Integrated substance abuse and child welfare services for women: a progress review
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Integrated substance abuse and child welfare services for women: a progress review.

Marsh J.C., Smith B.D., Bruni M.
Children and Youth Services Review: 2011, 33, p. 466–472.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Marsh at

This US-focused review calls for parents with substance use problems in the child welfare system to receive integrated services which comprehensively assess health and social problems and systematically match needs to problems in the context of a positive client-provider relationship.

Summary Perhaps the greatest distinction between substance abuse and child welfare systems results from treatment goals and philosophies. Substance abuse treatment has been heavily influenced by recovery movements which emphasise abstinence through supportive, self-policing peers and paraprofessionals, sharply contrasting with the regulation orientation of child welfare systems largely driven by legislation designed to protect children rather than to treat or rehabilitate parents and families. Despite overwhelming evidence that substance-involved families in the child welfare system are dealing with multiple problems, assessment strategies in these two service sectors respectively focus narrowly on either substance abuse or child welfare. Consequently, both service systems are ill-equipped to identify the broad range of client problems or to provide comprehensive services to address them.

As well as contributing to ineffective services and poor child welfare outcomes, lack of coordination and integration of substance abuse and child welfare systems has meant clients do not receive treatments of proven effectiveness. For example, medications such as buprenorphine for opiate addiction and naltrexone for opiate or alcohol addiction are rarely prescribed.

Since the late 1990s, specific system- and service-level strategies have been developed to coordinate and integrate the provision of substance abuse and child welfare services, meaning that women are remaining in treatment longer and are more likely to reduce substance use and be reunified with their children. The strategies described below provide useful guidelines for developing components of effective, evidence-based programmes for substance-involved women in the child welfare system.

Research has shown that linkage or access services designed to reduce specific barriers that limit access for women – such as lack of child care or transportation – enable them to remain in treatment and reduce post-treatment drug use. There is also consistent evidence that substance abuse counselling reduces substance use. In child welfare, a primary treatment tool is training designed to increase the parent's capacity to provide a safe and stable environment for the child. However, evaluations of such programmes have been limited to their specific impacts on child welfare outcomes. Evidence is accumulating that matching services to specific client-identified needs is the most effective way to deliver comprehensive services within substance abuse treatment. The clientprovider relationship is a reasonably consistent predictor of retention in treatment, but an inconsistent predictor of post-treatment substance use. Each of these components – access services, substance abuse services, matched services, and the clientprovider relationship – can serve as a mediator or a mechanism through which positive substance abuse outcomes are achieved.

The comprehensive service model advocated by this review promotes integration at the service delivery level through comprehensive assessment which documents all the client's co-occurring health and social problems and systematically matches service needs to problems in the context of a positive clientprovider relationship. It also promotes service integration by distinguishing between matched and outcome-targeted services. In relation to the latter, while substance abuse counselling allied with medications has a well-documented relation to reductions in substance use, child welfare interventions (primarily parent training) have had a less well-documented impact on the child welfare outcomes of reunification and enhanced child well-being. In general, child welfare interventions are less specified and less targeted on specific outcomes. Specifying outcome-targeted services requires providers to be clear that services are in place specifically designed to impact the outcome of interest.

Despite such evidence that comprehensive health and social services improve substance abuse, health, mental health, and child welfare outcomes, comprehensive services for women have become less available, parents in the child welfare system are left with unmet service needs, and women continue to experience reduced access compared to men. Child welfare systems have made substantial progress in identifying and responding to parental substance abuse problems, but some need to shift from an emphasis on compliance with standard service packages and treatment approaches towards evidence-based strategies incorporating pharmacological therapies, levels of care, and comprehensive health and social services responding to a range of service and concrete needs. Child welfare researchers, policymakers, and practitioners must continue to support and evaluate these shifts as well as to direct public attention to the larger social and economic conditions that adversely affect so many families involved with child welfare services.

Last revised 20 April 2011

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