Statement of the Honorable Kristine D. Ragaglia,
Commissioner, Connecticut Department of Children and Families,
accompanied by
Thomas A. Kirk, Jr., Ph.D.,
Deputy Commissioner, Connecticut Department of Mental Health and Addiction Services

Testimony Before the House Committee on Ways and Means
Subcommittee on Human Resources

Hearing on Child Protection Issues
March 23, 2000

Good afternoon, Madam Chair and Members of the Subcommittee on Human Resources. Thank you for the opportunity to testify before you today on this important topic. My name is Kristine Ragaglia, and I am the Commissioner of the Connecticut Department of Children and Families (DCF). With me today is Dr. Thomas Kirk, Deputy Commissioner of the Connecticut Department of Mental Health and Addiction Services (DMHAS). In our state, DCF is mandated to provide mental health, substance abuse and protective services to children. DMHAS is responsible for the adult population and is the state's lead agency for substance abuse services.

I would like to begin by commenting on the extent of substance abuse among families involved with the child protection system and the challenge this presents for achieving permanency for children within the timelines mandated by the Adoption and Safe Families Act (ASFA). I would then like to highlight and comment on Connecticut's Project SAFE (Substance Abuse Family Evaluation), an innovative and collaborative approach to dealing with these issues. Dr. Kirk will then discuss the specific treatment needs of this population and the importance of developing working partnerships between child welfare agencies and substance abuse providers in the effort towards improving outcomes for children and families.

The rise in substance abuse among many of the parents involved with the child welfare system has complicated the system's efforts to protect children. Substance abuse is extremely destructive and is a major factor leading to the abuse and neglect of children. The impact of substance abuse on children is a critical issue. Over the last 10 years, the number of abused and neglected children has doubled nationwide, from 1.4 million in 1986 to more than 3 million in 1997. Substance abuse was a factor in 70 percent of those cases. The impact of drugs and alcohol abuse in such cases is dramatic and has been identified as a contributing factor in a significant number of child fatalities. It is estimated that 5 children die each day as a result of neglect and abuse. Children whose parents abuse substances are almost three times more likely to be abused and four times more likely to be neglected than other children.

If substance abuse issues are left unaddressed, many of the system's efforts to protect children and to promote positive change in families will be wasted. We need to break the cycle of the intergenerational transmission of substance abuse and child abuse and neglect. Children with substance abusing parents are more likely than other children to suffer from significant developmental delays and have a higher risk of developing substance abuse problems as adults. In addition, these children are more likely to abuse and neglect their own children when they become parents. Moreover, children of substance abusing parents have an increased likelihood of being placed in out-of-home care.

Given the often difficult task of identifying and securing appropriate and timely substance abuse treatment for parents whose children are in out-of-home care, children have historically remained in placement longer than might otherwise be necessary. As you are aware, the federal government enacted ASFA in 1997 in an effort to address this concern and the need to move children into permanent living arrangements as quickly as possible following placement into foster care. Connecticut supports the goals of ASFA and the emphasis it places on timely permanency for children. More specifically, ASFA set out shortened timelines for seeking terminations of parental rights and requires the states to seek termination of parental rights within 15 months of a child entering foster care unless certain exemptions apply (i.e. the child is placed with a relative, there is a compelling reason that termination is not in the best interests of the child, or appropriate reunification services were not provided). These shortened timelines have increased the urgency and need to target substance abuse prevention and treatment services for parents involved in the child welfare system.

Connecticut has addressed these issues by developing and implementing an innovative program called Project SAFE. The program was initially developed in 1995 to improve the child protection system by screening for substance abuse, and Gov. John G. Rowland provided leadership in making the necessary changes in the child protection system. Project SAFE was one of the first programs to directly link the child protection system with the adult substance abuse treatment system on a statewide basis. The program presently provides centralized intake procedures and priority access to substance abuse evaluations, drug screens, and outpatient treatment services.

As a result of this collaborative program, direct line social work staff in DCF have an ability to secure timely substance abuse evaluations and screenings in cases where substance abuse issues are identified. Since the program began, DCF staff has made over 25,000 unduplicated referrals for substance abuse evaluations and screenings, and there are approximately 5,000 new referrals a year. By tracking clients, we have been able to monitor the show rates for evaluation screening and outpatient treatment as well as retention in treatment. These efforts have assisted us in maximizing resources.

At the time Project SAFE was created, DCF began to hire substance abuse specialists to serve as consultants to social workers in the regional offices. This provided the needed expertise and training for the DCF social workers to make the program work between the two systems and created the necessary infrastructure. The results of Project SAFE have also provided the court system with necessary information regarding access to and availability of substance abuse services in Connecticut.

We found that the Project SAFE client is likely to be new to the adult treatment system and to present with complex and multiple needs. Almost 60% of the referrals from Project SAFE are women. Approximately 67% of clients referred for a substance abuse evaluation keep the appointments, although some areas having show rates of above 75%. More than 56% of those evaluated receive recommendations for substance abuse treatment. Given that a significant number of clients are found to require substance abuse treatment following the initial evaluation, there is a clear need for collaboration with and access to necessary and appropriate treatment programs.

As noted above, ASFA created new challenges for Project SAFE by creating shortened timelines for developing permanency plans for children and by emphasizing the state's responsibility to provide reasonable efforts to reunify children with their parents following placement into foster care. There was a clear need to create a strategic plan for Project SAFE in collaboration with DMHAS that would meet the complex needs of our clients within the timelines mandated by ASFA. We needed to identify and assess the impact these new requirements would have not only on DCF but also on the substance abuse treatment system. The child protection system could not address the issue of substance abuse on its own. The substance abuse system needed to begin addressing issues such as gender, family functioning, trauma and parenting skills. Similarly, the child protection system needed to gain knowledge about substance abuse screening and treatment.

To address these needs, a new strategic planning partnership was created in 1998 called Project SAFE Phase II. This collaboration has provided an opportunity to improve screening, assessment, bridge the gaps in data and knowledge, develop joint outcome measures, enhance children's services and share in resource development.

Connecticut's Alcohol and Drug Policy Council provided the support and leadership for this interagency collaboration by developing client-based models. One model was developed for women and children that focused on the specific and unique needs of these clients. In addition, in an effort to promote reunification of families when appropriate, Connecticut implemented a program called Supportive Housing for Recovering Families. Based on the client-based model, the program supports and assists clients in finding safe, drug-free housing and provides in-home intensive case management services for parents who have made substantial gains in their substance abuse treatment and plan to be reunified with their children. The early success rate based on the criteria for those entering the program is close to 80%. One reason this program works so well is that the service closely monitors the parent's compliance with adult outpatient substance abuse treatment.

The new partnership between the child protection system and substance abuse providers has created innovative and unique opportunities for research and education regarding substance abuse, child development and prevention. While parental substance abuse may increase the likelihood of out-of-home placement for children, studies show that the overwhelming majority of children affected by parental substance abuse remain in the custody of their parents.

There are a number of projects that we are involved with in collaboration with the academic community to help break the cycle of substance abuse and child abuse and neglect and to assist in maintaining children in their own homes whenever possible. These projects include integrating parenting groups within substance abuse treatment settings. More specifically, the Relational Psychotherapy Mother's Group in New Haven, Connecticut has found that mothers receiving this service were at lower risk for maltreating their children, reported higher levels of involvement with their children and greater parental satisfaction compared to mothers who did not receive this service.

The experience in Connecticut is that substance abuse can and should be identified by the child protection system. The challenge lies in developing and maintaining working partnerships between the child protection system and the substance abuse treatment system and in developing, implementing and funding effective treatment and prevention programs.

To discuss these challenges, I'd like to introduce my colleague, Dr. Thomas Kirk, Deputy Commissioner of DMHAS. Thank you again for giving Connecticut the opportunity to testify before you today on this important and timely topic.

Thomas A. Kirk, Jr., Ph.D., Deputy Commissioner
Connecticut Department of Mental Health & Addiction Services

Thank you. It is a privilege to testify before you today on such an important issue: children, families and recovery. I am Dr. Thomas A. Kirk, Jr., Deputy Commissioner for the Connecticut Department of Mental Health and Addiction Services.

Treatment does work. But today's traditional treatment settings work better for some than others. The traditional treatment system is geared primarily for the "majority" population of drug abusers (male heroin users with criminal justice involvement) and treatment slots and strategies for women (marijuana users with young children) are often not available.

Let me tell you a story about Cathy J. She has had periodic episodes of excessive drinking over the past few years, and especially so in the past six months since separating from her abusive husband. This 32-year-old mother of two now lives with friends who also drink. Depression disturbs her sleep and precipitates episodes of rage, usually directed at her son, Jack. Jack, who used to be a good student, is now failing in school. Cathy is determined to make things better, but she needs help.

We know that approximately 1.84 million American women per year, like Cathy J., are abusing alcohol or drugs (U.S. Public Health Service). We also know the impact of these women's substance use on their children is huge:

Use of substances during pregnancy causes significant problems for the fetus (Brown & Zukerman, 1991).

During childhood, these children are at risk for emotional and behavioral health problems (Hawley et al., 1995).

Women who abuse substances are more likely to abuse and neglect their children (Kelly, 1992).

Women who abuse substances are usually themselves past victims of childhood sexual abuse. Among women in inpatient substance abuse programs, about 75% report childhood sexual abuse (Rosenhow et al., 1988). This history of trauma leaves women more likely to have problems with self-injury, eating disorders, abusive relationships, as well as abusing their own children. To be effective, programs for women must treat trauma. They must focus on nurturing relationships and provide gender-specific group treatment for women who have been victimized by men. They must provide childcare, focus on parenting, and place more attention on other barriers facing mothers who are substance abusers, such as their immediate needs for safe housing and jobs.

In our work with the Connecticut Department of Children and Families around Project SAFE, Phase II, we have learned that we must understand, "Who is the client?" and "How are they different than the entire treatment population?" To be effective, treatment services must be tailored to the individual's needs and circumstances. To answer these questions, we have developed a system of assessment to determine: (1) risk to the child, (2) readiness for treatment and (3) the severity of the substance abuse problem.

Because of the early identification provided through Project SAFE, Connecticut is seeing an expanded treatment population. This expanded population requires a new service mix that our current service system can not fully address. These services fall outside of the parameters of our current funding sources.

Women are entering the treatment system in earlier stages of the addiction cycle. The client is not only the individual with a substance abuse problem, but also her children and family. We need to build a range of service options that fit these circumstances.

Our service system needs to be able to build a family recovery plan rather than focusing solely on the individual. We need to look differently at our expectations for outcomes, considering the health and safety for the children, quality of life, and other critical factors for family life. We need to build into that system engagement specialists that may work with a client for weeks or months to develop her readiness for treatment. Once actively engaged, retention specialists can sustain and expand the duration in treatment. This is what Connecticut is doing!

What works for women and their families?

Case management is effective in getting and keeping women in treatment by tailoring programs to their individual needs and addressing barriers to getting to treatment (Erickson et al., 1997; Brindis & Theidon, 1997). Case management is associated with decreases in substance use, increased enrollment in educational and vocational programs, reduced legal involvement, improved child birth weight, and increased social support (Linehart et al., 1996), as well as retention in treatment (Haller, 1991).

Focusing on child welfare can be a helpful, motivating factor in treating women (Coletti, 1980), and permitting substance abusing women to live with their children during treatment is associated with longer stays in treatment (Hughes et al., 1995; Szuster et al., 1996).

Using a family focus for treatment, and especially parenting training, improves self-esteem and parenting attitudes (Camp & Finkelstein, 1997).

Providing attention to trauma issues along with substance abuse treatment results in greater improvements in substance use, and fewer trauma-related symptoms (Najavits et al., 1998).

In Connecticut, we are finding that using women in recovery as engagement specialists, outreach workers, and other peer support roles significantly improves the likelihood of connecting women to treatment and other support services.

The message I would like to leave you with today is that filling this newly identified gap in treatment--services mentioned above using a family-based model--will result in healthier and safer children and families. Filling the gap will provide an opportunity to break a tragic cycle of abuse and addiction that is handed down from generation to generation.

Thank you.

References

Blending Perspectives and Building Common Ground: A report to congress on Substance Abuse and Child Protection, U.S. Department of Health and Human Services (DHHS) 1999.

No SAFE Haven: Children of Substance Abusing Parents by The National Center on Addiction and Substance Abuse (CASA) 1999 Columbia University.

McCurdy, K and Daro D. Current trends in child abuse reporting and fatalities: The results of the 1993 survey annual fifty-state survey. Chicago, National Committee for Prevention of Child Abuse 1994.

Connecticut Department of Children and Families Substance Abuse Study prepared by Tere Foley, 1994.

State of Connecticut Project Safe Phase II 1999, by Dr. Nancy Young, PhD.

Connecticut Alcohol and Drug Policy Reports 1999 and updated report for 2000.

Luthar, S.S. and Suchman, N.E. Relational Mothers' Group: A developmentally informed intervention for at risk mothers. Development and Psychopathology, in press.