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Increasing Family Reunification for Substance‐Abusing Mothers and Their Children: Comparing Two Drug Court Interventions in Miami

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This study provides a quasi-experimental test of 80 consecutive enrollments in the Miami-Dade (Florida) Dependency Drug Court in order to examine the impact of a family-based and gender specific intervention, Engaging Moms Program (EMP), on drug court graduation and family reunification. We compared EMP with case management services (CMS). Results indicated that 72% of mothers in the EMP graduated from drug court, and 70% were reunified with their children. In contrast, 38% of mothers receiving CMS graduated from drug court, and 40% were reunited with their children. EMP, then, appears to be a promising family drug court intervention.
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Increasing Family Reunification for
Substance-Abusing Mothers and Their Children:
Comparing Two Drug Court Interventions
in Miami
By Gayle A. Dakof, Judge Jeri B. Cohen, and Eliette Duarte
ABSTRACT
This study provides a quasi-experimental test of 80 consecutive enrollments in
the Miami-Dade (Florida) Dependency Drug Court in order to examine the impact of
a family-based and gender specific intervention, Engaging Moms Program (EMP), on
drug court graduation and family reunification. We compared EMP with case man-
agement services (CMS). Results indicated that 72% of mothers in the EMP gradu-
ated from drug court, and 70% were reunified with their children. In contrast, 38%
of mothers receiving CMS graduated from drug court, and 40% were reunited
with their children. EMP, then, appears to be a promising family drug court
intervention.jfcj_1033 11..23
Parental substance abuse has been associated with numerous negative consequences
for children, including recurring maltreatment (Walsh, MacMillan, & Jamieson, 2003;
Gayle A. Dakof, Ph.D, is a Research Associate Professor at the University of Miami Miller School of
Medicine, Department of Epidemiology and Public Heath, Center for Treatment Research on Adolescent
Drug Abuse. Dr Dakof specializes in the development and testing of family-based treatment models directed
toward preventing and treating adolescent substance abuse and delinquency and child maltreatment.
Correspondence: gdakof@med.miami.edu.
Judge Jeri B. Cohen, J.D., has been a Circuit Court Judge for the State of Florida Eleventh Judicial
Circuit for over ten years. In 1999, Judge Cohen founded the Miami-Dade Dependency Drug Court; she also
initiated the Miami-Dade County Recidivism Project in DUI court.
Eliette Duarte, M.S., has worked with the Miami-Dade Dependency Drug Court since its founding
in 1999, and is currently the dependency drug court coordinator. She trains and supervises drug court
specialists, serves as team liaison, and is responsible for drug court quality control procedures.
Authors’ Note: Completion of this research was supported by the State of Florida Department of
Children and Families and State of Florida Eleventh Judicial Circuit Court. The authors thank Deborah
Robinson, Sharon Abrams, and Paul Indelicato for facilitating this research. We also thank Hua Li for help
in data analysis.
Juvenile and Family Court Journal 60, no. 4 (Fall) 11
© 2009 National Council of Juvenile and Family Court Judges
Wolock & Magura, 1996; Wolock, Sherman, Feldman, & Metzger, 2001); long stays in
foster care (Dore, Doris, & Wright, 1995; Zuravian & DePanfilis, 1997) and low rates of
family reunification (U.S. General Accounting Office, 2003); economic deprivation,
instability in the home, and poor childrearing practices (Dishion, Patterson, & Reid,
1988; Magura & Laudet, 1996; Mayes & Bornstein, 1996; Wills, Schreibman, Benson, &
Vaccaro, 1994); exposure to domestic violence (VanDeMark et al., 2005); and impaired
physical and behavioral development and mental health and substance use disorders (e.g.,
Cohen & Brook, 1987; Conners et al., 2004; Luthar, Cushing, Merikangas, & Roun-
saville, 1998; Singer et al., 2002). Not surprisingly, large numbers of child maltreatment
cases involve drug-using parents (Semidei, Radel, & Nolan, 2001; Wolock et al., 2001;
Young, Gardner, & Dennis, 1998), many of whom continue using drugs even while under
court supervision (Murphy et al., 1991).
Federal child welfare laws, most notably the Adoption and Safe Families Act
(ASFA) of 1997, and state statutes implementing those and other changes have dramati-
cally changed the operation of juvenile/family courts. Courts, for example, have been
required to take a more active role in developing service plans for families and in ensuring
that each child is placed in a permanent and stable home (Hardin, 1996; Harrell &
Goodman, 1999). During the reunification process, parents are court-ordered to complete
various programs designed to address the problems that brought the child to the
attention of state authorities. If parents successfully complete the programs, their chil-
dren may be returned to them. If not, and reunification is not possible, courts must
continue permanency planning efforts for the child, which may include termination of
parental rights to free the child for adoption. ASFA also shortened the time for the
permanency determination from 18 months to 12 months and, as a result, the perma-
nency planning hearing must be held within 12 months after the finding of dependency.
The demands ASFA placed on child welfare systems and juvenile/family courts,
combined with the growing numbers of substance-abusing parents involved in child
welfare proceedings, have strained the systems’ ability to successfully resolve cases in the
expeditious manner required by law. Acknowledging the systemic changes, Magura and
Laudet (1996) concluded that “a paradigmatic shift is taking place whereby the child
welfare field is recognizing the need to deal with substance abuse as it relates to issues of
family dynamics and early childhood interventions” (p. 211). Many courts have looked at
the promising results from criminal drug courts (Belenko, 2001), and have turned to
dependency drug courts as the answer (Harrell & Goodman, 1999; Semidei et al., 2001).
As a result, dependency drug courts have multiplied.
Drug courts, with their emphasis on recovery and personal transformation in lieu of
punishment, embody the principles of therapeutic jurisprudence (Belenko, 1998;
Goldkamp & Weiland, 1993; Wexler & Winick, 1991). A court that adheres to those
principles uses the social sciences to guide judicial programs and decisions designed to
rehabilitate the participant. For example, the core elements of drug courts include
comprehensive assessment of service needs, regular use of drug testing, linking the
participant to services, and a non-adversarial relationship between the parties.
As of June 2009, there were over 250 dependency drug courts operating in the
United States (Bureau of Justice Assistance, 2009). Although there is significant enthu-
12 | JUVENILE AND FAMILY COURT JOURNAL / Fall 2009
siasm for dependency drug courts (Edwards & Ray, 2005), there have been few investi-
gations of their effectiveness (Belenko, 2001; Green, Furrer, Worcel, Burrus, & Finigan,
2009). A small number of evaluations indicate that the dependency drug court has
promise (Boles, Young, Moore, & DiPirro-Beard, 2007; Green, Furrer, Worcel, Burrus, &
Finigan, 2007; Haack, Alemi, Nemes, & Cohen, 2004) even though there are wide
variations between drug courts (Green et al., 2009). As a result, the verdict is still out
about the general effectiveness of dependency drug courts and the components of effective
drug courts in particular.
Family/dependency drug courts were established to assist courts and child welfare
agencies in their efforts to help parents overcome their drug dependency so they can
provide a healthy and safe environment for their children and avoid losing their parental
rights. Each family/dependency court has unique features, but most share basic compo-
nents. For example, to graduate, participants must have successfully completed substance
abuse treatment; have a specified period of continuous abstinence; show evidence of a safe
and stable living situation; spend a substantial period adequately performing the parent
role; and have a life plan in place (e.g., employment, education, vocational training;
Cooper & Bartlett, 1998).
Moreover, most family/dependency drug courts employ court caseworkers who
provide case management services to the participants, including referrals to treatment
and other court-ordered services, developing a recovery service plan, and monitoring and
reporting clients’ ongoing progress to the court. Although the influential role of the drug
court judge and substance abuse treatment program to positive outcomes has been noted
(Edwards & Ray, 2005; NADCP, 1997), little attention has been focused on intervention
models, drug court caseworkers, and the quality of their work.
One intervention program, the Engaging Moms Program (EMP), was initially
conceived as a brief, family-oriented intervention aimed at facilitating treatment for
mothers with substance-exposed infants. An initial study of the approach (Dakof et al.,
2003) indicated that it successfully facilitated the entry and retention of mothers who
were abusing drugs but not seeking drug treatment. For example, 88% of mothers
randomly assigned to EMP enrolled in drug treatment programs as compared to 46% of
mothers assigned to the usual community services. Further, 67% of mothers in EMP
remained in treatment for at least four weeks as compared to a 38% retention rate among
the control group of mothers. Based on these findings and the interest they generated
among child advocates in Miami, in 2001 the EMP was expanded in scope and duration
and adapted for use in the dependency drug court in the Eleventh Judicial Circuit in
Miami-Dade County, Florida. Up until then, the Court had been using a standard
recommended intervention protocol that relied on extensive judicial oversight and
standard court-based case management services (Cooper & Bartlett, 1998; Harrell &
Goodman, 1999; Monchick, Scheyett, & Pfeifer, 2006; NADCP, 1997).
The aim of this study was to examine the effectiveness of the EMP when compared
to standard family/dependency drug court case management services (CMS). It was
hypothesized that significantly more mothers involved in EMP, as compared to mothers
receiving CMS, would: (a) graduate from the family/dependency drug court; and (b) be
reunified with their children.
Dakof et al. / INCREASING FAMILY REUNIFICATION | 13
METHOD
Design and Procedures
Once the Dependency Drug Court decided to adopt EMP to replace standard case
management, independent of any research goals, we took the opportunity to analyze
extant court record data on child welfare outcomes on mothers enrolled in drug court
prior to and then after the programmatic change. This study is, as a result, a natural
experiment of 80 consecutive admissions into dependency drug court. All women who
were enrolled in drug court during the target two years were included in the analysis.
Enrollment covered a two-year period, and follow-up was conducted 15 months after a
mother’s entry into drug court. The first phase was the 12-month Case Management
Phase, which consisted of dependency drug court-based caseworkers delivering a standard
case management model, (N=37), and the second 12-month period, the Engaging
Moms Phase, consisted of dependency drug court-based caseworkers delivering the
alternative EMP model (N=43). After obtaining approval from the Institutional Review
Board, data for the study was gathered from extant court records by court personnel who
then provided the first author a de-identified, completely anonymous database.
Intervention Groups
Mothers in both phases had the same judge and were expected to follow the same
basic dependency drug court requirements: i.e., completing drug treatment and remain-
ing drug free; completing parenting classes and demonstrating adequate parenting skills;
participating in educational/vocational training, domestic violence, or other counseling
as ordered by the judge; obtaining adequate and stable housing; and being gainfully
employed or in school. There were no policy, legal, or structural changes during the
course of the study other than the implementation of the Engaging Moms Program.
The basic dependency drug court program that was provided to all mothers was
organized into four phases, and a mother progressed through the phases based on her level
of substance abuse treatment and compliance with court orders. For example, during the
first month of dependency drug court, mothers were required to attend weekly drug court
hearings, and if reports to the court indicated that the mother was progressing well,
attendance at court hearings was typically reduced to twice monthly. During the second
phase of the program, which lasted three months, clients continued to attend twice
monthly hearings, but in the next three-month phase, attendance at hearings was reduced
to once a month. During the fourth and final phase, which extended to graduation from
the drug court program, the mothers attended hearings every 6 to 12 weeks. The
multi-phased process included a collaborative team approach that involved the court
caseworkers, child welfare workers, treatment providers, parent educators, and other
social and health care service providers as needed. Drug court caseworkers had weekly
contact with their clients, either in person or by telephone through phase 2, then
bi-weekly in phase 3, and monthly in phase 4. Workers were available more frequently
on an as-needed basis. The caseload for drug court caseworkers was between 10-15 active
14 | JUVENILE AND FAMILY COURT JOURNAL / Fall 2009
cases. The only difference between the CMS and EMP groups was the working relation-
ship between the drug court caseworker and the mothers; all other aspects of the
programs, including overall requirements, phases, and sanctions and rewards, were
exactly the same.
Drug Court Caseworkers. Seven women, all with Masters Degrees in counseling or
social work (four White Non-Hispanic and three Hispanic), delivered the Case Manage-
ment Services program. Five of the seven (two White Non-Hispanic and three Hispanic)
then delivered the Engaging Moms Intervention. Overall, the CMS caseworkers had an
average of 5.86 years of experience in the field before they engaged in delivering services
and the EMP caseworkers had 5.8 years of prior experience. The caseworkers were trained
by experts in court case management and EMP before delivering the interventions, and
they participated in one booster training each year. All caseworkers received weekly
supervision from the drug court coordinator.
Case Management Services (CMS) provided by the court was consistent with standard
dependency/family drug court models (e.g., Boles et al., 2007), and provided five key case
management functions: assessment, planning, linkage, monitoring, and advocacy (Mon-
chick et al., 2006). The overall objective was to assess needs, engage in collaborative
intervention planning, provide referral to suitable drug abuse treatment and other
services, coordinate the system of care providing services to the mother, closely supervise
and monitor compliance with court orders, and advocate for the mother with service
providers. Case managers served as liaisons between the court, substance abuse treatment
providers, child welfare, and the client. The case manager was responsible for making
referrals to treatment and other court-ordered services, developing a recovery service plan,
monitoring and reporting clients’ ongoing progress to the court, reducing any barriers to
the delivery of treatment and other services, and providing emotional and practical
support to the mother.
Engaging Moms Program (EMP) was adapted for use in a family drug court context. It
is a gender-specific and family-based intervention. EMP was designed to help mothers
succeed in drug court by helping them comply with all court orders, including attending
substance abuse and other intervention programs (e.g., domestic violence counseling,
parenting classes, etc.), attending court sessions, remaining drug free, and demonstrating
the capacity to parent their children. EMP caseworkers conducted individual and conjoint
sessions with the mother and her family, focusing on six core areas of change: (1) motivation
and commitment to succeed in drug court and to change her life; (2) the emotional
attachment between the mother and her children; (3) relationships between the mother and
her family of origin; (4) parenting skills; (5) mother’s romantic relationships; and (6)
emotional regulation, problem solving, and communication skills. The EMP theory of
change believes that change in the six core areas is essential if the drug-using mother is to
achieve sobriety and be able to adequately care for her children.
EMP caseworkers facilitate change in the six core areas by conducting a series of
integrated individual and family sessions (e.g., individual sessions with mother, indi-
vidual sessions with family/partner, family and couple sessions, etc.). The intervention is
organized in three stages: Stage 1: Alliance and Motivation; Stage 2: Behavioral Change;
and Stage 3: Launch to an Independent Life.
Dakof et al. / INCREASING FAMILY REUNIFICATION | 15
In Stage 1, the caseworker focuses on two goals: building a strong therapeutic alliance
with the mother and her family and enhancing the mother’s motivation, as well as her
family’s motivation to change. EMP caseworkers provide total support to both the mother
and her family. They empower and validate, highlight strengths and competence, build
confidence in the program, and are very compassionate, loving, and nurturing. To enhance
motivation, the EMP caseworker highlights the pain, guilt, and shame that the mother and
her family have experienced, and the high stakes involved (e.g., losing a child to the child
welfare system) while simultaneously creating positive expectations and hope.
Stage 2 is focused on behavioral change in both the mother and her family/spouse.
EMP has several goals for this stage. First, caseworkers enhance the emotional attachment
between the mother and her children by working individually with the mother to help
her explore her maternal role. There are also sessions between the mother and her children
designed to enhance her commitment to her children. Equally important, caseworkers
work to enhance the attachment between the mother and her family of origin and/or
spouse by helping the family restrain negativity and offer practical and emotional support
to the mother. Considerable attention is devoted to repairing the mother’s relationship
with her family which frequently has been damaged by past hurts, betrayals, and
resentments. Romantic relationships, typically with men, have often been a source of pain
and distress for many of the mothers involved in the child welfare system. The EMP
program addresses those relationships by helping the mother conduct a relationship life
review, including examining tensions between having a relationship and being a mother.
The caseworkers help the mother examine the relationship choices she has made, and
continues to make, teaching her how to make better decisions for herself and her children.
EMP caseworkers also help the mother deal with slips, mistakes, setbacks, and relapses in
a non-punitive and therapeutic manner (i.e., forward looking). Finally, in Stage 2, EMP
caseworkers help facilitate the mother’s relationship with court personnel (judge, child
welfare workers, and attorneys) and treatment or other service providers. The EMP
caseworker conducts “shuttle diplomacy” between the mother and service providers to
prevent and resolve problems and to ensure that the mother is taking full advantage of
the provided services. Similarly, the caseworkers facilitate therapeutic jurisprudence
in the courtroom by preparing mothers for court appearances and advocating for her
before the judge and at the weekly drug court case reviews.
In Stage 3, the final launching phase, the EMP caseworker helps the mother prepare
for independence by developing a practical and workable routine for everyday life;
addressing how the mother will balance self care, children and work; outlining a plan for
dealing with common emergencies with children and families; developing a detailed
relapse prevention plan; and addressing how the mother will deal with potential prob-
lems, mistakes, and setbacks.
Data Source
Data for this study were extracted by drug court personnel from extant family drug
court records on 80 women enrolled in the Miami Dependency Drug Court, and a
de-identified dataset was provided for data analysis.
16 | JUVENILE AND FAMILY COURT JOURNAL / Fall 2009
Participant characteristics. Information on the following characteristics was collected:
age; race/ethnicity (Black non-Hispanic, White non-Hispanic, Hispanic, other); number
of children; educational attainment (less than high school, completed high school, more
than high school); public assistance status; marital status (never married currently
married or partnered, divorced, separated, or widowed); drug of choice (cocaine, mari-
juana, alcohol, polydrug); age at first drug use; age at birth of first child; lifetime arrests;
lifetime physical abuse; and lifetime sexual abuse.
Graduation from family drug court and reunification with children. Drug court docu-
ments were reviewed to determine whether the mother graduated from the drug court
and was reunified with any of her children. Decisions regarding graduation and reunifi-
cation are made by the drug court judge, and hence are subject to the ordinary biases
operating in all judicial decision making. The dependency drug court team, consisting of
the CMS or EMP caseworker, child welfare workers, substance abuse treatment providers,
and others, makes recommendations to the judge about graduation and reunification. The
judge, in reviewing the mother’s history and progress, makes the final decision whether
a mother should or should not graduate from the drug court program. Child welfare
outcomes were categorized into one of three possible categories: (1) reunification, (2)
voluntary surrender, or (3) termination of parental rights.
RESULTS
Participants
Data extracted from administrative court records (See Table 1) indicate that
mothers involved in Dependency Drug Court were primarily Black or Hispanic,
in their 30s, low income, and with little education. On average, they had
approximately three children and were 21 at the birth of their first child. The majority
were unmarried. Many of the mothers had a history of trauma as a consequence of
being a victim of physical and/or sexual abuse and/or being arrested. In most cases, the
drug of choice was cocaine or crack. The information suggests that the women in the
program had limited resources and considerable challenges, which is similar to par-
ticipants in other studies examining substance-abusing and child welfare-involved
parents (e.g., Dawson & Berry, 2002; Maluccio & Ainsworth, 2003; Walsh et al.,
2003).
To determine whether the CMS and EMP groups were equivalent at baseline,
one-way analyses of variance (ANOVA) were conducted for the continuous variables of
age, number of children, age at first drug use, and age at birth of first child. Chi-square
tests were used for the categorical variables of race/ethnicity, education, public assistance,
marital status, drug of choice, lifetime physical abuse, and lifetime sexual abuse. There
were no statistically significant differences between the two groups on any of these
variables at baseline. Thus, even though the study was not a randomized design, the two
groups were equivalent at baseline on key demographic variables.
Dakof et al. / INCREASING FAMILY REUNIFICATION | 17
Dependency Drug Court Graduation and Family Reunification Analyses
Hypothesis 1 predicted that mothers in the EMP would be significantly more likely
to graduate from family drug court than mothers in the case management program. As
shown in Table 2, this hypothesis was supported (c2(1, N=80) =9.43, p=.002), with
72% of the mothers receiving EMP successfully graduating from dependency/family
drug court compared to 38% of the mothers receiving CMS.
Hypothesis 2 predicted that mothers in EMP would be significantly more likely to
be reunified with their children 15 months after entry in the dependency drug court than
mothers participating in standard case management. As shown in Table 2, this hypoth-
esis was also supported (c2(2, N=80) =7.59, p=.022), with 70% of the mothers
TABLE 1
Baseline Participant Characteristics for Each Engagement Group
Characteristics
Dependency Drug Court
Engaging Moms Services as Usual
n(%) / M (SD) n(%) / M (SD)
Race/Ethnicity
Black 26 (60) 20 (54)
Hispanic 12 (28) 10 (27)
White, non-Hispanic 3 (7) 6 (16)
Other 2 (5) 1 (3)
Number of Children 3.5 (1.9) 3.1 (1.9)
Education
<High School 27 (63) 20 (54)
High School Graduate 13 (30) 13 (35)
>High School 3 (7) 4 (11)
On Public Assistance 34 (79) 33 (89)
Marital Status
Never Married 26 (61) 19 (52)
Married or with Partner 7 (16) 9 (24)
Divorced/Separated/Widowed 10 (23) 9 (24)
Drug of Choice
Cocaine/Crack 23 (53) 24 (65)
Marijuana 6 (14) 1 (3)
Polydrug (3 or more) 14 (33) 12 (32)
Age First Drug Use 18 (5.4) 19.6 (5.8)
Age First Baby Born 21 (5.9) 21.5 (6.0)
Lifetime Arrests 2.6 (3.5) 2.5 (4.1)
Lifetime Physical Abuse 19 (53) 16 (44)
Lifetime Sexual Abuse 13 (36) 10 (28)
18 | JUVENILE AND FAMILY COURT JOURNAL / Fall 2009
receiving EMP being reunited with their children 15 months after entry into drug court
compared to 40% of the mothers receiving CMS.
DISCUSSION
The results demonstrate that EMP has considerable promise in fostering reunifi-
cation for substance-involved mothers enrolled in dependency drug court. Seventy-two
percent of the mothers graduated from drug court, and 70% were reunified with their
children.
Drug court graduation rates for the Engaging Moms Program compare favorably
with drug court graduation rates generally, which range from 23% (Vito & Tewksbury,
1999) to 57% (Sechrest & Shicor, 2001), averaging about 47% (Belenko, 2001). The
15-month family reunification rates of 70% compare favorably with family reunification
rates among drug-using and child welfare-involved mothers which have historically been
under 25% (Choi & Ryan, 2006; Ryan, Marsh, Testa, & Louderman, 2006), and family
drug courts which range from 42% to 91% (Green et al., 2009).
Even though the results of this study suggest that EMP shows promise as a
family/dependency drug court intervention, the study has several major limitations and
should be considered only as a hypothesis-generating study and not a hypothesis-testing
study. First, it was a naturalistic study, taking advantage of a programmatic shift within
the dependency drug court and essentially examined whether the programmatic changes
(implementing EMP) showed better child welfare outcomes than standard drug court
case management practices. Thus, its non-randomized design contains serious threats to
internal validity. Also, the judge was not blind to the interventions by court caseworkers
which could possibly bias the outcomes toward EMP. It is possible that since the judge
was responsible for bringing EMP to the dependency drug court, and perhaps expected
TABLE 2
Graduation from Family Drug Court and Family Reunification
Dependency Drug Court
Engaging Moms Services as Usual
n(%) n(%)
Drug Court Graduation
Graduate 31 (72) 14 (38)
Did not Graduate 12 (28) 23 (62)
Family Reunification
Reunified 30 (70) 15 (40)
Voluntary Surrender 4 (9) 4 (11)
Filed for TPR 9 (21) 18 (49)
Dakof et al. / INCREASING FAMILY REUNIFICATION | 19
better outcomes, she may have been biased toward graduating mothers from drug court
and reunifying them with their children. It is also important to recognize that the judge
making the decisions examined in this study was also the founder of the dependency drug
court in Miami, so if there was any bias in favor of EMP, there would have also been a bias
toward the case management phase because the judge would want to demonstrate that
the dependency drug court could be successful. Although it is likely that there was some
judicial bias for successful results, it is important to recognize that a judge’s first duty is
to protect the children, and it is highly unlikely that a judge would allow reunification
if he or she thought the children would be at risk.
The data were limited to information contained in the court records, which pro-
hibited us from examining factors that might have influenced reunification, such as
domestic violence, mental health disorders, housing, and related factors. Finally, there
were no measures of intervention integrity or quality of the clinical work. Although court
caseworkers received weekly supervision in the model they were implementing, we
cannot know if they were consistently adhering to the models. Also, it is important to
recognize that the five staff who delivered the EMP also delivered the standard case
management, and it is possible that they had better outcomes with EMP, not because of
the nature of the EMP intervention but simply because they were more experienced in
working with the drug court populations and procedures because EMP was implemented
after CMS. Nevertheless, there are very few studies examining permanency and family
reunification in the context of family or dependency drug court, and despite its limita-
tions, this study is a first step to examining how EMP may be well-suited for dependency
drug court settings.
Drug abuse among women with children is a serious social and public health
problem that not only damages the mothers, but also places their children at risk of
abuse, neglect, and myriad social, health, and behavioral problems. Moreover, mothers
involved in the child welfare system who have substance abuse problems are more likely
to have their parental rights terminated than non-drug-using, child welfare-involved
mothers (Marcenko, Kemp, & Larson, 2000). Thus, there is increasing urgency to develop
new ways of working with substance-abusing parents involved in the child welfare
system (Kerwin, 2005; Maluccio & Ainsworth, 2003; Marsh & Cao, 2005; Young et al.,
1998). Efforts to protect children by healing and strengthening their mothers is arguably
the best way to improve child outcomes, especially when considering results which
indicate that substance abuse interventions delivered to parents, even when not directly
targeting the children, have been shown to improve the psychosocial functioning of
children (Kelley & Fals-Stewart, 2002; Moos, Finney, & Cronkite, 1990).
The challenges faced by substance-abusing mothers involved in the child welfare
system are monumental, but the effort seems worthwhile when one considers the impact
of maternal success or failure on the developmental trajectory of their children. Results
from this and other studies (e.g., Marsh, Ryan, Choi, & Testa, 2006; Grella & Greenwell,
2004) suggest that mothers need comprehensive and intensive interventions to overcome
their addiction and other life problems. Thus, any intervention that facilitates recovery
and family reunification must be further evaluated and replicated. Even though depen-
dency drug courts have an increasingly important role to play in combating these
20 | JUVENILE AND FAMILY COURT JOURNAL / Fall 2009
problems and promoting healthy families, there are few well-specified intervention
programs aimed at drug-abusing mothers suitable for use in these drug courts. The
results from this pilot study and other evaluations (Green et al., 2009) suggest that not
all dependency drug court models are equal, and it is imperative that we begin to discover
the key ingredients of effective dependency drug courts. The Engaging Moms Depen-
dency Drug Court Model has the potential to enhance a mother’s chances for reunifica-
tion, consistent with ASFA timelines, despite the challenges of substance abuse, poverty,
mental health issues, and trauma. If the promising results presented here are replicated
in more highly controlled studies, the impact on an under-served population could be
considerable, and could promote a stronger and more effective partnership among the
judiciary, child welfare caseworkers, and treatment providers.
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... The final sample of six studies included two RCTs (Dakof et al., 2010;Donohue et al., 2014) and four non-randomised controlled studies (Dakof et al., 2009;Harwin et al., 2018;Schaeffer et al., 2013;Worcel et al., 2008). Although a controlled study, Schaeffer et al. (2013) reported some secondary outcomes as pre-post comparisons in the intervention group. ...
... All the six studies combined substance use treatment services with related family-oriented services for both the mothers and their children. Dakof et al. (2009Dakof et al. ( , 2010) used a multidimensional family therapy-based programme called Engaging Mothers Program (EMP) to motivate the mothers to attend their treatment and court sessions. An EMP-trained counsellor facilitated this change through a series of individual and family sessions, which targeted the mothers' motivation, commitment, problem solving, and parenting skills. ...
... Due to the lack of randomisation and potential selection of participants, particularly the matched control groups, the risk of bias was increased to at least a moderate level for all four non-randomised controlled studies (Dakof et al., 2009;Harwin et al., 2018;Schaeffer et al., 2013;Worcel et al., 2008). However, Worcel et al. (2008) was assessed to have a high risk of bias due to inequivalent groups at baseline, which indirectly introduced potential confounds to the study. ...
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Approximately half of mothers receiving substance use treatment are involved with childcare proceedings. This review aims to determine whether integrated treatment programmes for mothers with substance use problems are effective in preventing out-of-home placement (temporally/permanent) and influencing other maternal factors such as patterns of substance use, treatment completion and parenting behaviours. Six trials were identified—two randomised controlled trials and four non-randomised controlled studies. The pooled sample of participants was 1717. The results showed that mothers who participated in integrated treatment programmes were significantly less likely to have the children removed from their care (Odds Ratio (OR) = 0.40, 95% CI = 0.27, 0.61), more likely to complete substance use treatment ( OR = 3.01, 95% CI = 1.79, 5.06), and more likely to reduce their alcohol consumption (Standardised Mean Difference (SMD) = −0.40, 95% Cl = −0.78, −0.01) and drug use ( SMD = −0.30, 95% CI = −0.53, −0.07). However, non-significant reductions were observed for parent–child conflict ( SMD = −0.35, 95% CI = −0.72, 0.03) and child abuse risk ( SMD = −0.03, 95% CI = −0.36, 0.31). While the findings from this review suggest that mothers involved in integrated treatment programmes could potentially be less likely to experience out-of-home child placements and more likely to improve substance use treatment outcomes, little evidence exists for the effectiveness of these interventions. Further research, particularly high-quality RCTs, is required to demonstrate and persuade health and public policy on the far-reaching value of the integrated approaches.
... • In most programs, a major emphasis is placed on referral to specialized resources available in the community (e.g. comprehensive services, liaison with the local addiction center) 4,5,7,11,12,24 ; on caseload reduction 7,9,10,21,24,26 and strength-based approach targeting the development of the alliance between parents and casemanager 20,22 • Many programs, mostly in the US, are adapted to the many specific needs of their community: ...
... • Parental substance abuse 4,7,11,12,27 : Involve a collaboration between CPS, court, CSAs, to bring intensive judicial supervision, integrated treatment, drug testing, and rewards or punishments based on compliance with treatment; ...
... The two RCTs, 413,415 and one quasi-experimental study, 420 investigated the impact of the Engaging Moms Program (EMP; n range: 62-103), a 12 to a 15-month program of family support in addition to the standard FDAC content. Of these, one RCT, 413 and quasi-experimental study, 420 showed that a brief 8-week EMP intervention resulted in significantly higher treatment engagement of problematic parents at 3-months follow-up, compared to regular community support. ...
... The two RCTs, 413,415 and one quasi-experimental study, 420 investigated the impact of the Engaging Moms Program (EMP; n range: 62-103), a 12 to a 15-month program of family support in addition to the standard FDAC content. Of these, one RCT, 413 and quasi-experimental study, 420 showed that a brief 8-week EMP intervention resulted in significantly higher treatment engagement of problematic parents at 3-months follow-up, compared to regular community support. However, there were no significant differences in completion rates of treatments. ...
... ndrews, Motz et al. (2018) conducted a retrospective chart review of a comprehensive programme for substance misusing mothers (n=160) in Toronto, Canada, finding antenatally referred mothers stayed engaged in the service longer than those referred postnatally: suggesting a critical time for engaging mothers with children at increased risk of abuse.Dakof, Cohen et al. (2009) evaluated a comprehensive court-based programme for mothers who abuse drugs (n=80), the Engaging Moms ...
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... ■ ■ Deliver individual counseling to parents or guardians on a weekly basis for at least the first phase of the program (Worcel et al., 2007). (Dakof et al., 2009(Dakof et al., , 2010(Dakof et al., , 2015, Functional Family Therapy (Datchi & Sexton, 2013), and Multisystemic Therapy (Henggeler et al., 2006;Swenson et al., 2009). ■ ■ Deliver counseling and case management services in participants' homes when indicated (Dauber et al., 2012;Henggeler et al., 2006). ...
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Background: Parental substance use is a substantial public health and safeguarding concern. There have been a number of trials of interventions relating to substance-using parents that have sought to address this risk factor, with potential outcomes for parent and child. Objectives: To assess the effectiveness of psychosocial interventions in reducing parental substance use (alcohol and/or illicit drugs, excluding tobacco). Search methods: We searched the following databases from their inception to July 2020: the Cochrane Drugs and Alcohol Group Specialised Register; CENTRAL; MEDLINE; Embase; PsycINFO; CINAHL; Applied Social Science (ASSIA); Sociological Abstracts; Social Science Citation Index (SSCI), Scopus, ClinicalTrials.gov, WHO ICTRP, and TRoPHI. We also searched key journals and the reference lists of included papers and contacted authors publishing in the field. Selection criteria: We included data from trials of complex psychosocial interventions targeting substance use in parents of children under the age of 21 years. Studies were only included if they had a minimum follow-up period of six months from the start of the intervention and compared psychosocial interventions to comparison conditions. The primary outcome of this review was a reduction in the frequency of parental substance use. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Main results: We included 22 unique studies with a total of 2274 participants (mean age of parents ranged from 26.3 to 40.9 years), examining 24 experimental interventions. The majority of studies intervened with mothers only (n = 16; 73%). Heroin, cocaine, and alcohol were the most commonly reported substances used by participants. The interventions targeted either parenting only (n = 13; 59%); drug and alcohol use only (n = 5; 23%); or integrated interventions which addressed both (n = 6; 27%). Half of the studies (n = 11; 50%) compared the experimental intervention to usual treatment. Other comparison groups were minimal intervention, attention controls, and alternative intervention. Eight of the included studies reported data relating to our primary outcome at 6- and/or 12-month follow-up and were included in a meta-analysis. We investigated intervention effectiveness separately for alcohol and drugs. Studies were found to be mostly at low or unclear risk for all 'Risk of bias' domains except blinding of participants and personnel and outcome assessment. We found moderate-quality evidence that psychosocial interventions are probably more effective at reducing the frequency of parental alcohol misuse than comparison conditions at 6-month (mean difference (MD) -0.32, 95% confidence interval (CI) -0.51 to -0.13; 6 studies, 475 participants) and 12-month follow-up (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.03; 4 studies, 366 participants). We found a significant reduction in frequency of use at 12 months only (SMD -0.21, 95% CI -0.41 to -0.01; 6 studies, 514 participants, moderate-quality evidence). We examined the effect of the intervention type. We found low-quality evidence that psychosocial interventions targeting substance use only may not reduce the frequency of alcohol (6 months: SMD -0.35, 95% CI -0.86 to 0.16; 2 studies, 89 participants and 12 months: SMD -0.09, 95% CI -0.86 to 0.61; 1 study, 34 participants) or drug use (6 months: SMD 0.01, 95% CI -0.42 to 0.44; 2 studies; 87 participants and 12 months: SMD -0.08, 95% CI -0.81 to 0.65; 1 study, 32 participants). A parenting intervention only, without an adjunctive substance use component, may not reduce frequency of alcohol misuse (6 months: SMD -0.21, 95% CI -0.46 to 0.04, 3 studies; 273 participants, low-quality evidence and 12 months: SMD -0.11, 95% CI -0.64 to 0.41; 2 studies; 219 participants, very low-quality evidence) or frequency of drug use (6 months: SMD 0.10, 95% CI -0.11 to 0.30; 4 studies; 407 participants, moderate-quality evidence and 12 months: SMD -0.13, 95% CI -0.52 to 0.26; 3 studies; 351 participants, very low-quality evidence). Parents receiving integrated interventions which combined both parenting- and substance use-targeted components may reduce alcohol misuse with a small effect size (6 months: SMD -0.56, 95% CI -0.96 to -0.16 and 12 months: SMD -0.42, 95% CI -0.82 to -0.03; 2 studies, 113 participants) and drug use (6 months: SMD -0.39, 95% CI -0.75 to -0.03 and 12 months: SMD -0.43, 95% CI -0.80 to -0.07; 2 studies, 131 participants). However, this evidence was of low quality. Psychosocial interventions in which the child was present in the sessions were not effective in reducing the frequency of parental alcohol or drug use, whilst interventions that did not involve children in any of the sessions were found to reduce frequency of alcohol misuse (6 months: SMD -0.47, 95% CI -0.76 to -0.18; 3 studies, 202 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use at 12-month follow-up (SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants). The quality of this evidence was low. Interventions appeared to be more often beneficial for fathers than for mothers. We found low- to very low-quality evidence of a reduction in frequency of alcohol misuse for mothers at six months only (SMD -0.27, 95% CI -0.50 to -0.04; 4 studies, 328 participants), whilst in fathers there was a reduction in frequency of alcohol misuse (6 months: SMD -0.43, 95% CI -0.78 to -0.09; 2 studies, 147 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use (6 months: SMD -0.31, 95% CI -0.66 to 0.04; 2 studies, 141 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants). Authors' conclusions: We found moderate-quality evidence that psychosocial interventions probably reduce the frequency at which parents use alcohol and drugs. Integrated psychosocial interventions which combine parenting skills interventions with a substance use component may show the most promise. Whilst it appears that mothers may benefit less than fathers from intervention, caution is advised in the interpretation of this evidence, as the interventions provided to mothers alone typically did not address their substance use and other related needs. We found low-quality evidence from few studies that interventions involving children are not beneficial.
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This literature review was commissioned by the Child Safeguarding Practice Review Panel to investigate the evidence for how health professionals can best support parents with children considered to be at high risk of significant harm through abuse or neglect to ensure that safer sleep advice can be clearly understood and embedded in parenting practice. Therefore, this systematic review investigated three areas of the literature: interventions for improving the uptake of safer sleep advice in families with children considered to be at high risk for SUDI, interventions to improve engagement with support services in families with children considered to be at high risk of significant harm through abuse or neglect, and improving our understanding of the parental decision making processes for the infant sleep environment in families with children considered to be at high risk for SUDI.
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