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Increasing Stable Reunifications — October 2012 Sounding Board

29 Nov

by Dee Wilson

Since the passage of the Adoptions and Safe Families Act (AFSA) in 1997, the number of adoptions completed annually in the U.S. has more than doubled to more than 50,000 per year while the number of reunifications  and the percentage of exits from out-of-home care that are reunifications has remained stable or actually declined in most states. Perhaps it is not a surprise that a federal law establishing strict timelines for reunification and requiring child welfare agencies to take legal action to terminate parental rights, absent compelling reasons, when these timelines have been exceeded has resulted in increased adoptions, but not increased reunifications. In addition, federal law provides financial adoption incentives for states which greatly increase adoptions; and state child welfare systems can reinvest these federal funds in staff and infrastructure further increasing adoptions. There are no federal financial incentives for state child welfare systems which increase reunifications.

AFSA is not balanced public policy, but its passage is understandable given child welfare realities of the 1990s. The number of children in out-of-home care more than doubled from 1986-99 due to a substance abuse epidemic among low income populations, and many of the children entering out-of home-care (and often remaining in care for several years) were infants and other young children. Some studies published in the late 1980s and early 90s indicated that no more than 25% of substance abusing parents whose children had been removed from the home entered into, much less completed, drug treatment programs. Furthermore, the first generation of in-home family support programs for substance abusing parents with children appeared to be failures (see Besharov and Hanson, 1994). There was a period in the 1990s when many child welfare caseworkers and supervisors in Washington State were convinced that methamphetamine addicts could not be successfully treated in this state’s in-patient and out-patient programs. The goal of reunification appeared to be a lost cause for a sizeable fraction of parents whose children had been removed from the home, usually due to neglect associated with substance abuse and co – occurring mental health disorders.

Today, the possibility of increasing safe and stable reunifications appears more hopeful than when AFSA became law because of a better understanding of the needs of substance abusing parents who have lost custody of their children, along with the development, testing and implementation of evidenced based and promising programs and other research on reunification and reentry into care that has shed light on why reunifications succeed or fail.

Jill Berrick’s book, Take Me Home offers one of the most enlightening discussions of reunification practice published in recent years. Berrick conducted interviews with six women whose children had been removed from the home in California due to drug abuse, and who struggled (for years in some cases) to regain custody of their children. Berrick writes that “Parents’ stories about the path to reunification suggests a lonely experience that speaks largely to issues of compliance and less to changes in real-life circumstances.”

In Berrick’s powerful stories, public child welfare agencies appear largely clueless about the status and even the whereabouts of the children for whom they were legally responsible and the needs of parents seeking reunification. Berrick writes of one mother:

“When Tracy was working to reunify with (her 3 children), she needed to learn how to engage in positive parenting experiences; she needed a coach to help her learn techniques for managing her children’s now challenging behaviors; she needed support in responding to their needs in their new, dyadic, intimate, day-to day relationship. Tracy also needed concrete help establishing a home for her children. She needed an apartment in a new community, away from the familiar triggers she associated with the drug use of her past. She needed furniture, phone service, kitchen paraphernalia, bedding, clothes – Tracy needed all of these and had none. She needed an enriched child care program for her youngest and after-school services for the others. She needed reliable transportation. … she needed another bed, sheets and blankets. What Tracy needed was income to clothe and feed a very large family. What she got was another generic parenting class.”

Berrick can write confidently about Tracy’s needs because of her in-depth conversations with this mother, not because of her studies of large administrative data bases. Analysis of data is important, but it’s not a substitute for carefully listening to parents’ accounts of their experiences and needs. Practice models that bring caseworkers and other professionals into regular interpersonal contact with parents struggling through a recovery process provide a forum in which parents can be heard, and which provide an opportunity for professionals to give parents timely feedback on their progress.

One of the most promising developments in recent years has been the expanded use of family treatment drug courts (FTDC) with parents whose children have been made legally dependent and who are initially in out-of-home care. Family treatment drug courts involve regular (often weekly) meetings of parents and professionals in a court setting to review parents’ progress and needs. These team meetings provide a format for giving parents timely feedback (much of it positive) on their reunification efforts and the capacity to mobilize resources as needed. A few quasi-experimental studies of family treatment drug courts, including a recent Washington State study (Bruns, et al, 2012); have found increased reunification rates for parents who participate in family treatment drug courts.

Given that parents’ participation in a family treatment drug court is voluntary, there is a possibility that parental involvement in FTDC is a proxy for motivation, i.e., parents who agree to participate in a FTDC are initially more motivated to regain custody of children than parents who choose not to accept  FTDC structure and rules. There is no question that parental motivation to be reunified with their children is an important factor in successful reunifications, and probably accounts for the importance of a parent’s visitation track record in predicting a reunification outcome.  However, motivation to achieve a difficult goal such as reunification is not static; motivation to struggle with tough challenges can be strengthened or weakened by responses – or lack of same – in the social environment. If child welfare practitioners want parents to succeed in regaining custody of children, then they must engage in practices that strengthen parents’ positive motivation and overcome parental resistance to participation in treatment programs.

Early studies of substance abuse treatment for parents with open child welfare cases found low rates of parental enrollment in and completion of substance abuse treatment programs, even when failure to comply with court orders could mean termination of parental rights. There have been similar findings regarding the low percentage of depressed parents in public mental health settings who return for a second visit and go on to complete a course of treatment. Sometimes addicted parents are not ready to give up drugs and alcohol, but many parents appear to doubt whether courts and agencies will ever return children to their care regardless of what they do.  In addition, parents with trauma histories may have developed hopeless/ helpless ways of avoiding difficult challenges that makes failure a self-fulfilling prophecy.

Programs such as Engaging Moms in Florida, Washington State’s Parent Child – Assistance Program (PCAP) and Illinois’ recovery coaches are designed to overcome parental resistance to treatment and support parents’ completion of treatment programs. An increasing number of child welfare jurisdictions are investing in parent advocates and mentors who support parents’ efforts to reunify with their children over and above encouraging involvement in treatment programs. Emotional support and advocacy are important for parents who often distrust child welfare caseworkers and other professionals they may view as hostile or unsympathetic to their interests. 

One of the most difficult challenges facing caseworkers and courts is how to combine or sequence parenting skills programs with substance abuse and mental health treatment. There has been surprisingly little research that addresses this issue, though most professionals who work with troubled parents agree that overwhelming them with multiple demands is a formula for failure. In addition, until the past decade there was a sound basis for skepticism regarding the effectiveness of widely available parenting skills programs, most of which were not evidenced based and which were routinely mandated for parents involved in dependency actions regardless of results. There is also an articulate body of scholarly opinion that questions whether substance abuse treatment is necessary if the abusive or neglectful parenting that results in open child welfare cases can be changed by well tested parenting programs absent drug treatment.

One of the most positive developments in child welfare during the past decade has been the increasing availability of evidenced based parenting and/or promising programs such as Parent Child Interaction Therapy (PCIT) and Triple P. As a rule, these programs teach parents the power of praise and other rewards to shape child behavior in desirable ways, and include coaching of parents to develop useful skills.

Brook, McDonald and Yen have recently published (2012) results of a quasi-experimental study of use of the Strengthening Families Program (SFP) in Kansas to achieve reunification goals, an interesting use of a program designed for primary prevention. Brook, et al, found that 45% of families who participated in SFP were reunified with their children by 360 days from date of  removal compared to 27% of  the comparison group. According to these authors, SFP curriculums used in Kansas are for children 3-5 and 6-11. Half of the children in SFP entered the program after 225 days in foster care, a delay that suggests the likelihood that caseworkers encouraged parents to enter the program only after a lengthy course of substance abuse treatment or other treatment. The authors emphasize that SFP is a parenting program, and that sobriety was not a program goal. Nevertheless, caseworker use of the program suggests that they often used SFP in combination with other treatment programs and only after children had been in care for 7-8 months.

These authors plausibly suggest that there are some drug/alcohol abusing parents whose parenting issues can be effectively addressed without participation in substance abuse treatment programs. It is also likely that the timing of parents’ ability to benefit from skills based parenting programs varies widely; and that these differences have important implications for child welfare decision makers, i.e., the earlier parents can learn and utilize parenting skills, the earlier they can be reunified with their children. Conversely, some parents need a lengthy course of drug/alcohol treatment or mental health treatment before they can benefit from parenting skills programs. Reunification should be delayed in these cases.  But how can caseworkers determine which parents can benefit immediately, or after a brief period of time in treatment, from skill based parenting programs, and which parents will need many months of participation in treatment programs before they can acquire parenting skills? A cogent research based answer to this question does not seem to be available.    

Most studies continue to find that about 15% of reunified children re-enter out-of-home care in the first year following reunification, and 30% or higher re-enter care over a period of 3-5 years. A recent analysis (Barth, et al, 2010) of re-entry data from the National Study of Child and Adolescent Well Being (NSCAW) found a re-entry rate of 22.1% over 36 months of the study (not 36 months from date of reunification). Children, 0-5 who entered out-of-home care due to neglect, and school age children with serious behavior problems at baseline (soon after initial placement), were much more likely to re-enter care than abused  children placed out of the home or children with normal Child Behavior Checklist (CBCL) scores at baseline.       

 A common finding in studies of re-entry into care is that briefer stays in care (especially less than 6 months) are associated with higher rates of re-entry. When children enter care through voluntary agreements with parents, or for no longer than a few days or weeks, children may be returned to parents without a substance abuse or mental health assessment. Caseworkers often have a superficial understanding of family dynamics and family needs in many of these cases. However, even when parents have entered treatment programs, they may not be well established in a recovery process, or emotionally ready to meet the day in-day out needs of children. Shorter lengths of stay for children in out-of-home care may not be in sync with the therapeutic needs of parents with substance abuse issues.  

Extended (but time limited) and intensively monitored trial home visits can help to establish the readiness of parents in substance abuse and mental health treatment programs to tolerate the normal stresses of child rearing. Parents must be able to admit after trial visits of a few days or weeks that they are not ready to be reunified with their children without the fear that this type of candor will be used against them in court actions.

In addition, voluntary services need to be extended to parents with chronically relapsing conditions such as substance abuse and depression for at least a year following children’s return to the parent’s home. Furthermore, there is a small fraction of seriously cognitively impaired parents who will need case management services for as long as they have young children in their homes.  State laws that authorize the dismissal of dependency actions, and closure of child welfare services, 6 months after children have been returned home are not congruent with the known risk of relapse. Children may not need to re-enter out-of-home care following relapse depending on parental adherence to a documented safety plan; but child welfare intervention is often needed at these times.

Child welfare agencies can also reduce rates of re-entry by providing respite care to birth parents as needed; and this is easier to arrange when foster parents and birth parents have developed a positive relationship before children are returned to the birth parent’s home. Foster care can be used to support birth families as well as supplanting them.  

In next month’s Sounding Board, I will discuss how decision makers in the courts and child welfare systems can determine if children will be safe following reunification. Criteria for determining the risks and safety of reunifications, and services needed to increase reunification rates are related subjects, but not the same.


References

Barth, R., Guo  S., Weigensberg, E. , Christ, S., Bruhn, C., and Green, R., “Explaining Reunification and Reentry 3 Years After placement in Out-of-Home Care,” Chapter 8 in Child Welfare and Child Well Being: New Perspectives from the National Survey of Child and Adolescent Well Being, edited by  Mary Bruce Webb, Kathryn Dowd, Brenda Jones Harden, John Landsverk and Mark Testa, 2010.

Berrick, Jill Duerr, Take Me Home: Protecting America’s Vulnerable Children and Families, 2009.

Besharov, Douglas, and Hansen, Kristine, When Drug Addicts Have Children, 1994.

Brook, Jody, McDonald, Thomas and Yan, Yueqi, “An analysis of the impact of the Strengthening Families Program on family reunification in child welfare,” Children and Youth Services Review, 34, 2012.

Bruns, Eric, Pullmann, Michael, Weathers, Ericka, Wirschem, Mark, and

Murphy, Jill, “Effects of a Multidisciplinary Family Treatment Drug Court on Child and Family Outcomes: Results of a Quasi-Experimental Study,”  Child Maltreatment, August 2012.

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Posted by on November 29, 2012 in Uncategorized

 

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