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Children of substance abusers (COSAs) are at higher-than-average risk for developing substance abuse problems, mental health problems, and related behavioral and social problems (Adger, 1998; Huang et. al, 1998; Johnson and Leff, 1999). There is growing evidence that such outcomes can be minimized or prevented by appropriate educational and supportive interventions. The scientific literature and conventional wisdom both suggest that the family members of addicted persons in treatment should receive support services. School-aged and younger children are viewed as particularly benefitting from such structured programs as Children Are People Support Groups (Pieper and Zimmerman, 1996) and Strengthening Families (Kumpfer, 1992).
Research on the potential benefits of such interventions, however, does not address the issue of whether such programs are actually used. To clarify this question, the National Association for Children of Alcoholics (NACoA) conducted a nationwide survey of licensed substance abuse treatment programs during the first quarter of 1999. Through this survey, NACoA attempted to gain insights on what kinds of supportive education and counseling sessions are offered to the school age children of clients in treatment or aftercare. The survey was designed to identify barriers to, and opportunities for, further expansion of these potentially important prevention programs.
Methodology Data collection was conducted via a questionnaire mailed to licensed treatment centers listed in the National Directory of Drug Abuse and Alcoholism Treatment Programs (1996). Every 20th center providing treatment services in each state, with a minimum of three centers per state, was selected for the survey. The treatment providers surveyed for these programs included inpatient (IP) and outpatient (OP) treatment services, facilities offering both IP and OP services, and methadone treatment facilities. Undelivered surveys returned in the mail were handled by 1) re-sending the survey packet when the post office provided a forwarding address, or 2) when no forwarding information is available, selecting the next provider listed alphabetically in the Directory. The three-page survey was accompanied by a cover memo explaining the survey rationale and process. This was sent to the Treatment Director, using a first-class postage stamp rather than metered mail. Four trained volunteers made follow-up phone calls to those centers who did not respond by fax or mail after two weeks. At least three attempts (letter and a minimum of two follow-up telephone calls) were made to elicit a response to the survey.
The questionnaire posed the following to the substance abuse treatment providers:
Two hundred and forty (47%) of the 516 treatment centers surveyed responded to the survey. among respondents, 50% were outpatient clinics, 16% inpatient treat-ment centers, 28% had both inpatient and outpatient services, and 6% were metha-done clinics. Responses were equally distributed among providers of various sizes, ranging from small providers (30-100 clients per year) through very large treatment centers (>1,000 clients per year), and received from all 50 States and the District of Columbia. It is important to understand the resistance to responding to the questionnaire by treatment providers. Many of those who responded only did so after the volunteers made two follow up phone calls and re-faxed the survey to the treatment center. In debriefing the NACoA volunteers who conducted these follow-up calls, it became clear that community-based treatment staff feel overwhelmed trying to provide services to their clients. Many stated that they view surveys and other measurement instruments as an interruption in their service rather than a way to have their voice heard in the development of new materials. Others indicated that they were too busy to respond to surveys and some stated they would respond only if it were necessary for program funding. Findings
Sixty-nine percent of the treatment providers that responded to the survey indicated that they do not offer services to the school-aged children of their clients. Of these, two provided educational or counseling services to preschool children. As shown in Figure 1 on the following page, program cost was cited most frequently as a barrier for development and expansion of programs. Lack of access to appropriate materials and information was relatively infrequently cited as a problem; most treatment providers appear aware that educational resources for the population exist. Client and family resistance were cited as reasons against expansion of existing programs by approximately one-fourth of the providers who have attempted to offer such services. Treatment providers who have not attempted this type of intervention may not consider that their clients and family members may be resistant to participating in this type of educational program. "Other" barriers include inability to be reimbursed for family members with no diagnosis, lack of trained staff or of physical space for sessions, and insufficient clients with children at any given time to produce a cost-effective program. Differences among modalities. As shown in Figure 2 on the next page, providers offering outpatient care were most likely to report services for school-aged children of clients; inpatient and methadone maintenance programs were less likely to offer such services. Types of program. The specific content of the children's programs varied significantly among treatment providers. Most programs with services for children were developed in-house (72%) and provided on site (53%) by treatment program staff (80%). Barely one in ten (9%) of the providers offering educational or support services for children report purchasing a packaged program for this purpose After receiving descriptions of the COSA educational and support services offered by the treatment providers, five general types of program could be identified: • Children's counseling groups, combining education with therapy, constitute the service most often-offered to children of substance abuse patients. The average number of sessions per group ranged from 4-to-36; the average number of sessions attended per child was 6-to-8. One quarter of the children's counseling groups reported using a standard curriculum for the educational components. • Orientation sessions/family education programs are available in many facilities. In these programs, children receive education about addiction, its treatment, and the recovery process. Providers reported that the number of such orientation sessions offered range from 1-to-36. Most were offered once-per-week for 4-to-6 weeks. Not all children participate, even when such programs are offered, and COSAs typically attend two to six sessions. • Support groups tend to emphasize interaction among the children of substance-abusing patients. They also tend to minimize formal education and few use a standard curriculum. Support groups ranged from 6-to-24 sessions; although there was wide variation in the number of sessions attended and the percentage of children participating, children typically attended approximately 12 sessions. • Assessment and referral services identify the children's needs for educational and support activities conducted outside of the treatment environment. • Parenting skills education programs benefit children of treatment clients, even when children are not directly involved in the program. The majority of these programs (52%) reported using a set curriculum, unlike other types of COSA-related education and support services offered by treatment providers. The number of sessions ranged from one to 8. Most of the parenting programs did not include children as participants. Figure 3 on the following page illustrates disparities among the modalities of treatment providers offering educational and support services for children of substance-abusing patients. A majority of all providers offering COSA-related services provided counseling services for children. Providers with outpatient components typically offered additional evaluation and referral services for children of substance-abusing clients; inpatient only programs were less likely to offer such services. Multiple modality treatment providers also most frequently offered orientation for patients' family members. In contrast, inpatient providers often provided parenting skills education; outpatient providers and multiple modality providers were less likely to offer such services. Linkages to Other Services. Approximately one provider in five offering services for the children of addicted parents used referrals or contracted out for the services. Additionally: • 59% referred out for mental health counseling for the children. • 46% referred out for family violence programs. • 35% employed referrals to student assistance services, Staff and training issues. Many respondents included reference to staff availability and training as a barrier to starting or expanding a program. Very few programs (7%) made use of trained volunteers recruited from the community or contracted services out (6%). Funding sources. As noted earlier, many addiction treatment providers reported barriers to service delivery resulting from the cost of children's educational and support programs or or from difficulties to obtaining reimbursement. Providers who offered the services nevertheless reported diverse funding sources for their programs, as shown in Figure 4 below. Evaluations and quality control. Nearly one-third (31%) of providers reporting programs for children of clients indicated they have been formally evaluated. However, it is not clear whether all of the providers understood formal evaluation to mean more than state accreditation. Forty-two percent reported that there is an in-house staff evaluation process in place for the children’s program. An even larger number of providers (68%) reported a mechanism for client feedback and roughly half collected feedback from both parent and child. Discussion The primary finding is that fewer than one-third of the addiction treatment programs responding to the survey provide services to the school-aged children of their adult patients, despite general agreement that educational and supportive services for this population are important for prevention of future problems. Most of the programs provided are developed in-house and provided by the staff on-site, contributing to highly inconsistent content and extent of the services offered. This inconsistency makes it very difficult to measure or evaluate program objectives and outcomes, and indicates a strong need for the dissemination of core materials, with clear goals and objectives to best serve this population. Funding was found to be the most frequently-cited barrier to program implemen-tation or expansion. Clearly, one way to improve the situation is to change the funding mechanisms so that addiction is recognized as a family issue rather than an individual disease. Many public sector programs understand the family paradigm, but our individually-focused system of private healthcare financing continues to create a serious barrier to providing services from this model. The priority placed on individual recovery from addictive substance potentially delays efforts to address the mental health and family dynamic issues so often associated with addiction. In effect, treatment providers often want their patients to concentrate on their recovery from substance dependence first and respond to "distracting" family concerns only after recovery is significantly advanced. This focus on the individual also interferes with addressing relapse triggers from the stress of parenting and working with families to break the intergenerational cycle of addiction. However, more holistic multimodal and outpatient treatment providers appear to recognize these issues in their willingness to offer children's programs. As noted earlier, many respondents indicated that lack of trained staff, or time and resources to train staff, created barriers to development or expansion of COSA educational and support services. Program directors could be encouraged to explore alternatives to hiring new staff. It should be noted that some programs have been successful in having educational support groups run by trained volunteers from the community. This approach exposes clients' children to additional healthy adults who can focus on their needs without taking away attention from the needs of the parents and encourages outreach into the community that can generate other opportunities for collaboration. There is a need for adequate training, guidance, and well-defined program objectives and criteria to ensure that volunteers are able to provide consistent, high-quality support care. The Center for Substance Abuse Prevention has an Outreach to Children of Parents in Treatment (OCPT) project in early development. Since sixty percent of those who responded were interested in obtaining the materials to implement or expand a program, these centers could be considered for inclusion in the pilot testing phase of the OCPT resource. Citations Adger, H. (1998) Children in alcoholic families:Family dynamics and treatment issues. In: Principles of Addiction Medicine, Second Edition. Chevy Chase, MD: American Society of Addiction Medicine. pp. 1111-1114. Huang, LX, Cerbone, FC, and Gfroerer, JC (1998) Children At Risk Because of Parental Substance Abuse. Analyses of Substance Abuse and Treatment Need Issues. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Johnson, JL, and Leff, M (1999) Children of substance abusers: Overview of research findings. Pediatrics 103(5):1085-1099. Kumpfer, KL (1992) Strengthening America's Families. Rockville, MD: Office of Juvenile Justice and Delinquency Prevention, US Department of Justice. National Directory of Drug Abuse and Alcoholism Treatment Programs (1996) Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Pieper, D, and Zimmerman, JC (1996) Children from chemically-dependent families: An evaluative study. Journal for the Professional Counselor 11(2):35-40. |
