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Rebuilding a family bond: integrated service model assists families affected by substance use, child maltreatment.

When parents with substance use disorders (SUD) who are involved in the child protective service (CPS) system present in SUD treatment, children's well-being is at risk. Ideally, parental participation in SUD treatment could help children be maintained safely with their parents, but when children must be removed, CPS must abide by time limits imposed by the Adoption and Safe Families Act (ASFA) of 1998. Parents who cannot achieve stable recovery within 15 to 22 months may permanently lose custody of their children. It is urgent that families affected by addiction get the help they need, and quickly.

The family may be caught up in the cycle of substance abuse and child maltreatment. Abuse or neglect in childhood may trigger substance abuse problems in adulthood, (1) and when coupled with poverty and mental health problems that often co-exist, the now adult parents may have problems forming attachments with their own children. (2) Intervention is needed to interrupt an intergenerational cycle of substance abuse and child maltreatment that could worsen over time. How can we help these families?

START model

The Sobriety Treatment and Recovery Teams (START) model, an integrated program between CPS and SUD service providers, incorporates a number of strategies to engage families with parental substance abuse and child maltreatment in SUD treatment. Those strategies include peer recovery supports; quick access to CPS services and SUD treatment (including treatment for co-occurring disorders); a high level of collaboration between CPS and SUD treatment; engagement of both parents in services; and repeated efforts to engage families in treatment.

START was initiated in 2006 in Kentucky based on the model developed in Ohio (3), (4) and in response to compelling state statistics showing that almost 90% of children age 3 and younger in state custody were at risk in terms of their safety because of parental substance abuse. The program is directed and funded by the state CPS department (the Kentucky Department for Community Based Services) in partnership with the state behavioral health office that oversees contracts with local treatment providers (the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities).

The project could not operate without both CPS and SUD service providers at the table. But because CPS has to implement specific strategies, the initiative must have strong leadership within the CPS system.


START in Kentucky currently operates in two urban, one rural and one Appalachian site. While the model was developed in an urban setting, it also has been effective with adaptations in rural and Appalachian settings.

Based on work with 322 families, 531 adults and 451 children, this integrated program has produced twice the rates of sobriety and less than half the rates of placement of children in state custody (20% or less, vs. 41%) than typical practice. (5)

Specifically, 66% of women and 40% of men achieved sobriety at closure of their child welfare case, including clean drug tests and progress in both CPS and SUD treatment, compared with a 37% favorable discharge rate overall for CPS-involved clients served in publicly funded SUD treatment programs. These results reflect a cost offset of foster care expenses for CPS of $2.52 for every dollar spent on START substance use disorder treatment and family mentors.

Although this research found that 40% of parents with both child maltreatment and substance abuse lost custody of their children, national figures and rates of long-term permanent loss of custody are not known and are inconsistently tracked among states. We know that the risks to the child remain throughout childhood until age 18; even when reunited, children of substance-abusing parents are more likely to re-enter foster care, with the parents likely to lose custody again. (6)

Peer supports

Each START team includes a specially trained CPS social worker paired with a family mentor; the team works together on up to 15 cases. Family mentors are individuals with at least three years of sustained recovery from addiction, as well as experiences that sensitize them to child abuse and neglect. Family mentors also might be called "peer support specialists" or "recovery coaches: and have backgrounds similar to those hired within SUD treatment facilities.

The family mentor meets the family very quickly after the report of child abuse/neglect is made and investigated, to offer hope that the START program can help and that recovery is possible. Amid a sea of professionals, the family mentor can be a friendly face while "keeping things real" with parents. With "been there, done that" knowledge, the family mentor often can see through evasions of the START clients to help guide them toward the honesty necessary for recovery.

Family mentors help parents engage in treatment by accompanying them to their first four treatment appointments with a warm handoff. They also guide parents into recovery supports and provide coaching on relapse prevention, sober parenting and daily living skills. If a parent does not show up for treatment even one day, the family mentor locates the parent to re-engage him/her in the treatment process.

Contact with the family is often very intensive early on and then tapers off as the parents stabilize. Cases are typically open for 14 months, and the family mentors spend an average of 52 hours in direct contact with clients during that time.

The mentor's shared experience can also change CPS office culture, as child protective workers come to trust that recovery can happen. Mentors participate in case staffing, family team meetings, and assessments of child well-being, lending perspective to the process from a parent's point of view. Their opinions often are sought by judges and attorneys, their teammates, and other CPS workers in the office, helping their colleagues to understand the experience of a person with addiction and to learn how not to enable the parents in their illness but also not to punish parents for showing symptoms of their disease.

Quick access

To capitalize on the crisis that a CPS referral represents, cases accepted to START begin services an average of 10 days after the initial report to CPS. Within a day or two of referral, a family team meeting is called, involving the family and relatives, the CPS investigative worker, the START team, and the SUD treatment provider.

Treatment providers appreciate being an essential participant at this initial meeting, partly because much information is revealed that has a bearing on the SUD assessment, allowing for a quicker and smoother process and faster referral to the level of care the client needs.

Family team meetings use a shared decision-making approach in which all participants help develop a plan to keep the children safe, to begin the SUD assessment process, to explore family strengths and needs, and to identify resources to help support the family. When done well, the meeting can help reassure family members that the START team is there to help them achieve sobriety and stay safely with their children.

Quick access to assessment and treatment has been shown in our early studies to be associated with children being less likely to enter state custody. The SUD assessment is completed quickly so that START parents can begin treatment as soon as possible--before the sense of crisis has diminished. Twenty percent of assessments are conducted the same day as the family team meeting, usually right after the meeting in the CPS office, and 57% of parents are assessed within two days.

Once assessed, 50% of START parents begin active treatment sessions within four to five days of referral. Since 2007, speed of access to treatment has improved from 11.57 days to 3.2 days on average. Also, treatment has become more intensive, with the first five sessions occurring in 11.34 days now on average, vs. 33.37 days in 2007.

Since quick access and retention in treatment are so important to good outcomes, the NIATx change team model of process improvement has been used to decrease wait times and increase retention. Some strategies for improving access include coordinating child care arrangements at the Emily team meeting, providing transportation vouchers, and holding evening hours for treatment services. Retention has been improved by intensive service coordination, immediate follow-up on missed appointments, and increases in the intensity of outpatient programs.

The majority of START children are maintained safely in the home because of a combination of quick access to SUD assessment, treatment and wraparound supports; frequent home visits by the CPS worker and mentor; and creative approaches to parental supervision by relatives. When children do have to be placed in state custody or with a relative, the parents have frequent visitation. As a general rule, children who have been removed are not returned home until the parent has at least six months of documented sobriety and has experienced a gradual return of parenting responsibility. In this way the family is more prepared to be reunified and the children are less likely to be maltreated and removed again.

Collaboration and communication

Although CPS and SUD treatment providers have historically "not played well together," they must work in close collaboration for START to be effective. Teamwork includes working through historical mistrust and dislike, possibly through difficult conversations. In some instances, team building has taken the form of talking circles, complete with tears and storming in order finally to resolve old hurts that stand in the way of working relationships.

The START model calls for intensive collaboration and communication in the following ways:

* Co-location of staff. Even when SUD and CPS staff do not have offices in the same space, they are so frequently in each other's offices as to be very comfortable there. Specific spaces may be set aside for START meetings and consultations with staff and families. SUD and CPS staff often go on home visits together to re-engage families in services.

* Weekly reports. SUD providers submit weekly written reports to CPS that include attendance, participation in treatment, results of any drug tests (including missed or adulterated tests), progress, and barriers noted. These reports are invaluable as a communication tool but also for CPS to produce effective reports for the court. Random drug tests are done at least weekly at first and then with less frequency once the client has stabilized and treatment is less intensive. Clients have the option of signing an "admission of use" form rather than having point-of-use test results confirmed by a laboratory, saving money and building the therapeutic relationship.

* Frequent communication. Much informal communication also takes place between SUD providers and CPS, especially early in a new case when services are most intensive. Clients need to know that CPS and their treatment provider are on the same page and have the same information, so that splitting of the professional team is not possible. Among the many details communicated, some of the most important relate to attendance so that the START team can re-engage when needed, such as when relapse necessitates that child safety be immediately assessed. If children are still in the home, CPS must be diligent about monitoring child safety, which is tied to parental engagement in treatment and sobriety. The SUD treatment provider serves as an important partner in ensuring child safety.

* Regular meetings. CPS and SUD providers meet regularly to discuss cases, figure out better processes and communication methods, ensure that contract requirements are being met, obtain training, and make plans to improve the program. Full implementation of the START timeline and commitment to practice has taken two to four years of team building, cross-training and problem solving per site.

Engaging both parents

Historically, fathers have been neglected by both CPS and SUD treatment providers who often have not treated both parents simultaneously; both have placed a greater emphasis on working with mothers. Because mothers are more likely to engage in substance abuse if their male partner has a SUD, (7) helping fathers gain recovery can be an important part of helping families recover and be safe. Therefore, both fathers and mothers receive SUD assessment and treatment services, including for co-occurring disorders.

START actively includes fathers, including stepfathers and unmarried partners, in the program. The START teams persist in finding and inviting fathers to participate and in involving them in decision-making. Paternal relatives are considered as possible safe placements and sources of family support. In some cases fathers are considered the primary parent and can receive permanent custody. If both parents are in the home, they both must have documented sobriety in order for the home to be considered safe.

Repeated efforts to engage

START offers SUD treatment providers a unique and sometimes frustrating opportunity to continue working with clients even after a treatment attempt that did not result in sobriety. CPS is required to provide services to families until child permanency is achieved (which may be with the parent or parents, a relative, or when parental rights have been terminated and a child can be adopted outside of the family). Thus, if the parents do not become sober and stable after a first treatment attempt, the START team works to continue engagement with the family while the SUD provider gives an updated treatment recommendation and delivers services.

Each START client receives an average of 60 sessions of treatment over an average of 14.8 months. Only 23% receive one treatment modality, 28% receive two modalities, 18% receive three, and the remainder receive four or more. Seventy-nine percent of START clients are served in intensive outpatient programs (10P) at some point, perhaps as their primary treatment or as a step-down from residential treatment. Twenty-nine percent receive residential treatment and social or medical detoxification, respectively; 6.5% receive transitional living services; most parents receive some form of individual counseling; and all receive case management.

Some clients may complete one treatment, have documented sobriety, and have case closure in under a year. Others, based on evidence of continued use or relapse, may require multiple treatment episodes and modalities over several years. CPS and SUD providers work closely together to develop plans for each family that could effectively meet their needs; sometimes SUD providers have to be flexible with their admission and readmission policies.

Depending on factors such as client willingness to admit substance use and engage in treatment, whether significant progress has been made on the case plan, and where the case is relative to ASFA timeframes, CPS may choose to petition the courts for either an ASFA exception so that the client can build adequate time of documented sobriety, or for permanent child custody elsewhere.

Urban vs. rural settings

The timeframes and strategies laid out above are consistent across rural and urban settings, but the following special considerations arise in rural settings:

* Transportation is more challenging in rural and semi-rural areas, so more resources must be allocated to transporting families to treatment, court and other appointments.

* Many families and professionals in rural settings have personal connections such as being related by blood or marriage, having gone to school together, or sharing mutual friends. In order to avoid dual relationships, CPS and SUD staff must discuss any personal connections to clients, and make assignments to non-connected staff accordingly.

* There may not be as many experienced individuals seeking employment in rural areas. Some positions have had to be posted more than once in order to recruit the right applicant, and sometimes on-the-job training has to replace missing work experience and credentials.

* Recovery resources are not as abundant in some rural communities, so the START teams have helped start up self-help meetings. Family mentors have had to be coached on careful boundaries, since they often have to attend the same self-help meetings as the families they are serving.

* In some rural areas, there is much stigma against individuals with addiction and a lack of sound information about addiction and recovery; this plays out in such areas as criminal court, law enforcement and medical practices. In the rural START sites, considerable energy has been put into community education in the form of town hall meetings, public speakers and recovery events. Over time, attitudes have shifted, but champions who are willing to speak out in public are required.

The START program is a promising practice to improve outcomes for families with child maltreatment and substance use disorders. This article highlights strategies that may help substance abuse treatment providers in serving this population, and encourages them to engage in discussion with CPS professionals. A treatment manual that is currently in production will further refine the description of these strategies.


(1.) Dodge KA, Malone PS, Lansford JE, et al. (Eds.) A dynamic cascade model of the development of substance abuse onset. Monographs Soc Research Child Devel 2009; 74: 92-103.

(2.) Bergin C, McCollough P. Attachment in substance-exposed toddlers: the role of caregiving and exposure. Infant Mental Health J 2009; 30: 407-23.

(3.) Annie E. Casey Foundation. Family to Family Tools For Rebuilding Foster Care. START a Child Welfare Model for Drug-Affected Families. Retrieved May 15, 2012 from

(4.) Young NK, Gardner SL. Navigating the Pathways: Lessons and Promising Practices in Linking Alcohol and Drug Services With Child Welfare. Technical Assistance Publication 27. Rockville, Md.: U.S. Department of Health and Human Services; 2002.

(5.) Huebner RA, Willauer T, Posze L. The impact of Sobriety Treatment and Recovery Teams (START) on family outcomes. Families in Society: J Contemporary Soc Services 2012; 93: 196-203.

(6.) Brook J, McDonald T. Impact of parental substance abuse on the stability of family reunifications from foster care. Children Youth Serv Rev 2009; 31: 193-8.

(7.) McLanahan S, Garfinkel I, Reichman N, et al. The Fragile Families and Child Wellbeing Study, Bendheim-Thorman Center for Research on Child Wellbeing, 2003. Retrieved from


Lynn R. Posze, MA, is a licensed professional clinical counselor and Program Administrator in the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities, supporting programs for families involved in child welfare. Her e-mail address is Ruth A. Huebner, PhD, is a child welfare researcher specializing in empowerment evaluation. Her outcome and cost-benefit evaluation for START has helped establish the evidence base for this practice. Tina M. Willauer, MPA, is the START Director for the Kentucky Department for Community Based Services, overseeing START programs in four sites and consulting in several states.
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Author:Posze, Lynn R.; Huebner, Ruth A.; Willauer, Tina M.
Publication:Addiction Professional
Date:Mar 1, 2013
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