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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.