Commentary on Laslett et al. (2012): Integrating substance use disorder and child welfare interventions

Abstract

In analyses of data from child protection services in Victoria, Australia, Laslett et al. found that caregivers' alcohol and drug abuse put children at risk for recurrent abuse and neglect 1. These important findings are comparable to, and extend research on, child welfare systems in other countries 2, 3. In the USA, substance abuse is a factor in at least 70% of reported cases of child maltreatment. Compared with adults without substance use disorders, those with such disorders are 3–4 times more likely to report abusive and neglectful behavior toward their children. Caregiver alcohol or drug abuse is one of the major reasons that children are removed from their homes. Importantly, maltreated children of parents with substance abuse problems have poorer physical, intellectual, psychological and social outcomes, and are at elevated risk of developing substance abuse problems themselves 4. The inter-related issues of caretaker substance misuse and child maltreatment can be addressed by1 (i) linking substance use disorder and child welfare interventions, and (ii) 2identifying common mechanisms underlying substance use and child maltreatment problems. Because they are closely connected problems, caregiver substance abuse and child maltreatment call for improved linkages between substance use disorder treatment and child welfare systems, and for better recognition of the cross-problem within these systems 5. In fact, because of their clients' common characteristics, both systems need to address common risk factors, such as low self-esteem, anxiety and depression, poor coping skills and the stressors involved in sole parenting responsibilities, and economic instability 5, 6. Effective within-program practices that target some of these risk factors by integrating treatment for caregivers who abuse substances and maltreat their offspring encompass the provision of gender-specific treatment that includes offspring as clients, specialized health and mental health services, home visits, and practical assistance with transportation, child care and employment 6. Collaborative models that can enhance these, and other beneficial within-program, practices include locating substance use disorder treatment providers in child welfare settings, training staff members in the cross-problem, supporting substance use treatment providers and child welfare workers in creating joint case plans, referral to family drug courts, and establishing protocols for sharing confidential information between systems 7. Some barriers that need to be addressed to achieve more collaboration between substance use disorder and child welfare systems are differences in defining the client (caregiver or child), in reimbursement policies and in confidentiality mandates, and lack of staff training in, and understanding of, the cross-problem. For example, substance use disorder treatment providers need to be aware of the multiple problems and needs often experienced by child welfare clients, whereas child welfare workers need to be familiar with alcohol and other drug use screening, identification and assessment 2, 6. In addition, child welfare workers need to recognize that substance-abusing caregivers often require extensive and repeated treatment episodes to maintain recovery. The identification of common social processes underlying substance use and child maltreatment problems can enhance linkages between programs addressed to these problems and effective treatment for them. In this respect, some social processes or ‘active ingredients’ of effective treatment for substance use disorders include support, goal direction and structure, an emphasis on rewards for traditional or normative activities, a focus on positive norms and role models, and attempts to develop self-efficacy and coping skills 8. These social processes are also associated with sustained remission and recovery from substance use disorders 9. It is quite likely that comparable social processes are linked to effective child maltreatment interventions and can motivate caregivers to normalize their child-rearing practices and raise healthy, productive offspring. Notably, some of these social processes, such as the extent to which the family environment is supportive, goal-directed and structured, are involved in moderating the influence not only of caregiver substance misuse, but also of caregiver depression on child ill health and lack of well-being 10, 11. Spurred by Laslett and colleagues' and other comparable studies, and aided by conceptual frameworks that identify common social processes underlying substance use disorders and child maltreatment and thereby enhance linkages between the intervention systems addressed to these disorders, providers should be better able to reduce and prevent child maltreatment due to caregiver alcohol and other drug misuse and disorders. This work was supported by the Department of Veterans Affairs (VA) Office of Research and Development (Health Services Research & Development Service, RCS 00-001). The views expressed here are the authors' and do not necessarily represent the views of the Department of Veterans Affairs.