INTRODUCTION AND PURPOSE

The Division of State and Community Assistance of the Center for Substance Abuse Treatment (CSAT), in conjunction with the Administration on Children, Youth and Families (ACYF), held a two-day state team-building workshop September 11 and 12, 2001, in Boston, Massachusetts. The workshop was titled, Protecting Children: Substance Abuse and Child Welfare Working Together. This was the fourth and final CSAT/ACYF meetings to be held on this topic in 2001. These workshops are designed to help build the state infrastructure necessary to bring about coordinated delivery of care for children in the child welfare system and their parents in substance abuse treatment.

The Federal sponsors invited states to send teams of six individuals representing single state alcohol and other drug agencies, state child welfare agencies, members of the judiciary, and other agencies and individuals involved with families, including foster care, TANF, Medicaid, advocacy groups, and consumers. Team members completed a Collaborative Values Inventory prior to attending the workshop, which was designed to help them start thinking about the values and principles they share and those on which they need work to reach consensus.

In addition to their work in values clarification and state team-building, workshop attendees heard presentations on the Adoption and Safe Families Act (ASFA), family drug courts, safety and resiliency for children in substance abusing families, and successful approaches to collaborative work. The agenda for this workshop evolved from a national planning meeting held in Bethesda, MD, in November 2000.

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Tuesday, September 11

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WELCOME

H Richard (Rick) Sampson, Director
Division of State and Community Assistance
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
It is an honor and a pleasure to welcome you to this fourth in a series of regional workshops designed to improve the interface between child welfare and substance abuse treatment and prevention. For me, is it both personally and professionally a joy to see these two systems come together. We share similar values, issues, and needs, and it's important for us to bring to the table those who haven't been together before. In our three previous regional workshops, we've found that 60 percent of you are meeting for the first time. We hope you will find this to be informative and useful and that you'll provide us with your feedback so we can help states implement the changes we discuss. These meetings represent our attempt to build what we believe will be a lasting relationship with the Administration for Children, Youth and Families.

Stanley G. Gardner
Administration for Children and Families
Northeast Regional Office
Boston
I'm excited to be here. This is a timely effort to discuss team-building strategies. We're conducting a parallel effort with TANF (Temporary Assistance to Needy Families) and substance abuse treatment, and we encourage you to include TANF in your team-building activities. We all serve the same families. TANF will be reauthorized next year, and we believe the funds not being used for cash benefits can be used to help children and families.

Deborah Klein Walker, Ed.D.
Acting Bureau Director
Bureau of Substance Abuse Services
Massachusetts Department of Public Health
I look forward at the opportunity to examine what we're doing and enhance the interface between our systems. Currently, we have an interagency agreement with our child protective services agency. We can make the system better and foster health families, children, and communities. But we can't do it with these two agencies alone. We need to include representatives from mental health, domestic violence, housing, and health care, including Medicaid and Maternal and Child Health. We still have a long way to go in Massachusetts to figure out how to bring all these players together.

Kimberly Bishop
State Substance Abuse Coordinator
Massachusetts Department of Social Services
We are committed to keeping children safe and support parent in recovery. We created a substance abuse unit in the Department of Social Services and developed a special screening tool and drug testing protocol. We trained staff, and implemented pilot projects that gave priority access for substance abuse treatment to department clients. These programs include centralized intake, residential programs, and treatment readiness groups. In addition, we are integrating our efforts with the Bureau of Substance Abuse Services, sharing resources and developing a common language and mission. Confidentiality is still an issue between our agencies.

Catherine M. Nolan, M.S.W., A.C.S.W., Director
Office of Child Abuse and Neglect
Children's Bureau
Administration on Children, Youth and Families
Administration for Children and Families
I'd like to set this meeting in context. The Adoption and Safe Families Act (ASFA) required a report to Congress outlining the barriers to collaboration between the child welfare and substance abuse treatment systems. The Children's Bureau worked with CSAT and others in the Substance Abuse and Mental Health Services Administration and the Department of Health and Human Services (DHHS) to produce the April 1999 report, Blending Perspective and Building Common Ground. This report spawned a series of activities, including this year's regional meetings. Among the five general recommendations we made in the report, the first was to build collaborative working relationships at the Federal, state, and local level. We also said that DHHS, of which both agencies are a part, would lead the field toward improving communications and developing common ground between the child welfare and substance abuse treatment fields. Further, we made a commitment to not let this report sit on a shelf and gather dust.

Subsequently, we held a child maltreatment resource meeting and a meeting of key stakeholders to develop ways to carry out this mission. None of these meetings were smooth; there certainly was tension between our groups. As a result, we developed an interagency agreement with CSAT to help break down the barriers we saw. This is our fourth and final regional team-building workshop. The previous three have gone well, and we're pleased with the progress we've made. Take advantage of these two days together because as other participants have said, you'll never have the change to do this in the office. We're pleased to provide you with the opportunity to chip away at the barriers to communication and collaboration between our two systems. Thank you for joining us.

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GENERAL SESSIONS

Adoption and Safe Families Act: Foundations for Collaboration
H Richard (Rick) Sampson
I'd like to offer a special welcome to foster parents and judicial system representatives. I'm also pleased that we have State legislators here, because we need our lawmakers on our side. When it comes to having adequate resources, that can make all the difference.

I'm personally and professionally honored to be here. I ran a therapeutic foster care program for adolescents and I made promise to a group of foster kids that I would always be their advocate. These are remarkable kids. They are victims, but out of their experiences, they have developed incredible coping mechanisms and survival skills. These are the ingredients for their success. We have to appreciate their strengths, work with them, and give them the opportunity to break a multigenerational cycle of abuse and neglect.

It's easy to collaborate when the resources are there. Lack of resources creates tension and difficulty, but it also gives us both the opportunity and the responsibility to work together toward our mutual goal of healing children and families. Nationally, we're only serving 35 percent of the individuals in need of publicly funded substance abuse treatment. Child welfare caseloads are increasing. We know that 80 percent of out-of-home placements are because of substance abuse problems. We have to deal with the family. Kids do want to be with their parents, and Moms do love their children though they may not be able to care for them when they are under the influence of alcohol or other drugs.

ASFA introduces new demands. We can't work with Moms for years. We have to stop pushing and pulling clients between our systems and offer one-stop shopping. We also have to support each other, especially our young child welfare case workers. Predicting issues of safety and violence are difficult to do, but whether we're right or wrong is critical for the safety of the child. This is a difficult, challenging, and frightening job. We have to stay focused on the clients but care for the caregivers, too.

James A. Harrell
Acting Commissioner
Administration on Children, Youth and Families
Administration for Children and Families
The child welfare system has experienced serious problems. In the District of Columbia alone, there have been numerous fatalities, but the District is not different than other systems, just more concentrated. More than 30 State child welfare systems have been in receivership. Foster care was meant to be a temporary solution to child placement needs, yet children often got there and stayed forever. Foster care became a "dumping ground," in part because the Federal government paid for foster care but not for preventive services. Adoption is more difficult for children with special needs, for siblings, and for adolescents.

Passed in November 1997, ASFA was meant to reform the child welfare system and address many of these concerns. In essence, ASFA codified our consensus about the purpose of public child welfare services., which can be summed up by the words safety, permanency, and well-being. In particular, the legislation embodies the following key principles:

• Child safety is the primary concern that must guide all child welfare services.
• Foster care is a temporary setting and not the place for children to grow up.
• Permanency planning for children should be initiated as soon as the child is placed in a foster care setting.
• The child welfare system must focus on results and accountability.
• States should be given credit for innovative ideas on how to improve the child welfare system.

Our charge is to create an outcomes oriented, performance-based system. As we conduct our State child and family service reviews, we're learning about such innovative approaches as family drug courts and how they're making a difference. We're making changes and beginning to get ahead of the problems. I encourage you to use the Blending Perspectives report as a platform. As the report notes:

Families often come with serious problems to service systems which are fragmented, and as such are limited in their ability to facilitate safety, permanency and sobriety. The Adoption and Safe Families Act recognizes the importance of time to children and establishes an expectation of urgency in decision making regarding their welfare. The imperative for timely decisions for children and the time frames necessary for recovery should also create a sense of urgency for policy makers and providers of service. Those of us who work in the areas of substance abuse and child welfare services must recognize the immediate need to eliminate barriers to effective treatment. This report sets the stage for a number of actions which can improve the nation's capacity to serve families whose children are at the greatest risk. (p. 137)

I commend you for being here and responding to this charge.

Values Clarification: Building Toward a Joint Mission

Nancy K. Young, Ph.D., Director

Children and Family Futures

Irvine, CA

Sixty-three meeting participants responded to a pre-workshop questionnaire called the Collaborative Values Inventory. The survey was designed to help the child welfare and substance abuse treatment systems 1) clarify the underlying values in collaborative work; 2) develop common principles and goals; and 3) uncover differences in values that may impede cross-system collaboration. Often, differences in basic values and beliefs are the cause of the problem when even seemingly successful collaborations hit a roadblock. These differences can't be dismissed; they must be identified and discussed.

Individuals who completed the survey represent alcohol and other drug services (32); children's services (24); Medicaid providers (2); and others (5). There were no respondents from dependency or family court. Because court representatives often express views that differ from their counterparts in other systems, and because their responses in the other three regions were fairly consistent, I added the responses of 23 court personnel to the survey results.

The survey provides State teams the opportunity to begin a discussion about some key questions, including: 1) What do we believe together? and 2) What don't we agree on? It also allows respondents to compare their individual State responses to the regional responses as a whole.

Looking at the results, we see there was strong agreement among these respondents in some key areas. For example, nearly all respondents agreed that solving the problems caused by alcohol and other drug use would improve the lives of a significant number of children, families, and others in need. They also agreed that alcohol and other drug services and child welfare services should receive high priority for State funding. A majority of respondents (61 percent) believe that alcohol and other drug providers should prioritize women from the child welfare system as their most important clients to receive services.

However, some interesting differences emerged, which can help pinpoint important areas states need to discuss. For example, 66 percent of respondents overall, and more than 70 percent of alcohol and other drug providers, disagreed with the statement that "illegal drugs are a bigger problem in our State than use and abuse of alcohol." However, court respondents were less likely to disagree with this statement. This is an important issue that points to differences in the way we view the problem of illegal drugs.

Participants were evenly split regarding the statement "there is no way that a parent who abuses alcohol or other drugs can be an effective parent." Alcohol and other drug providers agreed with this statement, child welfare workers disagreed, and court respondents were more evenly split in their opinions on this issue. Eighty-three percent of respondents agreed that people who abuse alcohol and other drugs should be held fully responsible for their own actions. You need to think about what this means as you put services together.

A slight majority (53 percent) of respondents agreed that urine screens are an effective method for determining a parent's readiness to retain or regain custody of his/her children, but respondents from the courts and other agencies overwhelmingly agreed. Sixty-seven percent of respondents disagreed that alcohol and drug systems have enough money to address their problems and all they need is more effective programs. Court respondents spoke the loudest about the lack of resources.

Overall, a majority of respondents (72 percent) disagreed that allowing more services to be delivered by for-profit agencies would improve the effectiveness of services. But by a slight margin, respondents from agencies other than those in the alcohol and drug and child welfare systems agreed that for-profit agencies would be more accountable. Respondents from other systems, however, were most likely to disagree with the statement that "the most important causes of the problems of children and families cannot be addressed by government; they need to addressed within the family and by non-governmental organizations such as churches, neighborhood organizations, and self-help groups." A majority of respondents (61 percent) from all fields also disagreed with this statement.

A slight majority of respondents (53 percent) agreed that requiring all clients, regardless of income, to make some kind of payment for services would improve the effectiveness of services. Court respondents were more likely to be in favor of this concept.

Interestingly, the group was almost evenly split on the issue of whether people in recovery from substance abuse are the most effective counselors to work with their peers, but alcohol and drug respondents were most likely to disagree about the effectiveness of peer counselors. This response is counter to conventional thinking, and is consistent across all four regions. Anecdotally, we believe the answers might be different if we surveyed line staff rather than state agency representatives.

Overall, sixty percent of respondents disagreed that confidentiality of client records is the most important barrier that keeps alcohol and other drug providers and child welfare agencies from working together. But child welfare respondents and those from other systems agreed that confidentiality is the most important barrier to working together. A majority of respondents in both systems believe that most parents will be successful in alcohol and drug treatment and in family services.

Using the survey results, states can work together to discover what issues are important to them and how those issues play out in the ways they work together. Finally, they can ground these principles in reality by relating them to the three primary daily practice activities that take place between the two systems: 1) intake, screening and assessment; 2) engagement and retention in care; and 3) the provision of services to children.

Judicial Decisions: The Eyes of the Child

The Honorable William R. Byars, Jr.

Children's Law Office

University of South Carolina

The topic of my presentation is looking at our systems through the eyes of a child, and that couldn't be more appropriate today. We can't allow anybody to stop us from taking care of those who can't take care of themselves.

When I became a judge in South Carolina, I consulted with other judges about how they handled child welfare cases. They told me what they were told by the judges who were there when they came to the bench. There was a tendency to continue doing things the old way even in cases where the reasons for doing so were lost in time. I continued operating the way other judges told me to until I realized that the system was not working.

Before the Adoption and Safe Families Act (ASFA) was enacted, we had 500,00 children in foster care, 100,000 of whom were not going to permanent homes. In addition, our child protection system had become, in effect, a parent protection system. When the child got hurt we did not treat the child, we treated the parent. In 40 percent of cases, according to national statistics, the only service the child received was an assessment. We put our resources into treating the parents and put the children in foster care. They were raised there until they became juvenile delinquents. Then we spent a lot of money locking them up.

Children were not going back to their mothers; they were remaining in limbo. A great many families who wanted to adopt children were going to other countries because we had our own children locked away. I felt that it was the fault of the child welfare system, which just needed to follow the directions of the court. When the Kellogg Foundation invited me to Kalamazoo, MI, to discuss some new ideas in this area, I didn't realize the meeting would change my life.

I learned that in order to reform the system, we must first have a paradigm shift. But I was confused. What does this mean for real kids with real problems in real court rooms? At the same time, I observed the level of caring the Kellogg community has for children. They not only took children into their homes, they took children into their families. They adopted kids. I saw a commitment, a "fire-in-the belly" that I envied.

I returned to South Carolina and started to think about a paradigm shift and how to apply it to children who are abused and neglected. In the past family courts were concerned with two components­legal services and social welfare services. I realized we must now view the system as having three components, much like a three-legged stool. The legs of the stool are legal services, social welfare services, and now substance abuse services. All three legs of the stool must be present.

I also understood that we have to view the child welfare system through a child's eyes. Let me give you an example. Think about time through a child's eyes. When a judge continues a case for 90 days, that may be considered a short period of time for the law, but it may seem like forever to a child who is not living at home. Ninety days is the length of summer vacation, and you know that seems to stretch endlessly before a child when he or she gets out of school. They can't even conceive of it ending. When they do return to school, the nine-month school year seems like an eternity.

Is it really radical to have to decide within a year about a child's life? I don't think so; I'm a proponent of making decisions on a timely basis. Our children know fear and helplessness. Substance abuse is a factor in 90 percent of the cases we see. Often, these children doesn't know who will be there for them or who will make decisions about their lives. They feel powerless and full of fear, and we don't make the horror end on a child's time frame.

What are some of the fact that we know about substance abuse? We know most prisoners in jail have a substance abuse problem and that 50 to 80 percent have been abused. We believe that most of the mothers who abuse their children have a substance abuse problem. They can't parent effectively when they're using alcohol or drugs.

Remember, it's a three-legged system. We must have alcohol and drug abuse professionals in the court room. They're abandoning their professional responsibility if they're not there, because that leaves decisions to be made by the judges and the child welfare system. And we only have a year to fix the problem. We need to know when a parent leaves the court room that he or she has an appointment for treatment and a date for evaluation.

Confidentiality regulations often become a barrier to treating mothers in the child welfare system and hurt the people that they were intended to protect. If you have parents sign a confidentiality waiver up front, they almost never rescind it. Cases can move forward on a timely basis when professionals in all three systems work together, and when we put kids at the center of the system. It doesn't come easily, but it must be done.

We also must focus on prevention. We know that children of parents who abuse substances are more likely to abuse substances themselves, so we must began treating children early in the process. We spend most of our monies on the perpetrators, and we must not leave the victims out of the loop.

We all say we don't have time to do more, but how can we say we don't have time to help protect a child? Change can't come from the Federal level; it has to start at home. It doesn't take more money to change the system, it takes passion. We need to convene meetings of like-minded persons and, above all, see things through the eyes of a child.

Wednesday, September 12

SUCCESSFUL APPROACHES/BEST PRACTICES

Illinois: Empowering Families through Collaboration

Maya Hennessey

Administrator of Women and Youth Services

Office of Alcoholism and Substance Abuse

Illinois Department of Human Services

I love Project SAFE, and I'm pleased to be here to tell you about it. It's a privilege holding a new baby born drug free to a mother with other drug-affected children, or to help a mother get her children back. At our graduation program, we have children telling their mothers they're not afraid of them anymore. Even the judges cry.

Like many good ideas, the impetus for change came from outside the system, when a Department of Children and Family Services (DCFS) staff person realized that substance abuse was a problem in the department's most difficult cases. At the same time, the State Conference of Women Legislators was concerned about how to improve services for women, and the media was focused on the problem of drug-affected infants. We knew that punishing women wouldn't work. In truth, we have grown this program through trial and error; there is no failure, only feedback.

Project SAFE is a collaborative effort between DCFS and the Office of Alcoholism and Substance Abuse (OASA). Initially funded as a Federal demonstration program, the program is now funded by the State of Illinois. The proof of Project SAFE's success is in the numbers: an 81 percent completion rate and a 54 percent reunification rate.

Project SAFE clients are neglectful mothers addicted to alcohol, and nearly 100 percent have histories of domestic violence, including sexual abuse. Our women show an early onset and long duration of violence, with multiple perpetrators and further victimization in a system that doesn't believe them. Most are single but in intimate, often abusive, relationships. They are dependent both on toxic relationships and on public institutions.

These women are difficult to engage, and they are at high risk for relapse, but we build that into the program. We view relapse as an opportunity, not a measure of failure. As women progress through the program, their relapses are less intense and shorter in duration. We also recognize that women's alcoholism progresses differently than men's disease, a factor important in assessment and treatment. For example, a man gives up on relationships in the early stages of alcoholism. But women cling to their relationships to the end, so they can be much further advanced in their disease and still have a connection to family and friends.

Project SAFE program components include the following:

• Referrals. All clients sign an initial consent form on referral that allows the substance abuse provider to acknowledge whether or not the client arrived for treatment. As more information is needed, the consent form is expanded incrementally.
• Outreach. Outreach is one of the keys to Project SAFE's success. Outreach workers befriend the mother and gain her trust. They meet immediate needs and help remove barriers to substance abuse treatment. They are seen as an ally, not an enemy. Each outreach worker is assigned 8 to 12 families.
• Intensive outpatient treatment. We realized that our treatment needed to be gender sensitive, and that many of our mothers had, in essence, a full-time job meeting the various demands of the systems with which they interact. Some of them can't do 15 hours a week in group and individual treatment.
• Transportation. Initially viewed as an ancillary service, transportation has become an important assessment tool. Mothers and children are more open to sharing as they ride a van to appointments. Van transportation has become a sort of "traveling therapy group."
• Child care. Originally offered on-site, child care is now available at community sites and with friends and relatives. Once again, transportation to child care sites becomes an important time for outreach workers to see families interact.
• Parenting. Parenting education has to be introduced gradually, after staff gain the woman's trust. Project SAFE uses "experiential parenting," giving parents and children time to interact together so staff can observe a parent's behavior and correct it.
• Case management/coordination. Coordinating care for clients involved in multiple systems is time-consuming and complex. We've had trouble removing some of the barriers these women face. We need collaboration and trust between the alcohol and drug and child welfare systems, and we need to involve the courts, as well.
• Joint administration and evaluation. DCYF and OASA conduct joint site visits and provide on-site technical assistance.

We found that collaboration can be difficult, especially when you approach this work with different missions and different philosophical approaches. Data collection and analysis also became more difficult as our program grew. But working together, you can see problems from a larger perspective and share resources to save families.

Project SAFE wouldn't work without the collaboration we have between DCFS and OASA. We set policy at the State level and do problem-solving at the local level; collaboration is both horizontal and vertical in Illinois. We also know that staff support is essential to prevent burnout. It's difficult to face this level of trauma and tragedy on a daily basis.

We've been fascinated with the way other states have implemented Project SAFE, creating unique programs that meet their specific needs. In Connecticut, they brought mental health to the table; we found that difficult to do in Illinois. Connecticut also was able to implement Project SAFE in phases, putting all the necessary elements in place in Phase I and improving services in Phase II. We've borrowed some of the work their staff has done in experiential parenting. Clearly, this model can be successfully replicated, and we can learn from one another.

Connecticut: Retention of Women in Treatment

The Connecticut team was unable to remain in Boston due to the national tragedy. This presentation was given at the first State Team-Building Workshop in Savannah, GA, May 8-9, 2001.

Karen Snyder

Assistant Commissioner

Connecticut Department of Mental Health and Addiction Services

Connecticut is a small State with many agencies that interact with families in trouble. Though the administration of these agencies is different, the clients they serve don't fall into neat categories, which creates a need for collaboration to avoid fragmentation. Several of these efforts are already in place. Connecticut identifies all children receiving services from child protective services or children's mental health by age 16 who will require services after age 18. The state added money to the adult system to create transitional services for these youth.

In addition, all corrections clients are evaluated for mental illness. Those with medication needs are identified and tracked, and a discharge plan is prepared for their release to the community mental health system. Further, jail diversion teams are available in local courts.

The State has also initiated a set of service improvement goals that include: 1) a major trauma initiative; 2) an emphasis on evidence-based treatment; 3) a focus on addressing the totality of an individual's need for substance abuse, behavioral health, and trauma services; 4) the involvement of consumers in planning, developing, and delivering mental health and substance abuse services (with a special emphasis on destigmatizing these conditions); and 5) the development of local substance abuse authorities, similar to local mental health authorities, to coordinate service planning for individuals with substance abuse disorders.

Much of the hard work of coordination and collaboration takes place at the local level. Statewide, the Department of Mental Health and Addiction Services and the Department of Children and Families partnership is based on: 1) designated leadership and project responsibility; 2) joint program planning and evaluation; 3) regional service team meetings; 4) cross-training forums; 5) co-contracting; and 6) resource development and shared funding. The development of personal relationships and agreement on objectives also are key.

Peter Panzarella

Director of Substance Abuse Services

Connecticut Department of Children and Families

Project SAFE began in 1995 after three infant deaths in three months. Substance abuse was involved in each case, but the parents had not been screened. Project SAFE is a program for evaluation and treatment of alcohol and other drug dependency among parents in the child welfare system. The program is a collaboration among the State Department of Children and Families (DCF), the State Department of Mental Health and Addiction Services (DMHAS), and Advanced Behavioral Health (ABH), a network of nonprofit behavioral health providers.

Project SAFE services include a statewide centralized intake through a toll-free number. This gives DCF social workers priority access to ABH providers for drug screens, substance abuse evaluations, and a variety of outpatient substance abuse treatment services. The program also uses centralized data reports and electronic billing. The ABH provider network manages the quality of care.

As part of Phase I, Project SAFE staff created a specialized screening tool that includes information about both substance abuse and child welfare issues, and developed specific consent forms. DCF hired substance abuse specialists­licensed clinical social workers who are also certified alcoholism counselors­to serve as consultants, trainers, and provide some direct services to families.

The strengths of Phase I included: 1) a direct link between child welfare and substance abuse treatment; 2) priority access to substance abuse services for child welfare clients; 3) the simplicity of the system for child protective services workers; 4) the use of standardized clinical summaries and preferred practices; 5) a centralized data collection system; and 6) the development of DCF supportive housing for recovering families.

The limits of Phase I included: 1) limited collaboration between DCF and DMHAS, despite serving joint clients; 2) low rates of engagement and retention in treatment; 3) poor client outcomes; 4) a behavioral health approach narrowly focused on addiction; and 5) different values and priorities between the two systems.

Phase II includes a focus on improved outcomes for women, children, and families. Focus groups of clients and providers indicated that success with this population is based on the following: 1) respect and empathy toward the client; 2) direct and clear communication: 3) ongoing motivation and engagement; and 4) good relationships among child protective services staff and substance abuse treatment providers. Nancy Young of Children and Family Futures helped the state develop a strategic plan for the DCF/DMHAS collaboration.

The Phase II Project SAFE program serves between 5,000 and 6,000 unduplicated clients a year. Eighty-four percent of these parents are referred by DCF social workers because of allegations of substance abuse in the child protective services report. Alcohol is the most significant problem substance for men (80 percent), and cocaine is the most significant problem substance for women (60 percent). Cocaine use by women in the child welfare system is disproportionately higher than it is in the adult treatment system as a whole.

Judith Ford

Director of Women's Behavioral Health and Trauma

Connecticut Department of Mental Health and Addiction Services

Most women served by Project SAFE are ages 18 to 35. Fifty percent are Caucasian, and the balance are African American and Latina. They are in low paying jobs, with many on welfare, and they have co-occurring trauma, depression, and other anxiety disorders. They also experience significant social stressors, including their involvement with child protective services, current violence, and homelessness or risk of homelessness.

All of these women are mothers, but that fact is not being addressed in substance abuse treatment. Our culture places a high value on the maternal role, and a mother is evaluated as a person by her success in this role. It is difficult for women to discuss their ambivalence about their roles as mothers. Most treatment programs stress a woman's role as a parent to provide for the physical needs of her children, and her very involvement in the child welfare system implies she has been a failure in this role. Fear of losing her children is a negative incentive. Few treatment programs address issues of emotional attachment and nurturing that allow a woman to discuss her feelings about her child and give her a positive incentive to stay in treatment.

To help women and their children heal, Project SAFE Phase II services include the following:

• Outreach and engagement. Outreach workers help women meet immediate survival needs and build on their strengths.
• On-site child care. Having their children with them makes mothers feel more comfortable, and it allows substance abuse treatment providers to see how families interact.

• On-site parenting support. On-site parenting groups provide mothers with education and support in the context of their substance abuse treatment.
• Trauma education and treatment. Trauma services include assessment, a three-session education model, and trauma-sensitive treatment.
• Comprehensive substance abuse evaluations. Project SAFE is field testing a family-focused substance abuse evaluation that includes a trauma screen, as well as information about anxiety and mental health and motivation to change.

Much of the hard work of coordination and collaboration takes place at the local level. Statewide, the Department of Mental Health and Addiction Services and the Department of Children and Families partnership is based on: 1) designated leadership and project responsibility; 2) joint program planning and evaluation; 3) regional service team meetings; 4) cross-training forums; 5) co-contracting; and 6) resource development and shared funding. The development of personal relationships and agreement on objectives also are key.

Safety/Resilience: Children in Substance Abusing Families
Laurie S. Markoff, Ph.D.
Institute for Health and Recovery
Cambridge, MA
I'm the Director of Project WELL (Women Embracing Life and Recovery), one of nine sites around the country that is part of a SAMHSA study of women with co-occurring mental health and substance use disorders who also are affected by domestic violence. Karen Gould is director of the WELL Child Project.

We've had meetings across the country attended by administrators, clinicians, and consumers to come to consensus about key parts of the study. We learned it is vitally important for the voice of consumers to be in the room. When we talked about the children, our consumers felt defensive, anxious, angry, and put-down. Our clinicians felt accused, apologetic, and defensive. All of that changed when we allowed the consumers to do a presentation on the problems of parenting in recovery.

I'd like to talk to you today about safety and resiliency for children in substance-abusing families. Much of what I'm going to share are generalizations, but they are useful as a starting point. We know some of the common effects of addiction on the family. Parents are preoccupied with obtaining the substance, they often are physically absent, and they are emotionally disconnected from the rest of the family. Clearly, the children's needs are not being met.

Children in substance-abusing families live chaotic and unsafe lifestyles, with inconsistent discipline. Parents with low self-esteem may look for their children to meet their needs. The children's reality and feelings are denied and distorted. Children learn not to trust their feelings, and they feel shame and guilt. They may become impulsive and adopt some coping strategies that don't work well outside the home. Girls may develop depression, eating disorders, and physical stress-related problems, and boys may exhibit speech, behavior, and conduct disorders.

Sometimes a non-using parent or other supportive person can help mitigate the impact of substance abuse on the child. But racism, poverty, and violence intensify the negative affects. We know that physical, sexual, and emotional abuse are three times more common in alcoholic families than in the general population. Therefore, children in substance-abusing families have a higher likelihood of being abused and witnessing the abuse of others.

When we examine factors that impact the parent-child relationship, we find that many parents have not had appropriate parenting role models themselves. Traumatic memories may be stimulated for parents who were abused as children, especially when their own children reach the age at which the abuse began. These women didn't learn to manage their own feelings, so they can't help their children do so. Often, they have difficulty setting limits because they are afraid of hurting their child. We have to help them balance recovery needs with the needs of parenting. How can a mother attend 90 meetings in 90 days if she has five children?

Recovery can be difficult on a family, and you can't support the family if you miss this important fact. Recovery changes the roles and relationships among all family members. Children may have been taking care of their parents, and they lose this responsibility. Families need a great deal of long-term support to tolerate these changes and stay with a recovery program.

Initially, a parent may need to retain some denial to protect a fragile self-image. If they have to acknowledge everything all at once, they may relapse. As they work through their guilt and shame, they begin to understand that their past behavior was a consequence of their addiction and was not deliberate or intentional. They have to examine their own childhood, where addiction may have begun as a way to medicate feelings against the trauma they were experiencing.

Group settings can help women develop empathy for others and for themselves. They can learn that forgiving themselves is good but that doesn't mean their behavior was okay. As they look honestly at the impact of their behavior on their children, they can also learn the skills to help their children express their own feelings about their experiences.

Karen S. Gould, L.I.C.S.W.
Institute for Health and Recovery
Cambridge, MA
The Well Child Project promotes resiliency and case coordinator for children. Why do some children fare better even when they receive the same services as others? Research and experience tell us that we are all born with innate resiliency, but certain factors help foster and reinforce this. The possibility of change is always there if we look at this from a strengths-based model. This approach is about health and healing versus pathology and deficit, which is motivating to both staff and clients.

The experts tell us that resilient children are able to find emotional support outside the family, are responsive to help that is offered, are in good physical health and have above average intelligence, and have opportunities for meaningful contributions. This latter point is very important. Kids need a way to give back. Indeed, protective factors have more meaning when life has a sense of purpose. I once heard it said that kids will walk around trouble if they have somewhere to walk and someone to walk with.

Just as there are protective factors, we know there are risk factors for substance abuse in young people. Those who are rebellious and whose friends use drugs are more at risk, as are those whose parents have a positive attitude toward drug use. Children who lack life skills and ties to the community are also more likely to use or abuse substances. A sense of autonomy, a positive self-image, and a sense of purpose are protective factors that mitigate against substance abuse in children.

The WELL Child Project is operating in four of the SAMHSA sites for women with co-occurring disorders affected by domestic violence. It is a strengths-based, psychoeducational, resiliency promoting program for kids ages 5 to 10. We can't wait until they get older to begin this important work.

The children's study is guided by our core beliefs that children are entitled to have their voice heard; to be physically safe; to experience consistency; to have a sense of dignity and self-worth; to have control over their bodies; to receive respect, understanding, compassion and support; to have nurturing relationships with adults in their lives; to have confidentiality respected, except when safety issues arise; and to connect to community and natural supports. These values reflect what we know about fostering the attributes of resiliency.

Our nine-week intervention, with two booster sessions, is adapted from a domestic violence project in Minnesota (see Groupwork with Children of Battered Women, Peled and Davis, Sage Publications, 1995). The program's goals are to "break the secret" of abuse in families, to help children learn to protect themselves, to help them experience the group as a positive and safe environment, and to strengthen their self-esteem.

A case manager follows the child, and a child clinician advocate helps connect the child to healthy diversions, including, sports, Scouting, and church activities. Our focus is on the child, but we also must work with the family. We know that children are loyal to their families no matter what. They always are relived to feel safe, but in the end, they want to go home.

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