U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

50–489 CC 1998

PROTECTING CHILDREN FROM THE IMPACTS

OF SUBSTANCE ABUSE ON FAMILIES RECEIVING

WELFARE

HEARING

BEFORE THE

SUBCOMMITTEE ON HUMAN RESOURCES

OF THE

COMMITTEE ON WAYS AND MEANS

HOUSE OF REPRESENTATIVES

ONE HUNDRED FIFTH CONGRESS

FIRST SESSION

OCTOBER 28, 1997

Serial 105–31

Printed for the use of the Committee on Ways and Means

(
ii

COMMITTEE ON WAYS AND MEANS

BILL ARCHER, Texas, Chairman

PHILIP M. CRANE, Illinois

BILL THOMAS, California

E. CLAY SHAW, JR., Florida

NANCY L. JOHNSON, Connecticut

JIM BUNNING, Kentucky

AMO HOUGHTON, New York

WALLY HERGER, California

JIM MCCRERY, Louisiana

DAVE CAMP, Michigan

JIM RAMSTAD, Minnesota

JIM NUSSLE, Iowa

SAM JOHNSON, Texas

JENNIFER DUNN, Washington

MAC COLLINS, Georgia

ROB PORTMAN, Ohio

PHILIP S. ENGLISH, Pennsylvania

JOHN ENSIGN, Nevada

JON CHRISTENSEN, Nebraska

WES WATKINS, Oklahoma

J.D. HAYWORTH, Arizona

JERRY WELLER, Illinois

KENNY HULSHOF, Missouri

CHARLES B. RANGEL, New York

FORTNEY PETE STARK, California

ROBERT T. MATSUI, California

BARBARA B. KENNELLY, Connecticut

WILLIAM J. COYNE, Pennsylvania

SANDER M. LEVIN, Michigan

BENJAMIN L. CARDIN, Maryland

JIM MCDERMOTT, Washington

GERALD D. KLECZKA, Wisconsin

JOHN LEWIS, Georgia

RICHARD E. NEAL, Massachusetts

MICHAEL R. MCNULTY, New York

WILLIAM J. JEFFERSON, Louisiana

JOHN S. TANNER, Tennessee

XAVIER BECERRA, California

KAREN L. THURMAN, Florida

A.L. SINGLETON, Chief of Staff

JANICE MAYS, Minority Chief Counsel

SUBCOMMITTEE ON HUMAN RESOURCES

E. CLAY SHAW, JR., Florida, Chairman

DAVE CAMP, Michigan

JIM MCCRERY, Louisiana

MAC COLLINS, Georgia

PHILIP S. ENGLISH, Pennsylvania

JOHN ENSIGN, Nevada

J.D. HAYWORTH, Arizona

WES WATKINS, Oklahoma

SANDER M. LEVIN, Michigan

FORTNEY PETE STARK, California

ROBERT T. MATSUI, California

WILLIAM J. COYNE, Pennsylvania

WILLIAM J. JEFFERSON, Louisiana

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records

of the Committee on Ways and Means are also published in electronic form. The printed

hearing record remains the official version. Because electronic submissions are used to

prepare both printed and electronic versions of the hearing record, the process of converting

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process

is further refined.
iii

C O N T E N T S

Page

Advisory of October 20, 1997, announcing the hearing ........................................ 2

WITNESSES

U.S. General Accounting Office, Jane L. Ross, Director, Income Security

Issues, Health, Education, and Human Services Division ............................... 13

Barth, Richard P., University of California, Berkeley .......................................... 43

Center of the American Experiment, Mitchell B. Pearlstein ............................... 77

Children and Family Futures, Nancy K. Young ................................................... 34

Rangel, Hon. Charles B., a Representative in Congress from the State of

New York .............................................................................................................. 7

Reuter, Peter, University of Maryland .................................................................. 21

Satel, Sally L., Yale University School of Medicine .............................................. 70

Second Genesis, Inc., Gale Saler, and Judy Ogletree ........................................... 59

Teen Challenge, Inc., Dave Batty ........................................................................... 66

Westat, Inc., Nicholas Zill ....................................................................................... 26

SUBMISSIONS FOR THE RECORD

Child Welfare League of America, Inc., statement ............................................... 89

Haymarket Center, Chicago, IL, Ray Soucek, statement ..................................... 91

Legal Action Center, Washington, DC, Gwen Rubinstein, statement ................. 92

National Association of Alcoholism and Drug Abuse Counselors, Arlington,

VA, William D. McColl, statement ..................................................................... 97

Ramstad, Hon. Jim, a Representative in Congress from the State of

Minnesota, statement .......................................................................................... 99
(1)

PROTECTING CHILDREN FROM THE IMPACTS

OF SUBSTANCE ABUSE ON FAMILIES

RECEIVING WELFARE

TUESDAY, OCTOBER 28, 1997

HOUSE OF REPRESENTATIVES,

COMMITTEE ON WAYS AND MEANS, SUBCOMMITTEE ON HUMAN RESOURCES, Washington, DC.

The Subcommittee met, pursuant to notice, at 3:05 p.m., in room

B–318, Rayburn House Office Building, Hon. E. Clay Shaw, Jr.

(Chairman of the Subcommittee), presiding.

[The advisory announcing the hearing follows:]
2

ADVISORY

FROM THE COMMITTEE ON WAYS AND MEANS

SUBCOMMITTEE ON HUMAN RESOURCES

FOR IMMEDIATE RELEASE CONTACT: (202) 225–1025

October 20, 1997

No. HR–8

Shaw Announces Hearing on Protecting

Children From the Impacts of Substance Abuse

on Families Receiving Welfare

Congressman E. Clay Shaw, Jr., (R–FL), Chairman, Subcommittee on Human Resources of the Committee on Ways and Means, today announced that the Subcommittee will hold a hearing on issues related to protecting children from the prevalence and impacts of substance abuse on families receiving welfare. The hearing

will take place on Tuesday, October 28, 1997, in room B–318 of the Rayburn House

Office Building, beginning at 3:00 p.m.

Oral testimony at this hearing will be from invited witnesses only. Witnesses will

include representatives of the U.S. General Accounting Office, welfare and substance abuse experts, State welfare officials, and treatment providers. However, any

individual or organization not scheduled for an oral appearance may submit a written statement for consideration by the Committee and for inclusion in the printed

record of the hearing.

BACKGROUND:

Last year, Congress passed, and President Clinton signed, the new welfare reform

law (P.L. 104–193) that substantially changed the nation’s major cash welfare program, now called the Temporary Assistance for Needy Families program. The new

law established time limits on receipt of welfare benefits, set employment and training participation requirements, and authorized States to impose sanctions on recipients that fail to meet program expectations.

Researchers have identified substance abuse as a potential barrier to recipients’

successfully transitioning from welfare to work. In addition, parental drug use has

been linked to child abuse. Estimates of drug abuse among welfare recipients vary

greatly by the type of drug, legal status, and the population studied. However, some

assessments indicate that the use of illegal drugs is higher among welfare recipients

than among the general population.

In announcing the hearing, Chairman Shaw stated: ‘‘The Subcommittee wants to

examine the incidence of drug use among welfare recipients and the potential impacts of drug use on children. We are particularly interested in substance abuse as

a barrier to work and a factor in the placement of children into foster care. Changes

in national welfare rules have led many States to reform their policies for assessing,

referring, and treating drug users. It is time to examine what is known about the

effectiveness of drug treatment and to identify promising approaches to helping welfare recipients overcome substance abuse problems. This hearing is part of our ongoing efforts to ensure that the far-reaching changes made by the welfare reform legislation continue to meet with success.’’
3

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

Any person or organization wishing to submit a written statement for the printed

record of the hearing should submit at least six (6) single-space legal-size copies of

their statement, along with an IBM compatible 3.5-inch diskette in ASCII DOS Text

or WordPerfect 5.1 format only, with their name, address, and hearing date noted

on a label, by the close of business, Tuesday, November 11, 1997, to A.L. Singleton,

Chief of Staff, Committee on Ways and Means, U.S. House of Representatives, 1102

Longworth House Office Building, Washington, D.C. 20515. If those filing written

statements wish to have their statements distributed to the press and interested

public at the hearing, they may deliver 200 additional copies for this purpose to the

Subcommittee on Human Resources office, room B–317 Rayburn House Office Building, at least one hour before the hearing begins.

FORMATTING REQUIREMENTS:

Each statement presented for printing to the Committee by a witness, any written statement

or exhibit submitted for the printed record or any written comments in response to a request

for written comments must conform to the guidelines listed below. Any statement or exhibit not

in compliance with these guidelines will not be printed, but will be maintained in the Committee

files for review and use by the Committee.

1. All statements and any accompanying exhibits for printing must be typed in single space

on legal-size paper and may not exceed a total of 10 pages including attachments. At the same

time written statements are submitted to the Committee, witnesses are now requested to submit

their statements on an IBM compatible 3.5-inch diskette in ASCII DOS Text or WordPerfect

5.1 format. Witnesses are advised that the Committee will rely on electronic submissions for

printing the official hearing record.

2. Copies of whole documents submitted as exhibit material will not be accepted for printing.

Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material

not meeting these specifications will be maintained in the Committee files for review and use

by the Committee.

3. A witness appearing at a public hearing, or submitting a statement for the record of a public hearing, or submitting written comments in response to a published request for comments

by the Committee, must include on his statement or submission a list of all clients, persons,

or organizations on whose behalf the witness appears.

4. A supplemental sheet must accompany each statement listing the name, full address, a

telephone number where the witness or the designated representative may be reached and a

topical outline or summary of the comments and recommendations in the full statement. This

supplemental sheet will not be included in the printed record.

The above restrictions and limitations apply only to material being submitted for printing.

Statements and exhibits or supplementary material submitted solely for distribution to the

Members, the press and the public during the course of a public hearing may be submitted in

other forms.

Note: All Committee advisories and news releases are available on the World

Wide Web at ‘HTTP://WWW.HOUSE.GOV/WAYSlMEANS/’.

The Committee seeks to make its facilities accessible to persons with disabilities.

If you are in need of special accommodations, please call 202–225–1721 or 202–226–

3411 TTD/TTY in advance of the event (four business days notice is requested).

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above.

f
4

Chairman SHAW. Good afternoon.

Our purpose today is to investigate drug addiction and its role in welfare dependency, child abuse, and neglect. We have invited

witnesses to discuss the dimensions of the drug problem both

among families on welfare and in the Nation’s child protection programs. In addition we have invited witnesses who can describe programs that are designed to deal with drug addiction itself or with

the consequences of drug addiction, especially the consequences for

children.

There are several specific questions I hope will be addressed in

the course of today’s hearing. First, is there evidence of substantial

drug use among parents receiving support from the Nation’s welfare programs? Second, do we have programs with a track record

of helping parents, especially those already dependent on welfare,

end their drug addictions? Third, what actions, if any, should Congress take to reduce drugs among welfare parents and to protect

the children from the consequences of parental drug addiction? Anticipating some of today’s testimony, let me state that there does appear to be good evidence that parents receiving benefits

from temporary assistance for needy family programs have fairly

high levels of drug use. Members of this Subcommittee would like

to have information on whether this drug use will interfere with

the ability of the parents to get jobs and leave welfare. I am especially pleased we will receive testimony from the Sec- ond Genesis, the Teen Challenge Program, and several other witnesses about how we can help addicted parents deal with their

drug problems and become productive workers and better parents. There also appears to be very strong evidence that parents with children who have been taken into protective custody by the States

have very high levels of drug addiction. In some jurisdictions, perhaps three-quarters of these families have drug-addicted or druginvolved parents. This, of course, is a tragedy of immense proportion.

At a time when we are hoping to encourage States to make faster

determinations of whether abused and neglected children can be

returned to their families or placed with adoptive parents, drug addictions put the State and local officials making these decisions on

the horns of a dilemma. If the drug addiction has become serious

enough to be an important factor in removing children from their

home, how long should the State wait before moving to place the

children with an adoptive parent? What if it takes 2 years for the

parent to become rehabilitated? What if it takes 3 years? How long

should children be expected to wait?

Although I am not planning to introduce legislation on drugs and

welfare in the near future, at least not this year, I plan to keep

an eye on this issue and carefully consider any legislative recommendations made by today’s witnesses. Our Subcommittee must

continue to investigate whether changes in Federal law would help

States launch more effective programs to help parents and children

on welfare overcome the scourge of drug addiction.

[The opening statement follows:]

Opening Statement of Hon. E. Clay Shaw, Jr.

Our purpose today is to investigate drug addiction and its role in welfare dependency and child abuse and neglect. We have invited witnesses to discuss the dimen5

sions of the drug problem both among families on welfare and in the nation’s child

protection programs. In addition, we have invited witnesses who can describe programs that are designed to deal with drug addiction itself or with the consequences

of drug addiction—especially the consequences for children.

Here are several specific questions that I hope will be addressed in the course of

today’s hearing:

First, is there evidence of substantial drug use among parents receiving support

from the nation’s welfare programs?

Second, do we have programs with a track record of helping parents, especially

those already dependent on welfare, end their drug addictions?

Third, what actions, if any, should Congress take to reduce drug use among welfare parents and to protect children from the consequences of parental drug addiction?

Anticipating some of today’s testimony, let me state that there does appear to be

good evidence that parents receiving benefits from the Temporary Assistance for

Needy Families (TANF) program have fairly high levels of drug use. Members of

this Subcommittee would like to have information on whether this drug use will

interfere with the ability of parents to get jobs and leave welfare. I am especially

pleased that we will receive testimony from the Second Genesis program, the Teen

Challenge program, and several of our other witnesses about how we can help addicted parents deal with their drug problem and become productive workers and

better parents.

There also appears to be very strong evidence that parents with children who

have been taken into protective custody by the states have very high levels of drug

addiction. In some jurisdictions perhaps three-quarters of these families have drugaddicted or drug-involved parents.

This, of course, is a tragedy of immense proportions. At a time when we are hoping to encourage states to make faster determinations of whether abused and neglected children can be returned to their families or placed with adoptive families,

drug addictions put the state and local officials making these decisions on the horns

of a dilemma. If the drug addiction has become serious enough to be an important

factor in removing children from their home, how long should the state wait before

moving to place the child with an adoptive parent? What if it takes two years for

the parent to be rehabilitated? What if it takes three years? How long should children be expected to wait?

Although I am not planning to introduce legislation on drugs and welfare in the

near future, I plan to keep an eye on this issue and to carefully consider any legislative recommendations made by today’s witnesses. Our Subcommittee must continue

to investigate whether changes in federal law would help states launch more effective programs to help parents and children on welfare overcome the scourge of drug

addiction.

Chairman S

Mr. LEVIN. First of all, congratulations on your new hat.

HAW. At this time, Mr. Levin, you are recognized.

f

Chairman SHAW. Thank you.

Mr. LEVIN. My favorite kids book has the phrase in it, I like your

hat. I am reading it to my grandchildren.

Chairman SHAW. I am reading it to my grandchildren.

Mr. LEVIN. It is Go, Dog, Go, exactly.

Mr. CAMP. Poor literate group here.

Chairman SHAW. I seem to be behind on my reading.

Mr. RANGEL. Am I in the right place?

Mr. LEVIN. Yes, Mr. Rangel, welcome; and I will be very brief so

we can get to your testimony.

I have a statement, Mr. Chairman, that I ask be placed in the

record.

Chairman SHAW. Without objection. The statement of any of the

Members will be placed in the record if they wish to do so.

Mr. LEVIN. Our important and solemn job is make welfare-towork legislation, or at least to help in that direction; and to do
6

that, we have to be sensitive to the complex problems faced by families who are receiving TANF or who are involved in foster care,

and one of the problems faced by many of these families relates to

drug abuse. And there is evidence, as you say, Mr. Chairman, that this is a considerable problem, that a substantial number of people who are

receiving TANF have drug or other abuse problems. I think there

is also evidence there can be a successful addressing of this problem in many cases, and treatment is not today sufficiently available. So I look forward to this hearing. I think we have put together a very excellent set of witnesses, and we are privileged to have, as the leadoff witness, the Ranking

Democrat on our Committee.

[The opening statement follows:]

Opening Statement of Hon. Sander M. Levin, a Representative in Congress from the State of Michigan

This afternoon’s hearing is an important one and, I hope, the first of several we will hold to explore barriers facing welfare recipients moving to work. As we implement welfare reform and live up to our commitment to replace welfare with work,

we will maximize effectiveness only if we are sensitive to the complex problems

many of these families face. Substance abuse is clearly one of the serious problems. Estimates vary about the extent of the problem, with the highest estimates being that about one million

women on welfare need help with a drug or alcohol problem. Most research has concluded that the TANF population uses drug and alcohol at a rate that is higher than

the non-welfare population and that the majority of recipients who need treatment

are not receiving it. Even more troubling, it appears that parental substance abuse

is implicated in the majority of foster care cases in some parts of the country. Our challenge today and in the near future is to focus on the magnitude and the consequences of the problem, and most importantly, to learn more about successful

models for overcoming substance abuse problems so that parents can move from

welfare to work, can support their families, and can through example help their own

children avoid drugs. I look forward to hearing from witnesses today who have firsthand experience

with these problems. A special thanks to the Ranking Democrat on the Committee

on Ways and Means, Charlie Rangel, who so poignantly describes how the combination of poverty, lack of education, abuse, and hopelessness too often leads to addiction.

Chairman S

I would like to give a special welcome to our first witness today,

HAW. Thank you, Mr. Levin.

f

Mr. Rangel, who has, throughout his entire career in the Congress,

worked very hard in the area of drug abuse, and trying to find its

causes, its cure, and work to get rid of this terrible problem.

I first met Mr. Rangel 17 years ago when I came to Congress and

was on the Select Committee and was on your Subcommittee—I

don’t know if you remember it, but I remember it as a freshman

back then—and we worked very hard together throughout the

years. It is an area where Mr. Rangel and I disagree on a lot of

things, but I cannot think of one time that we have ever disagreed

in this particular area; and I compliment you for all the good work

that you have done for your country and for the people who have

gotten hooked on this terrible scourge that has plagued the country. It, in itself, is a tremendous cause of people not being able to

make it, not being able to get out in the work force. Drug abuse

has absolutely just—has penalized people beyond belief.
7

With that, Mr. Rangel.

STATEMENT OF HON. CHARLES B. RANGEL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW YORK

Mr. RANGEL. Thank you. I don’t think I will be able to bring

much of a solution to the problem we face, but I am familiar with

the problem and together I think we can find a solution.

Take a district like mine—which receives more per capita Federal funds than most congressional districts. But that is not something that I can run for reelection on because most of it is for

health care, AIDS, welfare, crime reduction, and homelessness; and

given all of this, I was able to work with Congressman Kemp and

Congressman Newt Gingrich to create the empowerment zone. To

make certain we weren’t just considering race and all of those

other controversial issues to determine eligibility for an empowerment zone, we just picked criteria—we used poverty, we used drug

abuse, we used crime, we used homelessness, we used unemployment, we used all of these things, and so you would know that welfare would be a part of the criteria. In other words, if you ever really take a look at where the schools are not functioning, where you

have the highest amount of unemployment, and joblessness because the family unit is not functioning the way we think it should,

you are going to find hopelessness, which leads to despair, which

leads to drugs, which leads to unwanted children, which leads to

violence, which leads to crime, and which leads to the ridiculous

situation that in the city of New York, we are paying $85,000 a

year to keep a kid in a detention center, while the unions are fighting with the mayor to find out if they can get $7,000 a year to keep

a kid in school.

What I am suggesting is, when it gets to rehabilitation, in most

of these cases, they have not been habilitated and there is very little you can do to rehabilitate.

I remember sometimes bringing Federal officials into my district

and, to my embarrassment, the rehabilitated addicts would come

up and say, Rangel, you are doing a great job; I go to the same rehabilitation center all the time, they really treat me fairly, these

are good people. And basically, it almost hurts to see how you can

detoxify somebody, make them drug free, give them self-esteem,

and find out they were just as uneducated when they were discharged and graduated as they were when they went on drugs. And

because the dollar is so competitive in rehabilitation, everybody

wants to know how many people went through, how many people

graduated, how many people reunited with their families; but if

they didn’t spend the money and time to give them job skills, the

self-esteem hurts them more than when they didn’t have it.

Of course, I have always supported the programs because having

the program reduces the habit, and to a large extent, keeps them

off the street and reduces crime. And some of the programs do

work, especially if the person involved has some skills and the program is dealing with training and job placement, rather than how

many numbers can we run through to a graduation, which gives

high expectations, but is really disappointing in the end.

But the whole point is that if we don’t deal with jobs in this

country—and it is not just the welfare program. My God, we have
8

1.6 million people that are locked up in jail as we go toward the

next century, talking about high skills, high-paying jobs. We are

talking about close to a trillion dollars when you include the health

benefits, food, maintenance, building of the prisons, the law enforcement system, diseases related to drugs—and 80 to 90 percent

of the people we are locking up are drug related, one way or the

other.

It seems to me there is one thing we know definitely and that

is that the prison population and, for the most part, the welfare

population, are unemployable; and one of the reasons we didn’t do

much with putting people to work was because it took more to

train them for work than to send a check.

Morally, it is the wrong thing to do. Everyone should have the

dignity and the pride of working; it means something to the family,

it means something to the community, it should mean something

to the church or synagogue. But in dollars and cents, to get someone prepared to do what the schools didn’t prepare them to do is

just stupid, and this is especially so when we have legislation that

comes before us that gives incentives to save money at the expense

of not making certain that basically we have a good public school

system and then, from there, parents can do whatever they want,

with or without incentives.

So I am suggesting that even though I don’t have an answer to

the problem that you are facing with the welfare recipient, there

is no question in my mind that we can make a difference—if we

can build partnerships with businesspeople who can tell us definitely what training and skills they need to hire somebody; if we

can make certain that that public school system does not just respond to a local school board, but responds to the job needs of the

people in that community, including small- and middle-sized businesses. If we make it the case that when they graduate they don’t

just earn a diploma but a job will be waiting for them, as somehow

they managed to do in the Army. Nobody asked me what I wanted

to do; they just said what they needed and went on to train me for

that particular job.

There is no reason why we can’t have a closer working relationship with our businesspeople and our school boards and our

schools, and to the extent that we are going to say that welfare recipients have to work and should be working, it seems to me it

should be the private sector that we should be depending on, and

if we have to, go to the drug rehabilitation centers to instill that

training there. To me, making someone drug free without giving

them the hope they are going to get a job is something that doesn’t

sustain itself.

I didn’t mean to come here and raise the problems to you, Mr.

Chairman, because as you said, for close to two decades, you and

I have been struggling to find the answer to this problem. But it

would seem to me we all should know that the better a school system, the better a job opportunity, then the better the chances we

are not dealing with welfare, crime, drugs, and eventually an impediment to the progress that this great Nation can make if we

didn’t just lock up people and give up so many of them to AIDS

and to hopelessness, as the case is with many of the welfare recipients.
9

And so it is a challenge that is present to all of us, and I look forward to working with all of you, toward that solution. [The prepared statement follows:]

Statement of Hon. Charles B. Rangel, a Representative in Congress from the State of New York

According to the Substance Abuse and Mental Health Services Administration, at least 600,000 AFDC recipients require treatment for alcohol- and other drug-related

problems; other national estimates indicate that as many as 1 million AFDC women

may need such help. Most assessments of drug or alcohol use predict that the AFDC

population uses drugs and alcohol more than the non-AFDC population. It should come as no surprise to us that AFDC recipients, particularly those who are long-term dependent, have significant drug and alcohol abuse problems. The

combination of poverty, lack of education, abuse, and hopelessness can easily lead

to addiction; and treatment resources, particularly for this population, are quite limited.

In fact, according to SAMSA, the great majority of women receiving public assist- ance do not get treatment for their alcohol-and other drug-related problems and

could benefit from treatment.

Instead of investing in education and treatment, we invest in prisons. It costs $85,000 to house each inmate at the Rikers Island detention center. That is $72,000

more than the cost to educate a child in public school for a year. This investment in prisons and longer jail sentences does not seem to have had much, if any, deterrent effect. Investing even more in this strategy does not make

much sense to me, particularly given our concern about the deficit. What we need

is a strategy that links prevention, treatment, law enforcement, and demand and

supply reduction. I wish I could say that I see such a strategy on the agenda of this

Congress, but I do not. All the news is not bad, however. There is evidence, from States, that treatment

can substantially improve employment status for the welfare population:

—Arkansas had a post-treatment employment increase of 127 percent;

—California saw increases in employment of over 60 percent;

—Colorado increases were 60 percent;

—Florida increases were 76 percent;

—Minnesota increases among public pay clients were 64 percent; and

—Missouri increases were 136 percent.

Remember, nearly 20 percent of all children in the US have a parent who used

an illicit drug in the past year; over 9 percent have parents who used illicit drugs

in the past month.

Blaming the drug or alcohol dependent parent accomplishes nothing. We need to

devote that same energy to solving what is a painful problem for many of America’s

families, including its poorest.

preting what you are saying, in reading between the lines, that jobChairman SHAW. Charlie, am I hearing you correctly, in interf

lessness, hopelessness, leads to drug abuse, and that the rehabilitation is not addressing that question? In addition to just getting

someone off of drugs, in other words, should we be looking to attaching job training to drug rehabilitation?

Mr. RANGEL. No question in my mind, Mr. Chairman.

Chairman SHAW. Is anyone doing that?

Mr. RANGEL. Some do, and they are expensive programs. As a

matter of fact, I can look at the success of a program and almost

see whether they are screening people to guarantee success. Where

you have programs in sophisticated neighborhoods where some doctor, some lawyer, some professional person made a mistake and

was hopelessly addicted, then they go to the Betty Ford Rehabilitation Center. They don’t need a lot of job training, they just have

to get back on track.
10

But when you search for the reason as to why would anybody go

on drugs in the first place, our kids are smart enough to see that

drugs hurt, they are smart enough to see friends dying, they are

smart enough to see people going to jail. Some of these kids go to

more funerals than they do graduations, so they are smart enough

to see it. So why would they do this? Because they don’t give a

damn. There is nothing they are going to lose.

They know that fast track and increased high-tech jobs do not

mean them; they know they are not going to lose their family’s

good name, and being arrested, to some of them—having been

abused and not even having had the ability to dream—going to jail

just isn’t any big deal.

As a matter of fact, the tragedy is when you find some kids who

have never been to jail, dressing and acting as if they have been

in and out of jail, so they can be accepted as a peer on the block.

And when a kid goes through all of this crying and the family love

is restored at graduation from a rehabilitation center, and then

finds out that his friends, who are doing something, shun him—

they can’t just go right back, they are still a form of junkie—it

takes a lot of love, and a lot of people don’t have it for the type

of people who have made these types of mistakes.

But there is one group they can always depend on, that is there

for them: the drug dealer; and if you don’t have a family structure

to carry you, and you are weak and you are young and you are immature. And if you make a baby, well, how would we counsel

them?

To a large extent, we have said they have already ruined their

lives, so now you apply for a check and we say, Well, you wretched

soul, you had better go to work. Well, we all agree, that is a great

principle, but, boy, have you got a job in habilitating someone so

that they are prepared to understand what the heck work is in the

first place.

So what I am saying is that we make one big mistake when we

don’t concentrate on stopping these things from happening, because

these are the problems we will be wrestling with, whether it means

welfare, whether it means HIV, whether it means crime.

I went to visit, a couple years ago, some kids in a rehabilitation

hospital that was in my district, and all these kids were sitting

around in wheelchairs with ‘‘Rangel is the greatest’’ on their Tshirts, so I knew they wanted something. And I was asking, what

did they want? And the director of the program told me that these

kids who have been shot in these drug wars, paralyzed for life,

wanted me to support a program that would put them in a private

home, an apartment, with a rehabilitation person, with a housekeeper, with a dietitian and all of this. And I was saying, Are you

crazy, and they were showing me that the cost of all of this was

a fraction of the cost of keeping them in that institution.

Now we know that public officials are not prepared to give money

to bum kids who shot each other, but we are prepared to pay

money to the institutions, the doctors, the psychiatrists, and the social workers. It is insane.

How many people in Congress could I ask for $84,000 to keep

one of my kids in school? But nobody has ever challenged in the

Congress the amount of money it takes to keep them in jail—and
11

certainly not in the city council and State legislatures, the legislative bodies.

My only plea is, do what you have to do to get reelected, but for

God’s sake, concentrate on building a school system that produces

productive people and that is not hopeless. Because in the Army

they took a lot of hopeless bums like me and turned them into

somebody. And with the proper discipline, and if the hope is there

and the drive is given there, because you are shown something at

the end of the line—at the end of the line for me was corporal

stripes, but for kids, it may be something else—but show them

something that you can get out of it and it works. And the thing

that hurts is that you know it works, the Congress knows it works.

So when I see tax bills described as education bills, like I did last

week, I say, If this makes you feel good, do it, but build up a public

school system first before you call this a K-to-12 bill.

Chairman SHAW. Do the other Members have any questions?

Mr. Collins.

Mr. COLLINS. Mr. Rangel, I know we come from different parts

of the country, and you come from an area that probably has a lot

more different circumstances or surroundings than I do, because

you are from an inner-city area, and I am from rural—middle of

Georgia. But we both see a lot of the same situations, maybe just

in different patterns.

In the area of education versus prisons, we do not adequately address the problem of drugs and crime and education. I think it is

going to take a large sum of money for each. The purpose of schools

and education is to teach what to do and how to do it properly, appropriately. The purpose of a prison is to, in some sense of the

word, teach that you didn’t do it right and you have infringed on

the rights of others. One is much more expensive than the other

one. But we have to pay attention to both.

We can’t just not put people in jail or prison—because they have

done wrong. That is a lesson to others that they won’t like what

they might reap from that type of system. But it is expensive and

it is going to be an expensive solution, but it will take a generation,

maybe even a generation and a half, to change the course of the

mindset of a lot of young people that are coming along. Because we

have a lot of youth today who are experiencing everyday problems,

they see it in the neighborhoods you spoke of, they see it in the

families you spoke of, and they are probably going to wind up being

taught an education medium from the prison system, rather than

from the education system.

But if we don’t address this—the young ones, the little ones that

are coming along, and focus on their education, focus on their families, focus on the fact that their peers, their role models, their parent or parents—in many places, one parent—is a role model that

does attend work, does have some type of skill or a job with no

skill. I know a lot of people who don’t really have what you say is

a skill, but they work every day, they make a living, they provide

for their family; and that, in itself, is a teacher to those young

ones. It is going to be an expensive process either way.

You mainly focused on just public education, but there are some

alternatives to public education out there too; and within the next

few days, or the last few days, we had a bill on the floor dealing
12

with just a little pilot program right here in the District of Columbia, dealing with education. It is worth trying. It may not work, but

a lot of things out there are not working today.

So I don’t think we just say we are going to do this in public education; I think we ought to look at any type of education program

or institution that we can—an education institution, not a prison—

for guidance and for help. And we are going to have to pay for it.

It is a pleasure to work with you on the Ways and Means Committee and to listen to you talk. I have said once before, I would

love to visit your area, your city, your district; I would also love for

you to visit mine.

Thank you, Mr. Chairman.

Mr. RANGEL. We have to do that. I agree with everything you

have said. I am not pessimistic that it is going to cost a lot of

money. I have found that I have more private sector entrepreneurs

that understand what I am saying than politicians, and they know

they can’t win at that bargaining table if this trend continues; and

they also know that the people that are locked up are employable

people and that people from the same families and the same communities that manage to discover the excitement of learning don’t

end up making those mistakes.

In the recently passed bipartisan tax bill, there are provisions

that take first steps building in a partnership with the private sector and relieving them of the responsibility for basic training—telephone operators—the companies complain that out of every 100 applicants, they can find only one qualified candidate and they have

to train that one. There is no reason why the schools can’t do this;

there is no reason why the specifications for each and every job—

and I am not talking about rocket scientists’ jobs, I am talking

about work jobs—why that cannot be taught in the schools. Everybody is not going to go to college, and they don’t have to go to college; there are jobs they can do, and the schools should be able to

at least say, you can do this and get a job. But higher education

should be made available, and other options should be there, but

no one should have to leave school without having a job available

to them in their community.

Mr. COLLINS. And a lot of our youth need to understand, there

are a lot of jobs that would be available, but if you get this stamp

on the record, it stays with you, and there are jobs that just won’t

allow you to be employed again.

I have a business in that range. I have a trucking company—

transportation, drivers—but if you get on your record any type of

drug violation, you are in deep trouble when it comes to trying to

find another job driving a truck or in any other area of transportation.

Mr. RANGEL. Except when there is a shortage, and if for some

reason there were enough Members of Congress that thought this

surplus we are talking about should be dedicated to rebuilding our

cities and our roads and our communication system and our transportation system, if somebody really thought that in order to have

successful international trade, we have to have successful ports and

roads and trains in order to do it; and I can tell you, there will be

more job opportunities than we can take, and the guy with the misdemeanor or nonviolent behavior, if he can handle one of those
13

shovels or one of those trucks, you can bet your life—he can get a

break and get back on the road. But, for now, if you can hire an

unemployed college kid, why deal with a guy who has these problems?

As a matter of fact, one country is now looking for soldiers, and

they are going to the prisons because no one wants to do that kind

of work. I really think one of the best investments we can make

is rebuilding our country, and creating the jobs to do it.

Anyway, we all have a lot to do, and politics is a big impediment

to moving forward a lot of times. But I didn’t mean it should just

be the public school; all I know is, without the public school, I

would not have been here today.

Chairman SHAW. That will be the final word.

Mr. RANGEL. Thank you.

Chairman SHAW. Thank you for taking the time to be with us.

The next panel of witnesses, if you would come to the table, we

have Jane Ross, Director of Income Security Issues, U.S. General

Accounting Office; Peter Reuter is a Ph.D., School of Public Affairs,

University of Maryland, College Park, Maryland; Nicholas Zill,

Ph.D., Vice President and Director, Child and Family Study Area,

of Westat, Inc., in Rockville, Maryland; Nancy Young, Ph.D., Director of Children and Family Futures in Irvine, California; and Richard Barth, Ph.D., Hutto Patterson Professor, School of Social Welfare at the University of California at Berkeley.

We have each of your full statements, which will be made a part

of the record, and we would invite you to proceed as you see fit,

and you are welcome to summarize.

Ms. Ross.

STATEMENT OF JANE L. ROSS, DIRECTOR, INCOME SECURITY

ISSUES, HEALTH, EDUCATION, AND HUMAN SERVICES

DIVISION, U.S. GENERAL ACCOUNTING OFFICE

Ms. ROSS. Thank you. Mr. Chairman and Members of the Subcommittee.

Each year nearly 1 million children in this country are victims

of abuse and neglect, and parental substance abuse is very often

a contributing factor in these cases. Although estimates vary widely, parental substance abuse may be involved in the majority of foster care cases in some locations, and in New York City, about 75

percent of confirmed cases of child abuse and neglect involve substance abuse by at least one parent or care giver. In House bill 867,

the Subcommittee indicated its concern about parental substance

abuse by directing the Secretary of HHS to recommend to the Congress ways to improve the coordination between substance abuse

and child welfare services; and today, in order to pursue your concern further, you ask us to discuss the implications of parental substance abuse for children and for the child welfare system. You also

ask us to comment on permanency planning for foster care cases

involving parental substance abuse. Let me briefly summarize our

findings.

First, let’s talk about the children. Parental substance abuse is

a problem that brings many children to the attention of the child

welfare system. In the case of newborns who are found to have

been prenatally exposed to drugs or alcohol, there is often an inves14

tigation to determine if there has been child abuse and neglect. In

some States, prenatal substance abuse—excuse me, prenatal substance exposure, by itself, constitutes abuse or neglect and is

grounds for removing a child from its parents.

In the case of older children, substance abuse can damage a parent’s ability to care for them and can lead to abuse or neglect.

When abuse or neglect have been documented, some of the children

are removed from the custody of parents and placed in foster care.

So that has to do with the children.

Once the child is in the foster care system, parental substance

abuse is a significant hurdle in that child’s path out of the system.

It is a hurdle that requires drug or alcohol treatment for the parent, in addition to other services for the family.

The nature of drug and alcohol addiction means a parent’s recovery can take a considerable amount of time. These parents also face

problems such as mental illness or homelessness, which further

complicate their cases. Foster care cases that involve parental substance abuse, therefore, place an additional strain on the child welfare system, which is already overburdened by the number of foster

care cases and their costs. There are currently about a half a million children in foster care and just the Federal cost of foster care

is over $3 billion this year.

Child welfare agencies are charged with ensuring that foster care

cases are resolved in a timely manner while making reasonable efforts to reunite children with their parents. Ideally, both of these

goals can be achieved. However, even for parents who are able to

recover from drug or alcohol abuse problems, recovery can be a

long process. Child welfare officials who are now trying to speed up

the process of making permanency decisions may have difficulty

making those decisions before they know whether the parent is

likely to succeed in drug treatment. So when parental substance

abuse is an issue in a foster care case, it may be difficult to reconcile minimizing time spent in foster care with reunification of

children with their parents. Fortunately, some States and localities

are testing initiatives that may help reconcile the two goals.

For example, Tennessee has a concurrent planning program that

allows caseworkers to work toward reunifying families while, at the

same time, developing an alternate permanency plan in case the

family reunification efforts don’t work. Under a concurrent planning approach, caseworkers emphasize to the parents that if they

don’t adhere to the requirements set forth, parental rights can be

terminated.

Also, the State of Illinois is just beginning a project to coordinate

substance abuse treatment for parents with child welfare services

for the family.

Finally, there is some early work going on to increase services

available to families after reunification. This initiative seems especially important as a complement to efforts to reunify families more

quickly.

To sum up, in seeking to achieve what is in the best interest of

children, foster care laws emphasize both family reunification and

achieving timely exits from foster care. Reconciling the goals for

children whose parents have substance abuse problems requires
15

1 In 1991, these locations accounted for 44 percent of young foster children in California; 81

percent of young foster children in New York; and 29 percent of young foster children in Pennsylvania.

balancing the rights of the parents with what is truly in the best

interest of the children.

Mr. Chairman, that concludes my statement.

[The prepared statement follows:]

Statement of Jane L. Ross, Director, Income Security Issues, Health,

Education, and Human Services Division, U.S. General Accounting Office

Mr. Chairman and Members of the Subcommittee:

Each year, nearly 1 million children in this country are the victims of abuse and

neglect by their parents or other caregivers, and parental substance abuse is very

often a contributing factor in these cases. Although estimates vary widely, there is

considerable literature that suggests that parental substance abuse is involved in

the majority of foster care cases in some locations. It is not surprising, therefore,

that the nature and effects of parental substance abuse are of concern to this Subcommittee, particularly in light of the dramatic increase in the foster care population, which was estimated to be almost half a million by the end of 1995.

Because of your concern, you asked us to discuss the implications of parental substance abuse for children and the child welfare system. You also asked us to comment on permanency planning for foster care cases involving parental substance

abuse, given the importance of family reunification.

My testimony today is based on our ongoing work for the Senate Committee on

Finance and previous work we have done in the child welfare and substance abuse

areas. (See Related GAO Products at the end of this statement.) Our ongoing work

on the implications of parental substance abuse for foster care primarily consists of

reviews of the substance abuse histories and drug treatment experiences of parents,

as well as the initiatives that might help achieve timely exits from foster care for

cases involving parental substance abuse. Most of the previous work I refer to here

involved an extensive review of the case files of representative samples of young foster children—those under 3 years of age—who were in foster care in Los Angeles

County, New York City, and Philadelphia County in 1986 and 1991. These locations

accounted for a substantial portion of their respective states’ population of young

foster children in 1991.1 Furthermore, over 50 percent of the nation’s foster children

were under the jurisdiction of these three states in that year.

Let me briefly summarize our findings. For many children, it is parental substance abuse that brings them to the attention of the child welfare system. When

a newborn has been found to have been prenatally exposed to drugs or alcohol, this

often triggers an investigation of suspected child abuse and neglect. In some states,

prenatal substance exposure itself constitutes neglect and is grounds for removing

a child from its parents. Substance abuse can damage a parent’s ability to care for

older children as well, and can lead to child abuse or neglect. As a result, some of

these children are removed from the custody of their parents and placed in foster

care.

Furthermore, once a child is in the system, parental substance abuse is a significant hurdle in their path out of the system—a hurdle that requires drug or alcohol

treatment for the parent in addition to other services for the family. The nature of

drug and alcohol addiction means a parent’s recovery can take a considerable

amount of time. Other problems these parents face, such as mental illness and

homelessness, further complicate these cases. Foster care cases that involve parental substance abuse, therefore, place an additional strain on a child welfare system

already overburdened by the sheer number of foster care cases.

Child welfare agencies are charged with ensuring that foster care cases are resolved in a timely manner and with making reasonable efforts to reunite children

with their parents. Ideally, both of these goals are to be achieved. However, even

for parents who are able to recover from drug or alcohol abuse problems, recovery

can be a long process. Child welfare officials may have difficulties making permanency decisions within shorter time frames before they know whether the parent is

likely to succeed in drug treatment. So, when parental substance abuse is an issue

in a foster care case, it may be difficult to reconcile these two goals. The foster care

initiatives and laws that some states and localities are instituting may help reconcile the goals of family reunification and timely exits from foster care for the cases

involving parental substance abuse.
16

2 42 U.S.C. 675(5)(C).

3 Adoption Promotion Act of 1997 (H.R. 867); Promotion of Adoption, Safety, and Support for

Abused and Neglected Children (S. 1195).

BACKGROUND

The child welfare system encompasses a broad range of activities, including

• child protective services (CPS), which investigates reports of child abuse and neglect;

• services to support and preserve families; and

• foster care for children who cannot live safely at home.

States and localities provide the majority of funds for foster care and child welfare

services, but federal funds are provided to states for the food, housing, and incidental expenses of foster children whose parents meet federal eligibility criteria. Federal funding for the administration and maintenance expenses of foster care was estimated at about $3.6 billion in 1997. Additional federal funds are provided to states

for a wide range of other child welfare and family preservation and support services,

and these were estimated at about $500 million in 1997.

As an integral part of the child welfare system, foster care is designed to ensure

the safety and well-being of children whose families are not caring for them adequately. Beyond food and housing, foster care agencies provide services to children

and their parents that are intended to address the problems that brought the children into the system. Agencies are also required to develop a permanency plan for

foster children to make sure they do not remain in the system longer than necessary. Usually, the initial plan is to work toward returning the children to their

parents. If attempts to reunify the family fail, the agency is to develop a plan to

place the children in some other safe, permanent living arrangement, such as adoption or guardianship. According to federal statute, the court must hold a permanency planning hearing no later than 18 months after a child enters foster care.2

Proposed federal legislation would shorten this time frame to 12 months,3 in the

hope of reducing the time a child spends in foster care. Some states have already

adopted this shorter time frame.

PARENTAL SUBSTANCE ABUSE OFTEN BRINGS CHILDREN TO THE ATTENTION OF THE

CHILD WELFARE SYSTEM

Children come to the attention of the child welfare system in two ways—either

shortly after birth because they were exposed to drugs or alcohol in-utero or sometime later because they have been abused or neglected. Children with substance

abusing parents enter foster care in either way.

Many state statutes require that drug- or alcohol-exposed infants be reported, and

some of these children are subsequently removed from the custody of their parents

if an investigation determines that they have been abused or neglected. In some

states, prenatal substance exposure itself constitutes neglect and is grounds for removing children from the custody of their parents. Large numbers of children in foster care are known to have been prenatally substance exposed. In an earlier study,

we estimated that close to two-thirds of young foster children in selected locations

in 1991 had been prenatally exposed to drugs and alcohol, up from about one-quarter in 1986.

In both years, cocaine was the most prevalent substance that young foster children were known to have been exposed to, and the incidence of this exposure increased from about 17 percent of young foster children in 1986 to 55 percent in

1991. Moreover, among those who had been prenatally exposed who were in foster

care in 1991, about one quarter had been exposed to more than one substance. The

actual number of young foster children who had been exposed to drugs or alcohol

in-utero may have been much higher because we relied on the mother’s self-reporting of drug or alcohol use or toxicology test results of the mother or infant to document prenatal exposure. Yet, not all children or mothers are tested at birth for

drugs, and even when they are tested, only recent drug or alcohol use can be confirmed.

Older children of substance abusing parents also may enter foster care because

they have been abused or neglected as a result of their parents’ diminished ability

to properly care for them. Abuse and neglect of children of all ages, as reported to

CPS agencies, more than doubled from 1.1 million to over 2.9 million between 1980

and 1994, and a Department of Health and Human Services (HHS) report found

that the number of CPS cases involving substance abuse can range from 20 to 90

percent, depending on the area of the country. For example, we recently found that

about 75 percent of confirmed cases of child abuse and neglect in New York City
17

involved substance abuse by at least one parent or caregiver. Many of these parents

live in drug-infested and poor neighborhoods that intensify family problems. Neglect is most frequently cited as the primary reason children are removed from the custody of their parents and placed in foster care. According to the Office of

Child Abuse and Neglect, the children of parents who are substance abusers are

often neglected because their parents are physically or psychologically absent while

they seek, or are under the influence of, alcohol and other harmful drugs. Sixtyeight percent of young children in foster care in California and New York in 1991

were removed from their parents as a result of neglect or caretaker absence or incapacity. No other reasons for removal accounted for a large portion of entries of

young children into foster care. Physical, sexual, and emotional abuse combined accounted for only about 7 percent of removals of these young children.

PARENTAL SUBSTANCE ABUSE PLACES ADDITIONAL STRAIN ON THE CHILD WELFARE

SYSTEM

Parental substance abuse not only adversely affects the well-being of children, it

also places additional strain on the child welfare system. The foster care population

increased dramatically between 1985 and 1995 and is estimated to have reached

about 494,000 by the end of 1995. As a consequence, foster care expenditures have

risen dramatically. Between 1985 and 1995, federal foster care expenditures under

title IV–E of the Social Security Act increased from $546 million to about $3 billion.

We found that a greater portion of foster care expenditures in some locations shifted

to the federal government between 1986 and 1991 because much of the growth in

the population of young foster children involved poor families who were eligible for

federal funding.

Parental substance abuse is involved in a large number of cases. We have previously reported that an estimated 78 percent of young foster children in 1991 in

selected locations had at least one parent who was abusing drugs or alcohol. Our

recent interviews with child welfare officials in Los Angeles County, California, and

Cook County, Illinois, have confirmed that the majority of foster care cases in these

counties for children of all ages involve parental substance abuse. Officials in these

locations stated not only that cocaine use among parents of foster children is still

pervasive but that the use of other highly addictive and debilitating drugs, such as

heroin and methamphetamines, appears to be on the rise. In addition, officials confirmed that use of multiple substances is common.

In addition to the large number of foster care cases involving parental substance

abuse, the complexities of these family situations place greater demands on the

child welfare system. Most of the families of the young foster children in selected

locations whose case files we reviewed had additional children in foster care, and

at least one parent was absent. About one-third of the families were homeless or

lacked a stable residence. Some had at least one parent who had a criminal record

or was incarcerated, and in some families domestic violence was a problem. In addition, child welfare officials in Los Angeles and Cook Counties recently told us that

dual diagnosis of substance addiction and mental illness is common among foster

parents. The National Institute of Mental Health reported in 1990 that most cocaine

abusers had at least one serious mental disorder such as schizophrenia, depression,

or antisocial personality disorder.

To illustrate the complexities of these cases and the influences the complexities

can have on outcomes from foster care, let me describe a case we recently reviewed

as part of our ongoing work. This case involves a woman with four children, all of

whom were removed from her custody as a result of neglect related to her cocaine

abuse. The youngest child entered foster care shortly after his birth. By that time,

the three older children had already been removed from their mother’s custody. All

four of the children were placed with their grandmother. The mother had a long history of cocaine abuse that interfered with her ability to parent. At least two of her

four children were known to have been prenatally exposed to cocaine. She also had

been convicted of felony drug possession and prostitution, lacked a stable residence,

and was unemployed. The father was never located, although it was discovered that

he had a criminal record for felony drug possession and sales.

Despite the mother’s long history of drug use and related criminal activity, she

eventually completed a residential drug treatment program that lasted about 1 year,

participated in follow-up drug treatment support groups, and tested clean for over

6 months. In addition, she completed other requirements for family reunification,

such as attending parenting and human immunodeficiency virus (HIV) education

classes, and she was also able to obtain suitable housing. Although the mother was

ultimately reunified with her youngest child, it took a considerable amount of time

and an array of social services to resolve this case. The child was returned to his
18

4 Recently, both California and Illinois enacted expedited time frames for holding a permanency planning hearing within 12 months. In addition, California enacted an even shorter time

frame of 6 months for children entering foster care under the age of 3. The changes to Illinois’

mother on a trial basis about 18 months after he entered foster care. The child welfare system retained jurisdiction for about another year, during which family maintenance services were provided.

In addition, many foster children have serious health problems, some of which are

associated with prenatal substance exposure, which further add to the complexity

of addressing the service needs of these families. We found that over half of young

foster children in 1991 had serious health problems, and medical research has

shown that many of the health problems that these children had, such as fetal alcohol syndrome, developmental delays, and HIV, may have been caused or compounded by prenatal exposure to drugs or alcohol.

Special supportive services and treatment will be needed by many of these children. Early identification of children who are HIV positive is particularly critical because medical advances in identification and treatment can enhance and prolong the

lives of these children. Some of these children require foster care either in institutions that can accommodate their medical needs or in foster family homes where the

caregivers are specially trained. Reunifying families can also be more difficult because of the additional strains that caring for medically fragile children places on

parents, who are at the same time recovering from drug or alcohol addictions.

Some caseworkers find it difficult to manage the high caseloads involving families

with increasingly complex service needs. Some states have experienced resource constraints, including problems recruiting and retaining caseworkers, shortages of

available foster parents, and difficulties obtaining needed services, such as drug

treatment, that are generally outside the control of the child welfare system. Caseworkers are also experiencing difficulties resolving cases. Once children are removed

from the custody of their parents, they sometimes remain in foster care for extended

periods.

PARENTAL SUBSTANCE ABUSE ADDS TO THE DIFFICULTY OF MAKING PERMANENCY

DECISIONS

The problem of children ‘‘languishing’’ or remaining in foster care for many years

has become a great concern to federal and state policymakers. While most children

are reunified with their parents, adopted, or placed with a guardian, others remain

in foster care, often with relatives, until they age out of the system. The circuitous

and burdensome route out of foster care—court hearings and sometimes more than

one foster care placement—can take years, be extremely costly, and have serious

emotional consequences for children.

Yet, making timely decisions about children exiting foster care can be difficult to

reconcile with the time a parent needs to recover from a substance abuse problem.

Current federal and state foster care laws emphasize both timely exits from foster

care and reunifying children with their parents. However, even for those who are

able to recover from drug and alcohol addictions, it can be a difficult process that

generally involves periods of relapse as a result of the chronic nature of addiction.

Achieving timely exits from foster care may sometimes conflict with the realities of

recovering from drug and alcohol addictions. The current emphasis on speeding up

permanency decisions will further challenge child welfare agencies.

Current federal law requires that states conduct a permanency planning hearing

within 18 months after a child enters foster care to determine whether family reunification should continue to be the goal, or whether some other permanent living arrangement, such as adoption or guardianship, should be pursued. The current emphasis on speeding up permanency hearings reflects concerns about children spending long periods of time in foster care. Pending federal legislation would shorten the

time allowed before holding a permanency planning hearing from 18 to 12 months.

As of early 1996, 23 states had already enacted shorter time frames for holding a

permanency planning hearing than required under federal law. In two of these

states, the shorter time frames apply only to younger children. It should be emphasized, however, that while a permanency planning hearing must be held within

these specified time frames, the law does not require that a final decision be made

at this hearing as to whether family reunification efforts should be continued or terminated.

Some drug treatment administrators and child welfare officials in these same locations believe that shorter time frames might help motivate a parent who abuses

drugs to recover. However, expedited time frames 4 may require that permanency
19

permanency legislation are currently in effect only in Cook County; they will go into effect

throughout the rest of the state beginning January 1, 1998.

decisions be made before it is known whether the parent is likely to succeed in drug

treatment. While one prominent national study found that a large proportion of cocaine addicts failed when they attempted to stay off the drug, we previously reported that certain forms of treatment do hold promise. In addition, progress has

been made in the treatment of heroin addiction through traditional methadone

maintenance programs and experimental treatments. However, even when the parent is engaged in drug treatment, treatment may last up to 1 or 2 years, and recovery is often characterized as a lifelong process with the potential for recurring relapses.

Some drug treatment administrators in Los Angeles and Cook Counties believe that treatment is more likely to succeed if the full range of needs of the mother are

addressed, including child care and parenting classes as well as assistance with

housing and employment, which help the transition to a drug-free lifestyle. These

drug treatment administrators also stressed how important it was for parents who

are reunited with their children to receive supportive services to continue their recovery process and help them care for their children. Determining the potential for an individual’s success in drug treatment is ex- tremely difficult given the variety of substances abused, types of treatment and program quality, differences in addiction and readiness for recovery, and definitions of

what constitutes ‘‘recovery.’’ However, the longer an individual is in treatment, the

greater the potential for improved behavior. Some caseworkers in Los Angeles and

Cook Counties said that shorter time frames for holding a permanency planning

hearing may be appropriate in terms of the foster child’s need for a permanent living arrangement. However, they also said that the likelihood of reunifying these

children with their parents when permanency decisions must be made earlier may

be significantly reduced when substance abuse is involved. In their view, the prospects of reunifying these families may be even worse if the level of services currently provided to them is not enhanced. In our ongoing work, we have found that states and localities are responding to the need for timely permanency for foster children through programmatic initiatives

and changes to permanency laws. Most of these initiatives and changes to permanency laws are very new, so there is little experience to draw upon to determine

whether they will help achieve timely exits from foster care for cases involving parental substance abuse. Furthermore, some of these initiatives and changes are controversial and reflect the challenge of balancing the rights of parents with what is

in the best interest of the child, within the context of a severely strained child welfare system. For example, California and Illinois have enacted statutory changes that specifi- cally address permanency for foster care cases involving parental substance abuse.

The Illinois legislature recently enacted new grounds for terminating parental

rights. Under this statute, a mother who has had two or more infants who were prenatally exposed to drugs or alcohol can be declared an unfit parent if she had been

given the opportunity to participate in treatment when the first child was prenatally

exposed. California has enacted new statutory grounds for terminating family reunification services if the parent has had a history of ‘‘extensive, abusive, and chronic’’

use of drugs or alcohol and has resisted treatment during the 3-year period before

the child entered foster care or has failed or refused to comply with a program of

drug or alcohol treatment described in the case plan on at least two prior occasions,

even though the programs were available and accessible. While such laws may help

judges make permanency decisions when the prospects for a parent’s recovery from

drug abuse seem particularly poor, these changes are not without controversy. Some

caseworkers and dependency court attorneys in Los Angeles and Cook Counties expressed concerns that a judge may closely adhere to the exact language in the statutes without considering the individual situation, and may disregard the extent to

which progress has been made toward recovery during the current foster care episode.

States and localities are undertaking programmatic initiatives that may also help to reconcile the goals of family reunification and timely exits from foster care, which

may conflict, particularly when parental substance abuse is involved. New permanency options are being explored as are new ways to prevent children from entering

foster care in the first place. We previously reported on Tennessee’s concurrent planning program that allows caseworkers to work toward reunifying families, while at

the same time developing an alternate permanency plan for the child if family reunification efforts do not succeed. Under a concurrent planning approach, caseworkers emphasize to the parents that if they do not adhere to the requirements
20

set forth in their case plan, parental rights can be terminated. Tennessee officials

attributed their achieving quicker exits from foster care for some children in part

to parents making more concerted efforts to make the changes needed in order to

be reunified with their children.

In addition, both California and Illinois have federal waivers for subsidized guardianship, under which custody is transferred from the child welfare agency to a legal

guardian. In Illinois, CPS cases involving prenatally substance exposed infants can

be closed by the child welfare agency without removing the child from the mother’s

custody if the mother can demonstrate sufficient parental capacity and is willing to

participate in drug treatment and receive other supportive services.

One jurisdiction is developing an approach to deliver what its officials describe as

enriched services to the parent. Illinois’ new performance contracting initiative provides an incentive for private agencies to achieve timely foster care exits for children

by compensating these agencies on the basis of their maintaining a prescribed caseload per caseworker. This necessitates that an agency find permanent living arrangements for a certain number of children per caseworker per year, or the agency

absorbs the cost associated with managing higher caseloads. A component of this

initiative is the provision of additional resources for improved case management and

aftercare services in order to better facilitate family reunification and reduce the

likelihood of reentry. Providing enriched services may make it less likely that judges

will rule that the child welfare agency has failed to make reasonable efforts to reunify parents with their children and thereby reduce delays in permanency decisionmaking.

OBSERVATIONS

In summary, children with substance abusing parents often come to the attention

of the child welfare system either at birth, because of prenatal substance exposure,

or later in life when they are found to have been abused or neglected. The families

of these children have increasingly complex service needs. Many are dually diagnosed with drug or alcohol addictions and mental illnesses, some are involved in

criminal activities, some are homeless, and most have additional children in foster

care. Burgeoning foster care caseloads entailing these complex family situations

have placed enormous strains on the child welfare system.

In seeking to achieve what is in the best interest of children, foster care laws emphasize both family reunification and achieving timely exits from foster care for children. Given the time it often takes a person to recover from drug and alcohol addictions, and the current emphasis on speeding up permanency decisions for foster children, these goals may conflict. Reconciling these goals for children whose parents

have a substance abuse problem presents a tremendous challenge to the entire child

welfare system in determining how to balance the rights of parents with what is

truly in the best interest of children. New state and local initiatives may help address this challenge. Through our ongoing work, we are continuing to explore the

impact of parental substance abuse on foster care, by, for example, examining parents’ substance abuse histories and their drug treatment experiences, as well as exploring initiatives that might help achieve timely foster care exits for cases involving parental substance abuse.

Mr. Chairman, this concludes my prepared statement. I would be happy to respond to any questions from you or other Members of the Subcommittee.

RELATED GAO PRODUCTS

Child Protective Services: Complex Challenges Require New Strategies (GAO/HEHS–97–115,

July 21, 1997).

Foster Care: State Efforts to Improve the Permanency Planning Process Show Some Promise

(GAO/HEHS–97–73, May 7, 1997).

Cocaine Treatment: Early Results From Various Approaches (GAO/HEHS–96–80, June 7,

1996).

Child Welfare: Complex Needs Strain Capacity to Provide Services (GAO/HEHS–95–208, Sept.

26, 1995).

Foster Care: Health Needs of Many Young Children Are Unknown and Unmet (GAO/HEHS–

95–114, May 26, 1995).

Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children (GAO/HEHS–94–

89, Apr. 4, 1994).

Drug Abuse: The Crack Cocaine Epidemic: Health Consequences and Treatment (GAO/HRD–

91–55FS, Jan. 30, 1991).

Drug-Exposed Infants: A Generation at Risk (GAO/HRD–90–138, June 28, 1990).
f

21

Chairman SHAW. Thank you.

Mr. Reuter.

STATEMENT OF PETER REUTER, PH.D., SCHOOL OF PUBLIC

AFFAIRS AND DEPARTMENT OF CRIMINOLOGY, UNIVERSITY

OF MARYLAND, COLLEGE PARK, MARYLAND

Mr. REUTER. Thank you. I was asked to address the question of

whether there are elevated levels of drug use among mothers on

welfare. This is very much a presentation about data and estimates.

The first thing to note is there are very few measurements of

drug use among AFDC recipients, in part because agencies had,

until recently, very little incentive to know anything about the

drug substance abuse problems of their clients. Moreover, it is inherently difficult to develop such measures, both for the agencies

and in more general settings, because they largely rely on selfreport, which has its own frailties as a method of learning about

these kinds of behaviors.

Moreover, the figures are likely to change very substantially over

time in response to changes in the business cycle. There are periods of high unemployment where the AFDC rolls have on them a

large number of short-term clients with very different substance

abuse patterns, including drug dependence, than those who are

long-term clients.

Moreover, in terms of making comparisons between AFDC and

the rest of the population, it is not obvious what is the right comparison group to offer. The AFDC population has a much higher

percentage of females than the general population; you certainly

would want to adjust for differences in usage by gender. Age is different. There are very low rates of use in the population over the

age of 50, very few welfare recipients are over the age of 50.

One might also want to make adjustments for other characteristics that distinguish the AFDC population from that of the general

population—for example, education, marital status, and so forth.

Once you start making those kinds of adjustments for purposes of

doing these kinds of comparisons, you have to ask the question,

What is the purpose of the comparison? And if this were a Committee concerned with the Nation’s drug problems, the question you

might be attempting to answer is, What share of the Nation’s drug

problems are found in the AFDC population. Then knowing something about relative usage rates, in particular, in the two groups,

would in fact be highly relevant.

But if one’s concern is, as I believe this Subcommittee’s hearing

description suggests, a concern about the transition from welfare to

employment or reducing child abuse and neglect on the part of

AFDC recipients, then the question is less the comparison between

AFDC and the rest of the population and simply, What is the rate

of substance abuse of various kinds in the AFDC population?

Having said that, there are a few pieces of evidence available.

They look very conflicting, but in fact I believe that is largely an

artifact of how analysts have gone about defining the problem and,

to some extent, the characteristics of the data that they have used.
22

3 ‘‘Only five states [out of 32] reported having estimates of the number of welfare recipients

with alcohol and drug problems.’’ Legal Action Center Making Welfare Reform Work: Tools for

Confronting Alcohol and Drug Problems Among Welfare Recipients New York, 1997, p.38.

Consistently, we see higher rates of use or abuse of illicit drugs

among AFDC clients than any reasonably defined comparison

group in the general population. I think the best analysis of this

is a recent study by the Office of Applied Studies of the Substance

Abuse and Mental Health Services Administration, which found

that, after adjusting for all the things that seemed relevant, the

rate of problem use among welfare recipients, female welfare recipients, seemed to be twice as high as that for an appropriate comparison group. That still—and it is hard to do the calculations from

what was presented in the report—suggests that problem drug use

among that population might well be less than 10 percent.

Another way of looking at this is to go to the other end of the

system and ask, What share of those in treatment are themselves

recipients of AFDC payments? There are about 250,000 women in

treatment, and approximately one-half, I think, are AFDC recipients. One reason we want to be focusing on the back end is that

the household surveys I cited before as providing estimates of the

prevalence of drug abuse or dependence among AFDC population

are known to generally provide substantial underestimates of drug

dependence. You might use them for these kinds of comparisons,

but they are probably poor ways of getting at the prevalence of substance abuse generally in the AFDC population. So I suggest, looking at treatment program data may be a useful way of

supplementing those data.

Finally, let me say this is not a static problem. Patterns of drug

use have changed substantially over the last 20 years in this country. The rate of initiation into drug use has been down substantially from its peak rates in the eighties. It shows some sign of upturn now. Thus, it may well be that the figures we are now looking

at are reasonable indicators of the next few years, but that further

out there will be larger increases in drug use in the AFDC population.

Thank you, Mr. Chairman.

[The prepared statement follows:]

Statement of Peter Reuter, Ph.D., School of Public Affairs and Department

of Criminology, University of Maryland, College Park, Maryland

SUMMARY

We have been asked to address the question of whether drug use is elevated

among mothers on welfare. The answer is almost certainly yes but the bits of data

available suggest that the differences are moderate. Looking at the more serious

problem, abuse or dependence on illicit drugs is found in only a small percentage

of welfare mothers. A figure as high as 15% would be hard to justify and it may

be less than 10 percent. Trends in drug use in the general population, suggest that

drug dependence within the welfare population is likely to become smaller rather

than greater in the next few years.

THE DATA AND ANALYTIC APPROACH

Because welfare agencies did not in the past have to concern themselves with

what led their clients to seek AFDC, little data are available on the extent of substance abuse in this population. Certainly agencies themselves claim little knowledge.3 Instead we have to rely largely on self-report surveys either of the general

household population, which include welfare clients, or specifically just of the latter
23

4 Center on Addiction and Substance Abuse Substance Abuse and Women on Welfare New

York, 1994. 5The report makes no specific reference to the source of its data; there is however no other

data source that would permit precisely the analyses that are reported. A later CASA report

Substance Abuse and Federal Entitlement Programs (1995) does refer to the 1991 NHSDA but

uses different categorizations in its charts so that it is impossible to determine if the analyses

are the same in the two documents. 6Grant, B. and D. Dawson ‘‘Alcohol and Drug Use, Abuse and Dependence among Welfare

Recipients’’ American J. Public Health 86 1450–1454. 7This is the definition used in the later publication Substance Abuse and Federal Entitlement

Programs.

population. There is also one indirect source, namely data on the extent of AFDC

participation by drug treatment clients. None of these is very satisfactory but weaving the three together can provide a moderately credible statistical portrait. Nor is it easy to decide on the appropriate method of making comparisons of drug use rates among welfare clients and the rest of the population. For example, surveys

show that young adults are much more likely than those over 35 to be current drug

users; in 1996 3.1 percent of those aged 26–34 reported use of cocaine in the prior

year, compared to only 0.8 percent of those 35 or over. Since adult welfare recipients

include few elderly, welfare recipients would show higher rates of drug use than the

population generally even if they had the same age-specific rates. Hence it is necessary to make adjustments to reflect factors other than welfare status that might

affect drug use rates; the appropriate adjustments are very much a matter of the

analyst’s judgment. Note also that the relative rate of drug use and abuse in the welfare population is likely to be cyclical. When unemployment is high, AFDC rolls (and presumably

TANF rolls in the future) will include large numbers of short-termers whose longterm employment prospects are relatively good. Measured rates of drug dependence

among welfare clients may decline, relative to the non-welfare population. Thus the

ratio may be highest when enrollment is lowest. We know of no study that has attempted to adjust for this. Finally, there is the question of what one should employ as a measure of drug use and, more importantly, drug abuse or dependence. Some analysts rely on the

frequency of drug use to define dependence or abuse. Other surveys have imbedded

in their questionnaire a version of a clinical definition of abuse or dependence. Problematic though the latter are, they are preferable to mere frequency definitions both

on conceptual and instrumental grounds; the clinical measures pose questions about

less stigmatized behaviors than do those focused on details of drug use.

ESTIMATES

The most widely cited estimates of the prevalence of drug use among welfare

mothers come from two national household surveys. They appear to show large differences but these are principally artifacts of the definitions chosen by analysts.

The Center on Addiction and Substance Abuse (CASA) published a short report

in 1994,4 apparently based on the 1991 National Household Survey on Drug Abuse

(NHSDA),5 asserting that ‘‘[m]others receiving AFDC are three times more likely to

abuse or be addicted to alcohol and drugs than mothers not receiving AFDC (27 percent compared to 9 percent)’’ (p.3) It concluded that ‘‘[a]t least 1.3 million adult welfare recipients currently abuse or are addicted to drugs and alcohol.’’ (p.7) With

fewer than 5 million adult welfare recipients, this is an alarming number.

More recently researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) published an analysis of the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES) which concluded that only 3.6% of AFDC recipients over

18 were drug dependent or drug abusers and that 7.6% were alcohol dependent.6

Moreover the authors concluded that rates for welfare recipients were ‘‘comparable

to rates of heavy drinking (14.8%), drug use (5.1%), alcohol abuse and/or dependence

(7.5%) and drug abuse and/or dependence (1.5%) among the subpopulation of the

United States not receiving welfare benefits.’’ (p.1453)

The principal explanation for these differences simply lie in the definitions of drug

abuse. The CASA report never explicitly described how it classified an individual

as a drug abuser or drug addict but it appears that using an illicit drug at least

once per month was sufficient for that diagnosis.7 In contrast, the NIAAA researchers focused on behavioral problems related to drug or alcohol abuse, which are part

of diagnostic instruments.

The CASA estimate seems far too high, particularly when we note that the vast

majority of the drug users in the NHSDA consumed only marijuana. A monthly user

of marijuana is certainly flouting the law regularly but may not have a serious be24

8Department of Health and Human Services Substance Use Among Women in the United

States 1997. Table 3.10. Problem drug use is defined as: dependent on an illicit drug (using

DSM–IV criteria); injection drug use; frequent user of illicit drug (e.g. weekly user of cocaine

or daily user of marijuana); used heroin or received treatment in the previous year. Factors used

to calculate the relative odds ratio include: age, race, marital status, education and family size.

The relative odds ratio of 1.92 is statistically significantly different from 1 at the 5 percent level. 9The report does not present adjusted figures for the non-welfare population. Note however

that for women aged 18–24 the unadjusted rate for problem drug use is 4.3% and falls sharply

after that. 10Department of Health and Human Services National Household Survey on Drug Abuse:

Population Estimates Rockville, Md. 1996. The cited figure is for weekly users. 11These estimates are cited in the annual National Drug Control Strategy. 12 Rhodes et al. What America’s Drug Users Spend on Illicit Drugs 1988–1993 Washington,

Office of National Drug Control Policy, 1995. 13Weisner, C and L. Schmidt ‘‘Alcohol and Drug Problems among Diverse Health and Social

Service Populations’’ American J. Public Health 83 824–829. 14The results for the welfare population are adjusted to represent the age, sex and ethnic distributions in the general population. 15The 1988 NHSDA reported that 7.5% of the household population used some drug other

than marijuana in the previous year. Other survey data suggest that most users of cocaine, heroin and other ‘‘harder’’ drugs contemporaneously use marijuana; if two thirds used marijuana,

that would suggest a household multiple drug use rate of at least 5 percent. 16 National Association of State Alcohol and Drug Abuse Directors State Resources and Services Related to Alcohol and Other Drug Problems1993 Washington, DC 1995.

havioral health problem with important adverse consequences either for the mother

or family. A more sophisticated analysis of the 1994 and 1995 NHSDA shows that,

adjusting for a number of demographic and family characteristics, a woman on welfare is almost twice as likely as those not on welfare to be classified as a problem

drug user.8 However, this suggests a rate for welfare women of less than 10 percent

perhaps even much less.9

That is not to say that rates as low as those reported by the NLAES or NHSDA

should be accepted at face value. These nationwide household surveys are known

to underestimate the prevalence of drug abuse and dependence. For example, in recent years the NHSDA has produced estimates of the total number of frequent cocaine users of about 700,000; 10 yet other estimates, reflecting the results of urinalysis of arrestees, generate estimates of about double that figure.11 Heroin dependence, estimated to affect about 600,000 persons,12 cannot be determined from the

NHSDA, mostly because of the instability of the lifestyles of heroin addicts. It would

be naive to rely solely on these general population surveys for estimates of the extent of drug use and abuse among AFDC recipients.

Many factors contribute to the weakness of these surveys in estimating the number of frequent users. First, many cocaine and heroin abusers are found outside of

households, whether they are homeless, incarcerated or otherwise institutionalized.

Though 98 percent of all Americans live in households, these other settings may

contain a substantial share of the tiny fraction that have drug abuse problems. For

example, if there are 4 million persons outside the houshold population and 15% of

them are drug dependent, not an unreasonable figure, then this 600,000 would constitute nearly 10% of the estimated number of drug dependent individuals and probably a much larger share of those dependent on cocaine or heroin. Second, drug

abusers are probably harder to reach when they are in households; they are less

likely to be there and available to respond at a specific time. Third, they are less

likely to report the full extent of their drug use.

An alternative approach has been to obtain data directly from samples of AFDC

clients. The Alcohol Research Group at the University of California, Berkeley has

been conducting research on a variety of public program settings in Northern California. They published initial results in 1993, reflecting data collection carried out

between 1986 and 1989.13 They found that 21 percent of welfare clients were multiple drug users, on a past year basis. In a general population survey in the same

geographic area, they found only 1 percent using more than one illicit drug.14 That

is an alarmingly large difference, suggesting that welfare recipients are twenty

times more likely to use drugs other than marijuana. However the results should

be treated with considerable skepticism because the rate in the general population

sample is so far below that found in national household surveys; the 1988 NHSDA

data for example suggests that about 5 percent had used more than one illicit drug

in the previous year.15

Another more speculative approach to estimation starts at the other end of the

process, namely with drug treatment. A large share of the 250,000 women reported

by state officials as being in drug treatment programs 16 are welfare recipients. With

a number of assumptions of varying plausibility about the probability that a woman
25

17Gerstein, D. et al. Alcohol and Other Drug Treatment for Parents and Welfare Recipients:

Outcomes, Costs and Benefits Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 1997. The report is not specific as to the definition

of a welfare recipient, so this figure may include some who receive General Assistance. 18Legal Action Center Making Welfare Reform Work: Tools for Confronting Alcohol and Drug

Problems Among Welfare Recipients New York, 1997. 19See ‘‘Drop in Homicide Rates Linked to Decline in Crack Epidemic’’ New York Times October 27, 1997, p.A12. 20Department of Health and Human Services Preliminary Results from the 1996 National

Household Survey on Drug Abuse Substance Abuse and Mental Health Services Administration,

1997. 21School of Public Affairs, Department of Criminology, University of Maryland. Mr. Reuter

delivered his testimony at the Committee hearing on October 28, 1997. 22Drug Policy Research Center, RAND Corporation.

who is drug dependent will enter treatment, it is possible to develop rough estimates of how many adult female welfare recipients are currently drug dependent.

We report here just some initial indicative calculations.

A study of the patient population of California’s drug and alcohol treatment programs in 1991–92 reports that 41 percent of female patients had received welfare

payments in the year before treatment.17 A survey of 17 treatment programs recently reported by the Legal Action Center reports that 56% of female clients are

AFDC recipients.18 If indeed half of the clients are welfare recipients and there are

4 million women over the age of 18 receiving welfare, then approximately 3% of any

year’s welfare recipient population would be classified as problem drug users under

the NHSDA definition for that reason alone. Given that treatment is thought to

reach only about one quarter of those most in need, that would suggest a figure closer to 10 percent for drug dependence among female adult welfare clients.

Given all these uncertainties, we suggest that it is likely that the rate of dependence on illicit drugs among AFDC mothers in recent years has been between 5 and

10 percent. Improving these estimates ought to have some urgency as the nation

moves to a welfare system aimed at getting clients into work.

THE FUTURE OF DRUG ABUSE AMONG WELFARE RECIPIENTS

The issue for welfare reform is only partly drug use levels among current recipients. Welfare reform is a policy change for the long haul and should reflect the prevalence of drug use likely to be found in new applicants for TANF.

Drug use patterns among the welfare population reflects those in the general population. Despite rising adolescent marijuana use, the available evidence suggests

that drug dependence among future cohorts of young adults is likely to decline for

a few years. Indeed, cocaine initiation rates have been low for the last decade in

the highest risk population groups. For example, the District of Columbia Pretrial

Services Agency (PSA) has conducted drug tests on all juvenile arrestees since 1987;

it is the only agency in the nation that does so. Marijuana positive rates have skyrocketed, from less than 10 percent in 1990 to 72 percent in 1997. However for all

other drugs the rates for drug positives among juvenile arrestees have been extremely low since 1990. Whereas in 1988 about 23 percent of juvenile arrestees tested positive for cocaine the rates since 1990 have never been higher than 9 percent

and frequently less than 5 percent. Similar declines in rates of cocaine use have

been reported among juvenile arrestees in other cities.19

In the general population, as reported in the NHSDA, cocaine initiation rates, i.e.

the number who start use of that drug in each year, have been relatively low for

some time, reflecting the sharp increase in the perception of the drug’s dangerousness. In 1984 an estimated 1.35 million persons used cocaine for the first time; that

figure was down to 650,000 in 1995. However it has risen sharply from its floor of

450,000 in 1992. Moreover, initiation rates have increased most rapidly for the

youngest age group tracked, 12–17; whereas in 1991 only 4.6 percent of 12–17 year

olds who had not previously tried cocaine experimented for the first time, the figure

had risen to 10.6 percent in 1995.20

It is difficult then to make projections as to the future patterns of drug use among

welfare mothers. General population initiation rates are still very much below their

1980s peaks. However, recent trends do suggest that there may be at least a modest

upturn in both use and abuse rates. It is unlikely though that this will lead to any

notable increase in drug dependence rates in the near future.

Peter Reuter 21

Patricia Ebener 22
f

26

Chairman SHAW. Thank You.

Mr. Zill.

STATEMENT OF NICHOLAS ZILL, PH.D., VICE PRESIDENT AND

DIRECTOR, CHILD AND FAMILY STUDY AREA, WESTAT, INC.,

ROCKVILLE, MARYLAND

Mr. ZILL. Good afternoon, Chairman Shaw and Members of the

Human Resources Subcommittee. My name is Nicholas Zill. I am

a research psychologist and director of the Child and Family Study

Area at Westat, a survey research firm here in the Washington

area. As part of my work at Westat and an earlier position as the

executive director of Child Trends, I have done a good deal of research on the characteristics of welfare families and the development and well-being of children in those families and in low-income

families that are not receiving welfare.

Chairman Shaw invited me here today to share with you what

this research has shown about the frequency of parental substance

abuse in welfare families and to comment on what the implications

of such abuse might be for the children in these families and for

efforts to move parents off welfare and into steady jobs.

The data I report to you come from two Federal surveys. One is

the National Household Survey on Drug Abuse, conducted regularly by the Substance Abuse and Mental Health Services Administration; the other is the National Pregnancy and Health Survey

that Westat conducted for the National Institute on Drug Abuse.

This was a survey of 2,612 women who gave birth during a 12-

month interval in 1992 and 1993. The women were located and

interviewed in a probability sample of maternity hospitals across

the United States.

What both of these surveys showed was the use of illicit drugs,

such as cocaine, heroin, and marijuana, is significantly more common among female welfare recipients than among the general population of American women. The Household Survey found illegal

drug abuse to be twice as common among female welfare recipients

as among women who did not receive welfare. The hospital survey

found illicit drug use during pregnancy was three times more common among women receiving AFDC than among those not receiving AFDC. Cocaine use during pregnancy, usually in the form of

crack, was 10 times higher among pregnant welfare recipients than

among nonrecipients.

The majority of women who, during pregnancy, used cocaine

were on welfare. At the same time, it is important to note it was

only a minority of welfare recipients who used prohibited drugs. Of

all female welfare recipients, about one in five used some illegal

drugs during the last year; of female recipients who were expecting, about one in seven used some unlawful drug, and about one

in twenty used crack or cocaine during their pregnancies. These

proportions are disquieting enough, but we must be careful not to

characterize all or even most AFDC recipients as drug abusers.

It is also the case, women in low-income families who did not receive AFDC used some drugs with almost the same frequency as
27

welfare mothers; thus, the phenomenon we are addressing could be

characterized as a poverty problem as much as a welfare problem.

Are young children whose mothers use illicit drugs, and crack in

particular, at greater risk of health and learning problems than

children whose mothers are not chronic drug users? We know expectant mothers who use cocaine are more likely to produce lowbirth-weight babies and babies who die during infancy. Some researchers believe they are also more likely to produce babies who

grow up to have neurological disorders and learning disabilities, although the long-term effects of prenatal crack exposure on children’s development are still being studied and debated.

Common sense suggests a woman who is not able to give up cocaine in order to protect the health of an unborn child in her womb

is likely to neglect other aspects of the child’s care as well, both

during pregnancy and after the child’s birth. There are lots of data

to support this supposition. The National Pregnancy and Health

Survey found, compared to expectant mothers not on welfare,

women in welfare families who became pregnant were 21⁄2 times

more likely to get prenatal care late or not at all. They were 60

percent more likely to gain inadequate amounts of weight during

pregnancy, and twice as likely to have a pregnancy too soon after

the birth of a previous child for optimum development of either.

These other neglectful behaviors were correlated with maternal

drug use.

Another Federal study, the National Maternal and Infant Health

Survey, found that infants from a welfare family were two-thirds

more likely to die during the first year of life as infants from

nonpoor families. An epidemiological study in North Carolina found

that young children in welfare families had significantly higher

rates of death due to unintentional injuries than those in nonwelfare families. Furthermore, the National Health Interview Survey

has found school-aged children from welfare families have significantly higher rates of grade repetition, classroom conduct problems,

and special education placements than their classmates from

nonpoor families. It is unlikely these negative outcomes for welfare

children are solely due to maternal drug use. Factors like low maternal IQ, poverty, and low maternal education are also important,

but there are clearly negative consequences for children when their

mothers engage in persistent patterns of detrimental health-related

behavior. Chronic drug use is often part of such a high-risk behavior pattern.

To close my testimony, I would like to leave the survey data and

turn to the question of whether welfare recipients who are drug

abusers should be treated differently from other recipients with respect to being required to find jobs and being subject to time limits

on their receipt of cash assistance. Should they, for example, be allowed to continue receiving welfare until they have been successfully treated for their substance abuse problems? I would argue

they should not.

Treatment of chronic substance abuse is a difficult and often

frustrating process. Successful outcomes are associated with the

abuser becoming fed up with their own self-destructive behavior

and being ready to change. Being given a guarantee of continued

welfare support does not increase motivation to change; it reduces
28

it. Although it seems like the humane thing to do, it is not wise.

It is also bad for the many welfare recipients who are not drug

abusers to have temporary assistance to needy families linked in

the public mind with subsidized addiction.

I am going to conclude my testimony there. I have a little more

I had to say about that, but I would request my extended statement and accompanying data tables be inserted into the record;

they provide fuller documentation of the survey findings I have

presented.

Thank you.

Mr. SHAW. It shall be, Dr. Zill.

[The prepared statement and attachments follow:]

Statement of Nicholas Zill, Ph.D., Vice President and Director, Child and

Family Study Area, Westat, Inc., Rockville, Maryland

Good afternoon, Chairman Shaw and Members of the Human Resources Subcommittee. My name is Nicholas Zill. I am a research psychologist and the Director

of the Child and Family Study Area at Westat, a survey research firm based in the

Washington area. As part of my work at Westat and in an earlier position as the

Executive Director of Child Trends, I have done a good deal of research on the characteristics of welfare families and the development and well-being of children in

those families and in low-income families that are not receiving welfare. This research was partly supported by contracts from federal agencies, such as the Office

of the Assistant Secretary for Planning and Evaluation of the Department of Health

and Human Services, and partly by grants from private foundations. Chairman

Shaw invited me here today to share with you what this research has shown about

the frequency of parental substance abuse in welfare families and to comment on

what the implications of such abuse might be for the children in these families and

for efforts to move parents off welfare and into steady jobs.

The data I report to you come from two federal surveys. One is the National

Household Survey on Drug Abuse conducted regularly by the Substance Abuse and

Mental Health Services Administration (SAMSHA). This is a survey of the civilian

population aged 12 years of age and older living in households in the United States.

The other is the National Pregnancy and Health Survey that Westat conducted for

the National Institute on Drug Abuse. This was a survey of 2,612 women who gave

birth during a 12-month interval in 1992–93. The women were located and interviewed in a probability sample of maternity hospitals across the U.S.

What both of these surveys showed was that the use of illicit drugs such as cocaine, heroin, and marijuana is significantly more common among female welfare

recipients than among the general population of American women. The household

survey found illegal drug use to be twice as common among female welfare recipients as among women who did not receive welfare. The hospital survey found that

illicit drug use during pregnancy was three times more common among women receiving Aid to Families With Dependent Children than among those not receiving

AFDC. Cocaine use during pregnancy (usually in the form of ‘‘crack’’) was ten times

higher among pregnant welfare recipients than among non-recipients.

At the same time, it is important to note that it was only a minority of welfare

recipients who used prohibited drugs. Of all female welfare recipients, about one in

five used some illegal drugs during the last year. Of female recipients who were expecting, about one in seven used unlawful drugs, and about one in twenty used

crack or cocaine during their pregnancies. These proportions are disquieting enough,

but we should be careful not to characterize all or even most AFDC recipients as

drug abusers. It is also the case that women in low-income families who did not receive AFDC used some drugs with almost the same frequency as welfare mothers.

Thus, the phenomenon we are addressing could be characterized as a poverty problem as much as a welfare problem.

Are young children whose mothers use illicit drugs, and crack in particular, at

greater risk of health and learning problems than children whose mothers are not

chronic drug users? We know that expectant mothers who use cocaine are more likely to produce low birth weight babies and babies who die during infancy. Some researchers believe they are also more likely to produce babies who grow up to have

neurological disorders and learning disabilities, although the long-term effects of

prenatal crack exposure on children’s development are still being studied and debated.
29

Common sense suggests that a woman who is not able to give up cocaine in order

to protect the health of an unborn child in her womb is likely to neglect other aspects of the child’s care as well, both during pregnancy and after the child’s birth.

There are lots of data to support this supposition. For example, the National Pregnancy and Health Survey found that, compared to expectant mothers not on welfare,

women in welfare families who became pregnant were two-and-a-half times more

likely to get prenatal care late or not at all. They were 60 percent more likely to

gain inadequate amounts of weight during pregnancy, and twice as likely to have

a pregnancy too soon after the birth of a previous child for optimum development

of either. These other neglectful behaviors were correlated with maternal drug use.

Another federal study, the National Maternal and Infant Health Survey, found

that infants from welfare families were two-thirds more likely to die during the first

year of life as infants from non-poor families. An epidemiological study in North

Carolina found that young children in welfare families had significantly higher rates

of death due to unintentional injuries than those in non-welfare families. The National Health Interview Survey has found that school-aged children from welfare

families have significantly higher rates of grade repetition, classroom conduct problems, and special education placements than their classmates from non-poor families. It is unlikely that these negative outcomes for welfare children are solely due

to maternal drug use. Factors like low maternal IQ, poverty, and low maternal education are also important, perhaps more important. But there are clearly negative

consequences for children when their mothers engage in a persistent pattern of detrimental health-related behavior. Chronic drug use is often part of such a high-risk

behavior pattern.

To close my testimony, I would like to leave the survey data and turn to the question of whether welfare recipients who are drug abusers should be treated differently from other recipients with respect to being required to find jobs and being

subject to time limits on their receipt of cash assistance. Should they, for example,

be allowed to continue receiving welfare until they have been successfully treated

for their substance abuse problems? I would argue that they should not. Treatment

of chronic substance abuse is a difficult and often frustrating process. Successful

outcomes are associated with the abuser becoming fed up with her own self-destructive behavior and being ready to change. Being given a guarantee of continued welfare support does not increase motivation to change, it reduces it. Although it seems

like a humane thing to do, it is not wise. It is also bad for the many welfare recipients who are not drug abusers to have Temporary Assistance to Needy Families

(TANF) linked in the public mind with subsidized addiction.

Certainly, TANF should provide treatment programs for recipients who have drug

problems. But treatment should occur in parallel with preparation for work and

transitional employment, not prior to it. There are plenty of examples outside of the

welfare world of people with substance abuse problems who are able to hold down

jobs. Like other recipients, those with substance abuse problems should be subject

to time limits on their receipt of cash assistance. It may be necessary to provide employers with extra inducements to take on welfare recipients who are drug abusers,

because drug abusers often steal to support their habits. The whole process is not

going to be easy. There are going to be painful failures. But this kind of approach

is still preferable to one which provides no incentive for overcoming drug dependence.

That concludes my testimony. I would request that my extended statement and

accompanying data tables be entered into the record. They provide fuller documentation of the survey findings I have presented. Thank you.

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Supplementary Statement by Nicholas Zill, Ph.D., Westat, Inc.

According to the National Household Survey on Drug Abuse (NHSDA) conducted

by the Substance Abuse and Mental Health Services Administration (SAMSHA), the

use of illicit drugs such as marijuana, cocaine, and heroin is more prevalent among

welfare recipients than in the general population (Colliver and Quinn, 1994). Specifically:

• Among females aged 15 and over living in households where AFDC benefits

were received, 21 percent reported some illicit drug use in the last year, and 10.5

percent reported use in the last month. These rates were twice as high as those for

females in non-AFDC households. (Table 1).

• The illicit drug most commonly abused by welfare recipients is marijuana, with

16 percent reporting use of this drug in the last year. This is double the rate of use

among females not in welfare households.

• Cocaine abuse is also common, usually in the form of crack, with 5.5 percent

of females in welfare households reporting cocaine use in the last year. This is nearly triple the rate of use among non-welfare females.

• Non-medical use of psychotherapeutic drugs such as tranquilizers, stimulants,

or barbiturates in the past year is reported by 6.9 percent of welfare females.

• Daily alcohol use is no more common among welfare recipients than among

other females. But binge drinking—having five or more drinks one or more times

in the past 30 days—is reported by 12.5 percent of females in welfare households,

nearly sixty percent higher than the rate among females from non-welfare households.

Illicit drug use is more common among some AFDC subgroups than among others.

In particular:

• Nearly 30 percent of welfare mothers who have never married have used illicit

drugs in the past year. This drug use rate is more than three times higher than

the rate among welfare mothers who are currently married. Welfare recipients who

are divorced or separated fall in between, with 19 percent having used some illegal

drug in the past year. (Table 2).

• Drug use is more common among welfare mothers who are looking for work

than among those currently employed full-time or not in the labor force.

• Drug use is more common among welfare recipients in their teens or twenties

than among those in their thirties or forties.

• Drug use is more common among white non-Hispanic or black non-Hispanic recipients than among Hispanic recipients.

• Drug use is less common among female recipients who are high school graduates (but no more) than among those who have not finished high school or those

who have some postsecondary schooling.

It is important to note that the above estimates are based on self-reported drug

use by welfare recipients and other survey respondents. Self-reports of drug use

have to be interpreted with caution, even when they come from surveys like the

NHSDA that go to extra lengths to assure respondents of anonymity and that no

negative consequences will occur to them from acknowledging use of illegal substances. Methodological studies in which chemical testing or other methods are used

to validate self-reports of drug use have found underreporting to be common, and

more so in some groups than in others. Questions that ask whether the person has

ever used illegal drugs or used them in the last year tend to produce more complete

self-identification of drug use than questions dealing with current use (use in last

month or week). Based on findings to date, we can be fairly confident that drug

abuse is more common among welfare recipients, but less confident about the exact

extent of use.

ILLICIT DRUG USE DURING PREGNANCY

Expectant mothers who use cocaine or other illicit drugs during their pregnancies

are more likely to produce low birth weight babies, babies who die during infancy,

and babies who grow up to have neurological disorders and learning disabilities. The

National Pregnancy and Health Survey found that among women who were receiving AFDC and gave birth during 1992–93, more than 13 percent reported using

some illicit drug during their pregnancies. This was more than three times the rate

of illicit drug use among expectant mothers who were not receiving AFDC, which

was about 4 percent (Table 3).

The study found that more than 5 percent of the expectant mothers receiving

AFDC reported cocaine use (usually in the form of ‘‘crack’’) during their pregnancies.

This was ten times higher than the cocaine use rate (0.5 percent) among expectant

mothers not receiving AFDC. Sixty percent of all the pregnancies in which cocaine
31

use was involved were to women receiving AFDC, whereas these women represented

less than 13 percent of all pregnancies during the study period.

Expectant mothers on welfare appeared to be more likely than nonwelfare mothers to have smoked marijuana—6 percent versus 3 percent—or made nonmedical

use of psychotherapeutic drugs, such as tranquilizers or antidepressants—3 percent

versus 1 percent. However, the differences involved were not large enough to be statistically significant. A small proportion of expectant mothers on welfare (1.6 percent) reported using methamphetamine, inhalants, or hallucinogens during their

pregnancies. Although this rate appeared to be 3 times higher than the rate among

nonwelfare mothers (0.5%), and more than twice as high as the overall rate of use

among expectant mothers (0.6%), these differences were also not statistically reliable. The proportion reporting use of heroin or methadone was much lower (less

than 0.1 percent) and not different from the overall rate or the rate for nonwelfare

mothers (both of which were 0.2 percent).

The study also found that welfare mothers were twice as likely as non-welfare recipient mothers to have smoked cigarettes during their pregnancies—37 percent versus 18 percent. On the other hand, there was no significant difference in the reported use of alcohol during pregnancy—21 percent and 19 percent (Table 3).

The illicit drug use rate among all women living in AFDC households who gave

birth during the study period was more than 11 percent. (The group included here

includes teenage daughters or other female relatives who gave birth during the

study period, as well as the welfare recipients themselves.) This was more than

three times higher than the 3 percent rate of illicit drug use among expectant mothers from nonpoor, nonwelfare households, and twice as high as the rate among all

expectant mothers, which was 5-and-a-half percent. It also appeared higher than the

rate found among women in poor, nonwelfare households (8 percent). However, the

latter difference was not statistically reliable (Table 4).

With regard to use of specific types of drugs, cocaine use and use of methamphetamine, inhalants, or hallucinogens seemed to be higher among welfare mothers than

among nonwelfare poor mothers. Again, however, the differences involved were not

statistically significant. Rates of marijuana use, nonmedical use of psychotherapeutic drugs, and heroin or methadone use were similar in the two low-income groups

(Table 4).

REFERENCES

Coiro, M.J., Zill, N., & Bloom, B. (1994). Health of our nation’s children. National Center for

Health Statistics. Vital and Health Statistics 10. Washington, DC: U.S. Government Printing

Office.

Colliver, J., & Quinn, E. (1994) Patterns of substance use and program participation. Report

prepared for the Office of the Assistant Secretary for Planning and Evaluation and the National

Institute on Drug Abuse, U.S. Department of Health and Human Services, Washington, DC.

Nelson, M.D., Jr. (1982). Socioeconomic status and childhood mortality in North Carolina.

American Journal of Public Health. 1131–3 (August).

Zill, N., Moore, K.A., Nord, C.W., and Stief, T. (1991). Welfare mothers as potential employees:

a statistical profile based on national survey data. Washington DC: Child Trends, Inc.

Zill, N., Moore, K.A., Smith, C.W., Stief, T., and Coiro, M.J. (1995). The life circumstances

and development of children in welfare families: a profile based on national survey data. In:

Chase-Lansdale, P.L., & Brooks-Gunn, J., editors. Escape from poverty: What makes a difference for poor children? New York: Cambridge University Press.

Zill, N. (1996). What we know about welfare families and what it means for welfare reform.

Report prepared for the American Enterprise Institute. Rockville, MD: Westat, Inc.

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Table 1. Prevalence of Reported Illicit Drug and Alcohol Use Among Females Aged

15 and Over Who Live in AFDC Recipient Households, Compared To Use by Females in Nonrecipient Households, United States, 1991

Females in:

AFDC recipient households

Nonrecipient

households

Recipients’

use rate as

percentage of

nonrecipients’

use

Type of drug or alcohol use:

Any illicit drug use in past year ............................. 21.1% 10.6% 200%

Marijuana use ................................................... 16.2% 7.2% 227%

Cocaine use ....................................................... 5.5% 1.9% 285%

Nonmedical use of psychotherapeutic drugs .. 6.9% 4.5% 154%

Daily alcohol use in past year ................................ 6.6% 5.4% 122% ns

Binge drinking in last month ................................. 12.5% 8.0% 157%

Note: Difference between recipients and nonrecipients is statistically reliable unless indicted by ‘‘ns.’’

Source: Author’s retabulation of data from Colliver, J., & Quinn, E. (December 1994). Patterns of Substance

Use and Program Participation. Washington, DC: U.S. Department of Health and Human Services, Office of

the Assistant Secretary for Planning and Evaluation and National Institute on Drug Abuse.

Table 2. Prevalence of Reported Illicit Drug Use Among Female AFDC Recipients by

Marital Status, Age, Race and Ethnicity, Educational Attainment, and Employment Status, United States, 1991

f

Percentage of

AFDC Recipients

Rate of illicit

drug use in

last year

All female AFDC recipients aged 15 and over ..................................... 100% 21.1%

Marital status:

Never married ........................................................................... 44% 29.8%

Separated or divorced .............................................................. 32% 19.3%

Currently married .................................................................... 20% 8.2%

Widowed .................................................................................... 4% ——

Age group:

15–19 years old ......................................................................... 14% 30.2%

20–25 years old ......................................................................... 22% 31.6%

26–30 years old ......................................................................... 17% 31.2%

31–35 years old ......................................................................... 14% 20.5%

36–40 years old ......................................................................... 12% ——

Over 40 years old ...................................................................... 21% 4.3%

Race/ethnicity:

White (non-Hispanic) ............................................................... 45% 22.5%

Black (non-Hispanic) ................................................................ 36% 23.4%

Hispanic .................................................................................... 14% 12.5%

Other ......................................................................................... 5% ——

Educational attainment: *

Less than high school ............................................................... 45% 22.4%

High school graduate ............................................................... 37% 17.4%

Some postsecondary schooling ................................................. 18% 23.3%

Employment status: *

Employed full time ................................................................... 14% 17.8%

Employed part time .................................................................. 11% ——

Looking for work ....................................................................... 22% 29.6%

Not in labor force ...................................................................... 53% 18.1%

——Subsample too small for stable estimate.

* Recipients aged 18 and over only.

Source: Author’s retabulation of data form Colliver, J., & Quinn, E. December 1994). Patterns of Substance

Use and Program Participation. Washington, DC: U.S. Department of Health and human Services, Office of

the Assistant Secretary for Planning and Evaluaiton and National Institute on Drug Abuse.
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Table 3. Illicit Drug, Cigarette, and Alcohol Use During Pregnancy by Women

Receiving and Not Receiving AFDC During 12 Months Prior to Birth of Child,

United States, 1992–93

Women giving birth during 12-month study

period Recipients’

use rate as

percentage of

nonrecipients’ rate

Percentage of

all drug-involved mothers who were

receiving

AFDC

Women currently receiving AFDCWomen not

receiving

AFDC

All women

giving birth

during period

During pregnancy mother

used:

Any illicit drug ............. 13.3% * 4.4% 5.5% 304% 30%

—Cocaine .................. 5.3% * 0.5% 1.1% 1,019% 60%

—Marijuana .............. 5.8% 2.5% 3.0% 229% 25%

—Nonmedical use of

psychotherapeutic

drug ....................... 3.3% + 1.3% 1.5% 259% 27%

—Methamphetamine,

inhalants, or

hallucinogens ........ 0.6% 0.5% 0.6% 339% 33%

—Heroine or methadone ....................... <0.1% 0.2% 0.2% .................... ....................

Cigarettes ..................... 37.4% * 17.9% 20.4% 208% 23%

Alcohol .......................... 20.6% 18.6% 18.8% 111% 14%

Unweighted sample

size ............................ 361 2,251 2,612 .................... ....................

Estimated number in

population ................. 506,17 3,515,319 4,021,494 .................... ....................

Weighted percentage ... 12.6% 87.4% 100.0%

* Significantly different from use rate of nonrecipients, p<.05

+ Significantly different from use rate of nonrecipients, p<.10

Source: Zill, N., and Loomis, L. Analysis of unpublished data from the National Pregnancy and Health Survey, National Institute on Drug Abuse, 1992–93. Westat, Inc., 1995.

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Table 4. Illicit Drug, Cigarette, and Alcohol Use During Pregnancy by Women from

AFDC Households, Poor Non-AFDC Households, and Nonpoor Households, United

States, 1992–93

Women giving birth during 12-month study period

Women in households receiving AFDCWomen in poor non-AFDC

households

Women in

nonpoor, nonAFDC householdsAll women

giving birth

During pregnancy mother

used:

Any illicit drug ..................... 11.4% 8.1% 3.4% 5.5%

—Cocaine .......................... 3.8% 0.9% 0.5% 1.1%

—Marijuana ..................... 5.6% 5.7% 1.6% 3.0%

—Nonmedical use of psychotherapeutic drug ..... 2.8% 2.5% 1.0% 1.5%

—Methamphetamine,

inhalants, or

hallucinogens ................ 1.1% 0.4% 0.5% 0.6%

—Heroine or methadone 0.2% 0.2% 0.1% 0.2%

Cigarettes ............................. 32.6% 25.4% 16.0% 20.4%

Alcohol .................................. 18.2% 10.9% 20.9% 18.8%

Unweighted sample size ..... 486 416 1,710 2,612

Estimated number in population ................................. 698,047 634,037 2,689,410 4,021,494

Weighted percentage ........... 17.4% 15.8% 66.9% 100.0%

Source: Zill, N., and Loomis, L. Analysis of unpublished data from the National Pregnancy and Health Survey, National Institute on Drug Abuse, 1992–93. Westat, Inc., 1995.

CHILDREN AND FAMILY FUTURES, IRVINE, CALIFORNIA

STATEMENT OF NANCY K. YOUNG, PH.D., DIRECTOR,

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Ms. YOUNG. Good afternoon. I am here today as a policy researcher, as an adviser to several States and communities and also

as an adoptive parent of two children, whose lives embody this

problem, families affected by alcohol and other drugs.

At the most important moment in the life of our children’s birth

mother, the moment when she had been told she was going to lose

custody of her children, she said, I want help, I will do anything

to get them back. Unfortunately, the answer which the child welfare system gave to her was, Call me next week; I will give you a

list of phone numbers for treatment, but I don’t have access to help

you get into the program and I don’t know if they have any vacancies. My testimony today is in hopes you will do all you can to provide a better answer to the hundreds of thousands of parents who

find themselves in that position.

Many, not all, but many of those parents are ready to do what

they need to do to end their abuse of alcohol and other drugs. But

the response they get from the three systems that are funded separately—welfare, child welfare, and substance abuse treatment—is

utterly inadequate, because those systems usually don’t talk to parents in a unified way and often don’t have the language to talk to

each other.

My message today includes three essential points. First, these

systems typically do not work together despite the fact that the

vast majority of the families entering the child welfare system have

substance abuse problems.
35

A basic first step has to be collecting better information on these

overlaps. We need the provision in H.R. 867, the Adoption Promotion Act, which requires the Secretary of HHS to look at the

substance abuse needs among the welfare system.

Second, focusing services and supports on children of substance

abusers assures the children most at risk that the next generation

of substance abusers will receive the help they need to break the

cycle of intergenerational dependency. Children of substance abusers, particularly substance abusing mothers, are at a greater risk

than their peers for alcohol and drug use, delinquency, poor school

performance, as well as depression and other psychiatric disorders.

They deserve and need services targeted directly to them, regardless of their parents’ compliance with treatment and recovery.

Third, we know treatment for alcohol and drug problems saves

tax dollars. It may not work for all people the first time, but it

works for enough people to have a very high payoff. The basic fact

about the poor connections between programs for children and families and substance abuse programs is that most treatment agencies don’t count children as part of their caseloads. At the same

time, child welfare agencies don’t systematically assess for alcohol

and drug problems.

The P.A.S.S. legislation, in its original form, required State agencies to report on these issues or to tell the Secretary of HHS what

they needed to be able to make this data available. We supported

that requirement because we believe that counting children who

need these services is vital. Counting children isn’t important for

the sake of the data alone; rather, we believe we will never be able

to stop the intergenerational aspect of alcohol and drug problems

until we get a handle on just how many children of substance abusers need more than a generalized prevention message.

We have found very few people fully understand the funding

streams for these fragmented systems. Each system has its own

rules, jargon, eligibility requirements, and expertise. The child welfare system is just beginning to move beyond a recognition that the

families they are trying to help have significant alcohol and drug

problems. Some are beginning to put the funding pieces together.

The good news is there are some powerful exceptions to the rule

of fragmentation among welfare, child welfare, and substance

abuse treatment programs. These models and early efforts exist in

Sacramento County, in Florida, and in Cleveland, to name only a

few of the sites. Congress could do a great deal to make these programs more comprehensible and to create hooks and glue to make

it easier for communities to put these programs together.

In the final analysis, it is about setting priorities. With limited

resources, the hard decisions come down to weighing the long-term

cost benefits of a focus on those children who are more likely to develop their own problems as a result of growing up in a family affected by alcohol and drug abuse.

I know how I would make that decision. I would make it in favor

of the children who will be affected by intergenerational poverty

and substance abuse. I would choose that way because it is more

cost effective, because it would ultimately benefit more people, and

because it is right. I believe we could have public policy at the

State and Federal level that says we should help every parent who
36

is chemically dependent who wants to do the hard work to overcome their addiction. That is not an entitlement, it is an investment.

No parents are entitled to the custody of their child if they will

not do all that is in their power to keep that child safe, but when

parents are ready and willing to do the work of recovery, the rest

of us should be there to help them. It is a good investment and a

necessary step in our overall efforts to keep families together and

children safe.

Thank you for your time today.

[The prepared statement follows:]

Statement of Nancy K. Young, Ph.D. Director, Children and Family

Futures, Irvine, California

INTRODUCTION

The need for AOD (alcohol and other drug) treatment services among parents in

both the welfare and child welfare systems is substantial, and far greater than current policy or practice recognize. These systems have many barriers to working together, including differences in attitudes toward clients, training and education, and

funding streams. The typical response to clients in the child protective services

(CPS) system needing AOD treatment is inadequate to assure that the intended outcomes of either system will be achieved. In the welfare system, the initial feedback

from states and communities preparing to implement welfare reform suggests that

very few have given the AOD problem the attention it deserves as a barrier to permanent work.

We can be more demanding of parents if we are more effective in securing resources needed for treating parents’ addiction. We have the tools we need to improve

our assessments of parents in the CPS and welfare systems who need resources

from the AOD system, but particularly in the child welfare system we need to use

assessment of both chemical dependency and family functioning that translates into

an assessment of risk to the children.

The adequacy of the connections between these systems can be assessed using a

five-part comprehensive policy framework that addresses: (1) daily practice; (2) information systems, evaluation, and outcomes; (3) budget and finance; (4) training

and staff development; and (5) alternative methods of service delivery.

WHAT IS NEEDED

1. Tools to assess the addiction problems of families, and training of welfare and

child welfare workers who can use those tools with an understanding of addiction

problems as they affect risk to the children.

2. A commitment to target prevention and intervention funding and programs to

the children of substance abusers in the welfare and child welfare systems, regardless of the parents’ status in securing and complying with treatment protocols.

3. Improved information systems that can monitor clients’ outcomes and distinguish between AOD clients with children and those without. Treatment agencies

must collect and track the number and child welfare status of children in clients’

families.

4. Assessment of both drug dependency and of family functioning, along with

awareness of the developmental stage of the child, in making judgments about removal or reunification. If treatment is fully available for the parent, a presumption

in favor of reunification should remain only as long as the parent has engaged in

treatment or an aftercare program.

5. A higher priority for the availability of AOD treatment slots and programs for

parents who are willing to make an effort to stay in treatment and follow-up services.

6. Inventories of the full range of funding sources and services available to parents which can fund expanded treatment and supportive services.

7. A focus on children, particularly the children of substance abusers, in each of

the reports that are issued by the federal government which monitor the nation’s

drug problem.

8. Marketing information about treatment effectiveness and cost offsets from effective treatment.
37

9. A commitment from community partners to ensure that supportive services to

families who have been reunified are available to families who have entered recovery from AOD problems.

10. Assessments of the effectiveness of AOD treatment programs using the latest

tools of treatment outcomes, and the shifting of resources from the least effective

to the most effective programs.

The Larger Context: Children, Families, Drugs and Alcohol

Beyond the boundaries of the CPS and welfare systems, there are extensive effects of alcohol and other drug abuse on children. There are millions of children affected by drugs and alcohol, living in families where use of drugs and alcohol pose

risks to child well-being. Seven million infants were exposed to alcohol during gestation, nearly seven million children under 18 live in families with one or more alcoholic parents and over six million children live with 3.4 million parents who used

an illegal substance in the last 30 days. An estimated total of 29 million children

of alcoholics includes 13–25% likely to become alcoholics. [National Pregnancy and

Health Survey, National Institute on Drug Abuse; Russell, Henderson, & Blume,

1985; U.S. Department of Health and Human Services, 1994.]

The overall economic impact of substance abuse on society was estimated by the

Substance Abuse and Mental Health Services Administration in 1992 at $116 billion

annually for alcohol abuse and $79 billion for drug abuse. These include costs of lost

productivity, health impact, criminal justice costs, motor vehicle accidents, and prenatal effects.

Philosophical differences between AOD treatment and welfare agencies

The differences in philosophical outlook between the two systems are based on different perspectives on:

• who is the client: children, parents, the family, or the community?

• which timetable should apply: child welfare law, the new welfare reform law,

AOD treatment timing, or the developmental needs of children at different ages?

• how can we reconcile zero tolerance, harm reduction, child safety, and family

preservation as contrasting philosophies in protecting children and stabilizing families?

The practical result of these differences is that the two systems find it difficult

to work together. In discussing front-line workers’ reactions to AOD issues, one child

welfare professional said in recent California discussions of these issues ‘‘For years

the workers have been saying it [substance abuse] isn’t on the form and it usually

isn’t in the allegation—so I don’t go looking for it.’’ A parallel comment from a treatment agency official was ‘‘We have not seen children as part of our responsibility.’’

The Timing Barriers

The timing differences are a very powerful driving force that underlies system incompatibility. We use the phrase ‘‘the four clocks’’ to refer to the four different timetables that may be affecting a family’s response to CWS–AOD problems: (1) the

CWS timetable of six-months reviews of a parent’s progress and the timing under

state and federal law governing termination of parental rights; (2) the timetable for

treatment and recovery, which often takes much longer than AOD funding allows;

(3) the timetable now imposed for TANF (former AFDC) clients who must find work

in 24 months and have a lifetime clock of 5 years for income assistance; and (4) the

developmental timetable that affects children, especially younger children, as they

achieve bonding and attachment with parents or loving adults—or fail to do so.

Since the late 1980’s, when the epidemic of crack cocaine began affecting child

protective services caseloads, more attention has been given to the question of how

much time to give to parents who have been reported for abuse or neglect and had

their children removed. The problem is that each system runs on a different clock.

The child protective services system increasingly focuses its concern on the developmental needs of children, especially younger ones, while the treatment system attempts to take into account the cycle of parents’ recovery and relapse that may take

much longer to stabilize and may have little to do with the needs of children whose

developmental sense of time is very different from adults. In effect, the basic assumptions about treatment are very different, with CPS focused upon AOD treatment as a means for achieving the goal of child safety, while AOD treatment seeks

the goal of clients’ functioning as a healthy adult, in which parenting is only one

facet of clients’ behavior.

Timing also varies according to the age of the children involved. With new discoveries about brain development over the past ten years, we have learned how important the first eighteen months of life are in forming the basis for a considerable

amount of both cognitive learning and emotional development. We also know more
38

1Farrow, F. Building Community Partnerships for Child Protection. Cambridge, MA: The

John F. Kennedy School of Government Harvard University. 1997.

about early bonding and what its absence from a child’s first years can cost in later

life. This all argues for faster vices, especially for younger children.

But in the treatment field, some of the lessons are contrary in their implications:

treatment is not a one-time event which happens and is over, but a lifetime journey.

That is why alcoholics and addicts often refer to themselves as ‘‘recovering’’ instead

of ‘‘recovered.’’ The treatment field has also evolved, with reduced emphasis on intensive residential care and more on longer-term interventions with ‘‘stepped-down,’’

ongoing aftercare services and community supports.

The treatment perspective, therefore, argues for a longer-term perspective—at the

same time that child welfare is moving toward greater emphasis upon shorter-range

impact on children. When these two perspectives on timing collide in the life of a

child and her parent, the difficulties of getting these two systems to work together

are compounded.

As stressed previously, we believe that we can be more demanding of parents if

the resources are there. By resources we mean not only the treatment resources but

also adequate assessments at the front-end of the process and a full partnership

with the community that mobilizes after care and family support resources to help

a newly sober parent stay clean and sober. This kind of community partnership is

described in depth in the recent report authored by Frank Farrow of the Center for

the Study of Social Policy.1 This community partnership model is being piloted in

four communities around the country with funding from the Edna McConnell Clark

Foundation.

If a 12-month clock is what fits best with the child’s developmental needs, the realities of welfare time limits, and proposed CPS policy changes, then we have to be

realistic about the community support needed to enhance the process of recovery on

a faster time table. The community has the right to ask the recovering parent to

do all that she can to keep her children safe and, at the same time, the community

should hold itself responsible for helping that parent in that critical work.

But, we need to understand the daily reality of a lower-income parent, often a single parent, struggling to raise his or her children while early in recovery. Nearly

all of us need respite from our daily balancing acts in the worlds of work and family.

But upper- and middle-income families can call a babysitter to get out of the house

for a few hours. It’s not that easy for a lower income parent in recovery. To have

a peer group, self-help group or a faith-based organization willing to provide that

support could make all the difference in the early months of recovery. That need

not be a governmental function; but the community needs to step up to the challenge. Taking the process of recovery seriously as a part of family reunification requires a more gradual transition from publicly-supported reunification services to

broad-based community support for these kinds of after care and respite care assistance. Terminating reunification services at the end of 12 months ignores the continuing need assuming that the parent is making progress in recovery for different

kinds of parent and family support services, both public and voluntary. Those services may make the difference between relapse and continued progress for a parent

who is trying to respond to the stress and responsibilities of having her children returned to her care.

While existing federal family support money could be used for this purpose, it is

extremely rare that the relationship between child welfare and treatment agencies

would be strong enough to ensure that this would happen.

The Emerging Consensus

At the same time, in those communities where the systems have worked together,

a consensus does emerge. Participants in this work agree that better-connected welfare, child welfare, and treatment agencies could achieve four purposes:

• Provide more effective services to more children and parents than the current

fragmented systems (the effectiveness goals);

• Do so in a way that preserves more families with greater child safety than today’s system (the family stability goal);

• Assist in making decisions about removal of children from those parents and

caretakers whose addiction remains a threat to their safety and well-being (the child

safety goal);

• Combine resources from the two systems which would serve more children and

families than either system could do separately, while working more actively to enlist other community agencies and organizations for families with less intensive

needs (the resource mobilization goal).
39

2The CWLA North American Commission on Chemical Dependency and Child Welfare. Children at the Front. Washington, D.C.: Child Welfare League of America. 3 Coles, C.D. ‘‘Addiction and Recovery’’ in G. Harold Smith, et al, (eds) Children, Families, and

Substance Abuse. Brookes Publishing.

Efforts to support children within their chemically dependent families must attempt to address chemical dependency in the family while meeting the developmental and safety needs of the children.2

The Client Targeting Barriers

Identifying which children and families should be targeted is also an issue. In the

view of some experts on the impact of substance abuse on children, there continues

to be disproportionate emphasis upon the problems of children who are born prenatally exposed to alcohol and other drugs, relative to the much larger number of

children affected by AOD problems after birth. With the dominant emphasis upon

prenatal exposure and adolescent drug use, the years between birth and adolescence

are under-emphasized, despite the obvious evidence that risk to children and youth

from AOD problems occurs during these years due to family and environmental exposure which has lasting effects in ways that in utero exposure doesn’t always have.

The substantial evidence that this is true includes the thousands of children in this

age group who are reported to CPS units, despite never having come to the attention of these agencies as a result of prenatal exposure. Some estimates place the

total percentage of all children affected by AOD at fifty times greater than those

testing positive for exposure to drugs at birth. Yet, the birth of a child who tests

positive for drugs is so traumatic and so clearly an occasion requiring intervention

that this critical juncture has been rightly perceived as an opportunity to take decisive action in a family which is undeniably high risk. The chart that follows places

in utero exposure in the larger context in which it belongs in the full range of ways

that children are exposed to alcohol and other drugs.

Carol Coles summarizes the message of this chart well in the edited collection,

Children, Families, and Substance Abuse

...the nature of interactions with parents, as well as other more directly experienced factors, often appear to have more effect on outcomes like emotional and cognitive development than does prenatal exposure to specific drugs.3

A further basis for the problems between the systems arises in the competing demands for AOD services for populations other than children and families. In part

due to the improving information base about what kinds of treatment work for

which kinds of clients, demands for AOD support services have multiplied from the

criminal justice system, the mental health system, and now, notably, the overlapping welfare/TANF system. Treatment for inmates has been an area of increasing

emphasis, given the number of drug offenders in state prisons and local jails. Resources in the AOD system are scarce in the short run, and the call for expanded
40

4McLellan, A.T., Metzger, D.S., Alterman, A.I., Woody, G.E., Durell, J. & O’Brien, C.P. Is Addiction Treatment ‘‘Worth It?’’ Public Health Expectations, Policy-based Comparisons. Philadelphia: The Penn-VA Center for Studies of Addiction and the Treatment Research Institute.

responsiveness to the special needs of children and families in the CPS system conflicts in important ways with these other demands.

Disagreements about the Nature of Addiction

Welfare and child welfare practitioners, like the general public, are part of a continuing debate over the fundamental nature of addiction as ‘‘bad acts by individuals

with free will’’ (in the language of the 1992 National Drug Control Strategy report)

or a public health problem caused by a condition that changes brain chemistry once

clients have progressed from use to abuse and dependency. As a result, the public

debate is often conducted in polar extremes, ranging from medicalization and legalization on one hand to zero tolerance and punitive strategies on the other. This argument from extremes often rules out middle-ground options such as treatment on

demand for all clients willing to comply with a treatment and aftercare plan.

It is now clear that both brain chemistry and motivation matter. Clients can be

held responsible for their actions, especially once consequences have been clearly set

out and treatment services have been clearly offered. And clearly offering services

doesn’t mean simply giving clients a list of phone numbers, which is an all-too-typical response of the two systems. Participants in the discussions between AOD and

CPS agencies in California point out that research in the addiction field shows conclusively that coerced clients are not more or less successful in treatment than ‘‘voluntary’’ clients. ‘‘Coerced’’ and ‘‘involuntary’’ are words sometimes used loosely in

child welfare and AOD treatment. Is a parent who has been told he/she will lose

parental rights acting voluntarily when checking into treatment—or being coerced?

Either way, such a parent has been held personally responsible, given a clear message about treatment, and offered help—which are essential preconditions for successful treatment—but not guarantee that success will follow.

However, it is also important to consider the reality of treatment compliance rates

when treating conditions that require substantial behavioral changes. Less than

50% of patients treated for insulin-dependent diabetes are compliant with their doctor’s orders regarding their medication. Less than 30% are compliant with their diet

and foot care. Among patients treated for hypertension, less than 30% are compliant

with their medications and diet.4 This data should not be used to excuse the behavior of persons in AOD treatment and all parents must be held accountable for the

safety of their children. Rather, this data should be used to assist clinicians and policymakers as they explore their expectations of AOD treatment and any sanctions

for noncompliance with treatment regimens.

The difference between how the child welfare and treatment systems respond to

licit and illicit drugs must also be addressed with greater realism. The fact is that

alcohol causes substantially more family disruption and lost economic benefits than

illegal drugs. As one child welfare official put it in a recent California meeting: ‘‘CPS

focuses on illegal substances and overlooks alcohol abuse and consequences on the

family.’’ To the extent that the CPS system does pay attention to substance abuse

issues, it is far more disproportionately focused on illicit than legal drugs, given the

overall damage done to children both prenatally and environmentally by alcohol.

The same is true, as shown by the recent debate on welfare reform, in the income

support arena.

We must also not lose sight of the front-line workers’ perspectives on all these

proposed reforms to work across system boundaries to help chemically dependent

parents. Reform does not flourish among workers with caseloads far beyond recommended levels. At the same time, new mandates affecting AOD workers also create externally-driven pressures on front-line workers. In both fields, the CWS–AOD

reforms we are proposing ask both sets of front-line workers to make large changes

in their daily practice, and going beyond pro forma consultation to serious involvement of workers in these changes in practice and policy is the only hope that workers will not view them as just another round of mandates without resources.

To insure that workers have the tools to make these changes, training funds must

be redirected and our universities must begin to include significant information

about AOD problems in the human service curriculum. Federal IV(e) training funds

for child welfare professionals have rarely been used to increase workers’ in-depth

knowledge of addiction and treatment. Both systems need added training content

that would enable both sets of workers to work across systems:
f

41

Chart 2: How Should Training Be Changed?

Desired CWS Training Content Desired AOD Training Content

AOD dependency: use, abuse, and dependency How the CPS system works

How to identify and intervene with AOD dependency.Trends in local CPS and out-of-home-care

Treatment modalities and effectiveness—what

providers do and their capacity—What local

resources exist and how they differ.

Local resources in the child welfare system:

parenting education, shelters, foster homes

AOD as a family disease; the dynamics of

AOD-abusing families; impact on parenting.

AOD as a family disease; the dynamics of

AOD-abusing families; impact on parenting

Confidentiality laws ............................................ Confidentiality laws

Matching level of functioning to levels of care .. Resources available for family-oriented interventions and family support/aftercare

The special needs of women and fathers/significant others.Developmental impact of AOD use—both prenatal and environmental—on children

The language used in AOD and other systems The language used in CWS and other systems

The ‘‘four clocks’’—different timetables in the

other systems.

The ‘‘four clocks’’—different timetables in the

f

other systems

In a recent discussion of training issues among AOD and CWS administrators,

several additional points were made:

• We need to train people for our vision of the new system, realistically presented,

not just let them adapt to today’s status quo.

• We are seeking links between a generic child welfare worker with direct ties

to and knowledge of AOD issues and an AOD worker who understands CPS, so that

an AOD counselor and child welfare worker can work together, not so that one

worker can do both jobs.

• Administrator and mid-level supervisor training is also needed, since some

front-line workers are much readier to make these changes in the interests of better

outcomes for their clients while some supervisors protect traditional ways of doing

things.

• Training only CPS and AOD workers will miss the other workers in other systems that need to know more about how these two systems can work with each

other.

• Training needs to actively involve both AOD providers and CPS clients with

AOD history. Academically-based training needs to recognize that front-line workers

and clients should have equal standing, not second-class roles.

• Training alone will not do the job; training has to be in the context of agencywide commitments to change policy and practice, or workers will return from their

innovative training programs to an unchanged agency and go back to doing what

they did before.

What Would a New System Look Like?

A newly linked CWS–AOD system would operate differently at the level of frontline workers, client contacts with both children and families, assessment of risk, referrals for services, accountability for results based on outcomes-driven information

systems, training for its workers, and the role of the community in support of families at the ‘‘front end’’ of CPS services but not yet in the formal system. The new

system would be capable of assessing and providing a differentiated response to children and families, responding to more sensitive and detailed assessment of both

family and substance abuse issues.

To summarize, a new partnership between CPS and AOD needs to be comprehensive, negotiated among equals, carefully staged in its development, and driven by

results-based accountability. Above all, the new system would have new partners,

primarily at the community level, who could accept a responsibility for those families who are not seriously enough engaged with CPS to merit formal investigations,

but who undeniably need help. As one AOD administrator put it, the reality test

for the concept of community partnerships was that ‘‘somebody else would step up
42

to the microphone’’ when a public explanation of child safety issues was needed,

rather than the media solely holding the CPS system accountable.

The new system would also include more than a two-way bridge between CPS and

AOD agencies, since for many of its clients more than these services and supports

are needed. Community-based aftercare, family supports, mental health, job training, literacy training—these are some of the many services and supports which go

beyond CWS and AOD services that are needed by families in the CWS system. As

one participant in an earlier session put it, ‘‘AOD treatment is not a stand-alone

service.’’

What Could Congress Do?

Many of these changes require action at the most local levels of the system, in

the communities where welfare reform, child welfare policy, and treatment programs co-exist today in largely separate worlds. Putting the pieces together is ultimately local work. But federal action could make a great difference. To review the

areas where congressional initiatives could be helpful:

• We need the PASS legislation (S. 1195), with its emphasis on identifying children in the system, making it easier to blend funds from different systems, and creating greater incentives for combining funding from welfare, child welfare, and

treatment funding sources.

• Congress could also issue annual inventories of all three sets of funding—welfare, child welfare, and AOD treatment—as a guide to communities who rarely get

an overview of all funding sources available to help children and families affected

by AOD issues.

• Congress could ensure that the data collection procedures in both the child welfare and AOD systems are changed so that they include data on both the parents

with AOD problems among child welfare cases and data on the children of parents

seeking AOD treatment. We need the provision in the Adoption Promotion Act (HR

867) which requires the Secretary of HHS to report on the substance abuse needs

in the child welfare system.

• Congress could ensure that reports issued from the national surveys on drug

abuse always include analyses of the data on the children in substance using families. At present, only special follow-up studies of the National Household Survey on

Drug Abuse have analyzed the data on children; the routine reports do not include

information on the children in the families affected by AOD.

• Congress could continue the oversight represented by these hearings through

inviting representatives of the model programs to talk about what they have done

and what additional support they need form the federal level.

• Congress could exercise its oversight for the TANF legislation to review the actual experience of parents with the greatest barriers to making the transition to

work. The range of estimates is wide, but we are building up a body of experience

every day that will tell all of us which estimates are most nearly accurate—and

more importantly, whether the resources set aside for treatment are adequate. The

dramatic declines in welfare caseloads do not tell us what is happening to the children in these families, or whether those leaving are those without AOD problems,

while those remaining may have even greater problems.

CONCLUSION

Many children’s lives are diminished by the inability of their parent to care for

them, and the inability or unwillingness of the larger society to help and compel

those parents to help their children by addressing their problems of addiction.

Thinking and acting more clearly about this critical dimension—accepting the challenge of creating a true family support system—could help far more children and

families than continuing to deny the equally important realities of addiction and the

potential of recovery in these families.

Chairman S

Dr. Barth.

HAW. Thank you, Dr. Young.

f
43

STATEMENT OF RICHARD P. BARTH, PH.D., HUTTO PATTERSON PROFESSOR, SCHOOL OF SOCIAL WELFARE, UNIVERSITY OF CALIFORNIA, BERKELEY, CALIFORNIA

Mr. BARTH. Thank you, Chairman Shaw and Members of the Subcommittee, for the opportunity to testify today. I am a professor

in the School of Social Welfare at the University of California,

Berkeley, where I have done research with the Child Welfare Research Center, which was originally funded by ACF. I also serve as

the principal investigator of the Abandoned Infants Assistance Resource Center, where we provide technical assistance and evaluation to Abandoned Infants Assistance Programs nationwide, and

are currently exploring innovative ways of serving drug- and HIVinfected families.

My objectives for today include identifying five points and provid- ing supporting information for these recommendations. The first

point is that the children whose parents are persistently poor and

involved with substance abuse are the families most likely to require child welfare services. Standard services provided by TANF

are unlikely to provide substantial benefit to the majority of these

very troubled families and additional efforts are needed. Second, reporting drug-exposed children for child abuse should be followed by thorough assessments of their needs. Placing them into

foster care may not infrequently be necessary to protect them from

the interactive risks of their own drug exposure and living in compromised environments; however, this is not a sufficient approach.

Third, reunification services for drug-involved families must be supplemented with a broader array of strategies to help minimize

the forces that result in relapse. These include intensive

postreunification services, residential treatment programs for

mothers and children, shared family care, and service-enriched

housing.

Fourth, shorter timeframes for children in substance-abusing

families, and indeed in all families, can be fairly and successfully

administered if child welfare and substance abuse services are redesigned to be more timely and comprehensive.

Fifth, extended services are needed for drug-affected children and

families, as these have a good chance of mitigating serious, longterm problems for them.

As we have heard so far, there is much consensus that the overlap between substance abuse and child welfare is greater than it

is between substance abuse and public welfare. Indeed, as the

Chairman indicated, there are estimates that as many as 75 or 90

percent of families involved with child welfare services are also involved with substance abuse problems.

However, these problems do interact with persistent poverty.

Clarise Walker and her colleagues found that among African-American parents in five major U.S. cities whose children entered foster

care in 1986, those that abused drugs were much more likely to be

receiving AFDC prior to the placement of their children. In fact 85

percent of the substance-abusing parents were receiving AFDC and

many had experienced long-term poverty.

We have recently examined infants who came into foster care in

California and compared their family situations to those of infants

who did not. One of the things we found was that being poor made
44

a difference, but that being poor and having a parent older than

30 made a much greater difference. These were often women who

had been poor and involved with childbearing for many years, and

they were the ones who had the greatest likelihood of having their

children enter foster care.

Even when a child is born drug exposed and child welfare authorities assess the situation, they may decide there are other alternatives besides placing a child into foster care. When they do,

they may still provide some in-house services, but these tend to be

so limited that the risks of harm to the child endure.

In a number of different studies in a number of different States,

we have seen that the children who are reported for abuse and neglect and assessed early on but who do not get services, later on

do come back into the child welfare system. This, I think, is a clarion call for providing more continuous services to those families,

even when foster care is not indicated.

Other information about a drug-involved family’s living situation,

their willingness to engage in efforts at recovery, and their use of

other services should, of course, be considered when a decision is

made in response to a report of child abuse and neglect. Is your

point that inadequate assessments result in overplacement or

underplacement, i.e., assuming willingness for recovery? Yet many

families do not receive such an adequate assessment. We must see

a time in the future when newborns who are born drug exposed receive such assessments that can lead to better treatment planning.

One thing we have learned from our years of working with these

families that are involved with drug abuse is that there are often

many children involved. For this testimony, we took a sample of

newborns who had come into care in 1995 and looked to see how

many of their siblings were already in care when the newborn entered into care.

Out of approximately 1,600 newborns, we found about 1,000 of

them had one or more siblings already in care. Overall, they had

about 2,600 siblings in care. On average, the siblings had been

there 41⁄2 years; 81 percent of those who had been in care had not

gone home or had come back into care. If one-third of the nearly

1,000 mothers who gave birth to these newborns in 1995 had been

successfully engaged in treatment upon the first birth recorded in

our data base and had no more drug-exposed births, nearly 4,000

foster care years would have been avoided at a savings of at least

$40 million for just the direct foster care placement costs.

So whatever our views are about the causes of substance abuse

and however much frustration we may have about this problem, we

must understand that from an economic standpoint, we must address the whole family. Helping mothers achieve recovery could

substantially reduce the number of children coming into foster

care.

One of the approaches we need to expand is something we are

calling ‘‘shared family care.’’ We are currently piloting this program

in California and Colorado, and it is being used in other States as

well. In addition to the kinds of residential treatment programs

you know of, shared family care involves placing mothers in recovery with their children, in the homes of foster parents. In this way,

we are not separating children from their parents but are still pro45

tecting the children by placing them with their family in foster

care. This approach helps support them and provides shelter for

them during the time of recovery. There is more about this in my

written testimony.

I thank you for the opportunity to testify.

[The prepared statement follows:]

Statement of Richard P. Barth, Ph.D., Hutto Patterson Professor, School of

Social Welfare, University of California, Berkeley, California

My name is Richard Barth. Thank you for the opportunity to testify today. I am

the Hutto Patterson Professor in the School of Social Welfare at the University of

California at Berkeley and the leader of the Child Welfare Research Center which

was originally established in 1990 with support from the Children’s Bureau and

ASPE. In this capacity, I have studied a variety of issues regarding the impact of

substance abuse on families and children and on child abuse and child welfare services dynamics. In particular, my colleagues and I have studied outcomes of the adoption of drug-exposed children, the impact of substance abuse on reunification from

foster care, and the service outcomes of newborns and infants who enter foster care.

I am also the Principal Investigator of the Abandoned Infants Assistance Resource

Center, and in that role, I have provided technical assistance and evaluation services to Abandoned Infants Assistance programs which are generating innovative

ways to serve infants and families affected by drugs and HIV.

OBJECTIVES FOR THE PREPARED TESTIMONY

My objective for the prepared testimony is to present and support five major

points.

• Children whose parents are persistently poor and involved with substance

abuse are most likely to require child welfare services. TANF is unlikely to provide

substantial benefit to the majority of these families.

• Reporting drug-exposed children for child abuse should be followed by thorough

assessments of their needs. Placing them into foster care may, not infrequently, be

necessary to protect them from the interactive risks of being born drug-exposed and

living in compromised family and community environments. This is not, however,

a sufficient approach.

• Reunification services for drug-involved children must be supplemented with a

broader array of strategies that help minimize the forces that result in relapse—

these include, intensive post-reunification services, residential treatment programs

for mothers and children, shared family care, and service-enriched housing.

• Shorter time frames for young children in substance abusing families can be

fairly and successfully administered if child welfare and substance abuse services

are redesigned to be more timely and comprehensive.

• Extended services are needed for drug-affected families and have a good chance

of preventing serious long-term problems for them.

BACKGROUND: SUBSTANCE ABUSE AND CHILD ABUSE AND THEIR OVERLAP

Little data but much consensus exists regarding the predominant role of substance abuse in families that are involved with child abuse and neglect and who lose

their children to foster care. In general, substance abuse appears to have a far

greater overlap with child welfare services than with public assistance programs.

Analysts have estimated that between 24–90% of all child maltreatment reports involving substance abuse (Feig, 1990; NCCAN, 1993; Tracy, 1994; Magura & Laudet,

1996). More than three-quarters of state child protection administrators across the

country report substance abuse as one of the top two problems presented by their

caseloads, the other one being housing (Wiese & Daro, 1995). Doug Besharov (1989)

concluded that over 73% of neglect-related child fatalities in 1987 were attributable

to parental alcohol and drug abuse. Ten years later, there is not good reason to

argue that this has changed.

Substance abuse clearly pre-disposes caregivers to neglect and abuse. A large

NIMH-funded study concluded that substance abusers had 3 times the odds of committing physical abuse and neglect—after controlling for social, demographic, and

psychiatric variables (Chaffin, Kelliher, & Hollenberg, 1996). These findings are

supportive of their earlier conclusions in which ‘‘close to half or more of abusive or

neglectful parents have a lifetime prevalence substance abuse disorder’’ (Kelleher,

Chaffin, Hollenberg, & Fischer, 1994; p. 200).
46

Whereas parents on welfare appear to have elevated rates of substance abuse and

child abuse, substance abuse is clearly more prevalent among maltreating families

than in poor families. In Zuravin and Grief’s (1989) comparison of maltreating and

non-maltreating AFDC mothers, non-maltreating mothers were significantly less

likely to report problems with alcohol or hard drugs (heroin, cocaine, LSD, PCP)

than CPS-involved mothers. Alcohol binges were reported by 3 times as many maltreating mother and four times as many maltreating mothers reported hard drug

use. Many families struggle with poverty and substance abuse and do not engage in child abuse or neglect. Yet, poverty and substance abuse undoubtedly interact to increase the need for child protection by community child welfare services. Clarice

Walker and her colleagues attempted to profile African-American children who entered foster care in 1986 in five major U.S. cities. They found that of parents whose

children entered foster care, those that abuse drugs are more often single parents,

were significantly more likely to not have a high school education, and were more

likely to be receiving AFDC prior to placement of their children. In fact, 85% of substance abusing parents were receiving AFDC and many had experienced long term

poverty. Although we lack direct evidence on the interactive effects of persistent

poverty and substance abuse on child welfare services, my colleague Barbara

Needell and I recently compared mothers who lose their infants to foster care and

those who do not (Needell & Barth, 1997). Whereas women receiving publicly-funded medical services had a higher risk in general, being poor was a much more significant predictor of placement into foster care if the mother was older than 30 at

the time of birth and had more prior births.

Even when a child is born drug-exposed and child welfare authorities do not as- sess the seriousness of the problem as requiring foster care, the risks for the drugexposed child endure. Jaudes, Ekwo and Van Voorhis (1995) tracked cases of maltreatment among a sample of 513 infants born exposed in-utero to illicit substances,

and found that about a third were later reported as maltreated. Of these, two-thirds

were subsequently substantiated. Overall, the rate of substantiated maltreatment

was found to be two to three times that of the general child population living in

the study area (the south side of Chicago). A follow-up study by Jaudes and Ekwo

also found higher eventual mortality among the drug-exposed sample. Goerge and

Harden (1993) looked to see what happened to infants born in Illinois who are reported to child protective services because of a positive drug test (this is a mandated

report under Illinois law). Only about 10% of those cases enter foster care immediately, although about one-third eventually end up in substitute care within three

years. Once admitted into care, these infants have particularly long stays in foster

care. In California, about one-in-six infants who entered foster care in 1988 was still

there eight years later. While parental substance abuse is considered a critical risk factor in the assessment of child abuse reports and positive drug toxicology tests may lead to an abuse

report, child welfare service agencies now generally concede that positive toxicology

tests are not, on their own, sufficient basis for legal action or the involuntary removal of children (NAPCWA, 1991). As the National Association of Public Welfare

Administrators advises in its guiding principles for working with substance abusing

families:

Parent(s) abuse substances to varying degrees. When substance abuse significantly interferes with parental responsibility and causes harm to the child, these

failures of parental duty provide the basis for substantiating a finding of abuse or

neglect (NAPCWA, 1991).

Thus, neither the use of substances while pregnant, nor parental substance abuse

per se, legally constitutes child neglect. Other information about the living situation,

willingness to engage in efforts at recovery, and the family’s use of other services

must also be considered. This seems to me to be the correct standard. Still, parental

substance abuse during pregnancy is clearly reason for a child welfare services assessment upon the birth of a child to determine whether additional grounds for establishing abuse exist and to ascertain whether the dyad might benefit from voluntary or mandated services.

I believe that we must see a time in the future when newborns affected by drugs

are routinely and thoroughly assessed by public health or child welfare services and

a range of services are made available to them. There are several reasons why this

is so important. First, we clearly need to pay greater attention to the safety of drugexposed children—the data on their high mortality rates is not to be ignored. Secondly, this helps us to provide intervention services at the earliest possible time.

Children who are born drug-and alcohol-exposed have needs for early assessment

and intervention; in their study for the CDC, Ann Streissguth and her colleagues

(1996) found that early intervention and living in a stable and nurturing home were
47

two of the most important predictors of good adult functioning for children born

with fetal alcohol syndrome and fetal alcohol affects. David Olds and his colleagues

(1997) have also shown important prevention effects from early and prolonged home

visiting services. Third, is the impetus that early assessments provide toward prompt decision mak- ing and the shortening of unnecessarily long stays in foster care. Children who are

born drug-exposed and come back into foster care at age 3 may have experienced

a variety of developmentally threatening environments and have a far greater likelihood of subsequently being adopted if they cannot return to their biological home.

Indeed, children who enter foster care between the ages of 3 and 5 have the lowest

rates of reunification within the first six years because they are too young to protect

themselves at home but not easily placed for adoption (Barth, 1997). Substantial concerns about the approach of assessing and engaging virtually every family that gives birth to a substance-exposed child will not subside, however,

until we are able to show a fundamental fairness in determining who gets assessed

for substances and until we have adequate resources to provide to families. They

most be more varied and effective than the current status quo which is to place children in foster care while providing little or no service to their mothers. I will discuss

some of these desirable service changes later in this testimony. Removing children at birth without providing substantial assistance to their mothers has other serious limitations as a strategy. Child welfare programs that fail

to address parental substance abuse and focus primarily or exclusively on child protection will not help prevent subsequent substance-exposed births. For this testimony, my colleague Barbara Needell examined the foster care and family histories

of a cohort of 1,576 newborns brought into foster care in 1995 in California for reasons of neglect and abandonment (signals that these were cases involving substance

abuse). We learned that 60% of these children (nearly 1,000) already had at least

one sibling in foster care. Indeed, they had a total of 2,634 siblings who were in

foster care at some time from 1988 to their date of entry in 1995; about 25% of these

newborns had 3 or more siblings in foster care. About 75% of these children were

3 years old or younger—children with long and expensive spells in foster care ahead

of them. Among the siblings of the infants who came into care, 81% of them were

still in care or back in care. Newborns had siblings in foster care, on average, for

four and one-half years—a total of about 12,000 foster care years. About half of the

mothers (47%) who had multiple siblings entering foster care were younger than 21

at the birth of the first sibling. However, when you examine maternal age of the

mothers at the time of the last newborn entering care, 47% of those mothers are

over age 30. Clearly, a few parents who continue to generate births of children born

exposed to substances have a substantial impact on the foster care caseload. If onethird of these nearly 1,000 mothers had been successfully engaged in treatment

upon the first birth recorded in these data, and had no more drug-exposed births,

a minimum of 4,000 foster care placement years would be avoided at a saving of,

at least, $40,000,000 for these children alone. So whatever our views about the

causes of substance abuse and however much frustration we may have with mothers

who use drugs and alcohol during pregnancy (and fathers who encourage it), we

cannot ignore their impact on child welfare, medical, and educational costs that are

likely to accrue. Right now, about one-in-five children who enter foster care in the

United States is an infant. We must build our intervention capacity and resources

to interrupt these dynamics and reduce the rate of births of substance-exposed children who may enter foster care.

Although the substance abuse treatment services that are being provided in some

states as a component of TANF may help some families to become more attached

to the labor force than they are to destructive life styles, the families who are having multiple births of children who enter foster care are unlikely to benefit from

standard TANF services. These parents need outreach and treatment services that

are available to them even if they lose TANF eligibility because they no longer have

custody of their children.

Nor is substance abuse only a cause of infants entering foster care. Substance

abuse certainly predicts poorer case outcomes under existing service models for parents of children of older ages. Parental substance abuse has been identified as a predictor of poorer family functioning among child welfare cases, and repeated reporting to child welfare agencies (Wolock & Magura, 1996). Parents with documented

substance abuse problems are more likely to have previous child welfare services

involvement, to be rated by court investigators as presenting a ‘‘high risk’’ to their

children, to reject court-ordered services, and to have their children permanently removed (Murphy et al., 1991).

Two of my colleagues at Berkeley, Jill Duerr Berrick and Laura Frame (1997) recently completed a study of infants returning to foster care, trying to provide some
48

explanation for an earlier finding that 28% of infants who went home from foster

care returned to foster care within 3 years in California (Needell, Webster, Barth,

Armijo, 1996). They found that substance abuse by mothers at the time of placement was pervasive among all clients, but it was far more present in the re-entry

group and increased the odds of re-entry substantially. Interestingly, the odds of a

child re-entering care were not diminished by receipt of post-reunification services—

indeed, they were increased. It turns out, that the families that received post-reunification services in Alameda County were also the families with the longest history

of referrals to child welfare services. Basically, the level of post-reunification services that were provided were not sufficient to counteract these elevated risk factors

and preserve the placements. We can only hope that these higher levels of services

protected the children from harm and that the children were replaced into foster

care after early signs of parental relapse from treatment and not after substantial

injury to the children or their futures occurred. We have so much to learn, and have

so far done so little to try to learn it, about the necessary ingredients of reunification services.

TOWARD CHILD WELFARE AND SUBSTANCE ABUSE SERVICES REFORM

Although we have not previously gathered much longitudinal data that shows how

child welfare careers are affected by prior substance or the use of substance abuse

treatment services, researchers and program innovators have generated enough information to suggest some reasonable new approaches to programs and policy.

Timely and Coordinated Child Welfare and Substance Abuse Services

The ideal time frames for decision making vary considerably for children, substance abuse providers, parents, child welfare services, and the courts. Envisioning

the clocks above the registration desk in an international hotel offers a sense of the

disparate time frames for a child welfare case involving substance abuse (Cole,

Barth, Crocker, & Moss, 1996). Child welfare service providers certainly understand

the centrality of effective substance abuse services to the achievement of permanency outcomes, but the proportion of substance abusing families is overwhelming

to service providers, and their access to prompt and powerful substance abuse services is limited. Although child welfare services families may have priority for referral to substance abuse services in a given locality, they may have little clout in

other localities. Now that some states are requiring substance abuse services for

TANF recipients, the challenge of obtaining timely services may be greater. The difficulty of obtaining substance abuse services for child welfare clients would be substantially less under the provision of’S 1195 that child welfare service clients be

served first by programs receiving federal substance abuse treatment funds.

Child welfare service providers are frustrated with the difficulty of getting prompt

services, the unwillingness of substance abuse treatment providers to share information about the progression of treatment, and their reluctance to support decisions

to end services and terminate parental rights when treatment is not successful.

Some states are moving to fund substance abuse treatment programs under the

child welfare services authority; direct funding of child welfare agencies for substance abuse services is also a strategy worth additional consideration by the federal

government.

Shortening the time to a permanency planning decision from 18 months to 12

months—as is proposed in HR 967 and S 1195—is a sensible idea but has the potential to exacerbate the mismatch between the legal time frames. Expedited decision

making generates greater concerns about the time allowed for families to enter into

and take advantage of substance abuse services. I believe that there are hopeful

signs that we can bring these time frames together so that children are moved into

potential permanent placements at the earliest feasible time, so that parents have

a chance to take advantage of substance abuse services, and so that child welfare

service providers and the courts can make the best decisions in the shortest time.

When timely and comprehensive services are available, they can make a significant difference. Colorado’s new configuration of services for children under six entering foster care includes several features of such a restructured system that deserve

replication (Shirley Rhodus, personal communication, August 12, 1997). Child welfare services have received funding to develop their own slots for substance abuse

treatment so that they can ensure that families that need service begin them in the

first week after placement. They have reduced caseload sizes to 15 families in several counties and provide each case with two workers. These added resources allow

staff to provide intensive reunification services and concurrently plan for adoption

if the odds of reunification start to drop. The case receives a full case review at

three months—at that time, they may make a recommendation to place a child into
49

a concurrent planning foster home (one interested in adoption, if reunification with

the biological family does not succeed). By six months, they have enough information from their drug treatment providers and other service providers to determine

whether reunification is possible and, if not, to accelerate the plans for parental

rights termination and adoption. With few exceptions, permanent placements must

be made by 12 months.

The Oklahoma Infants Assistance Program provides comprehensive services to

families of drug-exposed mothers over a six to nine-month timeframe in order to ensure that the substance abuse treatment time frames can work within the permanency planning time frames. Their services often begin within a week of intake and

address issues of parenting and domestic violence as well as substance abuse treatment. Their experience suggests that early and comprehensive services can identify

the families that are benefitting from the services at far earlier points in the decision making process than have historically been the case (Martin Ward, personal

communication, October 25, 1997).

Although there are some who would make the axiomatic assertion that ‘‘relapse

is a predictable part of treatment,’’ there is evidence that the kind of relapse involved can signal whether there is a likelihood of treatment completion. Certainly,

we know that many parents will never make a serious start in drug treatment. In

a review of the outcomes of drug-treatment research, the reviewers concluded that

few users even completed the treatment, much less completed control over their addictions (Hoffman, Caudill, Koman, Luckey, Flynn & Hubbard, 1994). Many participants (between 42 and 85% in different studies) had dropped out of treatment by

the first month. Whereas, a single relapse is not enough to judge drug treatment

a failure, if that relapse ends involvement with drug treatment it is much more serious than if the parent resumes treatment quickly after the relapse.

Even when parents do complete six months of substance abuse services, this is

often not enough to end services and reunify children. Failed substance abuse treatment is heavily implicated in failed reunifications. Longer substance abuse services

and post-substance abuse case management could greatly improve the likelihood of

generating lasting treatment changes (Wells, Peterson, Gainey, Hawkins, &

Catalano, 1994; Seigal, Fisher, Rapp, Kelliher, Wagner, O’Brien, & Cole, 1996).

Longer-term Interventions for Drug-Exposed Children and Their Families

In addition to earlier provision of substance abuse services for parents, we need

to continue to explore and expand our interventions for children. Although the research on the immediate and long-term consequences of prenatal cocaine exposure

has not demonstrated any singular impact on children, it is fair to characterize

drug-exposed children as ‘‘at risk,’’ whether due to maternal substance use and/or

other environmental factors or the interaction between the two. These ‘‘at risk’’

characteristics interact with a substance-abusing parent’s lifestyle, stressors including poverty, and pre-existing parenting difficulties to create conditions which support a higher incidence of violence and child maltreatment (Kelley, 1992). The

steady entrances into foster care for children who were not immediately taken into

foster care in the aforecited Illinois study and the continued reentries into foster

care for at least three years for infants found in our California work show the continuing risks for children born into families involved with drugs and alcohol. We do

not know much about what occurs during those three years, but we can only guess

that a vast opportunity to make a developmental difference has been squandered.

There is clearly sufficient evidence about the problem of repeat drug-exposed pregnancies to fund demonstration projects and rigorous evaluations to assess the impact of continuous case management for parents who have drug-exposed births. At

minimum, we must maintain ongoing services to substance involved families who

do have their children reunified into their care.

We have new evidence that children who are reported for maltreatment after the

age of seven and not given child welfare services have about twice the likelihood

of later entering the California Youth Authority than children who receive in home

or foster care services (Jonson-Reid & Barth, 1997). Imagine what the impact might

be on building successful futures if we began those services at seven days or seven

weeks of life, instead of seven years. Abandoned Infants Assistance programs have

developed new models of reaching out to and following some of our most troubled

and addicted parents, but these services are available only on a demonstration basis

and only in the very first years of life. We must work toward a seamless stream

of services for the families that first come to our attention because they have mixed

parenting and substance abuse.
50

Programs to Improve Living Conditions for Drug-Involved Families Pursuing

Recovery

Without adequate housing, it is extremely difficult for individuals to focus on their recovery, and returning to the pretreatment living environment places women at

higher risk for relapse (Lewis, Haller, Branch, & Ingersoll, 1996). Yet affordable

housing which provides an environment conducive to recovery and quality family

life remains extremely scarce. Applicants for public housing must wait an average

of 19 months and as long as eight years for housing that is often unsafe and riddled

with drug problems and other criminal activity. Additionally, the average wait for

Section 8 rental assistance is more than two years, and families wait as long as five

years in some cities (U.S. Conference of Mayors, 1996). This housing crisis is particularly problematic for households headed by chemically addicted parents who

often have difficulty securing jobs which pay them enough to support their families

or afford decent market rate housing. Additionally, many of these families have

other social, emotional and/or physical issues that make it difficult for them to

maintain housing. As a result, families affected by alcohol or other drugs often end

up homeless or in emergency shelters which is not conducive to recovery and does

little toward helping them become self-sufficient. Without stable housing, it is difficult for parents to obtain gainful employment or provide their children with the

stability that is so critical for a child’s healthy development.

Inadequate housing or homelessness, accompanied by other factors such as parental drug abuse, was the primary reason for removing children from the home or

keeping them in foster care in over 25% of foster care cases (Zangrillo & Mercer,

1995). There is reason to believe that access to safe, affordable, and adequate housing, along with some form of treatment or recovery and a wide range of support

services, will assist chemically addicted parents to remain clean and sober, move toward self-sufficiency, and avoid re-involvement in the child welfare system. Shields

for Families in Compton, CA provides residential drug treatment services with permanent service-enriched housing to boost the likelihood that families can resist relapse. Programs like this need more attention and evaluation.

Shared family care is another approach to helping substance abusing families in

recovery to achieve their goals to preserve their families. Originated in Europe as

an extension of drug-and alcohol treatment services, shared family care involves the

placement of a recovering parent and her children into a host family (Barth, 1995;

Price & Barth, 1996). Now operational in Minnesota, Wisconsin, Colorado, and California, shared family care offers families the opportunity to live with and learn from

host families for between 6 and 12 months in order to reconstruct an orderly and

responsive family life. Because this approach does not meet the IVE requirement

of mother and child separation, it is not easily funded under our existing public policy. The provisions of S 1195 that allow time limited reunification services for mothers and children to live together in residential setting would greatly expand the

availability of this promising program.

CONCLUSIONS

Child welfare services are intended to protect the future of our most vulnerable

children. Historically, these have been children living in homes overwhelmed with

problems of substance abuse and violence. We know more about the extent of this

problem than ever before. Researchers and program innovators have many ideas

about ways that we might protect the developmental futures of children and, at the

same time, provide opportunities for rehabilitation to their parents. This is an opportune time to test the promise of programs that support more thorough assessments of drug-exposed children, more timely and focused drug treatment services

for child welfare clients, a variety of supportive housing options for families in recovery and reunification, and extended services to drug-and alcohol-exposed children

who have come to the attention of the child welfare service programs. The substance-affected child and family are the core constituency of child welfare services

and greater efforts are required to address their needs.

Note: I am grateful to Laura Frame, Sora Han, Sharon Ikami, Sophia Lee, Barbara

Needell, and Amy Price for their assistance preparing this statement.

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Casework

Chairman S

, 70, 76–84.

HAW. Thank you, Dr. Barth.

f
52

Mr. McCrery.

Mr. MCCRERY. Just a quick followup on something you just said,

Dr. Barth; and I have other questions I want to get to.

You said, we can save money basically if we put money up front

in drug treatment, so that we avoid the cost of foster care later.

Is that correct?

Mr. BARTH. For additional children, that is right.

Mr. MCCRERY. I seem to recall some statistics about the success

of drug treatment not being particularly good, so how can you guarantee if we spend money up front on drug treatment that we are

not going to have to spend money on foster care for subsequent

children, given the record of success in drug treatment programs?

Mr. BARTH. Well, my estimate of success on this was fairly modest, about one-third. I believe it is somewhat higher because I don’t

think we have fully explored what is involved in providing comprehensive drug treatment and how successful it could be.

One of the Abandoned Infants Assistance Programs in Oklahoma

that I reference in my written testimony is now providing intensive

drug treatment services, including parenting work and domestic violence and drug treatment at a very early point when the family

comes into care, usually in the first week. They are finding substantial success in working with families who are mandated to

come there in this particular program.

I don’t think there are guarantees, but I do believe we have

learned enough through the demonstration projects we have been

doing to have a good sense that such sources really can make a difference. When we see evidence on the repeated patterns of foster

care placements among the children of drug-involved mothers, we

can understand what is at stake with some of these families who

are having so many children come into foster care.

Mr. MCCRERY. Is there any data you are aware of that indicates

a higher success rate in drug treatment programs for parents than

for nonparents?

Mr. BARTH. I am not aware of such data. I would defer that to

anyone else on the panel who might have knowledge about that.

I think we are really just at the beginning of understanding how

to best save parents. Most custodial parents are women, and it has

really just been in the last few years that we have begun to understand what their particular treatment needs are.

Ms. YOUNG. If I can add to that, some of the major studies of

treatment effectiveness have neglected to look at exactly that issue.

Although we have good cost offset data from some of the studies—

Oregon, California—it has not been something we have looked at

specifically to look at the differences for parents or for women.

There is a secondary analysis of a California study that did look

specifically at the cost offsets for women and found lower cost offsets than the whole population, primarily related to the fact that

women are not as involved in the criminal justice system before

treatment as men are. There was still a cost offset that was derived

from providing treatment to the women in the CALDATA data

study.

Mr. MCCRERY. Thank you.

Dr. Zill, you have reached the conclusion that for welfare recipients that are drug abusers, it would not serve them well to exempt
53

them from the 5-year time limit. For example, and I think you said

the work requirements as well.

Does any of the rest of the panel have a problem with that? Do

you disagree with that conclusion? Have you thought about it?

Ms. YOUNG. I hate to do an ‘‘it depends,’’ but I think it does depend.

If someone is making progress in their treatment program and

is not yet ready to take on the responsibilities, which can be significant, of parenting and working and getting the transportation, the

things that are now required of them, then there should perhaps

be some extensions available for those particular cases. Again, I

would condition that on families that are participating and meeting

the compliance requirements of their plan in order to participate in

work and to continue to receive benefits.

Mr. MCCRERY. Dr. Zill, can you expound a little bit on why you

reached that conclusion? Why is it not to their benefit to exempt

them?

Mr. ZILL. First of all, because you are providing public support

for addiction, and I think that is bad for the person. I think it is

bad for the program; it gives a bad name to the program and the

many people who need temporary assistance who are not addicted.

Second, what seems to be a common thread when drug treatment

is successful, people come to the point they are prepared to change,

and I think all the motivation you can give people externally will

be a help. I don’t think it is a guarantee; I think you will have lots

of failures. In fact, you may need to give extra incentives to employers who hire such people because there is a problem of theft.

But certainly there are examples of people who are not on welfare

who hold down jobs and also have substance abuse problems, so it

is not unprecedented.

I don’t think there is any guaranteed success here, but I do think

the alternative is worse. I don’t think we should be subsidized.

Mr. MCCRERY. Basically, you are saying the motivation for success and treatment is less if they have an income stream from the

Government?

Mr. ZILL. Exactly.

Mr. REUTER. Can I just suggest there is one aspect that has to

be balanced against that?

The issue of how criminally active are recipients of public assistance when they are no longer receiving public assistance is one

that must also be weighed. I don’t have an answer, but I don’t

think it should be ignored.

Mr. MCCRERY. If we had an answer to that, we would all be better off. It is a very fundamental question and we may find out, if

we are successful in sticking to the welfare reforms that are in

place and 10 years down the road, looking back on the data of

crime and the commission of crime, people might have a better

sense of what the answer is. But that is a great question. I wish

we knew the answer now.

Thank you all very much for your testimony.

Chairman SHAW. Mr. Levin.

Mr. LEVIN. Well, I was thinking, you seem in sufficient agreement, but it wasn’t clear what the question should be. But Mr.

McCrery raises an interesting issue, and I think it probably vali54

dates the wisdom of our giving the States power to exempt a limited number of people, 20 percent, from the cutoff. Because I assume, if they want to, where there are people who are indeed moving along and moving away from their addiction, they have the

power to exempt them.

If they are moving away, presumably a continuation of benefits

would not necessarily be an incentive to continue drug use; in that

case, it could be an incentive to continue away from drug use,

right? So I am not sure there is really disagreement there.

And I would think, Mr. Chairman, that we ought to really—and

the legislation I think does this—stimulate inquiry into the longterm TANF recipient, because the data may differ. Although we

tend to stereotype, the majority of people move on and off of TANF

within 1 year.

But there is a substantial number that we have always worried

about, and you surely have people who are long-term recipients,

and for them, drug abuse may be the more serious problem. Is that

possible?

Ms. YOUNG. That is the information that came from Utah, which

had a welfare reform that targeted alcohol- and drug-using parents

prior to the Federal legislation. And they found—and they had a

no exemption policy. Everyone was required to participate in some

sort of work activity; they could define work activity more broadly

than most States have defined work activity. But they found, after

the initial wave of persons were able to get jobs, they had a higher

concentration of alcohol and drug problems than what they had in

their population at the beginning of their welfare reform initiative.

Mr. LEVIN. So as the States move with some success to reduce

the roles, the likelihood is there will be more long-term people who

are on the rolls than short-term—that is almost by definition, but

I think it is beyond that—and the drug abuse problems within that

population may be more serious, and therefore we need to focus on

the relationship of drug abuse in that population, right?

Ms. YOUNG. That is correct.

Mr. LEVIN. And are we doing enough of that research? Time is

running, so what should we do to focus in on that population?

Ms. YOUNG. There are a handful of States that have used their,

I believe, substance abuse money to do a good, methodologically

sound study of the TANF population, using a screening inventory

that can assess both alcohol and drug problems, psychological problems, social family relationships, legal problems.

One of those States is Florida, which is in its final planning

stages, so that they will have methodologically reliable data about

the TANF population and the addiction severity in the TANF population. We are hopeful they will be able to expand that to their

child welfare population also.

Mr. LEVIN. Also, the $3 billion program that was passed has a

focus on the longer term recipient, and I don’t remember offhand

the breadth we gave to the States in terms of applying funds or

problems that relate to drug abuse. They cannot use any of the

moneys directly for prevention or for a treatment program, but—

you can use TANF, but not the $3 billion.

Mr. ZILL. Representative, I did want to say——
55

Mr. LEVIN. I think what we are doing is kind of zeroing in. It

is kind of helpful to focus in on what the issue is all about.

We haven’t touched foster care in my questions, but on the TANF

population——

Mr. ZILL [continuing]. Some of the long-term recipients, it is not

a question of drug abuse; it is a question of low skills, related job

skills. And some of the people who are on welfare, who have drugabuse problems, in fact, have quite decent skills; the problem is,

they have a drug-abuse problem. So I think there is a higher incidence, but it is not the case for all long-term recipients.

Mr. LEVIN. And the last thing I want to do is stereotype any segment of TANF recipients, but it may be there is a greater incidence

of drug abuse among those who are on TANF longer term—there

may be some correlation; and if there is a correlation, it means, as

they become a larger proportion of TANF recipients, there has to

be more attention given to the drug abuse issue.

Thank you.

Chairman SHAW. Just to add to that, very briefly, a lot of these

people got in the fix they are in because of the drug abuse, so it

is a question of, they got in the program because they were poor

and they were poor because of drug abuse and particularly when

you get into crack cocaine that preys on the poor so terribly and

is so immediately addictive, almost is a foregone conclusion in

itself, once they get into that.

Ms. YOUNG. Chairman Shaw, I don’t believe we have evidence

that would necessarily support that because drug abuse is so interrelated to other issues—related to unemployment, to less than a

high school education, to the age of the person, and to marital status. So you are looking at something that is interrelated, and I

don’t believe there is evidence that would say the receipt of welfare

was something that was a precursor or that less than a high school

education was a precursor to drug abuse; those things are all

mixed in together. But there are higher rates among the unemployed.

Chairman SHAW. What I was saying is, once somebody gets into

that spiral—whether they are receiving TANF or not, once they get

into the spiral, their ability to take care of themselves and work

is greatly diminished, so that the drug itself, the use of the drug

itself, almost dictates the person is going to go into a life of poverty.

Ms. YOUNG. For all of us, yes.

Chairman SHAW. I was trying to establish a chicken-and-egg situation. It isn’t that people receiving benefits are more likely to fall

into drugs, as much as it is people using drugs are likely to fall

into a situation where they need the aid.

Mr. LEVIN. And I think I might say, the result of that is, it has

implications for whether it is 15 to 20 percent, for how that group

moves off of welfare into work. I think it has implications for the

programs that are necessary.

Chairman SHAW. Back into the situation you were talking about,

and that is, once we get down to the hardcore population, it is

going to be tough to be showing the successes we are showing now

in the early returns.

Mr. Collins.
56

Mr. COLLINS. Thank you, Mr. Chairman.

Ms. Young, Dr. Young, I have a canned question here pointed out

by staff that I want to ask you; then I want to ask you one of my

own. You described a highly fragmented Federal effort to combat

substance abuse. Would a block grant of these programs help,

where the Federal Government ends all or most of the current programs, provides money in a single stream to States, and removes

current fundamental Federal mandates and restrictions that accompany these funds?

Ms. YOUNG. In fact, I think a lot of the States have passed on

that block grant notion to their local regions and their counties,

and it has been up to the counties to put the pieces together.

I think the Federal Government could do a lot in order to make

it easier for the locals to determine what their own needs are and

being able to address those needs. I am not an expert on public financing of big social programs, so I would not want to say that

that would be the way to go; however, I do believe there are things

Congress could do to make it easier for the locals to be able to put

those pieces together.

A treatment center that operates in south central Los Angeles

has over 40 funding streams coming into its agency; the administrative nightmare for 40 funding streams is enormous. I am not

saying we need another funding stream by any means, but we certainly need to be able to put that together at a local level that

makes much more sense.

Mr. COLLINS. OK. Now for my question.

In all of these studies where you concentrated on the area of welfare, welfare recipients, and drug abuse among those recipients,

was there any part of these studies that focused beyond demand

and looked at supply? Maybe in the area where there was more

concentration by the local government on the enforcement—not on

the use of drugs, but on those who are trafficking in and selling

drugs? Where you might have had a shorter supply, a higher cost

for the demand, do you have anything like that that shows whether

there may be some variance of usage versus the——

Ms. YOUNG. Dr. Reuter does.

Mr. REUTER. Yes, I do. Supply——

Mr. COLLINS. What is your full name? We have got a place for

you too.

Mr. REUTER. There are no studies really for any population that

relate the intensity of enforcement to drug use, whether it is participation rates or frequency of abuse among those who do use.

First of all, it is very hard to get good measures of the intensity

of enforcement, and you have to do it in a way that allows you to

match that data against the way data are collected on demand.

There aren’t any studies that do that, whether for welfare or for

anything else.

Mr. COLLINS. I go back to the point Mr. Rangel made. Oftentimes, these people who get trapped in this type of lifestyle, their

best friend is the drug dealer, and I think we should concentrate

too not only on trying to help those who have been—who have gotten addicted to this problem, but that best friend who keeps them

addicted, who is making money out of the system; and I just wondered if there was any type of study that indicated whether there
57

might be less use in an area where you have stronger enforcement

of the supplier?

Mr. REUTER. Congressman, I agree that is a very reasonable hypothesis. There is no evidence that bears on it, but nothing that

contradicts it.

Mr. COLLINS. Have you attempted to do anything like that?

Mr. REUTER. Have I attempted? No. It is simply a data problem.

It is not conceptually difficult; it is just that there aren’t the data.

Mr. COLLINS. I think it would be an area to look at, rather than

always trying to look at how we can spend money on those who

have been trapped. That is a necessary evil, but the worst of the

evils are the ones who are supplying it. By God, they are the ones

we ought to set our sights on in trying to get them off the streets

and out of the way and shorten the supply, run the price up, and

maybe we would have a positive effect on those attempting to use

by pricing it out of the market.

I don’t care if you give them welfare or work; if they have a problem, they are going to spend whatever funds they get on that problem. So—that is enough.

Thank you, Mr. Chairman.

Mr. ZILL. There is a consistent body of evidence from the delinquency area, which does not speak to drug suppliers, per se, but

speaks to bad friends. These kinds of behaviors, including drug use,

are often linked to being tied into a group of peers who are users,

and so there is——

Mr. COLLINS. I am not talking about peers, I am talking about

the guy Mr. Rangel was talking about who becomes their best

friend, because they will keep them addicted and supplied. That is

not a best friend at all.

Mr. REUTER. There is the notion that there are two separate

groups: One is a set of people who sell, and the other is a set of

people who buy. In fact there is a population of frequent users of

drugs that moves across that boundary; a lot of people who are

drug users are frequent drug sellers. It is fairly hard to find someone who is an impoverished, frequent user of cocaine who is not

also at times a seller.

Whether locking them up does good for them, or anyone else, is

a reasonable question; but I think the notion that you go after the

suppliers, suggesting there is a different population, is probably not

in fact very helpful.

Mr. COLLINS. I think you are wrong.

Mr. REUTER. I am simply saying, analytically, it is not very helpful. It is not a policy statement.

Mr. COLLINS. Get out in the real world.

Chairman SHAW. Mr. Coyne.

Mr. COYNE. I yield to Mr. Rangel.

Chairman SHAW. Mr. Rangel.

Mr. RANGEL. Thank you.

Dr. Zill, was it your opinion that exempting addicted welfare recipients from the 5-year limit would encourage drug dependency?

Mr. ZILL. Continue drug dependency.

Mr. RANGEL. And what do you base that on?

Mr. ZILL. Well, as I stated in my testimony, what seems to be

a key in identifying that minority of cases where there is successful
58

drug treatment is some kind of a motivational change within the

person, and often you have success after a set of failures; and having some strong sense of motivation that if I get off this habit, I

can change my life in a positive way, that countering that with, if

you stay dependent, you are going to continue to get effortless

funds—admittedly, they are not very generous kinds of funds, but

you will get supported by the Government—I think is an incentive

in the wrong direction.

I am not saying this is going to create miracles. I don’t think it

is going to create miracles, but I think it is a bad policy to make

an exemption for people who are drug abusers.

Mr. RANGEL. Would it follow that if the limit was 4 years or 3

years or 2 years, that that would be an incentive to speed and encourage people to be——

Mr. ZILL. I believe that TANF should provide drug treatment

programs, but I think they should be in parallel with employment

training and preparation, because I don’t think you should have

treatment first and then employment. I think you should have the

two together.

Mr. RANGEL. I agree with that, but don’t get me confused. If cutting it off in 5 years is an incentive for a person to get off of drugs,

research would suggest that cutting it off in 2 or 3 or 4 years would

be a greater incentive.

Mr. ZILL. I don’t think the time limit is the important thing——

Mr. RANGEL. It is important enough for you to suggest that a

person not be exempted in 5 years. I agree with you that time is

important politically, but it is certainly not important in terms of

trying to help a person. A person that can go to work in 1 day, that

should be the time limit.

Mr. ZILL. If there is a good job waiting for them.

Mr. RANGEL. Fine. You talk about those with no skills. If there

are no skills and no jobs, you couldn’t possibly support just cutting

them off in 5 years, could you? We have a 20-percent safety net;

you would recommend that they fall in that group, wouldn’t you?

Mr. ZILL. Perhaps.

Mr. RANGEL. I don’t have any other questions.

Mr. ZILL. I do feel there is also a very bad aspect to this from

the point of all those people who need help who are not drug abusers, that when TANF is known as a program that supports drug

abuse, it paints the other people with a bad brush.

Mr. RANGEL. I was under the impression, and I haven’t had your

training, that these people who are drug abusers are sick people,

the same way as those who abuse alcohol; but you are saying we

should not treat them that way. It would be unfair to them. In

other words, you are subsidizing the sickness by giving treatment.

Mr. ZILL. If we had a treatment like immunization, you get this

injection and you will no longer be a drug abuser——

Mr. RANGEL. We don’t have that.

Mr. ZILL. We are talking about a behavior that is subject to motivational things for which we don’t have a 100-percent solution; in

fact, as was just stated, we have about a 33-percent solution.

Mr. RANGEL. But reduction in treatment for alcoholics and addicts, in your opinion, should encourage people to get better faster.

Mr. ZILL. Well, I think you understand——
59

Mr. RANGEL. I do understand.

Mr. ZILL. And I do think we have to be humane, but at the same

time have a program that is effective.

Mr. RANGEL. I understand.

Chairman SHAW. Mr. English.

Mr. ENGLISH. No questions.

Chairman SHAW. Well, I would like to thank this panel. I think

you have given us very good information and insight. Obviously, in

some of these areas, there is room for disagreement, and reasonable people can disagree; but I think that in the long run, I found

a lot of agreement among the witnesses, and I appreciate your testimony.

The final panel, and I want to announce to the Subcommittee

and to the testifying people, the House is going back in at 5 o’clock

and they are expecting at least one vote at that time. Without in

any way shortchanging the final panel or the Members’ ability to

question, if we finish by 5 o’clock, that is fine. If we don’t, we would

simply recess until such time that we can come back and continue

the hearing.

Gale—is it Slater or Slaughter?

Ms. SALER. Saler.

Chairman SHAW. Saler—deputy executive director at Second

Genesis in Bethesda; Judy Ogletree, former welfare recipient, receptionist at Second Genesis in Bethesda; Dave Batty, executive director of Teen Challenge, Inc., in Brooklyn, New York; Sally

Satel—Dr. Sally Satel, the Oasis Clinic in Washington, DC, and a

lecturer at Yale University School of Medicine; and Mitchell

Pearlstein, Ph.D.—president of Center of the American Experiment

in Minneapolis, Minnesota.

Ms. Saler.

STATEMENT OF GALE SALER, M.ED., CPC, CRC–MAC, DEPUTY

EXECUTIVE DIRECTOR, SECOND GENESIS, INC.; ACCOMPANIED BY JUDY OGLETREE, GRADUATE AND RECEPTIONIST, SECOND GENESIS, INC.

Ms. SALER. Thank you, Mr. Chairman. I want to thank you for

inviting Judy Ogletree and myself to appear before your Subcommittee. I am deputy executive director of Second Genesis, a notfor-profit corporation providing therapeutic services in Maryland,

Virginia, and the District of Columbia. I am also, by training, both

a vocational rehabilitation counselor and an addictions professional.

Therapeutic community programs provide substance abuse services using the disease model of addiction and incorporating the

principles of positive peer support with professional substance

abuse treatment. Our goal is to provide to individuals, families,

and communities the tools necessary to live safe, healthy, selfsufficient lives, free of drugs, crimes, violence, and exploitation.

Many of the clients referred to therapeutic communities have significant occupational and educational deficiencies resulting from

their years of substance abuse.

Most of our clients need habilitation, not rehabilitation, because

they never developed adequate social or coping skills. Interacting

within the healthy environment of the therapeutic community is a
60

vital part of treatment for our clients, and an important part of our

job is to help the folks we see identify a value to being clean, sober,

and self-sufficient and to recognize that, maybe for the first time,

they have something to lose if they decide to use drugs in the future.

It is important to know that successful treatment in the therapeutic community requires employment and a job or career path

appropriate to the education and skill level of the individual. Locally, we have been very lucky in this regard and worked very hard

at establishing corporate partnerships, and I would recommend

that the Subcommittee talk to some of the corporate partners who

have worked with substance abuse treatment.

I have included details in my written testimony of the process by

which therapeutic communities move clients simultaneously into

recovery and into the work force, and I think they address some

of what I know have been Mr. Rangel’s long-held concerns about

making sure that happens. It is useful to recognize that these processes—recovery and return to the work force—can be made to work

together, supporting the goal of the safe, healthy, self-sufficient individual.

What is essential for us to recognize is, this type of comprehensive plan requires immense coordination of services, ranging from

treatment to health care, to children’s services, to education, to vocational counseling, to housing, to child care, and so on. It is also

essential it be recognized, this is a process that does not happen

overnight or over 1 week or even over 1 month. We are teaching

essential life skills to folks, many of whom who do not have role

models for what we are teaching.

One of the programs operated by Second Genesis is designed to

provide treatment to women and their children up to age 10. That

is where Judy received her treatment, and this is a program that

allows a family to remain in residence and receive treatment together, mother and children. For approximately 6 months, with 3

to 6 months of aftercare and access to services for up to 2 years.

This program is one of the 50-plus programs nationwide currently

funded by Federal Center for Substance Abuse treatment dollars

and for which funding will be running out next year.

I invite you or any of your staff to come visit that program; it

is only a few miles away, off Pennsylvania Avenue. There you will

see the best of recovery and the best of welfare reform—women

helping women, women helping children, children helping children,

and families finding the proverbial bootstraps they need to return

to their communities as contributing members.

Some of you will ask, Does this really work. The answer for me

is simple. Clinically, I know treatment works. I also know that as

with most other diseases, treatment works best if you follow and

complete the prescribed treatment plan.

From January 1992 through December 1994, Second Genesis

participated in a national Institute for Drug Abuse-funded study

comparing standard and enhanced treatment protocols to which clients were randomly assigned by an outside source. The longitudinal results of this study clearly indicate the effectiveness of the

therapeutic community for improving psychological functioning,
61

post-treatment employment, and reducing substance abuse and

criminal activity.

The Center for Substance Abuse Research at the University of

Maryland conducted an independent followup, which found, in part,

that 79 percent of those who completed their treatment program

were drug free 2 years later, 65 percent of those who completed

their program had no further involvement with the criminal justice

system, and 85 percent of those who completed their program were

employed at the time of followup.

These statistics are impressive for two reasons. They confirm lifestyle changes in the majority of clients who complete treatment,

and they demonstrate the importance of completion of treatment

for positive outcomes.

Welfare reform has already moved many Americans off public assistance, but the States report that that first wave was the easiest

to employ. Greater challenges will be faced in making many of

those who remain employable; among those are our addicted populations.

Recovery from substance abuse is not just about people getting

clean and sober; it is about empowering people to make healthy

choices because they have been given the opportunity to succeed.

Judy is one such person.

Ms. OGLETREE. Hi, I am Judy, and I am one of the graduates of

Second Genesis. I am glad to be here today, Mr. Chairman.

I am here today on behalf of myself and a lot of working mothers

with children that were hooked on crack cocaine. Today, I can

proudly say that I am no longer hooked on crack cocaine. I am

working full time, I am a mother to my two kids today.

I was in the justice system as a criminal. I am no longer a criminal. I am working full time at Second Genesis as a receptionist. I

have my kids back in my life because they were placed in the foster

care system. They are currently living with me in a transitional

house. Also, I will have full custody of them, as of January.

As of November, I will be off of the welfare system for good, and

basically, that is what the welfare reform has done for me today.

The help of the welfare reform and the people in my life, such as

Second Genesis, if they had not given me a second chance at life,

I don’t think I would have made it out there alone. As I said, I can

proudly thank Second Genesis and people in my life, such as the

welfare system, for giving me and my children the assistance that

I needed.

I had a child that was born with a disability as a result of me

using—for 14 years on drugs and alcohol; but today my child is getting the special help that she needs to get through this state—

through the proper people, through Second Genesis. They taught

me how to become a loving parent, how to care for my child that

needed that special attention; and today I can say, she is going into

a regular pre-K schooling class, along with my son, who is doing

very well. He is also registered in a Head Start Program.

So I can proudly say today that welfare reform does work for

mothers that are single parents with children, or even for those

who aren’t single, but it does work. And the whole thing about it

is, you have to want to change; and it came to a point in my life

where I wanted to change; I wanted that change in my life, for my62

self and my children. They deserve a parent in their lives—and

today I can say they have a parent in their lives that is a very good

role model for them.

I get up every morning at 4 o’clock in the morning to be to work on time, I come home by 8 o’clock at night and they are still fed,

they are still clothed, and they are still bathed; and so today I can

proudly say that I am a hard-working citizen and a mother today. [The prepared statement follows:]

Statement of Gale Saler, M.Ed., CPC, CRC–MAC, Deputy Executive Direc- tor, Second Genesis, Inc.; Accompanied by Judy Ogletree, Graduate and

Receptionist, Second Genesis, Inc.

Mr. Chairman:

My name is Gale Saler. I am the Deputy Executive Director of Second Genesis, Inc., a not-for-profit corporation providing therapeutic community services in Maryland, Virginia, and the District of Columbia. I would like to thank the Chairman

for inviting Judy Ogletree and me to appear before the House Ways and Means Subcommittee on Human Resources today to discuss the challenges welfare reform is

placing on state governments, private industry, and welfare recipients. The response to welfare reform has differed among the states. In Maryland, the State Assembly has recognized the need to prepare recipients to become financially

independent by supporting substance abuse treatment as an important step. Second Genesis operates five (5) therapeutic communities in the Washington, D.C., metropolitan area. Four of our communities serve a mixed male/female adult

population. Our program in Upper Marlboro, Maryland, is a women’s and children’s

program designed to provide therapeutic community services for women who have

minor children under the age of 10. Our therapeutic community programs provide

substance abuse services in a residential setting using the disease model of addiction by incorporating the principles of positive peer support and professional substance abuse treatment.

Typically, clients referred to therapeutic communities have significant occupa- tional and educational deficiencies resulting from years of substance abuse. They

are considered hard core, and in general they are considered dangerous. Therapeutic

communities are designed to provide a whole range of services while the clients are

in residential treatment. Most of our clients need ‘‘habilitation,’’ not rehabilitation,

because they never developed adequate social or coping skills. Interacting socially

within a healthy community environment is a vital part of treatment for our clients.

The Client

Our typical clients are young (20s to 30s) and present several similar characteris- tics upon admission. Primary among these characteristics is a predictable pattern

of substance abuse that has resulted in increasing . During the course of the substance use other life goals have been sabotaged or severely delayed. Frequently the client has no work history or a sketchy work history that includes several minimum wage jobs with few if any benefits. The client lacks competitive

skills and has educational skills that are inadequate to compete for vocational training or career track positions. As a result of these deficiencies, our clients lack goal

setting and planning skills that are appropriate or reasonable given their education

and skill level.

The client often has a skewed or distorted definition of success with inflated and

unrealistic expectations due to media and cultural influences. This distorted image

is usually created to mask the lack of a positive life vision. Personally, the client lacks self-esteem which results in a poor self-image and a poor interview performance. The client usually has at least one ‘‘high maintenance’’

child whose needs frequently conflict with job demands. Generally, there is a family

history of welfare dependency, and frequently there is involvement with the criminal justice system.

Substance abuse treatment alone is not sufficient for a client with these problems

to stay clean and sober, much less succeed in finding meaningful employment.

A client who appears for treatment with these severe developmental and social

skill deficiencies feels he or she has little to lose by using alcohol or drugs. Helping

a client reach his or her developmental potential is a key to encouraging the client

work toward a future free from alcohol and drugs.

An important part of our job is making the clients feel that there is a value to

staying clean and sober—that maybe for the first time in their life they have something to lose if they choose to use alcohol or drugs in the future. The idea of making
63

healthy choices by avoiding the risk of losing a good job, a good relationship, or a

comfortable home is truly a new concept for most of our clients. The role of the

therapeutic community is to put interventions in place for vocational training, educational services, social skill building, conflict resolution and anger management,

and housing placement assistance that will support their success in recovery from

substance abuse.

Therapeutic community treatment involves multiple phases and multiple types of interventions. Although different clients may follow slightly different treatment

paths (based upon their developmental needs), all clients go through the following

phases: stabilization, orientation, identification of a need to make changes, external

pressure to change, discovery of skills (empowerment), and orchestrated success. Successful treatment requires employment in a job or career that is appropriate to the education and skill level of the client. In developing the pathway to successful

employment in thhe primary steps include:

Work Adjustment Training

Work adjustment training teaches accepted employment practices in a sheltered therapeutic environment by assigning jobs within the residence. Early in treatment,

job assignments are designed to enhance strengths and foster self esteem. As treatment progresses, assignments are designed to address clinical and behavioral weaknesses and teach frustration tolerance. During this phase, the client is challenged

to face those situations that could cause an employee to quit, lash out at co-workers,

or be insubordinate to a supervisor. The best therapy is the use of actual situations

that have caused the crisis, studying the reactions of the client, and discussing the

alternatives the client could have chosen. This therapeutic model empowers the client to use other alternatives to relieve a crisis.

The client begins to develop work skills by understanding the need to pay atten- tion to detail, the need to complete a task, taking pride in workmanship, and accepting responsibility and accountability. Most employment situations are hierarchical

in that most employees have supervisory, supervised, and peer relationships with

other staff. The client learns to understand the appropriate role he or she plays in

each relationship. The client also learns about employee rights, on-the-job advancement, and standard grievance procedures. Our goal is to create a client who will be a responsible, proud employee who un- derstands his or her appropriate role within an organization and is not fearful of

being held responsible or accountable for tasks that are assigned during the course

of employment.

Vocational Preparation

Vocational services begin when the client has experienced clinical and experiential success in the treatment and recovery program. Vocational services are earned by

the client by demonstrating pre-vocational skills, including a realistic desire to succeed. The vocational counseling services include assessment, guidance, planning, resume and interview preparation, and other related job-seeking skills.

Activities of Daily Living

Activities of daily living include groups with themes such as ‘‘appropriate behavior

on the job,’’ ‘‘peer relationships and socializing on the job,’’ ‘‘negative behavior,’’ and

‘‘entitlement.’’ Each group member learns the appropriate role in the workplace by

role playing situations and discussing alternative methods of resolving conflict.

Relapse prevention plays an important role for the client in understanding the

triggers and impulses that can lead to a return to substance use. The client learns

to avoid triggers and how to use his or her recovery program to avoid situations that

can lead to relapse.

The client learns to prepare a personal budget, how to use a bank, and how to

live within a budget. The client also learns to develop a healthy social network of

friends and hobbies to replace friends who may still be alcohol-or drug-involved or

hobbies that may be criminally related. The therapeutic community exposes the client to recreational and social alternatives that will create an environment supportive of continued recovery.

Vocational counseling is essential throughout the process of making the client

ready to seek employment. Developing behaviors and skills that are consistent with

successfully finding employment prepares the client for the challenges of locating

the right job and independent living.

Setting a Goal

The client learns to set a realistic goal that is obtainable given the resources, education, and training available. He or she must then determine if reaching the goal
64

will create an income adequate to meet basic needs. The client then is asked to determine what step and sacrifices will be necessary to reach the goal and if he or

she is prepared to make the sacrifices necessary to achieve the goal.

The Employment Plan

The client prepares a plan to achieve the employment goal that he or she has se- lected. The plan must include specific objectives for vocational preparation, unmet

educational needs, planning for child care and family needs, safe housing, and coping with relapse triggers. The plan also needs to have alternative choices for each

objective if circumstances or mistakes require the plan to be altered. The client

learns the need to remain focused on the objectives of the plan to reach the goal

of selected employment.

Carrying out the Plan

The client develops a job search strategy that includes developing a resume, iden- tifying references (personal and professional), and learning how to locate the most

likely sources of employment prospects. The client learns how to assess a job offer

by weighing the pros and cons, benefits, and other employment options. At the time

the client accepts a position, he or she learns to clarify any unsettled questions with

the prospective employer and establish a mutually agreeable starting date. The vocational counselor prepares the client for the first day on the new job when a new

employee’s desire to succeed may create stress for the employee (and everyone else).

The client then begins to activate the budget plan beginning with the first paycheck.

Moving Out

During the move out phase the client lives within the budget he or she has cre- ated, setting aside funds for housing, food, child care, transportation, legal fees (if

any), utilities, social needs, and savings. While the client is still in residence in the

treatment program the client places the funds in a bank where they are reserved

until such time as he or she has located a safe place to live, convenient to his or

her employment, that is within the budget the client developed based upon his or

her income.

Aftercare

The first goal of anyone in recovery is to stay clean and sober. All other goals and objectives are dependent on their being able to maintain sobriety. Aftercare

smoothes the transition for the client from the safety of the therapeutic community

to the hazards of the real world and all the relapse triggers associated with returning to the community. After the client is discharged from residential treatment he

or she continues to return to the program for outpatient aftercare to address issues

that occur after the client leaves treatment and begins to move toward independent

living.

Does Treatment Work?

From January 1993 through December 1994, Second Genesis participated in the D.C. Initiative, providing residential therapeutic community services in a ‘‘standard’’

and an ‘‘enhanced’’ treatment protocol. The longitudinal results from the D.C. Initiative clearly indicate the effectiveness of therapeutic community treatment for improving psychological functioning, post-treatment employment, and reducing substance abuse and criminal activity. Outpatient aftercare was a significant contributing factor to the success of clients who completed both the residential and outpatient

treatment components.

It should be noted that in addition to the having the developmental needs most

frequently seen in the population on public assistance, two-thirds of the population

that participated in the D.C. Initiative also had a pattern of involvement with the

criminal justice system. The Center for Substance Abuse Research (cesar) of the

University of Maryland has conducted follow-up studies on clients who participated

in the therapeutic community service of the D.C. Initiative. A summary of its findings includes the following:

• Seventy-nine percent (79%) of the persons who completed the program reported

they were drug-free more than two years after leaving treatment. Thirty-one percent

(31%) of the persons who did not complete the program were drug-free after two

years. The 79 percent figure was confirmed by drug tests taken three days prior to

the follow-up interview.

• Sixty-five percent (65%) of the persons who completed the program reported no

further involvement with the criminal justice system after treatment. Only 42 percent of the persons who did not complete the program reported no further criminal

involvement.
65

• Eighty-five percent (85%) of the persons who completed the program reported

being employed at the time of the follow-up interview. Only 61 percent of the persons who did not complete the program reported employment at the time of the

interview.

These statistics are impressive for two reasons: they confirm the life-style changes

in the majority of clients who completed treatment, and they demonstrate the importance of completion of treatment for positive outcome.

A reduction in involvement with the criminal justice system at the time of the

follow-up interviews was significant. These findings support the importance of treatment completion in the reduction of criminal activity and drug use in a sample that

was heavily involved in criminal activity prior to treatment.

The findings by CESAR of the clients who participated in the D.C. Initiative support the concept that substance abuse treatment, if it is to be successful, must also

accomplish significant life-style changes, incorporate developmental needs into the

treatment milieu and prepare the client for independent, drug-free living. (See Attached Table).

Summary

Welfare reform has moved millions of Americans off public assistance. Up until

this time, the persons who have successfully moved from public assistance have

been those who were easiest to employ or who had alternative support during the

transition to self-sufficiency. Greater challenges will be faced in providing services

to make others employable and self-sufficient. Recovery from substance abuse is not

just about people getting clean and sober, it is about people empowered to make

healthy choices because they have been given the opportunity to succeed in life

through recovery.

Attachments:

D.C.I. Statistics, CESAR, University of Maryland, 1997

Therapeutic Communities of America, Memorandum from Linda R. Wolf Jones to

Gale Saler, TCA Perspective on Welfare, Work and Drug Treatment

Second Genesis graduates of treatment in the D.C. Initiative used drugs less frequently and had fewer arrests than non-graduates.

f

Completed

Inpatient &

Outpatient at

Second Genesis

%

Completed

Neither

%

Used Drugs Post Dicharge (Self-Reports):

Alcohol .............................................................................................. 18 43

Marijuana ......................................................................................... 7 23

Cocaine ............................................................................................. 16 55

Crack ................................................................................................. 15 52

Heroin ............................................................................................... 8 11

Positive Urine Test Results:

Alcohol .............................................................................................. 6 10

Marijuana ......................................................................................... 7 10

Cocaine/Crack .................................................................................. 18 49

Heroin ............................................................................................... 12 6

Arrested 6 Months Post Discharge ........................................................ 9 28

Source: Center for Substance Abuse Research (CESAR), University of Maryland, College Park, Md.
f

66

THERAPEUTIC COMMUNITIES OF AMERICA

1612 CONNECTICUT AVENUE, N.W., SUITE 4–B

WASHINGTON, DC 20009

October 17, 1997

TO: Gale Saler

FROM: Linda R. Wolf Jones

Re: TCA Perspective on Welfare, Work and Drug Treatment

Therapeutic Communities of America (TCA) supports public policies that move

women from welfare to work, but cautions that women with substance abuse problems will not generally be able to succeed in making the transition unless their substance abuse is addressed through intervention and treatment.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996

(P.L. 104–193) limited the receipt of welfare benefits to no more than five years.

Substance-abusing welfare recipients will need treatment in order to achieve and

maintain self-sufficiency. However, the legislation did not address or add capacity

to the substance abuse treatment system. Individuals with dysfunctional life histories and severe substance abuse problems frequently require long term residential

treatement in order to achieve a drug free, self-sufficient life style; The number of

such treatment slots is very limited (estimated at no more than 15,000–20,000 nationwide, depending on the definition of ‘‘long term’’) and needs to be expanded. We

suggest that additional funding must be made available specifically for the creation

of long term residential treatment slots and the expansion of treatment capacity.

We are also disturbed by the fact that the Balanced Budget Act of 1997 (P.L. 105–

33) recognizes that individuals who require substance abuse treatment for employment are (and should be) a target population for the use of welfare-to-work funds,

but that substance abuse treatment is not specifically listed as one of the allowable

activites as work experience programs, on-the-job training, and readiness, placement

and post-employment services. For those with severe substance abuse problems,

treatment is a prerequisite to succeeding at a job. It may be that the list of allowable activities can be interpreted as including provision of substance abuse treatment, but States are not likely to make such an interpretation if not specifically told

that they can do so. Substance abuse treatment should be clearly identified as an

allowable activity (i.e., an activity meant to move individuals into, and keep them

in, unsubsidized employment) in the current law and any future legislation.

Chairman S

Mr. Batty.

HAW. Thank you.

f

STATEMENT OF DAVE BATTY, EXECUTIVE DIRECTOR, TEEN

CHALLENGE, INC., BROOKLYN, NEW YORK

Mr. BATTY. Chairman Shaw, I am pleased to be here on behalf

of Teen Challenge. I am Dave Batty, and I work with Teen Challenge in Brooklyn, New York.

For the past 39 years, Teen Challenge has worked not just with

teens, but also with adults and families affected by drugs and alcohol in 130 centers across the Nation. We are privately funded by

businesses, individuals, and churches, and we seek to work with

inner-city gangs, substance abusers and their families, teen runaways, those who have been sexually abused, and also persons with

HIV–AIDS.

Teen Challenge does extensive prevention training in community

settings. We also have long-term residential help for those who

have serious addictions. Teen Challenge provides over 3,100 beds

in their residential programs. As I have worked with Teen Chal67

lenge since 1968, I have seen the success of this in leading people

to a lifestyle that is free from addictions.

When I received the invitation to testify before this Subcommittee, I was told of your interest in hearing about organizations that

have success in getting people off welfare and off drugs.

In a survey of the women in our Brooklyn Teen Challenge, I

found 80 percent had been on welfare before coming to Teen Challenge. These ladies had been on welfare from 2 to 15 years. All had

been using drugs while on welfare. Many had used their welfare

checks to buy drugs. Seventy percent were working, and most of

these were being paid under the table while they were on welfare.

They used this money to support their drug habit. Eighty percent

had been in at least one other drug treatment program before coming to Teen Challenge.

Now, some of these ladies had started on welfare because of a

family crisis, but most came to believe the Government owed them

this money. It is clear that those who come to Teen Challenge are

not shining examples of the success of welfare. I would like to

share with you the examples of three women who have graduated

from Teen Challenge and are now working.

One 1991 graduate has been employed as a clerk typist at the

same job for 4 years. A 1990 graduate has been working at the

same job in the Bronx for 6 years as a social worker. Another lady,

who is HIV positive, is working very effectively as staff for Teen

Challenge in Brooklyn. She said, If I had not gone through Teen

Challenge, I would be out there on the streets getting everything

I possibly could from the Government.

So how does Teen Challenge help these welfare recipients to so

dramatically change their lifestyle? The drug prevention work that

Teen Challenge offers is faith based. We tell them they need to

change their whole way of living. They need more than drug rehabilitation; they need life transformation.

We believe the key to long-term change is to place high priority

on the spiritual component of their life. Establishing a personal relationship with God is the key to finding a path to freedom from

addictions. This personal relationship with God provides the desire

and the power to change their way of living.

In Teen Challenge, the residents attend classes dealing with

anger, attitudes, self-image, temptation, obedience to those in authority, just to name a few of the issues. Getting them physically

off their drug addiction usually only takes a few weeks, but developing a whole new way of living with a new sense of personal responsibility—that is why the Teen Challenge residential program

is 1 year long.

In 1975 the Federal Department of Health, Education and Welfare funded a study of the graduates of Teen Challenge to determine the effectiveness of this approach to help drug addicts. Under

the leadership of Dr. Catherine Hess, the former Assistant Chief of

the Cancer Control Program of the U.S. Public Health Service, this

study looked at those who had been out of the program for 7 years.

This study showed that 70 percent of Teen Challenge graduates

were living drug-free lives, abstaining from all narcotics, alcohol,

and marijuana. Seventy-five percent indicated their current status

as ‘‘employed’’; 87 percent of the graduates did not require addi68

tional drug treatment after leaving Teen Challenge; 72 percent had

continued their education after completing Teen Challenge.

A 1994 study by Dr. Roger Thompson, head of the Criminal Justice Department at the University of Tennessee at Chattanooga,

found similar results in looking at graduates who have been out of

the program from 2 to 15 years.

Teen Challenge has the proven cure for the drug epidemic. We

work with both males and females with a significant student population in Hispanics and Afro-Americans. The help Teen Challenge

offers cannot be forced on people; they must want to change. However, we have found that many of those who come to Teen Challenge had given up all hope of ever changing. They didn’t see any

way out until someone told them about Teen Challenge.

In conclusion, faith-based programs offer a high degree of success

in helping drug addicts kick their addiction for good and establish

a whole new lifestyle. Those who are using and abusing the welfare

system can be helped through an approach that gives primary

focus to meeting the spiritual needs of the person, in addition to

their life-controlling problems. There is a great need for the Federal Government to find appropriate ways to partner with faithbased programs which are proving to be so successful in treating

those with drug addictions.

[The prepared statement follows:]

Statement of Dave Batty, Executive Director, Teen Challenge, Inc.,

Brooklyn, New York

INTRODUCTION

I am Dave Batty, the executive director of Teen Challenge in Brooklyn, New York.

I am pleased to be here to testify on behalf of Teen Challenge.

For the past 39 years the Teen Challenge organization has been working with

youth, adults and families affected by drugs, alcohol and other life-controlling problems. In 130 centers across the nation which are privately funded by donations from

individuals, businesses and churches, we seek to work with inner-city gangs substance abusers and their families teen runaways those who have been sexually

abused and persons with HIV/AIDS

Teen Challenge does extensive prevention training in schools, churches and other

community settings. Long term residential help is also provided to those with serious addictions. Teen Challenge provides over 3,100 beds in their residential programs.

As I have worked with Teen Challenge since 1968, first as a volunteer and then

as a full time staff, I have seen the success of this program in leading people to

a lifestyle free from addictions.

When I received the invitation to testify before this sub-committee, I was told of

your interest in hearing from organizations which are having success in getting people off welfare and life-controlling problems that got them on welfare.

I conducted a survey of the women in our Brooklyn Teen Challenge and found

that

• had been on welfare before coming to Teen Challenge

• an additional 10% were receiving food stamps

• these ladies had been on welfare from 2 to 15 years

• many had used their welfare checks to buy drugs

• 70% were working and paid off the books while on welfare and used this money

to support their drug habit

• 80% had been in at least one other drug treatment program before coming to

Teen Challenge

Some of these ladies had started on welfare because of a family crisis. Most came

to believe the government owed them this money.

It is clear that those who come to Teen Challenge are not shining examples of

the success of welfare in its goal to help those in legitimate need and help them

move to become part of a productive work force in our nation.
69

I talked with three who have graduated from Teen Challenge and are now working.

1. One lady graduated in 1991 and has been employed as a clerk/typist at the

same job for 4 years.

2. Another lady graduated in 1990 and has been working at the same job in the

Bronx for 6 years as a social worker.

3. Another lady who is HIV+ is working very effectively as a staff at Teen Challenge in Brooklyn, NY. She said, ‘‘If I had not gone through Teen Challenge I would

be out there on the streets getting everything I possibly could from the government.’’

So how does Teen Challenge help these welfare recipients to so dramatically change

their lifestyle? The drug intervention work that Teen Challenge offers is faith-based.

At Teen Challenge we treat more than their drug addiction. We tell them they need

to change their whole way of living. They need more than drug rehabilitation, they

need life-transformation.

The key to the success of Teen Challenge is its holistic approach. We believe the

key to long term change of those in Teen Challenge is to place key priority on the

spiritual component of their life. Establishing a personal relationship with God is

foundational to finding the path to freedom from addictions. This personal relationship with God provides the desire and the power to change their way of living.

In Teen Challenge the residents attend class daily where the focus is not drug

education, but life education. Classes deal with anger, attitudes, self-images, temptation, personal work habits, obedience to those in authority, dealing with failure,

just to name a few. In each class the focus is on personal application of life principles, not just content mastery.

Getting them physically off their drug addiction usually takes only a few weeks

at the longest. But developing a whole new way of living, with new attitudes, new

habits, a new sense of personal responsibility—that’s why the Teen Challenge residential program is one year long.

In 1975 the Federal Department of Health, Education & Welfare funded a study

of the graduates of Teen Challenge to determine the effectiveness of this approach

to help drug addicts. Under the leadership of Dr. Catherine Hess, M.D., the former

assistant chief of the Cancer Control Program of the U.S. Public Health Service, this

study looked at those who had been out of the program for 7 years. This study

showed:

• 70% of Teen Challenge graduates were living drug-free lives, abstaining from

all narcotics, alcohol, and marijuana

• 75% indicated their current status as employed

• 87% of the graduates did not require additional drug treatment after leaving

Teen Challenge

• 72% had continued their education after completing Teen Challenge

• 90% had been arrested before entering the program. Only 30% had been arrested in the seven years following their graduation

For more information on this research project, see NIDA SERVICES RESEARCH

REPORT: AN EVALUATION OF THE TEEN CHALLENGE TREATMENT PROGRAM (DHEW Publication No. ADM. 77–425 Printed in 1977) and Research Summary by Dr. Catherine Hess. Both of these resources are available from Teen Challenge National Training & Resource Center, PO Box 1015, Springfield, MO 65801.

A 1994 study under the leadership of Dr. Roger Thompson, Head of the Criminal

Justice Department of at the University of Tennessee at Chattanooga found similar

results in looking at graduates who had been out of the program from 2 to 15 years.

• 67% of Teen Challenge graduates were living drug-free lives, abstaining from

all narcotics, alcohol, and marijuana

• 72% indicated their current status as employed

• 88% of the graduates did not require additional drug treatment after leaving

Teen Challenge

• 60% had continued their education after completing Teen Challenge

A complete report on this research is available from Teen Challenge National

Training & Resource Center, PO Box 1015, Springfield, MO 6580l.

Teen Challenge has the proven cure for the drug epidemic. We work with both

males and females, with significant student populations of Hispanics and AfroAmericans. Let me caution you—the help Teen Challenge offers cannot be forced on

people. They must want to change. However, we have found that many of those who

come to Teen Challenge had given up hope of ever changing. They didn’t see any

way out, until someone told them about Teen Challenge.

In conclusion, faith-based programs offer a high degree of success in helping drug

addicts kick their addiction and establish a whole new lifestyle. Those who are using

and abusing the welfare system can be helped through an approach that gives pri70

mary focus to meeting the spiritual needs of the person in addition to their life-controlling problems. There is a great need for the federal government to find appropriate ways to part- ner with faith-based programs which are proving to be so successful in treating

those with drug addictions.

Chairman S

Dr. Satel.

HAW. Thank you, Mr. Batty.

f

STATEMENT OF SALLY L. SATEL, M.D., PSYCHIATRIST, OASIS

CLINIC; AND LECTURER, YALE UNIVERSITY SCHOOL OF

MEDICINE

Dr. SATEL. Mr. Chairman, thank you for inviting me. I work as a psychiatrist at a drug treatment clinic here in the District of Columbia, and I think my primary qualification for appearing today

is that I have worked with so many patients whose recovery, in my

view, was actually undermined by the welfare payments that they

received.

What happened was that welfare, as a safety net, cushioned peo- ple from the painful consequences of their addiction; and that is

not good in the long run, because it is the very fact that consequences are painful that is the major impetus to recovery. In addition to this, of course, the cash payments were regularly used to

purchase drugs.

Obviously, there is a lot of talk about sending drug-abusing welfare clients to treatment, but I am not so sure that will be enough.

And the reason is, attendance in programs is so low, and these programs have few means to keep the patients in. They have little leverage to keep patients involved, to reward attendance, to reward

clean urines, sanction poor compliance.

So my suggestion is this: Use the welfare system as a leverage

and harness the incentive power of, say, cash benefits to combat

addiction by keeping people in treatment.

There is a drug clinic, for example, in Baltimore that is doing

something like this; the monetary incentives they use come from a

special research fund, but you can imagine they might be welfare

benefits. In this clinic, patients who are struggling with heroin and

cocaine get redeemable vouchers when they submit a clean urine

and attend job training. Attendance at the training is way up.

Now, this approach can be adapted by clinics that are treating

welfare recipients, so that the benefits themselves become the incentives for sustained attendance and ultimately recovery. But

right now, conventional treatment programs don’t have leverage to

keep patients coming back. In fact, they have a very mixed record

in treating patients and helping them to be drug free.

If you look at the second—the figure on the second page of my

testimony—you see huge dropout rates from outpatient treatment,

which is the most common form of treatment. About 1 in 10 complete 52 weeks, and, at minimum, 1 year is considered adequate

duration of treatment. That is a minimum.

When patients do finish, as others today have said, they can do

extremely well; but dropout is the rule, and then relapse becomes

the rule. And that is why I am skeptical that treatment, as usual,
71

is the way to go, is the easy answer for drug-abusing welfare recipients. The alternative, as I mentioned before, would be to merge the

functions of welfare, which is economic support, with the functions

of drug treatment, which is recovery.

Create an active arrangement where the person can, for example,

earn back payments, managed by a third party, possibly the treatment program itself, when the patient complies with the treatment.

This would entail clean urine, counseling, job training, or supportive employment.

I will just mention briefly a few programs that are trying this.

They are not using welfare payments. One of them, however, is

using SSI payments.

Harborview is a clinic in Seattle. It works with substance abusers who also have mental illness. This is a clinic where patients are

asked to sign over their SSI payments. And the clinic keeps their

bank account and acts as their representative payee. Rent and

other basics are taken care off, and the patients earn back whatever is left over; they earn back those discretionary funds through

their compliance with treatment. Ultimately, they can get control

of their bank account if compliant with the program.

The results show that after entering this payee program, compared to before, attendance and treatment are up, hospitalizations

for drug-related complications are down, and jail time is way down.

Another program I will tell you about briefly is a clinic run by

the University of Texas working with pregnant cocaine users; they

receive payments, again, for attending clinics and keeping prenatal

visits. And those women who received the payments attended far

more clinic visits, had cleaner urines, in fact, were cocaine free

when the babies were born, and their babies were less likely to be

premature.

Finally, at the University of Alabama, addicts are given standard

treatment, plus an opportunity to participate in supervised work as

a positive reward for abstinence. If you have a dirty urine that day,

you can’t work. If you can’t work, you don’t get paid that day. If

you get two clean urines, you can work again.

And the researchers there have found again, higher attendance

at treatment and greater drug abstinence among the individuals

participating in the incentive program.

So, of course, I am in favor of treatment for drug-abusing recipients who can’t quit drugs on their own, but you have to keep in

mind four things. Drug treatment really only works when people

complete it. Dropout rates are high. You can keep patients in treatment longer with incentives and sanctions, and it would be a good

idea to use the naturally occurring welfare benefits to provide these

incentives.

I think this is a wonderful opportunity to take a system that for

many, has induced dependence and use it to help shape their autonomy.

Thank you very much.

[The prepared statement follows:]
72

Statement of Sally L. Satel, M.D., Psychiatrist, Oasis Clinic; and Lecturer,

Yale University School of Medicine

Mr. Chairman and Members of the Committee:

Thank you for inviting me. My primary qualification for appearing here today is

that I treat many addicted patients whose progress in therapy is undermined by the

welfare payments they receive. This safety net is well-intentioned but, unfortunately, it cushions the painful consequences of addiction. And it is the very fact that

consequences are painful that provides the major impetus to recovery. Also, of

course, cash welfare payments are regularly used to buy drugs. This unwitting sabotage can be redressed, I am confident, to help patients lead healthier lives, be better

parents and contribute to society.

• I am skeptical, however, that such gains can be achieved through standard

treatment which gives patients only modest incentives to fully comply, let alone become drug-free.

• The welfare system, however, provides an excellent opportunity to wield carrot

and stick for the purposes of drug rehabilitation.

• We can use the incentives of the welfare benefits themselves as leverage to

change behavior.

One model takes place in a Baltimore clinic where addicted patients get redeemable vouchers when they submit a clean urine screen or attend job training sessions.

This kind of behavioral approach could be adapted so that welfare benefits themselves become incentives to recovery.

• Although welfare was meant for a different purpose—to support for mothers

with children—we shouldn’t be reluctant to use it to help them combat addiction.

BACKGROUND

Review of Treatment Effectiveness:

Although the signature of the Center for Substance Abuse Treatment is ‘‘treatment works,’’ data show, more accurately, that treatment can work but that drop

out is high and relapse to drugs like heroin and cocaine is the rule. For example,

after 52 weeks, about 10% of patients remained enrolled in standard drug-free outpatient treatment (see figure and Hubbard RL et al.: ‘‘Drug Abuse Treatment’’;, U.

No. Carolina Press, 1989).
73

The good news, however, is that treatment almost always saves money—in this

sense, it ‘‘works,’’ (‘‘Socio-economic Evaluations of Addictions Treatment’’, President’s Commission on Model State Drug Laws, Dec. 1993). In the year after treatment, costs associated with enforcement and criminal justice and drug-related hospitalizations reliably decline by 25–60% with figure here treatment while employment goes up by about 10%. That means every dollar invested in treatment yields

four to seven in social savings. In addition, improvement increases the longer a patient stays in treatment beyond a critical period of at least 90 days.

A recent state-wide survey from California (California Drug and Alcohol Treatment Assessment, CALDATA) reported cost-benefit ratio of $1:7. This year, the Department of Health and Human Services produced an analysis that focused on the

welfare recipients in the CALDATA study. To my knowledge, this is the only large

scale evaluation of the effects of treatment on a welfare population. According to the

January 1997 report, ‘‘Alcohol and Other Drug Treatment for Parents and Welfare

Recipients—Outcomes, Costs and Benefits’’: (1) crime fell by 54 to 67% between the

year before and the year after treatment (including arrests and engaging in one or

more illicit activities such as drug dealing and shoplifting); (2) hospitalization

dropped by 58%;(3) cocaine use went down about 40% and heroin 14%; and (4) cost

benefit ratio for welfare recipients was 1:2.5.

Thus, CALDATA presents a socioeconomic analysis that, despite its shortcomings,

shows that treatment for recipients—even if it doesn’t work in the sense of stopping

drug use completely—is certainly worth it as a social investment.

Women with Children Least Likely to Benefit: Women are less likely to enter

drug treatment than men, a fact often ascribed to their lower likelihood of criminal

justice involvement (a common mechanism of referral to treatment). Some may be

fearful that they will lose their children if they come to the attention of doctors and

other authorities. Also, women are more likely to suffer clinical depression or distress associated with domestic violence. Thus, with her poor prognosis for employment, limited options and feelings of demoralization, many drug abusing welfare re74

cipients make the classic ‘‘rational economic decision’’ to depend on public assistance.

One of the major conclusions of the policy book ‘‘When Drug Addicts Have Children: Reorienting Child Welfare’s Response’’ (Ed. D. J. Besharov, Child Welfare

League of America, AEI Press 1994) is ‘‘assume that parental addiction to crack and

other drugs will not be cured ... even the best programs report that, in most cases,

they can break the pattern of crack usage only temporarily.’’ Outpatient care—by

far the most common mode of treatment—is passive. The patient may show up to

the clinic one day or she may not, she gives a clean urine or not ... and there’s little

leverage the program can wield to increase her participation.

What about residential treatment? Traditional treatment ranges from outpatient

clinic visits to long term (12–24 months) residential treatment. Residential is a form

of treatment often discussed as an option for TANF mothers (Jon Morgenstern MD,

consultant to State of New Jersey). It is epitomized by New York City’s Phoenix

House programs which seek to transform destructive patterns of thinking, feeling

and behavior that predispose to drug abuse. Through community living and cooperating with others, structured tasks, expectations and rules, patients learn self-discipline and responsibility; they are thus less resistant to authority and supervision

(attitudes essential for success in the workplace). Teen Challenge, also residential,

fosters recovery through religious conversion.

This is an ambitious program of change, yet data show that patients who complete it do extremely well. Among graduates of Phoenix House (the most extensively

studied of all residential programs) 90% are still working and law abiding five to

seven years later; 70% are completely drug free. The problem is, however, that drop

out rates are high: 30% within the first six weeks, about half make it through the

first year at Phoenix House and only about 15–20% finish.

Opportunity to assess residential treatment for mother and children: Unfortunately, there is little quality data on the effectiveness of mother-and-child residential treatment programs compared to less expensive options. Nor are there data on

the optimal length of stay.

Residential treatment has advantages for women reluctant to seek help out of fear

their children will be taken away. Pregnant women, in particular, may worry about

arrest if they come to the attention of doctors or other authorities. It also side-steps

the no-children-allowed rule. Currently, if a woman is lucky enough to find a scarce

residential bed, chances are children are not allowed or the limit is one child only.

Understandably, many women don’t want to leave other children behind with relatives or foster care. Lastly, residential care solves housing and day care problems,

the former representing a major source of disorganization in the lives of welfare

mothers and their children.

Despite its advantages, there are two big problems with mother-and-child residential treatment. The first is cost; $30,000 per family minimum. Second, even if states

were willing to spend the money, it would take several years to build this infrastructure. States need a more immediate solution.

CONTINGENCY MANAGEMENT—LEVERAGE AS A SOLUTION

Treatment can be very helpful if the patient completes it so how do we improve

retention? The bold answer: coercion. Several ways to ‘‘coerce’’ patients into substance abuse treatment are (1) through criminal court-order; (2) threat of loss of

child custody through protective services and, (3) suspension of welfare support unless the woman agrees to treatment. But can patients who are forced into treatment

benefit? Yes. Counterintuitive as this may seem, data reliably show that outcomes

for coerced patients are as good or better than traditional voluntary patients. Drug

abusers may be court-ordered to treatment by the criminal justice system or, more

rarely, committed by a civil judge because of severe mental or physical debilitation

due to severe addiction (Institute of Medicine: Treating Drug Problems, 1990).

What is CM? Using rewards and punishment to shape behavior is hardly new.

For children and adults, respectively, contingency management (CM) arrangements

take the form of ‘‘if you do X (eat spinach), you can get Y (dessert)’’ and/or ‘‘if you

don’t do A (show up for work on time), something aversive will occur (you won’t get

paid).’’

Research on CM: A large body of research shows that this can be applied in treating drug abusers. One of the earliest studies concerned deteriorated skid row alcoholic volunteers. Ten were randomly chosen to be eligible for housing, medical care,

clothing, employment services if their blood alcohol levels were below a minimum

level. The other ten could obtain these services from the Salvation Army as usual.

The volunteers who were rewarded for not drinking, had far better outcomes in
75

terms of maintaining sobriety and employment (Miller PM: Arch Gen Psychiatry,

32:915–18, 1975).

More recent studies on CM use vouchers redeemable for goods. The bulk of con- trolled research on this subject has been conducted by psychologists Steve Higgins

of the University of Vermont and Ken Silverman of John Hopkins University. Their

work consistently demonstrates that patients who abuse cocaine or heroin substantially reduce or cease drug use and remain in treatment longer when given vouchers

for each negative urine submitted. Silverman and colleagues also conducted a small

pilot project which showed that unemployed heroin users on methadone had significantly increased attendance at job skills training when they were given vouchers

based on attendance.

Regarding work itself as a treatment intervention makes good sense. In many

ways, it is the ideal therapy for hard-to-serve welfare recipients by instilling and

rewarding discipline, responsibility, and cooperation with authority and colleagues.

CM Drawback: A problem with CM is the tendency to resume drug use, albeit at

a lower level than before treatment, when the reward contract is withdrawn. This

may be due, in part, to the short duration of the research projects. Three to six

months is not enough time to enable the person to learn new skills, secure a job

and attain the measure of personal growth needed to live drug-free. Another problem is the cost of the vouchers; in these studies the ‘‘rewards’’ were written into the

grant budget but real-world treatment can’t provide monetary incentives. Yet these

two obstacles to CM could be remedied by using TANF payments as the contingencies. Once the recipient is transitioned to the workplace, the employer could continue to drug test former recipients—who now have something to lose—as a condition of employment.

How Should CM work? Psychiatrist Thomas J. Crowley of the University of Colorado recommends:

• make the consequences very clear: Written agreements or contracts should spell

out what kinds of violations (missed appointments, dirty urines, etc) will trigger

what kinds of sanctions.

• make consequences incremental, immediate and highly predictable. Rewards

and sanctions are more effective when they are experienced frequently. Sanctions

need not be harsh if they are administered predictably and with immediacy. An

Urban Institute analysis of the Washington DC drug court shows that immediate

sanctions like a few days in jail after the first positive urine can have a beneficial

effect on drug use compared to the absence of predictable sanctions.

TANF AS A VEHICLE FOR REHABILITATION

Not all drug abusing TANF recipients require treatment, let alone residential care

with its long length of stay and expense. Some recipients will respond to less aggressive forms of intervention, starting with urine testing.

Urine Testing Alone: Some drug abusers simply respond to the consequences of

positive urines (Urban Institute report on Washington DC Pre-Trail Services). One

woman, now completely abstinent, told me that she wanted to get a job as a truck

driver explicitly because ‘‘they’ll take my urine regularly and it’ll help me control

myself.’’ Women who need more help to keep urines clean can enroll on their own

in treatment-as-usual and/or Narcotics Anonymous.

It is important to realize that not everyone who uses drugs has a raging habit.

Some people can even use crack and cocaine in a sporadic manner. Often my patients have dirty urines because ‘‘I just had some money that day’’ or ‘‘I ran into

a friend who had cocaine last week’’ or ‘‘I got mad at my boyfriend and I figured

what the hell.’’ These are examples of deliberate use. And deliberate use means the

ability to abstain if the consequences are meaningful.

Another patient, a young man whose urines were often positive for tranquilizers,

heroin and cocaine, started turning in clean urines. His explanation? ‘‘I got arrested

two months ago and my probation officer checks my urine weekly.’’ He says I’m

going to jail if I give him a positive. I’m telling you, getting arrested was the best

thing that ever happened to me.’’

Free Standing CM: If urines remain positive, then all cash and redeemable benefits should be handled by a responsible payee. It is important that drug abusing recipients do not have direct access to cash (perhaps not even food stamps since they

can be traded for cash). Not only is this cash used to purchase drugs (recall Rosa

Cunningham—the welfare matriarch portrayed by Washington Post reporter Leon

Dash), it is also siphoned away from the valid recipients—the children.

Also, cash itself can be a powerful trigger for drug craving, especially cocaine. I

have literally never met a drug using patient who did not use all or part of a benefit

check (welfare check, veterans benefits, SSI income) to buy drugs. What’s more,
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when asked, patients readily admit this, many conceeding they’d be better off if the

money were direct-deposited into a bank and there was a limit imposed on withdrawals.

Using contingency management, women can earn back their welfare payments, perhaps on a semi-weekly basis, by producing clean urines. If recipients are engaged

in job training or employment, their welfare payments can be earned back for each

day worked. However, if their urine is dirty, they should not be allowed to work that

day. This model is employed by Dr. Jesse Milby at the University of Alabama at Bir- mingham School of Medicine where addicts are provided standard treatment plus

housing and opportunity for supervised work as positive rewards for abstinence. A

comparison group received standard treatment only. Dirty urines prevented subjects

in the first group from working that day and they had to move back to a homeless

shelter. However, if they produced two consecutive clean urines, they could return

to the house and job. Results showed that the housing-job contingency group had

a significantly higher abstinence rate than comparison patients. If the these or other forms of intervention are insufficient, the recipient should enter formal treatment. If she refuses, child custody becomes an issue (and a potential leverage to compliance). Formal Treatment with CM: Treatment could range from weekly counseling and self-help like AA to day-long intensive outpatient visits with supervised workshop

employment or job training. An arrangement could be developed wherein expenses

for housing and other basics are taken care of by case manager via electronic transfer/direct deposit and patients ‘‘earn back’’ the remaining cash by complying with

treatment and submitting clean urines. The key feature is that the welfare payment

becomes the leverage to compliance. Vignette #1: Psychiatrist Andrew Shaner of the West Los Angeles VA Medical Center has started a cash incentive program for cocaine-addicted schizophrenics attending an outpatient clinic. In cooperation with the regional social security authority, monetary rewards will be drawn from the patients’ own SSI disability checks.

Dr. Shaner sought to initiate this CM procedure after he observed a strong temporal

relationship between the receipt of monthly benefit checks and the use of cocaine

and increase in psychotic symptoms in over 100 patients. (A Shaner, et. al.: New

England Journal of Medicine. 333:777–783, 1995.) Vignette #2: Johns Hopkins University researchers use redeemable voucher con- tingencies (up to $10/day) to keep pregnant addicts—a notoriously hard-to-retain

population—in outpatient day-long treatment. The study lasted thirty seven days,

during which there was high drop out (roughly 60% at the end of 30 days) but the

women who received financial incentives for each day attended during the first week

had between 5 and 20% higher attendance over the course of the project (Svikis DS:

Drug and Alcohol Dependence. 48:33–41, 1997).

Vignette #3: At Harborview Medical Center in Seattle, Dr. Richard K. Ries directs

a clinic for mentally ill substance abusers. The most disabled patients are asked to

sign over their SSI check to the outpatient clinic which then acts as their ‘‘representative payee’’ and manages their bank accounts. Rent and other basics are covered by the payee and the patient is allowed to ‘‘earn back’’ discretionary funds

through compliance with treatment. Ultimately he gets control of the bank account

when he has demonstrated the ability to manage money responsibly (Am J Addiction, in press). Even though these patients were the sickest in his clinic, after signing over their funds they were significantly more likely to attend treatment sessions

than their healthier counterparts and as likely to participate in job training sessions

and to stay out of the hospital and jail.

Coordination with the Criminal Justice System: According to a recent survey of

state welfare and state alcohol and drug officials by the Legal Action Center (Making Welfare Reform Work, Sept. 1997), 19% of AFDC women in treatment are there

as a condition of parole or probation and another 21% percent had felony convictions. Conceivably, the welfare system could coordinate with the criminal justice

system to impose rewards and sanctions on recipient offenders based on their compliance with care.

Today, there are almost 200 drug courts nationwide. Non-violent drug-related offenders are diverted to drug court treatment programs. These programs have heavy

judicial involvement and are explicitly built around a graded sanctions schedule

(e.g., one dirty urine, 1 night in jail; the second dirty urine, 3 nights in jail and so

on) but the ability to use the welfare cash benefit as a reward would likely enhance

the therapeutic leverage. A new GAO report on drug courts (July 1997—GAO/GGD–

97–106) documents mean retention rates of 71% compared with anemic rates of 10–

20% mentioned earlier. This impressive result is due to the combination of coercion

and graduated sanctions.
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KEY POINTS

• Drop out from treatment is very high. Simply prescribing more treatment-asusual—while far better than nothing at all—may not be good enough for many.

• States should capitalize on the proven virtues of leverage to enhance retention

in treatment and to shape behavior directly. Locales that adopt innovations are social laboratories and should be encouraged to evaluate their work rigorously.

• Some advocates will criticize manipulation of benefits as intrusive and coercive,

but from a clinical standpoint coercion is a valid intervention. If anything, it would

irresponsible not to apply the accumulated research and experience showing the

value of incentives.

• Welfare reform provides an excellent opportunity to transform the perverse reward of public entitlements into constructive incentives that promote recovery and

autonomy using the very same, naturally occurring benefits that the system now offers.

For too long the security of welfare benefits—just knowing they were there, no

matter what—has actually facilitated a dual dependence: on the system itself, and

on drugs. Facing real consequences for using drugs is often a turning point for the

addict, putting her on the arduous path to recovery. At the same time, real rewards

for ‘‘playing by the rules’’ help develop responsible citizenship.

Chairman S

Dr. Pearlstein.

HAW. Thank you.

f

STATEMENT OF MITCHELL B. PEARLSTEIN, PH.D., PRESIDENT,

CENTER OF THE AMERICAN EXPERIMENT, MINNEAPOLIS,

MINNESOTA

Mr. PEARLSTEIN. Mr. Chairman, thank you very much—Members

of the Subcommittee, particularly since I am the last speaker to attend this afternoon, I would like to speak more personally than

perhaps it would be usual in such a circumstance.

Chairman SHAW. Dr. Satel, would you move that microphone

over?

Mr. PEARLSTEIN. As I was saying, I would like to speak quite

personally in the few moments that I have.

I come at this question from several perspectives. As you perhaps

have seen in the written statement, I run a think tank, a conservative, free-market think tank in Minneapolis. My wife is a social

worker who runs homeless programs—excuse me—out of a Lutheran church in Minneapolis. And we have just adopted a little

girl, Nicole, who is now 61⁄2 years old, who was born drug positive.

In the formal statement that you have, I do discuss the connection—my interpretation of the connection between welfare and

drugs and adoption. What I would like to do exclusively in the next

3 or 4 minutes is to emphasize one point, and that is that we must

rescue children faster. Translated—and this is terrifically sensitive

and terrifically tough—that means terminating parental rights in

many instances faster.

Let me tell you about Nicole. We have had her since last November 22, which brings new meaning to that date, let me tell you; and

we will officially adopt her on November 21. My wife and I have

known her since birth. Diane is actually her godmother. She was

born marijuana positive; her birth mother had done crack earlier

in the pregnancy. The first time I met her, she was about 6 weeks

old. She was shaking. It was right around Easter. I am not trained
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in this area, but it was clear to me that this child had a drug problem.

She was adopted once before, you should know. We believe, by

the way, that we are her sixteenth placement. But Nicole was put

in preadoptive placement the first time in March 1995. She was

given back to Hennepin County 1 year later because she was too

much for that first couple to handle.

I would ask you to think hard about what it means to have 16

placements and you are not yet 6 years old.

It was medically confirmed, I am afraid, just last month that she

had been sexually abused. She has been diagnosed suffering from

ADHD, attention deficit and hyperactivity disorder. She has also

been diagnosed as suffering from reactive attachment disorder,

which translated means she doesn’t trust any grownups terrifically

well.

When my wife and I were going through our training in Hennepin County 1 year ago, a social worker matter of factly said that

just about 98, 99 percent of children who have spent extended periods in foster care have been sexually abused. I said at the time,

I could not believe that. Perhaps I was wrong.

How is my daughter doing? Well, all things considered, I think

pretty well, though I am the first person—and my wife is the first

person—to tell you that raising a child like Nicole is not easy. Raising any child is not easy. But a child with this kind of background,

and sometimes you need to know I look in her face, particularly

after we have been fighting, and I think perhaps what this child

has gone through, and I just dissolve away in love for her.

Let me tell you about another little girl that we have been foster

parents to that we tried to adopt and could not. Her name is Annie,

not her real name, but for today’s purposes it is Annie. She is 71⁄2

years old. We haven’t seen her in 4 years. We used to be her unofficial foster parents. She has been in foster care in Ohio for 4 years

this month with very little time away from that situation. Her father, her biological father, credibly claims to have fathered 14 children. Annie and her younger sister have just—just been taken

away from him; parental rights were just terminated earlier this

month. All the other children had either been taken away from him

or he had abandoned them or they had died on his watch.

I ask the question, What in the world took 4 years? Why did it

take 4 years before these children were freed for a better life?

The final point, at American experiment we are beginning a

major project that will, we hope, significantly increase the number

of children adopted in Minnesota homes by loving Minnesota families. And I was in a meeting recently with our adoption lawyer,

who also was involved in the center; and it had been a particularly

difficult day with Nicole. My wife and I were there, and I said glibly, in a dark way, We want to have this project so other parents

could have this great joy that we are having this afternoon—not a

statement I am terrifically proud of.

And she called me up short, and she said, No, what you want to

do with this project is make certain there are many more children

rescued far quicker than has been the case with Nicole, so they are

not so terribly damaged by the time they are adopted.

Thank you very much.
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[The prepared statement follows:]

Statement of Mitchell B. Pearlstein, Ph.D., President, Center of the

American Experiment, Minneapolis, Minnesota

Mr. Chairman and Members of the Committee, my name is Mitchell B. Pearlstein

and I’ve been asked to appear today in two roles: both as an analyst and as an adoptive father.

As founder and president of Center of the American Experiment—a conservative

and free-market public policy institute in Minneapolis—I have spent the last nearly

8 years thinking hard, writing frequently, and hosting many public programs about

education, fatherlessness, adoption, welfare, drugs and suchlike. Which is to say,

I’ve spent a lot of time thinking about endangered children. By saying this, I don’t

mean to suggest that I’ve hit upon reams of good answers. Neither do I mean to

suggest that I consider myself a scholar in these broad areas in the narrow sense

of the term. While I hold a doctorate in educational administration from the University of Minnesota, run a ‘‘think tank,’’ and have held other public policy jobs in and

out of government, I’m more comfortable viewing myself as a reasonably well-versed

generalist rather than as a specialist when it comes to many of the questions before

you today.

Yet having allowed that, I do recognize that I bring an important perspective to

the table by virtue of being an adoptive father of a little girl, Nicole, now six and

a-half, who has suffered an extraordinarily tough start in life. And in a not dissimilar vein, my testimony this afternoon is contoured by the fact that my wife, Diane

McGowan, is a social worker and the executive director of Our Saviour’s Housing,

a church-based, tough-loving program for homeless and formerly homeless men,

women and children in Minneapolis.

In other words, Mr. Chairman, and at the risk of presumption, I just may be the

only conservative think tank president in the United States who has recently adopted a special needs child (whom, Im sorry to say, tested positive at birth for illegal

drugs) and whose wife, moreover, works daily and intimately with homeless and

other very troubled clients. It is from these vantage points that I would like to

speak this afternoon. I also have, you should know, three adult stepsons from my

wife’s first marriage.

Before proceeding, though, might I ask a favor of all who may come upon this

statement? Testifying before a congressional Committee, and then having that testimony published in the Congressional Record, is anything but a private act. I decided, however, to write as personally and openly as I have because of the stakes

involved: In bluntest terms, thousands of boys and girls need to be rescued, not only

from the chemical and other abuses of their parents, but also from a child-welfare

system that, for a variety of reasons, is capable of rescuing only some of them.

Which is to say, while I very much hope that what I have to say is attended to,

I also would hope that my family’s privacy—particularly that of my daughter—

might be respected to the greatest extent possible.

Let me begin by talking about Nicole and how my wife and I have come to adopt

her. (Technically, our adoption will not be official until November 21, though I assure you I have viewed Nicole as our daughter in every loving and permanent sense

of that word ever since she came to live with us on November 22, 1996.)

My wife, Im proud to say, is the kind of social worker who often brings her work

home with her. This was the case when, over Easter weekend in 1991, she and I

were asked by Nicoles birth mother to provide emergency respite care for her 6-

week-old baby. While I am not professionally trained in the effects of drugs on infants, I must tell you it was immediately clear to me that Nicole had been exposed,

as she cried to the point of near-tremors almost constantly. I did later learn that

she had been born marijuana positive and that her birth mother had smoked crack

earlier in her pregnancy.

My wife and I stayed in reasonably close contact with Nicole over the next several

years even though she wound up spending most of that time in various out-of-home

placements. Diane, in fact, had become Nicoles godmother in the spring of 1992. We

stayed in direct contact until March 1995 when Nicole was put in her first pre-adoptive placement. I’ll return to this matter in a moment, but first I need to fill in some

blanks about her birth mother.

Doris (not her real name), voluntarily gave up parental rights to Nicole either in

late 1994 or early 1995. Nicole was her fifth child—and the fifth boy or girl whom

she had either given up on her own or who had been taken away by the state. As

for Nicoles birth father, he has never been involved in her life beyond conception.

A drug dealer by trade, Ive recently been informed that he is serving a life term
80

in prison for murder. Doris doesnt recall his last name, and almost needless to say,

they were not married. Without rationalizing away Doris morally and otherwise unacceptable decision to do drugs during her pregnancy with Nicole, I have no hesitation in acknowledging

the coarseness and unfairness of Doris own life. Her parents were chemically dependent. She has suffered all manner of abuse. She has been diagnosed with a serious mental illness. Early in her pregnancy with Nicole she was set afire when a

drug deal went bad, leaving her in the burn unit of Hennepin County Hospital for

several weeks, where she received prescribed drugs—and later also did illegal drugs. Given this prologue, Im not opposed to giving Doris a measure of credit for rec- ognizing that she was not capable of raising Nicole and, in light, forfeiting her parental rights. But the fact remains, the little girl who was to become my daughter

had been condemned to a simply dreadful start. The best my wife and I can figure, we are Nicole’s 16th placement. Yes, many of these were short, emergency stints when, for example, Doris went off on one

binge or another and her boyfriend (not Nicole’s biological father) couldnt cope

alone. But several placements were of much longer duration. These included 2 years

with a foster family before her first pre-adoptive placement, in March 1995, and

then 8 months in that same foster home when, after exactly a dozen months, the

pre-adoptive family gave Nicole back to Hennepin County because she was too much

for them to handle.

Ladies and gentlemen, I would ask you to think hard about what it means to live in 16 different places—which is not necessarily to say homes—before you are 6

years old. I also would ask you to consider a few other things about Nicole. It was recently confirmed medically that she had been sexually abused, quite like- ly more than once. She also has been diagnosed as suffering ADHD (attention deficit

and hyperactivity disorder). Im well aware of the fact that diagnosing ADHD is

more art than science, and that the term has been known to be used profligately.

But let me assure you, this is not the case here. When Diane and I were going through Hennepin County-sponsored, pre-adoptive training last year, several instructors reported—I’m tempted to say almost as a matter of fact—that most children who are veterans of the foster care system tend to

wind up (1) having been sexually abused; and (2) suffering from ADHD. In fact, one

instructor estimated that upward of 98 or 99 percent of all such children are sexually assaulted. I immediately objected, arguing that hardly any social phenomenon

is known to occur so frequently, and that at any rate, I just couldnt imagine the

problem being so pervasive. Perhaps I was wrong. How is Nicole doing now? In many ways, better than what one might imagine. But for all the progress she has made, for all the medical and psychological care

she is receiving, and for all the love she is now bathed in, there remains, deep in

her, a flood of anger and distrust. Yet who can blame her for harboring such poison?

More briefly now, let me say something about another little girl my wife and I

have tried to adopt in the past, Annie (not her real name). Annie is now seven and

a-half, not that we have seen her for 4 years, as she has been in foster care in Ohio

almost all that time.

Annie is the daughter of two of my wife’s clients, Meg and Johnny (again not their

real names), and as with Nicole, we have known her since birth. Both Diane and

I are Annie’s godparents, and we also were her frequent, if unofficial, foster parents

in the early nineties. (One reason we were ‘‘unofficial’’ is that Annie is part American Indian while Diane and I are not, and the Federal Indian Child Welfare Act

didn’t take kindly to our care giving. But I digress.)

In the fall of 1993, Johnny and Meg (who have never been married) moved to

Ohio and quickly proceeded to do things that led child-protection officials there to

rightly place their young daughter in protective custody. She has remained in foster

care in Ohio ever since. In part, this is the case because Johnny’s parental rights

to Annie, and to her younger sister Gloria, were terminated only in the last few

weeks. In Johnny, it needs to be noted, we are talking about a man who credibly

claims to have fathered 14 children, with all 14 now having been taken from him

by government, or abandoned by him, or found dead on his watch. As for Meg, she

voluntarily gave up rights to the two girls a couple of years ago once she concluded

she could not care for them. She may have AIDS.

What did Johnny and Meg actually do to justify having Annie taken from them

on a number of occasions in Minnesota and Ohio? On generous days I’m willing to

concede that they have tried to love her, and Gloria, as best as they know how. But

the fact remains, their ability to raise their daughters successfully was severely

compromised by drugs, alcohol, mental illness, frequent arrests, unemployment, and

so forth. Annie, for example, tested positive for crack at birth. She tested positive

for cocaine again later on, likely by way of secondhand smoke. The fact that she
81

wound up being required to repeat kindergarten may or may not have been incidental.

Question: Why in the world, given all this, were Johnny’s parental rights terminated less than a month ago? Why were his two girls kept in limbo so outrageously

long?

Another key question, given the subject of today’s hearing, is whether any of the

birth parents I’ve been talking about were ever afforded the chance to participate

in a drug rehabilitation program while they were on welfare? Doris, Johnny, and

Meg, as one might expect, have received a combination of benefits, including AFDC,

SSI, and General Assistance.

The short answer is that yes, each has been provided multiple opportunities to

get straight, not that any of the three has ever stuck with any treatment program.

(I don’t have a clue about what second, third and fourth chances might have been

extended to Nicole’s birth father by taxpayers before he was imprisoned, perhaps

for a last time.) Some surely will argue that none of these programs were exactly

right or fitting or sufficiently funded. But the larger truth is that neither Doris, nor

Johnny, nor Meg has ever found it within themselves to keep clean, either for themselves or for their children.

So much for stories and comments drawn from my personal life. What do I conclude from all of this in terms of policy and in terms of our culture itself? Permit

me to quickly expand on three points having to do with (1) the Muzak-quality of

drug and alcohol abuse in the United States; (2) the importance of faith-based programs in combating such excesses; and (3) the need, in many instances, of terminating parental rights much faster so that supremely at-risk children can be adopted—

and, thereby, physically and emotionally saved—much more successfully.

We have all seen data and heard stories about the hard toll exacted personally,

socially, and financially by chemical excesses and addictions. The dollar amounts,

for example, no matter how rigorously or casually calculated, are always labeled immense, accurately so, I’m sure.

But for present purposes, I have no interest in citing numbers, never mind how

huge and telling they may be, as I’m sure others who are better equipped either

have or will do so. Instead, I want to argue that regardless of how big a problem

we may think excessive drinking and illicit drug use are, they are almost certainly

larger still—be our focus the nexus with welfare or not.

This is the case, I would contend, because the very implicitness of boozing and

narcotizing in so much that is melancholy and broken all around us has made our

reactions more muted than sharp. Alcoholism? Drug abuse? Sure they’re problems.

Big ones. But my sense is that are sensed by most people, most of the time, more

as background noise than as sirens. Drugs and too much drink are downplayed precisely because they are embedded in the landscape.

Now, needless to say, sirens do blare for individuals and families racked at any

moment by insobriety. But the broader point to be made is that drug and alcohol

abuse routinely grabs holds of us in the same way that Muzak does—meaning not

vividly at all.

Back in the early eighties I served on the staff of former Minnesota Gov. Al Quie.

I still remember how he would talk about how drugs and/or alcohol had been at

each and every scene, so to speak, whenever he returned to the office following

meetings of state pardons board. I have few doubts that much the same can be said

about the overwhelming majority of child neglect and abuse cases. Yet still—exempting for hearings like this, and at the risk of an overdone metaphor—the nation

routinely seems to be in a haze, numbed to the pervasiveness and destructiveness

of drugs.

What might this suggest? One thing is that we need plenty of treatment avenues.

But it’s precisely in areas such as this that policy deliberations suffer from excessive

confidence in the efficacy of ‘‘programs.’’

Almost always running through such public conversations is the presumption that

if only enough dollars are ‘‘invested,’’ results would be excellent. But on closer consideration, almost everyone knows this is not the way either the world works or recovery works, as just about everyone knows of men and women who have ‘‘graduated’’ any number of times from treatment programs—only to go tumbling off an

identical number of wagons. Recall Doris, Johnny, and Meg and their repeated failure to take advantage of the public dollars invested in them.

Ungrounded confidence in the effectiveness of treatment programs—especially secular ones—is but the flip side to the half-obliviousness that surrounds chemical dependency in the first place. The most important question about healing we can ask

has little to do with whether we are really ‘‘committed’’ as a society to helping drug

addicts and alcoholics. The short answer to that one is yes, as witness all the money
82

we spend every year, as well as the many job and other protections now afforded

to chemically dependent individuals. The key question, rather, has to do with what kinds of treatment programs we should more earnestly seek to create and replicate. The answer, I would suggest,

is spiritually driven ones. The kinds, frequently, without a lot of formally

credentialed therapists on staff. The kinds, quite frankly, which give orthodox

secularists and many governmental grant makers the willies. But the kinds of programs which friends such as Bob Woodson of the National Center for Neighborhood

Enterprise, and Marvin Olasky of the University of Texas—as well as friends and

colleagues doing great things in Minnesota—have convinced me are most adept at

performing near miracles in turning very troubled lives around. Nonetheless, it would be fraudulent if I let it go at that; if I suggested that enough ‘‘near miracles’’ could be assured for those who seriously harm their children

if only right treatments were divined and backed. We know this is not possible. And

it’s for this reason that I’ve come to reluctantly conclude that we must terminate

the rights of unfit parents more frequently, and more quickly, than we generally do.

Putting matters directly, we need to find the fortitude to speed up the process by

which parental rights are ended when it is demonstrably clear that children are

being ruined. Suffice it to say, I’m well aware of the implications of what I’ve just said. As some- one who runs a conservative think tank, I am not enthused about urging government to become more energetic in investigating families. But after several years of

thinking things through, I’m more convinced than ever that we must fundamentally

reorient the child-protection system in favor of vulnerable children. This is the case insofar as prevailing law and ideology in child-protection circles since the early eighties—emphasizing the rigid pursuit of ‘‘family preservation’’ even

when there is barely a shred of a viable family to reconstruct—have been a disaster.

We all know the resulting numbers, starting with the fact that almost 2,000 infants

and young children in the United States die from neglect and abuse by parents and

care givers every year, with upward of half of them dying after they and their families enter the child-protection system. If I do say so, and not with a little surprise, I’ve discovered that most of my coun- terparts on the right also have come to agree that we need to terminate parental

rights faster. This is a remarkable development given the strong and intuitive opposition of most conservatives to further extending government’s reach into the life of

families.

I just cited the almost 2,000 infants and young children who die at the hands of their parents and care givers every year. Another very sad, in this instance, Minnesota-based fact is this: The number of American-born children adopted by nonrelatives in my state fell from more than 2,500 in 1970 to less than 500 in 1995—even

though the number of children removed from their biological homes, at least temporarily and for a host of reasons, exploded across the country during this span. As

with anything so complex, there are several reasons for this drastic decline in adoptions, including the aforementioned emphasis on family preservation and, particularly in Minnesota, a disproportionate emphasis on the racial matching of adoptive

parents and children. But quite obviously, if as a society we seek, for good cause,

to increase the rate of terminations of parental rights, we are obliged to find ways

of increasing the rate of adoptions.

This is not the time or place to detail exactly how this might be done. For no

other reason, this is the case because adoption—as is true with just about every

issue addressed in this statement—is principally a state and local matter, not a

Washington one. It’s also not necessary to dwell on the intricacies of adoption because we already have identified the most important step in increasing their likelihood: Ratcheting up terminations of parental rights so that more children are freed

for new lives. But having said that, let me conclude this way:

Nearly a year into the process, I’m not the same romantic I once was about adoption, at least when it comes to children, like Nicole, who have been victimized horribly. There is no getting around the fact that boys and girls who are exposed to

drugs in utero and afterward, who bounce from placement to placement, who are

sexually abused, and who suffer any number of other assaults to body and spirit,

are not necessarily easy children to raise.

Beyond dealing with behavioral problems fed by anger, distrust, and perhaps neurological damage, adoptive parents are called on to collaborate on an ongoing basis

with a seeming platoon of social workers, therapists, pediatricians, lawyers and

other professionals. Often, my wife and I wonder how people without the flexibility

we’re fortunate to have in our work lives can ever do justice to a child like Nicole.

Sometimes, in truth, we wonder if we’re doing her justice, given our professional obligations as well as our (advancing middle) age.
83

But at the same time, we very much recognize that grownups are not afforded

the sacred opportunity every day to save a child, and that little girls like Nicole

largely have run out of good chances for a decent life by the time they start school

or by the time their first tooth falls out.

Which is just one more way, Mr. Chairman and Members of the Committee, of

making the case that children in drug-poisoned situations must be rescued quicker,

so that new wounds are not allowed to pile on, day after day and year after year.

Chairman S

Mr. McCrery.

HAW. Thank you, Doctor.

f

Mr. MCCRERY. Let me start with Ms. Ogletree. I am going to ask

you a few questions.

I am just curious about, because they relate to some other considerations that we go through in looking at the welfare system

and welfare reform that is in place, and some problems that may

come up, first of all, How old are your children? You have two children.

Ms. OGLETREE. I have a set of twins that are 3, 3 years old.

Mr. MCCRERY. Three years old?

Ms. OGLETREE. Yes.

Mr. MCCRERY. Why do you have to get up at 4 o’clock in the

morning? And why do you not get home until 8 o’clock at night?

Ms. OGLETREE. For one, I am dedicated as an employee, where

I live at; making a change in my life is becoming responsible as a

parent, OK? And for me, at this stage in my recovery, I would go

to any means, any length to be a responsible parent to my kids and

show them that I am a good role model and, today, that I am somebody.

So—that means for me to get up at 4 o’clock every morning, get

to work, be on time, and to be comfortable on my job so when I

start, I am ready to work, then that is what it takes.

Mr. MCCRERY. So do you live that far away from your work? Is

that——

Ms. OGLETREE. It is a commute. It is about a 1-hour commute,

an hour and a half in the morning. So the commute is very long,

but I am willing to do that.

Mr. MCCRERY. And where do your kids go when you leave?

Ms. OGLETREE. My kids go to the babysitter. And the babysitter,

in turn, puts them on the bus to go to school in the morning.

Mr. MCCRERY. OK. And what about in the evening? What happens to your children in the evening?

Ms. OGLETREE. OK. When I come home from work, they are at

the babysitter’s. She takes them off the bus. One goes in the morning, and one goes in the afternoon. So one is usually with her in

the afternoon. While the one is in school, the other one is coming

off the bus. So it is, you know, difficult for her, too. So——

Mr. MCCRERY. Now, I thought I heard you say that you are in

a transitional home; is that not correct?

Ms. OGLETREE. Yes, I am.

Mr. MCCRERY. That is correct?

Ms. OGLETREE. Yes, it is.

Mr. MCCRERY. So, is the babysitter provided by the transitional

home——
84

Ms. OGLETREE. Transitional home——

Mr. MCCRERY [continuing]. Or provided by——

Ms. OGLETREE. No, the babysitter is not provided by the transitional home. The babysitter is in a program that works with drugs

and alcohol. And she was willing to work with me, as long as I was

doing what was expected of myself as far as my recovery. And you

don’t find too many people like that, so I guess I could say I was

fortunate.

Mr. MCCRERY. Yes. So are you paying the babysitter?

Ms. OGLETREE. Yes, sir. I am paying them out of my pocket, yes.

Mr. MCCRERY. So when you are out of the transitional home,

what are your plans? Are you going to be able to afford a place to

live and a babysitter? Are you going to try to find a place closer

to your work, or what is your plan?

Ms. OGLETREE. Well, my plan is by—well, I have up to 2 years

in my transitional house; and within that time, I have plans to

transitional out into a regular setting where I can afford my own

place, get the experience on my job that I need to transitional out

into a regular apartment, affordable housing, that I can afford and

affordable day care for my kids.

Mr. MCCRERY. OK. Well, good luck.

Ms. OGLETREE. Thank you.

Mr. MCCRERY. Thank you very much for your testimony.

Mr. Batty, how is your program funded?

Mr. BATTY. It is privately funded.

Mr. MCCRERY. What does that mean?

Mr. BATTY. Individual contributions, businesses and churches

provide the bulk of that support, as opposed to a government subsidy.

Mr. MCCRERY. OK.

Dr. Satel, you have testified that you think we ought to link welfare payments—I presume you mean TANF payments, cash welfare

payments——

Dr. SATEL. Right.

Mr. MCCRERY [continuing]. For compliance with treatment programs.

Dr. SATEL. Yes.

Mr. MCCRERY. And then you mentioned that some other places

are linking things such as SSI payments on a voluntary basis. The

folks in treatment voluntarily give their SSI payments over to the

treatment center?

Dr. SATEL. Right.

Mr. MCCRERY. And they give them back if they are successful.

So, would you recommend tying some other entitlement programs

to compliance with treatment programs, like SSI benefits or food

stamps or——

Dr. SATEL. Yes. We had an interesting model for this called

DA&A, drug abuse and alcoholism. Until 1995 the Social Security

Administration considered addiction to be a disease, and addicts

were given benefits just like everyone else who was disabled. There

was a lot of trouble with the DA&A Program. As you remember,

few people went to treatment; a lot of that money ended up subsidizing addiction. There was a linkage formed between SSA and

treatment programs but that legislation was reversed about 1 year
85

after it went into effect. Nevertheless, that was a model for making

benefits contingent upon compliance with treatment.

Here, I am talking about a much more—I guess I could say a

more micromanaged form of that, ideally at the level of the treatment program. A colleague of mine has been collaborating with the

State of New Jersey trying to help the State to come up with some

creative ideas. For example, for compliance with work requirements and treatment if the person needed it, the State could give

them improved housing vouchers. And also food stamps are important to control, because if the person is actively using drugs, again

they are converted into cash and sold and used to buy drugs.

Mr. MCCRERY. OK. Thank you. Thank you all for your testimony.

Chairman SHAW. Thank you, Mr. McCrery.

I might add that the States can do that with the TANF payments

if—if they can.

Mr. Levin.

Mr. LEVIN. Just quickly, so others can join in, the States have

the discretion. So let me ask you, how do you, with TANF, how—

let’s say that, with drug addicts, there is kind of an up and down—

not off in a straight line.

So let’s say for a few months, the person hasn’t used drugs. And

then the person does for 1 month, the fourth month, and has two

children. How do you—you have to link these two creatively, don’t

you? I mean you can’t just——

Dr. SATEL. Right.

Mr. LEVIN [continuing]. Have a mechanical linkage.

Dr. SATEL. In the written testimony, I went into that a little bit.

If a recipient started to deteriorate badly, you would give her the—

you could give people a lot of choices; but one choice could be residential care—obviously, a person can’t be maintained as an outpatient if she is heavily using drugs. Her children aren’t safe; she

is using.

I wouldn’t stop the clock either; I agree with Mr. Zill on that.

One of my key points here is that the reason why people drop out

of treatment at such high rates and why compliance with treatment is so poor is because there are no consequences. Ultimately,

if they violate every rule and expectation associated with welfare

or with the treatment program, I suppose they could run out of

safety nets. If they did land on the street and if they did—as Professor Reuter was saying earlier, they would likely resort to crime,

but we have something called drug courts which are wonderful innovations. And they take people who have been arrested for drug

crimes, misdemeanors, or felonies. There is one in the District of

Columbia, and it is a diversionary program where offenders are

sent to treatment instead of jail. And there are very, very clear consequences for not keeping up with the treatment program, ultimately ending up with the person having to fulfill a jail sentence.

Not that many people have to do that. And if they comply with the

treatment and finish it, then their offense gets expunged at the

end.

In fact, if I could just add, the District of Columbia drug court

did a very interesting demonstration project a few years ago where

they had one cohort in treatment and another just getting sanctions. These people were told, if your urine is dirty, you are going
86

to go to jail for a night. If it is dirty the second time, 2 nights and

so on, progressively.

And the group with just the sanctions were told, If you think you

need some treatment, go to AA, get it on your own, but we are just

looking at the urines. And this is what is going to happen to you

if your urines are positive, so you know up front.

That group did better than the group in treatment. And that has

a lot to do with the unaccountable way that particular treatment

program worked. And it is very similar, unfortunately, to the average treatment program out there.

Mr. LEVIN. OK. I think others should question.

Thank you.

Chairman SHAW. Mr. Coyne.

Mr. COYNE. I have no questions.

Chairman SHAW. Mr. Rangel.

Mr. RANGEL. I have none.

Chairman SHAW. I would like to make an observation here with

regard to Ms. Ogletree and Ms. Saler and going back to what Charlie Rangel was saying and then, Mr. Batty, from your standpoint,

it appears here that there is a common thread. If somebody is getting into a job or looking or training for a job, the cure rate is much

better. Or if it is a spiritual awakening, it is much better.

I think what we are doing, where Charlie was talking about—

put me in jail, so what; my family name, so what—I think it is

more a question of self-worth, self-dignity, and feeling good about

yourself and having some expectations of yourself than other people having expectations of you.

Ms. Saler, you used a statistic, you put the two back to back, and

I may have missed them, but did you say—what is the correlation

between people who find a job and those that are successful in the

completion of your program?

Ms. SALER. With the—in the study that was done, what was important was that those who completed treatment at the time that

the independent followup was done, 85 percent of them were employed. One of the connections that we were able to make in this

is that we were able to actually see people who had made lifestyle

changes that supported their recovery, and the converse of that,

their completed treatment supported making those changes.

So what we spend a lot of time with internally in treatment is

looking daily, weekly, quarterly at a minimum, for an overall picture, who is not staying in treatment. When are they leaving?

What can we do differently? What needs to be done better? What

is missing for this group at this time? And spending a lot of time.

And I would say that many of my colleagues in the field do the

same thing, looking at what it is we can do.

And knowing the consequences is important. I would just mention in regard to part of that, just a few weeks ago, we sponsored

a conference for women in Maryland who are in treatment; 150

women from around the State of Maryland came. And the theme

of the conference was ‘‘Welfare Reform: What Does It Mean to

You.’’ And officials from the State of Maryland, folks in recovery,

all came together and presented two women who are going through

the process in varieties of programs around the State, what it is
87

that all of this meant and how it impacted them. And if they didn’t

think it was real, they had better get with it pretty quickly.

And it was very interesting to—Judy was there and a lot of other

women. And they both felt they had the information they needed.

They also felt empowered because it was very clear to them what

the State was willing to do to help them, what the treatment programs were willing to do to help them, and what was expected of

them. And I would throw that out as one other type of thing that

is going on. And it is a tool in working with folks that are going

through this.

Frequently, just sitting down and giving folks the information

and letting them know what the consequences are and making sure

we follow through on the consequences are really important.

Chairman SHAW. Ms. Ogletree, let me ask you a question. If you

had come out of the program and just gone home and received benefits and not gone to work, would it have been harder for you to

stay clean?

Ms. OGLETREE. Yes, it would have. When I first came out of the

program, I wasn’t working; I was unemployed. And I did receive

benefits for 2 months after I left treatment. I then got a job at Second Genesis as a receptionist. I was still looking for employment.

And I had some of the job skills. And it was just more incentive

to want to get off welfare reform, welfare system with the reform

going on and everything like that. And I knew I always had it in

me to go back to work and be the responsible adult that I should

be.

So after treatment, I did stay on welfare for 2 months.

Chairman SHAW. I appreciate all of your testimony today. I think

it is——

Mr. MCCRERY. Mr. Chairman.

Chairman SHAW. Yes.

Mr. MCCRERY. If you would allow me.

Chairman SHAW. Surely. Go ahead.

Mr. MCCRERY. I would like to ask Ms. Saler a question. How

many employees do you have?

Ms. SALER. At Second Genesis?

Mr. MCCRERY. Yes.

Ms. SALER. Approximately 110 right now.

Mr. MCCRERY. And how many of those are women with small

children; do you know, offhand?

Ms. SALER. One-third.

Mr. MCCRERY. One-third?

Ms. SALER. That would be a rough guess, one-third to one-half.

Mr. MCCRERY. I gather you don’t provide any child care for your

employees?

Ms. SALER. We have at our women and children’s program, we

have it onsite, but no, we don’t, we—it is a problem. It is an issue

for us for bringing—we do hire a lot of single mothers, working

mothers, and that is an issue. It continues to be an issue. And it—

and as we return more and more women to the workforce, child

care is becoming a major issue.

I will sit—and when I get into talking about people getting back

to work at vocations, I’ll say there is vocational counseling, child
88

care, skills training and child care, and housing and child care; and

how are we going to handle it?

Mr. MCCRERY. Have you looked at providing onsite child care for

your employees?

Ms. SALER. Yes, we have.

Mr. MCCRERY. And what is the obstacle?

Ms. SALER. Cost.

Mr. MCCRERY. Cost.

Chairman SHAW. Is liability a part of that? I hear that also.

Ms. SALER. We have actually at our women’s and children’s program, we already have children onsite, and that has not been an

issue. I am less worried about the liability.

One of the issues becomes, in the current climate, getting the

funding for treatment. We work—we do work with public dollars,

and what we are getting paid for treatment is far below what the

private for-profit sector is paid on average in our—most of our regular programs we get paid about $55 a day. The women and children’s program, we get about $125 a day to work with the entire

family. So——

Mr. MCCRERY. Your total funding comes from public sources?

Ms. SALER. Public and private. We work—we do work on contract

with the States and the local jurisdictions, and then we—we do

some work with private insurance companies, employee assistance

programs, things like that.

Chairman SHAW. Again, I want to thank this panel.

Mr. Pearlstein, good luck with your daughter and your coming

adoption.

Mr. PEARLSTEIN. Thank you very much.

Chairman SHAW. And we are adjourned.

[Whereupon, at 5:15 p.m., the hearing was adjourned.]

[Submissions for the record follow:]
89

1 National Committee for the Prevention of Child Abuse (NCPCA). Current Trends in Child

Abuse Reporting and Fatalities: NCPCA’s 1996 Annual Fifty State Survey, Chicago, IL: NCPCA

Publications. 2 2 NCPCA, 1996.

3 3 NCPCA, 1996.

4 4 NCPCA, 1996.

5Tatara, T., American Public Welfare Association. Research Notes. (1997, March).

6 6 NCPCA, 1996.

7 Newmark, L. (November 15, 1995).’’Parental drug testing in child abuse and neglect cases:

Major findings.’’ Presented at the 46th Annual Meeting of the American Society of Criminology.

Washington, DC: The Urban Institute.

Statement of Child Welfare League of America, Inc.

The Child Welfare League of America (CWLA) welcomes this opportunity to submit testimony. We commend the subcommittee for its efforts to examine the links

between substance abuse and child abuse and neglect. Our comments focus on substance abuse as a factor in the placement of children into foster care, and highlight

the need for and examples of interventions that keep children safe and help families

recover.

CWLA’s 900-member public and private agencies across the country work everyday to improve conditions for children and families at risk and in crisis. Serving

over 2.5 million children and their families each year, CWLA member agencies provide a wide array of services including child protective services, family preservation,

family support, adoption, family foster care, treatment foster care, residential group

care, adolescent pregnancy prevention, child day care, emergency shelter care, substance abuse treatment, independent living, and youth development.

NEED FOR PROTECTION AND CARE INCREASES

• In 1996, an estimated 3,126,000 children were reported to child protective services agencies as alleged victims of child maltreatment.1 From 1987 to 1996, the total

number of children reported abused or neglected increased 45%.2 The number of reports substantiated has increased by approximately 14% over the same period.

• In 1996, nearly one million children were confirmed victims of child maltreatment.3

• Last year, an estimated 1,046 children, or three children per day, died as a result of child abuse and neglect; 82% of the victims are under the age of five, and

42% are less than one year old at the time of their death.4

• When child protective services determines that a child cannot be safely cared

for at home the child is removed to a safer place. Preliminary estimates indicate

that 502,000 children in the U.S. lived in out-of-home care—family foster care, kinship care, or residential care—at the end of 1996.5

SUBSTANCE ABUSE HIGHLY INVOLVED IN ABUSE AND NEGLECT REPORTS

The use of drugs and abuse of alcohol among families is a pervasive and disturbing trend that continues to have a devastating impact on the safety and well-being

of children. Although it is difficult to quantify a causal relationship between alcohol

and other drug (AOD) use and child maltreatment, experts agree there is a high

correlation between parental chemical dependency and child abuse and neglect.

• Nearly eighty percent of states report that parental substance abuse is one of

the top two problems exhibited by families reported for maltreatment.6

• Drug testing of families with abused and neglected children in the District of

Columbia Family Court in 1995 revealed that two in three parents tested positive

for cocaine and one in seven tested positive for heroin and other opiates.7

Identifying family members who are chemically involved and assessing how AOD

use affects their ability to provide a safe, nurturing living environment are critical

steps in determining risk of maltreatment for children. Once substance abusing

caregivers are identified, child welfare professionals struggle to find and provide appropriate treatment. Even if treatment services are available, the timeframes for effective treatment may exceed timeframes to achieve permanency for children. A

wait for residential AOD treatment for women with children may be close to 10

months in some parts of the country.

CWLA’S 1997 AOD SURVEY REVEALS GREAT NEED, FEW RESOURCES

In 1997, CWLA surveyed state public child welfare agencies in order to obtain a

baseline measure of the types of policies, programs and data collection efforts in
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8 8 U.S. Department of Health and Human Services, Center for Substance Abuse Treatment.

(1995). Study of grantees administered by the Women’s and Children’s Branch. Rockville, MD:

author. 9 Breitbart, V, Chavkin, W, and Wise, PH (1994). Accessibility of drug treatment for pregnant

women: A survey of programs in five cities. American Journal of Public Health, 84(10), 1658–

1661.

place to support chemically involved families, with a special emphasis on children

and youths in out-of-home care. Survey respondents estimated that:

• 67% of parents involved with the child welfare system need AOD treatment;

• Child welfare agencies could only provide services for 31% of those parents in

need;

• Less than half of all states report that training on recognizing and dealing with

AOD problems is available for foster parents;

• Only 9 states (of 47 states responding) provide similar training for kinship care

providers yet 30 percent of all children currently in out-of-home care are in kinship

care living with a relative;

• 83% could not provide the number of youth in out-of-home care whose parents

are chemically dependent;

• Only 11% believe that children and parents with AOD problems can be treated

in a timely manner (less than 1 month);

• 42% rely on school-based education drug prevention programs as the only form

of prevention services available for youth in out-of-home care;

• 94% could not provide the number of youth in out-of-home care known to abuse

AOD themselves.

EFFECTIVE TREATMENT EXISTS; SUPPLY AND ACCESS REMAIN VERY LIMITED

Treatment is a cost-effective strategy for intervening to stop the cycle of destruction and despair that substance abuse inflicts on children and families. Programs

providing comprehensive services and attending to the continuing treatment needs

of women are most beneficial. The U.S. Department of Health and Human Services’

Center for Substance Abuse Treatment recently reported on women’s outcomes for

their grantees providing comprehensive programs targeted to post-partum women

and their infants.8

Of the women in treatment:

• 95% reported uncomplicated, drug-free births;

• 81% were referred by the criminal justice system and had no new charges following treatment;

• 75% who successfully completed treatment remained drug-free; and

• 40% eliminated or reduced their dependence on welfare.

Of their children:

• 65% were returned from foster care; and

• 84% who participated in treatment with their mothers improved their school

performance.

As noted earlier, such interventions are in short supply. In general, traditional

substance abuse treatment services have been tailored to male addicts not to

women. Very few substance abuse treatment programs provide child care or adequate alternatives for women who seek treatment, creating a significant barrier for

women who need help. A 1993 survey of drug treatment programs in five cities

found that most accept pregnant women (83% of outpatient and 70% of residential

programs), but only 20% both accept pregnant women and provide child care. In

three of the five cities surveyed, no residential programs accepted pregnant women

and provided child care.9

The most effective and responsive solution to the chemical dependency/child abuse

dynamic is preventing the problem in the first place. We must educate the public

on the devastating health consequences of AOD abuse and the emotional and physical hazards of growing up in a chemically involved household. We must develop better means to identify and provide a continuum of treatment and support services

to chemically involved families. Without additional prevention and treatment resources, the child welfare system will continue to wage a war against substance

abuse that it cannot win.

We again applaud the efforts of this subcommittee to investigate the difficult and

complex links between substance abuse and child abuse and neglect. We look forward to continuing to work with you to help children stay safe.
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Statement of Ray Soucek, Haymarket Center, Chicago, Illinois

Mr. Chairman, I am writing on behalf of Haymarket Center, a comprehensive drug treatment center located on the West side of Chicago, in reference to your Subcommittee’s recent hearing on Substance Abuse in Welfare Families. Established in

1975, Haymarket is the third largest substance abuse treatment center in the State

of Illinois, providing services to more than 13,000 people annually. Our organization

is deeply concerned with the effect of welfare reform on recipients with drug and

alcohol abuse problems.

The link between substance abuse and welfare recipients is significant. A study conducted by Aid to Families with Dependent Children (AFDC) of drug and alcohol

use among adult recipients found that between 15–20% of welfare recipients have

drug and alcohol problems. Another study conducted by researchers at the National

Institute on Alcohol Abuse and Alcoholism (NIAAA) based on data from the 1992

National Longitudinal Alcohol Epidemiologic Survey, estimated that 17.9% of welfare recipients are dependent on alcohol and drugs, compared to 8.9% of non-recipients. Put simply, welfare recipients report a higher rate of drug and alcohol abuse

than non-recipients do.

Mr. Chairman, it is our belief that States must address the issue of dependency in order to prepare more welfare recipients to enter the workforce. With the new

Welfare-to-Work stipulations, States must pay for the effects of substance abuse regardless of whether they pay for treatment. Ignoring the problem will result in

States having an estimated 20% of their workforce with a major job-readiness impediment, causing heavy financial burden for the State. The new welfare law mandates that work participation rates amongst recipients rise from 25–50% between

1997 and 2002, with States receiving fines for non-compliance. An even more expensive consequence having to take over when untreated alcohol and drug abuse problems prevent recipients from leaving welfare within the designated time limit. There are two subgroups within the welfare population that pose significant chal- lenges to Welfare-to-Work self-sufficiency efforts: abusers with co-occurring disorders, and substance abusing welfare mothers.

What is the effect of co-occurring disorders on diagnosis and treatment?

Co-occurring disorders are a common problem among all people with substance abuse disorders. It is estimated that half of all people with substance abuse problems have co-occurring disorders, involving psychiatric as well as substance abuse

disorders. Often one problem can be considered primary and the other secondary,

but more often, the patient is disabled by both disorders and requires integrated

treatment. These people often fall victim to inadequate or ineffective treatment services, and lack of insurance coverage for their problems. According to M. Susan Ridgeley, J.D., M.S.W., Associate Professor, Department of Mental Health and Law policy at the University of Florida, there are numerous aspects of co-occurring disorders that make the problem more debilitating to the patient and the system: • Patients often suffer from more severe psychiatric symptomatology • High rates of relapse and rehospitalization • Worse course in treatment of the psychiatric disorder • More admissions to emergency rooms and noncompliance with treatment interventions • Increased acting out suicidal and criminal behavior • Less able to carry out activities needed to manage their lives Mr. Chairman, this last characteristic common to patients with co-occurring dis- orders is especially significant to the self-sufficiency goals of the Welfare-to-Work

program, and in reducing the incidence of drug abuse among welfare recipients.

With increased pressure from the new laws to get welfare recipients into the workforce, less time is likely to be spent getting to the root of the problem. Co-occurring

patients are expensive to the system because they often are not properly diagnosed.

The solution is providing incentives for physicians and counselors to make diagnosis

and treatment for co-occurring disorders the ônormö rather than the exception.

Why do dependent welfare mothers often not receive treatment?

According to a September 1997 study produced by the Legal Action Center (LAC),

titled Making Welfare Reform Work: Tools for Confronting Drug and Alcohol Problems Among Welfare Recipients, there are many common barriers to treatment for

women with children. And according to the Department of Health and Human Serv92

ices, in 1991 it was estimated that 5.6 million mothers with children living at home

had used drugs during the past six months. The LAC study said these women face

unique obstacles in receiving treatment, including: 1. Stigma: Studies have discussed the multitude of self-deprecating feelings women with substance abuse problems have experienced. According to the LAC,

‘‘these emotions can lead to an immobilizing sense of depression and isolation and

ultimately prevent women from asking for help.’’ 2. Lack of Child Care: A 1996 survey in Substance Abuse Report reported that few substance abuse treatment centers provide child care, often acting as a deterrent for welfare mothers from seeking treatment, according to William Walden,

Commissioner of the New Jersey Department of Human Services. Ther to meet increased demand for child care services. The problem of lack of quality child care for

all welfare recipients is compounded for those with substance abuse problems. Before welfare mothers need quality child care while they are working, they need quality child care while in treatment, making centers that do provide child care and clinical child services more appealing.

3. Fear of Losing Custody of Their Children: Since many States take punitive action against mothers with drug problems, women often are afraid to admit their addiction and seek treatment.

4. Fear of Prosecution: In State v. Whitner the South Carolina Supreme Court

ruled that women can be held criminally liable for their actions during pregnancy.

The fear of prosecution by those welfare mothers who use drugs while pregnant coincides with fear of losing custody of children.

5. Victims of Violence: Women with substance abuse problems have high rates of

being victimized by violence, a problem that affects their recovery from addiction.

6. Safe Housing: Drug-free safe housing is important for many recovering women.

However, safe housing has become more and more difficult to obtain due to The

Housing Opportunity Extension Act of 1996, which permits authorities to deny

housing to former drug and alcohol abusers due to the potential threat they pose

to other residents.

Mr. Chairman, States must overcome these barriers by identifying welfare mothers with substance abuse problems and providing them with proper treatment. It

is clear that the consequences for ignoring the problems are severe. Child welfare

and foster care costs are increasing dramatically. Alcohol and drug abuse are among

the top factors for children entering welfare and foster care. According to a 1994

GAO study, almost 80% of young children who entered foster care in 1991 in California, New York, and Pennsylvania, had at least one parent with a drug or alcohol

addiction. The cost of placing a child in the welfare or foster care system is 2 to

16 times more than the cost of individual federally funded drug treatment. According to a LAC study, ‘‘Providing alcohol and drug treatment prevention services for

[welfare] families could protect children, reduce welfare caseloads, and produce significant savings for the federal and state governments.’’

The reformed welfare system must recognize the needs of recipients wif recipients

are expected to achieve self-sufficiency and job-readiness. Investments in treatment,

especially for those with co-occurring disorders and welfare mothers, will be much

more cost effective for the system and beneficial to recipients in the long run.

Statement of Gwen Rubinstein, M.P.H., Deputy Director of National Policy,

Welfare reform, now unfolding, presents states with many opportunities and chalLegal Action Center, Washington, DC

f

lenges. It will not be long before we know whether this experiment will succeed in

its key mission of moving many Americans from welfare to work.

Reform of the child welfare and foster care systems will also be enacted soon.

That initiative will present a set of new challenges to states, which are already

grappling with many other complex reform initiatives inside and outside of the welfare system.

We commend the Subcommittee on Human Resources of the House Committee on

Ways and Means for calling this hearing, and we appreciate the opportunity to provide written testimony for the record. Alcoholism and drug dependence often are

major barriers to self-sufficiency for welfare recipients, and we welcome discussion

of how our national policy can confront thisproblem humanely, productively, and

cost-effectively.

The Legal Action Center is a law and policy organization focusing on alcohol,

drug, and HIV/AIDS issues. The Center also represents the National Coalition of
93

1 Entities that have published studies include: Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services: National Center on Addiction and Substance Abuse at Columbia University; and National Institute of Alcohol Abuse and Alcoholism,

National Institutes of Health. 2Those States included Kansas, which reported that 20 to 50 percent of its caseload would

fail a drug test, North Carolina, which said 35 percent of its welfare clients were at risk for

alcohol or drug problems, and Oregon, which estimated that 50 to 60 percent of its welfare caseload was alcohol or drug related. 3General Accounting office, Foster Care: Parental Drug Abuse Has Alarming Impact on Young

Children, 1994, p. 7. 4Washington State Department of Social and health Services, ‘‘Chemical Dependence Among

DHS Clinets: A Departmental problem,’’ October 31, 1996, p. 10. 5 Brandeis University, institute for Health Policy, Substance Abuse: The Nation’s Number One

Health Problem—Key Indicators for Policy, 1993. 6 Ibid.

7 Child Welfare League of America, ‘‘Through the Eyes of a Child: A National Agenda for Addressing Chemical Dependency,’’ (Working Draft), 1992, p. 27.

State Alcohol and Drug Treatment and Prevention Associations, a coalition of 34

state treatment and prevention associations in 30 states around the country. These

associations represent providers on the front lines of treatment and prevention who

daily confront the dramatic need to maintain and strengthen services for individuals

and families with drug and alcohol problems.

A key component to the success of both of these reforms, we believe, is the adoption of a balanced and comprehensive approach to addressing alcohol and drug problems among all Americans, but particularly low-income Americans. If reforms are

to succeed, they must make a steadfast commitment to identifying children and

adults who have or are on the brink of an alcohol or drug problem and providing

them appropriate alcohol and drug treatment and prevention services.

The Legal Action Center recently completed a major study for the Annie E. Casey

Foundation entitled ‘‘Making Welfare Reform Work: Tools for Confronting Alcohol

and Drug Problems Among Welfare Recipients’’ (copy attached). This statement incorporates some of our study’s leading findings and recommendations. We request

that the entire study be included in the record.

ALCOHOLISM, DRUG DEPENDENCE, AND WELFARE

Several national studies have attempted to determine how many welfare recipients have alcohol and drug problems; all have concluded that between 15 and 20

percent of welfare recipients do.1 This could translate nationally into between

400,000 and 800,000 adult welfare recipients needing treatment to move into recovery, off welfare, and into jobs.

Few states, however, know the prevalence of alcoholism and drug dependence in

their welfare caseloads. Earlier this year, the Legal Action Center surveyed state

welfare officials and state alcohol and drug officials to gauge their knowledge and

plans concerning welfare reform and addiction. Our report found that only five

states had any data on the number of welfare recipients with drug or alcohol problems.2

This lack of information will undoubtedly hamper state and local planning and

reduce the likelihood that alcohol and drug problems will be confronted with enough

thought to be handled most effectively.

ALCOHOLISM, DRUG DEPENDENCE, AND CHILD WELFARE

Abuse and neglect associated with parental alcohol and drug abuse are among the

most common reasons for entering the child welfare system, and drug-and alcoholrelated foster care placements have been increasing. Almost 80 percent of young

children who entered foster care in 1991 in California, New York, and Pennsylvania

had at least one parent who was abusing drugs or alcohol, compared to 52 percent

in 1986.3

In Washington State, 41 percent of infants placed in out-of-home care in 1995

were born to 1mothers who abused alcohol or other drugs during their pregnancy.4

In New York, crack cocaine alone was blamed for a three-fold increase in the city’s

child abuse and neglect cases in the late 1980s.5

Out-of-home placements for children whose parents have alcohol or drug problems

have contributed to skyrocketing foster care costs. Federal expenditures on foster

care increased 300 percent between 1986 and 1991—from $637 million to more than

$2.2 billion.6 In Illinois, the added medical and related costs of caring for 2,500 cocaine-affected infants in child welfare custody were $60 million in 1991.7
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8 U.S. House of Representatives, 1996 Green Book: Background Materials and Data on Programs Within the Jurisdiction of the Committee on Ways and Means, 1996, pp. 714–724. 9Substance Abuse and Mental health Services Administration, FY 98 Budget Justification.

10 National Development and Research Institutes, ‘‘Preventive Services Outcome Assessment:

A Survey of Contracted Agencies, Preliminary Results,’’ March 1995. 11Dean R. Gerstein, et. al, ‘‘Alcohol and Other Drug Treatment for Patents and Welfare Recipients: Outcomes, Costs, and Benefits,’’ January 1997, p. 29. 12 Center for Substance Abuse Treatment, ‘‘The National Treatment Improvement Evaluation

Study—The President Effects of Substance Abuse Treatment, One Year Later,’’ September 1996,

p. 11.

Providing adequate alcohol and drug treatment and prevention services for these families would protect children, reduce child welfare caseloads, and produce significant savings for the federal and state government. Foster care costs in 1994 ranged

from $4,800 per year for placement in family foster care to $36,500 per year for

placement in group care.8 This is two to 16 times more than the cost per person

for federally funded drug treatment.9

Yet legislation passed in House this spring and in the Senate over the weekend to speed up adoption of children in foster care virtually ignores the relationship between addiction and child welfare. In fact, the Senate version of the bill, at the last

moment, lost three important provisions to address that issue: a General Accounting

Office study to explore the relationship between child welfare placement and alcoholism and drug dependence, allowance for foster care funding (under Title IV–E

of the Social Security Act) to help pay for residential treatment in the case of children being reunited with a parent in treatment, and a new priority in the Substance

Abuse Block Grant for parents in families involved in the child welfare system. These problems can be overcome, but not if they are ignored. In a recent study of 475 New York child welfare cases that received a range of preventive services (including alcohol and drug treatment), 98 percent of the families avoided foster care

placement, domestic violence decreased in 93 percent of the families, child physical

and sexual abuse decreased in 100 percent of the families, and 48 percent of the

families sustained abstinence from alcohol and drugs.10

TREATMENT IS EFFECTIVE BUT UNDERFUNDED

Empirical research has shown that after alcohol and drug treatment, women re- duce their reliance on welfare and increase their employment.11 12 We believe these

findings support public policy that promotes treatment for welfare recipients with

alcohol and drug problems as a way of helping them find and keep jobs and leave

the welfare rolls. (I have attached a copy of the National Treatment Improvement

Evaluation Study and ask that it be included in the record.) Individual recovery stories also demonstrate the effectiveness of treatment:

• CD is a 38-year-old woman who has been in recovery for two years, since she entered residential treatment at Project Return in New York City for crack abuse.

She has three children—ages 12, 7, and 6 years old—who had been in kinship foster

care with her mother while CD was abusing drugs. After treatment, CD was reunited with all of her children. CD is a former welfare recipient who has been employed for nearly one year as a nurse’s assistant. • SS is a 38-year-old white woman who had lost custody of her three children due

to her long history of substance abuse when she entered Par Village in St. Petersburg, Florida, for treatment. Her drug use included crack cocaine, alcohol, and heroin. Between 1992 and 1994, SS participated in treatment and was able to regain

custody of her children one by one. She has worked diligently to develop and practice her recovery and vocational skills. After treatment, SS established a home for

her and her children and enrolled in St. Petersburg Junior College, where she continues her studies and is employed by the Work Study Program. SS and her children are very involved in the worship and activities at their church in Clearwater,

Florida, and she is an active participant in 12-step programs throughout Pinellas

County.

These success stories are occurring all over America, yet publicly funded treatment programs such as Project Return or PAR Village are not always readily available in many communities. Waiting lists are common, and the most difficult treatment to find in virtually any community is a residential program for women and

children.

The main source of federal funding for alcohol and drug treatment, the Substance

Abuse Prevention and Treatment Block Grant, has been stagnant. It will be allocated $1.36 billion in FY 98, the same as in FY 97. According to our study, only

nine states plan to increase their own appropriations for alcohol and drug treatment

for welfare families.
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13The IMD exclusion, originally drafted to prevent funding of large mental hospitals, has been

extended to include even cost-efficient substance abuse treatment programs. IMDs are facilities

with more than 16 treatment beds.

Drug and alcohol treatment services are also not well covered under state Medicaid plans because they are optional. And reimbursement is expressly disallowed for

all Medicaid-covered services provided to recipients between 22 and 64 years of age

in residential treatment facilities classified as Institutions for Mental Diseases

(IMDs).13

Finally, about 20 states are likely to deny cash welfare and food stamps to individuals with drug felony convictions, thus reducing funds that have been available

for alcohol and drug treatment. Cash welfare and food stamps have helped to pay

for room and board in residential alcohol and drug treatment programs for women

with children. But the new federal welfare law prohibits giving these benefits to individuals with drug felony convictions, unless states ‘‘opt out.’’

Treatment programs serving women are, predictably, concerned about these

trends. Our study found that most expect welfare reform to decrease their revenue

but increase their caseload.

POLICY RECOMMENDATIONS

The Legal Action Center submits the following policy recommendations to the

Subcommittee for addressing alcohol and drug problems among welfare recipients

and families involved in the child welfare system:

Identify Welfare Recipients and Families Involved in the Child Welfare System Who

Have Alcohol and Drug Problems.

The first step in breaking the cycle that keeps addicted people and later generations dependent on welfare or involved with the child welfare system is identifying,

easily and cost-effectively, welfare recipients who have alcohol and drug problems.

• Conduct Screening and Refer Welfare Recipients and Families Involved with

the Child Welfare System Identified as Having Alcohol or Drug Problems for Treatment; Penalize Only Those With Alcohol and Drug Problems Who Refuse to Enter

Available Treatment.

Many short and simple screening tools—both written and verbal—are available

for identifying individuals with drug and alcohol problems. They can easily be integrated into the existing welfare intake process, as some states and localities (such

as New York, Oregon, and Utah) have already done, or child welfare intake process

(as Sacramento County has done). Those identified as having alcohol and drug problems can then be referred for further clinical assessment and appropriate treatment,

if needed.

• Reject Drug Testing as a Method of Identifying Individuals With Alcohol and

Drug Problems.

Limited resources should not be invested in drug testing because it yields little

useful information at too high a cost.f screening and assessment described above is

far more effective at a fraction of the cost.

• Train Welfare and Child Welfare Caseworkers to Administer Screening Protocols and Refer Clients for Services.

The knowledge and skills of welfare and child welfare caseworkers are of critical

importance in helping welfare recipients overcome both their short-and long-term

barriers to working, including alcohol and drug problems. If caseworkers are in as

much denial as their clients are about these problems, even the most well-designed

state initiative is doomed to fail.

Promote and Encourage Treatment and Recovery Among Welfare Recipients.

Helping individuals who are dependent both on welfare and alcohol and drugs

enter treatment and overcome their addiction is an effective way to move them from

welfare to work and reduce child abuse and neglect.

• Provide Treatment to Welfare Recipients Whose Addiction Prevents Them from

Working, and Encourage Their Participation in Treatment by Not Counting Time

Spent in Treatment Toward Their Time Limit on Welfare.

Ideally, welfare recipients identified as having alcohol and drug problems should

have ready access to treatment. National, state, and local policies should make

every effort to increase the availability of treatment for welfare recipients needing

it, particularly treatment designed for women with children, and make it more attractive by exempting individuals in treatment from the welfare time limits.

• Draw on All Possible Sources of Treatment Funding.
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The new welfare reform and adoption reform laws provide no new funding for alcohol and drug treatment. But treatment can still be funded by increasing federal

appropriations for the Substance Abuse Block Grant, state allocation of welfare savings to treatment, state transfer of welfare money to the Social Services Block

Grant, and Federal or state expansion of Medicaid reimbursement for treatment.

• Define Appropriate Work Components of Treatment as a Work or Community

Service Under the Welfare Law, and Ensure that Work and Treatment Are Coordinated.

Some work activities (as defined in the new welfare law) are integral parts of

some alcohol and drug treatment programs. Counting them as work—whether by

contracting with treatment programs to provide them or coordinating treatment

with other work activities—will ensure that states have more welfare recipients to

count toward their minimum work participation rates (so they will avoid penalties)

and that welfare recipients striving toward recovery will gain work experience within the suoportive context of their treatment program.

• Eliminate the Felony Drug Conviction Ban.

The federal government should eliminate the welfare law’s ban on welfare and

food stamps for individuals convicted of drug felonies. The drug felony conviction

ban shrinks available treatment resources, strips the criminal justice system of resources it needs for mandatory drug and alcohol treatment, and shreds the safety

net for individuals who have been in recovery, worked, and paid taxes, and their

families.

Promote Prevention and Early Intervention for Welfare Recipients and Their Children.

Addiction and welfare can both be inter-generational; effective prevention and

intervention can break the cycle for many families forever.

• Integrate Prevention and Early Intervention Services into Welfare Reform.

Preventing parents and children on welfare from developing alcohol and drug

problems—or intervening early in the process—can keep families together, maintain

safe environments for children, and help more families make a successful transition

from welfare to work. All of these would decrease welfare and child welfare caseloads and save states money. The benefits to individuals, families, and communities

would be great.

• Draw On All Available Sources of Prevention Funding.

Prevention activities can be funded both inside and outside of the new welfare law

and at the national, state, and local levels. Key federal sources of funding that

should be increased include the Substance Abuse Block Grant and programs under

the Center for Substance Abuse Prevention and Safe and Drug-Free Schools and

Communities Act.

CONCLUSION

Many welfare recipients have alcohol and drug problems. Their children (and

many adult welfare recipients) are themselves at high risk for becoming dependent

on or abusing alcohol or drugs. To succeed, welfare reform must confront this problem in a balanced and effective way that includes alcohol and drug treatment and

prevention services.

Many families involved in the child welfare system also have alcohol and drug

problems, putting both children and parents at risk. The child welfare system must

confront this problem in a balanced and effective way that includes alcohol and drug

treatment and prevention services.

Adopting a reasoned and comprehensive approach can simultaneously meet the

goals of welfare reform, reduce alcohol and drug addiction and abuse, and improve

the lives of our children, families, and communities.
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1Gerstein, Dean R. et. al., U.S. Department of Health and Human Services, Office of the Assistance Secretary for Planning and Evaluation, Alcohol and Other Drug Treatment for Parents

and Welfare Recipients: Outcomes, Costs and Benefits, January 1997. 2 Ibid.

3 Center for Substance Abuse Treatment, National Treatment Improvement Evaluation Study,

September 1996.

Statement of William D. McColl, Director of Government Relations; on

Behalf of National Association of Alcoholism and Drug Abuse Counselors,

Arlington, Virginia

f

On behalf of the National Association of Alcoholism and Drug Abuse Counselors (NAADAC), please accept the following comments regarding protecting children

from the prevalence and impact of substance abuse on families receiving welfare.

NAADAC, with more than 18,000 members, is the largest national organization representing the interests of alcoholism and drug abuse treatment and prevention professionals across the United States.

Research has clearly shown that children are highly affected by alcoholism and

drug addiction within the family. Families on welfare face additional pressures from

joblessness and poverty. Nevertheless, these issues are not insoluble. NAADAC reiterates three fundamental principles to deal with alcoholism and drug addiction, applicable not only to welfare, but also to society at large. First, alcoholism and other

drug dependency must be addressed primarily as a public health problem. Second,

access to appropriate care, delivered by credentialed professionals, must be provided

to persons dependent on alcohol and other drugs. Finally, public and private funding

must be significantly increased and policies improved to provide adequate levels of

care for persons dependent on alcohol and other drugs.

By following these fundamental principles, our nation can begin to reduce the tremendous burden faced by victims of the diseases of alcoholism and drug addiction.

Treating these diseases will result in safer children, restored families and inproved

communities. NAADAC adds the following specific program solutions below, designed to enhance the nation’s ability to help those children caught in the difficult

position of being on welfare with one or more parents who have the disease of alcoholism or drug addiction.

TREATMENT MUST BE A FUNDAMENTAL PART OF FEDERAL AND STATE WELFARE

PROGRAMS—WELFARE

In 1996, Congress fundamentally changed the federal welfare law to require that

states move people from public assistance to work. As states begin to implement the

new welfare requirements, the National Association of Alcoholism and Drug Abuse

Counselors (NAADAC) supports policies and legislation which acknowledge the vital

role of alcohol and drug treatment in helping individuals who are addicted to alcohol

and other drugs to find employment and achieve self-sufficiency.

State policymakers must be made aware that treatment positively affects the ability of this population to move into employment. According to one recent study, 5.2%

of adults in Aid to Families With Dependent Children (AFDC) households are so severely impaired by alcoholism and/or drug addiction problems that they are unable

to participate in immediate employment or training activities.1 This group must receive treatment if they are to become capable of work. An additional 11.2% of AFDC

adults are somewhat impaired and may require alcoholism and drug addiction treatment concurrent with work or training activities.2

Alcoholism and drug addiction treatment is capable of cost-effectively moving clients from the ranks of the unemployment to work. The National Treatment Improvement Evaluation Study showed that people who complete treatment increased

the rate of past year employment by 18.7% while decreasing income received from

welfare programs by 10.7%.2 In addition state governments will save significant

public funds by reducing the medical costs that result from this disease, helping

people to live independently from welfare and public assistance, reducing the number of crimes committed by people who are addicted, and lowering the cost of incarceration.3

Much of the funding of the welfare system is in block grant form which allows

each state a substantial opportunity to decide how they will spend their funds.

NAADAC recommends that states place a portion of welfare funding into alcohol

and drug treatment to help ensure success in moving people into jobs. State treat98

4 Ibid.

5 NAADAC, Position Statement, Drug Testing, March 1996. NAADAC, Position Statement,

Drug Screens, April 15, 1987.

ment agencies and treatment advocates must educate state legislatures, executives,

policy makers, and welfare agencies to ensure that those most responsible for implementing welfare requirements clearly understand the need for treatment.

CHANGES TO THE 1996 WELFARE LAW

NAADAC urges one significant change to the 1996 welfare reform law. The law

currently makes any individual convicted of a drug-related felony ineligible for food

stamps and Temporary Assistance to Needy Families (TANF), previously AFDC.

This provision unnecessarily sanctions people who are suffering from the diseases

of alcoholism and drug addiction. The loss of food stamps and TANF reduces families’ total allotments by the amount of funding which would have gone to the ineligible person. This may jeopardize an entire family’s well-being because benefits support entire families, not just the individuals who use them. Children are particularly

vulnerable to these reductions. Moreover, many treatment providers use TANF and

food stamp benefits to help support the costs of room and board associated with residential treatment. Loss of access to even this meager funding source may cause a

patient to lose treatment opportunities.

Patients who complete treatment require stability and continuing care to ensure

a successful transition to drug free life. There is no provision for restoration of benefits in the new welfare law upon an individuals entrance into recovery. Consequently the stability that this source of funding could bring to people in recovery

is lost. We urge Congress to repeal this lifetime ban. Short of repeal, Congress

should take steps to mitigate possible damage from this provision by exempting persons who are seeking treatment, have completed treatment, are pregnant, or who

are otherwise disabled. NAADAC notes that states are currently allowed to opt out

of this provision. They should do so.

DRUG TESTING AND THE WELFARE LAW

The welfare law now allows states to require that welfare recipients be tested for

drug use and to apply sanctions for positive tests. NAADAC again reiterates its position that ‘‘the purpose of drug testing must be rehabilitative and not punitive.’’ 4

We are concerned that blanket drug testing programs will be accomplished at high

cost to the state without leading to effective treatment people addicted to drugs.

Testing will not effectively address the alcohol and prescription pharmaceutical addiction problems of welfare recipients, and will not, by itself, adequately identify

people who are addicted to those illegal drugs which are most commonly tested. To

correctly identify persons addicted to drugs, state welfare agencies must professionally assess and screen recipients in addition to, or in place of, drug testing.

Upon positively identifying an individual who is suffering from alcoholism or drug

addiction, agencies must provide access to an adequate level of alcohol and drug addiction treatment from licensed or certified alcohol and drug treatment counselors.

CONCLUSION

In summation, the best way to help people who are on welfare and who suffer

from alcoholism or addiction to drugs is to provide them with treatment. Treatment

is the most cost-efficient and effective means of ensuring that welfare recipients suffering from these diseases are able to move from dependence on cash assistance to

employment and self-sufficiency. NAADAC supports efforts to reform the welfare

law to ensure that persons who are suffering from the diseases of alcoholism and

drug addiction do not suffer from discrimination.5 In particular, provisions barring

persons convicted of drug-related felonies from receiving food stamps and TANF are

onerous and make treatment inaccessible to those who are most in need of this service. Finally, NAADAC encourages states to make every effort to ensure that drug

testing is rehabilitative and not punitive. If drug testing is used, states should provide adequate access and funding for treatment by certified and licensed counselors.
f

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Statement of Hon. Jim Ramstad, a Representative in Congress from the

State of Minnesota

Mr. Chairman, thank you for calling this hearing to discuss the impacts of substance abuse on families receiving welfare. I would also like to thank you for inviting Dr. Mitch Pearlstein, my friend from the Center of the American Experiment

in Minnesota, to testify today.

I know many of the people speaking today will explain that alcoholism and drug

addition are painful, destructive occurrences with staggering public costs. We all

know addictions cause health care costs to rise and contribute to the overwhelming

amount of crime, violence and domestic abuse in our nation today.

Despite these facts, I couldn’t agree more with Dr. Pearlstein’s assessment that

this nation ‘‘seems to be in a haze, numbed to the pervasiveness and destructiveness

of drugs.’’ That’s why this hearing, to shed light on the devastation all drugs can

create, is so important.

The most important costs, of course, are the personal costs. Alcoholism and drug

addiction permeate all races and all income levels. They afflict both the abuser and

his/her family—most dramatically, the children. Dr. Pearlstein gives an emotional

personal account of how it has affected his family, especially his adopted daughter.

As one who has been sober for 16 years, I know treatment works. I also realize

that many factors affect treatment success, and just like chemotherapy and radiation for cancer victims, traditional treatment programs cannot have a 100% success

rate.

We should look at alternative programs, as Dr. Pearlstein suggests in his testimony. Frankly, I believe we should consider anything that will effectively help a

person fight addictive tendencies. I am glad to learn through today’s witnesses

about the kinds of treatment programs that are working across this nation so we

can try to replicate them for others.

And for those who won’t or can’t fight addiction, Mr. Pearlstein is absolutely correct—we must remove the children from their care and get the children into a stable, loving and nurturing family as soon as possible.

Certainly, any welfare/foster care system that keeps just one child in harms way

or away from a loving family just one day longer than necessary needs improvement. Unfortunately, more than one child is severely neglected by our system every

year. Dr. Pearlstein tells of 2,000 infants and young children in the U.S. who die

from neglect and abuse by parents and caregivers every year. We also know that

over 500,000 children linger in our foster care system awaiting adoption.

Because alcoholism and drug addition are so pervasive and destructive and can

most greatly harm the most vulnerable in our society—our children—I would like

to thank you again, Mr. Chairman, for calling this hearing. I look forward to the

testimony of today’s witnesses and learning more about ways we can fight addiction

and improve the lives of America’s children and families.

Æ