Dakof G.A., Cohen J.B., Henderson C.E. et al.
Journal of Substance Abuse Treatment: 2010, 38, p. 263–274.
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US researchers may have found a better way to support mothers at risk of losing custody of their children so they engage in and benefit from substance use treatment and meet family court requirements, meaning more children can safely stay with their parents.
Summary The family environment of the children of problem substance users is often compromised by instability, neglect, and poor parenting. Improving parental functioning – especially reducing substance use – makes children safer and improves child welfare outcomes. However, substance use treatment completion rates among parents who come into contact with the child welfare system are low. For solutions to these problems, many communities have turned to family drug courts. Adapted from the adult drug court model, family drug courts were established to enhance the effectiveness of child welfare agencies by increasing enrolment and retention in substance use treatment, motivating parents to address their addiction, and coordinating the many services needed to stabilise families. Unlike typical drug courts, these courts do not operate in the criminal justice system, most participants are women, and the court addresses the dual issues of parental addiction/recovery and child safety and custody. Most family drug courts employ court counsellors who refer clients to substance use treatment and other services, develop a recovery plan, and monitor and report clients’ ongoing progress to the court.
Family drug courts aim to enhance the effectiveness of child welfare agencies by promoting engagement in substance use treatment, motivating parents to address their addiction, and coordinating the services needed to stabilise families.
To further promote treatment engagement and family court compliance of mothers facing loss of custody of their children, a programme was developed for court counsellors which involved the mother’s family and other significant figures in their lives.
Compared to a more typical case management role, the tested programme led to more mothers retaining their parental rights and greater improvements in substance use, health, family functioning, and risk of child abuse.
However, samples were small and by the end of the study several of the differences between the two sets of mothers were also small.
The Engaging Moms Program – the focus of this study – is a family-oriented intervention shown to have succeeded in its objectives of facilitating treatment entry and short-term retention among mothers of infants who have been exposed to parental substance use. It was then adapted for use in a family drug court context and (relative to usual case management services) found in a non-randomised trial to improve completion of the drug court programme (72% versus 38%) and the proportion of mothers reunited with their children (70% versus 40%). Although the results were encouraging, this study had several limitations, leading to the current randomised trial comparing in a family drug court context the effectiveness of the Engaging Moms Program versus intensive case management of the kind recommended for such courts.
During the recruitment period of the trial, 62 of the 69 mothers who attended a family drug court in Miami in the USA agreed to join the study. They averaged 30 years of age, were mainly black or Hispanic, poor, unemployed and poorly educated. Just 1 in 10 were married. As children, many had been victims of physical and sexual abuse and most currently suffered serious mental health problems. They used a mixture of drugs including alcohol and cocaine and averaged about three lifetime arrests.
Mothers in the study were subject to the usual 12–15 month regimen of court hearings, supervision and support. Additionally, court counsellors were specially trained and supervised to deliver one of the programmes being compared as alternative ways to engage and retain these mothers in substance treatment and improve child and parental outcomes. The 62 women were randomly selected such that equal numbers were allocated to the Engaging Moms option or the comparator.
Neither option was a treatment in its own right, but sought to promote treatment entry, retention and benefit, as well as satisfactory completion of the drug court programme. Intensive case management counsellors aimed to develop a strong therapeutic relationship with the mother, assess her needs, plan support, link her to services, monitor progress, and advocate on her behalf. In contrast, the Engaging Moms Program (based on multidimensional family therapy) engaged not just with the mother and with services but with the mother’s social network, especially her family. For example, in stage two of the programme focused on changing behaviour, counsellors conducted individual and joint sessions with the mother and her family and or partner. These dealt with: the mother’s motivation and commitment to succeed in drug court and to change her life; the emotional attachment between the mother and her children; her relationships with her family of origin; her parenting skills; her romantic relationships; and emotional regulation, problem solving, and communication skills. Considerable attention was devoted to repairing the mother’s relationship with her family, often damaged by hurts, betrayals, and resentments. Also the counsellor facilitated the mother’s relationship with court personnel and service providers and helped prepare her for court appearances, during which they advocated for the mother.
Regardless of the approach to which they had been allocated, during the trial mothers saw their counsellors for on average about 40 hours, but the Engaging Moms Program included seven hours of family sessions versus just under four in the case management option.
Research workers assessed the mothers several times up to 18 months following drug court intake (97% of assessments were completed), when information on child welfare status was extracted from court records. This primary outcome was defined as positive if the mother retained her parental rights, either having sole or joint custody of the children, or when the children were under the guardianship of a relative. Other outcomes considered not to be positive involved termination of the mother’s parental rights and the child being placed with a relative or in foster care.
The small number of mothers in this pilot study limited the chances of statistically significant findings, so the focus instead was on whether the differences between outcomes from the Engaging Moms Program and case management were large enough that with a bigger sample they might have proved statistically significant.
Of the 31 Engaging Moms mothers, 24 had retained their parental rights compared to 17 of the 31 case management mothers, an advantage for Engaging Moms which narrowly missed the conventional criterion for statistical significance. These figures included 16 Engaging Moms mothers who had sole custody of their child compared to 12 allocated to case management. Over twice as many case management mothers had their children removed to foster care – 9 versus 4. Two-thirds of Engaging Moms mothers satisfactorily completed the drug court programme compared to about half the case management mothers.
Over the first three months both sets of mothers significantly improved in terms of their substance use, mental and physical health, family functioning, risk posed to child, and employment, improvements maintained or augmented through the remainder of the 18-month follow-up. In no case were these improvements significantly greater among Engaging Moms mothers, but several outcomes substantially favoured these mothers. They were more likely to further reduce their drinking, experience greater improvements in mental and physical health and family functioning, and more steeply decreased their risk of child abuse. At the three-month follow-up, on all three relationship dimensions they also reported significantly stronger therapeutic relationships with their counsellors.
The Engaging Moms Program delivered in the context of a family drug court increased the likelihood of positive outcomes for mothers (retention of parental rights and improved welfare and functioning) in comparison to intensive case management. In all domains of functioning, families assigned to Engaging Moms showed improvement that was equal to or better than families assigned to case management. Arguably the primary mechanisms leading to better results were a stronger therapeutic alliance with the counsellor and more extensive family involvement.
Although the results of this pilot study are encouraging, there are important limitations. The primary one is that a small sample size limits the scope for testing differences between outcomes in the two sets of mothers and weakens the reliability of the results; different results might be obtained with larger samples.
commentary Commending the Engaging Moms Program is its apparent non-punitive humanity and the plausibility of its strategy of repairing what may have been a damaging social network and engaging it in supporting the mother, promising not just the short-term gains which the study was able to document, but a more stable, long-term future for mother and child. Particularly encouraging is the non-diminution of the gains and sometimes their augmentation over the period after the interventions ended. As well as benefiting the families involved, long-term reduction in social costs can be expected. With family drug and alcohol courts spreading in the UK, the Engaging Moms model might be adapted to further improve their outcomes for parent and child.
However, convincingly demonstrating the advantages of the approach for maternal and child welfare is a difficult task when so much else is going on in the mothers’ lives, when the basic family drug court programme is the same for both intervention and comparison mothers, and when the comparator is itself seemingly a humane and well structured approach. Details below.
As the authors observed, if replicated with a larger sample, the difference in the retention of parental rights, and probably too in resort to foster care, would have been statistically significant, but also a larger sample may show these to have been unreliable findings. On the other measures of maternal welfare and family functioning and safety, though there were substantial extra improvements among the Engaging Moms group, in some cases this mainly reflected a drop from an initially higher level of severity. By the end of the study the differences in absolute terms between the two sets of mothers were generally very small. Several of the researchers were involved in developing the programme they evaluated, raising the possibility of their somehow favouring the programme, a
The so-called ‘researcher allegiance’ effect. In several social research areas,1 programme developers and other researchers with an interest in the programme&‘s success have been found to record more positive findings than fully independent researchers, possibly an instance of the general finding2 that expectations (eg of teachers of their pupils) affect performance via unintended changes in how the individual is treated. Such overlaps between developers and researchers are endemic3 in drug problem and other social research areas.
3. http://dx.doi.org/10.1016/j.evalprogplan.2007.06.004 in substance use research. Also it has to be acknowledged that termination of a mother’s parental rights and placement of the child elsewhere is not necessarily a negative outcome from the point of view of the child’s long-term welfare. On this issue we can only rely on the professionalism and child-centredness of the Engaging Moms counsellors, and on the presumption that if there had been over-enthusiastic advocacy, the court would not have been unduly swayed.
The first family drug and alcohol court in Britain was piloted at an inner London family court initially for three years to the end of 2010. Researchers concluded that more parents seen by these specialist courts than by comparison courts had controlled their substance misuse by the end of proceedings and been reunited with their children. They were also engaged in more substance misuse services over a longer period. Evidence of cost savings were noted in relation to court hearings, out-of-home placements, and fewer contested proceedings. Parents and staff felt this was a better approach than ordinary care proceedings. A later report from the same study with a longer follow-up of more families reinforced the earlier findings. More family drug and alcohol court parents had stopped misusing substances and dealt with other problems, and more mothers had been reunited with their children, but this 36% v 24% gap was not statistically significant.
The main weakness of this UK study is that in some known respects and perhaps in others not known, the comparison families differed from the family drug court families in ways which might have affected child welfare outcomes, regardless of the type of court proceedings. Also, through a preceding feasibility study the researchers had been involved in developing the programme they evaluated. As with the featured study, this raises the possibility of their somehow favouring the new intervention they helped to create.
Three NHS professionals who helped develop the first court in London have explained that it differs from normal family courts in its multi-disciplinary assessment and intervention team made up of both child workers (child protection social workers and a child and adolescent psychiatrist) and adult workers (substance misuse workers and an adult psychiatrist), plus volunteers with personal experience of overcoming substance misuse, some of whom are court ‘graduates’. Court proceedings form an integral part of the treatment process. The family works with the same judge throughout and compared to normal courts, the court takes a less adversarial approach to care proceedings, the parent speaking directly to the judge in the absence of lawyers.
Similar courts have now opened in Gloucestershire and Milton Keynes and as reported in 2015, more were due to open in 2015/16 in areas including East Sussex, Kent and Medway, Plymouth, Torbay and Exeter, and West Yorkshire, funded by the Department for Education. Despite this significant expansion, as in London, these courts will sit once a week and hear relatively few cases.
From the USA the first large-scale outcome study of a family drug court compared the progress (as revealed by court and administrative records) of mothers and children processed through three such courts with those processed through normal channels either in the same areas or in similar areas without a family drug court. An attempt was made to statistically even out relevant differences between the two sets of families. Findings favoured the family drug courts. Mothers processed through these courts were more likely to be unified with their children, who spent less time in out-of-home placements. More drug court mothers entered substance use treatment and they did so more rapidly, stayed longer and were more likely to complete the programme. However, the relative benefits arising from the family drug courts were at best a minor influence on child custody outcomes, and the study could not be sure that all relevant differences between the two sets of families had been accounted for.
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Last revised 28 May 2015. First uploaded 20 May 2015
STUDY 2008 Final report on the evaluation of ‘Option 2’