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History and Legislative Context for Waivers
Public Law 103-432, authorized by Congress in 1994, introduced the concept of Federal waivers to child welfare programs. Conceived as a strategy for generating new knowledge about innovative and effective child welfare practices, waivers grant States flexibility in the use of Federal funds for alternative services and supports that promote safety and permanency for children in the child protection and foster care systems. The 1994 law authorized the Department of Health and Human Services to approve a total of ten child welfare waiver demonstration projects. The Adoption and Safe Families Act (ASFA) of 1997 extended and expanded the authority to use waivers for child welfare programs, authorizing the Secretary of Health and Human Services to approve up to ten new demonstration projects each year. Through the waivers, States may spend Federal funds in a manner not normally allowed under current Federal laws and regulations in support of innovative child welfare practices. Knowledge gained through these waivers provides a valuable source of information that can be used to inform changes in policy and practice aimed at improving service delivery and enhancing the achievement of national child welfare priorities.
Federal child welfare waivers primarily affect the use of funds under title IV-E of the Social Security Act, which applies to payments for foster care. Available on an unlimited entitlement basis, title IV-E reimburses States for a portion of foster care maintenance expenses paid on behalf of eligible children and for related administrative costs. Among the requirements for eligibility is that children be removed from a family that would have qualified for the former AFDC grant under guidelines in effect in July 1996. Through the child welfare waiver legislation, States may apply to use title IV-E funds for supports and services other than foster care maintenance payments that protect children from abuse and neglect, preserve families, and promote permanency. Under a waiver, States may also expend Title IV-E funds on non-IV-E eligible children. When implementing a waiver project, States must remain in compliance with the following provisions of title IV-E:
All requirements relating to the conduct of periodic foster care reviews;
Requirements specifying safeguards for children during out-of-home placement;
Required permanency hearings for children in State custody; and
Requirements governing information to be included in a foster child's case plan.
The Department of Health and Human Services typically approves child welfare waivers for up to five years, although at the discretion of the Secretary they may be extended beyond five years. In addition to the provisions described above, waiver demonstrations must remain cost-neutral to the Federal government (i.e., States cannot receive more in Federal reimbursement than the State would have received in the absence of the demonstration) and they must undergo rigorous program evaluation to determine their efficacy. Since 1996, 17 States have implemented 25 child welfare waiver demonstration components through 20 title IV-E agreements. Some States have multiple waiver agreements, and some waiver agreements have multiple components. These projects examine innovative child welfare service strategies in several areas, including:
Assisted guardianship/kinship care;
Capped IV-E allocations and flexible funding to local agencies;
Managed care payment systems;
Services for caregivers with substance use disorders;
Intensive service options;
Enhanced training for child welfare staff;
Adoption services; and
Tribal administration of IV-E funds.
This synthesis report focuses specifically on the experiences and evaluation findings of the four States that have implemented substance abuse waiver demonstrations.
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Growth of Interest in Assisted Guardianship Waivers
Over the last decade, a compelling body of evidence has grown that illustrates the major role of parental substance use disorders in many cases of child maltreatment, child welfare involvement, and foster care placement. Most studies report that between one-third and two-thirds of substantiated child abuse and neglect reports involve substance abuse (U.S. Department of Health and Human Services, 1999). A brief review of recent national and state-level studies echoes this finding on the prevalence of substance use disorders in child welfare populations:
A 1994 U.S. General Accounting Office report estimated that the number of cases in which parental drug abuse was the reason children entered foster care rose from 52 percent in 1986 to 78 percent in 1991 in Los Angeles, New York, and Philadelphia (GAO, 1994).
According to a review of national estimates by Young, Gardner, and Dennis (1998), of the nearly one million children with a substantiated report of abuse and neglect in 1995, at least 50 percent had parents with substance use disorders.
Data compiled by the State of Illinois in 1995 estimated that the percentage of children in foster care who were reunified with their families dropped significantly between 1990 and 1995 due to "epidemic levels of parental drug abuse" (Illinois Department of Children and Family Services, 1995).
A 1998 study by the National Center on Addiction and Substance Abuse (CASA) revealed that over three-fourths of surveyed professionals (81.6 percent) identified alcohol in conjunction with other drugs as major contributors to child abuse and neglect (Reid, 1999).
A 1998 study of Massachusetts' child welfare system estimated that between 70 and 80 percent of all child welfare referrals in that State involve some form of substance abuse (Institute for Health Recovery, 1998).
Children's safety and well-being are compromised in multiple ways when their parents abuse or are dependent on drugs or alcohol. Parents' inability to engage in appropriate parenting practices results in their children being deprived of basic nurturing activities and experiences. Parental abuse or dependence on one or more substances may prevent them from being emotionally or physically available to their children, rendering them more susceptible to emotional or physical trauma. Poor parental decisions regarding supervision are likely to place children at greater risk of physical harm. The cost of a parent's drug abuse diverts financial resources from providing for the basic physical needs of children, such as food and safe housing. Parental substance use disorders can, in some instances, lead to increased exposure to physical or sexual abuse. Finally, substance abuse combined with abusive parental behaviors can foster intergenerational patterns of substance use disorders and child maltreatment.
The stresses placed on child welfare systems by parental substance use disorders underscore the need for new or strengthened relationships with other agencies to facilitate the effective provision of treatment services. The breadth and depth of parental substance use problems, accompanied by the need to build or strengthen cross-organizational relationships, places considerable pressure on public child welfare agencies. However, many child welfare agencies struggle with identifying the best strategies for addressing the problems of substance-abusing caregivers. Some of the most serious challenges facing child welfare agency staff include insufficient expertise and training in identifying and addressing substance use disorders and a lack of available treatment resources, especially inpatient facilities for women and facilities that will accept women with their children.
The use of the title IV-E waiver demonstrations to implement substance abuse projects reflects a growing national realization that the substance abuse issues of parents must be addressed to decrease the incidence of out-of-home placement, reduce lengths of stay of children in out-of-home placement, and reduce the costs associated with foster care. These demonstrations have provided States with the means to institute reforms and explore the extent to which child welfare systems can more effectively address safety, permanency, and well-being for children in families with substance-abusing parents.
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Overview of the Substance Abuse Waiver Demonstrations
Since 1996, four States have implemented substance abuse waiver demonstrations: Delaware, New Hampshire, Illinois, and Maryland. Findings from Delaware, which completed its five-year demonstration project in December 2002, are summarized in this paper from its March 2002 final report. Findings from New Hampshire, which began its effort in 1999 and continues under a short-term waiver extension, are based on its September 2003 interim report and a March 2004 progress report. Illinois, which started its initiative in April 2000, described project results in a May 2003 interim report, a June 2004 progress report, and a November 2004 progress report. Maryland, which began implementation in October 2001, terminated its demonstration early in December 2002 because of various implementation problems. These implementation barriers are summarized in its semi-annual report covering April 2002 through September 2002. Because of its decision to terminate the waiver early, Maryland obtained no data on the outcomes of its demonstration.
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Key Characteristics of Assisted Guardianship Demonstration Projects
States implementing substance abuse waiver demonstrations must meet the requirements and limitations applicable to all waiver demonstrations, e.g., by providing all procedural and safety protections for children in foster care, conducting a rigorous evaluation, and maintaining cost neutrality. Beyond these core requirements, States have had great latitude in developing interventions that address the needs of children and their parents with substance use disorders. As Table 1 illustrates, the States vary considerably in terms of their target populations, organizational characteristics, and service delivery models. Given these substantial differences in program features, readers should exercise caution in comparing evaluation findings across States that implemented substance abuse waiver demonstrations.
Table 1
Summary of State Substance Abuse Waiver Demonstrations
State |
Program Features |
Target Population |
Geographic Scope |
Child’s IV-E Status |
Avg. Length of Service |
Delaware |
|
Children in out-of-home care or likely to enter out-of-home care due to parental substance use disorders. |
Implemented statewide. |
Both IV-E eligible and non-IV-E eligible. |
8 months for foster case cases; 9 months for non-foster care cases. |
Illinois |
|
Custodial parents with a substance use disorder who have a child in out-of-home care; includes custodial parents who deliver drug-exposed infants. |
Implemented in Cook County, IL. |
Both IV-E eligible and non-IV-E eligible. |
Reunification cases: Exp. group =14 months; Control group =19 months.
Adoption cases: Exp. group = 37 months; Control group = 38 months. |
Maryland |
|
Mothers or other female primary caregivers with a child in out-of-home care or at risk of placement due to parental substance use disorders. |
Implemented in Baltimore City and Prince George’s and Baltimore Counties. |
Both IV-E eligible and non-IV-E eligible. |
Not reported |
New Hampshire |
|
Families involved in CPS with caregiver substance abuse as a major referral reason. |
Implemented in 2 district CPS offices ( Nashua & Manchester). |
Both IV-E eligible and non-IV-E eligible. |
Not reported |
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Target Populations
Delaware and Maryland included families with children in foster care as well as those with children at risk of placement in their projects' target populations. Families in these States enrolled in the waiver demonstration following maltreatment assessment and CPS case opening. Like Delaware and Maryland, New Hampshire included families with children either at risk of placement or already in foster care, but had a somewhat broader definition of its target population in that families entered the demonstration immediately at CPS intake rather than after a maltreatment investigation and CPS case opening. Although referrals for substance abuse services could occur at any time, these three States expected case managers to assess the need for substance abuse services during their earliest meetings with families in an effort to prevent placement or facilitate earlier reunification. In contrast, Illinois has limited its substance abuse demonstration to parents with a child already in out-of-home placement and focused on increasing reunification rates and reducing lengths of stay in foster care. In Illinois, any caregiver who has lost custody of a child due to probable alcohol and drug abuse, including but not limited to post-partum women with a substance-exposed infant, is eligible for the demonstration project as long as s/he is assessed within 90 days of the temporary custody hearing. All four States included both IV-E eligible and non-IV-E eligible children in their target populations.
Geographic Scope
The four demonstrations varied considerably in terms of their geographic scope. Delaware, a small state with only three counties, operated its demonstration statewide, whereas the other States limited their projects to one or two counties or municipalities.
Public-Private Partnerships
Another key difference among the States' demonstrations involved their use of public-private partnerships to provide substance abuse services. In New Hampshire, all principal service providers, including the substance abuse counselors, are public agency employees. In contrast, the other three demonstrations incorporated some degree of collaboration between public child welfare departments and privately contracted service providers. Illinois' Department of Children and Family Services contracted with a private case management firm to provide intensive case management services to parents with children in foster care referred for chemical dependency treatment. Maryland's demonstration centered on collaborative "Family Support Service Teams" consisting of substance abuse counselors, former substance abusers in recovery serving as mentors, parent aides, and privately contracted treatment providers. In Delaware, substance abuse counselors were employed by a contracted substance abuse treatment agency but in practice functioned like public employees by working on-site at county child welfare offices and by complying with Delaware Division of Family Services policies and procedures.
Service Delivery Models
Major differences exist in the service delivery models and service philosophies adopted by the States for their waiver demonstrations. Three States - Delaware, Maryland, and New Hampshire - have focused on the early identification of parents with substance use disorders and service referrals. These referrals were designed to link families to existing treatment resources and supportive services in the community in order to encourage caregivers to enter treatment and to prevent out-of-home placement. In contrast, Illinois has emphasized the recovery of caregivers who are not yet in treatment but whose children have already been removed from the home, using intensive case management and supportive services to improve treatment participation and retention rates, to facilitate reunification of parents with their children, and to increase the timeliness of decisions regarding other permanency options. Core features of each State's service delivery model are described in more detail below.
Delaware
Delaware's project essentially operated as a referral program, in which privately contracted substance abuse counselors were co-located with child protection case managers in county CPS offices to engage in joint case planning and decision-making. The State established one such "treatment unit" with a co-located substance abuse counselor in each of its three counties. The primary responsibilities of the substance abuse counselor included linking clients to substance abuse treatment and providing support services to clients while they awaited treatment entry.
New Hampshire
Through New Hampshire's Project First Step waiver demonstration, licensed alcohol and drug abuse counselors (LADCs) work with child protection workers in an advisory and supportive capacity, using their clinical skills to provide training, assessment, treatment, and case management services. LADCs conduct an initial drug and alcohol assessment concurrently with CPS' maltreatment investigation. Each LADC is involved proactively from the outset in the risk and safety assessment to facilitate better decisions regarding child safety and possible out-of-home placement. Depending on a parent's level of cooperation, LADCs may provide direct outpatient treatment or procure treatment services on the parent's behalf, thereby improving the timeliness of access to substance abuse treatment services and increasing the potential for positive treatment outcomes. LADCs have the option to continue working directly with caregivers for an additional two months following completion of the maltreatment assessment or child protection case opening.
New Hampshire gave wide latitude to its two participating CPS district offices in which the demonstration was implemented, resulting in the establishment of two markedly different staffing arrangements. The Nashua district office chose to maintain its existing staffing structure, in which multiple supervisors oversee separate teams of caseworkers that provide services to families participating in the waiver demonstration. Consistent with the demonstration's service model, the Manchester district office designated one CPS supervisor to oversee all staff involved in waiver-related service delivery. The State expected that these differences in implementation might influence programmatic outcomes.
Illinois
Illinois' demonstration incorporates a proactive, intensive service philosophy. Its service model centers on the use of privately contracted case management specialists known as "Recovery Coaches" who directly engage families throughout the treatment process and provide needed post-treatment support. The Recovery Coach works with the parent, the child welfare caseworker, and the substance abuse treatment provider to remove barriers to treatment, engage the parent in treatment, provide outreach to re-engage the parent if necessary, and offer ongoing support to the parent and family throughout the duration of the child welfare case. As mentioned above, the Illinois model differs from those of other States in that it focuses on treatment retention and recovery for caregivers referred to, but not yet enrolled, in treatment and with a child already in out-of-home placement.
Maryland
Maryland planned to implement the most collaborative case management model among the four States, in which privately contracted chemical addiction counselors would work with child welfare case managers, parent aides, and volunteer mentors in "Family Support Services Teams" (FSSTs) to assess the needs of family members and determine appropriate treatment options. Maryland's demonstration differed from other State demonstrations in that participating caregivers could be assigned to one of three pre-determined treatment modalities: (1) inpatient care for women and their children, (2) intermediate care (28-day residential care), and (3) intensive outpatient treatment. The FSST's chemical addiction counselor was authorized to provide interim treatment services until the caregiver entered treatment.
Program Intake and Substance Abuse Assessment
States with substance abuse waivers adopted widely varying approaches to enrolling families into their demonstrations and to assessing the presence and severity of substance use disorders. Table 2 summarizes key differences among the States in their intake and substance abuse assessment processes. As with the differences in target populations and service models discussed above, these distinct approaches to program intake and assessment render direct comparisons of the waiver demonstrations more difficult and reiterate the need for caution in interpreting evaluation findings across the States.
Table 2
Enrollment and Assessment Processes in States
With Substance Abuse Waivers
State |
Timing of Enrollment into the Demonstration (assignment to experimental or comparison/control group) |
Timing of Substance Abuse Assessment |
Party(ies) Responsible for Assessment |
Assessment Instrument(s) |
Delaware |
Following maltreatment investigation and determination that alleged substance abuse represents a threat to child safety. |
Following CPS case opening. |
CPS case manager and/or substance abuse counselor. |
Parental Substance Abuse Inventory |
Illinois |
At time of referral for substance abuse treatment. Parents for whom treatment is indicated are randomly assigned to the experimental or control group. |
Within 90 days following Temporary Custody Hearing and prior to referral for treatment and assignment to demonstration. |
Substance-abuse assessment counselors employed through Illinois’ JCAP program. |
|
Maryland |
After CPS case opening and following screening by a specialized intake worker to determine program eligibility. Eligible women were randomly assigned to the experimental or control group. |
Following eligibility screening and assignment to Family Support Services Team (FSST). |
Joint assessment by chemical addiction counselor and child welfare case manager. |
|
New Hampshire |
At time of initial maltreatment report; prior to maltreatment substantiation or CPS case opening. |
After assignment to the experimental group (enhanced substance abuse services). |
Licensed Alcohol and Drug Abuse Counselor (LADC). |
Substance Abuse Subtle Screening Inventory (SASSI) |
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Delaware
Delaware adopted a less structured, open-ended process of case intake and substance abuse assessment, in which screening and assessment could occur throughout the life of the case and involve multiple professionals in a CPS unit. The intake process for demonstration participants began with a CPS unit's child protection investigative worker, who screened caregivers with a report of alleged child maltreatment for suspected or documented substance abuse issues. To facilitate identification of these caregivers, the investigative worker administered a brief screening tool called the Simple Screening Instrument. If the screening indicated that suspected or documented substance abuse by a caregiver posed a threat to the child's safety, the caregiver was then referred for CPS case management services. Once assigned to a CPS unit, either a CPS caseworker or the co-located substance abuse counselor conducted a more in-depth assessment of the caregiver's substance abuse problems using a tool known as the Parental Substance Abuse Risk Inventory. With a more detailed profile of the client's substance abuse behaviors and needs, the CPS case manager then coordinated with the substance abuse counselor to link the client to substance abuse treatment and support services and to monitor the clients' progress in entering and completing treatment.
Illinois
Illinois developed a rigorously structured enrollment and assessment process for its waiver demonstration, with assessment occurring prior to a caregiver's referral for treatment services and assignment to the substance abuse waiver demonstration. As mentioned earlier, Illinois' demonstration only targets caregivers with alleged or documented substance use disorders who already have a child in out-of-home placement. The demonstration's intake process begins following a temporary custody hearing, at which time the State gains legal custody of the child and assigns the family to a child welfare agency for services. At the time of the hearing or within 90 days thereafter, the judge, case worker, or attorney may refer the caregiver to the Juvenile Court Assessment Program (JCAP), a project established by the Illinois Department of Children and Family Services to assess the nature and severity of caregivers' substance abuse issues and to make appropriate treatment referrals.
Through JCAP, caregivers undergo substance abuse assessments administered by privately contracted, licensed chemical dependency counselors working on-site at the juvenile court. Chemical dependency counselors conduct the assessments in accordance with criteria developed by the American Society of Addiction Medicine (ASAM); all eligible caregivers, regardless of whether they are later assigned to receive enhanced substance abuse services or traditional services, participate in this assessment process. Following the assessment, the counselor makes a same-day referral to a substance abuse treatment provider if indicated. It is at this point that enrollment into the State's waiver demonstration occurs: caregivers assigned to agencies in the experimental group receive traditional child welfare services plus the enhanced services of a Recovery Coach, whereas caregivers assigned to agencies in the control group receive only traditional child welfare services.
Maryland
Maryland's intake and substance abuse assessment process was similar to Delaware's process in that assessments occurred following assignment to the demonstration and were conducted jointly by child protection case managers and substance abuse specialists. To determine eligibility for the project, Maryland designated specialized case screeners to review the files of women in participating jurisdictions with open CPS cases; women with a stated or suspected substance use disorder who had a child in or at-risk of out-of-home placement were deemed eligible to participate in the project. The screeners then forwarded eligible cases to an independent evaluation contractor, who randomly assigned women to the experimental group or to a control group. Upon assignment to the experimental group, mothers were referred to the Family Support Services Team (FSST) for substance abuse assessment and referral for treatment services. Once referred to the FSST, the team's case manager and chemical abuse counselor were to conduct a joint assessment of the needs of all family members, including a determination of the extent of the mother's substance use disorder and its impact on her ability to ensure the safety and well-being of her children. Maryland planned to use a highly comprehensive and global assessment protocol that evaluated the children and mothers' intellectual functioning and the mother's psychosocial and psychiatric history as well as the prevalence and severity of substance abuse. In its proposed assessment protocol, Maryland included the Mini-Mental Status Examination, the Comprehensive Addictions and Psychological Evaluation (CAAPE), the Parenting Stress Inventory (PSI), the Achenbach Child Behavior Checklist, and a specially designed structured interview. Only caregivers assigned to the experimental group were to undergo this extensive assessment process.
New Hampshire
New Hampshire's intake and assessment process differs from the processes in other States in that families are enrolled in the demonstration immediately at the time of an initial maltreatment report, prior to completion of a maltreatment assessment and CPS case opening. Following receipt of this abuse or neglect report, the State's evaluation contractor at the University of New Hampshire randomly assigns families to the experimental group or to the control group. Experimental group families have access to enhanced substance abuse services through a Licensed Alcohol and Drug Abuse Counselor (LADC) working in conjunction with a child protection worker. Caregivers in the control group receive traditional child protection and substance abuse referral services. The caregiver's formal substance abuse assessment occurs following assignment to the demonstration and is conducted by the LADC using the Substance Abuse Subtle Screening Inventory (SASSI). As in the case of Delaware and Maryland, only caregivers assigned to the experimental group undergo a formal and immediate in-house substance abuse assessment. For control group caregivers, the administration of a substance abuse assessment by a child protection worker or a contracted out-of-office counselor is done at the discretion of each caregiver's child protection worker.
New Hampshire designed its enrollment procedures in response to its unique characteristics as a largely rural State with a comparatively small child welfare population. In New Hampshire, only 15 percent of maltreatment reports typically result in an abuse or neglect substantiation; of these substantiated cases, only half require court involvement. In addition, the length of the maltreatment assessment process in New Hampshire - up to 60 days - further slows the rate at which maltreatment reports are substantiated and CPS intervention is ordered. Thus, it would have been difficult to enroll adequate numbers of parents in the demonstration if eligibility were limited to substantiated cases with a court order for CPS involvement. Given these considerations, the State decided in advance of the waiver's implementation that the enrollment and assessment of caregivers with a potential substance use disorder should begin sooner rather than later.
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2Aid to Families with Dependent Children, the predecessor to the current Federal Temporary Assistance to Needy Families (TANF) program.Back
3In 2004 and 2005 three additional States - Arizona, Minnesota and Wisconsin - received approval for, but have not yet implemented, their child welfare waiver demonstrations.Back
3Alcohol and Other Drug Abuse.Back
3American Society of Addiction Medicine.Back
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