Parental Substance Abuse: Implications for Children, the Child Welfare System, and Foster Care Outcomes

Parental Substance Abuse: Implications for Children, the Child Welfare System, and Foster Care Outcomes (Testimony, 10/28/97, GAO/T-HEHS-98-40).

For many children, it is parental substance abuse that first brings them to the attention of the child welfare system. The discovery that a newborn has been prenatally exposed to drugs or alcohol often triggers an investigation of suspected child abuse and neglect. In some states, prenatal substance exposure itself constitutes neglect and is grounds for removing a child from its parents' custody. Substance abuse can undermine a parent's ability to care for older children as well and can lead to child abuse or neglect. As a result, some of these children are removed from the home and placed in foster care. Moreover, once a child is in the system, parental substance abuse is a significant hurdle in their path out of the system--a hurdle that requires drug or alcohol treatment for the parent in addition to services for the family. The nature of drug and alcohol addiction means that a parent's recovery can be lengthy. These cases are often further complicated by such problems as mental illness and homelessness. Foster care cases involving parental substance abuse, therefore, further strain a child welfare system already overburdened by the sheer number of foster care cases. Although child welfare agencies are supposed to resolved foster care cases in a timely manner and make a reasonable effort to reunite children with their parents, treating parental drug or alcohol problems can be a long process. As a result, it may be difficult for child welfare officials to make permanency decisions within shorter time frames before they know whether the parent is likely to succeed in drug or alcohol treatment.

--------------------------- Indexing Terms -----------------------------

REPORTNUM: T-HEHS-98-40 TITLE: Parental Substance Abuse: Implications for Children, the Child Welfare System, and Foster Care Outcomes DATE: 10/28/97 SUBJECT: Foster children Child custody State programs Drug treatment Child abuse Alcohol or drug abuse problems Child care programs IDENTIFIER: Los Angeles (CA) New York (NY) Philadelphia (PA)

****************************************************************** ** This file contains an ASCII representation of the text of a ** ** GAO report. Delineations within the text indicating chapter ** ** titles, headings, and bullets are preserved. Major ** ** divisions and subdivisions of the text, such as Chapters, ** ** Sections, and Appendixes, are identified by double and ** ** single lines. The numbers on the right end of these lines ** ** indicate the position of each of the subsections in the ** ** document outline. These numbers do NOT correspond with the ** ** page numbers of the printed product. ** ** ** ** No attempt has been made to display graphic images, although ** ** figure captions are reproduced. Tables are included, but ** ** may not resemble those in the printed version. ** ** ** ** Please see the PDF (Portable Document Format) file, when ** ** available, for a complete electronic file of the printed ** ** document's contents. ** ** ** ** A printed copy of this report may be obtained from the GAO ** ** Document Distribution Center. For further details, please ** ** send an e-mail message to: ** ** ** ** <info@www.gao.gov> ** ** ** ** with the message 'info' in the body. ** ******************************************************************

Cover ================================================================ COVER

Before the Subcommittee on Human Resources, Committee on Ways and Means, House of Representatives

For Release on Delivery Expected at 3:00 p.m. Tuesday, October 28, 1997

PARENTAL SUBSTANCE ABUSE - IMPLICATIONS FOR CHILDREN, THE CHILD WELFARE SYSTEM, AND FOSTER CARE OUTCOMES

Statement of Jane L. Ross, Director Income Security Issues Health, Education, and Human Services Division

GAO/T-HEHS-98-40

GAO/HEHS-98-40T

(116008)

Abbreviations =============================================================== ABBREV

CPS - child protective services HHS - Department of Health and Human Services HIV - human immunodeficiency virus

PARENTAL SUBSTANCE ABUSE: IMPLICATIONS FOR CHILDREN, THE CHILD WELFARE SYSTEM, AND FOSTER CARE OUTCOMES ============================================================ Chapter 0

Mr. Chairman and Members of the Subcommittee:

Each year, nearly 1 million children in this country are the victims of abuse and neglect by their parents or other caregivers, and parental substance abuse is very often a contributing factor in these cases. Although estimates vary widely, there is considerable literature that suggests that parental substance abuse is involved in the majority of foster care cases in some locations. It is not surprising, therefore, that the nature and effects of parental substance abuse are of concern to this Subcommittee, particularly in light of the dramatic increase in the foster care population, which was estimated to be almost half a million by the end of 1995.

Because of your concern, you asked us to discuss the implications of parental substance abuse for children and the child welfare system. You also asked us to comment on permanency planning for foster care cases involving parental substance abuse, given the importance of family reunification.

My testimony today is based on our ongoing work for the Senate Committee on Finance and previous work we have done in the child welfare and substance abuse areas. (See Related GAO Products at the end of this statement.) Our ongoing work on the implications of parental substance abuse for foster care primarily consists of reviews of the substance abuse histories and drug treatment experiences of parents, as well as the initiatives that might help achieve timely exits from foster care for cases involving parental substance abuse. Most of the previous work I refer to here involved an extensive review of the case files of representative samples of young foster children--those under 3 years of age--who were in foster care in Los Angeles County, New York City, and Philadelphia County in 1986 and 1991. These locations accounted for a substantial portion of their respective states' populations of young foster children in 1991.\1 Furthermore, over 50 percent of the nation's foster children were under the jurisdiction of these three states in that year.

Let me briefly summarize our findings. For many children, it is parental substance abuse that brings them to the attention of the child welfare system. When a newborn has been found to have been prenatally exposed to drugs or alcohol, this often triggers an investigation of suspected child abuse and neglect. In some states, prenatal substance exposure itself constitutes neglect and is grounds for removing a child from its parents. Substance abuse can damage a parent's ability to care for older children as well, and can lead to child abuse or neglect. As a result, some of these children are removed from the custody of their parents and placed in foster care.

Furthermore, once a child is in the system, parental substance abuse is a significant hurdle in their path out of the system--a hurdle that requires drug or alcohol treatment for the parent in addition to other services for the family. The nature of drug and alcohol addiction means a parent's recovery can take a considerable amount of time. Other problems these parents face, such as mental illness and homelessness, further complicate these cases. Foster care cases that involve parental substance abuse, therefore, place an additional strain on a child welfare system already overburdened by the sheer number of foster care cases.

Child welfare agencies are charged with ensuring that foster care cases are resolved in a timely manner and with making reasonable efforts to reunite children with their parents. Ideally, both of these goals are to be achieved. However, even for parents who are able to recover from drug or alcohol abuse problems, recovery can be a long process. Child welfare officials may have difficulties making permanency decisions within shorter time frames before they know whether the parent is likely to succeed in drug treatment. So, when parental substance abuse is an issue in a foster care case, it may be difficult to reconcile these two goals. The foster care initiatives and laws that some states and localities are instituting may help reconcile the goals of family reunification and timely exits from foster care for the cases involving parental substance abuse.

-------------------- \1 In 1991, these locations accounted for 44 percent of young foster children in California; 81 percent of young foster children in New York; and 29 percent of young foster children in Pennsylvania.

BACKGROUND ---------------------------------------------------------- Chapter 0:1

The child welfare system encompasses a broad range of activities, including

-- child protective services (CPS), which investigates reports of child abuse and neglect;

-- services to support and preserve families; and

-- foster care for children who cannot live safely at home.

States and localities provide the majority of funds for foster care and child welfare services, but federal funds are provided to states for the food, housing, and incidental expenses of foster children whose parents meet federal eligibility criteria. Federal funding for the administration and maintenance expenses of foster care was estimated at about $3.6 billion in 1997. Additional federal funds are provided to states for a wide range of other child welfare and family preservation and support services, and these were estimated at about $500 million in 1997.

As an integral part of the child welfare system, foster care is designed to ensure the safety and well-being of children whose families are not caring for them adequately. Beyond food and housing, foster care agencies provide services to children and their parents that are intended to address the problems that brought the children into the system. Agencies are also required to develop a permanency plan for foster children to make sure they do not remain in the system longer than necessary. Usually, the initial plan is to work toward returning the children to their parents. If attempts to reunify the family fail, the agency is to develop a plan to place the children in some other safe, permanent living arrangement, such as adoption or guardianship. According to federal statute, the court must hold a permanency planning hearing no later than 18 months after a child enters foster care.\2 Proposed federal legislation would shorten this time frame to 12 months,\3 in the hope of reducing the time a child spends in foster care. Some states have already adopted this shorter time frame.

-------------------- \2 42 U.S.C. 675(5)(C).

\3 Adoption Promotion Act of 1997 (H.R. 867); Promotion of Adoption, Safety, and Support for Abused and Neglected Children (S. 1195).

PARENTAL SUBSTANCE ABUSE OFTEN BRINGS CHILDREN TO THE ATTENTION OF THE CHILD WELFARE SYSTEM ---------------------------------------------------------- Chapter 0:2

Children come to the attention of the child welfare system in two ways--either shortly after birth because they were exposed to drugs or alcohol in-utero or sometime later because they have been abused or neglected. Children with substance abusing parents enter foster care in either way.

Many state statutes require that drug- or alcohol-exposed infants be reported, and some of these children are subsequently removed from the custody of their parents if an investigation determines that they have been abused or neglected. In some states, prenatal substance exposure itself constitutes neglect and is grounds for removing children from the custody of their parents. Large numbers of children in foster care are known to have been prenatally substance exposed. In an earlier study, we estimated that close to two-thirds of young foster children in selected locations in 1991 had been prenatally exposed to drugs and alcohol, up from about one-quarter in 1986.

In both years, cocaine was the most prevalent substance that young foster children were known to have been exposed to, and the incidence of this exposure increased from about 17 percent of young foster children in 1986 to 55 percent in 1991. Moreover, among those who had been prenatally exposed who were in foster care in 1991, about one quarter had been exposed to more than one substance. The actual number of young foster children who had been exposed to drugs or alcohol in-utero may have been much higher because we relied on the mother's self-reporting of drug or alcohol use or toxicology test results of the mother or infant to document prenatal exposure. Yet, not all children or mothers are tested at birth for drugs, and even when they are tested, only recent drug or alcohol use can be confirmed.

Older children of substance abusing parents also may enter foster care because they have been abused or neglected as a result of their parents' diminished ability to properly care for them. Abuse and neglect of children of all ages, as reported to CPS agencies, more than doubled from 1.1 million to over 2.9 million between 1980 and 1994, and a Department of Health and Human Services (HHS) report found that the number of CPS cases involving substance abuse can range from 20 to 90 percent, depending on the area of the country. For example, we recently found that about 75 percent of confirmed cases of child abuse and neglect in New York City involved substance abuse by at least one parent or caregiver. Many of these parents live in drug-infested and poor neighborhoods that intensify family problems.

Neglect is most frequently cited as the primary reason children are removed from the custody of their parents and placed in foster care. According to the Office of Child Abuse and Neglect, the children of parents who are substance abusers are often neglected because their parents are physically or psychologically absent while they seek, or are under the influence of, alcohol and other harmful drugs. Sixty-eight percent of young children in foster care in California and New York in 1991 were removed from their parents as a result of neglect or caretaker absence or incapacity. No other reasons for removal accounted for a large portion of entries of young children into foster care. Physical, sexual, and emotional abuse combined accounted for only about 7 percent of removals of these young children.

PARENTAL SUBSTANCE ABUSE PLACES ADDITIONAL STRAIN ON THE CHILD WELFARE SYSTEM ---------------------------------------------------------- Chapter 0:3

Parental substance abuse not only adversely affects the well-being of children, it also places additional strain on the child welfare system. The foster care population increased dramatically between 1985 and 1995 and is estimated to have reached about 494,000 by the end of 1995. As a consequence, foster care expenditures have risen dramatically. Between 1985 and 1995, federal foster care expenditures under title IV-E of the Social Security Act increased from $546 million to about $3 billion. We found that a greater portion of foster care expenditures in some locations shifted to the federal government between 1986 and 1991 because much of the growth in the population of young foster children involved poor families who were eligible for federal funding.

Parental substance abuse is involved in a large number of cases. We have previously reported that an estimated 78 percent of young foster children in 1991 in selected locations had at least one parent who was abusing drugs or alcohol. Our recent interviews with child welfare officials in Los Angeles County, California, and Cook County, Illinois, have confirmed that the majority of foster care cases in these counties for children of all ages involve parental substance abuse. Officials in these locations stated not only that cocaine use among parents of foster children is still pervasive but that the use of other highly addictive and debilitating drugs, such as heroin and methamphetamines, appears to be on the rise. In addition, officials confirmed that use of multiple substances is common.

In addition to the large number of foster care cases involving parental substance abuse, the complexities of these family situations place greater demands on the child welfare system. Most of the families of the young foster children in selected locations whose case files we reviewed had additional children in foster care, and at least one parent was absent. About one-third of the families were homeless or lacked a stable residence. Some had at least one parent who had a criminal record or was incarcerated, and in some families domestic violence was a problem. In addition, child welfare officials in Los Angeles and Cook Counties recently told us that dual diagnosis of substance addiction and mental illness is common among substance abusing parents. The National Institute of Mental Health reported in 1990 that most cocaine abusers had at least one serious mental disorder such as schizophrenia, depression, or antisocial personality disorder.

To illustrate the complexities of these cases and the influences the complexities can have on outcomes from foster care, let me describe a case we recently reviewed as part of our ongoing work. This case involves a woman with four children, all of whom were removed from her custody as a result of neglect related to her cocaine abuse. The youngest child entered foster care shortly after his birth. By that time, the three older children had already been removed from their mother's custody. All four of the children were placed with their grandmother. The mother had a long history of cocaine abuse that interfered with her ability to parent. At least two of her four children were known to have been prenatally exposed to cocaine. She also had been convicted of felony drug possession and prostitution, lacked a stable residence, and was unemployed. The father was never located, although it was discovered that he had a criminal record for felony drug possession and sales.

Despite the mother's long history of drug use and related criminal activity, she eventually completed a residential drug treatment program that lasted about 1 year, participated in follow-up drug treatment support groups, and tested clean for over 6 months. In addition, she completed other requirements for family reunification, such as attending parenting and human immunodeficiency virus (HIV) education classes, and she was also able to obtain suitable housing. Although the mother was ultimately reunified with her youngest child, it took a considerable amount of time and an array of social services to resolve this case. The child was returned to his mother on a trial basis about 18 months after he entered foster care. The child welfare system retained jurisdiction for about another year, during which family maintenance services were provided.

In addition, many foster children have serious health problems, some of which are associated with prenatal substance exposure, which further add to the complexity of addressing the service needs of these families. We found that over half of young foster children in 1991 had serious health problems, and medical research has shown that many of the health problems that these children had, such as fetal alcohol syndrome, developmental delays, and HIV, may have been caused or compounded by prenatal exposure to drugs or alcohol.

Special supportive services and treatment will be needed by many of these children. Early identification of children who are HIV positive is particularly critical because medical advances in identification and treatment can enhance and prolong the lives of these children. Some of these children require foster care either in institutions that can accommodate their medical needs or in foster family homes where the caregivers are specially trained. Reunifying families can also be more difficult because of the additional strains that caring for medically fragile children places on parents, who are at the same time recovering from drug or alcohol addictions.

Some caseworkers find it difficult to manage the high caseloads involving families with increasingly complex service needs. Some states have experienced resource constraints, including problems recruiting and retaining caseworkers, shortages of available foster parents, and difficulties obtaining needed services, such as drug treatment, that are generally outside the control of the child welfare system. Caseworkers are also experiencing difficulties resolving cases. Once children are removed from the custody of their parents, they sometimes remain in foster care for extended periods.

PARENTAL SUBSTANCE ABUSE ADDS TO THE DIFFICULTY OF MAKING PERMANENCY DECISIONS ---------------------------------------------------------- Chapter 0:4

The problem of children "languishing" or remaining in foster care for many years has become a great concern to federal and state policymakers. While most children are reunified with their parents, adopted, or placed with a guardian, others remain in foster care, often with relatives, until they age out of the system. The circuitous and burdensome route out of foster care--court hearings and sometimes more than one foster care placement--can take years, be extremely costly, and have serious emotional consequences for children.

Yet, making timely decisions about children exiting foster care can be difficult to reconcile with the time a parent needs to recover from a substance abuse problem. Current federal and state foster care laws emphasize both timely exits from foster care and reunifying children with their parents. However, even for those who are able to recover from drug and alcohol addictions, it can be a difficult process that generally involves periods of relapse as a result of the chronic nature of addiction. Achieving timely exits from foster care may sometimes conflict with the realities of recovering from drug and alcohol addictions. The current emphasis on speeding up permanency decisions will further challenge child welfare agencies.

Current federal law requires that states conduct a permanency planning hearing within 18 months after a child enters foster care to determine whether family reunification should continue to be the goal, or whether some other permanent living arrangement, such as adoption or guardianship, should be pursued. The current emphasis on speeding up permanency hearings reflects concerns about children spending long periods of time in foster care. Pending federal legislation would shorten the time allowed before holding a permanency planning hearing from 18 to 12 months. As of early 1996, 23 states had already enacted shorter time frames for holding a permanency planning hearing than required under federal law. In two of these states, the shorter time frames apply only to younger children. It should be emphasized, however, that while a permanency planning hearing must be held within these specified time frames, the law does not require that a final decision be made at this hearing as to whether family reunification efforts should be continued or terminated.

Some drug treatment administrators and child welfare officials in these same locations believe that shorter time frames might help motivate a parent who abuses drugs to recover. However, expedited time frames\4 may require that permanency decisions be made before it is known whether the parent is likely to succeed in drug treatment. While one prominent national study found that a large proportion of cocaine addicts failed when they attempted to stay off the drug, we previously reported that certain forms of treatment do hold promise. In addition, progress has been made in the treatment of heroin addiction through traditional methadone maintenance programs and experimental treatments. However, even when the parent is engaged in drug treatment, treatment may last up to 1 or 2 years, and recovery is often characterized as a lifelong process with the potential for recurring relapses.

Some drug treatment administrators in Los Angeles and Cook Counties believe that treatment is more likely to succeed if the full range of needs of the mother are addressed, including child care and parenting classes as well as assistance with housing and employment, which help the transition to a drug-free lifestyle. These drug treatment administrators also stressed how important it was for parents who are reunited with their children to receive supportive services to continue their recovery process and help them care for their children.

Determining the potential for an individual's success in drug treatment is extremely difficult given the variety of substances abused, types of treatment and program quality, differences in addiction and readiness for recovery, and definitions of what constitutes "recovery." However, the longer an individual is in treatment, the greater the potential for improved behavior. Some caseworkers in Los Angeles and Cook Counties said that shorter time frames for holding a permanency planning hearing may be appropriate in terms of the foster child's need for a permanent living arrangement. However, they also said that the likelihood of reunifying these children with their parents when permanency decisions must be made earlier may be significantly reduced when substance abuse is involved. In their view, the prospects of reunifying these families may be even worse if the level of services currently provided to them is not enhanced.

In our ongoing work, we have found that states and localities are responding to the need for timely permanency for foster children through programmatic initiatives and changes to permanency laws. Most of these initiatives and changes to permanency laws are very new, so there is little experience to draw upon to determine whether they will help achieve timely exits from foster care for cases involving parental substance abuse. Furthermore, some of these initiatives and changes are controversial and reflect the challenge of balancing the rights of parents with what is in the best interest of the child, within the context of a severely strained child welfare system.

For example, California and Illinois have enacted statutory changes that specifically address permanency for foster care cases involving parental substance abuse. The Illinois legislature recently enacted new grounds for terminating parental rights. Under this statute, a mother who has had two or more infants who were prenatally exposed to drugs or alcohol can be declared an unfit parent if she had been given the opportunity to participate in treatment when the first child was prenatally exposed. California has enacted new statutory grounds for terminating family reunification services if the parent has had a history of "extensive, abusive, and chronic" use of drugs or alcohol and has resisted treatment during the 3-year period before the child entered foster care or has failed or refused to comply with a program of drug or alcohol treatment described in the case plan on at least two prior occasions, even though the programs were available and accessible. While such laws may help judges make permanency decisions when the prospects for a parent's recovery from drug abuse seem particularly poor, these changes are not without controversy. Some caseworkers and dependency court attorneys in Los Angeles and Cook Counties expressed concerns that a judge may closely adhere to the exact language in the statutes without considering the individual situation, and may disregard the extent to which progress has been made toward recovery during the current foster care episode.

States and localities are undertaking programmatic initiatives that may also help to reconcile the goals of family reunification and timely exits from foster care, which may conflict, particularly when parental substance abuse is involved. New permanency options are being explored as are new ways to prevent children from entering foster care in the first place. We previously reported on Tennessee's concurrent planning program that allows caseworkers to work toward reunifying families, while at the same time developing an alternate permanency plan for the child if family reunification efforts do not succeed. Under a concurrent planning approach, caseworkers emphasize to the parents that if they do not adhere to the requirements set forth in their case plan, parental rights can be terminated. Tennessee officials attributed their achieving quicker exits from foster care for some children in part to parents making more concerted efforts to make the changes needed in order to be reunified with their children.

In addition, both California and Illinois have federal waivers for subsidized guardianship, under which custody is transferred from the child welfare agency to a legal guardian. In Illinois, CPS cases involving prenatally substance exposed infants can be closed by the child welfare agency without removing the child from the mother's custody if the mother can demonstrate sufficient parental capacity and is willing to participate in drug treatment and receive other supportive services.

One jurisdiction is developing an approach to deliver what its officials describe as enriched services to the parent. Illinois' new performance contracting initiative provides an incentive for private agencies to achieve timely foster care exits for children by compensating these agencies on the basis of their maintaining a prescribed caseload per caseworker. This necessitates that an agency find permanent living arrangements for a certain number of children per caseworker per year, or the agency absorbs the cost associated with managing higher caseloads. A component of this initiative is the provision of additional resources for improved case management and aftercare services in order to better facilitate family reunification and reduce the likelihood of reentry. Providing enriched services may make it less likely that judges will rule that the child welfare agency has failed to make reasonable efforts to reunify parents with their children and thereby reduce delays in permanency decisionmaking.

-------------------- \4 Recently, both California and Illinois enacted expedited time frames for holding a permanency planning hearing within 12 months. In addition, California enacted an even shorter time frame of 6 months for children entering foster care under the age of 3. The changes to Illinois' permanency legislation are currently in effect only in Cook County; they will go into effect throughout the rest of the state beginning January 1, 1998.

OBSERVATIONS ---------------------------------------------------------- Chapter 0:5

In summary, children with substance abusing parents often come to the attention of the child welfare system either at birth, because of prenatal substance exposure, or later in life when they are found to have been abused or neglected. The families of these children have increasingly complex service needs. Many are dually diagnosed with drug or alcohol addictions and mental illnesses, some are involved in criminal activities, some are homeless, and most have additional children in foster care. Burgeoning foster care caseloads entailing these complex family situations have placed enormous strains on the child welfare system.

In seeking to achieve what is in the best interest of children, foster care laws emphasize both family reunification and achieving timely exits from foster care for children. Given the time it often takes a person to recover from drug and alcohol addictions, and the current emphasis on speeding up permanency decisions for foster children, these goals may conflict. Reconciling these goals for children whose parents have a substance abuse problem presents a tremendous challenge to the entire child welfare system in determining how to balance the rights of parents with what is truly in the best interest of children. New state and local initiatives may help address this challenge. Through our ongoing work, we are continuing to explore the impact of parental substance abuse on foster care, by, for example, examining parents' substance abuse histories and their drug treatment experiences, as well as exploring initiatives that might help achieve timely foster care exits for cases involving parental substance abuse.

-------------------------------------------------------- Chapter 0:5.1

Mr. Chairman, this concludes my prepared statement. I would be happy to respond to any questions from you or other Members of the Subcommittee.

RELATED GAO PRODUCTS =========================================================== Appendix 1

Child Protective Services: Complex Challenges Require New Strategies (GAO/HEHS-97-115, July 21, 1997).

Foster Care: State Efforts to Improve the Permanency Planning Process Show Some Promise (GAO/HEHS-97-73, May 7, 1997).

Cocaine Treatment: Early Results From Various Approaches (GAO/HEHS-96-80, June 7, 1996).

Child Welfare: Complex Needs Strain Capacity to Provide Services (GAO/HEHS-95-208, Sept. 26, 1995).

Foster Care: Health Needs of Many Young Children Are Unknown and Unmet (GAO/HEHS-95-114, May 26, 1995).

Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children (GAO/HEHS-94-89, Apr. 4, 1994).

Drug Abuse: The Crack Cocaine Epidemic: Health Consequences and Treatment (GAO/HRD-91-55FS, Jan. 30, 1991).

Drug-Exposed Infants: A Generation at Risk (GAO/HRD-90-138, June 28, 1990).

*** End of document. ***