This study examined the relationship of mothers’, children’s, and treatment-related factors to child reunification following mothers’ participation in drug treatment; importantly, although reunification accounted for the most frequent outcome among the children (44%), over half of the children did not reunify with their mothers (25% were adopted and 10% remained in placement, with the remainder in diverse types of other outcomes).
Several aspects of their mothers’ treatment participation were related to reunification outcomes. The rate of treatment retention for at least 90 days (or completion) in this study (about 50%) was higher than that reported in previous studies with child-welfare-involved mothers; yet the relationship of treatment retention/completion to a greater likelihood of reunification is consistent with prior research. This finding reinforces the importance of sufficient time in treatment, particularly given the complex service needs presented by these mothers. Alternatively, this finding may reflect a self-selection effect, in that mothers who comply more with their treatment plan, as seen in their longer retention in treatment, are more likely to reunify with their children because of other attributes that predict retention, rather than reunification resulting from a treatment effect that can be attributable to longer retention or treatment completion. This confound (between participant characteristics that are associated with both the likelihood of retention and child reunification) is an inherent aspect of nonexperimental study designs, and thus, study findings should be qualified by this consideration.
An important finding from the study is that reunification was enhanced among mothers who were treated in programs that provided a broader range of employment/educational services, as well as family/children’s services. Outcome studies of drug treatment have increasingly emphasized the provision of services that address the specific needs of participants and particularly the importance of providing a range of comprehensive services (i.e., “wraparound services”) in addition to the core elements of drug treatment (Marsh, Cao, & D’Aunno, 2004
; Pringle, Emptage, & Hubbard, 2006
). In the past 10 to 15 years, specialized programs and services have been developed that aim to improve the parenting ability of substance-abusing mothers and to increase the coordination of treatment services with the child welfare system (Jansson, Svikis, & Beilenson, 2003
; Moore & Finkelstein, 2001
; Wingfield & Klempner, 2000
). Yet access to programs that provide these more enhanced services remains limited. Fewer than half of all substance abuse treatment programs actually provide parenting or family-related services (Grella & Greenwell, 2004
; Marsh, D’Aunno, & Smith, 2000
), and these services are not uniformly available even in programs that are “specialized” to address the service needs of mothers (Olmstead & Sindelar, 2004
; Smith & Marsh, 2002
). Furthermore, family services and parenting interventions may not be implemented in ways that address the specific needs of treatment participants who are simultaneously involved with the child welfare system, such as their need for employment services (Kerwin, 2005
The study findings showed that more severe impairments in functioning, particularly higher levels of employment and psychiatric severity, lessened the likelihood of reunification. In addition to the possible self-selection effect noted above, it may be the case that more disadvantaged mothers are also more likely to come to the attention of child welfare for possible child maltreatment and, from there, to be referred to treatment. Among the study sample, over half had prior contact with child welfare services, including children who had previously been placed into out-of-home care or adopted, suggesting the sustained nature of the problems that brought them to the attention of child welfare. Drug treatment services in the absence of other supportive services may be insufficient to address the economic, parenting, and other needs of these mothers. Child-welfare-involved mothers in treatment are typically younger and have more children than other mothers in treatment but are less likely to have employable skills or prior work history (Grella et al., 2006
; Jones, 2004
; Shillington, Hohman, & Jones, 2001
). Further, because economic instability is often associated with other impairments that make it difficult to attain self-sufficiency (Jayakody, Danziger, & Pollack, 2000
), substance-abusing mothers who enter into the child welfare system face multiple barriers to attaining economic self-sufficiency, which may be a key factor in determining parenting capability and child placement outcomes.
Although mothers whose primary substance was heroin or other opioids were a minority among the sample (10.5%), their likelihood of reunification was substantially less (by about 60%) compared with mothers who were primary alcohol users. Our prior research with the CalTOP sample showed that child-welfare-involved mothers who were heroin/opioid users were older (particularly compared with primary users of methamphetamine) and had longer treatment histories (Grella et al., 2006
). Other research with mothers who are heroin/opioid users has shown substantial impairments in their functioning, often stemming from their long duration of drug use, residential instability, low levels of education and employment, and limited access to social support (Lundgren, Schilling, Fitzgerald, Davis, & Amodeo, 2003
). Most of such mothers do not reside with their children and/or have frequent interruptions in their caregiving relationships (Schilling, Mares, & El-Bassel, 2004
) and often display low levels of maternal involvement and bonding with children (Suchman & Luthar, 2000
; Suchman et al., 2005
). Clearly, heroin-using mothers face substantial obstacles to family reunification and suggest that substance abuse treatment participation itself may not be sufficient to address their broader range of impairments and corresponding service needs.
In contrast, mothers who had more severe legal problems were actually more likely to reunify with their children as compared with others. This finding may stem from external mandates that encourage treatment participation among women who are simultaneously involved with the criminal justice system (although referral from the criminal justice system was not itself associated with reunification). Furthermore, mothers who were self-referred to treatment or referred by another individual (e.g., family or friend) were half as likely to be reunified with their children compared with mothers who were referred by another treatment provider. Thus, for treatment participation to influence reunification outcomes, it appears that the involvement of other service providers, such as through referral, monitoring, or supervision, is critical. This is also evident in the greater likelihood of reunification among mothers who had a history of referral to treatment in their child welfare case records (although we note that one limitation of the data obtained from child welfare records on referral to treatment is that these data do not necessarily correspond with referral to the current [CalTOP] treatment episode).
Several characteristics of children were associated with reunification, as would be expected from prior research; for example, newborns and very young children (less than 3 years) were less likely to be reunified, as were those who were in kin placements. Moreover, the more extensive the child’s involvement in the child welfare system, as seen in longer time spent in the current placement episode, more moves within the episode, and more prior placements, the less likely the child was to be reunified with his or her mother. These aspects of children’s placement history may reflect more problematic behavior of the children, which also makes them harder to parent, particularly for mothers who have psychological and other impairments, and lessens the likelihood of reunification, independent of the mother’s treatment participation.
4.1. Study limitations
The study findings are necessarily limited by some aspects of the study design. In particular, the data used to characterize services available within the treatment programs rely upon the self-report of the program administrator. We do not know whether the availability of these services nor the degree to which the individual participants actually received these services while in treatment was accurately reported. The study provides evidence of an association between program-level characteristics and reunification outcomes but does not explain the mechanisms of the observed association. That is, the program-level variables may be associated with other, unmeasured, characteristics of programs that are associated with child welfare outcomes, such as quality or training of staff, treatment orientation or approach, or the type of relationship between the treatment program and the child welfare agency, such as a greater degree of integration or coordination of services. Such relationships should be tested in future studies.
Further, given the naturalistic study design, findings on the relationships among mother, child, and program characteristics with child welfare outcomes are correlational. The study cannot address whether treatment in programs that provided more educational/employment or family/children’s services actually resulted in improved employment outcomes or parenting capabilities of the participants. As noted previously, there may be selection effects, in which mothers who are more likely to reunify with their children, for a variety of reasons, are also more likely to be referred to particular treatment programs and that mothers who are more likely to comply with treatment may also be more likely to reunify with their children, regardless of the treatment received. Experimental designs in which mothers are randomly assigned to different types of treatment programs or service configurations within programs would provide stronger evidence of causality. In addition, generalizability of study findings is limited by the specific characteristics of participants in the CalTOP evaluation study, as well as by the child welfare policies and practices within the California counties participating in the study. For example, close to half of the sample reported primary methamphetamine use, which is more typical of California treatment admissions than treatment participants in other states (Finnerty, 2004
Yet this study has several advantages over previous studies of the relationship of substance abuse treatment to child welfare outcomes. Foremost is the use of administrative data, rather than self-report, to characterize the relevant aspects of mothers’ and children’s involvement with child welfare services. Further, the relatively large sample size of both mothers and children and the multisite nature of the CalTOP study provided considerable variability in characteristics at all three levels examined (mothers, children, and treatment programs), which enabled us to apply an analytic approach that capitalized on the multilevel nature of these data in relation to the outcome.