Parents with a substance use disorder (SUD) are at a higher risk for parenting practices that result in adverse outcomes in children (Harris-McKoy, Meyer, McWey, & Henderson, 2014).
Literature suggests that some negative parenting practices include inconsistent discipline, poor monitoring, negative perceptions of child behavior, and expectations of children that are not developmentally-appropriate (Hoghughi & Long, 2004; Mayes & Truman, 2012 as cited in Harris-McKoy et al., 2014). Other problematic parenting experiences include maladaptive coping skills, chronic employment problems, and failure to prove safe and stable housing (Hoghughi & Long, 2004; Mayes & Truman, 2012). Children whose parents have SUD problems are almost three times more likely to be abused, and more than four times likelier to be neglected as opposed to children whose parents have no SUD-related issues (Taylor, 2011). According to Carter and Myers (2007), SUD problems are some of the strongest predictors of substantiation of physical neglect cases in Child Protective Services (CPS), along with caregiver mental health problems.
The Fourth National Incidence Study of Child Abuse and Neglect (NIS-4) found that SUD use accounted for 11 percent of child maltreatment cases investigated by CPS (Sedlak et al., 2010). It is also estimated that 700,000 children in Child Welfare Services (CWS) had parents with SUD problems (Young & Gardner, 2009). According to the Child Welfare Information Gateway (2014), 295,000 parents who received treatment for a SUD had one or more children removed by CPS.
Considering the prevalence and the consequences of SUD in families, social service workers, and SUD therapists need to become knowledgeable about this issue in order to develop effective prevention and intervention strategies. This paper aims to delineate the issue of parental SUD by examining the characteristics of families with SUD problems, consequences of SUD in families; and child welfare services’ experiences in the US. The major goal of this paper is to provide a review of this problem and to offer recommendations to address it.
Consequences of Child Maltreatment in the Context of Alcohol and Other Drugs
As stated, parental SUD is a risk factor for child maltreatment. Repercussions of child maltreatment, displayed in childhood and into adulthood, can cause severe impairment in intrapersonal, interpersonal, academic, and occupational domains of life. Children who experience maltreatment are more prone to develop emotional and behavioral problems, including emotional dysregulation, trauma symptoms, and externalizing and internalizing problem behavior such as anxiety and aggression (Shipman, Edwards, Brown, Swisher, & Jennings, 2005; Dunn, McLaughlin, Slopen, Rosand, & Smoller, 2013; Oshri, Rogosch, & Cicchetti, 2013; Holmes, Yoon, Voith, Kobulsky, & Steigerwald, 2015; Font & Berger, 2015).
Exposure to SUD within the family exacerbates the adverse consequences of maltreatment, since SUD as well as behaviors associated with SUDs comes with various co-occurring problems, such as poverty, domestic violence, and involvement in criminal activities such as drug dealing, prostitution, or theft (Taylor, 2011). In addition to societal misfortunes, parents with SUD struggle with co-occurring mental and health issues that include depression, anxiety, HIV/AIDS, and others (Taylor, 2011).
The fact that families struggling with SUD face various severe issues forces our treatment industries to look at the situation from an ecological perspective, instead of the limited substance use framework. For example, Cash and Wilke (2003) found that individuals with a SUD is resulting in child neglect when combined with additional risk factors. For example, caregivers’ personal history of sexual abuse was found to be an important predictor of child neglect (Cash & Wilke, 2003). Other predictors include poverty, high levels of anxiety in caregivers, difficulty finding childcare, high-risk SUD social networks, and severity of drug use and drug of choice (Cash & Wilke, 2003). In NIS-4, alcohol was found to have slightly more of an impact (13 percent) as opposed to other drugs (10 percent). Alcohol was involved more often in cases of physical and emotional abuse, 22 percent, while other drugs, such as heroin, were involved mostly in emotional neglect, 21 percent (Sedlak et al., 2010; Taylor, 2011). The percentages were also found to be more pronounced if the perpetrators were biological parents.
The Characteristics of Families in the CPS System
Even though families with SUD issues are greatly represented in child welfare services, not every family with SUD problems enter the system. Research suggests that women who are involved in CPS are, on average: two years younger; have more children; are arrested more often; are more likely to be mandated to receive treatment; have more treatment failure; and are more likely to be referred to other treatment programs at discharge than women who are not involved in CPS (Shillington, Hohman, & Jones, 2001). These women are also more likely to have attended SUD outpatient or day treatment rather than residential treatment. Being on psychiatric medication for coexisting mental health problems and receiving less parental support are also risk factors for women to be involved in CPS (Taplin & Mattick, 2013).
“Unsuccessful” SUD treatment outcomes and a continuation of substance use increase the likelihood that families reenter the child welfare system after reunification. According to Brook and McDonald (2009), children whose caregivers use both alcohol and other drugs are more likely to enter the system than children whose parents do not use any alcohol and drugs. Children whose primary caregivers have drug only or alcohol only problems are also at heightened risk for reentry (Brook & McDonald, 2009). Other risk factors include high-risk potential for caretaker criminal behavior, absence of law enforcement involvement during the initial investigation, and being a single African American woman (Fuller & Wells, 2003).
The Adoption and Safe Families Act (ASFA) and Termination of Parental Rights
In 1997, The Adoption and Safe Families Act (ASFA) was enacted to reduce the length of time children spend in foster care, prevent future parental abuse by promoting adoption, and make timely permanency decisions to avoid further harm (Harris-McKoy et al., 2014). The major goal of AFSA is to make decisions based on the best interest of the child, which conventionally has been interpreted as preventing further harm to children by unfit parents (Harris-McKoy et al., 2014).
Once a child enters into the child welfare system due to parental SUD issues, various factors determine whether the child would be reunified with their family or if parental rights were terminated. However, usually, the decision depends on whether parents demonstrate that they have successfully improved the circumstances that initially caused the removal of their children before the hearings start (Harris-McKoy et al., 2014). According to Hong, Ryan, Hernandez, and Brown (2014), parents with SUD treatment failures and inability to improve parenting skills are more likely to experience termination of parental rights (TPR). Parents who have coexisting mental health problems and incarceration records also are more at risk for TPR (Meyer, McWey, McKendrick, & Henderson, 2010). The same study found that parents whose rights were terminated had more risk factors than those who experienced reunification. Among those risk factors, poverty and unemployment were very common, although these factors are debilitating both for those with TPR decisions and for those who reunify with their families (Meyer et al., 2010). Even if families reunify in the end, the literature indicates that parental SUD problems increase the time children spend in foster care and it slows the process of reunification (Lloyd & Akin, 2014). However, this effect is different depending on the levels of alcohol or drug use. According to Lloyd and Akin (2014), alcohol has no effect on time children spent in foster care, while parents who use other drugs, their cases take six more months on average to be finalized. The drug cases were also 13 percent less likely to experience reunification (Lloyd & Akin, 2014).
Barriers to Treatment
There are two important components to take into account concerning the treatment of parents with a SUD: the time it takes them to engage in treatment and the progress they are able to achieve in treatment before the hearings are initiated (Harris-McKoy et al., 2014). Unfortunately, there are micro- and macro-level barriers that interfere with these treatment components. The major barriers parents encounter include limited treatment facilities appropriate for parents, lack of effective treatment options, uncoordinated services among providers (i.e., CWS and SUD treatment facilities), limited time and resources that prevent parents from engaging in multiple agencies, and poverty (Harris-McKoy et al., 2014). Other barriers reflect several systemic weaknesses, such as high turnover rates of caseworkers (Kernan & Lansford, 2004), high caseloads for caseworkers and parents’ lawyers (Miller, 2009), and lack of funding of agencies that work with parents (Young & Gardner, 2009). As mentioned, since SUD is not the only problem families in the system experience, coexisting health, mental health, and other financial, legal, and interpersonal difficulties also contribute to the complexity of the problem.
Recommendations for Practice, Research, and Policy
Since SUD problems in families are multifaceted, the prevention and intervention strategies should also be multifaceted, addressing micro-, meso-, and macro-level components of the issue. These strategies should aim to reduce the frequency of entrance into the CWS, to enhance chances of reunification once in the system, and to improve mental and physical health. Professional therapists might consider these approaches when working with families, all the while keeping in mind the individual needs and strengths of their clients and families. The risk and protective factors for SUDs, as well as for placement into the system, mentioned in this paper should be addressed at the earliest opportunity. SUD treatment providers should identify barriers to treatment such as lack of provision of childcare, support services, and culturally specific services (Shillington et al., 2001). Too often, treatment facilities do not offer accommodations for the entire family, which deters mothers from seeking treatment. A family-centered approach might resolve some of these barriers for families with SUD problems. Where appropriate, families could receive services at home, thus avoiding the removal of children for extended periods. Adding services that allow for in-home treatment gives the parent an incentive to seek help, as it decreases the fear of having the children removed or of the family unit disintegrating.
At the macro-level, therapists and treatment leaders can advocate for policies that consider both the children’s best interests and the nature of substance abuse and its treatment. Treatment should be viewed from a holistic framework to address physical and mental health issues, as well as housing, employment, and poverty. More public and private treatment facilities that provide evidence-based practice and that are accessible to patients with children is crucial to addressing this problem. Advocating for additional funding to create treatment facilities that encompass the entire family, or to reformat current facilities’ budgets to incorporate space for families, is recommended to help increase motivation towards treatment, which will in turn increase the number of successful recoveries.
When addressing mental health, treatment facilities may find the need for an eclectic approach, which combines different treatment modalities in order to reach each individual and family in the best possible way. Treatment modalities might include, but are not limited to traditional Twelve Step programs, family therapy, cognitive behavioral therapy, and if necessary, medication (Taylor, 2011). The family-oriented therapeutic community model is another promising method of comprehensive rehabilitation, which takes into consideration the impact that SUD has on each family member, as well as the family as a whole system. In this model, instead of separating the family while the parent seeks treatment, with children being placed into foster care, the family is gathered in a stable treatment setting for eighteen and twenty-four months with care and assistance from a health care team including a psychologist, physician, substance use specialist, childcare worker, and others (Taylor, 2011). SUD treatment should screen for and treat illicit drug use, and this may include methadone management or other medication-assisted treatment, as well as timely entry into residential care or other appropriate treatment programs (Lloyd & Akin, 2014). These facilities would do well to intentionally coordinate their services and communicate regularly with CWS.
When considering SUD treatment options, it is imperative to focus on past personal trauma in addition to the current behaviors associated with substance use. As discussed throughout the paper, parents with SUD are more likely to have experienced some form of prior trauma. To effectively change behaviors, agencies and policies need to address traumatic events associated with the onset of SUD. Punitive approaches to SUD treatment have been shown to be ineffective and may exacerbate unhealthy behaviors when moralism is the focus, rather than compassion and recovery. Trauma-informed interventions are becoming more widely utilized for other mental illnesses, but it is difficult to find an abundance of literature, which incorporates evidence-based trauma therapy as part of SUD treatment. Trauma interventions not only benefit the parent, but the children as well. Several different research articles found that children reared with parents with addictions were more prone to suffer many kinds of adversities as well as a lack of parental guidance. Healthy coping mechanisms are necessary for families when dealing with life stressors early, as maladaptive coping mechanisms can compound the problem in the future.
In conclusion, there is much room for improvement and further research in the treatment of SUD in family systems. A focus on rehabilitation, collaboration with child welfare services, and holistic treatment for the entire family is necessary in order to strengthen families and reduce the multigenerational impact of SUD in families.
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