Executive Summary

Synthesis of Findings from the State Substance Abuse Title IV-E Waiver Demonstration Projects
Executive Summary

Since 1996, four States have implemented substance abuse waiver demonstrations: Delaware, New Hampshire, Illinois, and Maryland. Three States - Delaware, Maryland, and New Hampshire - focused on the early identification of parents with substance use disorders and service referrals, linking families to existing treatment resources and supportive services to encourage caregivers to enter treatment and prevent out-of-home placement. 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.

All States conducting substance abuse waiver demonstrations were required to conduct rigorous program evaluations with outcome and process components. Three States - Maryland, Illinois, and New Hampshire - employed random assignment designs for their outcome evaluations. Delaware used a comparison group design to examine differences in outcomes among clients in child protection units with access to enhanced substance abuse case management services compared with outcomes for clients in matched units without access to a substance abuse case manager.

Major findings and lessons learned from the demonstrations are summarized below. In interpreting the findings of these projects, it is important to note that with the exception of Illinois, most States had small sample sizes and/or encountered other problems in implementing their evaluations that placed caveats on the interpretation of their findings. Furthermore, because considerable differences in size, population characteristics, levels of urbanicity, and child welfare laws and policies, caution should be exercised in making comparisons across States regarding the effectiveness of their substance abuse demonstrations in improving child welfare outcomes.

Major Process Findings

All four States faced serious problems with referrals and enrollments into their demonstrations. Among other implementation problems, very limited enrollment led Maryland to terminate its substance abuse demonstration early. Over time, Illinois was able to bring its enrollment numbers up to nearly expected levels.
Illinois' demonstration experienced the greatest success in connecting caregivers to treatment services, with approximately 73 percent of parents assigned to the experimental group participating in treatment at some point in time, compared with 50 percent of parents in the control group, a statistically significant difference. Other States faced several implementation obstacles that limited clients' timely access to treatment.
Among the States, only Delaware and Illinois collected specific data on the number of enrolled caregivers who remained in or successfully completed substance abuse treatment. Illinois reported modest improvements in substance abuse treatment initiation and retention; as of June 2004, 59 percent of active clients in the experimental group had either completed or were actively engaged in treatment. Delaware experienced more difficulties retaining clients in treatment; by the end of the State's waiver demonstration, only 24 percent of closed experimental group cases were actively engaged in or had completed treatment.
Other implementation challenges reported by the States included inadequate worker training and education, staff turnover, and differences in the management styles and professional philosophies of child welfare workers and substance abuse counselors.

Major Outcome Findings

Overall, outcomes related to permanency and reunification were more difficult to affect in all States than outcomes related to treatment access, engagement, and retention:

Foster Care Placement Rates: Delaware and New Hampshire studied the effects of their substance abuse demonstrations on foster care placement rates, defined as the proportion of in-home children enrolled in the demonstration who later entered out-of-home placement. Neither State found conclusive evidence that access to enhanced substance abuse services reduced rates of entry into foster care.
Placement Stability: Illinois and New Hampshire assessed the effects of their demonstrations on placement stability, defined as the average number of times a child in foster care changes placement settings. To date, neither State has found evidence that access to enhanced substance abuse services improves placement stability.
Placement Duration: Three States - Delaware, Illinois, and New Hampshire - studied the effects of their demonstrations on the duration of out-of-home placements. Delaware and Illinois demonstrated positive effects of their demonstrations on length of time in foster care placement. In particular, findings from Illinois suggest that children in families with access to intensive substance abuse services spend considerably less time in foster care. According to the State's latest progress report, children in the experimental group who returned home spent an average of 421 days in out-of-home care compared with 563 days for control group children, a statistically significant difference of 142 days.
Permanency Rates: Illinois and New Hampshire examined the effects of their substance abuse demonstrations on permanency, defined as exits from foster care to reunification, guardianship, or adoption. Neither State reported significant effects of its demonstration on reunification or other permanency outcomes.
Maltreatment Recurrence: Illinois and New Hampshire evaluated the effects of their substance abuse waiver demonstrations on maltreatment recurrence. The latest findings from Illinois indicate that families with access to enhanced demonstration services may experience less subsequent maltreatment, with a smaller, statistically significant proportion of experimental group caregivers having a repeat maltreatment allegation compared with control group caregivers. To date, New Hampshire has uncovered no effect of its waiver demonstration on subsequent maltreatment referrals.
Child and Family Well-Being: New Hampshire has reported some initial positive well-being findings, including declines in problem child behaviors, reduced public assistance participation, increased parental employment, and increased enrollment in education programs. While many of these findings lack statistical significance, the pattern of somewhat improved outcomes across a number of domains suggests a positive trend for families receiving enhanced demonstration services.

Lessons Learned from the Substance Abuse Waiver Demonstrations

To maximize referral rates, States must examine their assumptions regarding the identification of substance use disorders in their child welfare populations and carefully define the target populations for their demonstrations.
Child welfare staff need early and ongoing training regarding substance abuse waiver demonstrations.
Front-line child welfare staff also need better training and tools to identify and assess substance use disorders. To have an impact on families, improved identification must be accompanied by access to adequate and appropriate substance abuse treatment resources to which clients can be referred following identification of a substance use disorder.
Successful child welfare - substance abuse collaborations require careful service coordination, strong managerial support, and consistent communication between child welfare staff and substance abuse professionals.
States need reliable information tracking systems to promote the coordination of case management services and to improve the quality of evaluation data.
To ensure cost neutrality, States must carefully define the eligibility criteria for their substance abuse waiver demonstrations.

In summary, all four waiver States experienced implementation problems, especially in recruiting caregivers to participate in their substance abuse demonstrations. However, the available evaluation findings suggest that intensive, proactive case management can improve access to treatment services and may have a modest positive impact on treatment retention and completion rates. Overall, the States' outcome evaluations uncovered no strong positive effects of the substance abuse demonstrations on foster care placement rates, placement stability, reunification rates, or permanency rates. Some evidence - particularly from Illinois - suggests that a substance abuse demonstration may reduce the duration of foster care placements and lower the risk of maltreatment recurrence. Other States considering the development of new interventions for the families of caregivers with substance use disorders are encouraged to study the lessons learned from these early demonstrations.

¹Due in part to the fact that their target populations included families with children who had not yet been placed in foster care, two States (Delaware and New Hampshire) experienced more difficulty achieving cost neutrality. In other words, the cost of serving families in their experimental groups was not able to be offset by decreases in foster care costs.Back

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