1. Overview of the State Substance Abuse Child Welfare Waiver Demonstrations National Conference on Substance Abuse, Child Welfare, and the Courts January 31, 2007 Anaheim, California Elliott Graham, Ph.D.

2. Part I Overview 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.

3. 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.)

4. 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)

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

6. 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

7. Services for Caregivers with Substance Use Disorders

8. 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).

9. Key Features of Substance Abuse Waiver Demonstrations StateKey Program FocusTarget Population ScopeIV-E Status DE  Early identification of substance use disorders  Service referral  Linking families to existing treatment resources Children in or at risk of out-of-home care due to parental substance use StatewideIV-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 referral  Linking 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 referral  Linking 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

10. Substance Abuse Waiver Demonstrations – Enrollment and Assessment Procedures StateTiming 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)

11. SA Demonstrations – General Caregiver Characteristics VariableNew HampshireIllinois Mean Age3332 Gender87% Female71% Female Race90% Caucasian81% African American Presence of Mental Health Issues 18% Top Three Drugs Used (in order of prevalence) 1. Alcohol 2. Marijuana 3. Cocaine 1. Cocaine 2. Heroin 3. 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% - Neglect 23% Physical Abuse 24% - SEI 33% - Substantial Risk of Physical Abuse/Harm

12. StateResearch Design Sample Size (# of Cases) Experimental GroupControl/Comparison Group In- home cases Out- of- home cases TotalIn- home cases Out- of- home cases Total DelawareComparison group 398132530368162530 IllinoisRandom assignment NA943 * 943NA366 * 366 MarylandRandom assignment -- 9 9 New Hampshire Random assignment 1833922218233215 Evaluation of the SA Waiver Demonstrations - Summary of Research Designs *As of June 2005

13. 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

14. Evaluation of the SA Waiver Demonstrations - Summary of Key Child Welfare Outcomes of Interest State Outcomes Placement Avoidance Placement Length Placement Stability Foster Care Exit Maltx. Recurrence Foster Care Re-entry Child/ Family Well- Being DE ✔✔ IL N/A ✔✔✔✔ NH ✔✔✔✔✔✔

15. 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

16. Part II Summary 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.

17. 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).

18. 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.

19. 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

20. 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

21. 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).

22.  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.)

23.  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.)

24. Key Lessons Learned (cont.) Need to consider ultimate child welfare program goals: –Placement prevention? –Increased permanency? –Reduced time in out-of-home care?

25. 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))?

26. Key Lessons Learned (cont.) Need to ensure availability of substance abuse treatment services.

27. 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.