Overview of the StateSubstance Abuse Child Welfare Waiver

Demonstrations

National Conference on Substance Abuse, Child Welfare, and the Courts

January 31, 2007

Anaheim, California

Elliott Graham, Ph.D.

Part IOverview of Title IV-E Waivers

• Authorized by Congress in 1994.

• Allows states to use title IV-E funds for supports and services other than foster care maintenance to promote key child welfare outcomes (maltreatment prevention, family preservation, permanency).

• Allows states to expend title IV-E funds on non-IV-E eligible children.

• Waivers approved for 5-years; one 5-year extension possible.

• Since 1996, 22 states have implemented 30 different waiver demonstrations.

• Four states – California, Iowa, Michigan, and Virginia – received approval for new waivers in March 2006.

Overview of Title IV-E Waivers (cont.)

Overview of Title IV-E Waivers

• Most common types of implemented demonstrations include:

– Subsidized guardianship (10)

– Managed care (6)

– Flexible funding/capped IV-E

allocations (5)

– Substance abuse services (4)

Authority to grant new waivers expired on March 31, 2006.

Child Welfare Outcomes of Interest

• Placement avoidance

• Placement duration

• Exits to permanency (i.e., reunification, guardianship, or adoption)

• Placement stability (i.e., number of changes in placement setting per child)

• Maltreatment recurrence

• Foster care re-entry

• Child and family well-being

Services for

Caregivers with Substance Use Disorders

Overview of Substance Abuse Waiver Demonstrations

• Four states have implemented SA waivers since 1996:– Delaware (implemented July 1996; ended

September 2002).– New Hampshire (implemented Nov. 1999; waiver

ended in November 2005, but continues using Title IV-B funds).

– Illinois (implemented April 2000; long-term extension granted January 1, 2007).

– Maryland (implemented October 2001; terminated early in December 2002).

Key Features of Substance Abuse Waiver Demonstrations

State Key Program Focus Target Population

Scope IV-E Status

DE Early identification of substance use disorders Service referralLinking families to existing treatment resources

Children in or at risk of out-of-home care due to parental substance use

Statewide IV-E eligible and non-IV-E eligible

IL Treatment retention and recovery for caregivers already referred to treatment and with a child in out-of-home placement

Parents referred for treatment with a child already in out-of-home placement

Cook County, IL

IV-E eligible and non-IV-E eligible

MD Early identification of substance use disorders Service referralLinking families to existing treatment resources

Mothers or other female primary caregivers with a child in or at risk of placement due to parental substance use

Baltimore City, Prince George’s & Baltimore Counties

IV-E eligible and non-IV-E eligible

NH Early identification of substance use disorders Service referralLinking families to existing treatment resources

Families involved in CPS with caretaker substance abuse as major referral reason

2 CPS district offices

IV-E eligible and non-IV-E eligible

Substance Abuse Waiver Demonstrations – Enrollment and Assessment Procedures

State

Timing of Enrollment

Timing of SA Assessment

Parties Responsible

for Assessment

Screening/Assessment Instruments

DE Following CPS investigation and determination that alleged substance abuse represents threat to child safety

Following CPS case opening

CPS case manager and/or substance abuse counselor

Parental Substance Abuse Inventory

IL At time of referral for substance abuse treatment

Within 90 days following Temporary Custody Hearing, prior to referral for SA treatment

Substance abuse assessment counselor

AODA assessment protocol in accordance with ASAM criteria.

MD After CPS case opening, following screening to determine program eligibility

Following eligibility screening and assignment to Family Support Services Team

Joint assessment by chemical addiction counselor and child welfare case manager

Multiple instruments, including Parenting Stress Inventory (PSI) and Achenbach Child Behavior Checklist

NH At time of initial maltreatment report; prior to maltreatment substantiation or CPS case opening

After assignment to experimental group

Licensed Alcohol and Drug Abuse Counselor

Substance Abuse Subtle Screening Inventory (SASSI)

SA Demonstrations – General Caregiver Characteristics

Variable New Hampshire Illinois

Mean Age 33 32

Gender 87% Female 71% Female

Race 90% Caucasian 81% African American

Presence of Mental Health Issues

18% 18%

Top Three Drugs Used (in order of prevalence)

1. Alcohol 2. Marijuana 3. Cocaine

1. Cocaine2. Heroin3. Alcohol

Usage Rate for Top Drug

Alcohol - 40% of caregivers reported having 4+ drinks at

any given time

Cocaine - 38% of caregivers reported using cocaine several times per

week

Top Two Presenting Problems

54% - Neglect23% Physical Abuse

24% - SEI33% - Substantial Risk of

Physical Abuse/Harm

State Research Design

Sample Size (# of Cases)

Experimental Group Control/Comparison Group

In-home cases

Out-of-

home cases

Total In-home cases

Out-of-

home cases

Total

Delaware Comparison group

398 132 530 368 162 530

Illinois Random assignment

NA 943* 943 NA 366* 366

Maryland Random assignment

-- -- 9 -- -- 9

NewHampshire

Random assignment 183 39 222 182 33 215

Evaluation of the SA Waiver Demonstrations - Summary of Research Designs

*As of June 2005

• Small sample sizes.• Maryland terminated its demonstration early

and reported no outcome findings.• Only two states - Illinois and New Hampshire

- used random assignment designs.• Differences in size, population characteristics,

levels of urbanicity, availability of substance abuse treatment resources, and child welfare laws and policies limit cross-state comparisons.

Evaluation of Substance Abuse Waiver Demonstrations – Methodological Limitations and

Caveats

Evaluation of the SA Waiver Demonstrations -Summary of Key Child Welfare Outcomes of Interest

State

Outcomes

PlacementAvoidance

Placement

Length

Placement

Stability

Foster CareExit

Maltx.Recurren

ce

Foster Care

Re-entry

Child/FamilyWell-Being

DE ✔ ✔

IL N/A ✔ ✔ ✔ ✔

NH ✔ ✔ ✔ ✔ ✔ ✔

• All States: Problems with referrals and enrollments.• All States: Problems with data collection and

tracking.• Maryland and Delaware: Inadequate training in

identifying substance abuse.• Maryland and Delaware: Differences in

management styles and professional philosophies of child welfare and substance abuse professionals.

• Delaware: Scarcity of residential treatment and intensive outpatient programs.

Substance Abuse Demonstrations– Implementation Challenges

Part IISummary and Conclusions

What have we learned about the

outcomes of SA waivers?

• Difficult to achieve change.

• Effect sizes are small.

• Findings not always consistent over time or across implementation sites.

• No negative outcomes for children and families in experimental groups.

Summary of Key Outcomes

• Access to enhanced substance abuse services:

– Increased participation in substance abuse treatment (IL and NH).

– Reduced length of stay in foster care (DE and IL).

– Modestly increased reunification rates (IL).– Reduced maltreatment recurrence (IL).– Improved child and family well-being (NH).

Key Lessons Learned

• Need to accurately estimate the size and characteristics of the target population.

– Parents with substance use disorders often have multiple co-occurring problems that complicate identification, referral, enrollment, and delivery of services.

Example: Co-Occurring Problems in Illinois

• Major life problems beyond substance abuse included inadequate housing, mental health issues, and domestic violence.

• 21% of families in which substance abuse was identified as the only major life problem achieved reunification compared with 11% of families dealing with one additional life problem.*

• Overall, 73% of enrolled families were experiencing at least three major life problems simultaneously.

*Statistically significant

Key Lessons Learned (cont.)

• Need to improve identification, screening, referral, and assessment procedures:

– Worker training– Supervisory review– Selection/development of assessment tools– Simplification of referral procedures

Screening and Identification – the Case of Maryland

Of 913 cases screened for enrollment between October 1, 2001 and August 31, 2002:

• Only 283 had an identified substance use disorder (31 percent).

Of the 283 cases with an identified substance use disorder, most were ineligible because:• 136 were participating in another substance

abuse treatment project;• 32 had a dual diagnosis of a mental health

problem along with a substance use disorder;• 6 involved allegations of sexual abuse;• 35 involved child abandonment; and• 44 could not be located or were otherwise

unavailable to participate in the demonstration (e.g., due to incarceration, unknown whereabouts, etc.).

Referrals and Enrollment – the Case of Maryland (cont.)

That left only 27 caregivers (3 percent) with a known substance use disorder who were not otherwise disqualified or unavailable to participate in the demonstration.

Referrals and Enrollment – the Case of Maryland (cont.)

Key Lessons Learned (cont.)

• Need to consider ultimate child welfare program goals:

– Placement prevention?– Increased permanency?– Reduced time in out-of-home care?

Key Lessons Learned (cont.)

• Need to consider timing of intervention:

– Focus more on front end (early identification of substance abuse (e.g., NH, DE, and MD))?

OR

– On back end (treatment access and retention (e.g., IL))?

Key Lessons Learned (cont.)

• Need to ensure availability of substance abuse treatment services.

Building an Infrastructure to Support the Evaluation of Substance

Abuse Service Programs

• How can we establish better linkages between services and outcomes?

– Development of logic models.– Collection of case-level data to track service

utilization.– Development of improved client databases and

tracking systems.