide a foundation for larger, more strategic efforts, or they may lead to less emphasis on opportunities to affect the larger system's resources through a formal policy agenda. The effect of such partnerships in making these choices remains to be seen.

Family Drug Court. The Family Drug Court approach uses the impressive authority of the court, which is a substantial force for reform and can also mandate participation in treatment. However, reforms that are restricted to the court system may ignore the rest of the CWS-AOD systems and thus lack the resources to make court powers effective. Court systems have also found it difficult to divert scarce program funding to evaluations of the effectiveness of court-mandated programs to which their clients have been referred.

These summary comments on the nine models should make clear that these are evolving approaches. Some of the concerns we have expressed may not apply to all the sites that have adopted an approach, but we have sought to reflect what practitioners have said and what our own experience has shown about the advantages and drawbacks of these approaches. Described below are a few of the projects that are spotlighted in the matrix.

The Clark Community Partnerships

The Edna McConnell Clark Foundation's Community Partnership sites (Cedar Rapids, Iowa; St. Louis, Missouri; Louisville, Kentucky; and Jacksonville, Florida) are implementing a four-part strategy:

• Develop an individualized course of action for each child and family identified by community members as being at substantial risk of child abuse or neglect;
• Organize a network of neighborhood and community supports, including a neighborhood site for agency CWS staff, as well as neighborhood "helpers"
• Establish new policies and practices within the CWS agency, including consulting with partner agencies and intensifying focus on families with a recurrent pattern of child maltreatment; and
• Develop a collaborative decision-making capacity to sustain the partnership.

The strategy plan for the Clark projects explicitly emphasizes that both substance abuse and family violence have been included in the policy changes sought in the child welfare system:

Community Partnership Plan: Sites are asked to ensure that as part of the development of each plan, assessment is made of whether substance abuse and domestic violence are problems for the family. If they are, the family's action plan is expected to include activities that will alleviate these problems. ... CWS agencies will establish close working relation  
ships (and possible joint operating procedures) with domestic violence service providers and with substance abuse providers ... Substance abuse prevention and treatment programs must be immediately available within the network and to the CWS agency [Center for the Study of Social Policy 1997].

Each sites' assessment and action plan is to include a response to "reports of abuse and neglect with a differential response based on the severity of the situation and the future risk to the child." These efforts are expected to go beyond the formal agency networks to natural helpers and the staff of community-based agencies, such as child care providers, schools, faith-based organizations, and recreation agencies. CWS staff are being relocated into neighborhood locations, not only as a new work site, but to enable deeper family assessments and become familiar with and tap into local services and supports for families.

In Louisville, meetings have been held at the neighborhood level among providers and neighborhood residents, planning for "sober housing units" has begun in the target neighborhood, and a substance abuse coordinator has been hired for the project. In Jacksonville, community meetings have led to a set of proposals for neighborhood-level initiatives that are being prioritized for implementation in 1998. AOD treatment providers have joined CWS staff and neighborhood residents in an active planning group that has been addressing AOD issues.

The Delaware Title IV-E Waiver

Delaware is the only state that expressly targeted AOD problems in its application for a federal Title IV-E waiver. Granted in June 1996, Delaware's waiver was one of the initial 10 state waivers for child welfare agencies authorized by P.L. 103-432. (The Adoption and Safe Families Act legislation of 1997 authorizes DHHS to grant an additional 10 state waivers.) Under the waiver, the state is using foster care funds (Title IV-E) to fund substance abuse counselors and to co- locate them with child protective staff. A component of the evaluation is to ensure that the project is cost neutral to the federal government.

Listed below are the objectives of the project:

• Prevent or delay entry of children into out-of-home care because of parental substance abuse, or reduce the time in care in 50% of the families receiving multidisciplinary team services;
• Reduce the amount of time between identification of a substance abuse problem and completion of an evaluation and subsequent treatment; and
• Ensure permanency for children by verifying that reasonable efforts have been made to prevent placement and that appropriate reunification services have been made available.

The staff use a team approach, with the child protective worker focusing on child protection and safety issues and the substance abuse counselor identifying the extent of the AOD problem and its impact on child safety. The substance abuse counselor assists the family with linkages to treatment resources and provides support and treatment during the early stages of the AOD intervention. An extensive evaluation is being conducted using random assignment of cases to control and demonstration sites.*

The Starting Early/Starting Smart Program

The Casey Family Program, in conjunction with federal agencies (the Substance Abuse and Mental Health Services Administration [SAMHSA], the Health Resources and Services Administration [HRSA], the Administration on Children and Families [ACF], and the Department of Education) began an effort in 1997 to support five primary care and seven early childhood integrated service sites. One of these sites emphasizes child welfare populations: in Cook County, Illinois, foster parents for a group of children who have been removed from their families because of substance abuse will be provided extensive support while birth parents will be in treatment The demonstration's evaluation is conducted through a data coordination center that is studying two questions: (1) Will integrated services increase access to substance abuse and mental health services for children and families? (2) Will integrated services improve outcomes for the children and the families?**

* The contact person for Delaware's program is Candace R. Charkow, Treatment Program Manager, Division of Family Services, Department of Services for Children, Youth and Their Families, 1825 Faulkland Road, Wilmington, DE 19805; 302/633-2601.  
**The contact person for the Casey Family Program is Ruth W. Massinga, Chief Executive Officer, Seattle, WA; 206/282-7300.

The Cuyahoga County START (Sobriety Treatment and Recovery Teams) Program

Having documented that 75% of child welfare intake involved alcohol and other drug abuse, officials in Cuyahoga County, Ohio, launched a program in 1996 that built on earlier AOD-targeted efforts to weave together the strengths of AOD treatment providers with the needs of child welfare families. The elements of the program are listed below:

• Expanded worker training in AOD issues;
• Random urinalysis as a motivation booster for parents in treatment;
• Safety plans that address AOD problems explicitly;
• Natural support providers and relatives;
• Referrals to four local AOD treatment agencies; and,
• An explicit message to clients that says...

We want you to understand now, at the beginning, that permanent custody of your child will depend on this success. You must stop your drug use if you are going to have responsibility for your child [Cuyahoga County Department of Child & Family Services 1996].

The target group is the estimated 150 women a year who deliver babies and show a positive toxicology screen for any drug. A key feature of the program is the use of "child welfare advocates," who are recovering AOD abusers recruited from local welfare offices and past child welfare caseloads.

The Sacramento County Alcohol and Other Drug Treatment Initiative (AODTI). In response to the flood of AOD cases in social service and public health caseloads, the Sacramento County Department of Health and Human Services enacted in 1993 an initiative to incorporate substance abuse services as an integral part of its service delivery systems. The program received full endorsement from the Sacramento County Board of Supervisors, the Human Services Cabinet, and the Criminal Justice Cabinet.

The training component of the initiative focused on three levels:

• Level I - Basic introduction to AOD terminology and identification,  
  
• Level II - Advanced assessment and intervention skills including certification in administering the Substance Abuse Subtle Screening Inventory (SASSI), and  
  
• Level III - Group treatment skills with substance-abusing clients.

Level I was required for all Department of Health and Human Services personnel. Level II was required for all personnel who "carry a caseload." Level III training was required for all County AOD counseling staff and was voluntary for all other staff who completed Level II and agreed to participate in facilitating AOD group services. The program's three levels of training had been completed by more than 2,000 health and human service staff members and other community agencies by early 1998. Sacramento currently requires that workers begin AOD training after their first three months on the job. (The lessons of this initiative are discussed in Chapter 3.) The training was evaluated with a pre- and post-training test that assessed participants' knowledge, attitudes, and beliefs. Post-training results showed considerable initial approval from line employees. The substantive areas of the training that produced the most positive responses to the pre- and post-training questions included the following:

• The awareness that alcoholism and drug dependence are diseases,  
  
• The awareness that professionals can help clients in denial,  
  
• The effectiveness of different modalities of treatment for different kinds of clients,  
  
• The relevance of client measures of functioning in addition to abstinence,
• Alleviating the misapprehension that the AODTI sought to make all professionals into drug counselors,  
  
• Definitions and symptoms of AOD dependence,  
  
• The potential for all human service professionals to conduct substance abuse interventions, and  
  
• Awareness of phases of recovery as measures of parents' readiness for child custody.

Overall, workers gave highly favorable scores on the questions: "I think this training will result in a change in how I do my job," "I will recommend to my coworkers that they participate in this training," and "I think that it is important that the department is undertaking this training program." An important distinction emerged, as it often does in training, among changes in knowledge, attitudes, and expected versus observed behavior. In answer to the question "as a result of this training, the primary change that I will make in the way I do my job is...," workers responded far more often "feel more knowledgeable in dealing with AOD problems" than they agreed with "be more understanding and sensitive to clients with AOD problems." The least frequent response was "be more willing to confront and talk about AOD problems," suggesting the greater difficulty of turning new attitudes into new practices.

At the peak of implementation, around January 1997, approximately two-thirds of all child welfare workers (outside the permanent placement bureau where parents have already been assessed for risk) were submitting AOD assessments. Later in 1997, the CPS crisis (see box on page 39) resulted in a reduction of assessments to a point where few were coming in from workers.

The actual procedure for AOD assessment and referral under the AODTI involved three steps:

1. Classifying the client (use of the SASSI was at workers' discretion as a tool to assist in this classification) as falling into one of five categories:
   • Having no AOD problem,
   • Substance user,
   • Substance abuser,
   • Chemically dependent not in recovery, or
   • Chemically dependent in recovery.
2. Determining, among those clients assessed with an AOD- related problem, their level of functioning based on a Likert scale across seven domains that are commonly used in AOD assessment protocols:

   • Medical problems,
   • Social relationships,
   • Legal problems,
   • Housing problems,
   • Mental health problems,
   • Family problems, or
   • Employment problems.
3. Referral to one or more of nine treatment options based on a grid that indicates appropriate patient placement guidelines for referrals to a continuum of treatment programs.

During the period in which assessments were at peak levels, 63% of all clients assessed were described as having an AOD problem at some level, with another 14% described as chemically dependent and in recovery. As a finding from the most comprehensive AOD assessment process systematically applied to all CWS-entering parents, this statistic correlates with many other national studies, which find 40 to 80% of CWS- involved parents have an AOD problem.

An important intervention developed as a part of the AODTI makes clear that the effort was designed and implemented as much more than a training program; this was the use of "pre- treatment groups" run by social workers and/or AOD counselors. In contrast to a frequent CWS agency practice of referring clients with AOD problems to a "waiting list" at a treatment program (which some have derisively called "referral on demand" in contrast with the policy of treatment on demand), the AODTI used these pretreatment groups as a means of immediately engaging the clients who needed AOD treatment. Clients are involved in a group setting that includes parents with similar problems from whom they can receive support. In some cases, this may be the only intervention required. In the case of higher risk, lower functioning parents, the groups serve as interim services while waiting for an intensive treatment slot to open. Approximately one- third of AODTI clients with AOD problems were referred to such groups at the peak period of assessments.

The Pensacola Family Drug Court

After 15 years on the bench, Judge John Parnham has a vision of a Family-Focused Community Justice System. To achieve that vision, he has changed his approach in working with families with AOD- related problems and believes that the Dependency Court should serve the community as a form of "therapeutic jurisprudence, empowering families to be in a healthy environment." In a strong collaborative effort among the court; the district AOD program administrator, Dr. Paul Rollings; the district Family Safety and Preservation administration; and the staff at Pathways Treatment Center, the principles that have been used in adult criminal drug courts have been implemented in the family dependency court since 1997.*

The families brought into the drug court have generally had open cases in the Family Safety and Preservation Division for many years and have all been court-ordered to complete a treatment plan. Drug court families are from the family reunification and court-ordered family supervision programs. If the case worker finds that the family is not cooperating in their treatment plan and the parent(s) have AOD problems, the case is referred to the state attorney's office for filing contempt of court charges. The parent is ordered to appear in front of Judge Parnham and if the parent is in violation of the court order, has no psychiatric problems that would interfere with the treatment, and agrees to participate in the drug court services, the family can be accepted to the drug court program.

AOD treatment services are provided in four phases by Pathways, a local AOD treatment provider. Although there are timelines set for each phase, the time limits are flexible and adjusted for each client's progress in treatment. The phases of treatment are:

• Phase 1. 4 hours per day, 4 days per week for 5 weeks;
• Phase 2. 4 hours per day, 2 days per week for 3 to 6 months;
• Phase 3. 1 1/2 hours per day, 2 days per week for 6 months; and
• Phase 4. Long-term case management for approximately 6 months.

There are weekly court appearances and random selections for urine tests during Phase 1. Court appearances and drug testing is less frequent as the structure of the program becomes less rigorous over time.

Each member of the drug court team believes that the key component of its success is the emphasis on linkages among the partners.

* For additional information on the Pensacola Drug Court, contact Dr. Paul Rollings, Program Administrator, Florida Department of Children and Families Substance Abuse Program; 850/444-8366.

There are weekly case planning meetings in which each team member has a voice in reaching consensus on rewards and sanctions to be delivered under the authority of the court. Most important in case planning is the view from each perspective on the treatment team on the client's "patterns of behavior." Even if a client is testing clean, if the AOD counselor or CWS social worker believe that the client is not demonstrating a change in his/her behavior patterns, they can request the imposition of sanctions. Sanctions used by the court include more frequent court appearances, daily urine tests, community service jobs, and when necessary, jail time.

Putting the Models in Context

In summarizing the state of the art of CWS-AOD relations in 1992, the CWLA Commission at that time said

Currently, the child welfare and AOD service systems operate independently from each other, using different eligibility criteria, restrictive funding streams, and sometimes conflicting program requirements, creating a maze that severely limits access [CWLA 1992].

Today, in 1998, the practices and policies in the exemplary agencies we have discussed in this chapter have advanced well beyond this summary description. We have made progress, despite the large obstacles that remain. The "maze that severely limits access" is still there, arguably more confusing because of new categorical legislation and the lack of adequate data collection.

But the recognition of the problem of AOD abuse by parents in the child welfare system is much wider than it was in the early 1990s. Demonstration programs, as noted in this section, have shown that advances in AOD treatment can make a difference in child welfare outcomes. The 1992 judgment of inadequate community response is still true of many communities, but practice innovation is expanding the number of child welfare agencies that are trying to break out of this status quo. We turn now to an assessment of child welfare innovation, as it provides further evidence of the progress that has been made.

Child Welfare Trends, Practice Innovations, and AOD-related Issues

Several recent trends and practice innovations in the child welfare field are closely related to the AOD problems addressed in this guidebook. Some are changes in child welfare practice that could result in more effective handling of AOD problems, but others may present barriers to closer links with AOD treatment agencies. The following material discusses these innovations as they influence and are influenced by AOD problems. Some of the common themes in these innovations and trends include family-centered practice and strengths-based or solution-focused practice. These approaches identify and build on the strengths of the families in the child welfare system, while recognizing that those strengths are challenged by the forces that cause and are affected by AOD abuse.

Kinship Care

While not a new innovation, kinship care has expanded in the past decade to a point where it makes up as much as one-half of new placements in some states and counties, and it can be seen as both a major resource and a challenge in weaving together AOD and CWS practice and policy. On the one hand, kinship care is undeniably a resource that has provided safe, loving homes for thousands of children whose parents were unable to care for them responsibly, due to their own AOD and other problems. As of 1994, approximately 2.15 million children–just over 3% of all children in the United States— were estimated to live in the care of relatives without a parent present [Harden et al. 1997]. Since "concurrent planning" (described on page  
44) relies on kinship care as an early option, the use of this form of care is likely to increase rather than decrease in years ahead, as more restrictive time limits for both CWS and TANF begin to take hold.

At the same time, the intergenerational, genetic factors in AOD use and abuse, while not determinative, are highly correlative within families, and policy needs to take into account the possibility that the AOD issues may be present in the kinship setting in ways that can affect children. As Ivory Johnson has written, inadequate kinship care "can be another system of abuse and neglect for vulnerable children" [Johnson 1994]. The AOD issues in kinship arrangements are at least as important as they are in other caregivers' homes, and should be assessed as such. Johnson emphasizes that workers dealing with kinship arrangements

must be skilled in family assessment to be able to understand the implications of chemical abuse and dependence on one's ability to provide adequate parenting and protection. The dynamics of chemical abuse and dependency must be part of the core training for kinship caregivers and staff members.

One recent assessment of kinship foster care based on a review of 77 cases underscored the difficulty of dealing with AOD issues when both the caregiver and the parent are experiencing AOD problems, as would be expected since they are both affected by the familial roots of AOD dependence [Gleeson et al. 1997]. The rationale for whole- family treatment is always strong, but addressing the intergenerational issues in kinship care is a special challenge, due to the greater likelihood that some of the underlying factors contributing to mal- treatment could be present in the kinship setting as well as in the biological home. An especially difficult set of issues must be dealt with by caregivers and agency workers when birth parents are still actively abusing substances or are incarcerated [Crumbley & Little 1997].

The broad principles that appear to have the best chance of ensuring that kinship care will provide safe and supportive homes for children include the following:

• Screening and assessment of the families in sufficient depth to address AOD issues explicitly;
• Adequate resources for kinship families;
• A recognition by public policy and agency workers' practices that kinship care is different from family foster care and requires different services and supports; and
• Clarity about how kinship care and permanency planning interact, both in policy and in individual case planning.

Racial and cultural issues are deeply ingrained in kinship care and must be explicitly and sensitively addressed. As Johnson and many others note, "the kinship care arrangement is a practice rooted in the African and American experience" [Johnson 1994], and is of great importance in Native American communities as well.

Concurrent Planning

The goal of concurrent planning is timely permanency for children. In contrast with sequential planning (which seeks reunification and then, if these efforts prove unsuccessful, introduces alternative permanency plans), concurrent planning provides for parental reunification and rehabilitation efforts while simultaneously developing an alternative permanent plan for the child. An agency using concurrent planning methods simultaneously offers services to families while exploring alternative permanent options. The agency reviews relative/ kinship placement options and seeks foster/adoption placement as a backup plan if reunification is not possible in 12 or 18 months. All options are discussed, including active rehabilitation efforts, voluntary relinquishment, and relative guardianship. Frequent, consistent, and meaningful visitation is used as a high predictor of reunification in concurrent planning. Concurrent planning for children and families requires caseload adjustments to reflect the more intensive level of services delivered by child welfare workers.

AOD problems are critical to concurrent planning, since the "fork in the road" often comes when the agency makes a decision about whether parents are able to resume their responsibility for their children. Some child welfare practitioners have expressed the view that AOD problems are in fact the most important barrier to making concurrent planning work. In their view, without adequate means of referring parents to treatment, monitoring their progress, and making a well-grounded assessment of the risk of returning children, concurrent planning cannot succeed.

The State of Colorado, for example, uses concurrent planning to make early decisions on families needing substance abuse services. Staff have new resources for AOD treatment slots and reduced caseloads that enable intensive reunification services combined with concurrent planning for adoption based on parental performance in treatment. At three months the case is reviewed and a recommendation is prepared for concurrent foster care or adoption. By six months, the agency feels it has adequate information from AOD treatment providers to determine whether reunification is likely and, if not, to accelerate termination of parental rights. "With few exceptions, permanent placements must be made by 12 months" [Barth 1997].

This speeding up of the "AOD clock" runs the risk that parents who need longer than 12 months to achieve parenting skills and personal stability will have lost their children by the time they get their lives together. But the alternative in this difficult set of choices is waiting for the parents, at an obvious cost to the children if the parents are not successful. In some cases, the CWS legal clock and the child's developmental clock will become a higher priority and may take precedence over the slower running AOD recovery clock.

Family Decision-Making Models

As documented in a recent publication of the American Humane Association, agencies have begun to use an approach to families called Family Group Decision Making (FGDM), that emphasizes building on the strengths of families and using a solution-based approach to resolve family problems that may lead to out-of-home placement. This approach includes a family case conferencing model developed in New Zealand and the Family Unity Model developed in Oregon and based on the Family Group Conferencing model.

Both processes use family meetings as the central mechanism to develop a family resource plan, drawing on the resources of the family, the extended family, and community agencies. The family assumes responsibility for the plan and takes ownership of the steps needed to carry it out.

The Family Unity Model uses a trained facilitator to assist the extended family unit in developing the family resource plan. In the Family Group Conferencing model, a facilitator provides initial guidance to the family but the family develops the plan, with the facilitator leaving the room when the extended family deliberations are under way.

These models are quite appealing in the reduced intrusiveness they bring to families' lives and their ability to hold families accountable for their own actions. They also offer an approach that is effective with diverse cultural groups. A further advantage pointed out by some state officials is that FGDM models create a team for the worker to be part of, which can be a welcome support for a younger, less experienced worker who no longer needs to make all decisions by herself.

While there is not as yet a significant body of evidence about the effectiveness of these models, the combination of an approach that is more respectful of clients and provides workers more resources has led a number of states and counties to adopt FGDM. As with concurrent planning, however, some practitioners would caution that implementing these approaches with social workers assigned their current levels of caseloads will not be successful. It remains to be seen if these added resources will be made available.

The Family Support Movement

Some of the programmatic and philosophical underpinnings of the community partnerships approach are firmly rooted in earlier ideas about family support, building on family strengths, the need for natural supports as well as public and nonprofit services, and respect for the cultural and community origins of families. Securing support from the community in helping parents in the CWS system is at the core of the community partnership approach.

Some documents produced by the family support movement have given AOD issues scant attention, but the field as a whole varies widely in the depth of its approach to AOD concerns. Yet there is extensive evidence that self-help approaches, both neighborhood-based and faith- based, can help families both in early intervention and in community- based aftercare support from networks of natural helpers that include other parents in recovery. In addressing the issue of whether a strengths- based approach makes it difficult to address a family's AOD problems, some practitioners would agree with the statement by one reviewer that

... In no case do we view "family strengths" as an approach that ignores needs—rather it is an approach that uses family and personal resources, successes, and capabilities as essential components of creating plans to successfully address needs such as AOD, violence reductions, improved parenting, etc. [Anonymous communication with author, 1998].

It is not difficult to see the conceptual links between family support practice and increased community involvement in AOD issues.

Two of the core principles of family support, as set forth in a series of publications by the Family Resource Coalition of America, are especially relevant. If one defines "having control over important aspects of their lives" and "equitable access to resources in the community" to include addressing AOD problems as they affect millions of children, the family support movement can become an important part of the effort to strengthen community support to parents with AOD problems [Family Resource Coalition 1996].

Another source of family support is the school-linked services movement. Services for AOD-related problems among parents have been included in several efforts: in Florida's statewide efforts to develop "full-service schools," and in statewide efforts in New Jersey, Kentucky, and California. These initiatives go well beyond the pilot project stage to widespread innovations in which public and community workers are brought into and linked with schools in family resource centers.

A specific form of family support program is home visiting. In an increasing number of communities, home visiting programs have been linked to child welfare reforms. Lawrence Sherman's extensive survey of crime reduction programs for the U.S. Department of Justice included a review of "family-based prevention" initiatives such as home visiting, and concluded:

Perhaps the most promising results in all areas of crime prevention are found in the evaluations of home visitation programs. While these findings are often combined with other institutional elements, such as preschool, there is a large and almost uniformly positive body of findings on this practice [Sherman et al. 1997].

Home visiting programs have at times included counseling and treatment for AOD problems, especially those that are revealed by a positive toxicological screen at birth. But many programs have emphasized referral out to treatment agencies rather than equipping line staff to screen or provide pretreatment services.

References

Barth, R. (October 28, 1997). Substance abuse and child welfare: Problems and proposals. Testimony before the Subcommittee on Human Resources, Committee on Ways and Means, U.S. House of Representatives.

Center for the Study of Social Policy. (1997). Strategies to keep children safe: Why community partnerships will make a difference. Washington DC: Author.

Child Welfare League of America. (1992). Children at the front: A different view of the war on alcohol and drugs. Washington, DC: Author.

Crumbley, J., & Little, R. (Eds.). (1997). Relatives raising children:

An overview of kinship care. Washington, DC: Author.

Cuyahoga County Department of Child and Family Services. (1996).

S.T.A.R.T.—Sobriety treatment and recovery teams. Cleveland, OH: Author.

Family Resource Coalition. (1996). Guidelines for family support practice. Chicago, IL: Author.

Gleeson, J. P., O'Donnel, J., & Bonecutter, F. J. (1997). Understanding the complexity of practice in kinship foster care. Child Welfare, 76, 801-826.

Harden, A. W., Clark, R. C., & Maguire, K. (1997). Informal and formal kinship care. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

Johnson, I. L. (1994). Kinship care. In D. Besharov (Ed.), When drug addicts have children. Washington, DC: American Enterprise Institute and Child Welfare League of America.

Sherman, L. W., Gottfredson, D., MacKenzie, D., Eck, J., Reuter, P.,

& Bushway, S. (1997). Preventing crimes: What works, what doesn't, what's promising. Washington, DC: National Institute of Justice.

3 Lessons of the Models

The preceding discussion of the models and innovations that have been developed to respond to the problem of AOD abuse among child welfare clients reveals nine common themes. These themes provide lessons from the many attempts to improve the links between AOD and child welfare systems.*

Lesson #1

Values matter, especially when the issues touch AOD and poverty.

Our attitudes about drug use (and use of alcohol, the consequences of which are often much more serious) and poverty are among the most stereotyped topics in our society. As a result, the public debate on these subjects tends to lurch from extreme to extreme, rarely confronting the "gray areas" where difficult decisions are necessary. The public and its opinion leaders exhibit polar extremes of reaction and overreaction to "crises" that become media-visible and then fade. From denial that there is a problem, attitudes then shift toward a crisis mentality in which expensive "quick fixes" are attempted.

* This section owes a great deal to three authors (whose works have been disseminated and supported by the Annie E. Casey Foundation): Lisbeth Schorr in the United States, and Gerald Smale and John Brown in Great Britain, whose work has been published by the National Institute of Social Work (NISW). There is a rich set of literature on policy and program implementation in the United States, notably work done during the past 25 years that began with Wildavsky and Pressman's seminal Implementation in 1973. Schorr, Smale, and Brown have all built from this earlier work, renewing it and giving it special relevance for policy aimed at children and families. Schorr's new book Common Purpose is a follow-up work to her 1988 book, Within Our Reach, and addresses the problem of taking successful pilot projects to scale. Smale and Brown's work has been undertaken as part of the Managing Change and Innovation Programme of the NISW. See Brown, J. (1996). Chance favours the prepared mind. London: National Institute for Social Work. With the exception of Brown's title, quotes from Brown and Smale have been Americanized in spelling.

At the same time, we compartmentalize our attitudes about these difficult issues. This is shown by the widespread inability to see the connection between socially acceptable drug use (e.g., caffeine, nicotine, alcohol, prescription drugs) and drug "abuse." The public equates drug abuse with the use of "hard drugs" by low-income persons, rather than the abuse of alcohol or the misuse of mood-altering drugs by middle- and upper-income persons.

In CWS-AOD reform, these attitudes can make it difficult to sustain public support for middle-ground reforms. In a number of communities, the debate about "zero-tolerance" policies that insist on abstinence for CWS clients is almost solely focused on illegal substances, ignoring the far greater impact of alcohol on child and family problems. This has made it difficult to realistically discuss the financial costs and psychological impacts of strictly enforcing such policies by removing all children from homes where parents are using drugs.

In Sacramento, a public discussion of the merits of "harm reduction" as a public policy toward AOD use was made more difficult following incidents of children's deaths in