How can family-based residential treatment programs help reduce substance use and improve child welfare outcomes?

On average, 8.7 million children in the U.S. (about 12 percent of children under 18) live with at least one parent with a substance use disorder.¹ This statistic is incredibly alarming given that parental substance use disorders are associated with significant and far-reaching negative outcomes for children, including health problems, increased likelihood of mental health disorders, decreased emotional regulation, increased delinquency, and low academic performance.^2,3 In addition, parental substance use disorders have been linked to impaired parenting skills, lower levels of supervision and responsiveness to children, poorer quality parent-child attachments, increased conflict and exposure to violence, and inconsistent discipline.^4,5 As a result, parental substance use disorders also increase the likelihood of child maltreatment and involvement with the child welfare system.⁶

In a study that examined outcomes for children in the child welfare system, researchers found that 79 percent of maltreatment reports involving parental substance use disorders were substantiated, compared to 18 percent of maltreatment reports that did not involve them.⁷ According to the study, reports involving parental substance use disorders were also twice as likely to result in placement in foster care.⁸ This is particularly noteworthy given that children removed from homes where a parental substance use disorder was present tend to spend longer periods of time in out-of-home placements than their peers and are less likely than most other subgroups in the child welfare system to reunify with family.⁹ These poor outcomes have the potential to affect a substantial amount of children. For instance, in 2018, the U.S. Department of Health and Human Services reported that among the children who entered foster care in FY 2017, about 40 percent were removed due to some degree of parental substance use. Moreover, regional estimates of the prevalence rate of substance use disorders among families in the child welfare system tend to be higher than the national average.^10,11

To address parental substance use disorders and mitigate the numerous outcomes associated with both parental substance use and child welfare involvement, several child welfare agencies and jurisdictions have invested in family-based residential treatment programs that address parental substance use. This brief will provide an overview of these types of family-based residential treatment programs, discuss why they are important, and highlight some of the child welfare-related outcomes documented thus far.¹

The historical disconnect between treatment programs for substance use disorders and the child welfare system

Despite serving the same populations, treatment programs for substance use disorders and the child welfare system have historically worked separately to address the needs of parents with substance use disorders. In many instances, this has hindered the two systems’ ability to share best practices and coordinate and integrate efforts.¹² In the last decade or so, the federal Substance Abuse and Mental Health Services Administration and the Administration for Children and Families have made notable efforts to address service gaps for parents with substance use disorders; however many parents continue to experience significant barriers to accessing services. Parents often need programs that address the difficulties of both parenting and recovery, but many substance use disorder programs focus solely on adults and their substance use, not their role as parents. Given this, when parents seek treatment for substance use disorders, they have limited access to programs that provide child care, have visitation policies that support regular contact with their children, or include residential treatment options that allow their children to reside with them during treatment.¹³ As a result, parents often face significant barriers to both entering and completing treatment while also preserving their relationships with their children. This is not ideal given that the parent-child relationship is often a primary motivation for parents to achieve and maintain sobriety, and has been found to positively impact success during treatment.¹⁴ Ultimately, a lack of services that focus on both substance use and parenting can deter parents from entering treatment, increase disruption for children, lead to the need for out-of-home care, impede the child welfare system’s efforts to achieve reunification, and increase costs for child welfare agencies.¹⁵ Consequently, some child welfare agencies have begun to partner with substance use disorder treatment programs to explore various ways to keep children safely with their parents while their parents address their disorder. Family-based residential treatment is an example of a coordinated intervention being used by child welfare agencies and substance use disorder programs for parents who need intensive levels of support.

Family-based residential treatment programs

Traditional residential treatment programs provide intensive clinical treatment to individuals with substance use disorders while they reside in a live-in health care facility. Participants in these programs often are purposefully removed from their home environments and are isolated from their family and friends for a period of time, based on the belief that a change in environment can help enable behavior modification, facilitate self-motivated recovery, and enhance peer support from others in recovery.¹⁶

Alternatively, family-based residential treatment (also known as family-based recovery¹⁷) was created to more effectively provide dual treatment for parental recovery and healthy parent-child attachment and well-being. Family-based residential treatment programs allow parents and their children to remain together (or have frequent visits when something prohibits them from living together) while the parent receives substance use disorder treatment in a residential setting. Research has shown that parents with substance use disorders tend to have more parenting difficulties that can lead to child abuse and neglect than their peers who do not suffer from substance use disorders.¹⁸ Therefore, the focus of family-based residential treatment expands beyond individual recovery to include prevention of child maltreatment, family preservation and reunification, and family self-sufficiency.¹⁹ While receiving services, parents and children reside in a safe, supervised living situation and receive wraparound services. Services often include physical health services, parent education, early childhood programming, individual and group therapy, parent-child therapy, vocational services, case management, childcare, respite care, recovery coaching, and access to safe drug-free housing.^20,21 This model allows child welfare agencies to avoid placing children in out-of-home care because the wraparound services are able to meet a family’s needs.

Outcomes

The shift from individual to family-based residential treatment has been found to have a significant impact on parental recovery, as well as child welfare outcomes. As a result of the intentional focus on the parent-child relationship, findings have shown that:

• Women allowed to reside in residential treatment with their children — or have access to frequent visitation — often remain in treatment for longer periods of time, are more likely to complete treatment, and are less likely to have their children removed or remain out of the home.²² For example, SHIELDS for Families’ Exodus program²³ in Los Angeles reported that 81 percent of program participants in the last five years successfully completed its residential treatment program, which is almost four times the national average.
• Volunteers of America Mid-States found positive outcomes for pregnant and parenting mothers served by Freedom House, a women’s addiction recovery program in Kentucky that provides a continuum of support to treat women’s chemical dependency, break the cycle of addiction, and reunite families separated due to addiction. According to a survey, 90 percent of mothers who completed residential family-based treatment were highly satisfied with the services and 100 percent felt they benefited from the program.²⁴
• Native American Connections’ Patina Wellness Center reported positive outcomes for parents served by its residential treatment program. Participants include parents with substance use disorders and their young children, as well as pregnant women with substance use disorders. According to the report, 92 percent of participants completed treatment and 67 percent of the pregnant and parenting women still in recovery had not used substances six months post-treatment, a figure that increased to 75 percent at 12 months post-treatment. 

In a study of two family-based residential treatment programs for adults with substance use disorders who are involved in the child welfare system — Minnesota’s Wayside House and Oregon’s OnTrack — found that treatment for substance use disorders coupled with family strengthening services drastically improved child welfare outcomes:

• Wayside House reported that 94 percent of the children it served were free from abuse and neglect and 70 percent remained at home 12 months after their parent completed the program.
• OnTrack reported that 95 percent of the children it served were free from abuse and neglect during the time their parents received treatment.²⁵

These studies, along with the other research mentioned earlier in this brief, indicate that family-based residential treatment is a very promising practice for both addressing the needs of parental substance use disorders and improving child welfare outcomes. A better understanding of these programs — and other services that improve outcomes for families impacted by substance use disorders and the child welfare system — has never been more critical. For the first time ever, under the Family First Prevention Services Act, federal Title IV–E foster care maintenance payments can be made for a child in foster care placed with a relative in a licensed residential family-based treatment facility for up to 12 months, making this the most opportune time to examine and invest in family-based residential treatment programs for parents with substance use disorders. Programs worthy of investment must be evidence-based and provide trauma-informed services, parenting skills, education, and both individual and family counseling.

1 Lipari, R.N. & Van Horn, S.L. (2017). Children living with parents who have a substance use disorder. The CBHSQ Report: August 24, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.
2 Hanson, K. E., Saul, D. H., Vanderploeg, J. J., Painter, M., & Adnopoz, J. (2015). Family-based recovery: An innovative in-home substance abuse treatment model for families with young children. Child Welfare, 94(4), 161-183.
3 Neger & Prinz. (2015). Interventions to address parenting and parental substance abuse: Conceptual and methodological considerations. Clinical Psychology Review, 39, 71-82.
4 Wiegmann, W. (2016). Impact of residential versus outpatient substance abuse treatment on child welfare outcomes: A secondary analysis of NSCAW II data (Doctoral Dissertation).
5 Neger & Prinz. 2015
6 Rivera, M., & Sullivan, R. (2015). Rethinking child welfare to keep families safe and together: Effective housing-based supports to reduce child trauma, maltreatment recidivism, and re-entry into foster care. Child Welfare, 94(4), 185-204.
Wiegmann, 2016
7 Wulczyn, F. (2009). Epidemiological perspectives on maltreatment prevention. The Future of Children, 19(2), 39–66.
8 Wulczyn, 2009
9 Rivera & Sullivan, 2015
Wiegmann, 2016
10 Data on substance use disorder as a risk factor for families involved in the child welfare system are not systematically collected nationwide. There is significant variation within and across jurisdictions with regard to how they document substance use disorders, and also in national child welfare data systems like the National Child Abuse and Neglect Data System (NCANS) and the Adoption and Foster Care Analysis and Reporting System (AFCARS).
11 Seay, K. (2015). How many families in child welfare services are affected by parental substance use disorders? A common question that remains unanswered. Child welfare, 94(4), 19-51.
12 Examples of programs where child welfare agencies and treatment programs for substance use disorders are coordinating efforts include programs such as Kentucky’s Sobriety Treatment and Recovery Teams, Connecticut’s Family-Based Recovery, and Illinois’ Recovery Coaches. See How can families affected by substance use disorder safely stay together? for more information on these programs.
13 Wiegmann, 2016
14 Wiegmann, 2016
15 Hammond, GC, McGlone, A. (2013). Residential family treatment for parents with substance use disorders who are involved with child welfare: two perspectives on program design, collaboration, and sustainability. Child Welfare, 92(6), 131-50.
16 Wiegmann, 2016
17 While family-based residential treatment and family-based recovery are sometimes used interchangeably, it is important to note that unlike traditional family-based residential treatment, family-based recovery is an in-home treatment program. Both provide substance use disorder treatment, individual and group psychotherapy, parent-child support and developmental guidance, and comprehensive case management. See What is Connecticut’s Family-Based Recovery Program for additional information on family-based recovery.
18 Neger, & Prinz, 2015
19 Hammond & McGlone, 2013
20 Rivera & Sullivan, 2015
21 Hammond & McGlone, 2013
22 Wiegmann, 2016
23 SHIELDS for Families’ Exodus program stopped offering services in February of 2018. SHIELDS for Families continues to offer other family-centered substance use treatment programs.
24 Volunteers of America: Mid-States. (n.d.). Freedom House Women’s Addiction Recovery Program – Louisville. Retrieved from https://www.voamid.org/locations/freedom-house/
25 Hammond & McGlone, 2013