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CORK Bibliography: Foster Care

91 citations. January 1997 to present

Prepared: March 2009

Alpert LT. Research review: Parents' service experience - A missing element in research on foster care case outcomes. Child & Family Social Work 10(4): 361-366, 2005. (28 refs.)

A large body of child protection literature focuses on termination of parental rights, family reunification, and children's re-entry into care as outcomes for children in foster care. Studies have investigated child, placement, family, and parent variables as predictors of case outcome. However, one important group of variables remains largely unstudied: factors related to parents' service experience. Parents' service experience includes parents' perceptions of and involvement in the various services in which they must participate in order to recover their children from foster care (e.g. mandated treatment programmes such as substance abuse rehabilitation, parenting skills classes, etc.). The parental perspective on the foster care process is a critical element in the life of a child protection case, and its influence on case outcome must be explored. A brief review of the current literature on case outcome predictors is provided and parents' service experience is highlighted as an area in need of investigation. Suggestions for the measurement of parents' service experience are also offered.

Aronson M. Children of alcoholic mothers: Results from Goteborg, Sweden. IN: Streissguth A; Kanter J, eds. The Challenge of Fetal Alcohol Syndrome: Overcoming Secondary Disabilities. Seattle: University of Washington Press, 1997. pp. 15-24. (Book refs.)

This chapter summarizes the outcomes of three studies of children on alcoholic mothers -- a retrospective, a prospective, and a matched comparison group. The results highlight the multiplicity of factors, both prenatal and postnatal that have an impact on the physical and psychological development. Among the general findings were that children had more severe and higher rates of disturbances when heavy alcohol consumption occurred throughout pregnancy. By way of contrast, those for whom heavy alcohol use was restricted to the first 11 weeks were normal developmentally and had no conspicuous school difficulties. Foster care placement does not significantly alter the presence of developmental retardation, perceptual difficulties, attention deficit, and post-natal growth retardation, suggesting that these are primary disabilities. However, children who remain in families with an active alcoholic mother have double handicaps, had more sever psychological problems. Foster care placement can optimize but not normalize functioning.

Aronson M; Hagberg B. Neuropsychological disorders in children exposed to alcohol during pregnancy: A follow-up study of 24 children to alcoholic mothers in Goteborg, Sweden. Alcoholism: Clinical and Experimental Research 22(2): 321-324, 1998. (15 refs.)

This paper reports on a follow-up study of 24 children to alcoholic mothers at 12 to 14 years of age. The mothers were offered support to help them stop drinking during pregnancy and was grouped to time point of instituted sobriety. Six of the 24 children attended a school for the mentally retarded, and 11 children had some kind of special education. The children have difficulties in mathematics, logical conclusions, visual perception, spatial relations, and short- range memory/attention. Sixteen children were in foster care. A clear correlation between the occurrence and severity of neuropsychological problems and the degree of alcohol exposure in utero was found.

Astley SJ; Stachowiak J; Clarren SK; Clausen C. Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population. Journal of Pediatrics 141(5): 712-717, 2002. (25 refs.)

We determined the prevalence of fetal alcohol syndrome (FAS) in a foster care population and evaluated the performance of the FAS Facial Photographic Screening Tool. All children enrolled in a Washington State Foster Care Passport Program were screened for three conditions: (1) the FAS facial phenotype from a photograph, (2) evidence of brain damage with prenatal alcohol exposure from their Health and Education passport, and/or (3) other syndromes identifiable from a facial photograph. Screen-positives received diagnostic evaluations at a FAS Diagnostic and Prevention Network clinic. The prevalence of FAS in this foster care population was 10 to 15/1000, or 10 to 15 times greater than in the general population. The screening tool performed with 100% sensitivity, 99.8% specificity, 85.7% predictive value positive, and 100% predictive value negative. We conclude that the foster care population is a high- risk population for FAS. The screening tool performed with very high accuracy and could be used to track FAS prevalence over time in foster care to accurately assess the effectiveness of primary prevention efforts.

Backovic D; Marinkovic JA; Grujic-Sipetic S; Maksimovic M. Differences in substance use patterns among youths living in foster care institutions and in birth families. Drugs: Education, Prevention and Policy 13(4): 341-351, 2006. (27 refs.)

Aim: The aim of this study was to determine differences in psychosocial context of occurrence of cigarette smoking and alcohol and drugs use between adolescents living in foster homes and those living with parents. Methods: The study examined 58 adolescents (14 - 17 years) living in foster homes and 245 living with parents using an anonymous questionnaire. Findings: Consumption of tobacco and cannabis was more common in the group of children living in foster homes. They tried these substances earlier and used them more frequently. The most important predictor for current smoking was the number of peers who smoked. Another important predictor of current smoking was an expressed feeling of loneliness. The studied groups did not differ significantly in the occurrence of alcohol drinking. Conclusions: These results suggest that suitable prevention programmes with emphases on social groups living under adverse conditions are needed. Further research should be conducted to give more detailed insight into the reasons and psychosocial factors that precipitate the start and perpetuation of these habits in diverse environments.

Barth RP. Research outcomes of prenatal substance exposure and the need to review policies and procedures regarding child abuse reporting. Child Welfare 80(2): 275-296, 2001. (47 refs.)

Research on the outcomes of drug-exposed children evinces elevated developmental risks from the interaction of subtle biological vulnerabilities and compromised parenting. States, however, have generally not reviewed the procedures and policies they developed in the early 1990s when there was less research and experience with these children. At that time the gravest risks related to perinatal substance exposure seemed to be excessively punitive treatment of mothers by overzealous criminal justice prosecutors. This article clarifies policy options for reporting and serving children who are born testing positive for controlled substances and also calls for strengthening existing state policies regarding child abuse reporting and response.

Beckwith B. Measurement of the early rearing environment: Caregiver-child interaction. IN: Rahdert ER, ed. Treatment for Drug-Exposed Women and Their Children: Advances in Research Methodology. NIDA Research Monograph 166. Rockville MD: National Institute on Drug Abuse, 1996. pp. 205-224

This chapter identifies measures that can be used to capture status and change in the quality and quantity of early caregiver-child interactions. Because maternal drug abuse often necessitates the use of alternative caregivers for the child, through either legal or informal arrangements, the measures discussed herein are suitable for the biological mother, father, or grandparent; professional foster parent; or any other designated primary caregiver. The discussion considers the significance of such measures in evaluating the efficacy of maternal intervention programs and in understanding the sequelae of prenatal drug exposure for children. The chapter also reviews the conceptual dimensions of caregiving, assessment procedures used in the home and laboratory, and level of analysis, whether by behavioral counts or rating scales. Comments on the strengths and pitfalls of specific measures also are included.

Public Domain.

Beeghly M; Frank DA; Rose-Jacobs R; Cabral H; Tronick E. Level of prenatal cocaine exposure and infant-caregiver attachment behavior. (review). Neurotoxicology and Teratology 25(1): 23-38, 2003. (113 refs.)

The objective of this longitudinal prospective cohort study was to determine whether level of prenatal cocaine exposure, or the interaction between level of prenatal cocaine exposure and contextual risk variables, was associated with a higher rate of infant-caregiver insecure attachment and disorganized attachment, or with alterations in infant crying or avoidant behavior, after controlling for prenatal exposure to alcohol, tobacco, and marijuana, the quality of the proximal caregiving environment, and other covariates. Subjects were 154 full-term 12-month-old infants (64 unexposed, 61 with lighter cocaine exposure, 29 with heavier cocaine exposure) and their primary caregivers from low-income, urban backgrounds. Exposure status was determined in the maternity ward by biologic assay (infant meconium and/or maternal or infant urine) and maternal self-report. At the 12-month follow-up visit, infants were videotaped with their primary caregiver in Ainsworth's Strange Situation. Reliable coders masked to exposure status scored videotapes for attachment variables, amount of crying, and level of avoidance. Contrary to popular perceptions, level of prenatal cocaine exposure was not significantly related to secure/insecure attachment status, disorganized attachment status, or rated level of felt security. Foster care status also was not associated with attachment status. However, heavier prenatal cocaine exposure, in interaction with maternal contextual variables (public assistance or multiparity) was associated with alterations in infant socio-affective behavior, including a higher level of behavioral disorganization, more avoidance of the caregiver, and less crying.

Besinger BA; Garland AF; Litrownik AJ; Landsverk JA. Caregiver substance abuse among maltreated children placed in out-of-home care. Child Welfare 78(2): 221-239, 1999. (20 refs.)

Child protective services (CPS) case records of 639 children placed in out-of-home care due to maltreatment were reviewed, and substance abuse by the child's caregiver prior to the child's placement was evaluated systematically. Based on several different sources of information, 79% of the caregivers were found to meet the criteria for caregiver substance abuse (CSA). Children with and without evidence of CSA differed on age, ethnicity, family composition, and type of maltreatment. The importance of operational specificity in defining CSA and implications for policy and service delivery are discussed.

Brindis CD; Clayson Z; Berkowitz G. Options for recovery: California's perinatal projects. Journal of Psychoactive Drugs 29(1): 89-99, 1997. (27 refs.)

In response to the increasing magnitude of problems related to perinatal exposure to alcohol and other drugs, a novel interagency collaboration was formed that involved the California Departments of Alcohol and Drug Programs, Developmental Services, Health Services, and Social Services. This collaboration was named Options for Recovery (OFR). Its mission was to promote the recovery of pregnant, postpartum, and parenting chemically dependent women and the enhancement of the health of their children by providing comprehensive and coordinated alcohol and other drug treatment, case management, and recruitment and training of foster parents and relative caregivers. Seven OFR pilot projects were selected. Findings from the three-year evaluation of the pilot projects showed that the initiative was successful in connecting women with essential services, promoting perinatal recovery and child health, and increasing family reunification of children in foster care. Women who were most likely to complete alcohol and other drug treatment were younger, high school graduates, mandated to treatment, or those who participated in treatment 150 days or more. Participants reported high levels of satisfaction with OFR. The findings indicate that OFR served the unique needs of high-risk perinatal populations. Future efforts should try to reach women early in their pregnancies and should provide a wide array of alcohol and other drug treatment approaches that are responsive to the myriad needs of women and their children.

Brown JV; Bakeman R; Coles CD; Platzman KA; Lynch ME. Prenatal cocaine exposure: A comparison of 2-year-old children in parental and nonparental care. Child Development 75(4): 1282-1295, 2004. (56 refs.)

Effects of prenatal cocaine exposure and parental versus nonparental care on outcome at 2 years of age were examined. The sample included 83 cocaine-exposed and 63 nonexposed children and their caregivers; 49 and 34 of the cocaine-exposed children experienced parental and nonparental care, respectively. Prenatal drug exposure was not related directly to children's outcome at 2 years of age. However, compared with cocaine-exposed children in parental care, those in nonparental care experienced a more optimal environment and performed better in several developmental domains at 2 years of age in spite of being at greater neonatal risk. Further analyses suggested that this protective effect of nonparental care was in part due to nonkin rather than kin care.

Byrd RS; Neistadt AM; Howard CR; Brownstein-Evans C; Weitzman M. Why screen newborns for cocaine: Service patterns and social outcomes at age one year. Child Abuse & Neglect 23(6): 523-530, 1999. (22 refs.)

Objective: To compare baseline characteristics, service provision, and child placement for infants exposed to cocaine in utero based on postnatal screening results. Methods: We studied a retrospective cohort of 40 consecutive drug- exposed, but seemingly healthy term infants who underwent urine drug screening in the newborn nursery of a community hospital. Using clinical and service agency data, two cocaine-exposed cohorts were compared (a) screen-positive at birth (n = 22) versus (b) screen- negative at birth (n = 18). Results: Both cocaine-exposed groups had similar infant birth weights, levels of paternal involvement, maternal ages, gravidity, parity, and lengths of gestation. Mothers in both groups had similar histories of prostitution, Door home environment, drug use, and prenatal drug rehabilitation. Mothers of screen-positive infants were more likely than mothers of screen-negative infants to have other children in foster care (27% vs. 6%, p = .07), to have experienced previous interventions by child protective services (CPS) (55% vs. 17%, p < .01), to have had no prenatal care (32% vs. 6%, p = .09), and fewer prenatal visits (4.7 vs. 8.6, p = .02). Compared to screen- negative infants, more screen-positive infants were referred to a high-risk infant tracking program (91% vs. 6%), referred to CPS (100% vs. 33%), placed outside the mother's home (50% vs. 22%), and had their mothers referred to drug rehabilitation (36% vs. 11%), (p < .01 for each). By 1 year of age, support services differed little between exposed cohorts. However, 6 of 22 screen-positive infants were in foster care and 3 were placed for adoption, while only 1 of the 18 screen-negative infants was in foster care and only 1 had been placed for adoption. There were no services available in this community to provide coordinated or comprehensive services or drug treatment specific to the needs of drug using mothers and drug exposed infants. Conclusions: Despite similarities between cocaine-exposed infants cared for in a normal newborn setting (with and without positive urine drug screens at birth), differences in referral services were noted. More striking than these differences was that services for families with drug-exposed infants are inadequate to even meet the needs of those families in our setting deemed to be at highest risk. Neonatal drug screening needs to be paired with effective services.

Carlson BE; Matto H; Smith CA; Eversman M. A pilot study of reunification following drug abuse treatment: Recovering the mother role. Journal of Drug Issues 36(4): 877-902, 2006. (49 refs.)

This qualitative study explored the experiences of women in recovery from drug abuse who had resumed parenting their children after child placement. Six mothers and I I service providers from substance abuse treatment and child welfare agencies were interviewed about their perceptions of the experience of being reunified with one's children following substance abuse treatment. Findings revealed that mothers have intense emotional reactions to having children placed, which can motivate recovery but also be a source of stress. A variety of supports were identified as necessary to prepare mothers for resuming care of children beyond substance abuse treatment including counseling, child care, financial support, and parenting education. Reunification, however desirable, was described as overwhelming and fraught with parenting challenges, such as effective limit setting with children. Numerous challenges and barriers to successful reunification were identified, such as stigmatization in the child welfare system. Implications for service delivery and research are discussed.

Carten AJ. Mothers in recovery: Rebuilding families in the aftermath of addiction. Social Work 41(2): 214-223, 1996. (24 refs.)

In the mid-1980's maternal substance abuse in the United States increased dramatically, resulting in significant increases in the foster care caseload. Moreover, because of systemic inequities children of poor women of color experienced increased risk of foster care placement. Partly in response to court decisions legitimating mothers' rights to rehabilitation and family preservation services and the increased costs of providing foster care services, New York City implemented the Family Rehabilitation Program as an alternative to placement. This article reports the findings of a qualitative, exploratory study that examined outcomes for 20 women who had successfully completed the program and identifies client characteristics associated with successful drug rehabilitation and practice interventions that support retention in drug treatment. Implications for the redirection of policy and practice to focus on prevention and family preservation for this underserved population are discussed.

Cowal K; Shinn M; Weitzman BC; Stojanovic D; Labay L. Mother-child separations among homeless and housed families receiving public assistance in New York City. American Journal of Community Psychology 30(5): 711-730, 2002. (51 refs.)

We examined the incidence, characteristics, and predictors of separations of children from mothers in 543 poor families receiving public assistance, 251 of whom had experienced homelessness during the previous 5 years. Forty-four percent of the homeless mothers and 8% of housed mothers were separated from one or more children. A total of 249 children were separated from 110 homeless families and 34 children from 23 housed families. Children were placed with relatives and in foster care but were rarely returned to their mothers. Maternal drug dependence, domestic violence, and institutionalization predicted separations, but homelessness was the most important predictor, equivalent in size to 1.9 other risk factors. We infer that policies regarding child welfare and substance abuse treatment should be changed to reduce unnecessary placements. Studies of homeless children who remain with families may be biased if separated children are excluded.

Das Eiden R; Peterson M; Coleman T. Maternal cocaine use and the caregiving environment during early childhood. Psychology of Addictive Behaviors 13(4): 293-302, 1999. (37 refs.)

The purpose of this study was to examine the quality of the caregiving environment for young children of polydrug cocaine-using mothers. Three aspects of the caregiving environment were examined: physical and social settings for development, maternal psychosocial functioning, and child rearing customs and attitudes. It was hypothesized that maternal cocaine use would be associated with more negative caregiving environments. Results indicated that cocaine-using mothers were more likely to have symptoms of posttraumatic stress disorder, experience or witness community violence, and use negative discipline and that their children were more likely to remain in foster care for longer periods of time, experience more changes in primary caregivers, and be visited by male caregivers less often. The implications of these findings for child adjustment and directions for future research are discussed.

Davidson-Arad B; Englechin-Segal D; Wozner Y; Gabriel R. Why social workers do not implement decisions to remove children at risk from home. Child Abuse and Neglect 27(6): 687-697, 2003. (45 refs.)

Objectives: The study explores why social workers do not always implement their decisions to remove children at risk from their homes. Method: Social workers in Israel filled out questionnaires for 96 children at risk at two points of time: When they began to consider whether or not to remove the child, they completed questionnaires tapping their own, the parents', and the children's features. Six months later, they reported their decision, whether or not they had carried it out, and if not, why not. Results: Some 21% of the workers' decisions were not implemented, almost all of them decisions to remove. The main reasons given were the objections of the parents and/or the child. Decisions were implemented for all the children whose mothers were alcohol or drug addicts. Implementation was lower for older children, children who were uncooperative with the social worker, and for children whose parents were uncooperative. It was also lower among experienced workers than novices. Conclusions: Further study is required to examine the generalizability of these findings to other countries, to understand better the reasons for the non-implementation, and to follow-up on the consequences of the non-implementation.

Dixon S; Thal D; Potrykus J; Dickson TB; Jacoby J. Early language development in children with prenatal exposure to stimulant drugs. Developmental Neuropsychology 13(3): 371-396, 1997

Early language development was assessed in 60 children of substance-abusing mothers (CSAMs) born at term and without other pre-or postnatal complications. The MacArthur Communicative Developmental Inventory was used in 2 studies: laboratory measures of a subset of children in Study 2 replicated and extended the results of Study 1. Results showed significant delays in all aspects of language measured for a sizable proportion of the CSAMs. Neither type of drug nor general developmental status predicted language ability. The small number of children in birth homes showed the best performance on all language measures; those in foster care, including relative care, showed the worst. In both studies, older CSAMs did more poorly than younger ones.

Dore MM; Doris JM. Preventing child placement in substance-abusing families: Research-informed practice. Child Welfare 77(4): 407-426, 1998. (52 refs.)

The authors present findings from their study of a placement prevention program designed to facilitate addiction treatment for substance-abusing mothers and other primary caregivers reported for child maltreatment. Relationships between involvement in the program, the status of addiction treatment, and the variety of outcomes for caregivers and their children were tested. Findings indicate that nearly half of the participants were able to complete addiction treatment and achieve sobriety. Those who used the program's child day care component were three times more likely to complete treatment. Implications for confronting the problem of substance- abusing caregivers in the child welfare system are drawn.

Doris JL; Meguid V; Thomas M; Blatt S; Eckenrode J. Prenatal cocaine exposure and child welfare outcomes. Child Maltreatment 11(4): 326-337, 2006. (41 refs.)

This study examines the relationship between prenatal cocaine exposure and child welfare outcomes. Seventy-six infants positive for cocaine at birth were matched to 76 negative infants. With prenatal care and maternal use of alcohol and tobacco controlled, cocaine-exposed infants had significant decrements in birth weight, length, head circumference, and depressed 5-min Apgar scores. This confirmed the health risk of prenatal cocaine exposure for the sample. Three-year follow-up data were obtained from the State Central Register and foster care records. Adjusting for prior maternal involvement with child welfare services the study groups did not differ in incidents of child maltreatment or foster care placement. These findings suggest that prenatal cocaine exposure is not a marker for abusive parenting. However, from the perspective of a cumulative risk model, the identification of cocaine-exposed infants at birth can form the starting point for the development of appropriate diagnostic and follow-up services for mother and child.

Frank DA; Jacobs RR; Beeghly M; Augustyn M; Bellinger D; Cabral H et al. Level of prenatal cocaine exposure and scores on the Bayley Scales of Infant Development: Modifying effects of caregiver, early intervention, and birth weight. Pediatrics 110(6): 1143-1152, 2002. (52 refs.)

Objectives. The objectives of this study were 1) to assess whether there is an independent association between the level of prenatal cocaine exposure and infants' developmental test scores after control of potential confounding variables; and 2) if such an association exists, to determine which biological and social variables, individually and in interaction with each other, may modify it. Methods. In a prospective, longitudinal study of 203 urban term infants, 3 cocaine exposure groups were defined by maternal report and infant meconium assay: unexposed, heavier cocaine exposure (>75th percentile self-reported days of use or meconium benzoylecognine concentration), or lighter cocaine exposure (all others). Examiners, masked to exposure history, tested infants at 6, 12, and 24 months of age with the Bayley Scales of Infant Development. Results. The final mixed linear regression model included as fixed covariates level of prenatal exposure to cocaine, alcohol, and cigarettes; prenatal marijuana exposure; gestational age and birth weight z score for gestational age; and gender. Age at test, caregiver at time of each test (biological mother, kinship caregiver, unrelated foster caregiver), and any previous child-focused early intervention were included as time-dependent covariates. There were no significant adverse main effects of level of cocaine exposure on Mental Development Index (MDI), Psychomotor Development Index (PDI), or Infant Behavior Record. Child-focused early intervention interacted with level of cocaine exposure such that heavily exposed children who received such intervention showed higher adjusted mean MDI scores than all other groups. Although the sample was born at or near term, there was also a significant interaction of cocaine exposure and gestational age on MDI scores, with those in the heavier exposure group born at slightly lower gestational age having higher mean MDI scores compared with other children born at that gestational age. There was also a significant interaction on MDI between child's age and caregiver. At 6 months, the adjusted MDI of children living with a kinship caregiver was 15.5 points lower than that of children living with their biological mother, but this effect was diminished and was no longer significant at 24 months (difference in means: 4.3 points). The adjusted mean MDI of children in unrelated foster care at 6 months was 8.2 points lower than children of biological mothers, whereas it was 7.3 points higher at 24 months. Early intervention attenuated the age-related decline in PDI scores for all groups. Birth weight <10th percentile was associated with lower PDI scores for children with heavier cocaine exposure and with lower MDI scores for all groups. Conclusions. Heavier prenatal cocaine exposure is not an independent risk factor for depressed scores on the Bayley Scales of Infant Development up to 24 months of age when term infants are compared with lighter exposed or unexposed infants of the same demographic background. Cocaine-exposed infants with birth weight below the 10th percentile for gestational age and gender and those placed with kinship caregivers are at increased risk for less optimal developmental outcomes. Pediatric clinicians should refer cocaine- exposed children to the child-focused developmental interventions available for all children at developmental risk.

Garcia SA. Primary socialization theory: Comments on racism, sexism, generational neglect, abuse, and abandonment. Substance Use & Misuse 34(7): 1005-1011, 1999. (14 refs.)

This article asks whether primary socialization theory adequately deals with the most distressed and disadvantaged members of society, whether for most of them the family, school, and peers are the primary sources of socialization. Children who are subjected to the effects of racism, sexism, physical and mental abuse, inferior dangerous schools, and abandonment to foster care from birth may find other sources of primary socialization which can be either negative and positive. "Nihilism" and "anomie" are used to describe such children's position in their societies, and the article asks if those without benefit of the three primary sources of socialization can find ways to create new and positive norms, or whether they are doomed to lives of hopelessness and deviance.

Graves RB; Openshaw DK; Ascione FR; Erickson SL. Demographic and parental characteristics of youthful sexual offenders. International Journal of Offender Therapy and Comparative Criminology 40(4): 300-317, 1996. (50 refs.)

This study, employing meta-analysis investigates 20 years of empirical data involving demographic and parental correlates of youthful sexual offenders. Three offender subtypes, pedophilic, sexual assault, and mixed offense youth, are identified. Pedophilic youth are described as being principally Caucasian, living in foster care, and having an education of less than or equal to 5th grade. They tend to be from lower to mid socioeconomic status (SES) maladaptive families. Mothers of these youth have been physically abused as children, and fathers abuse drugs. Sexual assault youth come from low- to mid-SES, single parent, dysfunctional families with fathers abusing alcohol. These youth are most often Caucasian. Mixed offense offenders are predominantly from lower SES families, are Caucasian, Protestants, and have equal or less than a high school education. Families are dysfunctional with paternal substance abuse. Fathers report being neglected as children, whereas mothers indicate physical abuse.

Green BL; Rockhill A; Furrer C. Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis. Children and Youth Services Review 29(4): 460-473, 2007. (30 refs.)

Although substance abuse is one of the primary reasons that parents become involved with the child welfare system, there is surprisingly little empirical research that examines the relationship of substance abuse treatment to child welfare outcomes. In this statewide longitudinal study of 1911 women who had children placed in substitute care, we examined the influence of three key factors in the treatment process on child welfare outcomes. Results indicated that when these women entered treatment more quickly, spent more time in treatment, or completed at least one treatment episode, their children spent fewer days in foster care and were more likely to be reunified with their parents. These findings were significant even controlling for families' levels of risk including treatment and child welfare history, substance abuse frequency and chronicity, and demographic risks. Implications of these findings for improvements in the way that treatment services are provided to women in the child welfare system are discussed.

Gregoire KA; Schultz DJ. Substance-abusing child welfare parents: Treatment and child placement outcomes. Child Welfare 80(4): 433-452, 2001. (51 refs.)

The authors present findings from their study of 167 child welfare parents referred for substance abuse assessments. Relationships between gender, prior treatment, court-ordered intervention, significant others' support, and treatment and placement outcomes are examined. Findings indicate significant others' support positively influences all outcomes while court-ordered intervention is not predictive. Prior treatment is associated with continued substance abuse. Gender differences exist for assessment completion and several client characteristics. Implications for practice are drawn.

Grella CE; Greenwell L. Correlates of parental status and attitudes toward parenting among substance-abusing women offenders. Prison Journal 86(1): 89-113, 2006. (73 refs.)

This study examined the correlates of loss of parental rights and attitudes toward parenting among a sample of substance-abusing women offenders (N=483). One third of the sample had lost parental rights to a child; these mothers were younger, but had more children, were less likely to have ever worked or been married, initiated regular drug use at a younger age, and were more likely to have been in foster care or adopted themselves and to have engaged in sex work. Higher self-efficacy, decision making ability, social conformity, and childhood problems were associated with less risky parental attitudes, whereas depression, lower education, and non-White ethnicity were associated with greater risk. Services that address the psychosocial needs of women offenders may increase the likelihood of successful family reunification following incarceration.

Haight W; Ostler T; Black J; Sheridan K; Kingery L. A child's-eye view of parent methamphetamine abuse: Implications for helping foster families to succeed. Children and Youth Services Review 29(1): 1-15, 2007. (28 refs.)

This report focuses on the experiences and perspectives of rural, Midwestern children aged 7-14 years who were involved with the public child welfare system because of their parents' methamphetamine abuse. Eighteen children participated in semi-structured, in-depth interviews focusing on their families of origin. Children reported exposure not only to their parents' and non-kin adults' methamphetamine and other substance abuse, but to a constellation of activities related to drug use or drug seeking behavior including violence within their homes and other criminal behavior. Children responded to the contexts in which they were reared in a variety of ways including accepting or actively resisting socialization messages that normalized substance abuse. The majority of children described involvement with law enforcement and child welfare as a "sad" and "scary" time in their families. Far from embracing their placement within safe and stable families, many children continued to express sadness, distress and resistance to legal and child welfare interventions even after months in foster care. Implications for facilitating the adjustment of children to foster care and beyond are discussed including providing foster parents with support and information about the contexts in which children have been reared and children's understanding of those contexts in order that they may interpret and respond to challenges that may emerge.

Hohman MM; Butt RL. How soon is too soon? Addiction recovery and family reunification. Child Welfare 80(1): 53-67, 2001. (19 refs.)

In order to assist child welfare workers involved in decision making regarding family reunification, this study examines the addiction recovery process and its impact on parenting behaviors. Two case examples applying this knowledge are presented, along with a discussion of their application to practice. In the model of alcoholism recovery, four stages of recovery are described: drinking, transition, early recovery, and ongoing recovery. Some of the risks for relapse are discussed. In a model of cocaine recovery, the stages leading to recovery described are withdrawal, the honeymoon stage (feeling optimistic), the wall (a depressive, discouraged, irritable phase), adjustment (a slow sense of recovery), and resolution (determined lifestyle changes). Although few studies have specifically investigated the recovery process on women, it has been suggested that low-income women in particular are prone to difficulty with recovery from substance addiction, as compared to their male counterparts. Two case studies illustrate these stages of recovery, and how these relate to recovery, particularly is bringing back together families affected by addiction. Social workers must have a working base knowledge of substance abuse and the dynamics involved in recovery. Applying the techniques outlined here will be a good indicator of how far along clients are in recovery. This can aid social workers in determining when clients are actively participating in their program, are active in treatment, and hopefully, are better able to parent their children.

Jaudes PK; Ekwo EE. Outcomes for infants exposed in utero to illicit drugs. Child Welfare 76(4): 521-534, 1997. (31 refs.)

The study reported here sought to determine whether substance-exposed infants who are maltreated have a higher risk of out-of-home placement than substance-exposed children who are not abused and rejected, as well as a higher risk of death than children in the general population. In a sample of 513 infants born at a Chicago medical center from 1985 through 1990, 480 (93.6%) had complete sociodemographic data available for analysis. Identifying data were used to search the Illinois death registry and a computerized central registry of child abuse reports. Both out-of-home placement and death were distinctly more likely if children had been exposed to drugs and maltreated. Such children should be closely followed.

Jonson-Reid M; Scott LD; McMillen JC; Edmond T. Dating violence among emancipating foster youth. Children and Youth Services Review 29(5): 557-571, 2007. (35 refs.)

Youth emancipating from foster care have been found to be at higher risk for many adverse outcomes. Only one prior published study exists, however, about the dating violence experiences of foster youth. Asking similar questions about dating violence, this study attempted to replicate the prior findings regarding prevalence and to explore associations between foster care placement history, maltreatment history and mental health/substance abuse and self-reported dating violence. The youth reported a higher prevalence of dating violence than found in studies of the general youth population. Self-reported PTSD symptoms and drug use were associated with higher likelihood of dating violence victimization. The majority of youth self-reporting as dating violence perpetrators also self-reported as victims. Implications for research and practice are discussed.

Karoll BR; Poertner J. Judges', caseworkers', and substance abuse counselors' indicators of family reunification with substance-affected parents. Child Welfare 81(2): 249-269, 2001. (38 refs.)

The decision to reunify children with their substance-affected parent is highly complex and requires a tremendous amount of work and change on the part of the affected parent. This exploratory study identified indicators for safe reunification of children placed in foster care due to parental substance abuse, judges who hear juvenile cases, private agency child welfare caseworkers, and substance abuse counselors from a large midwestern state were surveyed using an instrument composed of a preliminary list of indicators identified through focus groups with these professional groups. Responses from 196 professionals who rated the importance of each item and subsequent factor analysis resulted in identification of 97 indicators. These indicators were grouped into the categories of motivation, recovery, competency; and rehability; social support; parenting skills; and legal issues. Implications of the findings for practice are discussed.

Kovalesky A. Factors affecting mother-child visiting identified by women with histories of substance abuse and child custody loss. Child Welfare 80(6): 749-768, 2001. (32 refs.)

The influence of maternal substance abuse upon the placement of children in out-of-home care increased significantly in the 1980s and 1990s, affecting mother-child visiting in numerous ways. Content analysis of interview data from 15 mothers with histories of illegal drug use and child custody loss provides insight into five major factors that can promote or inhibit visiting: (1) mother's drug use and health status, (2) effects of visits on the child, (3) transportation, (4) scheduling/visit settings, and (5) support of others.

Krauss RB; Thurman SK; Brodsky N; Betancourt L; Giannetta J; Hurt H. Caregiver interaction behavior with prenatally cocaine-exposed and nonexposed preschoolers. Journal of Early Intervention 23(1): 62-73, 2000. (52 refs.)

This study examined the quality of caregiver-child interaction as measured by the Parent/Caregiver Involvement Scale (PCIS) with a sample of 41 preschoolers who were prenatally exposed to cocaine and 39 nonexposed preschoolers. Within the cocaine group, 19 children were in the care of relatives or foster caregivers and 22 were in the care of their biological mothers. Results suggest that mothers of nonexposed children were significantly more emotionally and developmentally appropriate than caregivers of prenatally cocaine-exposed children, and no significant differences in interaction behavior were found between biological mothers and foster caregivers of prenatally cocaine-exposed children. The importance of conceptualizing this population of children within the context of their environment is stressed.

Larrieu JA; Heller SS; Smyke AT; Zeanah CH. Predictors of permanent loss of custody for mothers of infants and toddlers in foster care. Infant Mental Health Journal 29(1): 48-60, 2008. (21 refs.)

The maltreating mothers of abused and neglected infants and toddlers were evaluated as part of an intensive intervention program. The purpose of this study was to examine cumulative risk versus specific risk factors that led to permanent loss of custody by mothers, predicated upon decisions by the Juvenile Court with regard to permanency planning. The following risk factors were analyzed as potential predictors of placement outcomes: maternal education, maternal history of abuse as a child, history of psychiatric difficulties, substance-abuse history, conviction history (excluding child-abuse charges), depressive symptomatology, degree of partner violence experienced, and cumulative number of risks the mother experienced. Results indicated that mothers who lost custody had significantly more risk factors than those who were reunified with their children. Cumulative risk was a stronger predictor than specific risk factors. Implications for intervention are discussed.

Lenz-Rashid S. Employment experiences of homeless young adults: Are they different for youth with a history of foster care? Children and Youth Services Review 28(3): 235-259, 2006. (72 refs.)

There are approximately 350,000 young people between the ages of 18 and 24 who are homeless each year in the United States and some were placed in foster care as a minor. The purpose of this study is to examine the baseline information and outcomes following an employment training program for homeless transitional youth. A comparison is made between those with a history of foster care (FC) and those without (NFC). At baseline, the FC had significantly more youth of African-American decent and significantly less Caucasian youth than the NFC. Additionally, the FC were significantly more likely to have mental health issues and current substance abuse issues than the NFC. Approximately 60% of participants from each group found employment within 3 months following the training and the mean hourly wage of all participants post-training was $9.27 ($9.55 NFC and $8.88 FC). Follow-up comparisons found that having a mental health issue most significantly predicted whether a youth found employment following the employment training program, even while taking into consideration foster care history and all other control variables. Hispanic FC youth had significantly higher hourly wages after controlling for all other variables when compared to Hispanic NFC youth.

Lery B. A comparison of foster care entry risk at three spatial scales. Substance Use & Misuse 43(2): 223-237, 2008. (35 refs.)

This study addresses the problem of operationalizing neighborhood boundaries by investigating foster care entry risk at three spatial scales. Foster care entries from a California county between 2000 and 2003 (n = 3,311) are geocoded to each of the three scales (N = 46 zip codes, 320 census tracts, and 983 block groups). Exploratory spatial data analysis is used to compare spatial autocorrelation of entry rates among scales. Results suggest that depending on how neighborhoods are defined, the geographic pattern of foster care incidence changes. Implications for accurately targeting services to high-risk neighborhoods and future research directions are noted.

Leslie LK; Kelleher KJ; Burns BJ; Landsverk J; Rolls JA. Foster care and Medicaid managed care. Child Welfare 82(3): 367-392, 2003. (69 refs.)

Children in the foster care system are often dependent on Medicaid for health care. These children, however, have more complex health care needs than the typical child receiving Medicaid. States are implementing Medicaid managed care programs as a way to control escalating costs while providing necessary services. This article reviews the issues surrounding delivery of managed health care services to children in foster care and describes several solutions.

Leventhal JM; Forsyth BWC; Qi KQ; Johnson L; Schroeder D; Votto N. Maltreatment of children born to women who used cocaine during pregnancy: A population-based study. Pediatrics 100(2 Pt 1): E71-E76, 1997. (18 refs.)

Background. Previous studies of maltreatment of children born to women who used cocaine during pregnancy have relied on either selected samples of infants identified at birth or biased, high-risk samples referred to protective services. Objective. To determine the relative risk of either maltreatment or placement outside the home during the first 2 years of life in children born to women who used cocaine during pregnancy compared with a sociodemographically similar comparison group. Patients. We reviewed the medical records of consecutive deliveries at Yale-New Haven Hospital from August 1, 1989 through September 30, 1990. Of the 1140 women who were eligible for the study, 173 had a positive history and/or a positive urine test for cocaine; 139 of the infants were included in the study. A comparison group of infants was chosen from 526 women whose obstetric records indicated that they had not used cocaine during pregnancy based on at least two separate notations in the record. For each of the 139 cocaine-exposed infants, an infant was chosen from the comparison group based on seven matching characteristics: date of birth, race, method of payment for the hospitalization, gestational age, mother's parity, mother's age at delivery, and timing of the first prenatal visit. Main Outcome Measures. Children's medical records at the only two hospitals in the region, the two neighborhood health centers, and the only health maintenance organization were reviewed from birth to 2 years of age. Each injury was classified by two independent reviewers who used predefined criteria to distinguish maltreatment (physical abuse, neglect, or abandonment) from unintentional injuries. Placements outside the home were categorized according to whether the placement was in foster care or with a relative. Main Results. The children were mainly African-Americans (80%), and most were enrolled in Medicaid (96.5%). By 2 years of age, 9.3% of the infants in the cocaine-exposed group versus 1.4% in the comparison group had been maltreated [matched relative risk = 6.5; 95% confidence interval (CI) = 1.47, 28.80], and 25.9% vs 8.6% had spent some time in placement (matched relative risk = 5.0; 95% CI = 2.08, 12.01). After controlling for differences between the groups in baseline clinical and social variables, the adjusted odds ratios for both maltreatment (3.98; 95% CI = .81, 22.80) and placement (1.66; 95% CI = .74, 17.83) decreased and were no longer statistically significant. Conclusion. In this population-based study, children born to women who used cocaine during pregnancy were at a substantially increased risk of maltreatment or placement outside the home compared with a sociodemographically similar comparison group. Differences in baseline variables between the two groups, however, partially accounted for this increased risk. Therefore, a mother's use of cocaine is more likely a marker of increased risk rather than a single explanatory variable.

Lewandowski CA; Hill TJ. The impact of foster care and Temporary Assistance for Needy Families (TANF) on women's drug treatment outcomes. Children and Youth Services Review 30(8): 942-954, 2008. (52 refs.)

This study assesses the impact of having a child in foster care and receiving cash benefits through Temporary Assistance for Needy Families (TANF) on women's completion of a residential drug treatment program. The study's hypothesis was that drug treatment completion rates for women who had children in foster care and/or who were receiving TANF would differ from women who did not receive these services. The sample included 117 women age 19 to 54, in a Midwestern state. Findings suggest that women with a child or children in foster care were less likely to complete treatment. Women receiving cash benefits were also somewhat less likely to complete treatment than women not receiving these services. Women with children in foster care had similar levels of psychological, employment, and drug and alcohol concerns as other women, as measured by the Addiction Severity Index. Future research should focus on identifying strategies that enhance retention rates of these vulnerable women. Implications for improving treatment retention are discussed in light of the Adoption and Safe Families Act of 1997 and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

Lewis MW. Relationship of prior custody loss to maternal-fetal bonding in a subsequent pregnancy. Children and Youth Services Review 28(10): 1169-1180, 2006. (48 refs.)

Maternal-fetal bonding is the emotional investment a woman has for her fetus and is the foundation for nurturance and protection. Effects of prior custody loss on bonding during a subsequent pregnancy have received scant attention but may resemble other reproductive losses. This study compares the strength of the maternal-fetal bond among women grouped according to lifetime history of custody loss. Sixty-seven pregnant women with a history of giving birth were assigned to either a Loss (13.4%) or Non-Loss (86.6%) group. They were administered a demographic questionnaire and standardized measures of maternal-fetal bonding, substance use, perceived social support, depressive symptoms, and economic status. The Loss group endorsed more pregnancies, more abortions, living with fewer children, less social support, and illicit drug use during the third trimester. The Loss group endorsed a stronger maternal-fetal bond compared to women in Non-Loss group. Multivariate analyses were exploratory due to the small sample size but suggest that pregnant women who have experienced one custody loss may differ from those who have experienced multiple custody losses. Future research with a larger sample is needed to examine the direction of the relationship between prior custody loss and maternal bonding to a subsequent fetus.

Linares LO. Substance-abusing mothers in the child welfare system. Women's Health Issues 8(4): 254-260, 1998. (9 refs.)

Federal demonstration programs funded by the Center for Substance Abuse Prevention (CSAP) have been aimed at preventing and/or treating alcohol, tobacco, and other drug (ATOD) use in pregnant women and women of childbearing age. The programs described in this article support women's development in various adult roles, one of which is childbearing. The ability of women to bear children is often one way in which ATOD-using women develop a connection to mainstream society and exert some control over their lives. That is, childbearing often serves to define a woman's role in a world that is otherwise disempowering. As one woman who had borne eight children by age 26 said: "As long as you take my babies away, I will keep having them."

Linares TJ; Singer LT; Kirchner HL; Short EJ; Min MO; Hussey P et al. Mental health outcomes of cocaine-exposed children at 6 years of age. Journal of Pediatric Psychology 31(1): 85-97, 2006. (59 refs.)

OBJECTIVE: To assess 6-year-old cocaine- and noncocaine-exposed children's mental health outcomes controlling for potential confounders. METHODS: The sample consisted of 322 children [169 cocaine exposed (CE) and 153 noncocaine exposed (NCE)] enrolled in a longitudinal study since birth. At age 6, children were assessed for mental health symptoms using the Dominic Interactive (DI), a child self-report measure, and the Child Behavior Checklist (CBCL), a caregiver report of behavioral problems. RESULTS: CE children were more likely to self-report symptoms in the probable clinical range for oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). In contrast, prenatal cocaine exposure was not related to child behavior based on the CBCL. After control for exposure, CE children in adoptive or foster care were rated as having more problems with aggression, externalizing behaviors, and total behavioral problems than NCE children and CE children in maternal or relative care. Also, CE children in adoptive or foster care self-reported more externalizing symptoms than CE children in maternal or relative care and NCE children. Findings could not be attributed to caregiver intelligence or depressive symptoms, or to the quality of the home environment. CONCLUSIONS: CE children report more symptoms of ODD and ADHD than nonexposed children. Adoptive or foster caregivers rated their CE children as having more behavioral problems than did maternal or relative caregivers of CE children or parents of NCE children. Although further studies are needed to understand the basis for the more negative ratings by adoptive or foster caregivers of their CE children, the self-report of CE children indicates a need for psychological interventions.

Littell JH; Girvin H. Correlates of problem recognition and intentions to change among caregivers of abused and neglected children. Child Abuse & Neglect 30(12): 1381-1399, 2006. (52 refs.)

Objective: To identify individual, family, and caseworker characteristics associated with problem recognition and intentions to change in a sample of caregivers who received in-home child welfare services following substantiated reports of child abuse or neglect. Methods: Caregivers were interviewed at 4 weeks, 16 weeks, and 1 year after referral for in-home services. In these interviews, the University of Rhode Island Change Assessment scale assessed problem recognition and ITC in relation to caregiving practices. Additional data were obtained from administrative records and surveys of in-home services caseworkers. We used growth models to identify caregiver, family, and caseworker characteristics associated with initial levels of problem recognition and intentions to change, and with changes in problem recognition and intentions to change over time. Results: Contrary to expectations, there were no overall increases in problem recognition and intentions to change during the first 4 months of in-home services. Problem recognition and intentions to change scores fluctuated over time, in relation to some external events, case characteristics, and caseworker characteristics; however, we were able to account for small portions of the variance in problem recognition and intentions to change. Controlling for social desirability bias and other variables in the analysis, negative life events, lack of network support, and the severity of caregiver depression were associated with greater PR; housing problems were associated with lower problem recognition. Caregiver depression and age were associated withintentions to change. Caregivers whose children had been removed from their homes showed significant increases in intentions to change in the first few months of in-home services. The duration of caseworkers' child welfare experience predicted increases in their clients' problem recognition in the first 4 months and more frequent contacts with an experienced caseworker predicted small, but significant increases in intentions to change over time. Conclusions: Problem recognition and intentions to change are associated with somewhat different case characteristics and may be affected by caseworkers' experience.

Lloyd C. Risk factors for problem drug use: Identifying vulnerable groups. Drugs: Education, Prevention and Policy 5(3): 217-232, 1998. (83 refs.)

There has been a growing interest in the risk factors associated with the onset of problem drug use -- as distinct from the onset of experimental use. This paper reviews research that has focused on these factors. The literature is divided into retrospective studies of problem users and prospective, longitudinal studies of young people. Risk factors include having parents or siblings with problem drug use, family disruption, poor attachment or communication with parents; child abuse, low school grades, truancy, exclusion from school, childhood conduct disorder, clime, mental disorder (in particular depression and suicidal behaviour during adolescence), social deprivation (although evidence is limited) and a young age of drug use onset. These factors are highly interconnected and best viewed as an interactive, 'web of causation'. On the basis of these findings it is possible to identify high risk or vulnerable groups -- the homeless, those 'looked after' by local authorities or in foster care; prostitutes, truants, those excluded from school, young offenders, children from families with substance-abusing parents or siblings and young people with conduct or depressive a disorders. While delivering successful preventive interventions to these groups will be a difficult challenge, they should be a focus for future work. A key issue held is the need to embed a drugs input within the work already delivered by the responsible agencies. Future research should concentrate or the prevalence and nature of drug use ill these groups, but there is also a need for longitudinal studies that can throw more light on the development of drug careers ill the UK.

MacMahon JR. Perinatal substance abuse: The impact of reporting infants to child protective services. Pediatrics 100(5): E11-E19, 1997. (56 refs.)

Objective. The purposes of this study were to follow the judicial placement of newborns with positive toxicology screening results and to determine how long such infants remained in foster care, separated from their mothers or other relatives, and the length of court dependency. We also determined the mothers' compliance with court orders, the availability and use of rehabilitative services, factors used by the court to determine the final disposition, and the eventual placement of the infants. Methods. The cohort sample consisted of all infants from San Mateo County (CA) born at Stanford University Hospital during a 2-year period whose urine tests in the well-baby nursery were positive for illicit substances. Fifty-three newborns were identified, and their medical records and court documents were matched and reviewed from birth until termination of judicial review (or 5 years). Data were summarized and analyzed by logistic regressions to identify predictors of specific outcomes. Results. All 53 infants had normal physical examinations and uneventful hospital courses. Their ethnic distribution, with 68% being African-American and 7% being Hispanic, differed from the rest of the nursery population, which was predominantly Hispanic. Twenty-six (46%) of the 53 infants were returned to their mothers within 1 week of birth; 39 (76%) of the infants were reunited with some relative within the first month of life. At 12 months of age, 10 infants (19%) remained in foster care; however, none remained in foster care beyond 18 months. The length of time infants were dependents of the court ranged from 1 month to >5 years; 70% of the cases were "closed" between 6 and 30 months of life. Nine (17%) were dependents of the court for >36 months. Final placement of the infants was 35 (66%) reunited with at least one parent, 9 (17%) in long-term guardianship relationships with other relatives, and 9 (17%) adopted. All of the mothers were ordered to complete a drug rehabilitation program; 24 mothers (44%) fully complied and had repeatedly drug-free urine tests; 2 others (4%) had drug-free urine tests after incomplete participation in drug rehabilitation. Twenty-two (42%) of the mothers never complied with drug rehabilitation. Subsequent drug use was evident in less than half of the mothers during the period of study. Only one mother was reported for child abuse. Characteristics that most strongly predicted failure in family reunification were a history of failed drug rehabilitation, previous involvement of Child Protective Services, or previous removal of a child because of substance abuse. Conclusion. Identifying and reporting newborns exposed to maternal substance abuse during pregnancy can be associated with beneficial changes in the environment of the infants and successful rehabilitation of many mothers. The use of judicial supervision, rehabilitative and supportive services, and long-term involvement of social services without criminal prosecution are key to successful outcome. This study supports the policy and recommendation of the American Academy of Pediatrics and should lessen health professionals' concerns about negative effects of reporting these patients to Child Protective Services.

Magura S; Laudet A; Kang SY; Whitney SA. Effectiveness of comprehensive services for crack-dependent mothers with newborns and young children. Journal of Psychoactive Drugs 31(4): 321-338, 1999. (78 refs.)

This article presents an outcome study of the Family Rehabilitation Program (FRP), a unique network of community-based programs in New York City that provides comprehensive services to families with drug-dependent parents, most caring for prenatally cocaine-exposed newborns. An admission sample of 173 mothers in 17 FRP sites was studied for one year; substance use was assessed by hair analysis and self-report. Mean length of retention was 10 months; half the clients were still active in the program at follow-up. Mothers completing or still active in FRP had higher rates of abstinence and substantially lower average levels of cocaine in their hair at follow-up than those exiting prematurely. The percent of families with children out of their homes did not increase significantly between admission and follow-up, and completing or remaining active in the program were associated with less out-of-home placement at follow-up.

Maluccio AN; Ainsworth F. Drug use by parents: A challenge for family reunification practice. Children and Youth Services Review 25(7): 511-533, 2003. (56 refs.)

Family reunification practice has been a cornerstone of child welfare services for the last decade or more. This practice is now challenged by a significant rise in the number of children entering out-of-home care due to abuse and neglect associated with parental drug use. These parents present a special problem for agencies in relation to reunification. Is it possible to ensure a child's safety and future development if reunification is pursued where parental drug use is ongoing? This article does three things. First, it cites the evidence about the incidence of drug use by parents of children in care. Second, it reviews the recent family reunification research and in so doing confirms the importance of family reunification efforts. Third, it proposes a three-stage model of enhanced reunification practice for use with parents to test the viability of reunification in situations where drug use remains an issue.

Marshall MF; Menikoff J; Paltrow LM. Perinatal substance abuse and human subjects research: Are privacy protections adequate? (review). Mental Retardation and Developmental Disabilities Research Reviews 9(1): 54-59, 2003. (9 refs.)

Privacy incursions in the clinical care of substance abusing pregnant women have gained lay and professional attention recently as the result of a high-profile Supreme Court finding in Ferguson vs City of Charleston et al. In March, 2001 the Supreme Court determined that nonconsensual drug screening of pregnant women by clinicians in a public hospital violated the women's Fourth Amendment rights to be secure against unreasonable search and seizure. Coercive or punitive policy approaches to perinatal substance abuse are often based on mistaken assumptions about the nature of addiction and the outcomes of punitive interventions. Much attention has been given to efforts to criminalize pregnancy for drug using women, and civil laws are also coming under increasing scrutiny. Although no state has passed a law criminalizing pregnancy and drug use, an estimated 250 women in more than 30 states have been prosecuted around the country on theories of "fetal abuse." A growing number of states (eighteen to date) have amended their civil child welfare laws to address specifically the subject of a woman's drug use during pregnancy. No one has examined how these laws and social policies could affect research that includes pregnant and parenting women; women (and their families) who stand to lose a great deal should their drug use be brought to the attention of child welfare or criminal justice authorities. We examine the adequacy of current protective mechanisms, such as federal certificates of confidentiality, in protecting research subjects (and investigators) who may be subject to punitive civil or criminal sanctions. We determine that current protective mechanisms may be insufficient to protect research subjects and that investigators and IRB members are often ignorant of the risks imposed by punitive policy approaches to perinatal substance abuse or fall prey to the same mistaken assumptions that inform punitive policies. We conclude that investigators and IRB members have a moral responsibility to understand local, state and national policies and laws governing perinatal substance abuse. Investigators and IRB members should balance the harms of punitive interventions against the protections that may, or may not be afforded to prospective research subjects as well as the prospective benefits, individual and social, of the research. In situations where criminal or punitive policies are in effect, investigators and IRB members should consider whether adequate protections can be achieved. In the context of inadequate protections, potential risks to prospective research subjects and their families may outweigh the individual or. social benefits that accrue from the research. Clinical researchers are professionally obligated to work toward amending laws and policies that 4, are not in. the best interests of prospective research subjects.

Mason S. Custody planning with HIV-affected families: Considerations for child welfare workers. Child Welfare 77(2): 161-177, 1998. (29 refs.)

Most of the literature on permanency planning is based on the assumption that HIV-infected parents have custody of their children. A growing number of children entering child protective services, however, have an HIV-infected parent. Whether reunification or adoption is the permanency goal, these parents are concerned about their children's future after the parents' death. This article is drawn from research on custody planning with HIV-infected parents, from clinical literature and experience, and from a training curriculum for child welfare workers developed and implemented by the author. The lessons learned about custody planning with HIV-involved families are applied to practice with families who are involved with the state because of abuse or neglect of their children.

McNichol T; Tash C. Parental substance abuse and the development of children in family foster care. Child Welfare 80(2): 239-256, 2001. (15 refs.)

To determine the impact of parental substance abuse on children, the cognitive skills and behavior ratings of 268 school-age children placed in family foster care were examined. As a group, the children in family foster care presented with low average cognitive skills and made significant improvement in cognitive functioning during placement. The children with prenatal exposure to drugs scored significantly lower in cognitive skills at the beginning of placement but made significantly more progress than the other children during placement. Behavior ratings by the foster parents and teachers revealed that 29% of the children had scores in the significant range, and the children exposed prenatally to drugs had a higher incidence of behavior problems at school compared to family foster care peers. Recommendations for further study of these factors and for enhancing outcomes for children in care are provided.

McWey LM; Henderson TL; Alexander JB. Parental rights and the foster care system: A glimpse of decision making in Virginia. Journal of Family Issues 29(8): 1031-1050, 2008. (19 refs.)

Using ecological theory and a mixed-methods approach, the authors examined family-court interactions for foster care decisions made in Virginia across three policy periods: 1980 to 1993, 1994 to 1997, and 1997 to present (9N = 95). For the first and last policy periods, quantitative analyses revealed significant differences in the rates at which parental rights were terminated. Differences also existed in termination rates for parents with mental health issues and limited IQs but not for parents with substance abuse issues or those with special-needs children. The best-interests-of-the-child standard and clear and convincing evidence were the primary legal principles used to determine whether to terminate parental rights or to reunify families. Suggestions were made to enhance the understanding of family professionals.

Miller KA; Fisher PA; Fetrow B; Jordan K. Trouble on the journey home: Reunification failures in foster care. Children and Youth Services Review 28(3): 260-274, 2006. (26 refs.)

We examined postreunification variables regarding parent characteristics, child characteristics, parent service utilization, child service utilization, family environment, and neighborhood environment as they relate to reunification failure. The sample for the study included foster children who, at reunification with their birth parents, ranged in age from 4-7 years. All participants were reunified with at least one parent. Among the variables found to significantly differentiate between failed and successful reunifications were parental utilization of substance abuse treatment, child utilization of special educational services, child utilization of individual, family, or group therapy, overall parenting skill level, appropriate use of discipline, and quality of neighborhood. We discuss the implications of these results for policies aimed at increasing the success rate of reunifications following foster care.

Minatrea NB. Early childhood antecedents in 10-to-19-year-old females abusing alcohol. Dissertation Abstracts International 57(7): 2881-A, 1997

Five early childhood antecedents which may later lead to the development of alcohol abuse in females were measured in this study. One hundred and fourteen females between the ages of 10 and 19, residing in five large residential group homes throughout South Carolina, comprised the sample for this study. Because the young women were not living with either parent or other family members, and had experienced early childhood traumas, they were, and are considered "at risk" and are of concern, to health-care providers. In an effort to increase the body of knowledge relating to the etiology of alcohol abuse for young women, this study assesses the probabilities of five early childhood antecedents to the prediction of later development of alcohol abuse in 10-to-19-year-old-females living in group home environments.

Moe V. Foster-placed and adopted children exposed in utero to opiates and other substances: Prediction and outcome at four and a half years. Journal of Developmental and Behavioral Pediatrics 23(5): 330-339, 2002. (54 refs.)

This article presents a Norwegian prospective, longitudinal study of children prenatally exposed to opiates and other substances under conditions of minimal postnatal social risk. Outcome at 4 1/2 years of age is presented. The study reports on the prediction of later intellectual performance, on the basis of the children's prenatal, perinatal, and early developmental status, as well as the foster or adoptive parents' socioeconomic level. Significant differences were found between the substance-exposed group and the comparison group on the Bayley Scales at age 1 year and on the McCarthy Scales at age 4 1/2 years. The findings showed that although the mean cognitive scores were within normal limits at age 4 1/2 years, a special weakness in the area of visual-motor and perceptual abilities was detected among the substance-exposed children. It is indicated that these areas of performance are especially sensitive to the effect of prenatal adversity. A special vulnerability among the substance- exposed boys, detected at an earlier age, persisted at 4 1/2 years. The study indicates that even if children experience adequate caregiving, the accumulation of biomedical risk factors associated with prenatal substance exposure is still a potential determinant of developmental problems, especially in the area of perceptual-performance functions. The study also hints at differential influences of biomedical and environmental variables on outcome at age 4 1/2 years.

Morehouse E; Tobler NS. Preventing and reducing substance use among institutionalized adolescents. Adolescence 35(137): 1-28, 2000. (36 refs.)

The Residential Student Assistance Program, serving high-risk, multiproblem, inner-city, primarily African-American and Latino youth, was evaluated for its ability to prevent and decrease alcohol and other drug use. Participants were drawn from several adolescent residential facilities: three foster care sites for abused, neglected, orphaned, or troubled adolescents, a nonsecure facility for adjudicated juvenile offenders, a treatment center for teens with severe psychiatric problems, and a locked county correctional facility. In addition, comparison groups were employed. A 5th-year outcome evaluation documented the program's effectiveness in both preventing and reducing substance use among participants, with impact related to program dosage. Qualitative process data clarified and strengthened confidence in the quantitative outcomes.

Nair P; Black MM; Schuler M; Keane V; Snow L; Rigney BA; Magder L. Risk factors for disruption in primary caregiving among infants of substance abusing women. Child Abuse & Neglect 21(11): 1039-1051, 1997. (52 refs.)

Objective: To identify perinatal factors that are predictive of disruption in primary caregiving among infants of substance abusing women. Method: A randomized longitudinal cohort study. One hundred and fifty two mother/infant dyads were assessed for evidence of disruption of primary care-giving or neglect during the first 18 months of life, defined by mother's inability to provide care. Data analyzed included neonatal characteristics, urine toxicology at delivery, maternal history of drug use, maternal depression, social support, and social and health history. Results: Sixty-six infants (43.4%) had disruption in their primary care during the first 18 months of their life, 86 infants (56.6%) remained in the care of their mothers. Women who were younger, were heroin users, had two or more children, had other children in foster care, and reported depressive symptoms were least likely to provide ongoing primary care for their infant. Conclusions: Although all infants born to substance abusing women are at a high risk for disruption in the continuity of their primary care-giving, maternal demographic and psychosocial factors present at delivery can predict which infants are likely to experience an early disruption in their primary care-giving. Identifying these families can enable health care providers to monitor them more closely and, when appropriate, encourage support from the extended family.

Ondersma SJ; Malcoe LH; Simpson SM. Child protective services' response to prenatal drug exposure: Results from a nationwide survey. Child Abuse & Neglect 25(5): 657-668, 2001. (12 refs.)

OBJECTIVE: This survey was conducted to: (1) document child protective services (CPS) agencies' actual practices regarding prenatal drug exposure; (2) examine urban and rural differences in CPS responses; (3) explore whether CPS practices varied as a function of county median income, birth rate, population size, or percent minority births; and (4) assess respondent satisfaction with their county's current responses. METHOD: Data were collected via a nationwide telephone survey of child welfare supervisors from two urban and two rural counties in every state (N = 200). RESULTS: Ninety percent of counties (100% of urban and 80% of rural) reported receiving referrals of infants with prenatal drug exposure. Among those receiving referrals, extreme variations in practice were found; all possible response options (from very inactive to very aggressive) were equally represented on key questions (e.g., filing court petitions, taking custody). Rural counties tended to have stronger responses than urban counties (t[175] = -2.26, p = .024). County response did not vary with county-level median family income, percent minority births, or birth rate. Despite wide variations in practice, the majority of respondents (69%) felt their county's response was appropriate. Of respondents who did indicate that their county's response was inappropriate, most (85%) felt that the county needed to do more to protect children. CONCLUSIONS: There is currently tremendous variation across US counties in CPS responses to, and beliefs regarding, the issue of prenatal drug exposure. Some of this variation is due to differences between urban and rural counties, with little variation explained by differences in median income or percent minority births at the county level. There is a need for research-based guidance and consensus building in CPS practice in this area.

Pearson J; Thoennes N. What happens to pregnant substance-abusers and their babies? Juvenile & Family Court Journal 47(2): 15-28, 1996

This is a report of a research project that selected jurisdictions with different types of laws and policies and collected information on how a sample of actual cases involving drug-affected infants had been handled in the setting. From this the authors draw conclusions about the types of voluntary and coercive intervention by courts, child welfare agencies, criminal justice agencies, and treatment programs that are associated with the most positive outcomes. The jurisdictions included regard substance abuse in a variety of ways, from public health issue to criminal matter requiring prosecution. The authors have generated a portrait of substance abusers and their experiences. They conclude that (a) maternal substance abusers are extremely poor and suffer many dysfunctions. (b) If the women had prior births they are often known to child protection agencies, and a sizable proportion have older children in the care of relative or foster care. (c) Maternal substance abusers tend to be heavy crack/cocaine users with a long history of drug use, some having delivered a previous drug-exposed infant. Medical personnel usually are the ones to flag prenatal and immediate post-partum substance abuse problems. (e) The proportion of cases reported to child protective services varies widely and varies for risk factors, ranging from 56% to 100% of cases. (f) Sites viewing substance abuse as a public health problem have a higher level of supportive services provided. (g) The majority of infants are sent home with the mothers without restrictions. (h) Of cases reported to child protective services, from 34% to 45% involve placement of the child; maternal race, ethnicity and marital state do not appear to influence the decision. (i) Sites differed with respect to the scale and nature of drug treatment provided. (j) Even where authorized civil commitment is extremely rare. (k) In respect to treatment outcome, recovery eluded most women, but many reduced their drug use. (l) Prenatal interventions enhance outcome minimizing the need for placement or leading to shorter placements stays. The report concludes with a discussion and recommendations for policy.

Petras DD; Massat CR; Essex EL. Overcoming hopelessness and social isolation: The ENGAGE model for working with neglecting families toward permanence. Child Welfare 81(2): 225-248, 2001. (48 refs.)

The Adoption and Safe Families Act of 1997 (ASFA) mandates policies designed to increase the frequency and speed with which permanency is achieved for children in the child welfare system. ASFA's focus is on child safety permanency, and well-being. The expectation that parents correct neglectful conditions within specified time frames places an increased ethical responsibility on child welfare staff. Carrying out this responsibility requires vigorous and innovative approaches to engaging and working with neglectful families. Drawing on a well- established conceptual framework for understanding the determinants of effective parenting, the authors derive the ENGAGE (Engagement, Needs assessment, Goal setting, Assessment of progress, Goal achievement, Ending work) model for achieving permanency within the policy structure. The model incorporates creative client engagement, assessment of family needs, mutual goal setting, the goal achievement process, termination, and aftercare.

Phelps L; Cottone JW. Long-term developmental outcomes of prenatal cocaine exposure. Journal of Psychoeducational Assessment 17(4): 343-353, 1999. (30 refs.)

The developmental outcomes of prenatal cocaine/polydrug exposure were evaluated using a multivariate research design that controlled for the possible confounding variables of age, sex, socioeconomic status, ethnicity, and caregiver status (i.e., biological parent, relative, foster care, and adoptive parent) using an exposed (n = 41) and nonexposed (n = 35) cohort of preschool children (mean age = 4.25). Results indicated that in utero drug exposure had no effect on cognitive, social, Language, and behavioral developmental outcomes as measured by the Stanford-Binet Intelligence Scale: 4th ed., the Social Skills Rating System, the Preschool Language Scale: 3rd ed., the Child Behavior Checklist, and the Vineland Adaptive Behavior Scale-Survey Form.

Pilowsky DJ; Lyles CM; Cross SI; Celentano D; Nelson KE; Vlahov D. Characteristics of injection drug using parents who retain their children. Drug and Alcohol Dependence 61(2): 113-122, 2000. (12 refs.)

While it is known that injection drug users (IDUs) often have their children removed or place them voluntarily, little is known about factors associated with whether IDU parents live with their children. We identified a community sample of 391 IDU parents with at least one child under age 14 (index IDU parents). For these IDU parents, 62% did not have any of their children under age 14 living with them. We assessed whether certain health factors, risk related behaviors, social indicators, and active drug use were related to whether children of IDUs were living with the index IDU parent. IDU parents who were living with their children were overwhelmingly more likely to be female, more likely to have health insurance, and engage in no- risk or low-risk drug practices, as compared to moderate/high-risk practices. Additionally, HIV negative and HIV positive asymptomatic parents were about three times more likely to be living with their children than HIV positive parents with clinical symptoms commonly seen among those suffering from HIV-related illnesses. HIV-related clinical symptoms, rather than HIV status per se, seem to be associated with retention of children.

Pilowsky DJ; Wu LT. Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care. Journal of Adolescent Health 38(4): 351-358, 2006. (40 refs.)

Purpose: To ascertain the prevalence of psychiatric symptoms and substance use disorders among adolescents with a lifetime history of foster care placement, using data from a nationally representative sample of U.S. adolescents. Methods: We studied adolescents aged 12-17 years in the public use file of the 2000 National Household on Drug Abuse (n = 19,430, including 464 adolescents with history of foster care placement). Psychiatric symptoms and substance use disorders were ascertained through direct interviewing of adolescents. Logistic regression analyses were used to estimate the odds of past-year psychiatric symptoms and substance use disorders among adolescents involved with foster care. as compared to those without a lifetime history of foster care placement (comparison croup). Results: Adolescents involved with foster care had more past-year psychiatric symptoms, and especially more conduct symptoms, and past-year substance use disorders than those never placed in foster care. Adolescents involved with foster care were about four times more likely to have attempted suicide in the preceding 12 months (adjusted odds ratio [AOR] 3.95; 95% confidence interval [CI] 2.78, 5.61), and about five times more likely to receive a drug dependence diagnosis in the same period (AOR 4.81; 95% CI 3.22, 7.18). Conclusions: Adolescents involved with foster care have a higher prevalence of psychiatric symptoms and drug use disorders than those never placed in foster care. Additionally, the results of this study suggest that they may be at elevated risk for suicide attempts.

Potocky M; McDonald TP. Evaluating the effectiveness of family preservation services for the families of drug-exposed infants: A pilot study. Research on Social Work Practice 6(4): 524-535, 1996. (12 refs.)

Twenty-seven families of drug exposed infants were followed during their participation in a community-based program designed to enhance child well-being and prevent out-of-home placement. The program consisted of multiple components including social work home visits, nursing services, early childhood education, support groups, and parent/child interaction groups. Results indicated that the program was particularly successful. In particular, participation in the support groups and the parent-child interaction groups were associated with successful placement outcome. The implications for social work practice are discussed in light of the parents' own perception of the program.

Risley-Curtiss C; Stromwall LK; Hunt DT; Teska J. Identifying and reducing barriers to reunification for seriously mentally ill parents involved in child welfare cases. Families in Society 85(1): 107-118, 2004. (52 refs.)

Forming judgments about parenting capacity, a necessary part of permanency planning, is much more difficult when the parent has a serious mental illness. The time necessary for effective treatment for such parents is often longer than the court-ordered time limit for family reunification. This puts mentally ill parents at a distinct disadvantage in their efforts to preserve their families. Using Arizona as an example, this article discusses the barriers in both child welfare and mental health systems to accurate and effective assessment and treatment. It presents recommendations for research and suggestions for child welfare personnel to enhance the potential for mentally ill parents to reunify with their children.

Rullo-Cooney D. Motivational interviewing: Changing substance abusers in intensive family preservation settings. Crisis Intervention 2(2): 147-158, 1996. (28 refs.)

Intensive Family Preservation Services (IFPS) has expanded throughout the country to prevent the unnecessary placement of children outside their homes. IFPS programs teach new skills to family members, encouraging behavior change. Problematic substance use in adults war not targeted as a goal for change, in families involved with Intensive Family Preservation Services. Now, IFPS workers can incorporate their skills to help family members with problematic substance use. Motivational Interviewing is an intervention process that increases awareness of the effects of substance use on the family system. In addition Motivational Interviewing increases the substance user's motivation to change the problematic drinking and drug behavior. Intensive Family Preservation Services workers have the skills to incorporate Motivational Interviewing into the crisis intervention process to reduce the risk of children being placed outside the home.

Sagatun-Edwards I; Saylor C. A coordinated approach to improving outcomes for substance-abusing families in juvenile dependency court. Juvenile & Family Court Journal 51(4): 1-16, 2000. (28 refs.)

This paper describes a coordinated approach to providing enhanced services for substance-abusing families in the juvenile dependency court, The enhanced services consisted of on interagency collaborative model including the Department of Social Services, Court Appointed Special Advocates, Public Health Nurses, and Family Support Specialists. The purpose of the intervention was to increase the likelihood of family reunification. Families were randomly assigned to either the enhanced services (N=48) or to a regular services group (N=41). Variables included social background factors, data related to court hearings and court orders, and final court outcomes regarding placement and custody Significant factors predicting final placement of the child were completion of court ordered programs, a stable home, and mothers' cooperation and motivation. Families who received the enhanced services had significantly higher rates of reunification of children with parents.

Scott LD Jr; Munson MR; McMillen JC; Ollie MT (1). Religious involvement and its association to risk behaviors among older youth in foster care. American Journal of Community Psychology 38(3/4): 223-236, 2006. (61 refs.)

This study examined religious involvement and its association to risk behaviors (sexual behavior, marijuana use, alcohol use, and cigarette use) among older youth in foster care (N = 383). Three dimensions of religious involvement were assessed--church or religious service attendance, religious practices, and religious beliefs. Findings showed that gender, ethnic group membership, sexual abuse history, and placement type were significantly associated with older foster care youth's religious involvement. Hierarchical logistic regression analyses showed that religious service attendance was associated with reduced odds of youth's engagement in sexual behavior in the past 2 months and current use of cigarettes. In addition, greater religious beliefs were associated with a reduction in odds of youth's use of alcohol in the past 6 months and current use of cigarettes. The consideration of religious involvement as a positive influence and resource that may reduce unhealthy risk behaviors among older youth in foster care is discussed.

Scott LD; Munson MR; McMillen JC; Ollie MT. Religious involvement and its association to risk behaviors among older youth in foster care. American Journal of Community Psychology 38(3-4): 223-236, 2006. (61 refs.)

This study examined religious involvement and its association to risk behaviors (sexual behavior, marijuana use, alcohol use, and cigarette use) among older youth in foster care (N=383). Three dimensions of religious involvement were assessed-church or religious service attendance, religious practices, and religious beliefs. Findings showed that gender, ethnic group membership, sexual abuse history, and placement type were significantly associated with older foster care youth's religious involvement. Hierarchical logistic regression analyses showed that religious service attendance was associated with reduced odds of youth's engagement in sexual behavior in the past 2 months and current use of cigarettes. In addition, greater religious beliefs were associated with a reduction in odds of youth's use of alcohol in the past 6 months and current use of cigarettes. The consideration of religious involvement as a positive influence and resource that may reduce unhealthy risk behaviors among older youth in foster care is discussed.

2006, Springer

Scott-Lennox J; Rose R; Bohlig A; Lennox R. The impact of women's family status on completion of substance abuse treatment. Journal of Behavioral Health Services & Research 27(4): 366-379, 2000. (24 refs.)

This study examines the role of family status and demographic characteristics in explaining the nearly 60% dropout rate for women in substance abuse treatment. Data from the administrative record files of the Illinois Office of Alcoholism and Substance Abuse (OASA) for the fiscal rear 1996-97 were analyzed for women age 12 or older who completed intake for publicly funded substance abuse treatment and whose outpatient treatment records were closed at year-end. Multivariate logistic regression models found that the likelihood of not completing treatment was greatest for women who were African American pregnant, had custody of minor children, or were younger than age 21. However African American women who had children in foster care were more likely to complete treatment. Implications for treatment and research are discussed.

Seale JP; Shellenberger S; Spence J. Alcohol problems in Alaska Natives: Lessons from the Inuit. American Indian and Alaska Native Mental Health Research 13(1): 1-31, 2006. (75 refs.)

In this Alaska Native study, cultural "insiders" analyzed problems associated with increased alcohol availability, factors which have reduced alcohol-related problems, and ideas for improving treatment in an Inuit community. Participants described frequent bingeing, blackouts, family violence, suicide, loss of child custody, and feelings of intergenerational grief. Helpful existing treatment approaches include alcohol ordinances, inpatient treatment programs, twelve-step groups, and religious involvement. Participants urged the development of family treatment approaches which integrate Inuit customs and values.

Simmel C; Brooks D; Barth RP; Hinshaw SP. Externalizing symptomatology among adoptive youth: Prevalence and preadoption risk factors. Journal of Abnormal Child Psychology 29(1): 57-69, 2001. (56 refs.)

The extent of symptomatology related to attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) was examined in a statewide sample of adopted youth, aged 4-18 years (n = 808). The use of normed questionnaires in a nonclinical sample decreased biases associated with past research on adopted children. According to parental report, a striking number of the youth qualified as manifesting significant symptom levels of externalizing behavior problems: 21% met symptom cutoffs for ADHD (with or without ODD) and 20% met criteria for ODD (with or without ADHD), for a combined total of 29% of the sample. A number of parent-reported, preadoptive risk factors distinguished these groups from one another and from the nonexternalizing youth. The clearest associated factors included histories of preadoption abuse/neglect, later age of adoption, prenatal drug exposure, and placement in multiple foster homes prior to adoption. We discuss implications regarding both etiology and current controversies surrounding the disproportionate levels of behavioral difficulties in adopted youth.

Slesnick N; Meade M. System youth: A subgroup of substance-abusing homeless adolescents. Journal of Substance Abuse 13(3): 367-384, 2001. (78 refs.)

Purpose: While many youths residing at homeless shelters will return home, many are placed in group or foster homes. Few researchers have examined the experiences of adolescents with a history of these out-of-home placements. This study examined shelter residents and compared the experiences of system and non-system youth. Methods: Information regarding youths' family functioning, substance use, depression and related problem behaviors was obtained from substance abusing system (n = 62) and non-system (n = 82) adolescents staying at local runaway shelters. Results: System males engaged in significantly more delinquent behaviors than did non-system males and system females. Alcohol and drug problem consequences were positively associated with longevity in the system, while having ever attempted suicide was negatively associated with system longevity. System youth reported: 1) taking more prescribed psychotropic medications 2) experiencing more sexual abuse, and 3) less parental overprotection, as compared to non-system youth. Gender differences were found in which females reported more conflictual problem solving interactions with their parents than did males, as well as more comorbid diagnoses. Implications: Although longitudinal research is needed, findings argue that without intervention efforts targeted at identified problem behaviors, youth are at risk to continue their system involvement into adulthood.

Smith BD; Testa MF. The risk of subsequent maltreatment allegations in families with substance-exposed infants. Child Abuse & Neglect 26(1): 97-114, 2002. (22 refs.)

Objective: This study seeks to: (1) assess the relationship between identified prenatal substance use and the risk of subsequent maltreatment allegations among families involved with child protective services; and (2) compare the types of safety threats encountered by children whose parents had substance-exposed infant (SEI) allegations to the types of safety threats faced by children whose parents had other types of allegations. Method: Survey data from a probability sample of parents were linked to state administrative data over a 33-month time frame. Cox regression models were conducted to assess the relative risk of subsequent allegations associated with parents whose child welfare case opened following an SEI allegation (the SEI group) compared to parents whose case opened following other types of allegations. Results: The likelihood of subsequent allegations is greater among parents in the SEI group. However, the increased risk sterns almost entirely from subsequent SEI-related allegations. Parents in the SEI group are not more likely to incur other types of allegations such as physical abuse or lack of supervision. Conclusions: An increased risk of subsequent maltreatment has been used to justify opening child protective cases on the basis of an SEI allegation alone. By looking closely at the types of subsequent allegations as well as the incidence of subsequent allegations, this research helps to clarify the maltreatment risks associated with SEI cases.

Smith DK; Johnson AB; Pears KC; Fisher PA; DeGarmo DS. Child maltreatment and foster care: Unpacking the effects of prenatal and postnatal parental substance use. Child Maltreatment 12(2): 150-160, 2007. (71 refs.)

Parental substance use is a well-documented risk for children. However, little is known about specific effects of prenatal and postnatal substance use on child maltreatment and foster care placement transitions. In this study, the authors unpacked unique effects of (a) prenatal and postnatal parental alcohol and drug use and (b) material and paternal substance use as predictors of child maltreatment and foster care placement transitions in a sample of 117 maltreated foster care children. Models were tested with structural equation path modeling. Results indicated that prenatal maternal alcohol use predicted child maltreatment and that combined prenatal maternal alcohol and drug use predicted foster care placement transitions. Prenatal maternal alcohol and drug use also predicted postnatal paternal alcohol and drug use, which in turn predicted foster care placements. Findings highlight the potential integrative role that maternal and paternal substance use has on the risk for child maltreatment and foster care.

Street K; Whitlingum G; Gibson P; Cairns P; Ellis M. Is adequate parenting compatible with maternal drug use? A 5-year follow-up. Child Care Health and Development 34(2): 204-206, 2008. (2 refs.)

Introduction: This prospective, cohort study compares child protection outcomes over the first 5 years of life in a group of children born to self-declared drug-using mothers recruited during pregnancy (cases) and a group of children matched for gestational age, chronological age, maternal neighbourhood and place of delivery whose mothers made no such declaration of problematic drug use (controls). Methodology We monitored local child protection registers to identify cohort members who came to the attention of the local authority. Results Of the 71 original cases and 142 original controls, 55 (77%) and 96 (68%) remained in the area enrolled in local schools at 5 years of age. In total, 26 (47.3%) of the case children were subject to child protection procedures compared with 18 (18.8%) of the control children. This risk difference of 28.5% (95% CI 13.2% to 43.9%) has increased marginally since our previous report in this journal of child protection outcomes at 18 months of age (32% vs. 7%). However, the level of intervention deemed necessary to protect the child has increased significantly with six cases (compared with one control child) taken into the care of the local authority. Conclusions: Despite early maternal intentions and multiple supportive interventions, 27% of children born to women with significant substance abuse problems in our area required child protection during the pre-school years. Child protection risk assessment procedures need to weigh problematic maternal drug use heavily. Intervention studies with child welfare outcomes are needed to identify the most effective harm reduction strategies and inform public debate on how we can minimize child abuse related to substance misuse.

Suchman NE; McMahon TJ; Zhang HP; Mayes LC; Luthar S. Substance-abusing mothers and disruptions in child custody: An attachment perspective. Journal of Substance Abuse Treatment 30(3): 197-204, 2006. (33 refs.)

Using an attachment framework, we examined (1) whether substance-abusing mothers' perceptions of how they were patented were related to the severity of their substance abuse and psychological maladjustment and (2) whether these two factors mediated the association between mothers' perceptions of how they were parented and their children's placement out of home. There were 108 mothers of 248 children who completed interviews upon admission to a methadone maintenance program for women. Measures included lifetime risk composite scores derived from the Addiction Severity Index, the Parental Bonding Instrument, and a demographics questionnaire. A multilevel modeling approach was used to model effects of the hierarchically organized data (e.g., children nested within families). Findings are consistent with an attachment perspective on parenting suggesting that the internal psychological processes of a parent play a critical role in the continuity of parenting.

Taussig HN; Clyman RB; Landsverk J. Children who return home from foster care: A 6-year prospective study of behavioral health outcomes in adolescence. Pediatrics 108(1): U62-U68, 2001. (63 refs.)

Objective. Returning children to their biological families after placement in foster care (ie, reunification) has been prioritized with legislation. Comprehensive studies of child behavioral health functioning after reunification, however, have not been conducted. This study examined outcomes for youth who were reunified after placement in foster care as compared with youth who did not reunify. Design. Prospective cohort. Setting. Children who entered foster care in San Diego, California, and who remained in foster care for at least 5 months. Participants. A cohort of 149 ethnically diverse youth, 7 to 12 years old, who entered foster care between May 1990, and October 1991. Seventy-five percent of those interviewed at Time 1 were interviewed at Time 2 (6 years later). Outcome Measures. 1) Risk behaviors: delinquent, sexual, self- destructive, substance use, and total risk behaviors; 2) Life-course outcomes: pregnancy, tickets/arrests, suspensions, dropping out of school, and grades; 3) Current symptomatology: externalizing, internalizing, total behavior problems, and total competence. Results. Compared with youth who were not reunified, reunified youth showed more self-destructive behavior (0.15 vs -0.11), substance use (0.16 vs -0.11), and total risk behavior problem standardized scores (0.12 vs -0.09). Reunified youth were more likely to have received a ticket or have been arrested (49.2% vs 30.2%), to have dropped out of school (20.6% vs 9.4%), and to have received lower grades (6.5 vs 7.4). Reunified youth reported more current problems in internalizing behaviors (56.6 vs 53.0), and total behavior problems (59.5 vs 55.7), and lower total competence (41.1 vs 45.0). There were no statistically significant differences between the groups on delinquency, sexual behaviors, pregnancy, suspensions, or externalizing behaviors. Reunification status was a significant predictor of negative outcomes in 8 of the 9 regression equations after controlling for Time 1 behavior problems, age, and gender. Conclusions. These findings suggest that youth who reunify with their biological families after placement in foster care have more negative outcomes than youth who do not reunify. The implications of these findings for policy and practice are discussed.

Thompson RG; Auslander WF. Risk factors for alcohol and marijuana use among adolescents in foster care. Journal of Substance Abuse Treatment 32(1): 61-69, 2007. (39 refs.)

This study examined the influences of individual and social risk factors on alcohol and marijuana use among a sample of foster care adolescents. Data were collected through baseline structured interviews with 320 adolescents (aged 15-18 years) who resided in foster care placements and participated in a larger evaluation study of an independent living program. Approximately 40% of the adolescents reported alcohol use, 36% reported marijuana use, and 25% reported both alcohol and marijuana use during the 6 months prior to the interview. Final logistic regression models indicated that having friends who used marijuana and other substances and having skipped school remained most predictive of using alcohol, marijuana, or both alcohol and marijuana. Recommendations for substance abuse prevention and treatment for these vulnerable adolescents are proposed.

Topley J; Windsor D; Williams R. Behavioural, developmental and child protection outcomes following exposure to Class A drugs in pregnancy. Child Care, Health and Development 34(1): 71-76, 2008. (11 refs.)

Background: The long-term consequences of intrauterine exposure to Class A drugs are still relatively undocumented, and much of the literature relates to the North American experience, where cocaine use predominates. In Britain, heroin and amphetamine use is more common and, within Britain, patterns of drug use vary. Clearly the long-term educational and welfare needs of these children will be enhanced if the behavioural, developmental and child-care outcomes are known. This study attempts to explore some of these issues. Methods The developmental, behavioural and child protection outcomes in a group of 62 children exposed to Class A drugs in utero were investigated when the children were in full-time schooling. Results: Seventy-four per cent (46/62) of the children at the time of the study had no educational or behavioural problems, and 11 (17.7%) were receiving extra support in school. No child had a statement of special educational need. Twelve (19.3%) were reported to have behaviour and concentration problems, and in four cases, this was attributed to poor-quality parenting at the time of the study. Three of the 12 children had fetal alcohol syndrome. Twenty-six (42%) children were placed on the Child Protection Register, and care orders or residence orders were granted for 22 (35.5%) of those who were placed on the register. All of the 22 children went into substitute care at some stage. Of these children, nine were adopted and 10 were placed permanently with other family members. Ten of the 62 (16.1%) children at the time of the study were of concern to professionals for child protection reasons, and four of them were on the Child Protection Register. Conclusions: This study suggests we can be reasonably optimistic about the developmental and behavioural outcomes for children exposed to Class A drugs in utero. Over 50% required an intervention by social services, and 31% were in substitute care at the time of the study. There were continuing child protection concerns in 16% at school entry.

Toutain S; Lejeune C. Family management of infants with fetal alcohol syndrome or fetal alcohol spectrum disorders. Journal of Developmental and Physical Disabilities 20(5): 425-436, 2008. (26 refs.)

We studied the effects on family life of medical, social, and/or judiciary decisions taken when 28 infants born between 1995 and 2003 to alcohol-abusing mothers and diagnosed with fetal alcohol syndrome (FAS) or fetal alcohol spectrum disorders (FASD) were discharged from a neonatology hospital unit near Paris. Medical files of these infants and their mothers' obstetrical files (when available) were retrieved from the hospital database; data was then collected and analyzed retrospectively. Post-discharge familial settings were established using questionnaires or telephone interviews with their doctors or the staff of the institutions where they were fostered. The 28 mothers of these FAS/FASD children all came from underprivileged backgrounds, had chronic health problems and/or lived with alcohol abusers. The neonatology team has to decide, at discharge, whether the families can provide a 'good environment' for their babies, if not, they refer them to the courts. In any case, the mother/parents must obey certain rules (such as respecting follow-up appointments for example). These FAS/FASD infants usually came from dysfunctional families, and at hospital discharge, 18% of them were put in care, while the mothers could be given court-approved visiting rights. When the infants lived with their biological families, the mothers' marital situation usually deteriorated within 2 years. The mothers/parents often proved unable to look after their babies properly; this was reported to the courts, and their children put in care. Based on our results, we recommend that the current management of families with FAS/FASD children should be reviewed.

Tyler R; Howard J; Espinosa M; Doakes SS. Placement with substance-abusing mothers vs. placement with other relatives: Infant outcomes. Child Abuse & Neglect 21(4): 337-349, 1997. (37 refs.)

Evaluating a subset of participants from a larger research project concerning comprehensive drug treatment services for pregnant substance-abusing women and their offspring, this investigation compared those mothers who retained custody of their infants following delivery with those who lost custody and whose infants were placed in the care of other relatives. There were no differences between the groups with respect to maternal demographics, substance abuse (as assessed by self-report prenatally and urine toxicology screens at birth), or mental health status, or with respect to newborn characteristics (including gestational age, birthweight, medical risk status). Further, care giving behaviors of mothers and relative caregivers showed no significant differences at 6 months. Infants who remained in the care of their biological mothers, however, demonstrated better cognitive development than infants in the care of relatives at 6 months. There was also a discrepancy in terms of safety at 6 months, in that there were three deaths and two reported cases of suspected child abuse/neglect among infants in the care of their mothers, and no deaths and no reports of suspected abuse among infants in relative foster care.

U.S. Department of Health and Human Services. Blending Perspectives and Building Common Ground. A Report to Congress on Substance Abuse and Child Protection. Washington DC: Department of Health and Human Services, 1999. (156 refs.)

This report was developed jointly by the Administration for Children and Families, the Substance Abuse and Mental Health Services Administration, and the Office of the Assistant Secretary for Planning and Evaluation. With the implementation of the Adoption and Safe Families Act (ADFA PL 105-89) there has been renewed emphasis on achieving permanency for children in the child welfare system, and finding effective ways to address concurrent substance abuse and child maltreatment problems. This act has required the Secretary of Health and Human Services to prepare a report for congress on substance abuse and child protection describing (1) the extent of the problem, the types of services provided to this population, (3) the effectiveness of these services; and (4) recommendations for legislative changes that might be needed to improve service coordination. This report is a response to that charge. Among the relevant findings is that 8.3 million children live with at least one parent who is alcoholic or in need of substance abuse treatment. Neglect is the predominant type of maltreatment. Once in foster care, children from these families tend to stay in care for longer periods of time than other children. While prenatal exposure to drugs is a concern, a significant factor in developmental outcomes is the postnatal environment. To best care for these children and their families, the child welfare and substance abuse services systems must learn to work together rather than as separate independent entities. To improve outcomes efforts must be targeted to prevention, as maltreated children are at high risk to be the next generation of neglectful parents; to strengthen training and improve identification skills of practitioners in both service systems; increase capacity for providing risk assessment, needs assessment and referral; increase the availability and access to appropriate levels of substance abuse treatment, maintain parents in treatment, and provide support for those in recovery. Recommendations are made for systems changes that can facilitate these goals. The Report is organized into eight sections. Following an introduction, there is an overview of the nature of substance abuse problems and their treatment; discussion of the nature of child maltreatment; the extent and scope of the problem; the complexity of child and family needs; the need for collaboration and overcoming barriers to quality service; models for service delivery; and recommendations for the future. There are three appendices with information on Medicaid services for substance abuse treatment; comprehensive treatment models for substance abusing women and their children; and key federal programs that fund substance abuse and child services.

Vanderploeg JJ; Connell CM; Caron C; Saunders L; Katz KH; Tebes JK. The impact of parental alcohol or drug removals on foster care placement experiences: A matched comparison group study. Child Maltreatment 12(2): 125-136, 2007. (46 refs.)

Research has established the coincidence of parental alcohol and other drug (AOD) use and child maltreatment, but few studies have examined the placement experiences and outcomes of children removed because of parental AOD use. The present study examines demographic characteristics and placement experiences of children removed from their homes because of parental AOD use (n = 1,333), first in comparison to the remaining sample of children in foster care (n = 4,554), then in comparison to a matched comparison group of children in foster care who were removed for other reasons (n = 1,333). Relative to the comparison sample, children removed for parental AOD use are less likely to experience co-occurring removal because of neglect and physical or sexual abuse and are more likely to be placed in relative foster care. In addition, these children remain in care longer, experience similar rates of reunification, and have significantly higher rates of adoption.

Wallace PM; Belcher HME. Drug exposed children and the foster care system: In the best interests of the child? Journal of Child & Adolescent Substance Abuse 7(1): 17-32, 1997. (42 refs.)

Children born to substance abusing women face many risks that can impede optimal developmental outcome. These risks include both potential neurologic and organic sequelae of intrauterine substance exposure, as well as additional risk factors in their postnatal environment. Foster care placement is a common occurrence among this population. The current study was conducted to explore the developmental status of a group of drug exposed infants and toddlers in foster care. Twenty-seven children placed through a church-based foster care program were observed. All but one of the children were African-American and nearly half (48%) had been placed shortly after birth. The children ranged in age from 1 to 29 months. Home environment and caregiver-child interaction was assessed using the HOME Inventory and the NCAS Feeding and Teaching Scales. Children were also given physical, neurological, and developmental assessments (Mean age 11.7 months). While the majority of the children fell within normal limits on developmental testing, 28% were considered at risk for cognitive delay and over half exhibited suspect or abnormal neurological signs. Many were felt to be at further risk because of poor home environment and/or caregiving. Implications for intervention and policy changes are discussed.

Ward J. Substance use among young people 'looked after' by social services. Drugs: Education, Prevention and Policy 5(3): 257-267, 1998. (23 refs.)

Young people looked after by social services have been identified as being at increased risk of having, or developing substance misuse problems. Despite such claims, there is a distinct lack of research on the extent and nature of substance use among 'looked after' young people. This paper reviews the published literature on substance use among this population and presents the preliminary findings from a Home Office Drugs Prevention Initiative (DPI) evaluation of a drug prevention intervention among young people living in a residential care establishment. A comparison of these findings with other research data on substance use among young people suggests that 'looked after' youngs people's substance use is higher than that of the general youth population. Although the substance use was generally recreational and not considered by the young people themselves to be problematic, this level of use, at this life stage, could place them at increased risk of movement into more problematic drug use in ensuing years. The feasibility and implications of implementing drug interventions with this group are also discussed.

Ward J; Henderson Z; Pearson G. One Problem among Many: Drug Use among Care Leavers in Transition to Independent Living. Home Office Research Study 260. London: Home Office, 2003. (72 refs.)

This report is one of five research reports published as part of the Vulnerable Groups Research Program. This specific report examines the way in which care leavers' drug use developed during the process of leaving state care to live independently. Care leavers face the challenge of setting up and managing a home, getting a job, coping financially and developing a support network at a very young age. The Children (leaving care) Act 2000 placed a new responsibility on social services to assist care leavers in this transition to independent living, beyond the age of 16. For a variety of reasons - adverse childhood experiences, a high incidence of psychological and behavioral problems and feelings of loss and fragmentation following time in care - young care leavers are considered particularly vulnerable to having or developing drug problems. Where drug use may have become established while living in state care, risky patterns of drug use may develop as a young person moves towards independence. This study proposes some areas where drugs services for young care leavers could be improved. Patterns of alcohol and illicit drug use are explored. A survey was conducted with 200 young people in the process of leaving care, or having recently left care, on their experiences with drugs, alcohol, and tobacco, together with other lifestyle and health issues. Thirty individuals of these participated in in-depth interviews and followed-up six months later. Findings revealed high levels of self-reported drug use but lower alcohol consumption compared with the general population.

Public Domain

Wobie K; Eyler FD; Garvan GW; Hou W; Behnke M. Prenatal cocaine exposure: An examination of-out-of-home placement during the first year of life. Journal of Drug Issues 34(1): 77-94, 2004. (46 refs.)

In a longitudinal, prospective study, three groups of infants were defined by placement status through age one: cocaine-exposed infants in out-of-home placement (n=66), cocaine-exposed infants who remained with their biological mother (n=79), and matched (race, socioeconomic status, parity, birth risk) noncocal. ne-exposed infants who remained, with their biological mother (n=141). Of this predominantly African-American, low socioeconomic status, multiparous cohort, 46%. of the women who used cocaine prenatally had infants in out-of-home placement at some time during the first year of life. The odds ratio for losing/relinquishing custody, for weeks of cocaine use during pregnancy was 6.0 (1.6, 22.0; 95% CI). More positive life experiences and higher education significantly improved the potential of retaining custody. Depression had a small but significant negative effect on the possibility of maintaining custody. The prenatal and post-partum period is an important time to provide services that encourage substance abuse recovery and associated factors of stability that facilitate an intact mother-infant dyad.