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)
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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. ***