Children's Bureau Website - Maryland - Services for Caregivers with Substance Use Disorders

Maryland

Demonstration Type:	Services for Caregivers with Substance Use Disorders¹
Approved:	September 16, 1999
Implemented:	October 1, 2001
Completed:	December 31, 2002²
Interim Evaluation Report Date:	Expected March 31, 2004
Final Evaluation Report Date:	Expected June 30, 2005

Target Population

Maryland’s substance abuse demonstration targeted mothers (or other female primary caregivers) with a child placed in out-of-home care or who were at risk of having a child placed in out-of-home care due to substance abuse.

Jurisdiction

Maryland planned to implement this project in Baltimore City and Prince George’s County. The project was later expanded to include all of Baltimore County.

Intervention

The State planned to develop Family Support Services Teams (FSST) comprised of Chemical Addiction Counselors, local child welfare agency staff, treatment providers, parent aides, and parent mentors (parents in recovery). The teams would be responsible for providing comprehensive, coordinated services to eligible families. Upon referral and assessment, mothers were assigned to one of three treatment options: (1) inpatient treatment for parents and their children, (2) intermediate care (28 day residential care), or (3) intensive outpatient treatment. Local child welfare agencies were responsible for coordinating the teams. Other team members assumed the lead in their particular area of expertise.

Treatment providers offered intensive case management and assisted in the provision of supportive services, including housing, employment, child care, and transportation. Core services included individual and group therapy and family therapy. In addition, treatment centers made available OB/GYN care and family planning clinics, HIV education and testing, relationship groups, parenting skills training, and groups for victims of domestic violence and sexual assault. Parent aides and mentors assisted with the transition to treatment and to a drug-free lifestyle while modeling appropriate behaviors.

Evaluation Design

The evaluation consisted of process, outcome, and cost-effectiveness components. Initially, the State planned to randomly assign 200 eligible women from two jurisdictions to the demonstration project, with 100 women assigned to the experimental group and 100 to the control group. Only women who already had a child placed in foster care were eligible for enrollment. Due to smaller than expected referral numbers, the State modified its implementation plan in January 2000 to include an additional 60 women residing in another jurisdiction who had children at risk of placement.

Maryland planned to track the following outcome measures: (1) number of re-investigations for abuse/neglect, (2) number of children who remain in foster care after 6 and 12 months of participation in the demonstration, (3) length of stay in foster care, (4) number of parents who complete treatment, (5) and number of parents who become drug-free and assume a healthy parenting role.

Evaluation Findings

Process Findings

Low enrollment was a significant barrier throughout the demonstration. As of September 2002 the sites had recruited 18 women to participate in the demonstration (nine women in the experimental group and nine women in the control group). Eight women in the experimental group were receiving inpatient or outpatient substance abuse treatment; one woman did not receive services due to incarceration.

As a result of the lower-than-anticipated referrals, the project evaluators conducted an intake study and facilitated focus groups with participating staff to identify problems and recommend strategies for increasing enrollment. The evaluators reviewed 913 cases that entered intake in the three participating jurisdictions between October 1, 2001 and December 31, 2002. They found that the percentage of intake cases with identified substance abuse either stated or implied in the referral was lower than expected.³ Evaluators found substance abuse indicated in 31 percent of cases at intake. Additionally, a number of factors made most of these cases ineligible for the demonstration, including the following:

Nearly one-half (49 percent) of the intake cases with identified substance abuse (n=280) were ineligible for the demonstration because they were already participating in an intensive services pilot project (in two of the three jurisdictions) that served mothers whose babies were identified as drug addicted at the time of birth.
An additional 11 percent of cases with identified substance abuse were potentially ineligible for study participation due to concerns about possible mental health problems.
Of the remaining intake cases with substance abuse indicated, two percent of cases were deemed ineligible because of the presence of sexual abuse in the family.
Thirteen percent of cases with substance abuse indicated showed “abandonment” as a reason for referral.
There was confirmation that the mother or other caretaker was available in only 38 percent (27) of the remaining 71 cases.

The evaluators concluded that in only 10 percent of intake cases with identified substance abuse were the mothers eligible and likely to be available for the demonstration project. These 27 cases represented only 3 percent of all cases reviewed for eligibility for the demonstration.

In May 2002 (seven months following implementation), the evaluators conducted three focus groups with staff in various positions in each of the three jurisdictions involved in the demonstration. Altogether, 18 workers participated in the focus groups. The evaluators identified the following challenges.

Focus group participants felt uninformed about the demonstration:

Participants were unclear about the distinctions between this project and other substance abuse initiatives.
Participants were unaware of the eligibility criteria and were unclear about which workers were responsible for presenting the study to clients.
All but one case worker had never seen a consent form for participation in the study.

Substance abuse was significantly underreported at intake:

Intake workers were not trained to conduct substance abuse screening and appeared uncomfortable identifying and addressing substance abuse issues, especially new workers.
Participants noted that “functional substance abuse” can be difficult to identify at intake. Continuing unit care workers often identified substance abuse problems after cases had been transferred from the intake unit.

Intake workers, already overburdened with child protection issues, did not have extra time and energy to attend to underlying problems such as substance abuse.
The randomization process used for purposes of evaluation complicated recruitment:

Some staff members felt they were denying services to women assigned to the control group.
Participants were unclear about who should obtain the women’s consent for the project.
Intake workers with various levels of expertise and knowledge of the project were responsible for recruitment. Institutional Review Board requirements prohibited the evaluators from contacting potential study participants until workers obtained consent from the women.

Workers had difficulty finding the mothers in order to recruit them, especially after their children were placed in care.

To address some of these barriers, the State modified the following procedures. The evaluators reported, however, that these changes did not have a significant effect on the demonstration:

The addictions specialist in one site began playing a more active role in training intake workers in identifying and confronting substance abuse.
One site extended the enrollment period.
One site expanded eligibility criteria by targeting mothers who delivered drug-exposed newborn infants at hospitals that were not already participating in another initiative (which would make them ineligible to participate in the demonstration).
The State expanded eligibility criteria in all sites to include cases with suspicion of substance abuse (rather than only those with substance abuse indicated) as well as cases in which substance abuse was not the primary reason for referral to child protective services.

Although the evaluators offered additional recommendations, they were found to be too burdensome, especially in light of the small effects they were expected to achieve. In addition, some proposed changes to the research design would have required Institutional Review Board approval. As a result of continuing implementation problems, the demonstration ended a year early and no outcome findings were reported.

¹Based on information submitted by the State as of January 2004. This was part of Maryland’s second waiver agreement, which had two project components (substance abuse services and a managed care payment system). Under the first waiver agreement, Maryland implemented an assisted guardianship/kinship permanence program. Back

²The original end date for the demonstration was December 2004. The demonstration ended two years early, however, due to a lower-than-expected number of eligible cases and other implementation problems. Back

³In its proposal for the waiver demonstration project, Maryland indicated that substance abuse was a factor in the removal of a child from home in 23 and 30 percent of cases in two of the project sites. Data on the percentage of intake cases with substance abuse indicated or implied is not available. Back

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