- Email: [email protected]
A comprehensive substance abuse treatment program for women and their children: an initial evaluation
Journal of Substance Abuse Treatment 21 (2001) 67 – 75
Regular article
A comprehensive substance abuse treatment program for women and their children: an initial evaluation Nicola A. Conners, Ph.D.a,*, Robert H. Bradley, Ph.D.b, Leanne Whiteside-Mansell, Ed.D.a, Cynthia C. Crone, M.N.Sc.a a
University of Arkansas for Medical Sciences, Little Rock, AR, USA b University of Arkansas at Little Rock, Little Rock, AR, USA
Received 28 August 2000; received in revised form 14 April 2001; accepted 1 May 2001
Abstract This article examines a comprehensive, residential substance abuse treatment program for women and their children. A majority of the 72 participants studied were African American single mothers, for whom crack/cocaine was the drug of choice. The women and their children were assessed repeatedly during treatment, and at 3, 6, and 12 months postdischarge. Program impact was estimated by comparing the outcomes of three groups that differed in the amount of treatment they received: early dropouts, late dropouts, and treatment graduates. Program graduates showed more positive outcomes than the nongraduate comparison groups in the areas of drug use and negative consequences of use, employment and self-sufficiency, and family interaction skills. Young children enrolled in treatment with their mothers were assessed using a developmental screening test, and older children with a measure of drug refusal skills. Results from both child measures suggest substantial improvement. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Women’s AOD treatment; Treatment outcomes; Program evaluation; Children of substance abusers; Substance abuse treatment
1. Introduction Women with children represent a special population for substance abuse treatment programs. The unique needs of women and the requirements of child rearing often complicate the efforts of service providers. Mothers with substance abuse problems often face a painful decision: Enter a treatment facility in hopes of recovery, or take care of their children. Even when there is the option to bring children into the treatment facility, it often means a severe disruption of family life, including stress on the children who must live for an extended period in a place that may seem very strange. Increasingly, substance abuse treatment providers are recognizing the special treatment needs of parenting women and are beginning to implement programs to address those needs. Federal agencies such as the National Institute on * Corresponding author. Arkansas CARES, University of Arkansas for Medical Sciences, Slot 711-1, 4301 W. Markham, Little Rock, AR 72205, USA. Tel.: +1-501-296-1760. E-mail address: [email protected] (N.A. Conners).
Drug Abuse (NIDA), the Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse Treatment (CSAT) have established programs to encourage the development, implementation, and evaluation of substance abuse treatment programs designed to serve pregnant and parenting women and their children. Substance abuse treatment providers must address several challenges when attempting to serve parenting women. First, they must enable potential clients to overcome the barriers to seeking treatment. Some practical barriers that women face when trying to find treatment include lack of transportation, safe housing, and financial resources to pay for treatment (Brunner, 1999; Howell & Chasnoff, 1999; Laken & Hutchins, 1996). Other barriers include a sense of shame and guilt that leads women to hide their drug problems, and opposition to treatment from family and friends who rely on women as caregivers (Beckman & Amaro, 1986; Finkelstein, 1994). Women also fear losing of custody of their children if they enter treatment, as few treatment programs allow children into residential treatment (Finkelstein, 1994; Howell & Chasnoff, 1999).
0740-5472/01/$ – see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 7 4 0 - 5 4 7 2 ( 0 1 ) 0 0 1 8 6 - 6
68
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Once in treatment, women frequently have alcohol- and drug-related issues that differ from those faced by men. Maternal substance abuse is associated with many other indicators of poor health and social problems, including mental illness, poverty, child abuse, risk for sexually transmitted diseases including HIV, and arrests and incarcerations. With any one of these problems, successful life functioning is difficult. When combined, the jeopardy to mother and child increases exponentially and reduces the likelihood of positive outcomes for both women and their children. Particularly pertinent to women are needs related to their roles as parents and caregivers. The burdens of parenthood often fall particularly hard on women who abuse alcohol and drugs, since they can rarely call upon family and friend support systems for financial help or help with child care. Mothers who are distanced from social support and who are preoccupied by their own addiction are often not able to provide effective, nurturing parenting to their children. Studies have shown that maternal use of drugs is associated with higher levels of parent related stress (Kelley, 1992), and children of substance users are considered to be at increased risk for physical abuse and neglect (Murphy et al., 1991; Wolock & Magura, 1996). To prevent child maltreatment, programs must deal with all of the usual issues related to recovery, plus begin the process of stabilizing the family, assisting the mother with to child management, rebuilding family relations, and learning skills needed to establish supportive ties with others. Of great importance is providing high quality care to the children themselves to minimize the effects of prenatal exposure to drugs and/or postnatal exposure to an environment characterized by addiction. Although there is a growing body of literature describing model substance abuse treatment programs for pregnant and parenting women (Coletti, Schinka, Hughes, Hamilton, Renard, 1995; Graham, Graham, Sowell, & Ziegler, 1997; Metsch et al., 1995; Namyniuk, Brems, & Carson, 1997), there is little research yet available about treatment outcomes for these women and their children. The few studies extant tend to involve preliminary analyses done on small samples, with little in the way of long-term follow-up. The limited outcome data available from both residential and nonresidential treatment programs suggest that comprehensive approaches to treatment can be effective in arresting some of the negative outcomes of substance abuse. Results from studies of outpatient programs for pregnant and parenting women show that these programs have had success in improving birth outcomes, and reducing problems related to substance abuse, parenting, interpersonal difficulties, and unemployment (Evenson, Binners, Cho, Schicht, & Topolski, 1998; Tanney & Lowenstein, 1997). There is also evidence that residential treatment programs for women with children have been effective in reducing addiction-related problems in families. Some of the positive
outcomes reported in studies of these programs include reductions in substance use, criminal behavior, emotional problems, family problems, parenting stress, and unemployment (Schumacher, Siegal, Socol, Harkless, & Freeman, 1996; Stevens & Arbiter, 1995; Uziel-Miller, Lyons, Kissiel, & Love, 1998; Wexler, Cuadrado, & Stevens, 1998). While these studies suggest that comprehensive programs for parenting women can be efficacious, a review of the literature reveals a need for studies designed to (a) assess a wide range of outcomes of women in substance abuse treatment; (b) include relatively long-term follow-up of clients (i.e. more than discharge assessments); (c) include postdischarge assessments of both treatment graduates and dropouts; and (d) assess the impact of comprehensive treatment services on children who enter treatment with their mothers. The present study examined a comprehensive substance abuse treatment program for parenting women and their children to determine its impact on a wide range of outcomes for both adult and child. The study addressed the following questions: (1) Did the program result in a sustained decrease in AOD use, and the negative consequences of AOD use? (2) Did the program result in greater selfsufficiency and social responsibility among participating women? (3) Is there evidence of improved family functioning among participating women and children? (4) In what ways did the program impact children enrolled in treatment with their mothers? 1.1. Program description The Arkansas Center for Addictions Research, Education, and Services (Arkansas CARES) is a licensed facility that provides residential and outpatient comprehensive substance abuse prevention and treatment services to low-income pregnant and parenting women, and their children. Arkansas CARES operates under the auspices of the University of Arkansas for Medical Sciences Department of Psychiatry. The program is accredited as a behavioral healthcare provider by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and is licensed as an alcohol and drug treatment program, adult and child mental health provider, childcare center, and early intervention program by the state of Arkansas. Care is provided by multidisciplinary teams. This article focuses on one component of Arkansas CARES, a residential program for parenting women and their children. This program was originally funded as a demonstration project by the Center for Substance Abuse Treatment (CSAT), and the project was called the Women and Children’s Recovery Center (WCRC). A list of the services provided by this program can be found in Table 1. As seen in Table 1, the Arkansas Cares/WCRC program provided a variety of alcohol- and drug-related treatment services, including daily AOD education groups, twice-weekly transportation to offsite Cocaine or Narcotics Anonymous groups, weekly relapse prevention
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75 Table 1 Services provided by the Arkansas CARES/WCRC Program 7-8 hour treatment day Alcohol and drug abuse assessment, education, and treatment Licensed mental health services for client, child, and family Onsite residence Licensed early intervention services Onsite licensed childcare Infant and toddler Preschool and school-age School-age summer program Parenting education and support Health services and education Community and onsite 12-step meetings Life skills training Group therapy Case management Group and individual counseling, covering the following areas: Denial The disease of addiction Physiology and pharmacology of tobacco, alcohol, and other drugs Effects of tobacco, alcohol, and other drugs on the mother and fetus Parenting the drug-exposed infant Women in relationships Women’s issues in recovery Loss and grief Family dynamics in recovery 12-step recovery Self-esteem building Relapse prevention AIDS and other sexually transmitted diseases Family planning Child development and care
groups, daily group counseling on alcohol- and drugrelated issues, and weekly individual counseling sessions. To meet the mental health needs of clients, primary therapists (mental health professionals) conducted daily group sessions and weekly individual therapy. The group and individual counseling sessions were designed to address family and relationship issues, grief and anger, self-esteem building, and other topics as listed in Table 1. A board-certified addiction psychiatrist performed intake psychiatric evaluations and referred clients for offsite care when indicated. In addition, the psychiatrist participated in the weekly meeting of the treatment team, which involved all mental health and alcohol and drug professionals involved in the care of the family. A variety of educational groups and case management services were offered by Arkansas CARES/WCRC to meet the practical needs of clients. Educational services offered weekly included: life skills training (including budgeting, household management, etc.), health education, and parenting education. For clients who were not high school graduates, on- and offsite GED programs were offered. Additionally, each client was assigned to a case manager who assisted them in accessing public assistance while in treatment, and with obtaining employment, housing, and transportation as they transitioned from the WCRC program.
69
Children in treatment with their mothers also received a variety of educational and mental health services. An onsite licensed child care center was available for full-day care of young children, and afterschool and full-day summer care for school-age children. Early intervention services were provided as needed to young children, and tutoring was provided to school-age children. Mental health services including group and individual counseling sessions were available to school-age children.
2. Method While the ideal design for estimating program impact involves the use of randomly assigned treatment and control groups, ethical and practical concerns prevented the use of a randomized design in this study. Because of the desire of Arkansas CARES management to provide treatment services to all eligible clients, in this evaluation study, program impact was estimated by comparing the outcomes of three groups that differed in the amount of treatment they received. The three treatment groups include clients who stayed in treatment less than 30 days, clients who stayed more than 30 days but ultimately left without completing treatment, and clients who successfully completed, or ‘‘graduated,’’ from the treatment program. Throughout the article, these groups will be referred to as ‘‘early dropouts,’’ ‘‘late dropouts,’’ and ‘‘graduates.’’ While the length of stay in treatment was longer on average for treatment graduates than the nongraduate groups, ‘‘graduation’’ from treatment was based upon the judgment of the clinical team involved in the clients’ treatment rather than length of stay alone. Because dividing the sample of 72 into three treatment groups resulted in small group sizes, and thus low power to detect differences between groups, we utilized two analytic approaches in this article. First, we used a traditional significance level of 0.05 to identify differences between treatment groups. Second, where the significance level was less than 0.10, we calculated an effect size to estimate the magnitude of the differences between groups, recognizing that with a small sample even a relatively large effect can be nonsignificant using the more stringent 0.05 criterion. To ensure a fair comparison between groups on each outcome measure, intake variables were examined to establish equivalency between the groups at admission to treatment using chi-square and ANOVA tests. Furthermore, in all analyses of mean postdischarge differences between treatment groups, ANCOVA was used, with intake scores included as covariates. Due to sample size limitations, a different approach was used for analyses involving data on children in treatment. Rather than comparing different treatment groups, repeated measures of outcomes and the use of measures with normative data were used. The evaluation of the Arkansas CARES program consisted of a baseline assessment of mothers and children
70
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
during the first week following entry into the program. Assessments were then repeated every three months after intake, for as long as the client remained in the treatment program. The first postdischarge assessment was scheduled three months after discharge from the residential treatment facility, followed by assessments at six and 12 months after discharge. Assessments included data collection from clients and children. Children, ranging in age from newborns through early adolescence, participated in the program at Arkansas CARES. The specific assessment battery used for each child varied as a function of age. When a client had more than one child participating in the treatment program, the youngest child was chosen as the target child, and that child received the most extensive assessment. The child closest to age 10 was chosen as the secondary target, and received a less extensive assessment. Two questionnaires designed for school-age children were administered to all children over age 8. All data were collected by a research assistant who served as part of an independent evaluation team, which also included an evaluator and a statistician. The research assistant conducted in-person interviews with each client, and administered paper-and-pencil questionnaires and developmental tests. Visits typically took place at Arkansas CARES while clients were in treatment, and in the homes of the clients once they were discharged from the program. The research assistant was frequently accompanied on follow-up visits by a case manager who offered assistance in locating and contacting clients to schedule follow-up visits, and also provided aftercare case management services. Of the 73 clients served by the Arkansas CARES program during the study period, 72 (99%) agreed to participate in the evaluation study and completed the intake assessment. All clients, regardless of their length of stay, were asked to continue their participation in the evaluation study after leaving treatment. At the end of the study, 89% of clients who had been discharged from the program for at least three months completed at least one postdischarge follow-up visit.
more than one substance were able to identify one substance as the primary problem, while other clients identified alcohol and drugs, or multiple drugs, as equal problems. More than three-fourths of clients in the early dropout and the graduate groups identified crack/cocaine as their primary drug, compared to just over half of the late dropouts. Arkansas CARES was not the first drug treatment experience for the majority of clients in all treatment groups. At least three-fourths of clients in each treatment group had an arrest record prior to admission, and one-third of clients also had an open child protective service case, indicating a substantiated charge of child abuse or neglect. While few clients in any treatment group were mandated (e.g., courtordered) to receive treatment, others may have been pressured to received treatment by persons involved in the criminal justice system or family service agencies. Significantly fewer early dropouts (25%) were involved with the legal system at intake (probation, parole, charges pending, etc.) compared to three-fourths of late dropouts and graduates. The majority of Arkansas CARES clients in all treatment groups had experienced either physical and/or sexual abuse in their life. Most of the children served by the Arkansas CARES program were African American, and 54.4% were male. Ages ranged from newborn to 14.9 years, with a majority of children being under the age of five. Sixty percent of children were prenatally exposed to drugs, and more than two-thirds to cigarettes. Only 7% had health problems serious enough to warrant admission to the neonatal intensive care unit at birth. 2.2. Instruments Some measures were added to the evaluation plan later than others; therefore, the number of clients reported on each measure varies depending on how long a particular measure was a part of the evaluation plan. For children, the number reported on each measure also varies depending on the age group that was assessed using each measure.
2.1. Sample description While most Arkansas CARES clients were African American, there were significantly more Caucasian women in the late dropout group (42.9%) than in the early dropout (21.4%) or graduate (13.3%) groups. Most clients in all groups were single mothers (either never married, separated, or divorced) with an average of 3 children. Clients ranged in age from 16 to 44, and clients who completed treatment were significantly older than clients who dropped out of treatment. With the exception of math scores, their scores on the Wide Range Achievement Test III were generally within normal range, and did not differ significantly by treatment group. Clients were asked to identify the substance that was the major problem for them. Many clients that used
2.2.1. Description of data collection instruments for mothers 1) Addiction Severity Index, 5th ed. The Addiction Severity Index (ASI) is a semistructured interview which is designed to gather information about aspects of a client’s life which may contribute to their substance abuse problem. The ASI covers seven areas: medical, employment/support, alcohol, drug, legal, family/social, and psychiatric (McLellan, Kushner, Metzger, Peters, Smith, 1992). The full ASI was completed at intake, and the recommended follow-up questions were repeated at follow-up. 2) Parenting Stress Index. The PSI is used to gauge the stress the client perceives as it relates to parenting. This instrument takes about 5 minutes to complete. The PSI consists of three scales (Parental Distress, Parent-Child
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Dysfunctional Interaction, and Difficult Child). Each scale yields a score, plus there is a total score. The PSI was normed on a large and diverse sample of women, including Caucasian, African American, Hispanic, and Asian mothers. Abidin (1995) has reported acceptable internal consistency and test-retest reliability in studies of high-risk families. Alpha reliability coefficients were computed using data from this study; the coefficients for the subscales ranged from 0.72 to 0.88, and the coefficient for the total stress scale was 0.92. 3) Outcomes of Addiction. The Outcomes of Addictions Questionnaire asks clients to indicate how frequently they have experienced various negative effects from drug or alcohol use (i.e., guilt, money problems, accidents) in the four weeks prior to the assessment. Scores on this measure can range from 0 to 45, with high scores indicating that the client is frequently experiencing many negative effects of drinking or drug use. If a client had not used any alcohol or drug in the four-week period prior to the assessment, the score was automatically 0. The overall alpha reliability coefficient was 0.96. This questionnaire was taken from the Substance Abuse Outcomes Module (Smith, Kramer, Babor, Burnam, Mosley, 1998). 4) Family Cohesiveness Scale. This brief form consists of nine items that are used to assess the degree to which the family acts as a single unit and expresses feelings of togetherness. The items were taken from the Family Environment Scale (Moos, 1974), which has been used with a diverse array of families, including several studies of highrisk populations. Since items are marked True or False, scores can range from 0 to 9, with higher scores indicating more cohesion. The overall alpha reliability coefficient for the FCS was 0.82. 5) Intake/Follow-up demographic update form. This instrument was developed by staff and evaluators to capture information about insurance, legal status, and the living situation of the client and her children. 6) The Wide Range Achievement Test III. The WRAT III is designed to assess basic spelling, reading, and mathematics competence. Scores on the WRAT III were converted to standard scores on a metric where the national mean is set at 100 and the SD is set at 15 (the same metric as IQ tests). The data were used as baseline information and to help describe the sample served by this program. The WRAT III manual includes information about its reliability and validity, and acceptable levels of both have been demonstrated (Wilkinson, 1993). 2.2.2. Description of data collection instruments for children 1) Refusal Skills. The child’s ability to resist using drugs or alcohol was measured by a scale designed for this project. Items in the scale address the child’s ability to deal with types of situations that might induce use of alcohol or other drugs. This instrument was completed by children eight years of age and older. The measure contains 19 items, each
71
scored on a 3-point scale (Yes = 0, Not Sure = 1, No = 2). Thus, scores can range from 0 to 38, with lower scores indicative of a greater degree of ability to resist the pressure to abuse substances. Alpha reliability coefficients were computed, and the reliability coefficient for the total score was 0.89. 2) Adaptive Behavior – Scales of Independent Behavior (Revised). The SIB-R is a comprehensive set of tests for measuring functional independence over a wide age range. Areas assessed include: motor development, daily living skills, social development, language, self-help skills, problem behaviors, and community adaptation. SIB also provides an index of maladaptive behavior, with scores convertible to an index with a mean of 0 and an SD of 10. Negative scores indicate maladaptive behavior (scores < 20, of a moderately serious nature). The tests are individually administered through a structured interview. Norms are provided from the infant level to the mature adult level. The SIB-R was normed on over 2,000 individuals selected to be representative of the U.S. population on gender, race, socioeconomic status, and geographic region. Acceptable levels of test-retest and inter-rater reliability are reported in the SIB-R manual, and evidence of the construct validity of the instrument is also included (Bruininks, Woodcock, Weatherman, & Hill, 1996). 3) Denver Developmental Screening Test II. The DDST II is an individually administered, norm-referenced, multiskill device designed to assess developmental progress and to identify children with developmental problems. It is normed for children from birth through age six, and was administered to all preschool-age children. It assesses fine-motor, gross-motor, language, and social competencies. Since it is a screening test, children receive a dichotomous rating (either suspect or within normal limits). The DDST II has been used to screen more than 50 million children throughout the world, including children of all major ethnic and cultural groups. The DDST II is widely recognized as being a valid and reliable instrument (Frankenburg & Dodds, 1992).
3. Results Of the 72 study participants, 62 (86%) received both intake and at least one follow-up assessment after discharge from treatment. Another two clients (3%) had not been discharged long enough at the end of the study to receive a follow-up visit. No follow-up data were available on four early dropouts, two late dropouts, and four graduates. Results are reported on all clients for whom both intake and at least one postdischarge follow-up information was available, regardless of client’s length of stay in the program or type of discharge. Data from the last postdischarge follow-up assessment were used in the analyses reported here. On average, early dropouts had been discharged from treatment for 7.8 months (SD = 3.94) at the time of their last
72
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Table 2 Treatment groups compared on key postdischarge outcomes Early Dropouts (n = 10) Using Alcohol or Drugs Intake 100% Follow-up ** 50.0%
Late Dropouts (n = 26)
Graduates (n = 26)
100% 61.5%
100% 15.4%
Homeless Intake Follow-up
40.0% 50.0%
39.1% 24.0%
41.7% 26.9%
Unemployed Intake Follow-up *
90.0% 70.0%
100% 64.0%
87.5% 26.9%
Poverty level income Intake 90.0% Follow-up 88.9% Arrested Intake Follow-up
90.0% 50.0%
100% 78.3%
87.5% 54.2%
87.0% 44.0%
83.3% 19.2%
* p < 0.05. ** p < 0.01.
follow-up assessment, compared to 8.5 months (SD = 3.58) for late dropouts, and 9.9 months (SD = 3.33) for graduates. 3.1. Substance use and negative consequences of use The report of drug use at all follow-up assessments was used to compute the percentage of clients that relapsed during the postdischarge follow-up period. As indicated in Table 2, 15% of graduates relapsed, compared with half of the clients in the early dropout group and 61% in the late dropout group. The difference in the relapse rates among the three treatment groups was significant (c2 = 11.97, df = 2, p = 0.003). At each assessment period, clients were asked to report the number of days they used each substance in the past 30 days. The mean number of days for each group is reported in Table 3. Because so few clients reported using heroin, methadone, opiates, barbiturates, hallucinogens, and inhalants at time of entry, those substances were combined to form the category of ‘‘other drugs.’’ No significant group differences were found on mean days of alcohol, crack/ cocaine, marijuana, or other drug use at intake, F (8, 100) = 1.0, p = 0.43. An ANCOVA controlling for intake drug use revealed that the three treatment groups were not significantly different on mean postdischarge days of alcohol, cocaine, marijuana, or other drug use, F (8, 102) = 0.67, p = 0.71. The distributions on all substances both at time of entry and postdischarge are highly skewed. The mean rate of use reported for all substances represents a somewhat inflated estimate of average use since high rates of use on the part of a small number of clients disproportionately affect the mean. An examination of the participant-reported negative effects of substance use (Outcomes of Addiction) at intake
revealed no significant differences among the treatment groups. We used ANCOVA to investigate differences in postdischarge scores on negative outcomes from addiction after controlling for intake scores, and found a significant difference between the three groups, F (2, 47) = 3.78, p = 0.03. Follow-up tests revealed that treatment graduates showed more improvement than late dropouts, and the effect size (d = 0.68) was large (Cohen, 1988). This suggests that the graduates had a greater decrease in drug-related problems than late dropouts. 3.2. Self-sufficiency and social responsibility As indicated in Table 2, most clients in all groups were unemployed at intake into treatment, and had a povertylevel income. At follow-up, 26.9% of treatment graduates were unemployed, compared to 70% of early dropouts, and 64% late dropouts (c2 = 9.08, df = 2, p = 0.01). In addition, fewer graduates (54.2%) had incomes below the poverty line than early dropouts (88.9%) or late dropouts (78.3%), though the difference was only marginally significant (c2 = 5.10, df = 2, p = 0.07). While fewer treatment graduates (26.9%) were homeless at followup than the other two treatment groups, the difference was nonsignificant. Over 80% of clients in all groups were arrested at least once prior to intake into the Arkansas CARES program. Fewer treatment graduates were arrested after treatment (19.2%) than early dropouts (50%) or late dropouts (44%)(c2 = 4.75, df = 2, p = 0.09). While only marginally significant, the percentage difference suggests a meaningful trend.
Table 3 Mean days of drug use out of past 30 Entry n
m (SD)
Follow-up m (SD)
Alcohol early dropouts late dropouts graduates
10 24 24
6.19 (7.50) 10.52 (11.51) 9.54 (8.49)
1.30 (2.58) 4.12 (7.92) 1.58 (5.93)
Cocaine/Crack early dropouts late dropouts graduates
10 24 24
15.90 (12.75) 11.16 (10.60) 13.96 (11.99)
0.30 (0.67) 3.08 (7.71) 0.92 (3.97)
Marijuana early dropouts late dropouts graduates
10 24 24
4.10 (8.20) 3.68 (6.70) 2.38 (5.93)
0.00 (0) 1.00 (2.06) 0.31 (1.57)
Other Drugs early dropouts late dropouts graduates
10 24 24
2.80 (5.41) 4.52 (11.57) 0.30 (1.22)
0.00 (0) 0.12 (0.60) 0.00 (0)
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
3.3. Parenting and family interaction skills Table 4 displays clients’ scores on the Parenting Stress Index and the Family Cohesion Scale (FCS). There were no significant differences on PSI or FCS scores at intake. Using ANCOVA to control for intake scores, we compared the postdischarge scores of the three treatment groups and found significant differences on the Parenting Distress scale F (2, 52) = 5.3, p = 0.008, with treatment graduates improving significantly more than the late dropouts. The effect size (d = 0.92) was large (Cohen, 1988). The Family Cohesion Scale (FCS) was used to assess the degree to which the family acts as a single unit and expresses feelings of togetherness. Using ANCOVA to control for intake scores, the difference in scores between treatment groups at follow-up was again marginally significant, F (2, 50) = 3.07, p = 0.055. Treatment graduates showed greater improvement than treatment dropouts. Effect size values suggest a large difference between treatment graduates and early dropouts (d = 0.96), and a medium-size difference between graduates and late dropouts (d = 0.52).
73
children receive a dichotomous rating (either ‘‘suspect’’ or ‘‘within normal limits’’). Results on the Denver II show that 63% of children at program entry scored in the range indicative of possible developmental delay, compared to only 43% at follow-up, t(29) = 1.79, p = 0.083. The effect size value (d = 0.40) suggests a medium-size effect (Cohen, 1988). 3.5. Behavior problems Children from Arkansas CARES tended to be in the normal range on the Scales of Independent Behavior, though they showed a tendency to display slightly more maladaptive behaviors than their chronological age mates. No differences were found from time of entry to the time of the postdischarge assessment. 3.6. Drug resistance skills
3.4. Child development
Children’s refusal skills were measured by a scale designed for this project. The improvement in Refusal Skills scores from entry to postdischarge was very nearly significant, t(22) = 2.03, p = 0.054. This suggests that at follow-up, children tended to feel better able to resist pressure to use alcohol or other drugs. The effect was medium-size (d = 0.57).
The Denver Developmental Screening Test II was used to assess children’s competencies. Because it is a screening test,
4. Discussion
Table 4 Mean scores on Parenting Stress Indexa (PSI) and Family Cohesion Scaleb Entry n PSI Parenting Distress Scale** early dropouts 10 late dropouts 24 graduates 24
m (SD)
Follow-up m (SD)
36.40 (9.64) 33.08 (6.29) 32.75 (5.99)
28.10 (10.40) 31.79 (8.64) 24.00 (8.30)
PSI Parent-Child Dysfunctional Interaction Scale early dropouts 10 29.40 (12.41) late dropouts 24 26.83 (9.25) graduates 24 22.54 (7.44)
25.40 (12.05) 25.62 (7.65) 20.62 (7.77)
PSI Difficult Child Scale early dropouts 10 late dropouts 24 graduates 24
32.70 (10.27) 34.16 (11.47) 30.12 (10.67)
27.90 (12.03) 31.37 (8.83) 27.41 (10.31)
PSI Total Stress Score early dropouts late dropouts graduates
10 24 24
98.50 (28.98) 94.08 (22.90) 85.41 (18.81)
81.40 (32.72) 88.79 (21.08) 72.04 (23.22)
Family Cohesion Scale early dropouts late dropouts graduates
9 22 23
3.89 (3.21) 5.22 (2.67) 4.92 (2.84)
4.66 (32.72) 5.95 (21.08) 7.17 (23.22)
a
Higher scores indicate greater stress. Higher scores indicate greater family cohesion. ** p < 0.01.
b
In this evaluation study, program impact was estimated by comparing the outcomes of three groups that differed in the amount of treatment they received: early dropouts, late dropouts, and treatment graduates. A comparison of the outcomes of the three treatment groups suggests while all groups showed some improvements, treatment graduates showed generally greater improvement, and in more areas. First, compared to dropouts, treatment graduates were far less likely to relapse after treatment. In fact, only 15% of treatment graduates reported a relapse in the period following discharge. Furthermore, compared to late dropouts, treatment graduates reported significantly fewer negative consequences related to drug use after discharge, such as physical problems and accidents. Second, treatment graduates were more likely than both nongraduate groups to become self-sufficient and socially responsible after treatment. At follow-up, treatment graduates were significantly more likely to be employed than treatment dropouts. Group differences were also seen in arrest rates and income. In fact, only 19% of graduates were arrested after treatment, compared to half of early dropouts, and 44% of late dropouts. While treatment graduates were less likely to report an income below the poverty line than treatment dropouts, the majority of clients in all groups remained poor after treatment. Third, there were group differences in the family interaction skills of clients. At follow-up assessments, treatment graduates reported less parental distress on the Parenting
74
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Stress Index than late dropouts. Graduates also showed a significantly greater improvement in family cohesion scores than early dropouts. This improvement in scores indicates that mothers felt that the bonds between family members were strengthened and that they were working together as members of a team. While treatment graduates moved toward sobriety, selfsufficiency, and improved family interaction skills, in some areas more long-term assistance may be required for these families. For example, the majority of graduates still had incomes below the poverty line after treatment, reducing the likelihood that they could effectively care for themselves and their children. While many Arkansas CARES clients became employed, their low-paying jobs did not allow them to move out of poverty. Furthermore, it is difficult for clients to advance their education in hopes of a better job while simultaneously caring for their children and providing financially for their family. The kinds of educational and support services needed for clients to succeed financially are outside the scope of even comprehensive drug treatment providers, but are needed nonetheless. Relatedly, the lack of improvement in the housing situations of clients are likely due to inadequacies in the current housing service system, including regulations that exclude people with past felony convictions from public housing communities. Given that the majority of Arkansas CARES had arrest records, affordable housing options at discharge from treatment were likely limited. Finally, regarding program impact on children, this study provides some evidence that the children who enrolled in the Arkansas CARES program with their mothers benefited from treatment. First, results from the DDST II suggest that fewer young children scored in the range indicative of a possible developmental delay at the follow-up assessments than at intake. Second, the perceived ability of older children to resist drugs or alcohol increased from intake to postdischarge follow-up. While the changes in both these scores were not significant using a stringent 0.05 criterion, they do represent positive trends. It should also be noted that at intake, many children received the highest possible refusal skills score, leaving little room for improvement. It was also difficult to show significant change because of the relatively small number of children from any particular age group, resulting in low statistical power. Results from the SIB showed no evidence of improvement in children’s behavior. However, the SIB relies on mother report, which may not be the most accurate way to assess children’s improvement in behavior problems. One difficulty with relying on mother report is that at intake some mothers may have downplayed any behavior problems of their child. They may have done this either because they feared that their child would not be welcome in the program if they had serious problems, or because they felt that the child’s problems were a reflection on the quality of their parenting during the period of their addiction. Another problem with mother
report is that because of the all-consuming nature of drug addiction, at intake some mothers simply may not have been aware of their children’s behavior problems. Other mothers had lost custody of their children prior to intake and may have been unable to accurately report on their children’s behaviors. 4.1. Limitations The primary limitation of this study was the inability to randomly assign clients to treatment and comparison groups. This limits our ability to attribute the changes seen exclusively to program impact. While the hope was that clients in the three treatment groups would be similar on all characteristics except length of time in treatment, and thus differences in outcomes might be attributed to treatment impact, the reality is that clients in the treatment groups were not the same. When compared on demographic variables at intake, the three groups were similar on all variables except age, race, and legal involvement. Treatment graduates were slightly older on average (about three years) than treatment dropouts, a higher percentage of women in the late dropout group were Caucasian, and early dropouts were less likely to have any legal involvement (probation, parole, etc.). We cannot know whether those differences, or differences in motivation or some unmeasured variable, were related to outcomes after treatment. What seems clear is that those clients who chose to stay in treatment and successfully graduate had much better outcomes than clients in the dropout groups. What is unclear is whether their success after treatment can be attributed to program impact or to greater levels of motivation prior to the start of treatment. The issue of motivation for treatment may be particularly important to consider in studies of parenting women in treatment. All men and women seeking treatment vary in their readiness for treatment, and differ in the extent to which they are pressured by external forces (probation officers, judges, employers) to complete treatment. However, children may serve as an additional motivating force for parenting women with additions. Mothers may be motivated by a desire to be a better parent, or by fears that they will lose custody of their children if they do not receive help with their addiction. We do not know to what extent these or other factors motivated Arkansas CARES clients to remain in treatment, or how the three groups compared in this study may have differed in their motivation. 4.2. Conclusion Overall, women who entered the program at Arkansas CARES showed both decreased drug use and increased employment. In addition, these clients showed improvements related to parenting and family interaction skills, and their children made developmental progress while in the program. There was also evidence of continued program impact on clients after leaving the program.
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
A continuing difficulty is providing appropriate transitional services after discharge. Although Arkansas CARES, along with other agencies, provides outpatient treatment services for addiction problems, there is inadequate availability and coordination of other needed family services, most notably housing, adult education, transportation, and child care. This leaves families, especially women, vulnerable to the many of negative factors that may ultimately lead to relapse. The cycle of negative consequences may begin again, not only for mothers but children as well. As of yet, few states or communities have adequate policies and funding designed to protect this highly vulnerable group of children. If such polices were implemented, they may not only prevent many long-term difficulties for the children themselves, but have the additional benefit of aiding the mothers’ recovery as well. Comprehensive services for addicted women will not only help promote well-being for their children, but continuous protective services for children will promote well-being for mothers.
Acknowledgments We are thankful for support provided by the Center for Substance Abuse Treatment (6HD8 T100970-05-01).
References Abidin, R. R. (1995). Parenting Stress Index Professional Manual (3rd ed.). Odessa, FL: Psychological Assessment Resources, Inc. Beckman, L. J., & Amaro, H. (1986). Personal and social difficulties faced by women and men entering alcoholism treatment. Journal of Studies on Alcohol, 47, 135 – 145. Bruininks, R. H., Woodcock, R. W., Weatherman, R. F., & Hill, B. K. (1996). Scales of independent behavior-revised: comprehensive manual. Chicago, IL: Riverside Publishing Company. Brunner, G. (1999). Community report. Little Rock, AR: Little Rock Community Programs Fighting Back Project, 1998 – 2001. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Academic Press. Coletti, S. D., Schinka, J. A., Hughes, P. H., Hamilton, N. L., Renard, C. G., Sicilian, O. M., Urmann, C. F., & Neri, R. L. (1995). Par Village for chemically dependent women: philosophy and program elements. Journal of Substance Abuse Treatment, 12, 289 – 296. Evenson, R. C., Binners, P. R., Cho, D. W., Schicht, W. W., & Topolski, J. M. (1998). An outcomes study of Missouri’s CSTAR alcohol and drug abuse programs. Journal of Substance Abuse Treatment, 15, 143 – 150.
75
Finkelstein, N. (1994). Treatment issues for alcohol- and drug-dependent pregnant and parenting women. Health and Social Work, 19, 7 – 15. Frankenburg, W. K., & Dodds, J. (1992). Denver II Training Manual (2nd ed.). Denver, CO: Denver Developmental Material, Inc. Graham, A., Graham, N., Sowell, A., & Ziegler, H. (1997). Miracle Village: a recovery community for addicted women and their children in public housing. Journal of Substance Abuse Treatment, 14, 275 – 284. Howell, E. M., & Chasnoff, I. J. (1999). Perinatal substance abuse treatment: findings from focus groups with clients and providers. Journal of Substance Abuse Treatment, 17, 139 – 148. Kelley, S. J. (1992). Parenting stress and child maltreatment in drugexposed children. Child Abuse and Neglect, 16, 317 – 328. Laken, M. P., & Hutchins, E. (1996). Recruitment and retention of substanceusing pregnant and parenting women: lessons learned. Arlington, VA: National Center for Education in Maternal and Child Health. McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 199 – 213. Metsch, L. R., Rivers, J. E., Miller, M., Bohs, R., McCoy, C. B., Morrow, C. J., Bandstra, E. S., Jackson, V., & Gissen, M. (1995). Implementation of a family-centered treatment program for substance-abusing women and their children: barriers and resolutions. Journal of Psychoactive Drugs, 27, 73 – 83. Moos, R. H. (1974). Family environment scale. Palo Alto, CA: Consulting Psychologists Press. Murphy, J. M., Jellinek, M., Quinn, D., Smith, G., Poitrast, F. G., et al. (1991). Substance abuse and serious child mistreatment: prevalence, risk, and outcome in a court sample. Child Abuse and Neglect, 15, 197 – 211. Namyniuk, L., Brems, C., & Carson, S. (1997). Southcentral Foundation – Dena A. Coy: a model program for the treatment of pregnant substance-abusing women. Journal of Substance Abuse Treatment, 14, 285 – 295. Schumacher, J. E., Siegal, S. H., Socol, J. C., Harkless, S., & Freeman, K. (1996). Making evaluation work in a substance abuse treatment program with children: Olivia’s house. Journal of Psychoactive Drugs, 28, 73 – 83. Smith, G. R., Kramer, T., Babor, T., Burnam, M. A., Mosley, C. L., Rost, K., & Burns, B. (1998). Substance Abuse Outcomes Module Users Manual (On-line; http://www.netoutcomes.net). Stevens, S. J., & Arbiter, N. (1995). A therapeutic community for substanceabusing pregnant women and women with children: process and outcome. Journal of Psychoactive Drugs, 27, 49 – 56. Tanney, M. R., & Lowenstein, V. (1997). One-stop shopping: description of a model program in provide primary care to substance-abusing women and their children. Journal of Pediatric Health Care, 11, 20 – 25. Uziel-Miller, N. D., Lyons, J. S., Kissiel, C., & Love, S. (1998). Treatment needs and initial outcomes of a residential recovery program for African-American women and their children. American Journal of Addiction, 7, 43 – 50. Wexler, H. K., Cuadrado, M., & Stevens, S. J. (1998). Residential treatment for women: behavioral and psychological outcomes. Drugs and Society, 13 (1&2), 213 – 233. Wilkinson, G. S. (1993). The Wide Range Achievement Test: Administration Manual. Wilmington, DE: Wide Range, Inc. Wolock, I., & Magura, S. (1996). Parental substance abuse as a predictor of child maltreatment re-reports. Child Abuse and Neglect, 20, 1183 – 1193.
Regular article
A comprehensive substance abuse treatment program for women and their children: an initial evaluation Nicola A. Conners, Ph.D.a,*, Robert H. Bradley, Ph.D.b, Leanne Whiteside-Mansell, Ed.D.a, Cynthia C. Crone, M.N.Sc.a a
University of Arkansas for Medical Sciences, Little Rock, AR, USA b University of Arkansas at Little Rock, Little Rock, AR, USA
Received 28 August 2000; received in revised form 14 April 2001; accepted 1 May 2001
Abstract This article examines a comprehensive, residential substance abuse treatment program for women and their children. A majority of the 72 participants studied were African American single mothers, for whom crack/cocaine was the drug of choice. The women and their children were assessed repeatedly during treatment, and at 3, 6, and 12 months postdischarge. Program impact was estimated by comparing the outcomes of three groups that differed in the amount of treatment they received: early dropouts, late dropouts, and treatment graduates. Program graduates showed more positive outcomes than the nongraduate comparison groups in the areas of drug use and negative consequences of use, employment and self-sufficiency, and family interaction skills. Young children enrolled in treatment with their mothers were assessed using a developmental screening test, and older children with a measure of drug refusal skills. Results from both child measures suggest substantial improvement. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Women’s AOD treatment; Treatment outcomes; Program evaluation; Children of substance abusers; Substance abuse treatment
1. Introduction Women with children represent a special population for substance abuse treatment programs. The unique needs of women and the requirements of child rearing often complicate the efforts of service providers. Mothers with substance abuse problems often face a painful decision: Enter a treatment facility in hopes of recovery, or take care of their children. Even when there is the option to bring children into the treatment facility, it often means a severe disruption of family life, including stress on the children who must live for an extended period in a place that may seem very strange. Increasingly, substance abuse treatment providers are recognizing the special treatment needs of parenting women and are beginning to implement programs to address those needs. Federal agencies such as the National Institute on * Corresponding author. Arkansas CARES, University of Arkansas for Medical Sciences, Slot 711-1, 4301 W. Markham, Little Rock, AR 72205, USA. Tel.: +1-501-296-1760. E-mail address: [email protected] (N.A. Conners).
Drug Abuse (NIDA), the Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse Treatment (CSAT) have established programs to encourage the development, implementation, and evaluation of substance abuse treatment programs designed to serve pregnant and parenting women and their children. Substance abuse treatment providers must address several challenges when attempting to serve parenting women. First, they must enable potential clients to overcome the barriers to seeking treatment. Some practical barriers that women face when trying to find treatment include lack of transportation, safe housing, and financial resources to pay for treatment (Brunner, 1999; Howell & Chasnoff, 1999; Laken & Hutchins, 1996). Other barriers include a sense of shame and guilt that leads women to hide their drug problems, and opposition to treatment from family and friends who rely on women as caregivers (Beckman & Amaro, 1986; Finkelstein, 1994). Women also fear losing of custody of their children if they enter treatment, as few treatment programs allow children into residential treatment (Finkelstein, 1994; Howell & Chasnoff, 1999).
0740-5472/01/$ – see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 7 4 0 - 5 4 7 2 ( 0 1 ) 0 0 1 8 6 - 6
68
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Once in treatment, women frequently have alcohol- and drug-related issues that differ from those faced by men. Maternal substance abuse is associated with many other indicators of poor health and social problems, including mental illness, poverty, child abuse, risk for sexually transmitted diseases including HIV, and arrests and incarcerations. With any one of these problems, successful life functioning is difficult. When combined, the jeopardy to mother and child increases exponentially and reduces the likelihood of positive outcomes for both women and their children. Particularly pertinent to women are needs related to their roles as parents and caregivers. The burdens of parenthood often fall particularly hard on women who abuse alcohol and drugs, since they can rarely call upon family and friend support systems for financial help or help with child care. Mothers who are distanced from social support and who are preoccupied by their own addiction are often not able to provide effective, nurturing parenting to their children. Studies have shown that maternal use of drugs is associated with higher levels of parent related stress (Kelley, 1992), and children of substance users are considered to be at increased risk for physical abuse and neglect (Murphy et al., 1991; Wolock & Magura, 1996). To prevent child maltreatment, programs must deal with all of the usual issues related to recovery, plus begin the process of stabilizing the family, assisting the mother with to child management, rebuilding family relations, and learning skills needed to establish supportive ties with others. Of great importance is providing high quality care to the children themselves to minimize the effects of prenatal exposure to drugs and/or postnatal exposure to an environment characterized by addiction. Although there is a growing body of literature describing model substance abuse treatment programs for pregnant and parenting women (Coletti, Schinka, Hughes, Hamilton, Renard, 1995; Graham, Graham, Sowell, & Ziegler, 1997; Metsch et al., 1995; Namyniuk, Brems, & Carson, 1997), there is little research yet available about treatment outcomes for these women and their children. The few studies extant tend to involve preliminary analyses done on small samples, with little in the way of long-term follow-up. The limited outcome data available from both residential and nonresidential treatment programs suggest that comprehensive approaches to treatment can be effective in arresting some of the negative outcomes of substance abuse. Results from studies of outpatient programs for pregnant and parenting women show that these programs have had success in improving birth outcomes, and reducing problems related to substance abuse, parenting, interpersonal difficulties, and unemployment (Evenson, Binners, Cho, Schicht, & Topolski, 1998; Tanney & Lowenstein, 1997). There is also evidence that residential treatment programs for women with children have been effective in reducing addiction-related problems in families. Some of the positive
outcomes reported in studies of these programs include reductions in substance use, criminal behavior, emotional problems, family problems, parenting stress, and unemployment (Schumacher, Siegal, Socol, Harkless, & Freeman, 1996; Stevens & Arbiter, 1995; Uziel-Miller, Lyons, Kissiel, & Love, 1998; Wexler, Cuadrado, & Stevens, 1998). While these studies suggest that comprehensive programs for parenting women can be efficacious, a review of the literature reveals a need for studies designed to (a) assess a wide range of outcomes of women in substance abuse treatment; (b) include relatively long-term follow-up of clients (i.e. more than discharge assessments); (c) include postdischarge assessments of both treatment graduates and dropouts; and (d) assess the impact of comprehensive treatment services on children who enter treatment with their mothers. The present study examined a comprehensive substance abuse treatment program for parenting women and their children to determine its impact on a wide range of outcomes for both adult and child. The study addressed the following questions: (1) Did the program result in a sustained decrease in AOD use, and the negative consequences of AOD use? (2) Did the program result in greater selfsufficiency and social responsibility among participating women? (3) Is there evidence of improved family functioning among participating women and children? (4) In what ways did the program impact children enrolled in treatment with their mothers? 1.1. Program description The Arkansas Center for Addictions Research, Education, and Services (Arkansas CARES) is a licensed facility that provides residential and outpatient comprehensive substance abuse prevention and treatment services to low-income pregnant and parenting women, and their children. Arkansas CARES operates under the auspices of the University of Arkansas for Medical Sciences Department of Psychiatry. The program is accredited as a behavioral healthcare provider by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and is licensed as an alcohol and drug treatment program, adult and child mental health provider, childcare center, and early intervention program by the state of Arkansas. Care is provided by multidisciplinary teams. This article focuses on one component of Arkansas CARES, a residential program for parenting women and their children. This program was originally funded as a demonstration project by the Center for Substance Abuse Treatment (CSAT), and the project was called the Women and Children’s Recovery Center (WCRC). A list of the services provided by this program can be found in Table 1. As seen in Table 1, the Arkansas Cares/WCRC program provided a variety of alcohol- and drug-related treatment services, including daily AOD education groups, twice-weekly transportation to offsite Cocaine or Narcotics Anonymous groups, weekly relapse prevention
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75 Table 1 Services provided by the Arkansas CARES/WCRC Program 7-8 hour treatment day Alcohol and drug abuse assessment, education, and treatment Licensed mental health services for client, child, and family Onsite residence Licensed early intervention services Onsite licensed childcare Infant and toddler Preschool and school-age School-age summer program Parenting education and support Health services and education Community and onsite 12-step meetings Life skills training Group therapy Case management Group and individual counseling, covering the following areas: Denial The disease of addiction Physiology and pharmacology of tobacco, alcohol, and other drugs Effects of tobacco, alcohol, and other drugs on the mother and fetus Parenting the drug-exposed infant Women in relationships Women’s issues in recovery Loss and grief Family dynamics in recovery 12-step recovery Self-esteem building Relapse prevention AIDS and other sexually transmitted diseases Family planning Child development and care
groups, daily group counseling on alcohol- and drugrelated issues, and weekly individual counseling sessions. To meet the mental health needs of clients, primary therapists (mental health professionals) conducted daily group sessions and weekly individual therapy. The group and individual counseling sessions were designed to address family and relationship issues, grief and anger, self-esteem building, and other topics as listed in Table 1. A board-certified addiction psychiatrist performed intake psychiatric evaluations and referred clients for offsite care when indicated. In addition, the psychiatrist participated in the weekly meeting of the treatment team, which involved all mental health and alcohol and drug professionals involved in the care of the family. A variety of educational groups and case management services were offered by Arkansas CARES/WCRC to meet the practical needs of clients. Educational services offered weekly included: life skills training (including budgeting, household management, etc.), health education, and parenting education. For clients who were not high school graduates, on- and offsite GED programs were offered. Additionally, each client was assigned to a case manager who assisted them in accessing public assistance while in treatment, and with obtaining employment, housing, and transportation as they transitioned from the WCRC program.
69
Children in treatment with their mothers also received a variety of educational and mental health services. An onsite licensed child care center was available for full-day care of young children, and afterschool and full-day summer care for school-age children. Early intervention services were provided as needed to young children, and tutoring was provided to school-age children. Mental health services including group and individual counseling sessions were available to school-age children.
2. Method While the ideal design for estimating program impact involves the use of randomly assigned treatment and control groups, ethical and practical concerns prevented the use of a randomized design in this study. Because of the desire of Arkansas CARES management to provide treatment services to all eligible clients, in this evaluation study, program impact was estimated by comparing the outcomes of three groups that differed in the amount of treatment they received. The three treatment groups include clients who stayed in treatment less than 30 days, clients who stayed more than 30 days but ultimately left without completing treatment, and clients who successfully completed, or ‘‘graduated,’’ from the treatment program. Throughout the article, these groups will be referred to as ‘‘early dropouts,’’ ‘‘late dropouts,’’ and ‘‘graduates.’’ While the length of stay in treatment was longer on average for treatment graduates than the nongraduate groups, ‘‘graduation’’ from treatment was based upon the judgment of the clinical team involved in the clients’ treatment rather than length of stay alone. Because dividing the sample of 72 into three treatment groups resulted in small group sizes, and thus low power to detect differences between groups, we utilized two analytic approaches in this article. First, we used a traditional significance level of 0.05 to identify differences between treatment groups. Second, where the significance level was less than 0.10, we calculated an effect size to estimate the magnitude of the differences between groups, recognizing that with a small sample even a relatively large effect can be nonsignificant using the more stringent 0.05 criterion. To ensure a fair comparison between groups on each outcome measure, intake variables were examined to establish equivalency between the groups at admission to treatment using chi-square and ANOVA tests. Furthermore, in all analyses of mean postdischarge differences between treatment groups, ANCOVA was used, with intake scores included as covariates. Due to sample size limitations, a different approach was used for analyses involving data on children in treatment. Rather than comparing different treatment groups, repeated measures of outcomes and the use of measures with normative data were used. The evaluation of the Arkansas CARES program consisted of a baseline assessment of mothers and children
70
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
during the first week following entry into the program. Assessments were then repeated every three months after intake, for as long as the client remained in the treatment program. The first postdischarge assessment was scheduled three months after discharge from the residential treatment facility, followed by assessments at six and 12 months after discharge. Assessments included data collection from clients and children. Children, ranging in age from newborns through early adolescence, participated in the program at Arkansas CARES. The specific assessment battery used for each child varied as a function of age. When a client had more than one child participating in the treatment program, the youngest child was chosen as the target child, and that child received the most extensive assessment. The child closest to age 10 was chosen as the secondary target, and received a less extensive assessment. Two questionnaires designed for school-age children were administered to all children over age 8. All data were collected by a research assistant who served as part of an independent evaluation team, which also included an evaluator and a statistician. The research assistant conducted in-person interviews with each client, and administered paper-and-pencil questionnaires and developmental tests. Visits typically took place at Arkansas CARES while clients were in treatment, and in the homes of the clients once they were discharged from the program. The research assistant was frequently accompanied on follow-up visits by a case manager who offered assistance in locating and contacting clients to schedule follow-up visits, and also provided aftercare case management services. Of the 73 clients served by the Arkansas CARES program during the study period, 72 (99%) agreed to participate in the evaluation study and completed the intake assessment. All clients, regardless of their length of stay, were asked to continue their participation in the evaluation study after leaving treatment. At the end of the study, 89% of clients who had been discharged from the program for at least three months completed at least one postdischarge follow-up visit.
more than one substance were able to identify one substance as the primary problem, while other clients identified alcohol and drugs, or multiple drugs, as equal problems. More than three-fourths of clients in the early dropout and the graduate groups identified crack/cocaine as their primary drug, compared to just over half of the late dropouts. Arkansas CARES was not the first drug treatment experience for the majority of clients in all treatment groups. At least three-fourths of clients in each treatment group had an arrest record prior to admission, and one-third of clients also had an open child protective service case, indicating a substantiated charge of child abuse or neglect. While few clients in any treatment group were mandated (e.g., courtordered) to receive treatment, others may have been pressured to received treatment by persons involved in the criminal justice system or family service agencies. Significantly fewer early dropouts (25%) were involved with the legal system at intake (probation, parole, charges pending, etc.) compared to three-fourths of late dropouts and graduates. The majority of Arkansas CARES clients in all treatment groups had experienced either physical and/or sexual abuse in their life. Most of the children served by the Arkansas CARES program were African American, and 54.4% were male. Ages ranged from newborn to 14.9 years, with a majority of children being under the age of five. Sixty percent of children were prenatally exposed to drugs, and more than two-thirds to cigarettes. Only 7% had health problems serious enough to warrant admission to the neonatal intensive care unit at birth. 2.2. Instruments Some measures were added to the evaluation plan later than others; therefore, the number of clients reported on each measure varies depending on how long a particular measure was a part of the evaluation plan. For children, the number reported on each measure also varies depending on the age group that was assessed using each measure.
2.1. Sample description While most Arkansas CARES clients were African American, there were significantly more Caucasian women in the late dropout group (42.9%) than in the early dropout (21.4%) or graduate (13.3%) groups. Most clients in all groups were single mothers (either never married, separated, or divorced) with an average of 3 children. Clients ranged in age from 16 to 44, and clients who completed treatment were significantly older than clients who dropped out of treatment. With the exception of math scores, their scores on the Wide Range Achievement Test III were generally within normal range, and did not differ significantly by treatment group. Clients were asked to identify the substance that was the major problem for them. Many clients that used
2.2.1. Description of data collection instruments for mothers 1) Addiction Severity Index, 5th ed. The Addiction Severity Index (ASI) is a semistructured interview which is designed to gather information about aspects of a client’s life which may contribute to their substance abuse problem. The ASI covers seven areas: medical, employment/support, alcohol, drug, legal, family/social, and psychiatric (McLellan, Kushner, Metzger, Peters, Smith, 1992). The full ASI was completed at intake, and the recommended follow-up questions were repeated at follow-up. 2) Parenting Stress Index. The PSI is used to gauge the stress the client perceives as it relates to parenting. This instrument takes about 5 minutes to complete. The PSI consists of three scales (Parental Distress, Parent-Child
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Dysfunctional Interaction, and Difficult Child). Each scale yields a score, plus there is a total score. The PSI was normed on a large and diverse sample of women, including Caucasian, African American, Hispanic, and Asian mothers. Abidin (1995) has reported acceptable internal consistency and test-retest reliability in studies of high-risk families. Alpha reliability coefficients were computed using data from this study; the coefficients for the subscales ranged from 0.72 to 0.88, and the coefficient for the total stress scale was 0.92. 3) Outcomes of Addiction. The Outcomes of Addictions Questionnaire asks clients to indicate how frequently they have experienced various negative effects from drug or alcohol use (i.e., guilt, money problems, accidents) in the four weeks prior to the assessment. Scores on this measure can range from 0 to 45, with high scores indicating that the client is frequently experiencing many negative effects of drinking or drug use. If a client had not used any alcohol or drug in the four-week period prior to the assessment, the score was automatically 0. The overall alpha reliability coefficient was 0.96. This questionnaire was taken from the Substance Abuse Outcomes Module (Smith, Kramer, Babor, Burnam, Mosley, 1998). 4) Family Cohesiveness Scale. This brief form consists of nine items that are used to assess the degree to which the family acts as a single unit and expresses feelings of togetherness. The items were taken from the Family Environment Scale (Moos, 1974), which has been used with a diverse array of families, including several studies of highrisk populations. Since items are marked True or False, scores can range from 0 to 9, with higher scores indicating more cohesion. The overall alpha reliability coefficient for the FCS was 0.82. 5) Intake/Follow-up demographic update form. This instrument was developed by staff and evaluators to capture information about insurance, legal status, and the living situation of the client and her children. 6) The Wide Range Achievement Test III. The WRAT III is designed to assess basic spelling, reading, and mathematics competence. Scores on the WRAT III were converted to standard scores on a metric where the national mean is set at 100 and the SD is set at 15 (the same metric as IQ tests). The data were used as baseline information and to help describe the sample served by this program. The WRAT III manual includes information about its reliability and validity, and acceptable levels of both have been demonstrated (Wilkinson, 1993). 2.2.2. Description of data collection instruments for children 1) Refusal Skills. The child’s ability to resist using drugs or alcohol was measured by a scale designed for this project. Items in the scale address the child’s ability to deal with types of situations that might induce use of alcohol or other drugs. This instrument was completed by children eight years of age and older. The measure contains 19 items, each
71
scored on a 3-point scale (Yes = 0, Not Sure = 1, No = 2). Thus, scores can range from 0 to 38, with lower scores indicative of a greater degree of ability to resist the pressure to abuse substances. Alpha reliability coefficients were computed, and the reliability coefficient for the total score was 0.89. 2) Adaptive Behavior – Scales of Independent Behavior (Revised). The SIB-R is a comprehensive set of tests for measuring functional independence over a wide age range. Areas assessed include: motor development, daily living skills, social development, language, self-help skills, problem behaviors, and community adaptation. SIB also provides an index of maladaptive behavior, with scores convertible to an index with a mean of 0 and an SD of 10. Negative scores indicate maladaptive behavior (scores < 20, of a moderately serious nature). The tests are individually administered through a structured interview. Norms are provided from the infant level to the mature adult level. The SIB-R was normed on over 2,000 individuals selected to be representative of the U.S. population on gender, race, socioeconomic status, and geographic region. Acceptable levels of test-retest and inter-rater reliability are reported in the SIB-R manual, and evidence of the construct validity of the instrument is also included (Bruininks, Woodcock, Weatherman, & Hill, 1996). 3) Denver Developmental Screening Test II. The DDST II is an individually administered, norm-referenced, multiskill device designed to assess developmental progress and to identify children with developmental problems. It is normed for children from birth through age six, and was administered to all preschool-age children. It assesses fine-motor, gross-motor, language, and social competencies. Since it is a screening test, children receive a dichotomous rating (either suspect or within normal limits). The DDST II has been used to screen more than 50 million children throughout the world, including children of all major ethnic and cultural groups. The DDST II is widely recognized as being a valid and reliable instrument (Frankenburg & Dodds, 1992).
3. Results Of the 72 study participants, 62 (86%) received both intake and at least one follow-up assessment after discharge from treatment. Another two clients (3%) had not been discharged long enough at the end of the study to receive a follow-up visit. No follow-up data were available on four early dropouts, two late dropouts, and four graduates. Results are reported on all clients for whom both intake and at least one postdischarge follow-up information was available, regardless of client’s length of stay in the program or type of discharge. Data from the last postdischarge follow-up assessment were used in the analyses reported here. On average, early dropouts had been discharged from treatment for 7.8 months (SD = 3.94) at the time of their last
72
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Table 2 Treatment groups compared on key postdischarge outcomes Early Dropouts (n = 10) Using Alcohol or Drugs Intake 100% Follow-up ** 50.0%
Late Dropouts (n = 26)
Graduates (n = 26)
100% 61.5%
100% 15.4%
Homeless Intake Follow-up
40.0% 50.0%
39.1% 24.0%
41.7% 26.9%
Unemployed Intake Follow-up *
90.0% 70.0%
100% 64.0%
87.5% 26.9%
Poverty level income Intake 90.0% Follow-up 88.9% Arrested Intake Follow-up
90.0% 50.0%
100% 78.3%
87.5% 54.2%
87.0% 44.0%
83.3% 19.2%
* p < 0.05. ** p < 0.01.
follow-up assessment, compared to 8.5 months (SD = 3.58) for late dropouts, and 9.9 months (SD = 3.33) for graduates. 3.1. Substance use and negative consequences of use The report of drug use at all follow-up assessments was used to compute the percentage of clients that relapsed during the postdischarge follow-up period. As indicated in Table 2, 15% of graduates relapsed, compared with half of the clients in the early dropout group and 61% in the late dropout group. The difference in the relapse rates among the three treatment groups was significant (c2 = 11.97, df = 2, p = 0.003). At each assessment period, clients were asked to report the number of days they used each substance in the past 30 days. The mean number of days for each group is reported in Table 3. Because so few clients reported using heroin, methadone, opiates, barbiturates, hallucinogens, and inhalants at time of entry, those substances were combined to form the category of ‘‘other drugs.’’ No significant group differences were found on mean days of alcohol, crack/ cocaine, marijuana, or other drug use at intake, F (8, 100) = 1.0, p = 0.43. An ANCOVA controlling for intake drug use revealed that the three treatment groups were not significantly different on mean postdischarge days of alcohol, cocaine, marijuana, or other drug use, F (8, 102) = 0.67, p = 0.71. The distributions on all substances both at time of entry and postdischarge are highly skewed. The mean rate of use reported for all substances represents a somewhat inflated estimate of average use since high rates of use on the part of a small number of clients disproportionately affect the mean. An examination of the participant-reported negative effects of substance use (Outcomes of Addiction) at intake
revealed no significant differences among the treatment groups. We used ANCOVA to investigate differences in postdischarge scores on negative outcomes from addiction after controlling for intake scores, and found a significant difference between the three groups, F (2, 47) = 3.78, p = 0.03. Follow-up tests revealed that treatment graduates showed more improvement than late dropouts, and the effect size (d = 0.68) was large (Cohen, 1988). This suggests that the graduates had a greater decrease in drug-related problems than late dropouts. 3.2. Self-sufficiency and social responsibility As indicated in Table 2, most clients in all groups were unemployed at intake into treatment, and had a povertylevel income. At follow-up, 26.9% of treatment graduates were unemployed, compared to 70% of early dropouts, and 64% late dropouts (c2 = 9.08, df = 2, p = 0.01). In addition, fewer graduates (54.2%) had incomes below the poverty line than early dropouts (88.9%) or late dropouts (78.3%), though the difference was only marginally significant (c2 = 5.10, df = 2, p = 0.07). While fewer treatment graduates (26.9%) were homeless at followup than the other two treatment groups, the difference was nonsignificant. Over 80% of clients in all groups were arrested at least once prior to intake into the Arkansas CARES program. Fewer treatment graduates were arrested after treatment (19.2%) than early dropouts (50%) or late dropouts (44%)(c2 = 4.75, df = 2, p = 0.09). While only marginally significant, the percentage difference suggests a meaningful trend.
Table 3 Mean days of drug use out of past 30 Entry n
m (SD)
Follow-up m (SD)
Alcohol early dropouts late dropouts graduates
10 24 24
6.19 (7.50) 10.52 (11.51) 9.54 (8.49)
1.30 (2.58) 4.12 (7.92) 1.58 (5.93)
Cocaine/Crack early dropouts late dropouts graduates
10 24 24
15.90 (12.75) 11.16 (10.60) 13.96 (11.99)
0.30 (0.67) 3.08 (7.71) 0.92 (3.97)
Marijuana early dropouts late dropouts graduates
10 24 24
4.10 (8.20) 3.68 (6.70) 2.38 (5.93)
0.00 (0) 1.00 (2.06) 0.31 (1.57)
Other Drugs early dropouts late dropouts graduates
10 24 24
2.80 (5.41) 4.52 (11.57) 0.30 (1.22)
0.00 (0) 0.12 (0.60) 0.00 (0)
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
3.3. Parenting and family interaction skills Table 4 displays clients’ scores on the Parenting Stress Index and the Family Cohesion Scale (FCS). There were no significant differences on PSI or FCS scores at intake. Using ANCOVA to control for intake scores, we compared the postdischarge scores of the three treatment groups and found significant differences on the Parenting Distress scale F (2, 52) = 5.3, p = 0.008, with treatment graduates improving significantly more than the late dropouts. The effect size (d = 0.92) was large (Cohen, 1988). The Family Cohesion Scale (FCS) was used to assess the degree to which the family acts as a single unit and expresses feelings of togetherness. Using ANCOVA to control for intake scores, the difference in scores between treatment groups at follow-up was again marginally significant, F (2, 50) = 3.07, p = 0.055. Treatment graduates showed greater improvement than treatment dropouts. Effect size values suggest a large difference between treatment graduates and early dropouts (d = 0.96), and a medium-size difference between graduates and late dropouts (d = 0.52).
73
children receive a dichotomous rating (either ‘‘suspect’’ or ‘‘within normal limits’’). Results on the Denver II show that 63% of children at program entry scored in the range indicative of possible developmental delay, compared to only 43% at follow-up, t(29) = 1.79, p = 0.083. The effect size value (d = 0.40) suggests a medium-size effect (Cohen, 1988). 3.5. Behavior problems Children from Arkansas CARES tended to be in the normal range on the Scales of Independent Behavior, though they showed a tendency to display slightly more maladaptive behaviors than their chronological age mates. No differences were found from time of entry to the time of the postdischarge assessment. 3.6. Drug resistance skills
3.4. Child development
Children’s refusal skills were measured by a scale designed for this project. The improvement in Refusal Skills scores from entry to postdischarge was very nearly significant, t(22) = 2.03, p = 0.054. This suggests that at follow-up, children tended to feel better able to resist pressure to use alcohol or other drugs. The effect was medium-size (d = 0.57).
The Denver Developmental Screening Test II was used to assess children’s competencies. Because it is a screening test,
4. Discussion
Table 4 Mean scores on Parenting Stress Indexa (PSI) and Family Cohesion Scaleb Entry n PSI Parenting Distress Scale** early dropouts 10 late dropouts 24 graduates 24
m (SD)
Follow-up m (SD)
36.40 (9.64) 33.08 (6.29) 32.75 (5.99)
28.10 (10.40) 31.79 (8.64) 24.00 (8.30)
PSI Parent-Child Dysfunctional Interaction Scale early dropouts 10 29.40 (12.41) late dropouts 24 26.83 (9.25) graduates 24 22.54 (7.44)
25.40 (12.05) 25.62 (7.65) 20.62 (7.77)
PSI Difficult Child Scale early dropouts 10 late dropouts 24 graduates 24
32.70 (10.27) 34.16 (11.47) 30.12 (10.67)
27.90 (12.03) 31.37 (8.83) 27.41 (10.31)
PSI Total Stress Score early dropouts late dropouts graduates
10 24 24
98.50 (28.98) 94.08 (22.90) 85.41 (18.81)
81.40 (32.72) 88.79 (21.08) 72.04 (23.22)
Family Cohesion Scale early dropouts late dropouts graduates
9 22 23
3.89 (3.21) 5.22 (2.67) 4.92 (2.84)
4.66 (32.72) 5.95 (21.08) 7.17 (23.22)
a
Higher scores indicate greater stress. Higher scores indicate greater family cohesion. ** p < 0.01.
b
In this evaluation study, program impact was estimated by comparing the outcomes of three groups that differed in the amount of treatment they received: early dropouts, late dropouts, and treatment graduates. A comparison of the outcomes of the three treatment groups suggests while all groups showed some improvements, treatment graduates showed generally greater improvement, and in more areas. First, compared to dropouts, treatment graduates were far less likely to relapse after treatment. In fact, only 15% of treatment graduates reported a relapse in the period following discharge. Furthermore, compared to late dropouts, treatment graduates reported significantly fewer negative consequences related to drug use after discharge, such as physical problems and accidents. Second, treatment graduates were more likely than both nongraduate groups to become self-sufficient and socially responsible after treatment. At follow-up, treatment graduates were significantly more likely to be employed than treatment dropouts. Group differences were also seen in arrest rates and income. In fact, only 19% of graduates were arrested after treatment, compared to half of early dropouts, and 44% of late dropouts. While treatment graduates were less likely to report an income below the poverty line than treatment dropouts, the majority of clients in all groups remained poor after treatment. Third, there were group differences in the family interaction skills of clients. At follow-up assessments, treatment graduates reported less parental distress on the Parenting
74
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
Stress Index than late dropouts. Graduates also showed a significantly greater improvement in family cohesion scores than early dropouts. This improvement in scores indicates that mothers felt that the bonds between family members were strengthened and that they were working together as members of a team. While treatment graduates moved toward sobriety, selfsufficiency, and improved family interaction skills, in some areas more long-term assistance may be required for these families. For example, the majority of graduates still had incomes below the poverty line after treatment, reducing the likelihood that they could effectively care for themselves and their children. While many Arkansas CARES clients became employed, their low-paying jobs did not allow them to move out of poverty. Furthermore, it is difficult for clients to advance their education in hopes of a better job while simultaneously caring for their children and providing financially for their family. The kinds of educational and support services needed for clients to succeed financially are outside the scope of even comprehensive drug treatment providers, but are needed nonetheless. Relatedly, the lack of improvement in the housing situations of clients are likely due to inadequacies in the current housing service system, including regulations that exclude people with past felony convictions from public housing communities. Given that the majority of Arkansas CARES had arrest records, affordable housing options at discharge from treatment were likely limited. Finally, regarding program impact on children, this study provides some evidence that the children who enrolled in the Arkansas CARES program with their mothers benefited from treatment. First, results from the DDST II suggest that fewer young children scored in the range indicative of a possible developmental delay at the follow-up assessments than at intake. Second, the perceived ability of older children to resist drugs or alcohol increased from intake to postdischarge follow-up. While the changes in both these scores were not significant using a stringent 0.05 criterion, they do represent positive trends. It should also be noted that at intake, many children received the highest possible refusal skills score, leaving little room for improvement. It was also difficult to show significant change because of the relatively small number of children from any particular age group, resulting in low statistical power. Results from the SIB showed no evidence of improvement in children’s behavior. However, the SIB relies on mother report, which may not be the most accurate way to assess children’s improvement in behavior problems. One difficulty with relying on mother report is that at intake some mothers may have downplayed any behavior problems of their child. They may have done this either because they feared that their child would not be welcome in the program if they had serious problems, or because they felt that the child’s problems were a reflection on the quality of their parenting during the period of their addiction. Another problem with mother
report is that because of the all-consuming nature of drug addiction, at intake some mothers simply may not have been aware of their children’s behavior problems. Other mothers had lost custody of their children prior to intake and may have been unable to accurately report on their children’s behaviors. 4.1. Limitations The primary limitation of this study was the inability to randomly assign clients to treatment and comparison groups. This limits our ability to attribute the changes seen exclusively to program impact. While the hope was that clients in the three treatment groups would be similar on all characteristics except length of time in treatment, and thus differences in outcomes might be attributed to treatment impact, the reality is that clients in the treatment groups were not the same. When compared on demographic variables at intake, the three groups were similar on all variables except age, race, and legal involvement. Treatment graduates were slightly older on average (about three years) than treatment dropouts, a higher percentage of women in the late dropout group were Caucasian, and early dropouts were less likely to have any legal involvement (probation, parole, etc.). We cannot know whether those differences, or differences in motivation or some unmeasured variable, were related to outcomes after treatment. What seems clear is that those clients who chose to stay in treatment and successfully graduate had much better outcomes than clients in the dropout groups. What is unclear is whether their success after treatment can be attributed to program impact or to greater levels of motivation prior to the start of treatment. The issue of motivation for treatment may be particularly important to consider in studies of parenting women in treatment. All men and women seeking treatment vary in their readiness for treatment, and differ in the extent to which they are pressured by external forces (probation officers, judges, employers) to complete treatment. However, children may serve as an additional motivating force for parenting women with additions. Mothers may be motivated by a desire to be a better parent, or by fears that they will lose custody of their children if they do not receive help with their addiction. We do not know to what extent these or other factors motivated Arkansas CARES clients to remain in treatment, or how the three groups compared in this study may have differed in their motivation. 4.2. Conclusion Overall, women who entered the program at Arkansas CARES showed both decreased drug use and increased employment. In addition, these clients showed improvements related to parenting and family interaction skills, and their children made developmental progress while in the program. There was also evidence of continued program impact on clients after leaving the program.
N.A. Conners et al. / Journal of Substance Abuse Treatment 21 (2001) 67–75
A continuing difficulty is providing appropriate transitional services after discharge. Although Arkansas CARES, along with other agencies, provides outpatient treatment services for addiction problems, there is inadequate availability and coordination of other needed family services, most notably housing, adult education, transportation, and child care. This leaves families, especially women, vulnerable to the many of negative factors that may ultimately lead to relapse. The cycle of negative consequences may begin again, not only for mothers but children as well. As of yet, few states or communities have adequate policies and funding designed to protect this highly vulnerable group of children. If such polices were implemented, they may not only prevent many long-term difficulties for the children themselves, but have the additional benefit of aiding the mothers’ recovery as well. Comprehensive services for addicted women will not only help promote well-being for their children, but continuous protective services for children will promote well-being for mothers.
Acknowledgments We are thankful for support provided by the Center for Substance Abuse Treatment (6HD8 T100970-05-01).
References Abidin, R. R. (1995). Parenting Stress Index Professional Manual (3rd ed.). Odessa, FL: Psychological Assessment Resources, Inc. Beckman, L. J., & Amaro, H. (1986). Personal and social difficulties faced by women and men entering alcoholism treatment. Journal of Studies on Alcohol, 47, 135 – 145. Bruininks, R. H., Woodcock, R. W., Weatherman, R. F., & Hill, B. K. (1996). Scales of independent behavior-revised: comprehensive manual. Chicago, IL: Riverside Publishing Company. Brunner, G. (1999). Community report. Little Rock, AR: Little Rock Community Programs Fighting Back Project, 1998 – 2001. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Academic Press. Coletti, S. D., Schinka, J. A., Hughes, P. H., Hamilton, N. L., Renard, C. G., Sicilian, O. M., Urmann, C. F., & Neri, R. L. (1995). Par Village for chemically dependent women: philosophy and program elements. Journal of Substance Abuse Treatment, 12, 289 – 296. Evenson, R. C., Binners, P. R., Cho, D. W., Schicht, W. W., & Topolski, J. M. (1998). An outcomes study of Missouri’s CSTAR alcohol and drug abuse programs. Journal of Substance Abuse Treatment, 15, 143 – 150.
75
Finkelstein, N. (1994). Treatment issues for alcohol- and drug-dependent pregnant and parenting women. Health and Social Work, 19, 7 – 15. Frankenburg, W. K., & Dodds, J. (1992). Denver II Training Manual (2nd ed.). Denver, CO: Denver Developmental Material, Inc. Graham, A., Graham, N., Sowell, A., & Ziegler, H. (1997). Miracle Village: a recovery community for addicted women and their children in public housing. Journal of Substance Abuse Treatment, 14, 275 – 284. Howell, E. M., & Chasnoff, I. J. (1999). Perinatal substance abuse treatment: findings from focus groups with clients and providers. Journal of Substance Abuse Treatment, 17, 139 – 148. Kelley, S. J. (1992). Parenting stress and child maltreatment in drugexposed children. Child Abuse and Neglect, 16, 317 – 328. Laken, M. P., & Hutchins, E. (1996). Recruitment and retention of substanceusing pregnant and parenting women: lessons learned. Arlington, VA: National Center for Education in Maternal and Child Health. McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 199 – 213. Metsch, L. R., Rivers, J. E., Miller, M., Bohs, R., McCoy, C. B., Morrow, C. J., Bandstra, E. S., Jackson, V., & Gissen, M. (1995). Implementation of a family-centered treatment program for substance-abusing women and their children: barriers and resolutions. Journal of Psychoactive Drugs, 27, 73 – 83. Moos, R. H. (1974). Family environment scale. Palo Alto, CA: Consulting Psychologists Press. Murphy, J. M., Jellinek, M., Quinn, D., Smith, G., Poitrast, F. G., et al. (1991). Substance abuse and serious child mistreatment: prevalence, risk, and outcome in a court sample. Child Abuse and Neglect, 15, 197 – 211. Namyniuk, L., Brems, C., & Carson, S. (1997). Southcentral Foundation – Dena A. Coy: a model program for the treatment of pregnant substance-abusing women. Journal of Substance Abuse Treatment, 14, 285 – 295. Schumacher, J. E., Siegal, S. H., Socol, J. C., Harkless, S., & Freeman, K. (1996). Making evaluation work in a substance abuse treatment program with children: Olivia’s house. Journal of Psychoactive Drugs, 28, 73 – 83. Smith, G. R., Kramer, T., Babor, T., Burnam, M. A., Mosley, C. L., Rost, K., & Burns, B. (1998). Substance Abuse Outcomes Module Users Manual (On-line; http://www.netoutcomes.net). Stevens, S. J., & Arbiter, N. (1995). A therapeutic community for substanceabusing pregnant women and women with children: process and outcome. Journal of Psychoactive Drugs, 27, 49 – 56. Tanney, M. R., & Lowenstein, V. (1997). One-stop shopping: description of a model program in provide primary care to substance-abusing women and their children. Journal of Pediatric Health Care, 11, 20 – 25. Uziel-Miller, N. D., Lyons, J. S., Kissiel, C., & Love, S. (1998). Treatment needs and initial outcomes of a residential recovery program for African-American women and their children. American Journal of Addiction, 7, 43 – 50. Wexler, H. K., Cuadrado, M., & Stevens, S. J. (1998). Residential treatment for women: behavioral and psychological outcomes. Drugs and Society, 13 (1&2), 213 – 233. Wilkinson, G. S. (1993). The Wide Range Achievement Test: Administration Manual. Wilmington, DE: Wide Range, Inc. Wolock, I., & Magura, S. (1996). Parental substance abuse as a predictor of child maltreatment re-reports. Child Abuse and Neglect, 20, 1183 – 1193.