[House Hearing, 105 Congress]
[From the U.S. Government Publishing Office]



 
   PROTECTING CHILDREN FROM THE IMPACTS OF SUBSTANCE ABUSE ON FAMILIES 
                           RECEIVING WELFARE

=======================================================================

                                HEARING

                               before the

                    SUBCOMMITTEE ON HUMAN RESOURCES

                                 of the

                      COMMITTEE ON WAYS AND MEANS
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED FIFTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 28, 1997

                               __________

                             Serial 105-31

                               __________

         Printed for the use of the Committee on Ways and Means


50-489 cc            U.S. GOVERNMENT PRINTING OFFICE
                             WASHINGTON : 1998





                      COMMITTEE ON WAYS AND MEANS

                      BILL ARCHER, Texas, Chairman

PHILIP M. CRANE, Illinois            CHARLES B. RANGEL, New York
BILL THOMAS, California              FORTNEY PETE STARK, California
E. CLAY SHAW, Jr., Florida           ROBERT T. MATSUI, California
NANCY L. JOHNSON, Connecticut        BARBARA B. KENNELLY, Connecticut
JIM BUNNING, Kentucky                WILLIAM J. COYNE, Pennsylvania
AMO HOUGHTON, New York               SANDER M. LEVIN, Michigan
WALLY HERGER, California             BENJAMIN L. CARDIN, Maryland
JIM McCRERY, Louisiana               JIM McDERMOTT, Washington
DAVE CAMP, Michigan                  GERALD D. KLECZKA, Wisconsin
JIM RAMSTAD, Minnesota               JOHN LEWIS, Georgia
JIM NUSSLE, Iowa                     RICHARD E. NEAL, Massachusetts
SAM JOHNSON, Texas                   MICHAEL R. McNULTY, New York
JENNIFER DUNN, Washington            WILLIAM J. JEFFERSON, Louisiana
MAC COLLINS, Georgia                 JOHN S. TANNER, Tennessee
ROB PORTMAN, Ohio                    XAVIER BECERRA, California
PHILIP S. ENGLISH, Pennsylvania      KAREN L. THURMAN, Florida
JOHN ENSIGN, Nevada
JON CHRISTENSEN, Nebraska
WES WATKINS, Oklahoma
J.D. HAYWORTH, Arizona
JERRY WELLER, Illinois
KENNY HULSHOF, Missouri

                     A.L. Singleton, Chief of Staff

                  Janice Mays, Minority Chief Counsel

                                 ______

                    Subcommittee on Human Resources

                  E. CLAY SHAW, Jr., Florida, Chairman

DAVE CAMP, Michigan                  SANDER M. LEVIN, Michigan
JIM McCRERY, Louisiana               FORTNEY PETE STARK, California
MAC COLLINS, Georgia                 ROBERT T. MATSUI, California
PHILIP S. ENGLISH, Pennsylvania      WILLIAM J. COYNE, Pennsylvania
JOHN ENSIGN, Nevada                  WILLIAM J. JEFFERSON, Louisiana
J.D. HAYWORTH, Arizona
WES WATKINS, Oklahoma


Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Ways and Means are also published 
in electronic form. The printed hearing record remains the official 
version. Because electronic submissions are used to prepare both 
printed and electronic versions of the hearing record, the process of 
converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                                                                   Page

Advisory of October 20, 1997, announcing the hearing.............     2

                               WITNESSES

U.S. General Accounting Office, Jane L. Ross, Director, Income 
  Security Issues, Health, Education, and Human Services Division    13

                                 ______

Barth, Richard P., University of California, Berkeley............    43
Center of the American Experiment, Mitchell B. Pearlstein........    77
Children and Family Futures, Nancy K. Young......................    34
Rangel, Hon. Charles B., a Representative in Congress from the 
  State of New York..............................................     7
Reuter, Peter, University of Maryland............................    21
Satel, Sally L., Yale University School of Medicine..............    70
Second Genesis, Inc., Gale Saler, and Judy Ogletree..............    59
Teen Challenge, Inc., Dave Batty.................................    66
Westat, Inc., Nicholas Zill......................................    26

                       SUBMISSIONS FOR THE RECORD

Child Welfare League of America, Inc., statement.................    89
Haymarket Center, Chicago, IL, Ray Soucek, statement.............    91
Legal Action Center, Washington, DC, Gwen Rubinstein, statement..    92
National Association of Alcoholism and Drug Abuse Counselors, 
  Arlington, VA, William D. McColl, statement....................    97
Ramstad, Hon. Jim, a Representative in Congress from the State of 
  Minnesota, statement...........................................    99


  PROTECTING CHILDREN FROM THE IMPACTS OF SUBSTANCE ABUSE ON FAMILIES 
                           RECEIVING  WELFARE

                              ----------                              


                       TUESDAY, OCTOBER 28, 1997

                  House of Representatives,
                       Committee on Ways and Means,
                           Subcommittee on Human Resources,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 3:05 p.m., in 
room B-318, Rayburn House Office Building, Hon. E. Clay Shaw, 
Jr. (Chairman of the Subcommittee), presiding.
    [The advisory announcing the hearing follows:]

ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

                    SUBCOMMITTEE ON HUMAN RESOURCES

                                                CONTACT: (202) 225-1025
FOR IMMEDIATE RELEASE

October 20, 1997

No. HR-8

                  Shaw Announces Hearing on Protecting

              Children From the Impacts of Substance Abuse

                     on Families Receiving Welfare

    Congressman E. Clay Shaw, Jr., (R-FL), Chairman, Subcommittee on 
Human Resources of the Committee on Ways and Means, today announced 
that the Subcommittee will hold a hearing on issues related to 
protecting children from the prevalence and impacts of substance abuse 
on families receiving welfare. The hearing will take place on Tuesday, 
October 28, 1997, in room B-318 of the Rayburn House Office Building, 
beginning at 3:00 p.m.
      
    Oral testimony at this hearing will be from invited witnesses only. 
Witnesses will include representatives of the U.S. General Accounting 
Office, welfare and substance abuse experts, State welfare officials, 
and treatment providers. However, any individual or organization not 
scheduled for an oral appearance may submit a written statement for 
consideration by the Committee and for inclusion in the printed record 
of the hearing.
      

BACKGROUND:

      
    Last year, Congress passed, and President Clinton signed, the new 
welfare reform law (P.L. 104-193) that substantially changed the 
nation's major cash welfare program, now called the Temporary 
Assistance for Needy Families program. The new law established time 
limits on receipt of welfare benefits, set employment and training 
participation requirements, and authorized States to impose sanctions 
on recipients that fail to meet program expectations.
      
    Researchers have identified substance abuse as a potential barrier 
to recipients' successfully transitioning from welfare to work. In 
addition, parental drug use has been linked to child abuse. Estimates 
of drug abuse among welfare recipients vary greatly by the type of 
drug, legal status, and the population studied. However, some 
assessments indicate that the use of illegal drugs is higher among 
welfare recipients than among the general population.
      
    In announcing the hearing, Chairman Shaw stated: ``The Subcommittee 
wants to examine the incidence of drug use among welfare recipients and 
the potential impacts of drug use on children. We are particularly 
interested in substance abuse as a barrier to work and a factor in the 
placement of children into foster care. Changes in national welfare 
rules have led many States to reform their policies for assessing, 
referring, and treating drug users. It is time to examine what is known 
about the effectiveness of drug treatment and to identify promising 
approaches to helping welfare recipients overcome substance abuse 
problems. This hearing is part of our ongoing efforts to ensure that 
the far-reaching changes made by the welfare reform legislation 
continue to meet with success.''
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Any person or organization wishing to submit a written statement 
for the printed record of the hearing should submit at least six (6) 
single-space legal-size copies of their statement, along with an IBM 
compatible 3.5-inch diskette in ASCII DOS Text or WordPerfect 5.1 
format only, with their name, address, and hearing date noted on a 
label, by the close of business, Tuesday, November 11, 1997, to A.L. 
Singleton, Chief of Staff, Committee on Ways and Means, U.S. House of 
Representatives, 1102 Longworth House Office Building, Washington, D.C. 
20515. If those filing written statements wish to have their statements 
distributed to the press and interested public at the hearing, they may 
deliver 200 additional copies for this purpose to the Subcommittee on 
Human Resources office, room B-317 Rayburn House Office Building, at 
least one hour before the hearing begins.
      

FORMATTING REQUIREMENTS:

      
    Each statement presented for printing to the Committee by a 
witness, any written statement or exhibit submitted for the printed 
record or any written comments in response to a request for written 
comments must conform to the guidelines listed below. Any statement or 
exhibit not in compliance with these guidelines will not be printed, 
but will be maintained in the Committee files for review and use by the 
Committee.
      
    1. All statements and any accompanying exhibits for printing must 
be typed in single space on legal-size paper and may not exceed a total 
of 10 pages including attachments. At the same time written statements 
are submitted to the Committee, witnesses are now requested to submit 
their statements on an IBM compatible 3.5-inch diskette in ASCII DOS 
Text or WordPerfect 5.1 format. Witnesses are advised that the 
Committee will rely on electronic submissions for printing the official 
hearing record.
      
    2. Copies of whole documents submitted as exhibit material will not 
be accepted for printing. Instead, exhibit material should be 
referenced and quoted or paraphrased. All exhibit material not meeting 
these specifications will be maintained in the Committee files for 
review and use by the Committee.
      
    3. A witness appearing at a public hearing, or submitting a 
statement for the record of a public hearing, or submitting written 
comments in response to a published request for comments by the 
Committee, must include on his statement or submission a list of all 
clients, persons, or organizations on whose behalf the witness appears.
      
    4. A supplemental sheet must accompany each statement listing the 
name, full address, a telephone number where the witness or the 
designated representative may be reached and a topical outline or 
summary of the comments and recommendations in the full statement. This 
supplemental sheet will not be included in the printed record.
      
    The above restrictions and limitations apply only to material being 
submitted for printing. Statements and exhibits or supplementary 
material submitted solely for distribution to the Members, the press 
and the public during the course of a public hearing may be submitted 
in other forms.
      

    Note: All Committee advisories and news releases are available on 
the World Wide Web at `HTTP://WWW.HOUSE.GOV/WAYS__MEANS/'.
      

    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you are in need of special accommodations, please 
call 202-225-1721 or 202-226-3411 TTD/TTY in advance of the event (four 
business days notice is requested). Questions with regard to special 
accommodation needs in general (including availability of Committee 
materials in alternative formats) may be directed to the Committee as 
noted above.
      

                                

    Chairman Shaw. Good afternoon.
    Our purpose today is to investigate drug addiction and its 
role in welfare dependency, child abuse, and neglect. We have 
invited witnesses to discuss the dimensions of the drug problem 
both among families on welfare and in the Nation's child 
protection programs. In addition we have invited witnesses who 
can describe programs that are designed to deal with drug 
addiction itself or with the consequences of drug addiction, 
especially the consequences for children.
    There are several specific questions I hope will be 
addressed in the course of today's hearing. First, is there 
evidence of substantial drug use among parents receiving 
support from the Nation's welfare programs? Second, do we have 
programs with a track record of helping parents, especially 
those already dependent on welfare, end their drug addictions? 
Third, what actions, if any, should Congress take to reduce 
drugs among welfare parents and to protect the children from 
the consequences of parental drug addiction?
    Anticipating some of today's testimony, let me state that 
there does appear to be good evidence that parents receiving 
benefits from temporary assistance for needy family programs 
have fairly high levels of drug use. Members of this 
Subcommittee would like to have information on whether this 
drug use will interfere with the ability of the parents to get 
jobs and leave welfare.
    I am especially pleased we will receive testimony from the 
Second Genesis, the Teen Challenge Program, and several other 
witnesses about how we can help addicted parents deal with 
their drug problems and become productive workers and better 
parents.
    There also appears to be very strong evidence that parents 
with children who have been taken into protective custody by 
the States have very high levels of drug addiction. In some 
jurisdictions, perhaps three-quarters of these families have 
drug-addicted or drug-involved parents. This, of course, is a 
tragedy of immense proportion.
    At a time when we are hoping to encourage States to make 
faster determinations of whether abused and neglected children 
can be returned to their families or placed with adoptive 
parents, drug addictions put the State and local officials 
making these decisions on the horns of a dilemma. If the drug 
addiction has become serious enough to be an important factor 
in removing children from their home, how long should the State 
wait before moving to place the children with an adoptive 
parent? What if it takes 2 years for the parent to become 
rehabilitated? What if it takes 3 years? How long should 
children be expected to wait?
    Although I am not planning to introduce legislation on 
drugs and welfare in the near future, at least not this year, I 
plan to keep an eye on this issue and carefully consider any 
legislative recommendations made by today's witnesses. Our 
Subcommittee must continue to investigate whether changes in 
Federal law would help States launch more effective programs to 
help parents and children on welfare overcome the scourge of 
drug addiction.
    [The opening statement follows:]

Opening Statement of Hon. E. Clay Shaw, Jr.

    Our purpose today is to investigate drug addiction and its 
role in welfare dependency and child abuse and neglect. We have 
invited witnesses to discuss the dimensions of the drug problem 
both among families on welfare and in the nation's child 
protection programs. In addition, we have invited witnesses who 
can describe programs that are designed to deal with drug 
addiction itself or with the consequences of drug addiction--
especially the consequences for children.
    Here are several specific questions that I hope will be 
addressed in the course of today's hearing:
    First, is there evidence of substantial drug use among 
parents receiving support from the nation's welfare programs?
    Second, do we have programs with a track record of helping 
parents, especially those already dependent on welfare, end 
their drug addictions?
    Third, what actions, if any, should Congress take to reduce 
drug use among welfare parents and to protect children from the 
consequences of parental drug addiction?
    Anticipating some of today's testimony, let me state that 
there does appear to be good evidence that parents receiving 
benefits from the Temporary Assistance for Needy Families 
(TANF) program have fairly high levels of drug use. Members of 
this Subcommittee would like to have information on whether 
this drug use will interfere with the ability of parents to get 
jobs and leave welfare. I am especially pleased that we will 
receive testimony from the Second Genesis program, the Teen 
Challenge program, and several of our other witnesses about how 
we can help addicted parents deal with their drug problem and 
become productive workers and better parents.
    There also appears to be very strong evidence that parents 
with children who have been taken into protective custody by 
the states have very high levels of drug addiction. In some 
jurisdictions perhaps three-quarters of these families have 
drug-addicted or drug-involved parents.
    This, of course, is a tragedy of immense proportions. At a 
time when we are hoping to encourage states to make faster 
determinations of whether abused and neglected children can be 
returned to their families or placed with adoptive families, 
drug addictions put the state and local officials making these 
decisions on the horns of a dilemma. If the drug addiction has 
become serious enough to be an important factor in removing 
children from their home, how long should the state wait before 
moving to place the child with an adoptive parent? What if it 
takes two years for the parent to be rehabilitated? What if it 
takes three years? How long should children be expected to 
wait?
    Although I am not planning to introduce legislation on 
drugs and welfare in the near future, I plan to keep an eye on 
this issue and to carefully consider any legislative 
recommendations made by today's witnesses. Our Subcommittee 
must continue to investigate whether changes in federal law 
would help states launch more effective programs to help 
parents and children on welfare overcome the scourge of drug 
addiction.
      

                                

    Chairman Shaw. At this time, Mr. Levin, you are recognized.
    Mr. Levin. First of all, congratulations on your new hat.
    Chairman Shaw. Thank you.
    Mr. Levin. My favorite kids book has the phrase in it, I 
like your hat. I am reading it to my grandchildren.
    Chairman Shaw. I am reading it to my grandchildren.
    Mr. Levin. It is Go, Dog, Go, exactly.
    Mr. Camp. Poor literate group here.
    Chairman Shaw. I seem to be behind on my reading.
    Mr. Rangel. Am I in the right place?
    Mr. Levin. Yes, Mr. Rangel, welcome; and I will be very 
brief so we can get to your testimony.
    I have a statement, Mr. Chairman, that I ask be placed in 
the record.
    Chairman Shaw. Without objection. The statement of any of 
the Members will be placed in the record if they wish to do so.
    Mr. Levin. Our important and solemn job is make welfare-to-
work legislation, or at least to help in that direction; and to 
do that, we have to be sensitive to the complex problems faced 
by families who are receiving TANF or who are involved in 
foster care, and one of the problems faced by many of these 
families relates to drug abuse.
    And there is evidence, as you say, Mr. Chairman, that this 
is a considerable problem, that a substantial number of people 
who are receiving TANF have drug or other abuse problems. I 
think there is also evidence there can be a successful 
addressing of this problem in many cases, and treatment is not 
today sufficiently available. So I look forward to this 
hearing.
    I think we have put together a very excellent set of 
witnesses, and we are privileged to have, as the leadoff 
witness, the Ranking Democrat on our Committee.
    [The opening statement follows:]

Opening Statement of Hon. Sander M. Levin, a Representative in Congress 
from the State of Michigan

    This afternoon's hearing is an important one and, I hope, 
the first of several we will hold to explore barriers facing 
welfare recipients moving to work. As we implement welfare 
reform and live up to our commitment to replace welfare with 
work, we will maximize effectiveness only if we are sensitive 
to the complex problems many of these families face.
    Substance abuse is clearly one of the serious problems. 
Estimates vary about the extent of the problem, with the 
highest estimates being that about one million women on welfare 
need help with a drug or alcohol problem. Most research has 
concluded that the TANF population uses drug and alcohol at a 
rate that is higher than the non-welfare population and that 
the majority of recipients who need treatment are not receiving 
it. Even more troubling, it appears that parental substance 
abuse is implicated in the majority of foster care cases in 
some parts of the country.
    Our challenge today and in the near future is to focus on 
the magnitude and the consequences of the problem, and most 
importantly, to learn more about successful models for 
overcoming substance abuse problems so that parents can move 
from welfare to work, can support their families, and can 
through example help their own children avoid drugs.
    I look forward to hearing from witnesses today who have 
firsthand experience with these problems. A special thanks to 
the Ranking Democrat on the Committee on Ways and Means, 
Charlie Rangel, who so poignantly describes how the combination 
of poverty, lack of education, abuse, and hopelessness too 
often leads to addiction.
      

                                

    Chairman Shaw. Thank you, Mr. Levin.
    I would like to give a special welcome to our first witness 
today, Mr. Rangel, who has, throughout his entire career in the 
Congress, worked very hard in the area of drug abuse, and 
trying to find its causes, its cure, and work to get rid of 
this terrible problem.
    I first met Mr. Rangel 17 years ago when I came to Congress 
and was on the Select Committee and was on your Subcommittee--I 
don't know if you remember it, but I remember it as a freshman 
back then--and we worked very hard together throughout the 
years. It is an area where Mr. Rangel and I disagree on a lot 
of things, but I cannot think of one time that we have ever 
disagreed in this particular area; and I compliment you for all 
the good work that you have done for your country and for the 
people who have gotten hooked on this terrible scourge that has 
plagued the country. It, in itself, is a tremendous cause of 
people not being able to make it, not being able to get out in 
the work force. Drug abuse has absolutely just--has penalized 
people beyond belief.
    With that, Mr. Rangel.

   STATEMENT OF HON. CHARLES B. RANGEL, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEW YORK

    Mr. Rangel. Thank you. I don't think I will be able to 
bring much of a solution to the problem we face, but I am 
familiar with the problem and together I think we can find a 
solution.
    Take a district like mine--which receives more per capita 
Federal funds than most congressional districts. But that is 
not something that I can run for reelection on because most of 
it is for health care, AIDS, welfare, crime reduction, and 
homelessness; and given all of this, I was able to work with 
Congressman Kemp and Congressman Newt Gingrich to create the 
empowerment zone. To make certain we weren't just considering 
race and all of those other controversial issues to determine 
eligibility for an empowerment zone, we just picked criteria--
we used poverty, we used drug abuse, we used crime, we used 
homelessness, we used unemployment, we used all of these 
things, and so you would know that welfare would be a part of 
the criteria. In other words, if you ever really take a look at 
where the schools are not functioning, where you have the 
highest amount of unemployment, and joblessness because the 
family unit is not functioning the way we think it should, you 
are going to find hopelessness, which leads to despair, which 
leads to drugs, which leads to unwanted children, which leads 
to violence, which leads to crime, and which leads to the 
ridiculous situation that in the city of New York, we are 
paying $85,000 a year to keep a kid in a detention center, 
while the unions are fighting with the mayor to find out if 
they can get $7,000 a year to keep a kid in school.
    What I am suggesting is, when it gets to rehabilitation, in 
most of these cases, they have not been habilitated and there 
is very little you can do to rehabilitate.
    I remember sometimes bringing Federal officials into my 
district and, to my embarrassment, the rehabilitated addicts 
would come up and say, Rangel, you are doing a great job; I go 
to the same rehabilitation center all the time, they really 
treat me fairly, these are good people. And basically, it 
almost hurts to see how you can detoxify somebody, make them 
drug free, give them self-esteem, and find out they were just 
as uneducated when they were discharged and graduated as they 
were when they went on drugs. And because the dollar is so 
competitive in rehabilitation, everybody wants to know how many 
people went through, how many people graduated, how many people 
reunited with their families; but if they didn't spend the 
money and time to give them job skills, the self-esteem hurts 
them more than when they didn't have it.
    Of course, I have always supported the programs because 
having the program reduces the habit, and to a large extent, 
keeps them off the street and reduces crime. And some of the 
programs do work, especially if the person involved has some 
skills and the program is dealing with training and job 
placement, rather than how many numbers can we run through to a 
graduation, which gives high expectations, but is really 
disappointing in the end.
    But the whole point is that if we don't deal with jobs in 
this country--and it is not just the welfare program. My God, 
we have 1.6 million people that are locked up in jail as we go 
toward the next century, talking about high skills, high-paying 
jobs. We are talking about close to a trillion dollars when you 
include the health benefits, food, maintenance, building of the 
prisons, the law enforcement system, diseases related to 
drugs--and 80 to 90 percent of the people we are locking up are 
drug related, one way or the other.
    It seems to me there is one thing we know definitely and 
that is that the prison population and, for the most part, the 
welfare population, are unemployable; and one of the reasons we 
didn't do much with putting people to work was because it took 
more to train them for work than to send a check.
    Morally, it is the wrong thing to do. Everyone should have 
the dignity and the pride of working; it means something to the 
family, it means something to the community, it should mean 
something to the church or synagogue. But in dollars and cents, 
to get someone prepared to do what the schools didn't prepare 
them to do is just stupid, and this is especially so when we 
have legislation that comes before us that gives incentives to 
save money at the expense of not making certain that basically 
we have a good public school system and then, from there, 
parents can do whatever they want, with or without incentives.
    So I am suggesting that even though I don't have an answer 
to the problem that you are facing with the welfare recipient, 
there is no question in my mind that we can make a difference--
if we can build partnerships with businesspeople who can tell 
us definitely what training and skills they need to hire 
somebody; if we can make certain that that public school system 
does not just respond to a local school board, but responds to 
the job needs of the people in that community, including small- 
and middle-sized businesses. If we make it the case that when 
they graduate they don't just earn a diploma but a job will be 
waiting for them, as somehow they managed to do in the Army. 
Nobody asked me what I wanted to do; they just said what they 
needed and went on to train me for that particular job.
    There is no reason why we can't have a closer working 
relationship with our businesspeople and our school boards and 
our schools, and to the extent that we are going to say that 
welfare recipients have to work and should be working, it seems 
to me it should be the private sector that we should be 
depending on, and if we have to, go to the drug rehabilitation 
centers to instill that training there. To me, making someone 
drug free without giving them the hope they are going to get a 
job is something that doesn't sustain itself.
    I didn't mean to come here and raise the problems to you, 
Mr. Chairman, because as you said, for close to two decades, 
you and I have been struggling to find the answer to this 
problem. But it would seem to me we all should know that the 
better a school system, the better a job opportunity, then the 
better the chances we are not dealing with welfare, crime, 
drugs, and eventually an impediment to the progress that this 
great Nation can make if we didn't just lock up people and give 
up so many of them to AIDS and to hopelessness, as the case is 
with many of the welfare recipients.
    And so it is a challenge that is present to all of us, and 
I look forward to working with all of you, toward that 
solution.
    [The prepared statement follows:]

Statement of Hon. Charles B. Rangel, a Representative in Congress from 
the State of New York

    According to the Substance Abuse and Mental Health Services 
Administration, at least 600,000 AFDC recipients require 
treatment for alcohol- and other drug-related problems; other 
national estimates indicate that as many as 1 million AFDC 
women may need such help. Most assessments of drug or alcohol 
use predict that the AFDC population uses drugs and alcohol 
more than the non-AFDC population.
    It should come as no surprise to us that AFDC recipients, 
particularly those who are long-term dependent, have 
significant drug and alcohol abuse problems. The combination of 
poverty, lack of education, abuse, and hopelessness can easily 
lead to addiction; and treatment resources, particularly for 
this population, are quite limited.
    In fact, according to SAMSA, the great majority of women 
receiving public assistance do not get treatment for their 
alcohol-and other drug-related problems and could benefit from 
treatment.
    Instead of investing in education and treatment, we invest 
in prisons. It costs $85,000 to house each inmate at the Rikers 
Island detention center. That is $72,000 more than the cost to 
educate a child in public school for a year.
    This investment in prisons and longer jail sentences does 
not seem to have had much, if any, deterrent effect. Investing 
even more in this strategy does not make much sense to me, 
particularly given our concern about the deficit. What we need 
is a strategy that links prevention, treatment, law 
enforcement, and demand and supply reduction. I wish I could 
say that I see such a strategy on the agenda of this Congress, 
but I do not.
    All the news is not bad, however. There is evidence, from 
States, that treatment can substantially improve employment 
status for the welfare population:

    --Arkansas had a post-treatment employment increase of 127 
percent;
    --California saw increases in employment of over 60 
percent;
    --Colorado increases were 60 percent;
    --Florida increases were 76 percent;
    --Minnesota increases among public pay clients were 64 
percent; and
    --Missouri increases were 136 percent.

    Remember, nearly 20 percent of all children in the US have 
a parent who used an illicit drug in the past year; over 9 
percent have parents who used illicit drugs in the past month.
    Blaming the drug or alcohol dependent parent accomplishes 
nothing. We need to devote that same energy to solving what is 
a painful problem for many of America's families, including its 
poorest.
      

                                

    Chairman Shaw. Charlie, am I hearing you correctly, in 
interpreting what you are saying, in reading between the lines, 
that joblessness, hopelessness, leads to drug abuse, and that 
the rehabilitation is not addressing that question? In addition 
to just getting someone off of drugs, in other words, should we 
be looking to attaching job training to drug rehabilitation?
    Mr. Rangel. No question in my mind, Mr. Chairman.
    Chairman Shaw. Is anyone doing that?
    Mr. Rangel. Some do, and they are expensive programs. As a 
matter of fact, I can look at the success of a program and 
almost see whether they are screening people to guarantee 
success. Where you have programs in sophisticated neighborhoods 
where some doctor, some lawyer, some professional person made a 
mistake and was hopelessly addicted, then they go to the Betty 
Ford Rehabilitation Center. They don't need a lot of job 
training, they just have to get back on track.
    But when you search for the reason as to why would anybody 
go on drugs in the first place, our kids are smart enough to 
see that drugs hurt, they are smart enough to see friends 
dying, they are smart enough to see people going to jail. Some 
of these kids go to more funerals than they do graduations, so 
they are smart enough to see it. So why would they do this? 
Because they don't give a damn. There is nothing they are going 
to lose.
    They know that fast track and increased high-tech jobs do 
not mean them; they know they are not going to lose their 
family's good name, and being arrested, to some of them--having 
been abused and not even having had the ability to dream--going 
to jail just isn't any big deal.
    As a matter of fact, the tragedy is when you find some kids 
who have never been to jail, dressing and acting as if they 
have been in and out of jail, so they can be accepted as a peer 
on the block. And when a kid goes through all of this crying 
and the family love is restored at graduation from a 
rehabilitation center, and then finds out that his friends, who 
are doing something, shun him--they can't just go right back, 
they are still a form of junkie--it takes a lot of love, and a 
lot of people don't have it for the type of people who have 
made these types of mistakes.
    But there is one group they can always depend on, that is 
there for them: the drug dealer; and if you don't have a family 
structure to carry you, and you are weak and you are young and 
you are immature. And if you make a baby, well, how would we 
counsel them?
    To a large extent, we have said they have already ruined 
their lives, so now you apply for a check and we say, Well, you 
wretched soul, you had better go to work. Well, we all agree, 
that is a great principle, but, boy, have you got a job in 
habilitating someone so that they are prepared to understand 
what the heck work is in the first place.
    So what I am saying is that we make one big mistake when we 
don't concentrate on stopping these things from happening, 
because these are the problems we will be wrestling with, 
whether it means welfare, whether it means HIV, whether it 
means crime.
    I went to visit, a couple years ago, some kids in a 
rehabilitation hospital that was in my district, and all these 
kids were sitting around in wheelchairs with ``Rangel is the 
greatest'' on their T-shirts, so I knew they wanted something. 
And I was asking, what did they want? And the director of the 
program told me that these kids who have been shot in these 
drug wars, paralyzed for life, wanted me to support a program 
that would put them in a private home, an apartment, with a 
rehabilitation person, with a housekeeper, with a dietitian and 
all of this. And I was saying, Are you crazy, and they were 
showing me that the cost of all of this was a fraction of the 
cost of keeping them in that institution.
    Now we know that public officials are not prepared to give 
money to bum kids who shot each other, but we are prepared to 
pay money to the institutions, the doctors, the psychiatrists, 
and the social workers. It is insane.
    How many people in Congress could I ask for $84,000 to keep 
one of my kids in school? But nobody has ever challenged in the 
Congress the amount of money it takes to keep them in jail--and 
certainly not in the city council and State legislatures, the 
legislative bodies.
    My only plea is, do what you have to do to get reelected, 
but for God's sake, concentrate on building a school system 
that produces productive people and that is not hopeless. 
Because in the Army they took a lot of hopeless bums like me 
and turned them into somebody. And with the proper discipline, 
and if the hope is there and the drive is given there, because 
you are shown something at the end of the line--at the end of 
the line for me was corporal stripes, but for kids, it may be 
something else--but show them something that you can get out of 
it and it works. And the thing that hurts is that you know it 
works, the Congress knows it works.
    So when I see tax bills described as education bills, like 
I did last week, I say, If this makes you feel good, do it, but 
build up a public school system first before you call this a K-
to-12 bill.
    Chairman Shaw. Do the other Members have any questions?
    Mr. Collins.
    Mr. Collins. Mr. Rangel, I know we come from different 
parts of the country, and you come from an area that probably 
has a lot more different circumstances or surroundings than I 
do, because you are from an inner-city area, and I am from 
rural--middle of Georgia. But we both see a lot of the same 
situations, maybe just in different patterns.
    In the area of education versus prisons, we do not 
adequately address the problem of drugs and crime and 
education. I think it is going to take a large sum of money for 
each. The purpose of schools and education is to teach what to 
do and how to do it properly, appropriately. The purpose of a 
prison is to, in some sense of the word, teach that you didn't 
do it right and you have infringed on the rights of others. One 
is much more expensive than the other one. But we have to pay 
attention to both.
    We can't just not put people in jail or prison--because 
they have done wrong. That is a lesson to others that they 
won't like what they might reap from that type of system. But 
it is expensive and it is going to be an expensive solution, 
but it will take a generation, maybe even a generation and a 
half, to change the course of the mindset of a lot of young 
people that are coming along. Because we have a lot of youth 
today who are experiencing everyday problems, they see it in 
the neighborhoods you spoke of, they see it in the families you 
spoke of, and they are probably going to wind up being taught 
an education medium from the prison system, rather than from 
the education system.
    But if we don't address this--the young ones, the little 
ones that are coming along, and focus on their education, focus 
on their families, focus on the fact that their peers, their 
role models, their parent or parents--in many places, one 
parent--is a role model that does attend work, does have some 
type of skill or a job with no skill. I know a lot of people 
who don't really have what you say is a skill, but they work 
every day, they make a living, they provide for their family; 
and that, in itself, is a teacher to those young ones. It is 
going to be an expensive process either way.
    You mainly focused on just public education, but there are 
some alternatives to public education out there too; and within 
the next few days, or the last few days, we had a bill on the 
floor dealing with just a little pilot program right here in 
the District of Columbia, dealing with education. It is worth 
trying. It may not work, but a lot of things out there are not 
working today.
    So I don't think we just say we are going to do this in 
public education; I think we ought to look at any type of 
education program or institution that we can--an education 
institution, not a prison--for guidance and for help. And we 
are going to have to pay for it.
    It is a pleasure to work with you on the Ways and Means 
Committee and to listen to you talk. I have said once before, I 
would love to visit your area, your city, your district; I 
would also love for you to visit mine.
    Thank you, Mr. Chairman.
    Mr. Rangel. We have to do that. I agree with everything you 
have said. I am not pessimistic that it is going to cost a lot 
of money. I have found that I have more private sector 
entrepreneurs that understand what I am saying than 
politicians, and they know they can't win at that bargaining 
table if this trend continues; and they also know that the 
people that are locked up are employable people and that people 
from the same families and the same communities that manage to 
discover the excitement of learning don't end up making those 
mistakes.
    In the recently passed bipartisan tax bill, there are 
provisions that take first steps building in a partnership with 
the private sector and relieving them of the responsibility for 
basic training--telephone operators--the companies complain 
that out of every 100 applicants, they can find only one 
qualified candidate and they have to train that one. There is 
no reason why the schools can't do this; there is no reason why 
the specifications for each and every job--and I am not talking 
about rocket scientists' jobs, I am talking about work jobs--
why that cannot be taught in the schools. Everybody is not 
going to go to college, and they don't have to go to college; 
there are jobs they can do, and the schools should be able to 
at least say, you can do this and get a job. But higher 
education should be made available, and other options should be 
there, but no one should have to leave school without having a 
job available to them in their community.
    Mr. Collins. And a lot of our youth need to understand, 
there are a lot of jobs that would be available, but if you get 
this stamp on the record, it stays with you, and there are jobs 
that just won't allow you to be employed again.
    I have a business in that range. I have a trucking 
company--transportation, drivers--but if you get on your record 
any type of drug violation, you are in deep trouble when it 
comes to trying to find another job driving a truck or in any 
other area of transportation.
    Mr. Rangel. Except when there is a shortage, and if for 
some reason there were enough Members of Congress that thought 
this surplus we are talking about should be dedicated to 
rebuilding our cities and our roads and our communication 
system and our transportation system, if somebody really 
thought that in order to have successful international trade, 
we have to have successful ports and roads and trains in order 
to do it; and I can tell you, there will be more job 
opportunities than we can take, and the guy with the 
misdemeanor or nonviolent behavior, if he can handle one of 
those shovels or one of those trucks, you can bet your life--he 
can get a break and get back on the road. But, for now, if you 
can hire an unemployed college kid, why deal with a guy who has 
these problems?
    As a matter of fact, one country is now looking for 
soldiers, and they are going to the prisons because no one 
wants to do that kind of work. I really think one of the best 
investments we can make is rebuilding our country, and creating 
the jobs to do it.
    Anyway, we all have a lot to do, and politics is a big 
impediment to moving forward a lot of times. But I didn't mean 
it should just be the public school; all I know is, without the 
public school, I would not have been here today.
    Chairman Shaw. That will be the final word.
    Mr. Rangel. Thank you.
    Chairman Shaw. Thank you for taking the time to be with us.
    The next panel of witnesses, if you would come to the 
table, we have Jane Ross, Director of Income Security Issues, 
U.S. General Accounting Office; Peter Reuter is a Ph.D., School 
of Public Affairs, University of Maryland, College Park, 
Maryland; Nicholas Zill, Ph.D., Vice President and Director, 
Child and Family Study Area, of Westat, Inc., in Rockville, 
Maryland; Nancy Young, Ph.D., Director of Children and Family 
Futures in Irvine, California; and Richard Barth, Ph.D., Hutto 
Patterson Professor, School of Social Welfare at the University 
of California at Berkeley.
    We have each of your full statements, which will be made a 
part of the record, and we would invite you to proceed as you 
see fit, and you are welcome to summarize.
    Ms. Ross.

 STATEMENT OF JANE L. ROSS, DIRECTOR, INCOME SECURITY ISSUES, 
HEALTH, EDUCATION, AND HUMAN SERVICES DIVISION,  U.S.  GENERAL  
                       ACCOUNTING  OFFICE

    Ms. Ross. Thank you. Mr. Chairman and Members of the 
Subcommittee.
    Each year nearly 1 million children in this country are 
victims of abuse and neglect, and parental substance abuse is 
very often a contributing factor in these cases. Although 
estimates vary widely, parental substance abuse may be involved 
in the majority of foster care cases in some locations, and in 
New York City, about 75 percent of confirmed cases of child 
abuse and neglect involve substance abuse by at least one 
parent or care giver. In House bill 867, the Subcommittee 
indicated its concern about parental substance abuse by 
directing the Secretary of HHS to recommend to the Congress 
ways to improve the coordination between substance abuse and 
child welfare services; and today, in order to pursue your 
concern further, you ask us to discuss the implications of 
parental substance abuse for children and for the child welfare 
system. You also ask us to comment on permanency planning for 
foster care cases involving parental substance abuse. Let me 
briefly summarize our findings.
    First, let's talk about the children. Parental substance 
abuse is a problem that brings many children to the attention 
of the child welfare system. In the case of newborns who are 
found to have been prenatally exposed to drugs or alcohol, 
there is often an investigation to determine if there has been 
child abuse and neglect. In some States, prenatal substance 
abuse--excuse me, prenatal substance exposure, by itself, 
constitutes abuse or neglect and is grounds for removing a 
child from its parents.
    In the case of older children, substance abuse can damage a 
parent's ability to care for them and can lead to abuse or 
neglect. When abuse or neglect have been documented, some of 
the children are removed from the custody of parents and placed 
in foster care. So that has to do with the children.
    Once the child is in the foster care system, parental 
substance abuse is a significant hurdle in that child's path 
out of the system. It is a hurdle that requires drug or alcohol 
treatment for the parent, in addition to other services for the 
family.
    The nature of drug and alcohol addiction means a parent's 
recovery can take a considerable amount of time. These parents 
also face problems such as mental illness or homelessness, 
which further complicate their cases. Foster care cases that 
involve parental substance abuse, therefore, place an 
additional strain on the child welfare system, which is already 
overburdened by the number of foster care cases and their 
costs. There are currently about a half a million children in 
foster care and just the Federal cost of foster care is over $3 
billion this year.
    Child welfare agencies are charged with ensuring that 
foster care cases are resolved in a timely manner while making 
reasonable efforts to reunite children with their parents. 
Ideally, both of these goals can be achieved. However, even for 
parents who are able to recover from drug or alcohol abuse 
problems, recovery can be a long process. Child welfare 
officials who are now trying to speed up the process of making 
permanency decisions may have difficulty making those decisions 
before they know whether the parent is likely to succeed in 
drug treatment. So when parental substance abuse is an issue in 
a foster care case, it may be difficult to reconcile minimizing 
time spent in foster care with reunification of children with 
their parents. Fortunately, some States and localities are 
testing initiatives that may help reconcile the two goals.
    For example, Tennessee has a concurrent planning program 
that allows caseworkers to work toward reunifying families 
while, at the same time, developing an alternate permanency 
plan in case the family reunification efforts don't work. Under 
a concurrent planning approach, caseworkers emphasize to the 
parents that if they don't adhere to the requirements set 
forth, parental rights can be terminated.
    Also, the State of Illinois is just beginning a project to 
coordinate substance abuse treatment for parents with child 
welfare services for the family.
    Finally, there is some early work going on to increase 
services available to families after reunification. This 
initiative seems especially important as a complement to 
efforts to reunify families more quickly.
    To sum up, in seeking to achieve what is in the best 
interest of children, foster care laws emphasize both family 
reunification and achieving timely exits from foster care. 
Reconciling the goals for children whose parents have substance 
abuse problems requires balancing the rights of the parents 
with what is truly in the best interest of the children.
    Mr. Chairman, that concludes my statement.
    [The prepared statement follows:]

Statement of Jane L. Ross, Director, Income Security Issues, Health, 
Education, and Human Services Division, U.S. General Accounting Office

    Mr. Chairman and Members of the Subcommittee:
    Each year, nearly 1 million children in this country are 
the victims of abuse and neglect by their parents or other 
caregivers, and parental substance abuse is very often a 
contributing factor in these cases. Although estimates vary 
widely, there is considerable literature that suggests that 
parental substance abuse is involved in the majority of foster 
care cases in some locations. It is not surprising, therefore, 
that the nature and effects of parental substance abuse are of 
concern to this Subcommittee, particularly in light of the 
dramatic increase in the foster care population, which was 
estimated to be almost half a million by the end of 1995.
    Because of your concern, you asked us to discuss the 
implications of parental substance abuse for children and the 
child welfare system. You also asked us to comment on 
permanency planning for foster care cases involving parental 
substance abuse, given the importance of family reunification.
    My testimony today is based on our ongoing work for the 
Senate Committee on Finance and previous work we have done in 
the child welfare and substance abuse areas. (See Related GAO 
Products at the end of this statement.) Our ongoing work on the 
implications of parental substance abuse for foster care 
primarily consists of reviews of the substance abuse histories 
and drug treatment experiences of parents, as well as the 
initiatives that might help achieve timely exits from foster 
care for cases involving parental substance abuse. Most of the 
previous work I refer to here involved an extensive review of 
the case files of representative samples of young foster 
children--those under 3 years of age--who were in foster care 
in Los Angeles County, New York City, and Philadelphia County 
in 1986 and 1991. These locations accounted for a substantial 
portion of their respective states' population of young foster 
children in 1991.\1\ Furthermore, over 50 percent of the 
nation's foster children were under the jurisdiction of these 
three states in that year.
---------------------------------------------------------------------------
    \1\ In 1991, these locations accounted for 44 percent of young 
foster children in California; 81 percent of young foster children in 
New York; and 29 percent of young foster children in Pennsylvania.
---------------------------------------------------------------------------
    Let me briefly summarize our findings. For many children, 
it is parental substance abuse that brings them to the 
attention of the child welfare system. When a newborn has been 
found to have been prenatally exposed to drugs or alcohol, this 
often triggers an investigation of suspected child abuse and 
neglect. In some states, prenatal substance exposure itself 
constitutes neglect and is grounds for removing a child from 
its parents. Substance abuse can damage a parent's ability to 
care for older children as well, and can lead to child abuse or 
neglect. As a result, some of these children are removed from 
the custody of their parents and placed in foster care.
    Furthermore, once a child is in the system, parental 
substance abuse is a significant hurdle in their path out of 
the system--a hurdle that requires drug or alcohol treatment 
for the parent in addition to other services for the family. 
The nature of drug and alcohol addiction means a parent's 
recovery can take a considerable amount of time. Other problems 
these parents face, such as mental illness and homelessness, 
further complicate these cases. Foster care cases that involve 
parental substance abuse, therefore, place an additional strain 
on a child welfare system already overburdened by the sheer 
number of foster care cases.
    Child welfare agencies are charged with ensuring that 
foster care cases are resolved in a timely manner and with 
making reasonable efforts to reunite children with their 
parents. Ideally, both of these goals are to be achieved. 
However, even for parents who are able to recover from drug or 
alcohol abuse problems, recovery can be a long process. Child 
welfare officials may have difficulties making permanency 
decisions within shorter time frames before they know whether 
the parent is likely to succeed in drug treatment. So, when 
parental substance abuse is an issue in a foster care case, it 
may be difficult to reconcile these two goals. The foster care 
initiatives and laws that some states and localities are 
instituting may help reconcile the goals of family 
reunification and timely exits from foster care for the cases 
involving parental substance abuse.

                               Background

    The child welfare system encompasses a broad range of 
activities, including
     child protective services (CPS), which 
investigates reports of child abuse and neglect;
     services to support and preserve families; and
     foster care for children who cannot live safely at 
home.
    States and localities provide the majority of funds for 
foster care and child welfare services, but federal funds are 
provided to states for the food, housing, and incidental 
expenses of foster children whose parents meet federal 
eligibility criteria. Federal funding for the administration 
and maintenance expenses of foster care was estimated at about 
$3.6 billion in 1997. Additional federal funds are provided to 
states for a wide range of other child welfare and family 
preservation and support services, and these were estimated at 
about $500 million in 1997.
    As an integral part of the child welfare system, foster 
care is designed to ensure the safety and well-being of 
children whose families are not caring for them adequately. 
Beyond food and housing, foster care agencies provide services 
to children and their parents that are intended to address the 
problems that brought the children into the system. Agencies 
are also required to develop a permanency plan for foster 
children to make sure they do not remain in the system longer 
than necessary. Usually, the initial plan is to work toward 
returning the children to their parents. If attempts to reunify 
the family fail, the agency is to develop a plan to place the 
children in some other safe, permanent living arrangement, such 
as adoption or guardianship. According to federal statute, the 
court must hold a permanency planning hearing no later than 18 
months after a child enters foster care.\2\ Proposed federal 
legislation would shorten this time frame to 12 months,\3\ in 
the hope of reducing the time a child spends in foster care. 
Some states have already adopted this shorter time frame.
---------------------------------------------------------------------------
    \2\ 42 U.S.C. 675(5)(C).
    \3\ Adoption Promotion Act of 1997 (H.R. 867); Promotion of 
Adoption, Safety, and Support for Abused and Neglected Children (S. 
1195).
---------------------------------------------------------------------------

Parental Substance Abuse Often Brings Children to the Attention of the 
                          Child Welfare System

    Children come to the attention of the child welfare system 
in two ways--either shortly after birth because they were 
exposed to drugs or alcohol in-utero or sometime later because 
they have been abused or neglected. Children with substance 
abusing parents enter foster care in either way.
    Many state statutes require that drug- or alcohol-exposed 
infants be reported, and some of these children are 
subsequently removed from the custody of their parents if an 
investigation determines that they have been abused or 
neglected. In some states, prenatal substance exposure itself 
constitutes neglect and is grounds for removing children from 
the custody of their parents. Large numbers of children in 
foster care are known to have been prenatally substance 
exposed. In an earlier study, we estimated that close to two-
thirds of young foster children in selected locations in 1991 
had been prenatally exposed to drugs and alcohol, up from about 
one-quarter in 1986.
    In both years, cocaine was the most prevalent substance 
that young foster children were known to have been exposed to, 
and the incidence of this exposure increased from about 17 
percent of young foster children in 1986 to 55 percent in 1991. 
Moreover, among those who had been prenatally exposed who were 
in foster care in 1991, about one quarter had been exposed to 
more than one substance. The actual number of young foster 
children who had been exposed to drugs or alcohol in-utero may 
have been much higher because we relied on the mother's self-
reporting of drug or alcohol use or toxicology test results of 
the mother or infant to document prenatal exposure. Yet, not 
all children or mothers are tested at birth for drugs, and even 
when they are tested, only recent drug or alcohol use can be 
confirmed.
    Older children of substance abusing parents also may enter 
foster care because they have been abused or neglected as a 
result of their parents' diminished ability to properly care 
for them. Abuse and neglect of children of all ages, as 
reported to CPS agencies, more than doubled from 1.1 million to 
over 2.9 million between 1980 and 1994, and a Department of 
Health and Human Services (HHS) report found that the number of 
CPS cases involving substance abuse can range from 20 to 90 
percent, depending on the area of the country. For example, we 
recently found that about 75 percent of confirmed cases of 
child abuse and neglect in New York City involved substance 
abuse by at least one parent or caregiver. Many of these 
parents live in drug-infested and poor neighborhoods that 
intensify family problems.
    Neglect is most frequently cited as the primary reason 
children are removed from the custody of their parents and 
placed in foster care. According to the Office of Child Abuse 
and Neglect, the children of parents who are substance abusers 
are often neglected because their parents are physically or 
psychologically absent while they seek, or are under the 
influence of, alcohol and other harmful drugs. Sixty-eight 
percent of young children in foster care in California and New 
York in 1991 were removed from their parents as a result of 
neglect or caretaker absence or incapacity. No other reasons 
for removal accounted for a large portion of entries of young 
children into foster care. Physical, sexual, and emotional 
abuse combined accounted for only about 7 percent of removals 
of these young children.

Parental Substance Abuse Places Additional Strain on the Child Welfare 
                                 System

    Parental substance abuse not only adversely affects the 
well-being of children, it also places additional strain on the 
child welfare system. The foster care population increased 
dramatically between 1985 and 1995 and is estimated to have 
reached about 494,000 by the end of 1995. As a consequence, 
foster care expenditures have risen dramatically. Between 1985 
and 1995, federal foster care expenditures under title IV-E of 
the Social Security Act increased from $546 million to about $3 
billion. We found that a greater portion of foster care 
expenditures in some locations shifted to the federal 
government between 1986 and 1991 because much of the growth in 
the population of young foster children involved poor families 
who were eligible for federal funding.
    Parental substance abuse is involved in a large number of 
cases. We have previously reported that an estimated 78 percent 
of young foster children in 1991 in selected locations had at 
least one parent who was abusing drugs or alcohol. Our recent 
interviews with child welfare officials in Los Angeles County, 
California, and Cook County, Illinois, have confirmed that the 
majority of foster care cases in these counties for children of 
all ages involve parental substance abuse. Officials in these 
locations stated not only that cocaine use among parents of 
foster children is still pervasive but that the use of other 
highly addictive and debilitating drugs, such as heroin and 
methamphetamines, appears to be on the rise. In addition, 
officials confirmed that use of multiple substances is common.
    In addition to the large number of foster care cases 
involving parental substance abuse, the complexities of these 
family situations place greater demands on the child welfare 
system. Most of the families of the young foster children in 
selected locations whose case files we reviewed had additional 
children in foster care, and at least one parent was absent. 
About one-third of the families were homeless or lacked a 
stable residence. Some had at least one parent who had a 
criminal record or was incarcerated, and in some families 
domestic violence was a problem. In addition, child welfare 
officials in Los Angeles and Cook Counties recently told us 
that dual diagnosis of substance addiction and mental illness 
is common among foster parents. The National Institute of 
Mental Health reported in 1990 that most cocaine abusers had at 
least one serious mental disorder such as schizophrenia, 
depression, or antisocial personality disorder.
    To illustrate the complexities of these cases and the 
influences the complexities can have on outcomes from foster 
care, let me describe a case we recently reviewed as part of 
our ongoing work. This case involves a woman with four 
children, all of whom were removed from her custody as a result 
of neglect related to her cocaine abuse. The youngest child 
entered foster care shortly after his birth. By that time, the 
three older children had already been removed from their 
mother's custody. All four of the children were placed with 
their grandmother. The mother had a long history of cocaine 
abuse that interfered with her ability to parent. At least two 
of her four children were known to have been prenatally exposed 
to cocaine. She also had been convicted of felony drug 
possession and prostitution, lacked a stable residence, and was 
unemployed. The father was never located, although it was 
discovered that he had a criminal record for felony drug 
possession and sales.
    Despite the mother's long history of drug use and related 
criminal activity, she eventually completed a residential drug 
treatment program that lasted about 1 year, participated in 
follow-up drug treatment support groups, and tested clean for 
over 6 months. In addition, she completed other requirements 
for family reunification, such as attending parenting and human 
immunodeficiency virus (HIV) education classes, and she was 
also able to obtain suitable housing. Although the mother was 
ultimately reunified with her youngest child, it took a 
considerable amount of time and an array of social services to 
resolve this case. The child was returned to his mother on a 
trial basis about 18 months after he entered foster care. The 
child welfare system retained jurisdiction for about another 
year, during which family maintenance services were provided.
    In addition, many foster children have serious health 
problems, some of which are associated with prenatal substance 
exposure, which further add to the complexity of addressing the 
service needs of these families. We found that over half of 
young foster children in 1991 had serious health problems, and 
medical research has shown that many of the health problems 
that these children had, such as fetal alcohol syndrome, 
developmental delays, and HIV, may have been caused or 
compounded by prenatal exposure to drugs or alcohol.
    Special supportive services and treatment will be needed by 
many of these children. Early identification of children who 
are HIV positive is particularly critical because medical 
advances in identification and treatment can enhance and 
prolong the lives of these children. Some of these children 
require foster care either in institutions that can accommodate 
their medical needs or in foster family homes where the 
caregivers are specially trained. Reunifying families can also 
be more difficult because of the additional strains that caring 
for medically fragile children places on parents, who are at 
the same time recovering from drug or alcohol addictions.
    Some caseworkers find it difficult to manage the high 
caseloads involving families with increasingly complex service 
needs. Some states have experienced resource constraints, 
including problems recruiting and retaining caseworkers, 
shortages of available foster parents, and difficulties 
obtaining needed services, such as drug treatment, that are 
generally outside the control of the child welfare system. 
Caseworkers are also experiencing difficulties resolving cases. 
Once children are removed from the custody of their parents, 
they sometimes remain in foster care for extended periods.

 Parental Substance Abuse Adds to the Difficulty of Making Permanency 
                               Decisions

    The problem of children ``languishing'' or remaining in 
foster care for many years has become a great concern to 
federal and state policymakers. While most children are 
reunified with their parents, adopted, or placed with a 
guardian, others remain in foster care, often with relatives, 
until they age out of the system. The circuitous and burdensome 
route out of foster care--court hearings and sometimes more 
than one foster care placement--can take years, be extremely 
costly, and have serious emotional consequences for children.
    Yet, making timely decisions about children exiting foster 
care can be difficult to reconcile with the time a parent needs 
to recover from a substance abuse problem. Current federal and 
state foster care laws emphasize both timely exits from foster 
care and reunifying children with their parents. However, even 
for those who are able to recover from drug and alcohol 
addictions, it can be a difficult process that generally 
involves periods of relapse as a result of the chronic nature 
of addiction. Achieving timely exits from foster care may 
sometimes conflict with the realities of recovering from drug 
and alcohol addictions. The current emphasis on speeding up 
permanency decisions will further challenge child welfare 
agencies.
    Current federal law requires that states conduct a 
permanency planning hearing within 18 months after a child 
enters foster care to determine whether family reunification 
should continue to be the goal, or whether some other permanent 
living arrangement, such as adoption or guardianship, should be 
pursued. The current emphasis on speeding up permanency 
hearings reflects concerns about children spending long periods 
of time in foster care. Pending federal legislation would 
shorten the time allowed before holding a permanency planning 
hearing from 18 to 12 months. As of early 1996, 23 states had 
already enacted shorter time frames for holding a permanency 
planning hearing than required under federal law. In two of 
these states, the shorter time frames apply only to younger 
children. It should be emphasized, however, that while a 
permanency planning hearing must be held within these specified 
time frames, the law does not require that a final decision be 
made at this hearing as to whether family reunification efforts 
should be continued or terminated.
    Some drug treatment administrators and child welfare 
officials in these same locations believe that shorter time 
frames might help motivate a parent who abuses drugs to 
recover. However, expedited time frames \4\ may require that 
permanency decisions be made before it is known whether the 
parent is likely to succeed in drug treatment. While one 
prominent national study found that a large proportion of 
cocaine addicts failed when they attempted to stay off the 
drug, we previously reported that certain forms of treatment do 
hold promise. In addition, progress has been made in the 
treatment of heroin addiction through traditional methadone 
maintenance programs and experimental treatments. However, even 
when the parent is engaged in drug treatment, treatment may 
last up to 1 or 2 years, and recovery is often characterized as 
a lifelong process with the potential for recurring relapses.
---------------------------------------------------------------------------
    \4\ Recently, both California and Illinois enacted expedited time 
frames for holding a permanency planning hearing within 12 months. In 
addition, California enacted an even shorter time frame of 6 months for 
children entering foster care under the age of 3. The changes to 
Illinois' permanency legislation are currently in effect only in Cook 
County; they will go into effect throughout the rest of the state 
beginning January 1, 1998.
---------------------------------------------------------------------------
    Some drug treatment administrators in Los Angeles and Cook 
Counties believe that treatment is more likely to succeed if 
the full range of needs of the mother are addressed, including 
child care and parenting classes as well as assistance with 
housing and employment, which help the transition to a drug-
free lifestyle. These drug treatment administrators also 
stressed how important it was for parents who are reunited with 
their children to receive supportive services to continue their 
recovery process and help them care for their children.
    Determining the potential for an individual's success in 
drug treatment is extremely difficult given the variety of 
substances abused, types of treatment and program quality, 
differences in addiction and readiness for recovery, and 
definitions of what constitutes ``recovery.'' However, the 
longer an individual is in treatment, the greater the potential 
for improved behavior. Some caseworkers in Los Angeles and Cook 
Counties said that shorter time frames for holding a permanency 
planning hearing may be appropriate in terms of the foster 
child's need for a permanent living arrangement. However, they 
also said that the likelihood of reunifying these children with 
their parents when permanency decisions must be made earlier 
may be significantly reduced when substance abuse is involved. 
In their view, the prospects of reunifying these families may 
be even worse if the level of services currently provided to 
them is not enhanced.
    In our ongoing work, we have found that states and 
localities are responding to the need for timely permanency for 
foster children through programmatic initiatives and changes to 
permanency laws. Most of these initiatives and changes to 
permanency laws are very new, so there is little experience to 
draw upon to determine whether they will help achieve timely 
exits from foster care for cases involving parental substance 
abuse. Furthermore, some of these initiatives and changes are 
controversial and reflect the challenge of balancing the rights 
of parents with what is in the best interest of the child, 
within the context of a severely strained child welfare system.
    For example, California and Illinois have enacted statutory 
changes that specifically address permanency for foster care 
cases involving parental substance abuse. The Illinois 
legislature recently enacted new grounds for terminating 
parental rights. Under this statute, a mother who has had two 
or more infants who were prenatally exposed to drugs or alcohol 
can be declared an unfit parent if she had been given the 
opportunity to participate in treatment when the first child 
was prenatally exposed. California has enacted new statutory 
grounds for terminating family reunification services if the 
parent has had a history of ``extensive, abusive, and chronic'' 
use of drugs or alcohol and has resisted treatment during the 
3-year period before the child entered foster care or has 
failed or refused to comply with a program of drug or alcohol 
treatment described in the case plan on at least two prior 
occasions, even though the programs were available and 
accessible. While such laws may help judges make permanency 
decisions when the prospects for a parent's recovery from drug 
abuse seem particularly poor, these changes are not without 
controversy. Some caseworkers and dependency court attorneys in 
Los Angeles and Cook Counties expressed concerns that a judge 
may closely adhere to the exact language in the statutes 
without considering the individual situation, and may disregard 
the extent to which progress has been made toward recovery 
during the current foster care episode.
    States and localities are undertaking programmatic 
initiatives that may also help to reconcile the goals of family 
reunification and timely exits from foster care, which may 
conflict, particularly when parental substance abuse is 
involved. New permanency options are being explored as are new 
ways to prevent children from entering foster care in the first 
place. We previously reported on Tennessee's concurrent 
planning program that allows caseworkers to work toward 
reunifying families, while at the same time developing an 
alternate permanency plan for the child if family reunification 
efforts do not succeed. Under a concurrent planning approach, 
caseworkers emphasize to the parents that if they do not adhere 
to the requirements set forth in their case plan, parental 
rights can be terminated. Tennessee officials attributed their 
achieving quicker exits from foster care for some children in 
part to parents making more concerted efforts to make the 
changes needed in order to be reunified with their children.
    In addition, both California and Illinois have federal 
waivers for subsidized guardianship, under which custody is 
transferred from the child welfare agency to a legal guardian. 
In Illinois, CPS cases involving prenatally substance exposed 
infants can be closed by the child welfare agency without 
removing the child from the mother's custody if the mother can 
demonstrate sufficient parental capacity and is willing to 
participate in drug treatment and receive other supportive 
services.
    One jurisdiction is developing an approach to deliver what 
its officials describe as enriched services to the parent. 
Illinois' new performance contracting initiative provides an 
incentive for private agencies to achieve timely foster care 
exits for children by compensating these agencies on the basis 
of their maintaining a prescribed caseload per caseworker. This 
necessitates that an agency find permanent living arrangements 
for a certain number of children per caseworker per year, or 
the agency absorbs the cost associated with managing higher 
caseloads. A component of this initiative is the provision of 
additional resources for improved case management and aftercare 
services in order to better facilitate family reunification and 
reduce the likelihood of reentry. Providing enriched services 
may make it less likely that judges will rule that the child 
welfare agency has failed to make reasonable efforts to reunify 
parents with their children and thereby reduce delays in 
permanency decisionmaking.

                              Observations

    In summary, children with substance abusing parents often 
come to the attention of the child welfare system either at 
birth, because of prenatal substance exposure, or later in life 
when they are found to have been abused or neglected. The 
families of these children have increasingly complex service 
needs. Many are dually diagnosed with drug or alcohol 
addictions and mental illnesses, some are involved in criminal 
activities, some are homeless, and most have additional 
children in foster care. Burgeoning foster care caseloads 
entailing these complex family situations have placed enormous 
strains on the child welfare system.
    In seeking to achieve what is in the best interest of 
children, foster care laws emphasize both family reunification 
and achieving timely exits from foster care for children. Given 
the time it often takes a person to recover from drug and 
alcohol addictions, and the current emphasis on speeding up 
permanency decisions for foster children, these goals may 
conflict. Reconciling these goals for children whose parents 
have a substance abuse problem presents a tremendous challenge 
to the entire child welfare system in determining how to 
balance the rights of parents with what is truly in the best 
interest of children. New state and local initiatives may help 
address this challenge. Through our ongoing work, we are 
continuing to explore the impact of parental substance abuse on 
foster care, by, for example, examining parents' substance 
abuse histories and their drug treatment experiences, as well 
as exploring initiatives that might help achieve timely foster 
care exits for cases involving parental substance abuse.
    Mr. Chairman, this concludes my prepared statement. I would 
be happy to respond to any questions from you or other Members 
of the Subcommittee.

                          Related GAO Products

    Child Protective Services: Complex Challenges Require New 
Strategies (GAO/HEHS-97-115, July 21, 1997).
    Foster Care: State Efforts to Improve the Permanency Planning 
Process Show Some Promise (GAO/HEHS-97-73, May 7, 1997).
    Cocaine Treatment: Early Results From Various Approaches (GAO/HEHS-
96-80, June 7, 1996).
    Child Welfare: Complex Needs Strain Capacity to Provide Services 
(GAO/HEHS-95-208, Sept. 26, 1995).
    Foster Care: Health Needs of Many Young Children Are Unknown and 
Unmet (GAO/HEHS-95-114, May 26, 1995).
    Foster Care: Parental Drug Abuse Has Alarming Impact on Young 
Children (GAO/HEHS-94-89, Apr. 4, 1994).
    Drug Abuse: The Crack Cocaine Epidemic: Health Consequences and 
Treatment (GAO/HRD-91-55FS, Jan. 30, 1991).
    Drug-Exposed Infants: A Generation at Risk (GAO/HRD-90-138, June 
28, 1990).
      

                                

    Chairman Shaw. Thank you.
    Mr. Reuter.

STATEMENT OF PETER REUTER, PH.D., SCHOOL OF PUBLIC AFFAIRS AND 
  DEPARTMENT OF CRIMINOLOGY, UNIVERSITY OF MARYLAND, COLLEGE 
                         PARK, MARYLAND

    Mr. Reuter. Thank you. I was asked to address the question 
of whether there are elevated levels of drug use among mothers 
on welfare. This is very much a presentation about data and 
estimates.
    The first thing to note is there are very few measurements 
of drug use among AFDC recipients, in part because agencies 
had, until recently, very little incentive to know anything 
about the drug substance abuse problems of their clients. 
Moreover, it is inherently difficult to develop such measures, 
both for the agencies and in more general settings, because 
they largely rely on self-report, which has its own frailties 
as a method of learning about these kinds of behaviors.
    Moreover, the figures are likely to change very 
substantially over time in response to changes in the business 
cycle. There are periods of high unemployment where the AFDC 
rolls have on them a large number of short-term clients with 
very different substance abuse patterns, including drug 
dependence, than those who are long-term clients.
    Moreover, in terms of making comparisons between AFDC and 
the rest of the population, it is not obvious what is the right 
comparison group to offer. The AFDC population has a much 
higher percentage of females than the general population; you 
certainly would want to adjust for differences in usage by 
gender. Age is different. There are very low rates of use in 
the population over the age of 50, very few welfare recipients 
are over the age of 50.
    One might also want to make adjustments for other 
characteristics that distinguish the AFDC population from that 
of the general population--for example, education, marital 
status, and so forth. Once you start making those kinds of 
adjustments for purposes of doing these kinds of comparisons, 
you have to ask the question, What is the purpose of the 
comparison? And if this were a Committee concerned with the 
Nation's drug problems, the question you might be attempting to 
answer is, What share of the Nation's drug problems are found 
in the AFDC population. Then knowing something about relative 
usage rates, in particular, in the two groups, would in fact be 
highly relevant.
    But if one's concern is, as I believe this Subcommittee's 
hearing description suggests, a concern about the transition 
from welfare to employment or reducing child abuse and neglect 
on the part of AFDC recipients, then the question is less the 
comparison between AFDC and the rest of the population and 
simply, What is the rate of substance abuse of various kinds in 
the AFDC population?
    Having said that, there are a few pieces of evidence 
available. They look very conflicting, but in fact I believe 
that is largely an artifact of how analysts have gone about 
defining the problem and, to some extent, the characteristics 
of the data that they have used. Consistently, we see higher 
rates of use or abuse of illicit drugs among AFDC clients than 
any reasonably defined comparison group in the general 
population. I think the best analysis of this is a recent study 
by the Office of Applied Studies of the Substance Abuse and 
Mental Health Services Administration, which found that, after 
adjusting for all the things that seemed relevant, the rate of 
problem use among welfare recipients, female welfare 
recipients, seemed to be twice as high as that for an 
appropriate comparison group. That still--and it is hard to do 
the calculations from what was presented in the report--
suggests that problem drug use among that population might well 
be less than 10 percent.
    Another way of looking at this is to go to the other end of 
the system and ask, What share of those in treatment are 
themselves recipients of AFDC payments? There are about 250,000 
women in treatment, and approximately one-half, I think, are 
AFDC recipients. One reason we want to be focusing on the back 
end is that the household surveys I cited before as providing 
estimates of the prevalence of drug abuse or dependence among 
AFDC population are known to generally provide substantial 
underestimates of drug dependence. You might use them for these 
kinds of comparisons, but they are probably poor ways of 
getting at the prevalence of substance abuse generally in the 
AFDC population. So I suggest, looking at treatment program 
data may be a useful way of supplementing those data.
    Finally, let me say this is not a static problem. Patterns 
of drug use have changed substantially over the last 20 years 
in this country. The rate of initiation into drug use has been 
down substantially from its peak rates in the eighties. It 
shows some sign of upturn now. Thus, it may well be that the 
figures we are now looking at are reasonable indicators of the 
next few years, but that further out there will be larger 
increases in drug use in the AFDC population.
    Thank you, Mr. Chairman.
    [The prepared statement follows:]

Statement of Peter Reuter, Ph.D., School of Public Affairs and 
Department of Criminology, University of Maryland, College Park, 
Maryland

                                Summary

    We have been asked to address the question of whether drug 
use is elevated among mothers on welfare. The answer is almost 
certainly yes but the bits of data available suggest that the 
differences are moderate. Looking at the more serious problem, 
abuse or dependence on illicit drugs is found in only a small 
percentage of welfare mothers. A figure as high as 15% would be 
hard to justify and it may be less than 10 percent. Trends in 
drug use in the general population, suggest that drug 
dependence within the welfare population is likely to become 
smaller rather than greater in the next few years.

                     The Data and Analytic Approach

    Because welfare agencies did not in the past have to 
concern themselves with what led their clients to seek AFDC, 
little data are available on the extent of substance abuse in 
this population. Certainly agencies themselves claim little 
knowledge.\3\ Instead we have to rely largely on self-report 
surveys either of the general household population, which 
include welfare clients, or specifically just of the latter 
population. There is also one indirect source, namely data on 
the extent of AFDC participation by drug treatment clients. 
None of these is very satisfactory but weaving the three 
together can provide a moderately credible statistical 
portrait.
---------------------------------------------------------------------------
    \3\ ``Only five states [out of 32] reported having estimates of the 
number of welfare recipients with alcohol and drug problems.'' Legal 
Action Center Making Welfare Reform Work: Tools for Confronting Alcohol 
and Drug Problems Among Welfare Recipients New York, 1997, p.38.
---------------------------------------------------------------------------
    Nor is it easy to decide on the appropriate method of 
making comparisons of drug use rates among welfare clients and 
the rest of the population. For example, surveys show that 
young adults are much more likely than those over 35 to be 
current drug users; in 1996 3.1 percent of those aged 26-34 
reported use of cocaine in the prior year, compared to only 0.8 
percent of those 35 or over. Since adult welfare recipients 
include few elderly, welfare recipients would show higher rates 
of drug use than the population generally even if they had the 
same age-specific rates. Hence it is necessary to make 
adjustments to reflect factors other than welfare status that 
might affect drug use rates; the appropriate adjustments are 
very much a matter of the analyst's judgment.
    Note also that the relative rate of drug use and abuse in 
the welfare population is likely to be cyclical. When 
unemployment is high, AFDC rolls (and presumably TANF rolls in 
the future) will include large numbers of short-termers whose 
long-term employment prospects are relatively good. Measured 
rates of drug dependence among welfare clients may decline, 
relative to the non-welfare population. Thus the ratio may be 
highest when enrollment is lowest. We know of no study that has 
attempted to adjust for this.
    Finally, there is the question of what one should employ as 
a measure of drug use and, more importantly, drug abuse or 
dependence. Some analysts rely on the frequency of drug use to 
define dependence or abuse. Other surveys have imbedded in 
their questionnaire a version of a clinical definition of abuse 
or dependence. Problematic though the latter are, they are 
preferable to mere frequency definitions both on conceptual and 
instrumental grounds; the clinical measures pose questions 
about less stigmatized behaviors than do those focused on 
details of drug use.

                               Estimates

    The most widely cited estimates of the prevalence of drug 
use among welfare mothers come from two national household 
surveys. They appear to show large differences but these are 
principally artifacts of the definitions chosen by analysts.
    The Center on Addiction and Substance Abuse (CASA) 
published a short report in 1994,\4\ apparently based on the 
1991 National Household Survey on Drug Abuse (NHSDA),\5\ 
asserting that ``[m]others receiving AFDC are three times more 
likely to abuse or be addicted to alcohol and drugs than 
mothers not receiving AFDC (27 percent compared to 9 percent)'' 
(p.3) It concluded that ``[a]t least 1.3 million adult welfare 
recipients currently abuse or are addicted to drugs and 
alcohol.'' (p.7) With fewer than 5 million adult welfare 
recipients, this is an alarming number.
---------------------------------------------------------------------------
    \4\ Center on Addiction and Substance Abuse Substance Abuse and 
Women on Welfare New York, 1994.
    \5\ The report makes no specific reference to the source of its 
data; there is however no other data source that would permit precisely 
the analyses that are reported. A later CASA report Substance Abuse and 
Federal Entitlement Programs (1995) does refer to the 1991 NHSDA but 
uses different categorizations in its charts so that it is impossible 
to determine if the analyses are the same in the two documents.
---------------------------------------------------------------------------
    More recently researchers at the National Institute on 
Alcohol Abuse and Alcoholism (NIAAA) published an analysis of 
the 1992 National Longitudinal Alcohol Epidemiologic Survey 
(NLAES) which concluded that only 3.6% of AFDC recipients over 
18 were drug dependent or drug abusers and that 7.6% were 
alcohol dependent.\6\ Moreover the authors concluded that rates 
for welfare recipients were ``comparable to rates of heavy 
drinking (14.8%), drug use (5.1%), alcohol abuse and/or 
dependence (7.5%) and drug abuse and/or dependence (1.5%) among 
the subpopulation of the United States not receiving welfare 
benefits.'' (p.1453)
---------------------------------------------------------------------------
    \6\ Grant, B. and D. Dawson ``Alcohol and Drug Use, Abuse and 
Dependence among Welfare Recipients'' American J. Public Health 86 
1450-1454.
---------------------------------------------------------------------------
    The principal explanation for these differences simply lie 
in the definitions of drug abuse. The CASA report never 
explicitly described how it classified an individual as a drug 
abuser or drug addict but it appears that using an illicit drug 
at least once per month was sufficient for that diagnosis.\7\ 
In contrast, the NIAAA researchers focused on behavioral 
problems related to drug or alcohol abuse, which are part of 
diagnostic instruments.
---------------------------------------------------------------------------
    \7\ This is the definition used in the later publication Substance 
Abuse and Federal Entitlement Programs.
---------------------------------------------------------------------------
    The CASA estimate seems far too high, particularly when we 
note that the vast majority of the drug users in the NHSDA 
consumed only marijuana. A monthly user of marijuana is 
certainly flouting the law regularly but may not have a serious 
behavioral health problem with important adverse consequences 
either for the mother or family. A more sophisticated analysis 
of the 1994 and 1995 NHSDA shows that, adjusting for a number 
of demographic and family characteristics, a woman on welfare 
is almost twice as likely as those not on welfare to be 
classified as a problem drug user.\8\ However, this suggests a 
rate for welfare women of less than 10 percent perhaps even 
much less.\9\
---------------------------------------------------------------------------
    \8\ Department of Health and Human Services Substance Use Among 
Women in the United States 1997. Table 3.10. Problem drug use is 
defined as: dependent on an illicit drug (using DSM-IV criteria); 
injection drug use; frequent user of illicit drug (e.g. weekly user of 
cocaine or daily user of marijuana); used heroin or received treatment 
in the previous year. Factors used to calculate the relative odds ratio 
include: age, race, marital status, education and family size. The 
relative odds ratio of 1.92 is statistically significantly different 
from 1 at the 5 percent level.
    \9\ The report does not present adjusted figures for the non-
welfare population. Note however that for women aged 18-24 the 
unadjusted rate for problem drug use is 4.3% and falls sharply after 
that.
---------------------------------------------------------------------------
    That is not to say that rates as low as those reported by 
the NLAES or NHSDA should be accepted at face value. These 
nationwide household surveys are known to underestimate the 
prevalence of drug abuse and dependence. For example, in recent 
years the NHSDA has produced estimates of the total number of 
frequent cocaine users of about 700,000; \10\ yet other 
estimates, reflecting the results of urinalysis of arrestees, 
generate estimates of about double that figure.\11\ Heroin 
dependence, estimated to affect about 600,000 persons,\12\ 
cannot be determined from the NHSDA, mostly because of the 
instability of the lifestyles of heroin addicts. It would be 
naive to rely solely on these general population surveys for 
estimates of the extent of drug use and abuse among AFDC 
recipients.
---------------------------------------------------------------------------
    \10\ Department of Health and Human Services National Household 
Survey on Drug Abuse: Population Estimates Rockville, Md. 1996. The 
cited figure is for weekly users.
    \11\ These estimates are cited in the annual National Drug Control 
Strategy.
    \12\ Rhodes et al. What America's Drug Users Spend on Illicit Drugs 
1988-1993 Washington, Office of National Drug Control Policy, 1995.
---------------------------------------------------------------------------
    Many factors contribute to the weakness of these surveys in 
estimating the number of frequent users. First, many cocaine 
and heroin abusers are found outside of households, whether 
they are homeless, incarcerated or otherwise institutionalized. 
Though 98 percent of all Americans live in households, these 
other settings may contain a substantial share of the tiny 
fraction that have drug abuse problems. For example, if there 
are 4 million persons outside the houshold population and 15% 
of them are drug dependent, not an unreasonable figure, then 
this 600,000 would constitute nearly 10% of the estimated 
number of drug dependent individuals and probably a much larger 
share of those dependent on cocaine or heroin. Second, drug 
abusers are probably harder to reach when they are in 
households; they are less likely to be there and available to 
respond at a specific time. Third, they are less likely to 
report the full extent of their drug use.
    An alternative approach has been to obtain data directly 
from samples of AFDC clients. The Alcohol Research Group at the 
University of California, Berkeley has been conducting research 
on a variety of public program settings in Northern California. 
They published initial results in 1993, reflecting data 
collection carried out between 1986 and 1989.\13\ They found 
that 21 percent of welfare clients were multiple drug users, on 
a past year basis. In a general population survey in the same 
geographic area, they found only 1 percent using more than one 
illicit drug.\14\ That is an alarmingly large difference, 
suggesting that welfare recipients are twenty times more likely 
to use drugs other than marijuana. However the results should 
be treated with considerable skepticism because the rate in the 
general population sample is so far below that found in 
national household surveys; the 1988 NHSDA data for example 
suggests that about 5 percent had used more than one illicit 
drug in the previous year.\15\
---------------------------------------------------------------------------
    \13\ Weisner, C and L. Schmidt ``Alcohol and Drug Problems among 
Diverse Health and Social Service Populations'' American J. Public 
Health 83 824-829.
    \14\ The results for the welfare population are adjusted to 
represent the age, sex and ethnic distributions in the general 
population.
    \15\ The 1988 NHSDA reported that 7.5% of the household population 
used some drug other than marijuana in the previous year. Other survey 
data suggest that most users of cocaine, heroin and other ``harder'' 
drugs contemporaneously use marijuana; if two thirds used marijuana, 
that would suggest a household multiple drug use rate of at least 5 
percent.
---------------------------------------------------------------------------
    Another more speculative approach to estimation starts at 
the other end of the process, namely with drug treatment. A 
large share of the 250,000 women reported by state officials as 
being in drug treatment programs \16\ are welfare recipients. 
With a number of assumptions of varying plausibility about the 
probability that a woman who is drug dependent will enter 
treatment, it is possible to develop rough estimates of how 
many adult female welfare recipients are currently drug 
dependent. We report here just some initial indicative 
calculations.
---------------------------------------------------------------------------
    \16\ National Association of State Alcohol and Drug Abuse Directors 
State Resources and Services Related to Alcohol and Other Drug 
Problems1993 Washington, DC 1995.
---------------------------------------------------------------------------
    A study of the patient population of California's drug and 
alcohol treatment programs in 1991-92 reports that 41 percent 
of female patients had received welfare payments in the year 
before treatment.\17\ A survey of 17 treatment programs 
recently reported by the Legal Action Center reports that 56% 
of female clients are AFDC recipients.\18\ If indeed half of 
the clients are welfare recipients and there are 4 million 
women over the age of 18 receiving welfare, then approximately 
3% of any year's welfare recipient population would be 
classified as problem drug users under the NHSDA definition for 
that reason alone. Given that treatment is thought to reach 
only about one quarter of those most in need, that would 
suggest a figure closer to 10 percent for drug dependence among 
female adult welfare clients.
---------------------------------------------------------------------------
    \17\ Gerstein, D. et al. Alcohol and Other Drug Treatment for 
Parents and Welfare Recipients: Outcomes, Costs and Benefits Department 
of Health and Human Services, Office of the Assistant Secretary for 
Planning and Evaluation, 1997. The report is not specific as to the 
definition of a welfare recipient, so this figure may include some who 
receive General Assistance.
    \18\ Legal Action Center Making Welfare Reform Work: Tools for 
Confronting Alcohol and Drug Problems Among Welfare Recipients New 
York, 1997.
---------------------------------------------------------------------------
    Given all these uncertainties, we suggest that it is likely 
that the rate of dependence on illicit drugs among AFDC mothers 
in recent years has been between 5 and 10 percent. Improving 
these estimates ought to have some urgency as the nation moves 
to a welfare system aimed at getting clients into work.

           The Future of Drug Abuse among Welfare Recipients

    The issue for welfare reform is only partly drug use levels 
among current recipients. Welfare reform is a policy change for 
the long haul and should reflect the prevalence of drug use 
likely to be found in new applicants for TANF.
    Drug use patterns among the welfare population reflects 
those in the general population. Despite rising adolescent 
marijuana use, the available evidence suggests that drug 
dependence among future cohorts of young adults is likely to 
decline for a few years. Indeed, cocaine initiation rates have 
been low for the last decade in the highest risk population 
groups. For example, the District of Columbia Pretrial Services 
Agency (PSA) has conducted drug tests on all juvenile arrestees 
since 1987; it is the only agency in the nation that does so. 
Marijuana positive rates have sky-rocketed, from less than 10 
percent in 1990 to 72 percent in 1997. However for all other 
drugs the rates for drug positives among juvenile arrestees 
have been extremely low since 1990. Whereas in 1988 about 23 
percent of juvenile arrestees tested positive for cocaine the 
rates since 1990 have never been higher than 9 percent and 
frequently less than 5 percent. Similar declines in rates of 
cocaine use have been reported among juvenile arrestees in 
other cities.\19\
---------------------------------------------------------------------------
    \19\ See ``Drop in Homicide Rates Linked to Decline in Crack 
Epidemic'' New York Times October 27, 1997, p.A12.
---------------------------------------------------------------------------
    In the general population, as reported in the NHSDA, 
cocaine initiation rates, i.e. the number who start use of that 
drug in each year, have been relatively low for some time, 
reflecting the sharp increase in the perception of the drug's 
dangerousness. In 1984 an estimated 1.35 million persons used 
cocaine for the first time; that figure was down to 650,000 in 
1995. However it has risen sharply from its floor of 450,000 in 
1992. Moreover, initiation rates have increased most rapidly 
for the youngest age group tracked, 12-17; whereas in 1991 only 
4.6 percent of 12-17 year olds who had not previously tried 
cocaine experimented for the first time, the figure had risen 
to 10.6 percent in 1995.\20\
---------------------------------------------------------------------------
    \20\ Department of Health and Human Services Preliminary Results 
from the 1996 National Household Survey on Drug Abuse Substance Abuse 
and Mental Health Services Administration, 1997.
---------------------------------------------------------------------------
    It is difficult then to make projections as to the future 
patterns of drug use among welfare mothers. General population 
initiation rates are still very much below their 1980s peaks. 
However, recent trends do suggest that there may be at least a 
modest upturn in both use and abuse rates. It is unlikely 
though that this will lead to any notable increase in drug 
dependence rates in the near future.

Peter Reuter \21\
---------------------------------------------------------------------------
    \21\ School of Public Affairs, Department of Criminology, 
University of Maryland. Mr. Reuter delivered his testimony at the 
Committee hearing on October 28, 1997.
---------------------------------------------------------------------------
Patricia Ebener \22\
---------------------------------------------------------------------------
    \22\ Drug Policy Research Center, RAND Corporation.
---------------------------------------------------------------------------
      

                                

    Chairman Shaw. Thank You.
    Mr. Zill.

STATEMENT OF NICHOLAS ZILL, PH.D., VICE PRESIDENT AND DIRECTOR, 
 CHILD AND FAMILY STUDY AREA, WESTAT, INC., ROCKVILLE, MARYLAND

    Mr. Zill. Good afternoon, Chairman Shaw and Members of the 
Human Resources Subcommittee. My name is Nicholas Zill. I am a 
research psychologist and director of the Child and Family 
Study Area at Westat, a survey research firm here in the 
Washington area. As part of my work at Westat and an earlier 
position as the executive director of Child Trends, I have done 
a good deal of research on the characteristics of welfare 
families and the development and well-being of children in 
those families and in low-income families that are not 
receiving welfare.
    Chairman Shaw invited me here today to share with you what 
this research has shown about the frequency of parental 
substance abuse in welfare families and to comment on what the 
implications of such abuse might be for the children in these 
families and for efforts to move parents off welfare and into 
steady jobs.
    The data I report to you come from two Federal surveys. One 
is the National Household Survey on Drug Abuse, conducted 
regularly by the Substance Abuse and Mental Health Services 
Administration; the other is the National Pregnancy and Health 
Survey that Westat conducted for the National Institute on Drug 
Abuse. This was a survey of 2,612 women who gave birth during a 
12-month interval in 1992 and 1993. The women were located and 
interviewed in a probability sample of maternity hospitals 
across the United States.
    What both of these surveys showed was the use of illicit 
drugs, such as cocaine, heroin, and marijuana, is significantly 
more common among female welfare recipients than among the 
general population of American women. The Household Survey 
found illegal drug abuse to be twice as common among female 
welfare recipients as among women who did not receive welfare. 
The hospital survey found illicit drug use during pregnancy was 
three times more common among women receiving AFDC than among 
those not receiving AFDC. Cocaine use during pregnancy, usually 
in the form of crack, was 10 times higher among pregnant 
welfare recipients than among nonrecipients.
    The majority of women who, during pregnancy, used cocaine 
were on welfare. At the same time, it is important to note it 
was only a minority of welfare recipients who used prohibited 
drugs. Of all female welfare recipients, about one in five used 
some illegal drugs during the last year; of female recipients 
who were expecting, about one in seven used some unlawful drug, 
and about one in twenty used crack or cocaine during their 
pregnancies. These proportions are disquieting enough, but we 
must be careful not to characterize all or even most AFDC 
recipients as drug abusers.
    It is also the case, women in low-income families who did 
not receive AFDC used some drugs with almost the same frequency 
as welfare mothers; thus, the phenomenon we are addressing 
could be characterized as a poverty problem as much as a 
welfare problem.
    Are young children whose mothers use illicit drugs, and 
crack in particular, at greater risk of health and learning 
problems than children whose mothers are not chronic drug 
users? We know expectant mothers who use cocaine are more 
likely to produce low-birth-weight babies and babies who die 
during infancy. Some researchers believe they are also more 
likely to produce babies who grow up to have neurological 
disorders and learning disabilities, although the long-term 
effects of prenatal crack exposure on children's development 
are still being studied and debated.
    Common sense suggests a woman who is not able to give up 
cocaine in order to protect the health of an unborn child in 
her womb is likely to neglect other aspects of the child's care 
as well, both during pregnancy and after the child's birth. 
There are lots of data to support this supposition. The 
National Pregnancy and Health Survey found, compared to 
expectant mothers not on welfare, women in welfare families who 
became pregnant were 2\1/2\ times more likely to get prenatal 
care late or not at all. They were 60 percent more likely to 
gain inadequate amounts of weight during pregnancy, and twice 
as likely to have a pregnancy too soon after the birth of a 
previous child for optimum development of either. These other 
neglectful behaviors were correlated with maternal drug use.
    Another Federal study, the National Maternal and Infant 
Health Survey, found that infants from a welfare family were 
two-thirds more likely to die during the first year of life as 
infants from nonpoor families. An epidemiological study in 
North Carolina found that young children in welfare families 
had significantly higher rates of death due to unintentional 
injuries than those in nonwelfare families. Furthermore, the 
National Health Interview Survey has found school-aged children 
from welfare families have significantly higher rates of grade 
repetition, classroom conduct problems, and special education 
placements than their classmates from nonpoor families. It is 
unlikely these negative outcomes for welfare children are 
solely due to maternal drug use. Factors like low maternal IQ, 
poverty, and low maternal education are also important, but 
there are clearly negative consequences for children when their 
mothers engage in persistent patterns of detrimental health-
related behavior. Chronic drug use is often part of such a 
high-risk behavior pattern.
    To close my testimony, I would like to leave the survey 
data and turn to the question of whether welfare recipients who 
are drug abusers should be treated differently from other 
recipients with respect to being required to find jobs and 
being subject to time limits on their receipt of cash 
assistance. Should they, for example, be allowed to continue 
receiving welfare until they have been successfully treated for 
their substance abuse problems? I would argue they should not.
    Treatment of chronic substance abuse is a difficult and 
often frustrating process. Successful outcomes are associated 
with the abuser becoming fed up with their own self-destructive 
behavior and being ready to change. Being given a guarantee of 
continued welfare support does not increase motivation to 
change; it reduces it. Although it seems like the humane thing 
to do, it is not wise. It is also bad for the many welfare 
recipients who are not drug abusers to have temporary 
assistance to needy families linked in the public mind with 
subsidized addiction.
    I am going to conclude my testimony there. I have a little 
more I had to say about that, but I would request my extended 
statement and accompanying data tables be inserted into the 
record; they provide fuller documentation of the survey 
findings I have presented.
    Thank you.
    Mr. Shaw. It shall be, Dr. Zill.
    [The prepared statement and attachments follow:]

Statement of Nicholas Zill, Ph.D., Vice President and Director, Child 
and Family Study Area, Westat, Inc., Rockville, Maryland

    Good afternoon, Chairman Shaw and Members of the Human 
Resources Subcommittee. My name is Nicholas Zill. I am a 
research psychologist and the Director of the Child and Family 
Study Area at Westat, a survey research firm based in the 
Washington area. As part of my work at Westat and in an earlier 
position as the Executive Director of Child Trends, I have done 
a good deal of research on the characteristics of welfare 
families and the development and well-being of children in 
those families and in low-income families that are not 
receiving welfare. This research was partly supported by 
contracts from federal agencies, such as the Office of the 
Assistant Secretary for Planning and Evaluation of the 
Department of Health and Human Services, and partly by grants 
from private foundations. Chairman Shaw invited me here today 
to share with you what this research has shown about the 
frequency of parental substance abuse in welfare families and 
to comment on what the implications of such abuse might be for 
the children in these families and for efforts to move parents 
off welfare and into steady jobs.
    The data I report to you come from two federal surveys. One 
is the National Household Survey on Drug Abuse conducted 
regularly by the Substance Abuse and Mental Health Services 
Administration (SAMSHA). This is a survey of the civilian 
population aged 12 years of age and older living in households 
in the United States. The other is the National Pregnancy and 
Health Survey that Westat conducted for the National Institute 
on Drug Abuse. This was a survey of 2,612 women who gave birth 
during a 12-month interval in 1992-93. The women were located 
and interviewed in a probability sample of maternity hospitals 
across the U.S.
    What both of these surveys showed was that the use of 
illicit drugs such as cocaine, heroin, and marijuana is 
significantly more common among female welfare recipients than 
among the general population of American women. The household 
survey found illegal drug use to be twice as common among 
female welfare recipients as among women who did not receive 
welfare. The hospital survey found that illicit drug use during 
pregnancy was three times more common among women receiving Aid 
to Families With Dependent Children than among those not 
receiving AFDC. Cocaine use during pregnancy (usually in the 
form of ``crack'') was ten times higher among pregnant welfare 
recipients than among non-recipients.
    At the same time, it is important to note that it was only 
a minority of welfare recipients who used prohibited drugs. Of 
all female welfare recipients, about one in five used some 
illegal drugs during the last year. Of female recipients who 
were expecting, about one in seven used unlawful drugs, and 
about one in twenty used crack or cocaine during their 
pregnancies. These proportions are disquieting enough, but we 
should be careful not to characterize all or even most AFDC 
recipients as drug abusers. It is also the case that women in 
low-income families who did not receive AFDC used some drugs 
with almost the same frequency as welfare mothers. Thus, the 
phenomenon we are addressing could be characterized as a 
poverty problem as much as a welfare problem.
    Are young children whose mothers use illicit drugs, and 
crack in particular, at greater risk of health and learning 
problems than children whose mothers are not chronic drug 
users? We know that expectant mothers who use cocaine are more 
likely to produce low birth weight babies and babies who die 
during infancy. Some researchers believe they are also more 
likely to produce babies who grow up to have neurological 
disorders and learning disabilities, although the long-term 
effects of prenatal crack exposure on children's development 
are still being studied and debated.
    Common sense suggests that a woman who is not able to give 
up cocaine in order to protect the health of an unborn child in 
her womb is likely to neglect other aspects of the child's care 
as well, both during pregnancy and after the child's birth. 
There are lots of data to support this supposition. For 
example, the National Pregnancy and Health Survey found that, 
compared to expectant mothers not on welfare, women in welfare 
families who became pregnant were two-and-a-half times more 
likely to get prenatal care late or not at all. They were 60 
percent more likely to gain inadequate amounts of weight during 
pregnancy, and twice as likely to have a pregnancy too soon 
after the birth of a previous child for optimum development of 
either. These other neglectful behaviors were correlated with 
maternal drug use.
    Another federal study, the National Maternal and Infant 
Health Survey, found that infants from welfare families were 
two-thirds more likely to die during the first year of life as 
infants from non-poor families. An epidemiological study in 
North Carolina found that young children in welfare families 
had significantly higher rates of death due to unintentional 
injuries than those in non-welfare families. The National 
Health Interview Survey has found that school-aged children 
from welfare families have significantly higher rates of grade 
repetition, classroom conduct problems, and special education 
placements than their classmates from non-poor families. It is 
unlikely that these negative outcomes for welfare children are 
solely due to maternal drug use. Factors like low maternal IQ, 
poverty, and low maternal education are also important, perhaps 
more important. But there are clearly negative consequences for 
children when their mothers engage in a persistent pattern of 
detrimental health-related behavior. Chronic drug use is often 
part of such a high-risk behavior pattern.
    To close my testimony, I would like to leave the survey 
data and turn to the question of whether welfare recipients who 
are drug abusers should be treated differently from other 
recipients with respect to being required to find jobs and 
being subject to time limits on their receipt of cash 
assistance. Should they, for example, be allowed to continue 
receiving welfare until they have been successfully treated for 
their substance abuse problems? I would argue that they should 
not. Treatment of chronic substance abuse is a difficult and 
often frustrating process. Successful outcomes are associated 
with the abuser becoming fed up with her own self-destructive 
behavior and being ready to change. Being given a guarantee of 
continued welfare support does not increase motivation to 
change, it reduces it. Although it seems like a humane thing to 
do, it is not wise. It is also bad for the many welfare 
recipients who are not drug abusers to have Temporary 
Assistance to Needy Families (TANF) linked in the public mind 
with subsidized addiction.
    Certainly, TANF should provide treatment programs for 
recipients who have drug problems. But treatment should occur 
in parallel with preparation for work and transitional 
employment, not prior to it. There are plenty of examples 
outside of the welfare world of people with substance abuse 
problems who are able to hold down jobs. Like other recipients, 
those with substance abuse problems should be subject to time 
limits on their receipt of cash assistance. It may be necessary 
to provide employers with extra inducements to take on welfare 
recipients who are drug abusers, because drug abusers often 
steal to support their habits. The whole process is not going 
to be easy. There are going to be painful failures. But this 
kind of approach is still preferable to one which provides no 
incentive for overcoming drug dependence.
    That concludes my testimony. I would request that my 
extended statement and accompanying data tables be entered into 
the record. They provide fuller documentation of the survey 
findings I have presented. Thank you.
      

                                

Supplementary Statement by Nicholas Zill, Ph.D., Westat, Inc.

    According to the National Household Survey on Drug Abuse 
(NHSDA) conducted by the Substance Abuse and Mental Health 
Services Administration (SAMSHA), the use of illicit drugs such 
as marijuana, cocaine, and heroin is more prevalent among 
welfare recipients than in the general population (Colliver and 
Quinn, 1994). Specifically:
     Among females aged 15 and over living in 
households where AFDC benefits were received, 21 percent 
reported some illicit drug use in the last year, and 10.5 
percent reported use in the last month. These rates were twice 
as high as those for females in non-AFDC households. (Table 1).
     The illicit drug most commonly abused by welfare 
recipients is marijuana, with 16 percent reporting use of this 
drug in the last year. This is double the rate of use among 
females not in welfare households.
     Cocaine abuse is also common, usually in the form 
of crack, with 5.5 percent of females in welfare households 
reporting cocaine use in the last year. This is nearly triple 
the rate of use among non-welfare females.
     Non-medical use of psychotherapeutic drugs such as 
tranquilizers, stimulants, or barbiturates in the past year is 
reported by 6.9 percent of welfare females.
     Daily alcohol use is no more common among welfare 
recipients than among other females. But binge drinking--having 
five or more drinks one or more times in the past 30 days--is 
reported by 12.5 percent of females in welfare households, 
nearly sixty percent higher than the rate among females from 
non-welfare households.
    Illicit drug use is more common among some AFDC subgroups 
than among others. In particular:
     Nearly 30 percent of welfare mothers who have 
never married have used illicit drugs in the past year. This 
drug use rate is more than three times higher than the rate 
among welfare mothers who are currently married. Welfare 
recipients who are divorced or separated fall in between, with 
19 percent having used some illegal drug in the past year. 
(Table 2).
     Drug use is more common among welfare mothers who 
are looking for work than among those currently employed full-
time or not in the labor force.
     Drug use is more common among welfare recipients 
in their teens or twenties than among those in their thirties 
or forties.
     Drug use is more common among white non-Hispanic 
or black non-Hispanic recipients than among Hispanic 
recipients.
     Drug use is less common among female recipients 
who are high school graduates (but no more) than among those 
who have not finished high school or those who have some 
postsecondary schooling.
    It is important to note that the above estimates are based 
on self-reported drug use by welfare recipients and other 
survey respondents. Self-reports of drug use have to be 
interpreted with caution, even when they come from surveys like 
the NHSDA that go to extra lengths to assure respondents of 
anonymity and that no negative consequences will occur to them 
from acknowledging use of illegal substances. Methodological 
studies in which chemical testing or other methods are used to 
validate self-reports of drug use have found underreporting to 
be common, and more so in some groups than in others. Questions 
that ask whether the person has ever used illegal drugs or used 
them in the last year tend to produce more complete self-
identification of drug use than questions dealing with current 
use (use in last month or week). Based on findings to date, we 
can be fairly confident that drug abuse is more common among 
welfare recipients, but less confident about the exact extent 
of use.

                   Illicit drug use during pregnancy

    Expectant mothers who use cocaine or other illicit drugs 
during their pregnancies are more likely to produce low birth 
weight babies, babies who die during infancy, and babies who 
grow up to have neurological disorders and learning 
disabilities. The National Pregnancy and Health Survey found 
that among women who were receiving AFDC and gave birth during 
1992-93, more than 13 percent reported using some illicit drug 
during their pregnancies. This was more than three times the 
rate of illicit drug use among expectant mothers who were not 
receiving AFDC, which was about 4 percent (Table 3).
    The study found that more than 5 percent of the expectant 
mothers receiving AFDC reported cocaine use (usually in the 
form of ``crack'') during their pregnancies. This was ten times 
higher than the cocaine use rate (0.5 percent) among expectant 
mothers not receiving AFDC. Sixty percent of all the 
pregnancies in which cocaine use was involved were to women 
receiving AFDC, whereas these women represented less than 13 
percent of all pregnancies during the study period.
    Expectant mothers on welfare appeared to be more likely 
than nonwelfare mothers to have smoked marijuana--6 percent 
versus 3 percent--or made nonmedical use of psychotherapeutic 
drugs, such as tranquilizers or antidepressants--3 percent 
versus 1 percent. However, the differences involved were not 
large enough to be statistically significant. A small 
proportion of expectant mothers on welfare (1.6 percent) 
reported using methamphetamine, inhalants, or hallucinogens 
during their pregnancies. Although this rate appeared to be 3 
times higher than the rate among nonwelfare mothers (0.5%), and 
more than twice as high as the overall rate of use among 
expectant mothers (0.6%), these differences were also not 
statistically reliable. The proportion reporting use of heroin 
or methadone was much lower (less than 0.1 percent) and not 
different from the overall rate or the rate for nonwelfare 
mothers (both of which were 0.2 percent).
    The study also found that welfare mothers were twice as 
likely as non-welfare recipient mothers to have smoked 
cigarettes during their pregnancies--37 percent versus 18 
percent. On the other hand, there was no significant difference 
in the reported use of alcohol during pregnancy--21 percent and 
19 percent (Table 3).
    The illicit drug use rate among all women living in AFDC 
households who gave birth during the study period was more than 
11 percent. (The group included here includes teenage daughters 
or other female relatives who gave birth during the study 
period, as well as the welfare recipients themselves.) This was 
more than three times higher than the 3 percent rate of illicit 
drug use among expectant mothers from nonpoor, nonwelfare 
households, and twice as high as the rate among all expectant 
mothers, which was 5-and-a-half percent. It also appeared 
higher than the rate found among women in poor, nonwelfare 
households (8 percent). However, the latter difference was not 
statistically reliable (Table 4).
    With regard to use of specific types of drugs, cocaine use 
and use of methamphetamine, inhalants, or hallucinogens seemed 
to be higher among welfare mothers than among nonwelfare poor 
mothers. Again, however, the differences involved were not 
statistically significant. Rates of marijuana use, nonmedical 
use of psychotherapeutic drugs, and heroin or methadone use 
were similar in the two low-income groups (Table 4).

                               References

    Coiro, M.J., Zill, N., & Bloom, B. (1994). Health of our nation's 
children. National Center for Health Statistics. Vital and Health 
Statistics 10. Washington, DC: U.S. Government Printing Office.
    Colliver, J., & Quinn, E. (1994) Patterns of substance use and 
program participation. Report prepared for the Office of the Assistant 
Secretary for Planning and Evaluation and the National Institute on 
Drug Abuse, U.S. Department of Health and Human Services, Washington, 
DC.
    Nelson, M.D., Jr. (1982). Socioeconomic status and childhood 
mortality in North Carolina. American Journal of Public Health. 1131-3 
(August).
    Zill, N., Moore, K.A., Nord, C.W., and Stief, T. (1991). Welfare 
mothers as potential employees: a statistical profile based on national 
survey data. Washington DC: Child Trends, Inc.
    Zill, N., Moore, K.A., Smith, C.W., Stief, T., and Coiro, M.J. 
(1995). The life circumstances and development of children in welfare 
families: a profile based on national survey data. In: Chase-Lansdale, 
P.L., & Brooks-Gunn, J., editors. Escape from poverty: What makes a 
difference for poor children? New York: Cambridge University Press.
    Zill, N. (1996). What we know about welfare families and what it 
means for welfare reform. Report prepared for the American Enterprise 
Institute. Rockville, MD: Westat, Inc.
      

                                

   Table 1. Prevalence of Reported Illicit Drug and Alcohol Use Among
Females Aged 15 and Over Who Live in AFDC Recipient Households, Compared
    To Use by Females in Nonrecipient Households, United States, 1991
------------------------------------------------------------------------
                                              Females in:
                              ------------------------------------------
                                                            Recipients'
                                   AFDC                     use rate as
                                recipient   Nonrecipient   percentage of
                                households   households   nonrecipients'
                                                                use
------------------------------------------------------------------------
Type of drug or alcohol use:
  Any illicit drug use in
   past year.................        21.1%         10.6%           200%
    Marijuana use............        16.2%          7.2%           227%
    Cocaine use..............         5.5%          1.9%           285%
    Nonmedical use of
     psychotherapeutic drugs.         6.9%          4.5%           154%
  Daily alcohol use in past
   year......................         6.6%          5.4%        122% ns
  Binge drinking in last
   month.....................        12.5%          8.0%           157%
------------------------------------------------------------------------
Note: Difference between recipients and nonrecipients is statistically
  reliable unless indicted by ``ns.''
Source: Author's retabulation of data from Colliver, J., & Quinn, E.
  (December 1994). Patterns of Substance Use and Program Participation.
  Washington, DC: U.S. Department of Health and Human Services, Office
  of the Assistant Secretary for Planning and Evaluation and National
  Institute on Drug Abuse.

      

                                


   Table 2. Prevalence of Reported Illicit Drug Use Among Female AFDC
   Recipients by Marital Status, Age, Race and Ethnicity, Educational
         Attainment, and Employment Status, United States, 1991
------------------------------------------------------------------------
                                                               Rate of
                                                 Percentage    illicit
                                                  of AFDC    drug use in
                                                 Recipients   last year
------------------------------------------------------------------------
All female AFDC recipients aged 15 and over...         100%        21.1%
Marital status:
    Never married.............................          44%        29.8%
    Separated or divorced.....................          32%        19.3%
    Currently married.........................          20%         8.2%
    Widowed...................................           4%         ----
Age group:
    15-19 years old...........................          14%        30.2%
    20-25 years old...........................          22%        31.6%
    26-30 years old...........................          17%        31.2%
    31-35 years old...........................          14%        20.5%
    36-40 years old...........................          12%         ----
    Over 40 years old.........................          21%         4.3%
Race/ethnicity:
    White (non-Hispanic)......................          45%        22.5%
    Black (non-Hispanic)......................          36%        23.4%
    Hispanic..................................          14%        12.5%
    Other.....................................           5%         ----
Educational attainment: *
    Less than high school.....................          45%        22.4%
    High school graduate......................          37%        17.4%
    Some postsecondary schooling..............          18%        23.3%
Employment status: *
    Employed full time........................          14%        17.8%
    Employed part time........................          11%         ----
    Looking for work..........................          22%        29.6%
    Not in labor force........................          53%        18.1%
------------------------------------------------------------------------
---- Subsample too small for stable estimate.
* Recipients aged 18 and over only.
Source: Author's retabulation of data form Colliver, J., & Quinn, E.
  December 1994). Patterns of Substance Use and Program Participation.
  Washington, DC: U.S. Department of Health and human Services, Office
  of the Assistant Secretary for Planning and Evaluaiton and National
  Institute on Drug Abuse.

      

                                


  Table 3. Illicit Drug, Cigarette, and Alcohol Use During Pregnancy by Women Receiving and Not Receiving AFDC
                        During 12 Months Prior to Birth of Child, United States, 1992-93
----------------------------------------------------------------------------------------------------------------
                                                Women giving birth during 12-month
                                                           study period                               Percentage
                                             ---------------------------------------   Recipients'   of all drug-
                                                                         All women     use rate as     involved
                                                 Women      Women not      giving     percentage of  mothers who
                                               currently    receiving      birth     nonrecipients'      were
                                               receiving       AFDC        during         rate        receiving
                                                  AFDC                     period                        AFDC
----------------------------------------------------------------------------------------------------------------
During pregnancy mother used:
  Any illicit drug..........................      13.3% *         4.4%         5.5%           304%           30%
    --Cocaine...............................       5.3% *         0.5%         1.1%         1,019%           60%
    --Marijuana.............................         5.8%         2.5%         3.0%           229%           25%
    --Nonmedical use of psychotherapeutic
     drug...................................       3.3% +         1.3%         1.5%           259%           27%
    --Methamphetamine, inhalants, or
     hallucinogens..........................         0.6%         0.5%         0.6%           339%           33%
    --Heroine or methadone..................        <0.1%         0.2%         0.2%  ..............  ...........
  Cigarettes................................      37.4% *        17.9%        20.4%           208%           23%
  Alcohol...................................        20.6%        18.6%        18.8%           111%           14%
  Unweighted sample size....................          361        2,251        2,612  ..............  ...........
  Estimated number in population............       506,17    3,515,319    4,021,494  ..............  ...........
  Weighted percentage.......................        12.6%        87.4%       100.0%
----------------------------------------------------------------------------------------------------------------
* Significantly different from use rate of nonrecipients, p<.05
+ Significantly different from use rate of nonrecipients, p<.10
Source: Zill, N., and Loomis, L. Analysis of unpublished data from the National Pregnancy and Health Survey,
  National Institute on Drug Abuse, 1992-93. Westat, Inc., 1995.

      

                                

 Table 4. Illicit Drug, Cigarette, and Alcohol Use During Pregnancy by Women from AFDC Households, Poor Non-AFDC
                           Households, and Nonpoor Households, United States, 1992-93
----------------------------------------------------------------------------------------------------------------
                                                          Women giving birth during 12-month study period
                                                 ---------------------------------------------------------------
                                                                                     Women in
                                                     Women in      Women in poor   nonpoor, non-     All women
                                                    households       non-AFDC          AFDC        giving birth
                                                  receiving AFDC    households      households
----------------------------------------------------------------------------------------------------------------
During pregnancy mother used:
  Any illicit drug..............................           11.4%            8.1%            3.4%            5.5%
    --Cocaine...................................            3.8%            0.9%            0.5%            1.1%
    --Marijuana.................................            5.6%            5.7%            1.6%            3.0%
    --Nonmedical use of psychotherapeutic drug..            2.8%            2.5%            1.0%            1.5%
    --Methamphetamine, inhalants, or
     hallucinogens..............................            1.1%            0.4%            0.5%            0.6%
    --Heroine or methadone......................            0.2%            0.2%            0.1%            0.2%
  Cigarettes....................................           32.6%           25.4%           16.0%           20.4%
  Alcohol.......................................           18.2%           10.9%           20.9%           18.8%
  Unweighted sample size........................             486             416           1,710           2,612
  Estimated number in population................         698,047         634,037       2,689,410       4,021,494
  Weighted percentage...........................           17.4%           15.8%           66.9%          100.0%
----------------------------------------------------------------------------------------------------------------
Source: Zill, N., and Loomis, L. Analysis of unpublished data from the National Pregnancy and Health Survey,
  National Institute on Drug Abuse, 1992-93. Westat, Inc., 1995.

      

                                

  STATEMENT OF NANCY K. YOUNG, PH.D., DIRECTOR, CHILDREN AND 
               FAMILY FUTURES, IRVINE, CALIFORNIA

    Ms. Young. Good afternoon. I am here today as a policy 
researcher, as an adviser to several States and communities and 
also as an adoptive parent of two children, whose lives embody 
this problem, families affected by alcohol and other drugs.
    At the most important moment in the life of our children's 
birth mother, the moment when she had been told she was going 
to lose custody of her children, she said, I want help, I will 
do anything to get them back. Unfortunately, the answer which 
the child welfare system gave to her was, Call me next week; I 
will give you a list of phone numbers for treatment, but I 
don't have access to help you get into the program and I don't 
know if they have any vacancies. My testimony today is in hopes 
you will do all you can to provide a better answer to the 
hundreds of thousands of parents who find themselves in that 
position.
    Many, not all, but many of those parents are ready to do 
what they need to do to end their abuse of alcohol and other 
drugs. But the response they get from the three systems that 
are funded separately--welfare, child welfare, and substance 
abuse treatment--is utterly inadequate, because those systems 
usually don't talk to parents in a unified way and often don't 
have the language to talk to each other.
    My message today includes three essential points. First, 
these systems typically do not work together despite the fact 
that the vast majority of the families entering the child 
welfare system have substance abuse problems.
    A basic first step has to be collecting better information 
on these overlaps. We need the provision in H.R. 867, the 
Adoption Promotion Act, which requires the Secretary of HHS to 
look at the substance abuse needs among the welfare system.
    Second, focusing services and supports on children of 
substance abusers assures the children most at risk that the 
next generation of substance abusers will receive the help they 
need to break the cycle of intergenerational dependency. 
Children of substance abusers, particularly substance abusing 
mothers, are at a greater risk than their peers for alcohol and 
drug use, delinquency, poor school performance, as well as 
depression and other psychiatric disorders. They deserve and 
need services targeted directly to them, regardless of their 
parents' compliance with treatment and recovery.
    Third, we know treatment for alcohol and drug problems 
saves tax dollars. It may not work for all people the first 
time, but it works for enough people to have a very high 
payoff. The basic fact about the poor connections between 
programs for children and families and substance abuse programs 
is that most treatment agencies don't count children as part of 
their caseloads. At the same time, child welfare agencies don't 
systematically assess for alcohol and drug problems.
    The P.A.S.S. legislation, in its original form, required 
State agencies to report on these issues or to tell the 
Secretary of HHS what they needed to be able to make this data 
available. We supported that requirement because we believe 
that counting children who need these services is vital. 
Counting children isn't important for the sake of the data 
alone; rather, we believe we will never be able to stop the 
intergenerational aspect of alcohol and drug problems until we 
get a handle on just how many children of substance abusers 
need more than a generalized prevention message.
    We have found very few people fully understand the funding 
streams for these fragmented systems. Each system has its own 
rules, jargon, eligibility requirements, and expertise. The 
child welfare system is just beginning to move beyond a 
recognition that the families they are trying to help have 
significant alcohol and drug problems. Some are beginning to 
put the funding pieces together.
    The good news is there are some powerful exceptions to the 
rule of fragmentation among welfare, child welfare, and 
substance abuse treatment programs. These models and early 
efforts exist in Sacramento County, in Florida, and in 
Cleveland, to name only a few of the sites. Congress could do a 
great deal to make these programs more comprehensible and to 
create hooks and glue to make it easier for communities to put 
these programs together.
    In the final analysis, it is about setting priorities. With 
limited resources, the hard decisions come down to weighing the 
long-term cost benefits of a focus on those children who are 
more likely to develop their own problems as a result of 
growing up in a family affected by alcohol and drug abuse.
    I know how I would make that decision. I would make it in 
favor of the children who will be affected by intergenerational 
poverty and substance abuse. I would choose that way because it 
is more cost effective, because it would ultimately benefit 
more people, and because it is right. I believe we could have 
public policy at the State and Federal level that says we 
should help every parent who is chemically dependent who wants 
to do the hard work to overcome their addiction. That is not an 
entitlement, it is an investment.
    No parents are entitled to the custody of their child if 
they will not do all that is in their power to keep that child 
safe, but when parents are ready and willing to do the work of 
recovery, the rest of us should be there to help them. It is a 
good investment and a necessary step in our overall efforts to 
keep families together and children safe.
    Thank you for your time today.
    [The prepared statement follows:]

Statement of Nancy K. Young, Ph.D. Director, Children and Family 
Futures, Irvine, California

                              Introduction

    The need for AOD (alcohol and other drug) treatment services among 
parents in both the welfare and child welfare systems is substantial, 
and far greater than current policy or practice recognize. These 
systems have many barriers to working together, including differences 
in attitudes toward clients, training and education, and funding 
streams. The typical response to clients in the child protective 
services (CPS) system needing AOD treatment is inadequate to assure 
that the intended outcomes of either system will be achieved. In the 
welfare system, the initial feedback from states and communities 
preparing to implement welfare reform suggests that very few have given 
the AOD problem the attention it deserves as a barrier to permanent 
work.
    We can be more demanding of parents if we are more effective in 
securing resources needed for treating parents' addiction. We have the 
tools we need to improve our assessments of parents in the CPS and 
welfare systems who need resources from the AOD system, but 
particularly in the child welfare system we need to use assessment of 
both chemical dependency and family functioning that translates into an 
assessment of risk to the children.
    The adequacy of the connections between these systems can be 
assessed using a five-part comprehensive policy framework that 
addresses: (1) daily practice; (2) information systems, evaluation, and 
outcomes; (3) budget and finance; (4) training and staff development; 
and (5) alternative methods of service delivery.

                             What is Needed

    1. Tools to assess the addiction problems of families, and 
training of welfare and child welfare workers who can use those 
tools with an understanding of addiction problems as they 
affect risk to the children.
    2. A commitment to target prevention and intervention 
funding and programs to the children of substance abusers in 
the welfare and child welfare systems, regardless of the 
parents' status in securing and complying with treatment 
protocols.
    3. Improved information systems that can monitor clients' 
outcomes and distinguish between AOD clients with children and 
those without. Treatment agencies must collect and track the 
number and child welfare status of children in clients' 
families.
    4. Assessment of both drug dependency and of family 
functioning, along with awareness of the developmental stage of 
the child, in making judgments about removal or reunification. 
If treatment is fully available for the parent, a presumption 
in favor of reunification should remain only as long as the 
parent has engaged in treatment or an aftercare program.
    5. A higher priority for the availability of AOD treatment 
slots and programs for parents who are willing to make an 
effort to stay in treatment and follow-up services.
    6. Inventories of the full range of funding sources and 
services available to parents which can fund expanded treatment 
and supportive services.
    7. A focus on children, particularly the children of 
substance abusers, in each of the reports that are issued by 
the federal government which monitor the nation's drug problem.
    8. Marketing information about treatment effectiveness and 
cost offsets from effective treatment.
    9. A commitment from community partners to ensure that 
supportive services to families who have been reunified are 
available to families who have entered recovery from AOD 
problems.
    10. Assessments of the effectiveness of AOD treatment 
programs using the latest tools of treatment outcomes, and the 
shifting of resources from the least effective to the most 
effective programs.

The Larger Context: Children, Families, Drugs and Alcohol

    Beyond the boundaries of the CPS and welfare systems, there 
are extensive effects of alcohol and other drug abuse on 
children. There are millions of children affected by drugs and 
alcohol, living in families where use of drugs and alcohol pose 
risks to child well-being. Seven million infants were exposed 
to alcohol during gestation, nearly seven million children 
under 18 live in families with one or more alcoholic parents 
and over six million children live with 3.4 million parents who 
used an illegal substance in the last 30 days. An estimated 
total of 29 million children of alcoholics includes 13-25% 
likely to become alcoholics. [National Pregnancy and Health 
Survey, National Institute on Drug Abuse; Russell, Henderson, & 
Blume, 1985; U.S. Department of Health and Human Services, 
1994.]
    The overall economic impact of substance abuse on society 
was estimated by the Substance Abuse and Mental Health Services 
Administration in 1992 at $116 billion annually for alcohol 
abuse and $79 billion for drug abuse. These include costs of 
lost productivity, health impact, criminal justice costs, motor 
vehicle accidents, and prenatal effects.
    Philosophical differences between AOD treatment and welfare 
agencies
    The differences in philosophical outlook between the two 
systems are based on different perspectives on:
     who is the client: children, parents, the family, 
or the community?
     which timetable should apply: child welfare law, 
the new welfare reform law, AOD treatment timing, or the 
developmental needs of children at different ages?
     how can we reconcile zero tolerance, harm 
reduction, child safety, and family preservation as contrasting 
philosophies in protecting children and stabilizing families?
    The practical result of these differences is that the two 
systems find it difficult to work together. In discussing 
front-line workers' reactions to AOD issues, one child welfare 
professional said in recent California discussions of these 
issues ``For years the workers have been saying it [substance 
abuse] isn't on the form and it usually isn't in the 
allegation--so I don't go looking for it.'' A parallel comment 
from a treatment agency official was ``We have not seen 
children as part of our responsibility.''

The Timing Barriers

    The timing differences are a very powerful driving force 
that underlies system incompatibility. We use the phrase ``the 
four clocks'' to refer to the four different timetables that 
may be affecting a family's response to CWS-AOD problems: (1) 
the CWS timetable of six-months reviews of a parent's progress 
and the timing under state and federal law governing 
termination of parental rights; (2) the timetable for treatment 
and recovery, which often takes much longer than AOD funding 
allows; (3) the timetable now imposed for TANF (former AFDC) 
clients who must find work in 24 months and have a lifetime 
clock of 5 years for income assistance; and (4) the 
developmental timetable that affects children, especially 
younger children, as they achieve bonding and attachment with 
parents or loving adults--or fail to do so.
    Since the late 1980's, when the epidemic of crack cocaine 
began affecting child protective services caseloads, more 
attention has been given to the question of how much time to 
give to parents who have been reported for abuse or neglect and 
had their children removed. The problem is that each system 
runs on a different clock. The child protective services system 
increasingly focuses its concern on the developmental needs of 
children, especially younger ones, while the treatment system 
attempts to take into account the cycle of parents' recovery 
and relapse that may take much longer to stabilize and may have 
little to do with the needs of children whose developmental 
sense of time is very different from adults. In effect, the 
basic assumptions about treatment are very different, with CPS 
focused upon AOD treatment as a means for achieving the goal of 
child safety, while AOD treatment seeks the goal of clients' 
functioning as a healthy adult, in which parenting is only one 
facet of clients' behavior.
    Timing also varies according to the age of the children 
involved. With new discoveries about brain development over the 
past ten years, we have learned how important the first 
eighteen months of life are in forming the basis for a 
considerable amount of both cognitive learning and emotional 
development. We also know more about early bonding and what its 
absence from a child's first years can cost in later life. This 
all argues for faster vices, especially for younger children.
    But in the treatment field, some of the lessons are 
contrary in their implications: treatment is not a one-time 
event which happens and is over, but a lifetime journey. That 
is why alcoholics and addicts often refer to themselves as 
``recovering'' instead of ``recovered.'' The treatment field 
has also evolved, with reduced emphasis on intensive 
residential care and more on longer-term interventions with 
``stepped-down,'' ongoing aftercare services and community 
supports.
    The treatment perspective, therefore, argues for a longer-
term perspective--at the same time that child welfare is moving 
toward greater emphasis upon shorter-range impact on children. 
When these two perspectives on timing collide in the life of a 
child and her parent, the difficulties of getting these two 
systems to work together are compounded.
    As stressed previously, we believe that we can be more 
demanding of parents if the resources are there. By resources 
we mean not only the treatment resources but also adequate 
assessments at the front-end of the process and a full 
partnership with the community that mobilizes after care and 
family support resources to help a newly sober parent stay 
clean and sober. This kind of community partnership is 
described in depth in the recent report authored by Frank 
Farrow of the Center for the Study of Social Policy.\1\ This 
community partnership model is being piloted in four 
communities around the country with funding from the Edna 
McConnell Clark Foundation.
---------------------------------------------------------------------------
    \1\ Farrow, F. Building Community Partnerships for Child 
Protection. Cambridge, MA: The John F. Kennedy School of Government 
Harvard University. 1997.
---------------------------------------------------------------------------
    If a 12-month clock is what fits best with the child's 
developmental needs, the realities of welfare time limits, and 
proposed CPS policy changes, then we have to be realistic about 
the community support needed to enhance the process of recovery 
on a faster time table. The community has the right to ask the 
recovering parent to do all that she can to keep her children 
safe and, at the same time, the community should hold itself 
responsible for helping that parent in that critical work.
    But, we need to understand the daily reality of a lower-
income parent, often a single parent, struggling to raise his 
or her children while early in recovery. Nearly all of us need 
respite from our daily balancing acts in the worlds of work and 
family. But upper- and middle-income families can call a 
babysitter to get out of the house for a few hours. It's not 
that easy for a lower income parent in recovery. To have a peer 
group, self-help group or a faith-based organization willing to 
provide that support could make all the difference in the early 
months of recovery. That need not be a governmental function; 
but the community needs to step up to the challenge. Taking the 
process of recovery seriously as a part of family reunification 
requires a more gradual transition from publicly-supported 
reunification services to broad-based community support for 
these kinds of after care and respite care assistance. 
Terminating reunification services at the end of 12 months 
ignores the continuing need assuming that the parent is making 
progress in recovery for different kinds of parent and family 
support services, both public and voluntary. Those services may 
make the difference between relapse and continued progress for 
a parent who is trying to respond to the stress and 
responsibilities of having her children returned to her care.
    While existing federal family support money could be used 
for this purpose, it is extremely rare that the relationship 
between child welfare and treatment agencies would be strong 
enough to ensure that this would happen.

The Emerging Consensus

    At the same time, in those communities where the systems 
have worked together, a consensus does emerge. Participants in 
this work agree that better-connected welfare, child welfare, 
and treatment agencies could achieve four purposes:
     Provide more effective services to more children 
and parents than the current fragmented systems (the 
effectiveness goals);
     Do so in a way that preserves more families with 
greater child safety than today's system (the family stability 
goal);
     Assist in making decisions about removal of 
children from those parents and caretakers whose addiction 
remains a threat to their safety and well-being (the child 
safety goal);
     Combine resources from the two systems which would 
serve more children and families than either system could do 
separately, while working more actively to enlist other 
community agencies and organizations for families with less 
intensive needs (the resource mobilization goal).
    Efforts to support children within their chemically 
dependent families must attempt to address chemical dependency 
in the family while meeting the developmental and safety needs 
of the children.\2\
---------------------------------------------------------------------------
    \2\ The CWLA North American Commission on Chemical Dependency and 
Child Welfare. Children at the Front. Washington, D.C.: Child Welfare 
League of America.

---------------------------------------------------------------------------
The Client Targeting Barriers

    Identifying which children and families should be targeted 
is also an issue. In the view of some experts on the impact of 
substance abuse on children, there continues to be 
disproportionate emphasis upon the problems of children who are 
born prenatally exposed to alcohol and other drugs, relative to 
the much larger number of children affected by AOD problems 
after birth. With the dominant emphasis upon prenatal exposure 
and adolescent drug use, the years between birth and 
adolescence are under-emphasized, despite the obvious evidence 
that risk to children and youth from AOD problems occurs during 
these years due to family and environmental exposure which has 
lasting effects in ways that in utero exposure doesn't always 
have. The substantial evidence that this is true includes the 
thousands of children in this age group who are reported to CPS 
units, despite never having come to the attention of these 
agencies as a result of prenatal exposure. Some estimates place 
the total percentage of all children affected by AOD at fifty 
times greater than those testing positive for exposure to drugs 
at birth. Yet, the birth of a child who tests positive for 
drugs is so traumatic and so clearly an occasion requiring 
intervention that this critical juncture has been rightly 
perceived as an opportunity to take decisive action in a family 
which is undeniably high risk. The chart that follows places in 
utero exposure in the larger context in which it belongs in the 
full range of ways that children are exposed to alcohol and 
other drugs.
[GRAPHIC] [TIFF OMITTED] T0489.002


    Carol Coles summarizes the message of this chart well in 
the edited collection, Children, Families, and Substance Abuse
    ...the nature of interactions with parents, as well as 
other more directly experienced factors, often appear to have 
more effect on outcomes like emotional and cognitive 
development than does prenatal exposure to specific drugs.\3\
---------------------------------------------------------------------------
    \3\ Coles, C.D. ``Addiction and Recovery'' in G. Harold Smith, et 
al, (eds) Children, Families, and Substance Abuse. Brookes Publishing.
---------------------------------------------------------------------------
    A further basis for the problems between the systems arises 
in the competing demands for AOD services for populations other 
than children and families. In part due to the improving 
information base about what kinds of treatment work for which 
kinds of clients, demands for AOD support services have 
multiplied from the criminal justice system, the mental health 
system, and now, notably, the overlapping welfare/TANF system. 
Treatment for inmates has been an area of increasing emphasis, 
given the number of drug offenders in state prisons and local 
jails. Resources in the AOD system are scarce in the short run, 
and the call for expanded responsiveness to the special needs 
of children and families in the CPS system conflicts in 
important ways with these other demands.

Disagreements about the Nature of Addiction

    Welfare and child welfare practitioners, like the general 
public, are part of a continuing debate over the fundamental 
nature of addiction as ``bad acts by individuals with free 
will'' (in the language of the 1992 National Drug Control 
Strategy report) or a public health problem caused by a 
condition that changes brain chemistry once clients have 
progressed from use to abuse and dependency. As a result, the 
public debate is often conducted in polar extremes, ranging 
from medicalization and legalization on one hand to zero 
tolerance and punitive strategies on the other. This argument 
from extremes often rules out middle-ground options such as 
treatment on demand for all clients willing to comply with a 
treatment and aftercare plan.
    It is now clear that both brain chemistry and motivation 
matter. Clients can be held responsible for their actions, 
especially once consequences have been clearly set out and 
treatment services have been clearly offered. And clearly 
offering services doesn't mean simply giving clients a list of 
phone numbers, which is an all-too-typical response of the two 
systems. Participants in the discussions between AOD and CPS 
agencies in California point out that research in the addiction 
field shows conclusively that coerced clients are not more or 
less successful in treatment than ``voluntary'' clients. 
``Coerced'' and ``involuntary'' are words sometimes used 
loosely in child welfare and AOD treatment. Is a parent who has 
been told he/she will lose parental rights acting voluntarily 
when checking into treatment--or being coerced? Either way, 
such a parent has been held personally responsible, given a 
clear message about treatment, and offered help--which are 
essential preconditions for successful treatment--but not 
guarantee that success will follow.
    However, it is also important to consider the reality of 
treatment compliance rates when treating conditions that 
require substantial behavioral changes. Less than 50% of 
patients treated for insulin-dependent diabetes are compliant 
with their doctor's orders regarding their medication. Less 
than 30% are compliant with their diet and foot care. Among 
patients treated for hypertension, less than 30% are compliant 
with their medications and diet.\4\ This data should not be 
used to excuse the behavior of persons in AOD treatment and all 
parents must be held accountable for the safety of their 
children. Rather, this data should be used to assist clinicians 
and policymakers as they explore their expectations of AOD 
treatment and any sanctions for noncompliance with treatment 
regimens.
---------------------------------------------------------------------------
    \4\ McLellan, A.T., Metzger, D.S., Alterman, A.I., Woody, G.E., 
Durell, J. & O'Brien, C.P. Is Addiction Treatment ``Worth It?'' Public 
Health Expectations, Policy-based Comparisons. Philadelphia: The Penn-
VA Center for Studies of Addiction and the Treatment Research 
Institute.
---------------------------------------------------------------------------
    The difference between how the child welfare and treatment 
systems respond to licit and illicit drugs must also be 
addressed with greater realism. The fact is that alcohol causes 
substantially more family disruption and lost economic benefits 
than illegal drugs. As one child welfare official put it in a 
recent California meeting: ``CPS focuses on illegal substances 
and overlooks alcohol abuse and consequences on the family.'' 
To the extent that the CPS system does pay attention to 
substance abuse issues, it is far more disproportionately 
focused on illicit than legal drugs, given the overall damage 
done to children both prenatally and environmentally by 
alcohol. The same is true, as shown by the recent debate on 
welfare reform, in the income support arena.
    We must also not lose sight of the front-line workers' 
perspectives on all these proposed reforms to work across 
system boundaries to help chemically dependent parents. Reform 
does not flourish among workers with caseloads far beyond 
recommended levels. At the same time, new mandates affecting 
AOD workers also create externally-driven pressures on front-
line workers. In both fields, the CWS-AOD reforms we are 
proposing ask both sets of front-line workers to make large 
changes in their daily practice, and going beyond pro forma 
consultation to serious involvement of workers in these changes 
in practice and policy is the only hope that workers will not 
view them as just another round of mandates without resources.
    To insure that workers have the tools to make these 
changes, training funds must be redirected and our universities 
must begin to include significant information about AOD 
problems in the human service curriculum. Federal IV(e) 
training funds for child welfare professionals have rarely been 
used to increase workers' in-depth knowledge of addiction and 
treatment. Both systems need added training content that would 
enable both sets of workers to work across systems:
      

                                


                Chart 2: How Should Training Be Changed?
------------------------------------------------------------------------
       Desired CWS Training Content         Desired AOD Training Content
------------------------------------------------------------------------
AOD dependency: use, abuse, and dependency  How the CPS system works
How to identify and intervene with AOD      Trends in local CPS and out-
 dependency.                                 of-home-care
Treatment modalities and effectiveness--    Local resources in the child
 what providers do and their capacity--      welfare system: parenting
 What local resources exist and how they     education, shelters, foster
 differ.                                     homes
AOD as a family disease; the dynamics of    AOD as a family disease; the
 AOD-abusing families; impact on parenting.  dynamics of AOD-abusing
                                             families; impact on
                                             parenting
Confidentiality laws......................  Confidentiality laws
Matching level of functioning to levels of  Resources available for
 care.                                       family-oriented
                                             interventions and family
                                             support/aftercare
The special needs of women and fathers/     Developmental impact of AOD
 significant others.                         use--both prenatal and
                                             environmental--on children
The language used in AOD and other systems  The language used in CWS and
                                             other systems
The ``four clocks''--different timetables   The ``four clocks''--
 in the other systems.                       different timetables in the
                                             other systems
------------------------------------------------------------------------


      

                                

    In a recent discussion of training issues among AOD and CWS 
administrators, several additional points were made:
     We need to train people for our vision of the new 
system, realistically presented, not just let them adapt to 
today's status quo.
     We are seeking links between a generic child 
welfare worker with direct ties to and knowledge of AOD issues 
and an AOD worker who understands CPS, so that an AOD counselor 
and child welfare worker can work together, not so that one 
worker can do both jobs.
     Administrator and mid-level supervisor training is 
also needed, since some front-line workers are much readier to 
make these changes in the interests of better outcomes for 
their clients while some supervisors protect traditional ways 
of doing things.
     Training only CPS and AOD workers will miss the 
other workers in other systems that need to know more about how 
these two systems can work with each other.
     Training needs to actively involve both AOD 
providers and CPS clients with AOD history. Academically-based 
training needs to recognize that front-line workers and clients 
should have equal standing, not second-class roles.
     Training alone will not do the job; training has 
to be in the context of agency-wide commitments to change 
policy and practice, or workers will return from their 
innovative training programs to an unchanged agency and go back 
to doing what they did before.

What Would a New System Look Like?

    A newly linked CWS-AOD system would operate differently at 
the level of front-line workers, client contacts with both 
children and families, assessment of risk, referrals for 
services, accountability for results based on outcomes-driven 
information systems, training for its workers, and the role of 
the community in support of families at the ``front end'' of 
CPS services but not yet in the formal system. The new system 
would be capable of assessing and providing a differentiated 
response to children and families, responding to more sensitive 
and detailed assessment of both family and substance abuse 
issues.
    To summarize, a new partnership between CPS and AOD needs 
to be comprehensive, negotiated among equals, carefully staged 
in its development, and driven by results-based accountability. 
Above all, the new system would have new partners, primarily at 
the community level, who could accept a responsibility for 
those families who are not seriously enough engaged with CPS to 
merit formal investigations, but who undeniably need help. As 
one AOD administrator put it, the reality test for the concept 
of community partnerships was that ``somebody else would step 
up to the microphone'' when a public explanation of child 
safety issues was needed, rather than the media solely holding 
the CPS system accountable.
    The new system would also include more than a two-way 
bridge between CPS and AOD agencies, since for many of its 
clients more than these services and supports are needed. 
Community-based aftercare, family supports, mental health, job 
training, literacy training--these are some of the many 
services and supports which go beyond CWS and AOD services that 
are needed by families in the CWS system. As one participant in 
an earlier session put it, ``AOD treatment is not a stand-alone 
service.''

What Could Congress Do?

    Many of these changes require action at the most local 
levels of the system, in the communities where welfare reform, 
child welfare policy, and treatment programs co-exist today in 
largely separate worlds. Putting the pieces together is 
ultimately local work. But federal action could make a great 
difference. To review the areas where congressional initiatives 
could be helpful:
     We need the PASS legislation (S. 1195), with its 
emphasis on identifying children in the system, making it 
easier to blend funds from different systems, and creating 
greater incentives for combining funding from welfare, child 
welfare, and treatment funding sources.
     Congress could also issue annual inventories of 
all three sets of funding--welfare, child welfare, and AOD 
treatment--as a guide to communities who rarely get an overview 
of all funding sources available to help children and families 
affected by AOD issues.
     Congress could ensure that the data collection 
procedures in both the child welfare and AOD systems are 
changed so that they include data on both the parents with AOD 
problems among child welfare cases and data on the children of 
parents seeking AOD treatment. We need the provision in the 
Adoption Promotion Act (HR 867) which requires the Secretary of 
HHS to report on the substance abuse needs in the child welfare 
system.
     Congress could ensure that reports issued from the 
national surveys on drug abuse always include analyses of the 
data on the children in substance using families. At present, 
only special follow-up studies of the National Household Survey 
on Drug Abuse have analyzed the data on children; the routine 
reports do not include information on the children in the 
families affected by AOD.
     Congress could continue the oversight represented 
by these hearings through inviting representatives of the model 
programs to talk about what they have done and what additional 
support they need form the federal level.
     Congress could exercise its oversight for the TANF 
legislation to review the actual experience of parents with the 
greatest barriers to making the transition to work. The range 
of estimates is wide, but we are building up a body of 
experience every day that will tell all of us which estimates 
are most nearly accurate--and more importantly, whether the 
resources set aside for treatment are adequate. The dramatic 
declines in welfare caseloads do not tell us what is happening 
to the children in these families, or whether those leaving are 
those without AOD problems, while those remaining may have even 
greater problems.

                               Conclusion

    Many children's lives are diminished by the inability of 
their parent to care for them, and the inability or 
unwillingness of the larger society to help and compel those 
parents to help their children by addressing their problems of 
addiction. Thinking and acting more clearly about this critical 
dimension--accepting the challenge of creating a true family 
support system--could help far more children and families than 
continuing to deny the equally important realities of addiction 
and the potential of recovery in these families.
      

                                

    Chairman Shaw. Thank you, Dr. Young.
    Dr. Barth.

     STATEMENT OF RICHARD P. BARTH, PH.D., HUTTO PATTERSON 
PROFESSOR, SCHOOL OF SOCIAL WELFARE, UNIVERSITY OF CALIFORNIA, 
                      BERKELEY, CALIFORNIA

    Mr. Barth. Thank you, Chairman Shaw and Members of the 
Subcommittee, for the opportunity to testify today. I am a 
professor in the School of Social Welfare at the University of 
California, Berkeley, where I have done research with the Child 
Welfare Research Center, which was originally funded by ACF. I 
also serve as the principal investigator of the Abandoned 
Infants Assistance Resource Center, where we provide technical 
assistance and evaluation to Abandoned Infants Assistance 
Programs nationwide, and are currently exploring innovative 
ways of serving drug- and HIV-infected families.
    My objectives for today include identifying five points and 
providing supporting information for these recommendations. The 
first point is that the children whose parents are persistently 
poor and involved with substance abuse are the families most 
likely to require child welfare services. Standard services 
provided by TANF are unlikely to provide substantial benefit to 
the majority of these very troubled families and additional 
efforts are needed.
    Second, reporting drug-exposed children for child abuse 
should be followed by thorough assessments of their needs. 
Placing them into foster care may not infrequently be necessary 
to protect them from the interactive risks of their own drug 
exposure and living in compromised environments; however, this 
is not a sufficient approach.
    Third, reunification services for drug-involved families 
must be supplemented with a broader array of strategies to help 
minimize the forces that result in relapse. These include 
intensive postreunification services, residential treatment 
programs for mothers and children, shared family care, and 
service-enriched housing.
    Fourth, shorter timeframes for children in substance-
abusing families, and indeed in all families, can be fairly and 
successfully administered if child welfare and substance abuse 
services are redesigned to be more timely and comprehensive.
    Fifth, extended services are needed for drug-affected 
children and families, as these have a good chance of 
mitigating serious, long-term problems for them.
    As we have heard so far, there is much consensus that the 
overlap between substance abuse and child welfare is greater 
than it is between substance abuse and public welfare. Indeed, 
as the Chairman indicated, there are estimates that as many as 
75 or 90 percent of families involved with child welfare 
services are also involved with substance abuse problems.
    However, these problems do interact with persistent 
poverty. Clarise Walker and her colleagues found that among 
African-American parents in five major U.S. cities whose 
children entered foster care in 1986, those that abused drugs 
were much more likely to be receiving AFDC prior to the 
placement of their children. In fact 85 percent of the 
substance-abusing parents were receiving AFDC and many had 
experienced long-term poverty.
    We have recently examined infants who came into foster care 
in California and compared their family situations to those of 
infants who did not. One of the things we found was that being 
poor made a difference, but that being poor and having a parent 
older than 30 made a much greater difference. These were often 
women who had been poor and involved with childbearing for many 
years, and they were the ones who had the greatest likelihood 
of having their children enter foster care.
    Even when a child is born drug exposed and child welfare 
authorities assess the situation, they may decide there are 
other alternatives besides placing a child into foster care. 
When they do, they may still provide some in-house services, 
but these tend to be so limited that the risks of harm to the 
child endure.
    In a number of different studies in a number of different 
States, we have seen that the children who are reported for 
abuse and neglect and assessed early on but who do not get 
services, later on do come back into the child welfare system. 
This, I think, is a clarion call for providing more continuous 
services to those families, even when foster care is not 
indicated.
    Other information about a drug-involved family's living 
situation, their willingness to engage in efforts at recovery, 
and their use of other services should, of course, be 
considered when a decision is made in response to a report of 
child abuse and neglect. Is your point that inadequate 
assessments result in overplacement or underplacement, i.e., 
assuming willingness for recovery? Yet many families do not 
receive such an adequate assessment. We must see a time in the 
future when newborns who are born drug exposed receive such 
assessments that can lead to better treatment planning.
    One thing we have learned from our years of working with 
these families that are involved with drug abuse is that there 
are often many children involved. For this testimony, we took a 
sample of newborns who had come into care in 1995 and looked to 
see how many of their siblings were already in care when the 
newborn entered into care.
    Out of approximately 1,600 newborns, we found about 1,000 
of them had one or more siblings already in care. Overall, they 
had about 2,600 siblings in care. On average, the siblings had 
been there 4\1/2\ years; 81 percent of those who had been in 
care had not gone home or had come back into care. If one-third 
of the nearly 1,000 mothers who gave birth to these newborns in 
1995 had been successfully engaged in treatment upon the first 
birth recorded in our data base and had no more drug-exposed 
births, nearly 4,000 foster care years would have been avoided 
at a savings of at least $40 million for just the direct foster 
care placement costs.
    So whatever our views are about the causes of substance 
abuse and however much frustration we may have about this 
problem, we must understand that from an economic standpoint, 
we must address the whole family. Helping mothers achieve 
recovery could substantially reduce the number of children 
coming into foster care.
    One of the approaches we need to expand is something we are 
calling ``shared family care.'' We are currently piloting this 
program in California and Colorado, and it is being used in 
other States as well. In addition to the kinds of residential 
treatment programs you know of, shared family care involves 
placing mothers in recovery with their children, in the homes 
of foster parents. In this way, we are not separating children 
from their parents but are still protecting the children by 
placing them with their family in foster care. This approach 
helps support them and provides shelter for them during the 
time of recovery. There is more about this in my written 
testimony.
    I thank you for the opportunity to testify.
    [The prepared statement follows:]

Statement of Richard P. Barth, Ph.D., Hutto Patterson Professor, School 
of Social Welfare, University of California, Berkeley, California

    My name is Richard Barth. Thank you for the opportunity to 
testify today. I am the Hutto Patterson Professor in the School 
of Social Welfare at the University of California at Berkeley 
and the leader of the Child Welfare Research Center which was 
originally established in 1990 with support from the Children's 
Bureau and ASPE. In this capacity, I have studied a variety of 
issues regarding the impact of substance abuse on families and 
children and on child abuse and child welfare services 
dynamics. In particular, my colleagues and I have studied 
outcomes of the adoption of drug-exposed children, the impact 
of substance abuse on reunification from foster care, and the 
service outcomes of newborns and infants who enter foster care. 
I am also the Principal Investigator of the Abandoned Infants 
Assistance Resource Center, and in that role, I have provided 
technical assistance and evaluation services to Abandoned 
Infants Assistance programs which are generating innovative 
ways to serve infants and families affected by drugs and HIV.

                 Objectives for the Prepared Testimony

    My objective for the prepared testimony is to present and 
support five major points.
     Children whose parents are persistently poor and 
involved with substance abuse are most likely to require child 
welfare services. TANF is unlikely to provide substantial 
benefit to the majority of these families.
     Reporting drug-exposed children for child abuse 
should be followed by thorough assessments of their needs. 
Placing them into foster care may, not infrequently, be 
necessary to protect them from the interactive risks of being 
born drug-exposed and living in compromised family and 
community environments. This is not, however, a sufficient 
approach.
     Reunification services for drug-involved children 
must be supplemented with a broader array of strategies that 
help minimize the forces that result in relapse--these include, 
intensive post-reunification services, residential treatment 
programs for mothers and children, shared family care, and 
service-enriched housing.
     Shorter time frames for young children in 
substance abusing families can be fairly and successfully 
administered if child welfare and substance abuse services are 
redesigned to be more timely and comprehensive.
     Extended services are needed for drug-affected 
families and have a good chance of preventing serious long-term 
problems for them.

     Background: Substance Abuse and Child Abuse and Their Overlap

    Little data but much consensus exists regarding the 
predominant role of substance abuse in families that are 
involved with child abuse and neglect and who lose their 
children to foster care. In general, substance abuse appears to 
have a far greater overlap with child welfare services than 
with public assistance programs. Analysts have estimated that 
between 24-90% of all child maltreatment reports involving 
substance abuse (Feig, 1990; NCCAN, 1993; Tracy, 1994; Magura & 
Laudet, 1996). More than three-quarters of state child 
protection administrators across the country report substance 
abuse as one of the top two problems presented by their 
caseloads, the other one being housing (Wiese & Daro, 1995). 
Doug Besharov (1989) concluded that over 73% of neglect-related 
child fatalities in 1987 were attributable to parental alcohol 
and drug abuse. Ten years later, there is not good reason to 
argue that this has changed.
    Substance abuse clearly pre-disposes caregivers to neglect 
and abuse. A large NIMH-funded study concluded that substance 
abusers had 3 times the odds of committing physical abuse and 
neglect--after controlling for social, demographic, and 
psychiatric variables (Chaffin, Kelliher, & Hollenberg, 1996). 
These findings are supportive of their earlier conclusions in 
which ``close to half or more of abusive or neglectful parents 
have a lifetime prevalence substance abuse disorder'' 
(Kelleher, Chaffin, Hollenberg, & Fischer, 1994; p. 200).
    Whereas parents on welfare appear to have elevated rates of 
substance abuse and child abuse, substance abuse is clearly 
more prevalent among maltreating families than in poor 
families. In Zuravin and Grief's (1989) comparison of 
maltreating and non-maltreating AFDC mothers, non-maltreating 
mothers were significantly less likely to report problems with 
alcohol or hard drugs (heroin, cocaine, LSD, PCP) than CPS-
involved mothers. Alcohol binges were reported by 3 times as 
many maltreating mother and four times as many maltreating 
mothers reported hard drug use.
    Many families struggle with poverty and substance abuse and 
do not engage in child abuse or neglect. Yet, poverty and 
substance abuse undoubtedly interact to increase the need for 
child protection by community child welfare services. Clarice 
Walker and her colleagues attempted to profile African-American 
children who entered foster care in 1986 in five major U.S. 
cities. They found that of parents whose children entered 
foster care, those that abuse drugs are more often single 
parents, were significantly more likely to not have a high 
school education, and were more likely to be receiving AFDC 
prior to placement of their children. In fact, 85% of substance 
abusing parents were receiving AFDC and many had experienced 
long term poverty. Although we lack direct evidence on the 
interactive effects of persistent poverty and substance abuse 
on child welfare services, my colleague Barbara Needell and I 
recently compared mothers who lose their infants to foster care 
and those who do not (Needell & Barth, 1997). Whereas women 
receiving publicly-funded medical services had a higher risk in 
general, being poor was a much more significant predictor of 
placement into foster care if the mother was older than 30 at 
the time of birth and had more prior births.
    Even when a child is born drug-exposed and child welfare 
authorities do not assess the seriousness of the problem as 
requiring foster care, the risks for the drug-exposed child 
endure. Jaudes, Ekwo and Van Voorhis (1995) tracked cases of 
maltreatment among a sample of 513 infants born exposed in-
utero to illicit substances, and found that about a third were 
later reported as maltreated. Of these, two-thirds were 
subsequently substantiated. Overall, the rate of substantiated 
maltreatment was found to be two to three times that of the 
general child population living in the study area (the south 
side of Chicago). A follow-up study by Jaudes and Ekwo also 
found higher eventual mortality among the drug-exposed sample. 
Goerge and Harden (1993) looked to see what happened to infants 
born in Illinois who are reported to child protective services 
because of a positive drug test (this is a mandated report 
under Illinois law). Only about 10% of those cases enter foster 
care immediately, although about one-third eventually end up in 
substitute care within three years. Once admitted into care, 
these infants have particularly long stays in foster care. In 
California, about one-in-six infants who entered foster care in 
1988 was still there eight years later.
    While parental substance abuse is considered a critical 
risk factor in the assessment of child abuse reports and 
positive drug toxicology tests may lead to an abuse report, 
child welfare service agencies now generally concede that 
positive toxicology tests are not, on their own, sufficient 
basis for legal action or the involuntary removal of children 
(NAPCWA, 1991). As the National Association of Public Welfare 
Administrators advises in its guiding principles for working 
with substance abusing families:
    Parent(s) abuse substances to varying degrees. When 
substance abuse significantly interferes with parental 
responsibility and causes harm to the child, these failures of 
parental duty provide the basis for substantiating a finding of 
abuse or neglect (NAPCWA, 1991).
    Thus, neither the use of substances while pregnant, nor 
parental substance abuse per se, legally constitutes child 
neglect. Other information about the living situation, 
willingness to engage in efforts at recovery, and the family's 
use of other services must also be considered. This seems to me 
to be the correct standard. Still, parental substance abuse 
during pregnancy is clearly reason for a child welfare services 
assessment upon the birth of a child to determine whether 
additional grounds for establishing abuse exist and to 
ascertain whether the dyad might benefit from voluntary or 
mandated services.
    I believe that we must see a time in the future when 
newborns affected by drugs are routinely and thoroughly 
assessed by public health or child welfare services and a range 
of services are made available to them. There are several 
reasons why this is so important. First, we clearly need to pay 
greater attention to the safety of drug-exposed children--the 
data on their high mortality rates is not to be ignored. 
Secondly, this helps us to provide intervention services at the 
earliest possible time. Children who are born drug-and alcohol-
exposed have needs for early assessment and intervention; in 
their study for the CDC, Ann Streissguth and her colleagues 
(1996) found that early intervention and living in a stable and 
nurturing home were two of the most important predictors of 
good adult functioning for children born with fetal alcohol 
syndrome and fetal alcohol affects. David Olds and his 
colleagues (1997) have also shown important prevention effects 
from early and prolonged home visiting services.
    Third, is the impetus that early assessments provide toward 
prompt decision making and the shortening of unnecessarily long 
stays in foster care. Children who are born drug-exposed and 
come back into foster care at age 3 may have experienced a 
variety of developmentally threatening environments and have a 
far greater likelihood of subsequently being adopted if they 
cannot return to their biological home. Indeed, children who 
enter foster care between the ages of 3 and 5 have the lowest 
rates of reunification within the first six years because they 
are too young to protect themselves at home but not easily 
placed for adoption (Barth, 1997).
    Substantial concerns about the approach of assessing and 
engaging virtually every family that gives birth to a 
substance-exposed child will not subside, however, until we are 
able to show a fundamental fairness in determining who gets 
assessed for substances and until we have adequate resources to 
provide to families. They most be more varied and effective 
than the current status quo which is to place children in 
foster care while providing little or no service to their 
mothers. I will discuss some of these desirable service changes 
later in this testimony.
    Removing children at birth without providing substantial 
assistance to their mothers has other serious limitations as a 
strategy. Child welfare programs that fail to address parental 
substance abuse and focus primarily or exclusively on child 
protection will not help prevent subsequent substance-exposed 
births. For this testimony, my colleague Barbara Needell 
examined the foster care and family histories of a cohort of 
1,576 newborns brought into foster care in 1995 in California 
for reasons of neglect and abandonment (signals that these were 
cases involving substance abuse). We learned that 60% of these 
children (nearly 1,000) already had at least one sibling in 
foster care. Indeed, they had a total of 2,634 siblings who 
were in foster care at some time from 1988 to their date of 
entry in 1995; about 25% of these newborns had 3 or more 
siblings in foster care. About 75% of these children were 3 
years old or younger--children with long and expensive spells 
in foster care ahead of them. Among the siblings of the infants 
who came into care, 81% of them were still in care or back in 
care. Newborns had siblings in foster care, on average, for 
four and one-half years--a total of about 12,000 foster care 
years. About half of the mothers (47%) who had multiple 
siblings entering foster care were younger than 21 at the birth 
of the first sibling. However, when you examine maternal age of 
the mothers at the time of the last newborn entering care, 47% 
of those mothers are over age 30. Clearly, a few parents who 
continue to generate births of children born exposed to 
substances have a substantial impact on the foster care 
caseload. If one-third of these nearly 1,000 mothers had been 
successfully engaged in treatment upon the first birth recorded 
in these data, and had no more drug-exposed births, a minimum 
of 4,000 foster care placement years would be avoided at a 
saving of, at least, $40,000,000 for these children alone. So 
whatever our views about the causes of substance abuse and 
however much frustration we may have with mothers who use drugs 
and alcohol during pregnancy (and fathers who encourage it), we 
cannot ignore their impact on child welfare, medical, and 
educational costs that are likely to accrue. Right now, about 
one-in-five children who enter foster care in the United States 
is an infant. We must build our intervention capacity and 
resources to interrupt these dynamics and reduce the rate of 
births of substance-exposed children who may enter foster care.
    Although the substance abuse treatment services that are 
being provided in some states as a component of TANF may help 
some families to become more attached to the labor force than 
they are to destructive life styles, the families who are 
having multiple births of children who enter foster care are 
unlikely to benefit from standard TANF services. These parents 
need outreach and treatment services that are available to them 
even if they lose TANF eligibility because they no longer have 
custody of their children.
    Nor is substance abuse only a cause of infants entering 
foster care. Substance abuse certainly predicts poorer case 
outcomes under existing service models for parents of children 
of older ages. Parental substance abuse has been identified as 
a predictor of poorer family functioning among child welfare 
cases, and repeated reporting to child welfare agencies (Wolock 
& Magura, 1996). Parents with documented substance abuse 
problems are more likely to have previous child welfare 
services involvement, to be rated by court investigators as 
presenting a ``high risk'' to their children, to reject court-
ordered services, and to have their children permanently 
removed (Murphy et al., 1991).
    Two of my colleagues at Berkeley, Jill Duerr Berrick and 
Laura Frame (1997) recently completed a study of infants 
returning to foster care, trying to provide some explanation 
for an earlier finding that 28% of infants who went home from 
foster care returned to foster care within 3 years in 
California (Needell, Webster, Barth, Armijo, 1996). They found 
that substance abuse by mothers at the time of placement was 
pervasive among all clients, but it was far more present in the 
re-entry group and increased the odds of re-entry 
substantially. Interestingly, the odds of a child re-entering 
care were not diminished by receipt of post-reunification 
services--indeed, they were increased. It turns out, that the 
families that received post-reunification services in Alameda 
County were also the families with the longest history of 
referrals to child welfare services. Basically, the level of 
post-reunification services that were provided were not 
sufficient to counteract these elevated risk factors and 
preserve the placements. We can only hope that these higher 
levels of services protected the children from harm and that 
the children were replaced into foster care after early signs 
of parental relapse from treatment and not after substantial 
injury to the children or their futures occurred. We have so 
much to learn, and have so far done so little to try to learn 
it, about the necessary ingredients of reunification services.

        Toward Child Welfare and Substance Abuse Services Reform

    Although we have not previously gathered much longitudinal 
data that shows how child welfare careers are affected by prior 
substance or the use of substance abuse treatment services, 
researchers and program innovators have generated enough 
information to suggest some reasonable new approaches to 
programs and policy.

Timely and Coordinated Child Welfare and Substance Abuse 
Services

    The ideal time frames for decision making vary considerably 
for children, substance abuse providers, parents, child welfare 
services, and the courts. Envisioning the clocks above the 
registration desk in an international hotel offers a sense of 
the disparate time frames for a child welfare case involving 
substance abuse (Cole, Barth, Crocker, & Moss, 1996). Child 
welfare service providers certainly understand the centrality 
of effective substance abuse services to the achievement of 
permanency outcomes, but the proportion of substance abusing 
families is overwhelming to service providers, and their access 
to prompt and powerful substance abuse services is limited. 
Although child welfare services families may have priority for 
referral to substance abuse services in a given locality, they 
may have little clout in other localities. Now that some states 
are requiring substance abuse services for TANF recipients, the 
challenge of obtaining timely services may be greater. The 
difficulty of obtaining substance abuse services for child 
welfare clients would be substantially less under the provision 
of'S 1195 that child welfare service clients be served first by 
programs receiving federal substance abuse treatment funds.
    Child welfare service providers are frustrated with the 
difficulty of getting prompt services, the unwillingness of 
substance abuse treatment providers to share information about 
the progression of treatment, and their reluctance to support 
decisions to end services and terminate parental rights when 
treatment is not successful. Some states are moving to fund 
substance abuse treatment programs under the child welfare 
services authority; direct funding of child welfare agencies 
for substance abuse services is also a strategy worth 
additional consideration by the federal government.
    Shortening the time to a permanency planning decision from 
18 months to 12 months--as is proposed in HR 967 and S 1195--is 
a sensible idea but has the potential to exacerbate the 
mismatch between the legal time frames. Expedited decision 
making generates greater concerns about the time allowed for 
families to enter into and take advantage of substance abuse 
services. I believe that there are hopeful signs that we can 
bring these time frames together so that children are moved 
into potential permanent placements at the earliest feasible 
time, so that parents have a chance to take advantage of 
substance abuse services, and so that child welfare service 
providers and the courts can make the best decisions in the 
shortest time.
    When timely and comprehensive services are available, they 
can make a significant difference. Colorado's new configuration 
of services for children under six entering foster care 
includes several features of such a restructured system that 
deserve replication (Shirley Rhodus, personal communication, 
August 12, 1997). Child welfare services have received funding 
to develop their own slots for substance abuse treatment so 
that they can ensure that families that need service begin them 
in the first week after placement. They have reduced caseload 
sizes to 15 families in several counties and provide each case 
with two workers. These added resources allow staff to provide 
intensive reunification services and concurrently plan for 
adoption if the odds of reunification start to drop. The case 
receives a full case review at three months--at that time, they 
may make a recommendation to place a child into a concurrent 
planning foster home (one interested in adoption, if 
reunification with the biological family does not succeed). By 
six months, they have enough information from their drug 
treatment providers and other service providers to determine 
whether reunification is possible and, if not, to accelerate 
the plans for parental rights termination and adoption. With 
few exceptions, permanent placements must be made by 12 months.
    The Oklahoma Infants Assistance Program provides 
comprehensive services to families of drug-exposed mothers over 
a six to nine-month timeframe in order to ensure that the 
substance abuse treatment time frames can work within the 
permanency planning time frames. Their services often begin 
within a week of intake and address issues of parenting and 
domestic violence as well as substance abuse treatment. Their 
experience suggests that early and comprehensive services can 
identify the families that are benefitting from the services at 
far earlier points in the decision making process than have 
historically been the case (Martin Ward, personal 
communication, October 25, 1997).
    Although there are some who would make the axiomatic 
assertion that ``relapse is a predictable part of treatment,'' 
there is evidence that the kind of relapse involved can signal 
whether there is a likelihood of treatment completion. 
Certainly, we know that many parents will never make a serious 
start in drug treatment. In a review of the outcomes of drug-
treatment research, the reviewers concluded that few users even 
completed the treatment, much less completed control over their 
addictions (Hoffman, Caudill, Koman, Luckey, Flynn & Hubbard, 
1994). Many participants (between 42 and 85% in different 
studies) had dropped out of treatment by the first month. 
Whereas, a single relapse is not enough to judge drug treatment 
a failure, if that relapse ends involvement with drug treatment 
it is much more serious than if the parent resumes treatment 
quickly after the relapse.
    Even when parents do complete six months of substance abuse 
services, this is often not enough to end services and reunify 
children. Failed substance abuse treatment is heavily 
implicated in failed reunifications. Longer substance abuse 
services and post-substance abuse case management could greatly 
improve the likelihood of generating lasting treatment changes 
(Wells, Peterson, Gainey, Hawkins, & Catalano, 1994; Seigal, 
Fisher, Rapp, Kelliher, Wagner, O'Brien, & Cole, 1996).

Longer-term Interventions for Drug-Exposed Children and Their 
Families

    In addition to earlier provision of substance abuse 
services for parents, we need to continue to explore and expand 
our interventions for children. Although the research on the 
immediate and long-term consequences of prenatal cocaine 
exposure has not demonstrated any singular impact on children, 
it is fair to characterize drug-exposed children as ``at 
risk,'' whether due to maternal substance use and/or other 
environmental factors or the interaction between the two. These 
``at risk'' characteristics interact with a substance-abusing 
parent's lifestyle, stressors including poverty, and pre-
existing parenting difficulties to create conditions which 
support a higher incidence of violence and child maltreatment 
(Kelley, 1992). The steady entrances into foster care for 
children who were not immediately taken into foster care in the 
aforecited Illinois study and the continued reentries into 
foster care for at least three years for infants found in our 
California work show the continuing risks for children born 
into families involved with drugs and alcohol. We do not know 
much about what occurs during those three years, but we can 
only guess that a vast opportunity to make a developmental 
difference has been squandered.
    There is clearly sufficient evidence about the problem of 
repeat drug-exposed pregnancies to fund demonstration projects 
and rigorous evaluations to assess the impact of continuous 
case management for parents who have drug-exposed births. At 
minimum, we must maintain ongoing services to substance 
involved families who do have their children reunified into 
their care.
    We have new evidence that children who are reported for 
maltreatment after the age of seven and not given child welfare 
services have about twice the likelihood of later entering the 
California Youth Authority than children who receive in home or 
foster care services (Jonson-Reid & Barth, 1997). Imagine what 
the impact might be on building successful futures if we began 
those services at seven days or seven weeks of life, instead of 
seven years. Abandoned Infants Assistance programs have 
developed new models of reaching out to and following some of 
our most troubled and addicted parents, but these services are 
available only on a demonstration basis and only in the very 
first years of life. We must work toward a seamless stream of 
services for the families that first come to our attention 
because they have mixed parenting and substance abuse.
Programs to Improve Living Conditions for Drug-Involved 
Families Pursuing Recovery

    Without adequate housing, it is extremely difficult for 
individuals to focus on their recovery, and returning to the 
pretreatment living environment places women at higher risk for 
relapse (Lewis, Haller, Branch, & Ingersoll, 1996). Yet 
affordable housing which provides an environment conducive to 
recovery and quality family life remains extremely scarce. 
Applicants for public housing must wait an average of 19 months 
and as long as eight years for housing that is often unsafe and 
riddled with drug problems and other criminal activity. 
Additionally, the average wait for Section 8 rental assistance 
is more than two years, and families wait as long as five years 
in some cities (U.S. Conference of Mayors, 1996). This housing 
crisis is particularly problematic for households headed by 
chemically addicted parents who often have difficulty securing 
jobs which pay them enough to support their families or afford 
decent market rate housing. Additionally, many of these 
families have other social, emotional and/or physical issues 
that make it difficult for them to maintain housing. As a 
result, families affected by alcohol or other drugs often end 
up homeless or in emergency shelters which is not conducive to 
recovery and does little toward helping them become self-
sufficient. Without stable housing, it is difficult for parents 
to obtain gainful employment or provide their children with the 
stability that is so critical for a child's healthy 
development.
    Inadequate housing or homelessness, accompanied by other 
factors such as parental drug abuse, was the primary reason for 
removing children from the home or keeping them in foster care 
in over 25% of foster care cases (Zangrillo & Mercer, 1995). 
There is reason to believe that access to safe, affordable, and 
adequate housing, along with some form of treatment or recovery 
and a wide range of support services, will assist chemically 
addicted parents to remain clean and sober, move toward self-
sufficiency, and avoid re-involvement in the child welfare 
system. Shields for Families in Compton, CA provides 
residential drug treatment services with permanent service-
enriched housing to boost the likelihood that families can 
resist relapse. Programs like this need more attention and 
evaluation.
    Shared family care is another approach to helping substance 
abusing families in recovery to achieve their goals to preserve 
their families. Originated in Europe as an extension of drug-
and alcohol treatment services, shared family care involves the 
placement of a recovering parent and her children into a host 
family (Barth, 1995; Price & Barth, 1996). Now operational in 
Minnesota, Wisconsin, Colorado, and California, shared family 
care offers families the opportunity to live with and learn 
from host families for between 6 and 12 months in order to 
reconstruct an orderly and responsive family life. Because this 
approach does not meet the IVE requirement of mother and child 
separation, it is not easily funded under our existing public 
policy. The provisions of S 1195 that allow time limited 
reunification services for mothers and children to live 
together in residential setting would greatly expand the 
availability of this promising program.

                              Conclusions

    Child welfare services are intended to protect the future 
of our most vulnerable children. Historically, these have been 
children living in homes overwhelmed with problems of substance 
abuse and violence. We know more about the extent of this 
problem than ever before. Researchers and program innovators 
have many ideas about ways that we might protect the 
developmental futures of children and, at the same time, 
provide opportunities for rehabilitation to their parents. This 
is an opportune time to test the promise of programs that 
support more thorough assessments of drug-exposed children, 
more timely and focused drug treatment services for child 
welfare clients, a variety of supportive housing options for 
families in recovery and reunification, and extended services 
to drug-and alcohol-exposed children who have come to the 
attention of the child welfare service programs. The substance-
affected child and family are the core constituency of child 
welfare services and greater efforts are required to address 
their needs.

Note: I am grateful to Laura Frame, Sora Han, Sharon Ikami, 
Sophia Lee, Barbara Needell, and Amy Price for their assistance 
preparing this statement.

                               References

    Barth, R.P. (1997). Effects of race and age on the odds of adoption 
vs. remaining in long-term foster care. Child Welfare, 76, 285-308.
    Barth, R. P. (1993). Shared family care: Child protection without 
parent-child separation. In R. P. Barth, J. Pietrzak, & M. Ramler, 
(Eds.), Families living with drugs and HIV: Intervention and treatment 
strategies (pp. 3-17). New York: Guilford Press,
    Berrick, J. D., & Frame, L. (1997). Factors associated with 
successful family reunification. UC Berkeley: Bay Area Social Services 
Consortium, Center for Social Services Research.
    Besharov, D. (1989). The children of crack: Will we protect them? 
Public Welfare, 46(4), 7-11.
    Chaffin, M., Kelleher, K., & Hollenberg, J. (1996). Onset of 
physical abuse and neglect: Psychiatric, substance abuse, and social 
risk factors from prospective community data. Child Abuse and Neglect, 
20(3), 191-203.
    Cole, E. S., Barth, R. P., Crocker, A. C., & Moss, K.G. (1996). 
Policy and practice challenges in serving infants and young children 
whose parents abuse drugs and alcohol. Boston, MA; Family Builders 
Network, 418 Commonwealth Avenue, Boston, MA 02215.
    Ekwo, E. E. & Jaudes, P. K. (1997). Outcomes for infants exposed in 
utero to elicit drugs. Child Welfare, 76, 521-534.
    Feig, L. (1990, January). Drug-exposed infants and children's 
service needs and policy questions. Washington, D.C.: U.S. Department 
of Health and Human Services.
    Goerge, R. M. & Harden, A. (1993). The impact of substance-affected 
infants on child protection services and substitute care caseloads: 
1985-1992. A report to the Illinois Department of Children and Family 
Services. University of Chicago: Chapin Hall Center for Children.
    Jaudes, P. K., Ekwo, E., & Van Voorhis, J. (1995). Association of 
drug abuse and child abuse. Child abuse and Neglect, 19(9), 1065-1075.
    Jonson-Reid, M., & Barth, R.P. (1997). Pathways from child abuse to 
the California Youth Authority. Paper presented to the California State 
Assembly Public Safety Committee, Los Angeles, CA. Available from the 
authors.
    Kelley, S.J. (1992). Parenting stress and child maltreatment in 
drug-exposed children. Child Abuse and Neglect, 16, 317-328.
    Kelleher, K., Chaffin, M., Hollenberg, J., & Fischer, E. (1994). 
Alcohol and drug disorders among physically abusive and neglectful 
parents in a community-based sample. American Journal of Public Health, 
84, 1586-1590.
    Lewis, R.A., Haller, L.H., Branch, D., & Ingersoll, K.S. (1996). 
Retention issues involving drug-abusing women in treatment research. In 
E.R. Rahdert (Ed.), treatment for drug-exposed women and their 
children: advances in research methodology. Rockville, MD: U.S. 
Department of Health & Human Services, NIH, NIDA.
    Magura, S. & Laudet, A.B. (1996). Parental substance abuse and 
child maltreatment: Review and implications for intervention. Children 
and Youth Services Review, 18(3), 193-220.
    Murphy, J. M., Jellinek, M., Quinn, D., Smith, G., Poitrast, F. G., 
& Goshko, M. (1991). Substance abuse and serious child maltreatment: 
Prevalence, risk, and outcome in a court sample. Child Abuse and 
Neglect, 15, 197-211.
    NAPCWA. (1991). Working with substance-abusing families and drug-
exposed children: The child welfare response. Public Welfare, 49(4), 
37.
    NCCAN (1993). Understanding child neglect. Washington, D.C.: 
Author.
    Needell, B. & Barth, R.P. (1997). Infants entering foster care 
compared to other infants using birth status indicators. Unpublished 
manuscript submitted for publication..
    Olds, D.L., Eckenrode, J., Henderson, C.R., Kitzman, H. (1997). 
Long-term effects of home visitation on maternal life course and child 
abuse and neglect: Fifteen-year follow-up of a randomized trial. JAMA, 
278, 637-643.
    Price, A. (1997). Permanent, Service-Enriched Housing for Families 
Affected by Alcohol and Other Drugs. Berkeley, CA: University of 
California, School of Social Welfare, Abandoned Infants Assistance 
Resource Center.
    Price, A. & Barth, R.P. (1996). Shared family care program 
guidelines. Berkeley, CA: University of California, School of Social 
Welfare, Abandoned Infants Assistance Resource Center.
    Siegal, H. A., Fisher, J. H., Rapp, R. C., Kelliher, C. W., Wagner, 
J. H., O'Brien, W. F., & Cole, P. A. (1996). Enhancing substance abuse 
treatment with case management: Its impact on employment. Journal of 
Substance Abuse Treatment, 13(2), 93-98.
    Streissguth, A.P., Barr, H.M., Kogan, J., & Bookstein, F.L. (1996). 
Understanding the occurrence of secondary disabilities in clients with 
FAS and FAE. Seattle, WA: University of Washington School of Medicine.
    Tracy, E. M. (1994). Maternal substance abuse: Protecting the 
child, preserving the family. Social Work, 39(5), 534-540.
    U.S. Conference of Mayors (1996). A status report on hunger and 
homelessness in America's cities: 1996. Washington, DC; United States 
Conference of Mayors.
    Walker, C. D., Zangrillo, P., & Smith, J. M. (1994). Parental drug 
abuse and African-American children in foster care. In R. Barth, J. D. 
Berrick, & N. Gilbert (Eds.), Child Welfare Research Review, Vol. I. 
New York: Columbia University Press.
    Wells, E. A., Peterson, P. L., Gainey, R. R., Hawskins, J. D., & 
Catalano, R.F. (1994). Outpatient treatment for cocaine abuse: A 
controlled comparison of relapse prevention and twelve-step approaches. 
American Journal of Drug and Alcohol Abuse, 20(1), 1-17.
    Wiese, D. & Daro, D. (1995). Current trends in child abuse 
reporting and fatalities: The results of the 1994 annual fifty state 
survey. National Committee to Prevent Child Abuse.
    Wolock, I. & Magura, S. (1996). Parental substance abuse as a 
predictor of child maltreatment re-reports. Child Abuse and Neglect, 
20(12), 1183-1193.
    Zuravin, S. J., & Grief, G. (1989). Normative and child-maltreating 
AFDC mothers. Social Casework, 70, 76-84.
      

                                

    Chairman Shaw. Thank you, Dr. Barth.
    Mr. McCrery.
    Mr. McCrery. Just a quick followup on something you just 
said, Dr. Barth; and I have other questions I want to get to.
    You said, we can save money basically if we put money up 
front in drug treatment, so that we avoid the cost of foster 
care later. Is that correct?
    Mr. Barth. For additional children, that is right.
    Mr. McCrery. I seem to recall some statistics about the 
success of drug treatment not being particularly good, so how 
can you guarantee if we spend money up front on drug treatment 
that we are not going to have to spend money on foster care for 
subsequent children, given the record of success in drug 
treatment programs?
    Mr. Barth. Well, my estimate of success on this was fairly 
modest, about one-third. I believe it is somewhat higher 
because I don't think we have fully explored what is involved 
in providing comprehensive drug treatment and how successful it 
could be.
    One of the Abandoned Infants Assistance Programs in 
Oklahoma that I reference in my written testimony is now 
providing intensive drug treatment services, including 
parenting work and domestic violence and drug treatment at a 
very early point when the family comes into care, usually in 
the first week. They are finding substantial success in working 
with families who are mandated to come there in this particular 
program.
    I don't think there are guarantees, but I do believe we 
have learned enough through the demonstration projects we have 
been doing to have a good sense that such sources really can 
make a difference. When we see evidence on the repeated 
patterns of foster care placements among the children of drug-
involved mothers, we can understand what is at stake with some 
of these families who are having so many children come into 
foster care.
    Mr. McCrery. Is there any data you are aware of that 
indicates a higher success rate in drug treatment programs for 
parents than for nonparents?
    Mr. Barth. I am not aware of such data. I would defer that 
to anyone else on the panel who might have knowledge about 
that.
    I think we are really just at the beginning of 
understanding how to best save parents. Most custodial parents 
are women, and it has really just been in the last few years 
that we have begun to understand what their particular 
treatment needs are.
    Ms. Young. If I can add to that, some of the major studies 
of treatment effectiveness have neglected to look at exactly 
that issue. Although we have good cost offset data from some of 
the studies--Oregon, California--it has not been something we 
have looked at specifically to look at the differences for 
parents or for women.
    There is a secondary analysis of a California study that 
did look specifically at the cost offsets for women and found 
lower cost offsets than the whole population, primarily related 
to the fact that women are not as involved in the criminal 
justice system before treatment as men are. There was still a 
cost offset that was derived from providing treatment to the 
women in the CALDATA data study.
    Mr. McCrery. Thank you.
    Dr. Zill, you have reached the conclusion that for welfare 
recipients that are drug abusers, it would not serve them well 
to exempt them from the 5-year time limit. For example, and I 
think you said the work requirements as well.
    Does any of the rest of the panel have a problem with that? 
Do you disagree with that conclusion? Have you thought about 
it?
    Ms. Young. I hate to do an ``it depends,'' but I think it 
does depend.
    If someone is making progress in their treatment program 
and is not yet ready to take on the responsibilities, which can 
be significant, of parenting and working and getting the 
transportation, the things that are now required of them, then 
there should perhaps be some extensions available for those 
particular cases. Again, I would condition that on families 
that are participating and meeting the compliance requirements 
of their plan in order to participate in work and to continue 
to receive benefits.
    Mr. McCrery. Dr. Zill, can you expound a little bit on why 
you reached that conclusion? Why is it not to their benefit to 
exempt them?
    Mr. Zill. First of all, because you are providing public 
support for addiction, and I think that is bad for the person. 
I think it is bad for the program; it gives a bad name to the 
program and the many people who need temporary assistance who 
are not addicted.
    Second, what seems to be a common thread when drug 
treatment is successful, people come to the point they are 
prepared to change, and I think all the motivation you can give 
people externally will be a help. I don't think it is a 
guarantee; I think you will have lots of failures. In fact, you 
may need to give extra incentives to employers who hire such 
people because there is a problem of theft. But certainly there 
are examples of people who are not on welfare who hold down 
jobs and also have substance abuse problems, so it is not 
unprecedented.
    I don't think there is any guaranteed success here, but I 
do think the alternative is worse. I don't think we should be 
subsidized.
    Mr. McCrery. Basically, you are saying the motivation for 
success and treatment is less if they have an income stream 
from the Government?
    Mr. Zill. Exactly.
    Mr. Reuter. Can I just suggest there is one aspect that has 
to be balanced against that?
    The issue of how criminally active are recipients of public 
assistance when they are no longer receiving public assistance 
is one that must also be weighed. I don't have an answer, but I 
don't think it should be ignored.
    Mr. McCrery. If we had an answer to that, we would all be 
better off. It is a very fundamental question and we may find 
out, if we are successful in sticking to the welfare reforms 
that are in place and 10 years down the road, looking back on 
the data of crime and the commission of crime, people might 
have a better sense of what the answer is. But that is a great 
question. I wish we knew the answer now.
    Thank you all very much for your testimony.
    Chairman Shaw. Mr. Levin.
    Mr. Levin. Well, I was thinking, you seem in sufficient 
agreement, but it wasn't clear what the question should be. But 
Mr. McCrery raises an interesting issue, and I think it 
probably validates the wisdom of our giving the States power to 
exempt a limited number of people, 20 percent, from the cutoff. 
Because I assume, if they want to, where there are people who 
are indeed moving along and moving away from their addiction, 
they have the power to exempt them.
    If they are moving away, presumably a continuation of 
benefits would not necessarily be an incentive to continue drug 
use; in that case, it could be an incentive to continue away 
from drug use, right? So I am not sure there is really 
disagreement there.
    And I would think, Mr. Chairman, that we ought to really--
and the legislation I think does this--stimulate inquiry into 
the long-term TANF recipient, because the data may differ. 
Although we tend to stereotype, the majority of people move on 
and off of TANF within 1 year.
    But there is a substantial number that we have always 
worried about, and you surely have people who are long-term 
recipients, and for them, drug abuse may be the more serious 
problem. Is that possible?
    Ms. Young. That is the information that came from Utah, 
which had a welfare reform that targeted alcohol- and drug-
using parents prior to the Federal legislation. And they 
found--and they had a no exemption policy. Everyone was 
required to participate in some sort of work activity; they 
could define work activity more broadly than most States have 
defined work activity. But they found, after the initial wave 
of persons were able to get jobs, they had a higher 
concentration of alcohol and drug problems than what they had 
in their population at the beginning of their welfare reform 
initiative.
    Mr. Levin. So as the States move with some success to 
reduce the roles, the likelihood is there will be more long-
term people who are on the rolls than short-term--that is 
almost by definition, but I think it is beyond that--and the 
drug abuse problems within that population may be more serious, 
and therefore we need to focus on the relationship of drug 
abuse in that population, right?
    Ms. Young. That is correct.
    Mr. Levin. And are we doing enough of that research? Time 
is running, so what should we do to focus in on that 
population?
    Ms. Young. There are a handful of States that have used 
their, I believe, substance abuse money to do a good, 
methodologically sound study of the TANF population, using a 
screening inventory that can assess both alcohol and drug 
problems, psychological problems, social family relationships, 
legal problems.
    One of those States is Florida, which is in its final 
planning stages, so that they will have methodologically 
reliable data about the TANF population and the addiction 
severity in the TANF population. We are hopeful they will be 
able to expand that to their child welfare population also.
    Mr. Levin. Also, the $3 billion program that was passed has 
a focus on the longer term recipient, and I don't remember 
offhand the breadth we gave to the States in terms of applying 
funds or problems that relate to drug abuse. They cannot use 
any of the moneys directly for prevention or for a treatment 
program, but--you can use TANF, but not the $3 billion.
    Mr. Zill. Representative, I did want to say----
    Mr. Levin. I think what we are doing is kind of zeroing in. 
It is kind of helpful to focus in on what the issue is all 
about.
    We haven't touched foster care in my questions, but on the 
TANF population----
    Mr. Zill [continuing]. Some of the long-term recipients, it 
is not a question of drug abuse; it is a question of low 
skills, related job skills. And some of the people who are on 
welfare, who have drug-abuse problems, in fact, have quite 
decent skills; the problem is, they have a drug-abuse problem. 
So I think there is a higher incidence, but it is not the case 
for all long-term recipients.
    Mr. Levin. And the last thing I want to do is stereotype 
any segment of TANF recipients, but it may be there is a 
greater incidence of drug abuse among those who are on TANF 
longer term--there may be some correlation; and if there is a 
correlation, it means, as they become a larger proportion of 
TANF recipients, there has to be more attention given to the 
drug abuse issue.
    Thank you.
    Chairman Shaw. Just to add to that, very briefly, a lot of 
these people got in the fix they are in because of the drug 
abuse, so it is a question of, they got in the program because 
they were poor and they were poor because of drug abuse and 
particularly when you get into crack cocaine that preys on the 
poor so terribly and is so immediately addictive, almost is a 
foregone conclusion in itself, once they get into that.
    Ms. Young. Chairman Shaw, I don't believe we have evidence 
that would necessarily support that because drug abuse is so 
interrelated to other issues--related to unemployment, to less 
than a high school education, to the age of the person, and to 
marital status. So you are looking at something that is 
interrelated, and I don't believe there is evidence that would 
say the receipt of welfare was something that was a precursor 
or that less than a high school education was a precursor to 
drug abuse; those things are all mixed in together. But there 
are higher rates among the unemployed.
    Chairman Shaw. What I was saying is, once somebody gets 
into that spiral--whether they are receiving TANF or not, once 
they get into the spiral, their ability to take care of 
themselves and work is greatly diminished, so that the drug 
itself, the use of the drug itself, almost dictates the person 
is going to go into a life of poverty.
    Ms. Young. For all of us, yes.
    Chairman Shaw. I was trying to establish a chicken-and-egg 
situation. It isn't that people receiving benefits are more 
likely to fall into drugs, as much as it is people using drugs 
are likely to fall into a situation where they need the aid.
    Mr. Levin. And I think I might say, the result of that is, 
it has implications for whether it is 15 to 20 percent, for how 
that group moves off of welfare into work. I think it has 
implications for the programs that are necessary.
    Chairman Shaw. Back into the situation you were talking 
about, and that is, once we get down to the hardcore 
population, it is going to be tough to be showing the successes 
we are showing now in the early returns.
    Mr. Collins.
    Mr. Collins. Thank you, Mr. Chairman.
    Ms. Young, Dr. Young, I have a canned question here pointed 
out by staff that I want to ask you; then I want to ask you one 
of my own. You described a highly fragmented Federal effort to 
combat substance abuse. Would a block grant of these programs 
help, where the Federal Government ends all or most of the 
current programs, provides money in a single stream to States, 
and removes current fundamental Federal mandates and 
restrictions that accompany these funds?
    Ms. Young. In fact, I think a lot of the States have passed 
on that block grant notion to their local regions and their 
counties, and it has been up to the counties to put the pieces 
together.
    I think the Federal Government could do a lot in order to 
make it easier for the locals to determine what their own needs 
are and being able to address those needs. I am not an expert 
on public financing of big social programs, so I would not want 
to say that that would be the way to go; however, I do believe 
there are things Congress could do to make it easier for the 
locals to be able to put those pieces together.
    A treatment center that operates in south central Los 
Angeles has over 40 funding streams coming into its agency; the 
administrative nightmare for 40 funding streams is enormous. I 
am not saying we need another funding stream by any means, but 
we certainly need to be able to put that together at a local 
level that makes much more sense.
    Mr. Collins. OK. Now for my question.
    In all of these studies where you concentrated on the area 
of welfare, welfare recipients, and drug abuse among those 
recipients, was there any part of these studies that focused 
beyond demand and looked at supply? Maybe in the area where 
there was more concentration by the local government on the 
enforcement--not on the use of drugs, but on those who are 
trafficking in and selling drugs? Where you might have had a 
shorter supply, a higher cost for the demand, do you have 
anything like that that shows whether there may be some 
variance of usage versus the----
    Ms. Young. Dr. Reuter does.
    Mr. Reuter. Yes, I do. Supply----
    Mr. Collins. What is your full name? We have got a place 
for you too.
    Mr. Reuter. There are no studies really for any population 
that relate the intensity of enforcement to drug use, whether 
it is participation rates or frequency of abuse among those who 
do use.
    First of all, it is very hard to get good measures of the 
intensity of enforcement, and you have to do it in a way that 
allows you to match that data against the way data are 
collected on demand. There aren't any studies that do that, 
whether for welfare or for anything else.
    Mr. Collins. I go back to the point Mr. Rangel made. 
Oftentimes, these people who get trapped in this type of 
lifestyle, their best friend is the drug dealer, and I think we 
should concentrate too not only on trying to help those who 
have been--who have gotten addicted to this problem, but that 
best friend who keeps them addicted, who is making money out of 
the system; and I just wondered if there was any type of study 
that indicated whether there might be less use in an area where 
you have stronger enforcement of the supplier?
    Mr. Reuter. Congressman, I agree that is a very reasonable 
hypothesis. There is no evidence that bears on it, but nothing 
that contradicts it.
    Mr. Collins. Have you attempted to do anything like that?
    Mr. Reuter. Have I attempted? No. It is simply a data 
problem. It is not conceptually difficult; it is just that 
there aren't the data.
    Mr. Collins. I think it would be an area to look at, rather 
than always trying to look at how we can spend money on those 
who have been trapped. That is a necessary evil, but the worst 
of the evils are the ones who are supplying it. By God, they 
are the ones we ought to set our sights on in trying to get 
them off the streets and out of the way and shorten the supply, 
run the price up, and maybe we would have a positive effect on 
those attempting to use by pricing it out of the market.
    I don't care if you give them welfare or work; if they have 
a problem, they are going to spend whatever funds they get on 
that problem. So--that is enough.
    Thank you, Mr. Chairman.
    Mr. Zill. There is a consistent body of evidence from the 
delinquency area, which does not speak to drug suppliers, per 
se, but speaks to bad friends. These kinds of behaviors, 
including drug use, are often linked to being tied into a group 
of peers who are users, and so there is----
    Mr. Collins. I am not talking about peers, I am talking 
about the guy Mr. Rangel was talking about who becomes their 
best friend, because they will keep them addicted and supplied. 
That is not a best friend at all.
    Mr. Reuter. There is the notion that there are two separate 
groups: One is a set of people who sell, and the other is a set 
of people who buy. In fact there is a population of frequent 
users of drugs that moves across that boundary; a lot of people 
who are drug users are frequent drug sellers. It is fairly hard 
to find someone who is an impoverished, frequent user of 
cocaine who is not also at times a seller.
    Whether locking them up does good for them, or anyone else, 
is a reasonable question; but I think the notion that you go 
after the suppliers, suggesting there is a different 
population, is probably not in fact very helpful.
    Mr. Collins. I think you are wrong.
    Mr. Reuter. I am simply saying, analytically, it is not 
very helpful. It is not a policy statement.
    Mr. Collins. Get out in the real world.
    Chairman Shaw. Mr. Coyne.
    Mr. Coyne. I yield to Mr. Rangel.
    Chairman Shaw. Mr. Rangel.
    Mr. Rangel. Thank you.
    Dr. Zill, was it your opinion that exempting addicted 
welfare recipients from the 5-year limit would encourage drug 
dependency?
    Mr. Zill. Continue drug dependency.
    Mr. Rangel. And what do you base that on?
    Mr. Zill. Well, as I stated in my testimony, what seems to 
be a key in identifying that minority of cases where there is 
successful drug treatment is some kind of a motivational change 
within the person, and often you have success after a set of 
failures; and having some strong sense of motivation that if I 
get off this habit, I can change my life in a positive way, 
that countering that with, if you stay dependent, you are going 
to continue to get effortless funds--admittedly, they are not 
very generous kinds of funds, but you will get supported by the 
Government--I think is an incentive in the wrong direction.
    I am not saying this is going to create miracles. I don't 
think it is going to create miracles, but I think it is a bad 
policy to make an exemption for people who are drug abusers.
    Mr. Rangel. Would it follow that if the limit was 4 years 
or 3 years or 2 years, that that would be an incentive to speed 
and encourage people to be----
    Mr. Zill. I believe that TANF should provide drug treatment 
programs, but I think they should be in parallel with 
employment training and preparation, because I don't think you 
should have treatment first and then employment. I think you 
should have the two together.
    Mr. Rangel. I agree with that, but don't get me confused. 
If cutting it off in 5 years is an incentive for a person to 
get off of drugs, research would suggest that cutting it off in 
2 or 3 or 4 years would be a greater incentive.
    Mr. Zill. I don't think the time limit is the important 
thing----
    Mr. Rangel. It is important enough for you to suggest that 
a person not be exempted in 5 years. I agree with you that time 
is important politically, but it is certainly not important in 
terms of trying to help a person. A person that can go to work 
in 1 day, that should be the time limit.
    Mr. Zill. If there is a good job waiting for them.
    Mr. Rangel. Fine. You talk about those with no skills. If 
there are no skills and no jobs, you couldn't possibly support 
just cutting them off in 5 years, could you? We have a 20-
percent safety net; you would recommend that they fall in that 
group, wouldn't you?
    Mr. Zill. Perhaps.
    Mr. Rangel. I don't have any other questions.
    Mr. Zill. I do feel there is also a very bad aspect to this 
from the point of all those people who need help who are not 
drug abusers, that when TANF is known as a program that 
supports drug abuse, it paints the other people with a bad 
brush.
    Mr. Rangel. I was under the impression, and I haven't had 
your training, that these people who are drug abusers are sick 
people, the same way as those who abuse alcohol; but you are 
saying we should not treat them that way. It would be unfair to 
them. In other words, you are subsidizing the sickness by 
giving treatment.
    Mr. Zill. If we had a treatment like immunization, you get 
this injection and you will no longer be a drug abuser----
    Mr. Rangel. We don't have that.
    Mr. Zill. We are talking about a behavior that is subject 
to motivational things for which we don't have a 100-percent 
solution; in fact, as was just stated, we have about a 33-
percent solution.
    Mr. Rangel. But reduction in treatment for alcoholics and 
addicts, in your opinion, should encourage people to get better 
faster.
    Mr. Zill. Well, I think you understand----
    Mr. Rangel. I do understand.
    Mr. Zill. And I do think we have to be humane, but at the 
same time have a program that is effective.
    Mr. Rangel. I understand.
    Chairman Shaw. Mr. English.
    Mr. English. No questions.
    Chairman Shaw. Well, I would like to thank this panel. I 
think you have given us very good information and insight. 
Obviously, in some of these areas, there is room for 
disagreement, and reasonable people can disagree; but I think 
that in the long run, I found a lot of agreement among the 
witnesses, and I appreciate your testimony.
    The final panel, and I want to announce to the Subcommittee 
and to the testifying people, the House is going back in at 5 
o'clock and they are expecting at least one vote at that time. 
Without in any way shortchanging the final panel or the 
Members' ability to question, if we finish by 5 o'clock, that 
is fine. If we don't, we would simply recess until such time 
that we can come back and continue the hearing.
    Gale--is it Slater or Slaughter?
    Ms. Saler. Saler.
    Chairman Shaw. Saler--deputy executive director at Second 
Genesis in Bethesda; Judy Ogletree, former welfare recipient, 
receptionist at Second Genesis in Bethesda; Dave Batty, 
executive director of Teen Challenge, Inc., in Brooklyn, New 
York; Sally Satel--Dr. Sally Satel, the Oasis Clinic in 
Washington, DC, and a lecturer at Yale University School of 
Medicine; and Mitchell Pearlstein, Ph.D.--president of Center 
of the American Experiment in Minneapolis, Minnesota.
    Ms. Saler.

STATEMENT OF GALE SALER, M.ED., CPC, CRC-MAC, DEPUTY EXECUTIVE 
 DIRECTOR, SECOND GENESIS, INC.; ACCOMPANIED BY JUDY OGLETREE, 
        GRADUATE AND RECEPTIONIST, SECOND GENESIS, INC.

    Ms. Saler. Thank you, Mr. Chairman. I want to thank you for 
inviting Judy Ogletree and myself to appear before your 
Subcommittee. I am deputy executive director of Second Genesis, 
a not-for-profit corporation providing therapeutic services in 
Maryland, Virginia, and the District of Columbia. I am also, by 
training, both a vocational rehabilitation counselor and an 
addictions professional.
    Therapeutic community programs provide substance abuse 
services using the disease model of addiction and incorporating 
the principles of positive peer support with professional 
substance abuse treatment. Our goal is to provide to 
individuals, families, and communities the tools necessary to 
live safe, healthy, self-sufficient lives, free of drugs, 
crimes, violence, and exploitation. Many of the clients 
referred to therapeutic communities have significant 
occupational and educational deficiencies resulting from their 
years of substance abuse.
    Most of our clients need habilitation, not rehabilitation, 
because they never developed adequate social or coping skills. 
Interacting within the healthy environment of the therapeutic 
community is a vital part of treatment for our clients, and an 
important part of our job is to help the folks we see identify 
a value to being clean, sober, and self-sufficient and to 
recognize that, maybe for the first time, they have something 
to lose if they decide to use drugs in the future.
    It is important to know that successful treatment in the 
therapeutic community requires employment and a job or career 
path appropriate to the education and skill level of the 
individual. Locally, we have been very lucky in this regard and 
worked very hard at establishing corporate partnerships, and I 
would recommend that the Subcommittee talk to some of the 
corporate partners who have worked with substance abuse 
treatment.
    I have included details in my written testimony of the 
process by which therapeutic communities move clients 
simultaneously into recovery and into the work force, and I 
think they address some of what I know have been Mr. Rangel's 
long-held concerns about making sure that happens. It is useful 
to recognize that these processes--recovery and return to the 
work force--can be made to work together, supporting the goal 
of the safe, healthy, self-sufficient individual.
    What is essential for us to recognize is, this type of 
comprehensive plan requires immense coordination of services, 
ranging from treatment to health care, to children's services, 
to education, to vocational counseling, to housing, to child 
care, and so on. It is also essential it be recognized, this is 
a process that does not happen overnight or over 1 week or even 
over 1 month. We are teaching essential life skills to folks, 
many of whom who do not have role models for what we are 
teaching.
    One of the programs operated by Second Genesis is designed 
to provide treatment to women and their children up to age 10. 
That is where Judy received her treatment, and this is a 
program that allows a family to remain in residence and receive 
treatment together, mother and children. For approximately 6 
months, with 3 to 6 months of aftercare and access to services 
for up to 2 years. This program is one of the 50-plus programs 
nationwide currently funded by Federal Center for Substance 
Abuse treatment dollars and for which funding will be running 
out next year.
    I invite you or any of your staff to come visit that 
program; it is only a few miles away, off Pennsylvania Avenue. 
There you will see the best of recovery and the best of welfare 
reform--women helping women, women helping children, children 
helping children, and families finding the proverbial 
bootstraps they need to return to their communities as 
contributing members.
    Some of you will ask, Does this really work. The answer for 
me is simple. Clinically, I know treatment works. I also know 
that as with most other diseases, treatment works best if you 
follow and complete the prescribed treatment plan.
    From January 1992 through December 1994, Second Genesis 
participated in a national Institute for Drug Abuse-funded 
study comparing standard and enhanced treatment protocols to 
which clients were randomly assigned by an outside source. The 
longitudinal results of this study clearly indicate the 
effectiveness of the therapeutic community for improving 
psychological functioning, post-treatment employment, and 
reducing substance abuse and criminal activity.
    The Center for Substance Abuse Research at the University 
of Maryland conducted an independent followup, which found, in 
part, that 79 percent of those who completed their treatment 
program were drug free 2 years later, 65 percent of those who 
completed their program had no further involvement with the 
criminal justice system, and 85 percent of those who completed 
their program were employed at the time of followup.
    These statistics are impressive for two reasons. They 
confirm lifestyle changes in the majority of clients who 
complete treatment, and they demonstrate the importance of 
completion of treatment for positive outcomes.
    Welfare reform has already moved many Americans off public 
assistance, but the States report that that first wave was the 
easiest to employ. Greater challenges will be faced in making 
many of those who remain employable; among those are our 
addicted populations.
    Recovery from substance abuse is not just about people 
getting clean and sober; it is about empowering people to make 
healthy choices because they have been given the opportunity to 
succeed.
    Judy is one such person.
    Ms. Ogletree. Hi, I am Judy, and I am one of the graduates 
of Second Genesis. I am glad to be here today, Mr. Chairman.
    I am here today on behalf of myself and a lot of working 
mothers with children that were hooked on crack cocaine. Today, 
I can proudly say that I am no longer hooked on crack cocaine. 
I am working full time, I am a mother to my two kids today.
    I was in the justice system as a criminal. I am no longer a 
criminal. I am working full time at Second Genesis as a 
receptionist. I have my kids back in my life because they were 
placed in the foster care system. They are currently living 
with me in a transitional house. Also, I will have full custody 
of them, as of January.
    As of November, I will be off of the welfare system for 
good, and basically, that is what the welfare reform has done 
for me today. The help of the welfare reform and the people in 
my life, such as Second Genesis, if they had not given me a 
second chance at life, I don't think I would have made it out 
there alone. As I said, I can proudly thank Second Genesis and 
people in my life, such as the welfare system, for giving me 
and my children the assistance that I needed.
    I had a child that was born with a disability as a result 
of me using--for 14 years on drugs and alcohol; but today my 
child is getting the special help that she needs to get through 
this state--through the proper people, through Second Genesis. 
They taught me how to become a loving parent, how to care for 
my child that needed that special attention; and today I can 
say, she is going into a regular pre-K schooling class, along 
with my son, who is doing very well. He is also registered in a 
Head Start Program.
    So I can proudly say today that welfare reform does work 
for mothers that are single parents with children, or even for 
those who aren't single, but it does work. And the whole thing 
about it is, you have to want to change; and it came to a point 
in my life where I wanted to change; I wanted that change in my 
life, for myself and my children. They deserve a parent in 
their lives--and today I can say they have a parent in their 
lives that is a very good role model for them.
    I get up every morning at 4 o'clock in the morning to be to 
work on time, I come home by 8 o'clock at night and they are 
still fed, they are still clothed, and they are still bathed; 
and so today I can proudly say that I am a hard-working citizen 
and a mother today.
    [The prepared statement follows:]

Statement of Gale Saler, M.Ed., CPC, CRC-MAC, Deputy Executive 
Director, Second Genesis, Inc.; Accompanied by Judy Ogletree, Graduate 
and Receptionist, Second Genesis, Inc.

    Mr. Chairman:
    My name is Gale Saler. I am the Deputy Executive Director 
of Second Genesis, Inc., a not-for-profit corporation providing 
therapeutic community services in Maryland, Virginia, and the 
District of Columbia. I would like to thank the Chairman for 
inviting Judy Ogletree and me to appear before the House Ways 
and Means Subcommittee on Human Resources today to discuss the 
challenges welfare reform is placing on state governments, 
private industry, and welfare recipients.
    The response to welfare reform has differed among the 
states. In Maryland, the State Assembly has recognized the need 
to prepare recipients to become financially independent by 
supporting substance abuse treatment as an important step.
    Second Genesis operates five (5) therapeutic communities in 
the Washington, D.C., metropolitan area. Four of our 
communities serve a mixed male/female adult population. Our 
program in Upper Marlboro, Maryland, is a women's and 
children's program designed to provide therapeutic community 
services for women who have minor children under the age of 10. 
Our therapeutic community programs provide substance abuse 
services in a residential setting using the disease model of 
addiction by incorporating the principles of positive peer 
support and professional substance abuse treatment.
    Typically, clients referred to therapeutic communities have 
significant occupational and educational deficiencies resulting 
from years of substance abuse. They are considered hard core, 
and in general they are considered dangerous. Therapeutic 
communities are designed to provide a whole range of services 
while the clients are in residential treatment. Most of our 
clients need ``habilitation,'' not rehabilitation, because they 
never developed adequate social or coping skills. Interacting 
socially within a healthy community environment is a vital part 
of treatment for our clients.

The Client

    Our typical clients are young (20s to 30s) and present 
several similar characteristics upon admission. Primary among 
these characteristics is a predictable pattern of substance 
abuse that has resulted in increasing . During the course of 
the substance use other life goals have been sabotaged or 
severely delayed.
    Frequently the client has no work history or a sketchy work 
history that includes several minimum wage jobs with few if any 
benefits. The client lacks competitive skills and has 
educational skills that are inadequate to compete for 
vocational training or career track positions. As a result of 
these deficiencies, our clients lack goal setting and planning 
skills that are appropriate or reasonable given their education 
and skill level.
    The client often has a skewed or distorted definition of 
success with inflated and unrealistic expectations due to media 
and cultural influences. This distorted image is usually 
created to mask the lack of a positive life vision.
    Personally, the client lacks self-esteem which results in a 
poor self-image and a poor interview performance. The client 
usually has at least one ``high maintenance'' child whose needs 
frequently conflict with job demands. Generally, there is a 
family history of welfare dependency, and frequently there is 
involvement with the criminal justice system.
    Substance abuse treatment alone is not sufficient for a 
client with these problems to stay clean and sober, much less 
succeed in finding meaningful employment.
    A client who appears for treatment with these severe 
developmental and social skill deficiencies feels he or she has 
little to lose by using alcohol or drugs. Helping a client 
reach his or her developmental potential is a key to 
encouraging the client work toward a future free from alcohol 
and drugs.
    An important part of our job is making the clients feel 
that there is a value to staying clean and sober--that maybe 
for the first time in their life they have something to lose if 
they choose to use alcohol or drugs in the future. The idea of 
making healthy choices by avoiding the risk of losing a good 
job, a good relationship, or a comfortable home is truly a new 
concept for most of our clients. The role of the therapeutic 
community is to put interventions in place for vocational 
training, educational services, social skill building, conflict 
resolution and anger management, and housing placement 
assistance that will support their success in recovery from 
substance abuse.
    Therapeutic community treatment involves multiple phases 
and multiple types of interventions. Although different clients 
may follow slightly different treatment paths (based upon their 
developmental needs), all clients go through the following 
phases: stabilization, orientation, identification of a need to 
make changes, external pressure to change, discovery of skills 
(empowerment), and orchestrated success.
    Successful treatment requires employment in a job or career 
that is appropriate to the education and skill level of the 
client. In developing the pathway to successful employment in 
thhe primary steps include:

Work Adjustment Training

    Work adjustment training teaches accepted employment 
practices in a sheltered therapeutic environment by assigning 
jobs within the residence. Early in treatment, job assignments 
are designed to enhance strengths and foster self esteem. As 
treatment progresses, assignments are designed to address 
clinical and behavioral weaknesses and teach frustration 
tolerance. During this phase, the client is challenged to face 
those situations that could cause an employee to quit, lash out 
at co-workers, or be insubordinate to a supervisor. The best 
therapy is the use of actual situations that have caused the 
crisis, studying the reactions of the client, and discussing 
the alternatives the client could have chosen. This therapeutic 
model empowers the client to use other alternatives to relieve 
a crisis.
    The client begins to develop work skills by understanding 
the need to pay attention to detail, the need to complete a 
task, taking pride in workmanship, and accepting responsibility 
and accountability. Most employment situations are hierarchical 
in that most employees have supervisory, supervised, and peer 
relationships with other staff. The client learns to understand 
the appropriate role he or she plays in each relationship. The 
client also learns about employee rights, on-the-job 
advancement, and standard grievance procedures.
    Our goal is to create a client who will be a responsible, 
proud employee who understands his or her appropriate role 
within an organization and is not fearful of being held 
responsible or accountable for tasks that are assigned during 
the course of employment.

Vocational Preparation

    Vocational services begin when the client has experienced 
clinical and experiential success in the treatment and recovery 
program. Vocational services are earned by the client by 
demonstrating pre-vocational skills, including a realistic 
desire to succeed. The vocational counseling services include 
assessment, guidance, planning, resume and interview 
preparation, and other related job-seeking skills.

Activities of Daily Living

    Activities of daily living include groups with themes such 
as ``appropriate behavior on the job,'' ``peer relationships 
and socializing on the job,'' ``negative behavior,'' and 
``entitlement.'' Each group member learns the appropriate role 
in the workplace by role playing situations and discussing 
alternative methods of resolving conflict.
    Relapse prevention plays an important role for the client 
in understanding the triggers and impulses that can lead to a 
return to substance use. The client learns to avoid triggers 
and how to use his or her recovery program to avoid situations 
that can lead to relapse.
    The client learns to prepare a personal budget, how to use 
a bank, and how to live within a budget. The client also learns 
to develop a healthy social network of friends and hobbies to 
replace friends who may still be alcohol-or drug-involved or 
hobbies that may be criminally related. The therapeutic 
community exposes the client to recreational and social 
alternatives that will create an environment supportive of 
continued recovery.
    Vocational counseling is essential throughout the process 
of making the client ready to seek employment. Developing 
behaviors and skills that are consistent with successfully 
finding employment prepares the client for the challenges of 
locating the right job and independent living.

Setting a Goal

    The client learns to set a realistic goal that is 
obtainable given the resources, education, and training 
available. He or she must then determine if reaching the goal 
will create an income adequate to meet basic needs. The client 
then is asked to determine what step and sacrifices will be 
necessary to reach the goal and if he or she is prepared to 
make the sacrifices necessary to achieve the goal.

The Employment Plan

    The client prepares a plan to achieve the employment goal 
that he or she has selected. The plan must include specific 
objectives for vocational preparation, unmet educational needs, 
planning for child care and family needs, safe housing, and 
coping with relapse triggers. The plan also needs to have 
alternative choices for each objective if circumstances or 
mistakes require the plan to be altered. The client learns the 
need to remain focused on the objectives of the plan to reach 
the goal of selected employment.

Carrying out the Plan

    The client develops a job search strategy that includes 
developing a resume, identifying references (personal and 
professional), and learning how to locate the most likely 
sources of employment prospects. The client learns how to 
assess a job offer by weighing the pros and cons, benefits, and 
other employment options. At the time the client accepts a 
position, he or she learns to clarify any unsettled questions 
with the prospective employer and establish a mutually 
agreeable starting date. The vocational counselor prepares the 
client for the first day on the new job when a new employee's 
desire to succeed may create stress for the employee (and 
everyone else). The client then begins to activate the budget 
plan beginning with the first paycheck.

Moving Out

    During the move out phase the client lives within the 
budget he or she has created, setting aside funds for housing, 
food, child care, transportation, legal fees (if any), 
utilities, social needs, and savings. While the client is still 
in residence in the treatment program the client places the 
funds in a bank where they are reserved until such time as he 
or she has located a safe place to live, convenient to his or 
her employment, that is within the budget the client developed 
based upon his or her income.

Aftercare

    The first goal of anyone in recovery is to stay clean and 
sober. All other goals and objectives are dependent on their 
being able to maintain sobriety. Aftercare smoothes the 
transition for the client from the safety of the therapeutic 
community to the hazards of the real world and all the relapse 
triggers associated with returning to the community. After the 
client is discharged from residential treatment he or she 
continues to return to the program for outpatient aftercare to 
address issues that occur after the client leaves treatment and 
begins to move toward independent living.

Does Treatment Work?

    From January 1993 through December 1994, Second Genesis 
participated in the D.C. Initiative, providing residential 
therapeutic community services in a ``standard'' and an 
``enhanced'' treatment protocol. The longitudinal results from 
the D.C. Initiative clearly indicate the effectiveness of 
therapeutic community treatment for improving psychological 
functioning, post-treatment employment, and reducing substance 
abuse and criminal activity. Outpatient aftercare was a 
significant contributing factor to the success of clients who 
completed both the residential and outpatient treatment 
components.
    It should be noted that in addition to the having the 
developmental needs most frequently seen in the population on 
public assistance, two-thirds of the population that 
participated in the D.C. Initiative also had a pattern of 
involvement with the criminal justice system. The Center for 
Substance Abuse Research (cesar) of the University of Maryland 
has conducted follow-up studies on clients who participated in 
the therapeutic community service of the D.C. Initiative. A 
summary of its findings includes the following:
     Seventy-nine percent (79%) of the persons who 
completed the program reported they were drug-free more than 
two years after leaving treatment. Thirty-one percent (31%) of 
the persons who did not complete the program were drug-free 
after two years. The 79 percent figure was confirmed by drug 
tests taken three days prior to the follow-up interview.
     Sixty-five percent (65%) of the persons who 
completed the program reported no further involvement with the 
criminal justice system after treatment. Only 42 percent of the 
persons who did not complete the program reported no further 
criminal involvement.
     Eighty-five percent (85%) of the persons who 
completed the program reported being employed at the time of 
the follow-up interview. Only 61 percent of the persons who did 
not complete the program reported employment at the time of the 
interview.
    These statistics are impressive for two reasons: they 
confirm the life-style changes in the majority of clients who 
completed treatment, and they demonstrate the importance of 
completion of treatment for positive outcome.
    A reduction in involvement with the criminal justice system 
at the time of the follow-up interviews was significant. These 
findings support the importance of treatment completion in the 
reduction of criminal activity and drug use in a sample that 
was heavily involved in criminal activity prior to treatment.
    The findings by CESAR of the clients who participated in 
the D.C. Initiative support the concept that substance abuse 
treatment, if it is to be successful, must also accomplish 
significant life-style changes, incorporate developmental needs 
into the treatment milieu and prepare the client for 
independent, drug-free living. (See Attached Table).

Summary

    Welfare reform has moved millions of Americans off public 
assistance. Up until this time, the persons who have 
successfully moved from public assistance have been those who 
were easiest to employ or who had alternative support during 
the transition to self-sufficiency. Greater challenges will be 
faced in providing services to make others employable and self-
sufficient. Recovery from substance abuse is not just about 
people getting clean and sober, it is about people empowered to 
make healthy choices because they have been given the 
opportunity to succeed in life through recovery.
    Attachments:
    D.C.I. Statistics, CESAR, University of Maryland, 1997
    Therapeutic Communities of America, Memorandum from Linda 
R. Wolf Jones to Gale Saler, TCA Perspective on Welfare, Work 
and Drug Treatment
    Second Genesis graduates of treatment in the D.C. 
Initiative used drugs less frequently and had fewer arrests 
than non-graduates.
      

                                


------------------------------------------------------------------------
                                                 Completed
                                                Inpatient &
                                                 Outpatient   Completed
                                                 at Second    Neither  %
                                                 Genesis  %
------------------------------------------------------------------------
Used Drugs Post Dicharge (Self-Reports):
  Alcohol.....................................           18           43
  Marijuana...................................            7           23
  Cocaine.....................................           16           55
  Crack.......................................           15           52
  Heroin......................................            8           11
Positive Urine Test Results:
  Alcohol.....................................            6           10
  Marijuana...................................            7           10
  Cocaine/Crack...............................           18           49
  Heroin......................................           12            6
Arrested 6 Months Post Discharge..............            9           28
------------------------------------------------------------------------
Source: Center for Substance Abuse Research (CESAR), University of
  Maryland, College Park, Md.

      

                                

                 Therapeutic Communities of America        
               1612 Connecticut Avenue, N.W., Suite 4-B    
                                       Washington, DC 20009
                                                   October 17, 1997

TO: Gale Saler
FROM: Linda R. Wolf Jones

Re: TCA Perspective on Welfare, Work and Drug Treatment

    Therapeutic Communities of America (TCA) supports public policies 
that move women from welfare to work, but cautions that women with 
substance abuse problems will not generally be able to succeed in 
making the transition unless their substance abuse is addressed through 
intervention and treatment.
    The Personal Responsibility and Work Opportunity Reconciliation Act 
of 1996 (P.L. 104-193) limited the receipt of welfare benefits to no 
more than five years. Substance-abusing welfare recipients will need 
treatment in order to achieve and maintain self-sufficiency. However, 
the legislation did not address or add capacity to the substance abuse 
treatment system. Individuals with dysfunctional life histories and 
severe substance abuse problems frequently require long term 
residential treatement in order to achieve a drug free, self-sufficient 
life style; The number of such treatment slots is very limited 
(estimated at no more than 15,000-20,000 nationwide, depending on the 
definition of ``long term'') and needs to be expanded. We suggest that 
additional funding must be made available specifically for the creation 
of long term residential treatment slots and the expansion of treatment 
capacity.
    We are also disturbed by the fact that the Balanced Budget Act of 
1997 (P.L. 105-33) recognizes that individuals who require substance 
abuse treatment for employment are (and should be) a target population 
for the use of welfare-to-work funds, but that substance abuse 
treatment is not specifically listed as one of the allowable activites 
as work experience programs, on-the-job training, and readiness, 
placement and post-employment services. For those with severe substance 
abuse problems, treatment is a prerequisite to succeeding at a job. It 
may be that the list of allowable activities can be interpreted as 
including provision of substance abuse treatment, but States are not 
likely to make such an interpretation if not specifically told that 
they can do so. Substance abuse treatment should be clearly identified 
as an allowable activity (i.e., an activity meant to move individuals 
into, and keep them in, unsubsidized employment) in the current law and 
any future legislation.
      

                                

    Chairman Shaw. Thank you.
    Mr. Batty.

 STATEMENT OF DAVE BATTY, EXECUTIVE DIRECTOR, TEEN CHALLENGE, 
                    INC., BROOKLYN, NEW YORK

    Mr. Batty. Chairman Shaw, I am pleased to be here on behalf 
of Teen Challenge. I am Dave Batty, and I work with Teen 
Challenge in Brooklyn, New York.
    For the past 39 years, Teen Challenge has worked not just 
with teens, but also with adults and families affected by drugs 
and alcohol in 130 centers across the Nation. We are privately 
funded by businesses, individuals, and churches, and we seek to 
work with inner-city gangs, substance abusers and their 
families, teen runaways, those who have been sexually abused, 
and also persons with HIV-AIDS.
    Teen Challenge does extensive prevention training in 
community settings. We also have long-term residential help for 
those who have serious addictions. Teen Challenge provides over 
3,100 beds in their residential programs. As I have worked with 
Teen Challenge since 1968, I have seen the success of this in 
leading people to a lifestyle that is free from addictions.
    When I received the invitation to testify before this 
Subcommittee, I was told of your interest in hearing about 
organizations that have success in getting people off welfare 
and off drugs.
    In a survey of the women in our Brooklyn Teen Challenge, I 
found 80 percent had been on welfare before coming to Teen 
Challenge. These ladies had been on welfare from 2 to 15 years. 
All had been using drugs while on welfare. Many had used their 
welfare checks to buy drugs. Seventy percent were working, and 
most of these were being paid under the table while they were 
on welfare. They used this money to support their drug habit. 
Eighty percent had been in at least one other drug treatment 
program before coming to Teen Challenge.
    Now, some of these ladies had started on welfare because of 
a family crisis, but most came to believe the Government owed 
them this money. It is clear that those who come to Teen 
Challenge are not shining examples of the success of welfare. I 
would like to share with you the examples of three women who 
have graduated from Teen Challenge and are now working.
    One 1991 graduate has been employed as a clerk typist at 
the same job for 4 years. A 1990 graduate has been working at 
the same job in the Bronx for 6 years as a social worker. 
Another lady, who is HIV positive, is working very effectively 
as staff for Teen Challenge in Brooklyn. She said, If I had not 
gone through Teen Challenge, I would be out there on the 
streets getting everything I possibly could from the 
Government.
    So how does Teen Challenge help these welfare recipients to 
so dramatically change their lifestyle? The drug prevention 
work that Teen Challenge offers is faith based. We tell them 
they need to change their whole way of living. They need more 
than drug rehabilitation; they need life transformation.
    We believe the key to long-term change is to place high 
priority on the spiritual component of their life. Establishing 
a personal relationship with God is the key to finding a path 
to freedom from addictions. This personal relationship with God 
provides the desire and the power to change their way of 
living.
    In Teen Challenge, the residents attend classes dealing 
with anger, attitudes, self-image, temptation, obedience to 
those in authority, just to name a few of the issues. Getting 
them physically off their drug addiction usually only takes a 
few weeks, but developing a whole new way of living with a new 
sense of personal responsibility--that is why the Teen 
Challenge residential program is 1 year long.
    In 1975 the Federal Department of Health, Education and 
Welfare funded a study of the graduates of Teen Challenge to 
determine the effectiveness of this approach to help drug 
addicts. Under the leadership of Dr. Catherine Hess, the former 
Assistant Chief of the Cancer Control Program of the U.S. 
Public Health Service, this study looked at those who had been 
out of the program for 7 years. This study showed that 70 
percent of Teen Challenge graduates were living drug-free 
lives, abstaining from all narcotics, alcohol, and marijuana. 
Seventy-five percent indicated their current status as 
``employed''; 87 percent of the graduates did not require 
additional drug treatment after leaving Teen Challenge; 72 
percent had continued their education after completing Teen 
Challenge.
    A 1994 study by Dr. Roger Thompson, head of the Criminal 
Justice Department at the University of Tennessee at 
Chattanooga, found similar results in looking at graduates who 
have been out of the program from 2 to 15 years.
    Teen Challenge has the proven cure for the drug epidemic. 
We work with both males and females with a significant student 
population in Hispanics and Afro-Americans. The help Teen 
Challenge offers cannot be forced on people; they must want to 
change. However, we have found that many of those who come to 
Teen Challenge had given up all hope of ever changing. They 
didn't see any way out until someone told them about Teen 
Challenge.
    In conclusion, faith-based programs offer a high degree of 
success in helping drug addicts kick their addiction for good 
and establish a whole new lifestyle. Those who are using and 
abusing the welfare system can be helped through an approach 
that gives primary focus to meeting the spiritual needs of the 
person, in addition to their life-controlling problems. There 
is a great need for the Federal Government to find appropriate 
ways to partner with faith-based programs which are proving to 
be so successful in treating those with drug addictions.
    [The prepared statement follows:]

Statement of Dave Batty, Executive Director, Teen Challenge, Inc., 
Brooklyn, New York

                              Introduction

    I am Dave Batty, the executive director of Teen Challenge 
in Brooklyn, New York. I am pleased to be here to testify on 
behalf of Teen Challenge.
    For the past 39 years the Teen Challenge organization has 
been working with youth, adults and families affected by drugs, 
alcohol and other life-controlling problems. In 130 centers 
across the nation which are privately funded by donations from 
individuals, businesses and churches, we seek to work with 
inner-city gangs substance abusers and their families teen 
runaways those who have been sexually abused and persons with 
HIV/AIDS
    Teen Challenge does extensive prevention training in 
schools, churches and other community settings. Long term 
residential help is also provided to those with serious 
addictions. Teen Challenge provides over 3,100 beds in their 
residential programs.
    As I have worked with Teen Challenge since 1968, first as a 
volunteer and then as a full time staff, I have seen the 
success of this program in leading people to a lifestyle free 
from addictions.
    When I received the invitation to testify before this sub-
committee, I was told of your interest in hearing from 
organizations which are having success in getting people off 
welfare and life-controlling problems that got them on welfare.
    I conducted a survey of the women in our Brooklyn Teen 
Challenge and found that
     had been on welfare before coming to Teen 
Challenge
     an additional 10% were receiving food stamps
     these ladies had been on welfare from 2 to 15 
years
     many had used their welfare checks to buy drugs
     70% were working and paid off the books while on 
welfare and used this money to support their drug habit
     80% had been in at least one other drug treatment 
program before coming to Teen Challenge
    Some of these ladies had started on welfare because of a 
family crisis. Most came to believe the government owed them 
this money.
    It is clear that those who come to Teen Challenge are not 
shining examples of the success of welfare in its goal to help 
those in legitimate need and help them move to become part of a 
productive work force in our nation.
    I talked with three who have graduated from Teen Challenge 
and are now working.
    1. One lady graduated in 1991 and has been employed as a 
clerk/typist at the same job for 4 years.
    2. Another lady graduated in 1990 and has been working at 
the same job in the Bronx for 6 years as a social worker.
    3. Another lady who is HIV+ is working very effectively as 
a staff at Teen Challenge in Brooklyn, NY. She said, ``If I had 
not gone through Teen Challenge I would be out there on the 
streets getting everything I possibly could from the 
government.'' So how does Teen Challenge help these welfare 
recipients to so dramatically change their lifestyle? The drug 
intervention work that Teen Challenge offers is faith-based. At 
Teen Challenge we treat more than their drug addiction. We tell 
them they need to change their whole way of living. They need 
more than drug rehabilitation, they need life-transformation.
    The key to the success of Teen Challenge is its holistic 
approach. We believe the key to long term change of those in 
Teen Challenge is to place key priority on the spiritual 
component of their life. Establishing a personal relationship 
with God is foundational to finding the path to freedom from 
addictions. This personal relationship with God provides the 
desire and the power to change their way of living.
    In Teen Challenge the residents attend class daily where 
the focus is not drug education, but life education. Classes 
deal with anger, attitudes, self-images, temptation, personal 
work habits, obedience to those in authority, dealing with 
failure, just to name a few. In each class the focus is on 
personal application of life principles, not just content 
mastery.
    Getting them physically off their drug addiction usually 
takes only a few weeks at the longest. But developing a whole 
new way of living, with new attitudes, new habits, a new sense 
of personal responsibility--that's why the Teen Challenge 
residential program is one year long.
    In 1975 the Federal Department of Health, Education & 
Welfare funded a study of the graduates of Teen Challenge to 
determine the effectiveness of this approach to help drug 
addicts. Under the leadership of Dr. Catherine Hess, M.D., the 
former assistant chief of the Cancer Control Program of the 
U.S. Public Health Service, this study looked at those who had 
been out of the program for 7 years. This study showed:
     70% of Teen Challenge graduates were living drug-
free lives, abstaining from all narcotics, alcohol, and 
marijuana
     75% indicated their current status as employed
     87% of the graduates did not require additional 
drug treatment after leaving Teen Challenge
     72% had continued their education after completing 
Teen Challenge
     90% had been arrested before entering the program. 
Only 30% had been arrested in the seven years following their 
graduation
    For more information on this research project, see NIDA 
SERVICES RESEARCH REPORT: AN EVALUATION OF THE TEEN CHALLENGE 
TREATMENT PROGRAM (DHEW Publication No. ADM. 77-425 Printed in 
1977) and Research Summary by Dr. Catherine Hess. Both of these 
resources are available from Teen Challenge National Training & 
Resource Center, PO Box 1015, Springfield, MO 65801.
    A 1994 study under the leadership of Dr. Roger Thompson, 
Head of the Criminal Justice Department of at the University of 
Tennessee at Chattanooga found similar results in looking at 
graduates who had been out of the program from 2 to 15 years.
     67% of Teen Challenge graduates were living drug-
free lives, abstaining from all narcotics, alcohol, and 
marijuana
     72% indicated their current status as employed
     88% of the graduates did not require additional 
drug treatment after leaving Teen Challenge
     60% had continued their education after completing 
Teen Challenge
    A complete report on this research is available from Teen 
Challenge National Training & Resource Center, PO Box 1015, 
Springfield, MO 6580l.
    Teen Challenge has the proven cure for the drug epidemic. 
We work with both males and females, with significant student 
populations of Hispanics and Afro-Americans. Let me caution 
you--the help Teen Challenge offers cannot be forced on people. 
They must want to change. However, we have found that many of 
those who come to Teen Challenge had given up hope of ever 
changing. They didn't see any way out, until someone told them 
about Teen Challenge.
    In conclusion, faith-based programs offer a high degree of 
success in helping drug addicts kick their addiction and 
establish a whole new lifestyle. Those who are using and 
abusing the welfare system can be helped through an approach 
that gives primary focus to meeting the spiritual needs of the 
person in addition to their life-controlling problems.
    There is a great need for the federal government to find 
appropriate ways to partner with faith-based programs which are 
proving to be so successful in treating those with drug 
addictions.
      

                                

    Chairman Shaw. Thank you, Mr. Batty.
    Dr. Satel.

STATEMENT OF SALLY L. SATEL, M.D., PSYCHIATRIST, OASIS CLINIC; 
        AND LECTURER, YALE UNIVERSITY SCHOOL OF MEDICINE

    Dr. Satel. Mr. Chairman, thank you for inviting me. I work 
as a psychiatrist at a drug treatment clinic here in the 
District of Columbia, and I think my primary qualification for 
appearing today is that I have worked with so many patients 
whose recovery, in my view, was actually undermined by the 
welfare payments that they received.
    What happened was that welfare, as a safety net, cushioned 
people from the painful consequences of their addiction; and 
that is not good in the long run, because it is the very fact 
that consequences are painful that is the major impetus to 
recovery. In addition to this, of course, the cash payments 
were regularly used to purchase drugs.
    Obviously, there is a lot of talk about sending drug-
abusing welfare clients to treatment, but I am not so sure that 
will be enough. And the reason is, attendance in programs is so 
low, and these programs have few means to keep the patients in. 
They have little leverage to keep patients involved, to reward 
attendance, to reward clean urines, sanction poor compliance.
    So my suggestion is this: Use the welfare system as a 
leverage and harness the incentive power of, say, cash benefits 
to combat addiction by keeping people in treatment.
    There is a drug clinic, for example, in Baltimore that is 
doing something like this; the monetary incentives they use 
come from a special research fund, but you can imagine they 
might be welfare benefits. In this clinic, patients who are 
struggling with heroin and cocaine get redeemable vouchers when 
they submit a clean urine and attend job training. Attendance 
at the training is way up.
    Now, this approach can be adapted by clinics that are 
treating welfare recipients, so that the benefits themselves 
become the incentives for sustained attendance and ultimately 
recovery. But right now, conventional treatment programs don't 
have leverage to keep patients coming back. In fact, they have 
a very mixed record in treating patients and helping them to be 
drug free.
    If you look at the second--the figure on the second page of 
my testimony--you see huge dropout rates from outpatient 
treatment, which is the most common form of treatment. About 1 
in 10 complete 52 weeks, and, at minimum, 1 year is considered 
adequate duration of treatment. That is a minimum.
    When patients do finish, as others today have said, they 
can do extremely well; but dropout is the rule, and then 
relapse becomes the rule. And that is why I am skeptical that 
treatment, as usual, is the way to go, is the easy answer for 
drug-abusing welfare recipients. The alternative, as I 
mentioned before, would be to merge the functions of welfare, 
which is economic support, with the functions of drug 
treatment, which is recovery.
    Create an active arrangement where the person can, for 
example, earn back payments, managed by a third party, possibly 
the treatment program itself, when the patient complies with 
the treatment. This would entail clean urine, counseling, job 
training, or supportive employment.
    I will just mention briefly a few programs that are trying 
this. They are not using welfare payments. One of them, 
however, is using SSI payments.
    Harborview is a clinic in Seattle. It works with substance 
abusers who also have mental illness. This is a clinic where 
patients are asked to sign over their SSI payments. And the 
clinic keeps their bank account and acts as their 
representative payee. Rent and other basics are taken care off, 
and the patients earn back whatever is left over; they earn 
back those discretionary funds through their compliance with 
treatment. Ultimately, they can get control of their bank 
account if compliant with the program.
    The results show that after entering this payee program, 
compared to before, attendance and treatment are up, 
hospitalizations for drug-related complications are down, and 
jail time is way down.
    Another program I will tell you about briefly is a clinic 
run by the University of Texas working with pregnant cocaine 
users; they receive payments, again, for attending clinics and 
keeping prenatal visits. And those women who received the 
payments attended far more clinic visits, had cleaner urines, 
in fact, were cocaine free when the babies were born, and their 
babies were less likely to be premature.
    Finally, at the University of Alabama, addicts are given 
standard treatment, plus an opportunity to participate in 
supervised work as a positive reward for abstinence. If you 
have a dirty urine that day, you can't work. If you can't work, 
you don't get paid that day. If you get two clean urines, you 
can work again.
    And the researchers there have found again, higher 
attendance at treatment and greater drug abstinence among the 
individuals participating in the incentive program.
    So, of course, I am in favor of treatment for drug-abusing 
recipients who can't quit drugs on their own, but you have to 
keep in mind four things. Drug treatment really only works when 
people complete it. Dropout rates are high. You can keep 
patients in treatment longer with incentives and sanctions, and 
it would be a good idea to use the naturally occurring welfare 
benefits to provide these incentives.
    I think this is a wonderful opportunity to take a system 
that for many, has induced dependence and use it to help shape 
their autonomy.
    Thank you very much.
    [The prepared statement follows:]

Statement of Sally L. Satel, M.D., Psychiatrist, Oasis Clinic; and 
Lecturer, Yale University School of Medicine

    Mr. Chairman and Members of the Committee:
    Thank you for inviting me. My primary qualification for 
appearing here today is that I treat many addicted patients 
whose progress in therapy is undermined by the welfare payments 
they receive. This safety net is well-intentioned but, 
unfortunately, it cushions the painful consequences of 
addiction. And it is the very fact that consequences are 
painful that provides the major impetus to recovery. Also, of 
course, cash welfare payments are regularly used to buy drugs. 
This unwitting sabotage can be redressed, I am confident, to 
help patients lead healthier lives, be better parents and 
contribute to society.
     I am skeptical, however, that such gains can be 
achieved through standard treatment which gives patients only 
modest incentives to fully comply, let alone become drug-free.
     The welfare system, however, provides an excellent 
opportunity to wield carrot and stick for the purposes of drug 
rehabilitation.
     We can use the incentives of the welfare benefits 
themselves as leverage to change behavior.
    One model takes place in a Baltimore clinic where addicted 
patients get redeemable vouchers when they submit a clean urine 
screen or attend job training sessions. This kind of behavioral 
approach could be adapted so that welfare benefits themselves 
become incentives to recovery.
     Although welfare was meant for a different 
purpose--to support for mothers with children--we shouldn't be 
reluctant to use it to help them combat addiction.

                               Background

    Review of Treatment Effectiveness:

    Although the signature of the Center for Substance Abuse 
Treatment is ``treatment works,'' data show, more accurately, 
that treatment can work but that drop out is high and relapse 
to drugs like heroin and cocaine is the rule. For example, 
after 52 weeks, about 10% of patients remained enrolled in 
standard drug-free outpatient treatment (see figure and Hubbard 
RL et al.: ``Drug Abuse Treatment'';, U. No. Carolina Press, 
1989).
[GRAPHIC] [TIFF OMITTED] T0489.001


    The good news, however, is that treatment almost always 
saves money--in this sense, it ``works,'' (``Socio-economic 
Evaluations of Addictions Treatment'', President's Commission 
on Model State Drug Laws, Dec. 1993). In the year after 
treatment, costs associated with enforcement and criminal 
justice and drug-related hospitalizations reliably decline by 
25-60% with figure here treatment while employment goes up by 
about 10%. That means every dollar invested in treatment yields 
four to seven in social savings. In addition, improvement 
increases the longer a patient stays in treatment beyond a 
critical period of at least 90 days.
    A recent state-wide survey from California (California Drug 
and Alcohol Treatment Assessment, CALDATA) reported cost-
benefit ratio of $1:7. This year, the Department of Health and 
Human Services produced an analysis that focused on the welfare 
recipients in the CALDATA study. To my knowledge, this is the 
only large scale evaluation of the effects of treatment on a 
welfare population. According to the January 1997 report, 
``Alcohol and Other Drug Treatment for Parents and Welfare 
Recipients--Outcomes, Costs and Benefits'': (1) crime fell by 
54 to 67% between the year before and the year after treatment 
(including arrests and engaging in one or more illicit 
activities such as drug dealing and shoplifting); (2) 
hospitalization dropped by 58%;(3) cocaine use went down about 
40% and heroin 14%; and (4) cost benefit ratio for welfare 
recipients was 1:2.5.
    Thus, CALDATA presents a socioeconomic analysis that, 
despite its shortcomings, shows that treatment for recipients--
even if it doesn't work in the sense of stopping drug use 
completely--is certainly worth it as a social investment.
    Women with Children Least Likely to Benefit: Women are less 
likely to enter drug treatment than men, a fact often ascribed 
to their lower likelihood of criminal justice involvement (a 
common mechanism of referral to treatment). Some may be fearful 
that they will lose their children if they come to the 
attention of doctors and other authorities. Also, women are 
more likely to suffer clinical depression or distress 
associated with domestic violence. Thus, with her poor 
prognosis for employment, limited options and feelings of 
demoralization, many drug abusing welfare recipients make the 
classic ``rational economic decision'' to depend on public 
assistance.
    One of the major conclusions of the policy book ``When Drug 
Addicts Have Children: Reorienting Child Welfare's Response'' 
(Ed. D. J. Besharov, Child Welfare League of America, AEI Press 
1994) is ``assume that parental addiction to crack and other 
drugs will not be cured ... even the best programs report that, 
in most cases, they can break the pattern of crack usage only 
temporarily.'' Outpatient care--by far the most common mode of 
treatment--is passive. The patient may show up to the clinic 
one day or she may not, she gives a clean urine or not ... and 
there's little leverage the program can wield to increase her 
participation.
    What about residential treatment? Traditional treatment 
ranges from outpatient clinic visits to long term (12-24 
months) residential treatment. Residential is a form of 
treatment often discussed as an option for TANF mothers (Jon 
Morgenstern MD, consultant to State of New Jersey). It is 
epitomized by New York City's Phoenix House programs which seek 
to transform destructive patterns of thinking, feeling and 
behavior that predispose to drug abuse. Through community 
living and cooperating with others, structured tasks, 
expectations and rules, patients learn self-discipline and 
responsibility; they are thus less resistant to authority and 
supervision (attitudes essential for success in the workplace). 
Teen Challenge, also residential, fosters recovery through 
religious conversion.
    This is an ambitious program of change, yet data show that 
patients who complete it do extremely well. Among graduates of 
Phoenix House (the most extensively studied of all residential 
programs) 90% are still working and law abiding five to seven 
years later; 70% are completely drug free. The problem is, 
however, that drop out rates are high: 30% within the first six 
weeks, about half make it through the first year at Phoenix 
House and only about 15-20% finish.
    Opportunity to assess residential treatment for mother and 
children: Unfortunately, there is little quality data on the 
effectiveness of mother-and-child residential treatment 
programs compared to less expensive options. Nor are there data 
on the optimal length of stay.
    Residential treatment has advantages for women reluctant to 
seek help out of fear their children will be taken away. 
Pregnant women, in particular, may worry about arrest if they 
come to the attention of doctors or other authorities. It also 
side-steps the no-children-allowed rule. Currently, if a woman 
is lucky enough to find a scarce residential bed, chances are 
children are not allowed or the limit is one child only. 
Understandably, many women don't want to leave other children 
behind with relatives or foster care. Lastly, residential care 
solves housing and day care problems, the former representing a 
major source of disorganization in the lives of welfare mothers 
and their children.
    Despite its advantages, there are two big problems with 
mother-and-child residential treatment. The first is cost; 
$30,000 per family minimum. Second, even if states were willing 
to spend the money, it would take several years to build this 
infrastructure. States need a more immediate solution.

             Contingency Management--Leverage as a Solution

    Treatment can be very helpful if the patient completes it 
so how do we improve retention? The bold answer: coercion. 
Several ways to ``coerce'' patients into substance abuse 
treatment are (1) through criminal court-order; (2) threat of 
loss of child custody through protective services and, (3) 
suspension of welfare support unless the woman agrees to 
treatment. But can patients who are forced into treatment 
benefit? Yes. Counterintuitive as this may seem, data reliably 
show that outcomes for coerced patients are as good or better 
than traditional voluntary patients. Drug abusers may be court-
ordered to treatment by the criminal justice system or, more 
rarely, committed by a civil judge because of severe mental or 
physical debilitation due to severe addiction (Institute of 
Medicine: Treating Drug Problems, 1990).
    What is CM? Using rewards and punishment to shape behavior 
is hardly new. For children and adults, respectively, 
contingency management (CM) arrangements take the form of ``if 
you do X (eat spinach), you can get Y (dessert)'' and/or ``if 
you don't do A (show up for work on time), something aversive 
will occur (you won't get paid).''
    Research on CM: A large body of research shows that this 
can be applied in treating drug abusers. One of the earliest 
studies concerned deteriorated skid row alcoholic volunteers. 
Ten were randomly chosen to be eligible for housing, medical 
care, clothing, employment services if their blood alcohol 
levels were below a minimum level. The other ten could obtain 
these services from the Salvation Army as usual. The volunteers 
who were rewarded for not drinking, had far better outcomes in 
terms of maintaining sobriety and employment (Miller PM: Arch 
Gen Psychiatry, 32:915-18, 1975).
    More recent studies on CM use vouchers redeemable for 
goods. The bulk of controlled research on this subject has been 
conducted by psychologists Steve Higgins of the University of 
Vermont and Ken Silverman of John Hopkins University. Their 
work consistently demonstrates that patients who abuse cocaine 
or heroin substantially reduce or cease drug use and remain in 
treatment longer when given vouchers for each negative urine 
submitted. Silverman and colleagues also conducted a small 
pilot project which showed that unemployed heroin users on 
methadone had significantly increased attendance at job skills 
training when they were given vouchers based on attendance.
    Regarding work itself as a treatment intervention makes 
good sense. In many ways, it is the ideal therapy for hard-to-
serve welfare recipients by instilling and rewarding 
discipline, responsibility, and cooperation with authority and 
colleagues.
    CM Drawback: A problem with CM is the tendency to resume 
drug use, albeit at a lower level than before treatment, when 
the reward contract is withdrawn. This may be due, in part, to 
the short duration of the research projects. Three to six 
months is not enough time to enable the person to learn new 
skills, secure a job and attain the measure of personal growth 
needed to live drug-free. Another problem is the cost of the 
vouchers; in these studies the ``rewards'' were written into 
the grant budget but real-world treatment can't provide 
monetary incentives. Yet these two obstacles to CM could be 
remedied by using TANF payments as the contingencies. Once the 
recipient is transitioned to the workplace, the employer could 
continue to drug test former recipients--who now have something 
to lose--as a condition of employment.
    How Should CM work? Psychiatrist Thomas J. Crowley of the 
University of Colorado recommends:
     make the consequences very clear: Written 
agreements or contracts should spell out what kinds of 
violations (missed appointments, dirty urines, etc) will 
trigger what kinds of sanctions.
     make consequences incremental, immediate and 
highly predictable. Rewards and sanctions are more effective 
when they are experienced frequently. Sanctions need not be 
harsh if they are administered predictably and with immediacy. 
An Urban Institute analysis of the Washington DC drug court 
shows that immediate sanctions like a few days in jail after 
the first positive urine can have a beneficial effect on drug 
use compared to the absence of predictable sanctions.

                  TANF As a Vehicle for Rehabilitation

    Not all drug abusing TANF recipients require treatment, let 
alone residential care with its long length of stay and 
expense. Some recipients will respond to less aggressive forms 
of intervention, starting with urine testing.
    Urine Testing Alone: Some drug abusers simply respond to 
the consequences of positive urines (Urban Institute report on 
Washington DC Pre-Trail Services). One woman, now completely 
abstinent, told me that she wanted to get a job as a truck 
driver explicitly because ``they'll take my urine regularly and 
it'll help me control myself.'' Women who need more help to 
keep urines clean can enroll on their own in treatment-as-usual 
and/or Narcotics Anonymous.
    It is important to realize that not everyone who uses drugs 
has a raging habit. Some people can even use crack and cocaine 
in a sporadic manner. Often my patients have dirty urines 
because ``I just had some money that day'' or ``I ran into a 
friend who had cocaine last week'' or ``I got mad at my 
boyfriend and I figured what the hell.'' These are examples of 
deliberate use. And deliberate use means the ability to abstain 
if the consequences are meaningful.
    Another patient, a young man whose urines were often 
positive for tranquilizers, heroin and cocaine, started turning 
in clean urines. His explanation? ``I got arrested two months 
ago and my probation officer checks my urine weekly.'' He says 
I'm going to jail if I give him a positive. I'm telling you, 
getting arrested was the best thing that ever happened to me.''
    Free Standing CM: If urines remain positive, then all cash 
and redeemable benefits should be handled by a responsible 
payee. It is important that drug abusing recipients do not have 
direct access to cash (perhaps not even food stamps since they 
can be traded for cash). Not only is this cash used to purchase 
drugs (recall Rosa Cunningham--the welfare matriarch portrayed 
by Washington Post reporter Leon Dash), it is also siphoned 
away from the valid recipients--the children.
    Also, cash itself can be a powerful trigger for drug 
craving, especially cocaine. I have literally never met a drug 
using patient who did not use all or part of a benefit check 
(welfare check, veterans benefits, SSI income) to buy drugs. 
What's more, when asked, patients readily admit this, many 
conceeding they'd be better off if the money were direct-
deposited into a bank and there was a limit imposed on 
withdrawals.
    Using contingency management, women can earn back their 
welfare payments, perhaps on a semi-weekly basis, by producing 
clean urines. If recipients are engaged in job training or 
employment, their welfare payments can be earned back for each 
day worked. However, if their urine is dirty, they should not 
be allowed to work that day.
    This model is employed by Dr. Jesse Milby at the University 
of Alabama at Birmingham School of Medicine where addicts are 
provided standard treatment plus housing and opportunity for 
supervised work as positive rewards for abstinence. A 
comparison group received standard treatment only. Dirty urines 
prevented subjects in the first group from working that day and 
they had to move back to a homeless shelter. However, if they 
produced two consecutive clean urines, they could return to the 
house and job. Results showed that the housing-job contingency 
group had a significantly higher abstinence rate than 
comparison patients.
    If the these or other forms of intervention are 
insufficient, the recipient should enter formal treatment. If 
she refuses, child custody becomes an issue (and a potential 
leverage to compliance).
    Formal Treatment with CM: Treatment could range from weekly 
counseling and self-help like AA to day-long intensive 
outpatient visits with supervised workshop employment or job 
training. An arrangement could be developed wherein expenses 
for housing and other basics are taken care of by case manager 
via electronic transfer/direct deposit and patients ``earn 
back'' the remaining cash by complying with treatment and 
submitting clean urines. The key feature is that the welfare 
payment becomes the leverage to compliance.
    Vignette #1: Psychiatrist Andrew Shaner of the West Los 
Angeles VA Medical Center has started a cash incentive program 
for cocaine-addicted schizophrenics attending an outpatient 
clinic. In cooperation with the regional social security 
authority, monetary rewards will be drawn from the patients' 
own SSI disability checks. Dr. Shaner sought to initiate this 
CM procedure after he observed a strong temporal relationship 
between the receipt of monthly benefit checks and the use of 
cocaine and increase in psychotic symptoms in over 100 
patients. (A Shaner, et. al.: New England Journal of Medicine. 
333:777-783, 1995.)
    Vignette #2: Johns Hopkins University researchers use 
redeemable voucher contingencies (up to $10/day) to keep 
pregnant addicts--a notoriously hard-to-retain population--in 
outpatient day-long treatment. The study lasted thirty seven 
days, during which there was high drop out (roughly 60% at the 
end of 30 days) but the women who received financial incentives 
for each day attended during the first week had between 5 and 
20% higher attendance over the course of the project (Svikis 
DS: Drug and Alcohol Dependence. 48:33-41, 1997).
    Vignette #3: At Harborview Medical Center in Seattle, Dr. 
Richard K. Ries directs a clinic for mentally ill substance 
abusers. The most disabled patients are asked to sign over 
their SSI check to the outpatient clinic which then acts as 
their ``representative payee'' and manages their bank accounts. 
Rent and other basics are covered by the payee and the patient 
is allowed to ``earn back'' discretionary funds through 
compliance with treatment. Ultimately he gets control of the 
bank account when he has demonstrated the ability to manage 
money responsibly (Am J Addiction, in press). Even though these 
patients were the sickest in his clinic, after signing over 
their funds they were significantly more likely to attend 
treatment sessions than their healthier counterparts and as 
likely to participate in job training sessions and to stay out 
of the hospital and jail.
    Coordination with the Criminal Justice System: According to 
a recent survey of state welfare and state alcohol and drug 
officials by the Legal Action Center (Making Welfare Reform 
Work, Sept. 1997), 19% of AFDC women in treatment are there as 
a condition of parole or probation and another 21% percent had 
felony convictions. Conceivably, the welfare system could 
coordinate with the criminal justice system to impose rewards 
and sanctions on recipient offenders based on their compliance 
with care.
    Today, there are almost 200 drug courts nationwide. Non-
violent drug-related offenders are diverted to drug court 
treatment programs. These programs have heavy judicial 
involvement and are explicitly built around a graded sanctions 
schedule (e.g., one dirty urine, 1 night in jail; the second 
dirty urine, 3 nights in jail and so on) but the ability to use 
the welfare cash benefit as a reward would likely enhance the 
therapeutic leverage. A new GAO report on drug courts (July 
1997--GAO/GGD-97-106) documents mean retention rates of 71% 
compared with anemic rates of 10-20% mentioned earlier. This 
impressive result is due to the combination of coercion and 
graduated sanctions.

                               Key Points

     Drop out from treatment is very high. Simply 
prescribing more treatment-as-usual--while far better than 
nothing at all--may not be good enough for many.
     States should capitalize on the proven virtues of 
leverage to enhance retention in treatment and to shape 
behavior directly. Locales that adopt innovations are social 
laboratories and should be encouraged to evaluate their work 
rigorously.
     Some advocates will criticize manipulation of 
benefits as intrusive and coercive, but from a clinical 
standpoint coercion is a valid intervention. If anything, it 
would irresponsible not to apply the accumulated research and 
experience showing the value of incentives.
     Welfare reform provides an excellent opportunity 
to transform the perverse reward of public entitlements into 
constructive incentives that promote recovery and autonomy 
using the very same, naturally occurring benefits that the 
system now offers.
    For too long the security of welfare benefits--just knowing 
they were there, no matter what--has actually facilitated a 
dual dependence: on the system itself, and on drugs. Facing 
real consequences for using drugs is often a turning point for 
the addict, putting her on the arduous path to recovery. At the 
same time, real rewards for ``playing by the rules'' help 
develop responsible citizenship.
      

                                

    Chairman Shaw. Thank you.
    Dr. Pearlstein.

 STATEMENT OF MITCHELL B. PEARLSTEIN, PH.D., PRESIDENT, CENTER 
       OF THE AMERICAN EXPERIMENT, MINNEAPOLIS, MINNESOTA

    Mr. Pearlstein. Mr. Chairman, thank you very much--Members 
of the Subcommittee, particularly since I am the last speaker 
to attend this afternoon, I would like to speak more personally 
than perhaps it would be usual in such a circumstance.
    Chairman Shaw. Dr. Satel, would you move that microphone 
over?
    Mr. Pearlstein. As I was saying, I would like to speak 
quite personally in the few moments that I have.
    I come at this question from several perspectives. As you 
perhaps have seen in the written statement, I run a think tank, 
a conservative, free-market think tank in Minneapolis. My wife 
is a social worker who runs homeless programs--excuse me--out 
of a Lutheran church in Minneapolis. And we have just adopted a 
little girl, Nicole, who is now 6\1/2\ years old, who was born 
drug positive.
    In the formal statement that you have, I do discuss the 
connection--my interpretation of the connection between welfare 
and drugs and adoption. What I would like to do exclusively in 
the next 3 or 4 minutes is to emphasize one point, and that is 
that we must rescue children faster. Translated--and this is 
terrifically sensitive and terrifically tough--that means 
terminating parental rights in many instances faster.
    Let me tell you about Nicole. We have had her since last 
November 22, which brings new meaning to that date, let me tell 
you; and we will officially adopt her on November 21. My wife 
and I have known her since birth. Diane is actually her 
godmother. She was born marijuana positive; her birth mother 
had done crack earlier in the pregnancy. The first time I met 
her, she was about 6 weeks old. She was shaking. It was right 
around Easter. I am not trained in this area, but it was clear 
to me that this child had a drug problem.
    She was adopted once before, you should know. We believe, 
by the way, that we are her sixteenth placement. But Nicole was 
put in preadoptive placement the first time in March 1995. She 
was given back to Hennepin County 1 year later because she was 
too much for that first couple to handle.
    I would ask you to think hard about what it means to have 
16 placements and you are not yet 6 years old.
    It was medically confirmed, I am afraid, just last month 
that she had been sexually abused. She has been diagnosed 
suffering from ADHD, attention deficit and hyperactivity 
disorder. She has also been diagnosed as suffering from 
reactive attachment disorder, which translated means she 
doesn't trust any grownups terrifically well.
    When my wife and I were going through our training in 
Hennepin County 1 year ago, a social worker matter of factly 
said that just about 98, 99 percent of children who have spent 
extended periods in foster care have been sexually abused. I 
said at the time, I could not believe that. Perhaps I was 
wrong.
    How is my daughter doing? Well, all things considered, I 
think pretty well, though I am the first person--and my wife is 
the first person--to tell you that raising a child like Nicole 
is not easy. Raising any child is not easy. But a child with 
this kind of background, and sometimes you need to know I look 
in her face, particularly after we have been fighting, and I 
think perhaps what this child has gone through, and I just 
dissolve away in love for her.
    Let me tell you about another little girl that we have been 
foster parents to that we tried to adopt and could not. Her 
name is Annie, not her real name, but for today's purposes it 
is Annie. She is 7\1/2\ years old. We haven't seen her in 4 
years. We used to be her unofficial foster parents. She has 
been in foster care in Ohio for 4 years this month with very 
little time away from that situation. Her father, her 
biological father, credibly claims to have fathered 14 
children. Annie and her younger sister have just--just been 
taken away from him; parental rights were just terminated 
earlier this month. All the other children had either been 
taken away from him or he had abandoned them or they had died 
on his watch.
    I ask the question, What in the world took 4 years? Why did 
it take 4 years before these children were freed for a better 
life?
    The final point, at American experiment we are beginning a 
major project that will, we hope, significantly increase the 
number of children adopted in Minnesota homes by loving 
Minnesota families. And I was in a meeting recently with our 
adoption lawyer, who also was involved in the center; and it 
had been a particularly difficult day with Nicole. My wife and 
I were there, and I said glibly, in a dark way, We want to have 
this project so other parents could have this great joy that we 
are having this afternoon--not a statement I am terrifically 
proud of.
    And she called me up short, and she said, No, what you want 
to do with this project is make certain there are many more 
children rescued far quicker than has been the case with 
Nicole, so they are not so terribly damaged by the time they 
are adopted.
    Thank you very much.
    [The prepared statement follows:]

Statement of Mitchell B. Pearlstein, Ph.D., President, Center of the 
American Experiment, Minneapolis, Minnesota

    Mr. Chairman and Members of the Committee, my name is 
Mitchell B. Pearlstein and I've been asked to appear today in 
two roles: both as an analyst and as an adoptive father.
    As founder and president of Center of the American 
Experiment--a conservative and free-market public policy 
institute in Minneapolis--I have spent the last nearly 8 years 
thinking hard, writing frequently, and hosting many public 
programs about education, fatherlessness, adoption, welfare, 
drugs and suchlike. Which is to say, I've spent a lot of time 
thinking about endangered children. By saying this, I don't 
mean to suggest that I've hit upon reams of good answers. 
Neither do I mean to suggest that I consider myself a scholar 
in these broad areas in the narrow sense of the term. While I 
hold a doctorate in educational administration from the 
University of Minnesota, run a ``think tank,'' and have held 
other public policy jobs in and out of government, I'm more 
comfortable viewing myself as a reasonably well-versed 
generalist rather than as a specialist when it comes to many of 
the questions before you today.
    Yet having allowed that, I do recognize that I bring an 
important perspective to the table by virtue of being an 
adoptive father of a little girl, Nicole, now six and a-half, 
who has suffered an extraordinarily tough start in life. And in 
a not dissimilar vein, my testimony this afternoon is contoured 
by the fact that my wife, Diane McGowan, is a social worker and 
the executive director of Our Saviour's Housing, a church-
based, tough-loving program for homeless and formerly homeless 
men, women and children in Minneapolis.
    In other words, Mr. Chairman, and at the risk of 
presumption, I just may be the only conservative think tank 
president in the United States who has recently adopted a 
special needs child (whom, Im sorry to say, tested positive at 
birth for illegal drugs) and whose wife, moreover, works daily 
and intimately with homeless and other very troubled clients. 
It is from these vantage points that I would like to speak this 
afternoon. I also have, you should know, three adult stepsons 
from my wife's first marriage.
    Before proceeding, though, might I ask a favor of all who 
may come upon this statement? Testifying before a congressional 
Committee, and then having that testimony published in the 
Congressional Record, is anything but a private act. I decided, 
however, to write as personally and openly as I have because of 
the stakes involved: In bluntest terms, thousands of boys and 
girls need to be rescued, not only from the chemical and other 
abuses of their parents, but also from a child-welfare system 
that, for a variety of reasons, is capable of rescuing only 
some of them. Which is to say, while I very much hope that what 
I have to say is attended to, I also would hope that my 
family's privacy--particularly that of my daughter--might be 
respected to the greatest extent possible.
    Let me begin by talking about Nicole and how my wife and I 
have come to adopt her. (Technically, our adoption will not be 
official until November 21, though I assure you I have viewed 
Nicole as our daughter in every loving and permanent sense of 
that word ever since she came to live with us on November 22, 
1996.)
    My wife, Im proud to say, is the kind of social worker who 
often brings her work home with her. This was the case when, 
over Easter weekend in 1991, she and I were asked by Nicoles 
birth mother to provide emergency respite care for her 6-week-
old baby. While I am not professionally trained in the effects 
of drugs on infants, I must tell you it was immediately clear 
to me that Nicole had been exposed, as she cried to the point 
of near-tremors almost constantly. I did later learn that she 
had been born marijuana positive and that her birth mother had 
smoked crack earlier in her pregnancy.
    My wife and I stayed in reasonably close contact with 
Nicole over the next several years even though she wound up 
spending most of that time in various out-of-home placements. 
Diane, in fact, had become Nicoles godmother in the spring of 
1992. We stayed in direct contact until March 1995 when Nicole 
was put in her first pre-adoptive placement. I'll return to 
this matter in a moment, but first I need to fill in some 
blanks about her birth mother.
    Doris (not her real name), voluntarily gave up parental 
rights to Nicole either in late 1994 or early 1995. Nicole was 
her fifth child--and the fifth boy or girl whom she had either 
given up on her own or who had been taken away by the state. As 
for Nicoles birth father, he has never been involved in her 
life beyond conception. A drug dealer by trade, Ive recently 
been informed that he is serving a life term in prison for 
murder. Doris doesnt recall his last name, and almost needless 
to say, they were not married.
    Without rationalizing away Doris morally and otherwise 
unacceptable decision to do drugs during her pregnancy with 
Nicole, I have no hesitation in acknowledging the coarseness 
and unfairness of Doris own life. Her parents were chemically 
dependent. She has suffered all manner of abuse. She has been 
diagnosed with a serious mental illness. Early in her pregnancy 
with Nicole she was set afire when a drug deal went bad, 
leaving her in the burn unit of Hennepin County Hospital for 
several weeks, where she received prescribed drugs--and later 
also did illegal drugs.
    Given this prologue, Im not opposed to giving Doris a 
measure of credit for recognizing that she was not capable of 
raising Nicole and, in light, forfeiting her parental rights. 
But the fact remains, the little girl who was to become my 
daughter had been condemned to a simply dreadful start.
    The best my wife and I can figure, we are Nicole's 16th 
placement. Yes, many of these were short, emergency stints 
when, for example, Doris went off on one binge or another and 
her boyfriend (not Nicole's biological father) couldnt cope 
alone. But several placements were of much longer duration. 
These included 2 years with a foster family before her first 
pre-adoptive placement, in March 1995, and then 8 months in 
that same foster home when, after exactly a dozen months, the 
pre-adoptive family gave Nicole back to Hennepin County because 
she was too much for them to handle.
    Ladies and gentlemen, I would ask you to think hard about 
what it means to live in 16 different places--which is not 
necessarily to say homes--before you are 6 years old. I also 
would ask you to consider a few other things about Nicole.
    It was recently confirmed medically that she had been 
sexually abused, quite likely more than once. She also has been 
diagnosed as suffering ADHD (attention deficit and 
hyperactivity disorder). Im well aware of the fact that 
diagnosing ADHD is more art than science, and that the term has 
been known to be used profligately. But let me assure you, this 
is not the case here.
    When Diane and I were going through Hennepin County-
sponsored, pre-adoptive training last year, several instructors 
reported--I'm tempted to say almost as a matter of fact--that 
most children who are veterans of the foster care system tend 
to wind up (1) having been sexually abused; and (2) suffering 
from ADHD. In fact, one instructor estimated that upward of 98 
or 99 percent of all such children are sexually assaulted. I 
immediately objected, arguing that hardly any social phenomenon 
is known to occur so frequently, and that at any rate, I just 
couldnt imagine the problem being so pervasive. Perhaps I was 
wrong.
    How is Nicole doing now? In many ways, better than what one 
might imagine. But for all the progress she has made, for all 
the medical and psychological care she is receiving, and for 
all the love she is now bathed in, there remains, deep in her, 
a flood of anger and distrust. Yet who can blame her for 
harboring such poison?
    More briefly now, let me say something about another little 
girl my wife and I have tried to adopt in the past, Annie (not 
her real name). Annie is now seven and a-half, not that we have 
seen her for 4 years, as she has been in foster care in Ohio 
almost all that time.
    Annie is the daughter of two of my wife's clients, Meg and 
Johnny (again not their real names), and as with Nicole, we 
have known her since birth. Both Diane and I are Annie's 
godparents, and we also were her frequent, if unofficial, 
foster parents in the early nineties. (One reason we were 
``unofficial'' is that Annie is part American Indian while 
Diane and I are not, and the Federal Indian Child Welfare Act 
didn't take kindly to our care giving. But I digress.)
    In the fall of 1993, Johnny and Meg (who have never been 
married) moved to Ohio and quickly proceeded to do things that 
led child-protection officials there to rightly place their 
young daughter in protective custody. She has remained in 
foster care in Ohio ever since. In part, this is the case 
because Johnny's parental rights to Annie, and to her younger 
sister Gloria, were terminated only in the last few weeks. In 
Johnny, it needs to be noted, we are talking about a man who 
credibly claims to have fathered 14 children, with all 14 now 
having been taken from him by government, or abandoned by him, 
or found dead on his watch. As for Meg, she voluntarily gave up 
rights to the two girls a couple of years ago once she 
concluded she could not care for them. She may have AIDS.
    What did Johnny and Meg actually do to justify having Annie 
taken from them on a number of occasions in Minnesota and Ohio? 
On generous days I'm willing to concede that they have tried to 
love her, and Gloria, as best as they know how. But the fact 
remains, their ability to raise their daughters successfully 
was severely compromised by drugs, alcohol, mental illness, 
frequent arrests, unemployment, and so forth. Annie, for 
example, tested positive for crack at birth. She tested 
positive for cocaine again later on, likely by way of 
secondhand smoke. The fact that she wound up being required to 
repeat kindergarten may or may not have been incidental.
    Question: Why in the world, given all this, were Johnny's 
parental rights terminated less than a month ago? Why were his 
two girls kept in limbo so outrageously long?
    Another key question, given the subject of today's hearing, 
is whether any of the birth parents I've been talking about 
were ever afforded the chance to participate in a drug 
rehabilitation program while they were on welfare? Doris, 
Johnny, and Meg, as one might expect, have received a 
combination of benefits, including AFDC, SSI, and General 
Assistance.
    The short answer is that yes, each has been provided 
multiple opportunities to get straight, not that any of the 
three has ever stuck with any treatment program. (I don't have 
a clue about what second, third and fourth chances might have 
been extended to Nicole's birth father by taxpayers before he 
was imprisoned, perhaps for a last time.) Some surely will 
argue that none of these programs were exactly right or fitting 
or sufficiently funded. But the larger truth is that neither 
Doris, nor Johnny, nor Meg has ever found it within themselves 
to keep clean, either for themselves or for their children.
    So much for stories and comments drawn from my personal 
life. What do I conclude from all of this in terms of policy 
and in terms of our culture itself? Permit me to quickly expand 
on three points having to do with (1) the Muzak-quality of drug 
and alcohol abuse in the United States; (2) the importance of 
faith-based programs in combating such excesses; and (3) the 
need, in many instances, of terminating parental rights much 
faster so that supremely at-risk children can be adopted--and, 
thereby, physically and emotionally saved--much more 
successfully.
    We have all seen data and heard stories about the hard toll 
exacted personally, socially, and financially by chemical 
excesses and addictions. The dollar amounts, for example, no 
matter how rigorously or casually calculated, are always 
labeled immense, accurately so, I'm sure.
    But for present purposes, I have no interest in citing 
numbers, never mind how huge and telling they may be, as I'm 
sure others who are better equipped either have or will do so. 
Instead, I want to argue that regardless of how big a problem 
we may think excessive drinking and illicit drug use are, they 
are almost certainly larger still--be our focus the nexus with 
welfare or not.
    This is the case, I would contend, because the very 
implicitness of boozing and narcotizing in so much that is 
melancholy and broken all around us has made our reactions more 
muted than sharp. Alcoholism? Drug abuse? Sure they're 
problems. Big ones. But my sense is that are sensed by most 
people, most of the time, more as background noise than as 
sirens. Drugs and too much drink are downplayed precisely 
because they are embedded in the landscape.
    Now, needless to say, sirens do blare for individuals and 
families racked at any moment by insobriety. But the broader 
point to be made is that drug and alcohol abuse routinely grabs 
holds of us in the same way that Muzak does--meaning not 
vividly at all.
    Back in the early eighties I served on the staff of former 
Minnesota Gov. Al Quie. I still remember how he would talk 
about how drugs and/or alcohol had been at each and every 
scene, so to speak, whenever he returned to the office 
following meetings of state pardons board. I have few doubts 
that much the same can be said about the overwhelming majority 
of child neglect and abuse cases. Yet still--exempting for 
hearings like this, and at the risk of an overdone metaphor--
the nation routinely seems to be in a haze, numbed to the 
pervasiveness and destructiveness of drugs.
    What might this suggest? One thing is that we need plenty 
of treatment avenues. But it's precisely in areas such as this 
that policy deliberations suffer from excessive confidence in 
the efficacy of ``programs.''
    Almost always running through such public conversations is 
the presumption that if only enough dollars are ``invested,'' 
results would be excellent. But on closer consideration, almost 
everyone knows this is not the way either the world works or 
recovery works, as just about everyone knows of men and women 
who have ``graduated'' any number of times from treatment 
programs--only to go tumbling off an identical number of 
wagons. Recall Doris, Johnny, and Meg and their repeated 
failure to take advantage of the public dollars invested in 
them.
    Ungrounded confidence in the effectiveness of treatment 
programs--especially secular ones--is but the flip side to the 
half-obliviousness that surrounds chemical dependency in the 
first place. The most important question about healing we can 
ask has little to do with whether we are really ``committed'' 
as a society to helping drug addicts and alcoholics. The short 
answer to that one is yes, as witness all the money we spend 
every year, as well as the many job and other protections now 
afforded to chemically dependent individuals.
    The key question, rather, has to do with what kinds of 
treatment programs we should more earnestly seek to create and 
replicate. The answer, I would suggest, is spiritually driven 
ones. The kinds, frequently, without a lot of formally 
credentialed therapists on staff. The kinds, quite frankly, 
which give orthodox secularists and many governmental grant 
makers the willies. But the kinds of programs which friends 
such as Bob Woodson of the National Center for Neighborhood 
Enterprise, and Marvin Olasky of the University of Texas--as 
well as friends and colleagues doing great things in 
Minnesota--have convinced me are most adept at performing near 
miracles in turning very troubled lives around.
    Nonetheless, it would be fraudulent if I let it go at that; 
if I suggested that enough ``near miracles'' could be assured 
for those who seriously harm their children if only right 
treatments were divined and backed. We know this is not 
possible. And it's for this reason that I've come to 
reluctantly conclude that we must terminate the rights of unfit 
parents more frequently, and more quickly, than we generally 
do. Putting matters directly, we need to find the fortitude to 
speed up the process by which parental rights are ended when it 
is demonstrably clear that children are being ruined.
    Suffice it to say, I'm well aware of the implications of 
what I've just said. As someone who runs a conservative think 
tank, I am not enthused about urging government to become more 
energetic in investigating families. But after several years of 
thinking things through, I'm more convinced than ever that we 
must fundamentally reorient the child-protection system in 
favor of vulnerable children.
    This is the case insofar as prevailing law and ideology in 
child-protection circles since the early eighties--emphasizing 
the rigid pursuit of ``family preservation'' even when there is 
barely a shred of a viable family to reconstruct--have been a 
disaster. We all know the resulting numbers, starting with the 
fact that almost 2,000 infants and young children in the United 
States die from neglect and abuse by parents and care givers 
every year, with upward of half of them dying after they and 
their families enter the child-protection system.
    If I do say so, and not with a little surprise, I've 
discovered that most of my counterparts on the right also have 
come to agree that we need to terminate parental rights faster. 
This is a remarkable development given the strong and intuitive 
opposition of most conservatives to further extending 
government's reach into the life of families.
    I just cited the almost 2,000 infants and young children 
who die at the hands of their parents and care givers every 
year. Another very sad, in this instance, Minnesota-based fact 
is this: The number of American-born children adopted by 
nonrelatives in my state fell from more than 2,500 in 1970 to 
less than 500 in 1995--even though the number of children 
removed from their biological homes, at least temporarily and 
for a host of reasons, exploded across the country during this 
span. As with anything so complex, there are several reasons 
for this drastic decline in adoptions, including the 
aforementioned emphasis on family preservation and, 
particularly in Minnesota, a disproportionate emphasis on the 
racial matching of adoptive parents and children. But quite 
obviously, if as a society we seek, for good cause, to increase 
the rate of terminations of parental rights, we are obliged to 
find ways of increasing the rate of adoptions.
    This is not the time or place to detail exactly how this 
might be done. For no other reason, this is the case because 
adoption--as is true with just about every issue addressed in 
this statement--is principally a state and local matter, not a 
Washington one. It's also not necessary to dwell on the 
intricacies of adoption because we already have identified the 
most important step in increasing their likelihood: Ratcheting 
up terminations of parental rights so that more children are 
freed for new lives. But having said that, let me conclude this 
way:
    Nearly a year into the process, I'm not the same romantic I 
once was about adoption, at least when it comes to children, 
like Nicole, who have been victimized horribly. There is no 
getting around the fact that boys and girls who are exposed to 
drugs in utero and afterward, who bounce from placement to 
placement, who are sexually abused, and who suffer any number 
of other assaults to body and spirit, are not necessarily easy 
children to raise.
    Beyond dealing with behavioral problems fed by anger, 
distrust, and perhaps neurological damage, adoptive parents are 
called on to collaborate on an ongoing basis with a seeming 
platoon of social workers, therapists, pediatricians, lawyers 
and other professionals. Often, my wife and I wonder how people 
without the flexibility we're fortunate to have in our work 
lives can ever do justice to a child like Nicole. Sometimes, in 
truth, we wonder if we're doing her justice, given our 
professional obligations as well as our (advancing middle) age.
    But at the same time, we very much recognize that grownups 
are not afforded the sacred opportunity every day to save a 
child, and that little girls like Nicole largely have run out 
of good chances for a decent life by the time they start school 
or by the time their first tooth falls out.
    Which is just one more way, Mr. Chairman and Members of the 
Committee, of making the case that children in drug-poisoned 
situations must be rescued quicker, so that new wounds are not 
allowed to pile on, day after day and year after year.
      

                                

    Chairman Shaw. Thank you, Doctor.
    Mr. McCrery.
    Mr. McCrery. Let me start with Ms. Ogletree. I am going to 
ask you a few questions.
    I am just curious about, because they relate to some other 
considerations that we go through in looking at the welfare 
system and welfare reform that is in place, and some problems 
that may come up, first of all, How old are your children? You 
have two children.
    Ms. Ogletree. I have a set of twins that are 3, 3 years 
old.
    Mr. McCrery. Three years old?
    Ms. Ogletree. Yes.
    Mr. McCrery. Why do you have to get up at 4 o'clock in the 
morning? And why do you not get home until 8 o'clock at night?
    Ms. Ogletree. For one, I am dedicated as an employee, where 
I live at; making a change in my life is becoming responsible 
as a parent, OK? And for me, at this stage in my recovery, I 
would go to any means, any length to be a responsible parent to 
my kids and show them that I am a good role model and, today, 
that I am somebody.
    So--that means for me to get up at 4 o'clock every morning, 
get to work, be on time, and to be comfortable on my job so 
when I start, I am ready to work, then that is what it takes.
    Mr. McCrery. So do you live that far away from your work? 
Is that----
    Ms. Ogletree. It is a commute. It is about a 1-hour 
commute, an hour and a half in the morning. So the commute is 
very long, but I am willing to do that.
    Mr. McCrery. And where do your kids go when you leave?
    Ms. Ogletree. My kids go to the babysitter. And the 
babysitter, in turn, puts them on the bus to go to school in 
the morning.
    Mr. McCrery. OK. And what about in the evening? What 
happens to your children in the evening?
    Ms. Ogletree. OK. When I come home from work, they are at 
the babysitter's. She takes them off the bus. One goes in the 
morning, and one goes in the afternoon. So one is usually with 
her in the afternoon. While the one is in school, the other one 
is coming off the bus. So it is, you know, difficult for her, 
too. So----
    Mr. McCrery. Now, I thought I heard you say that you are in 
a transitional home; is that not correct?
    Ms. Ogletree. Yes, I am.
    Mr. McCrery. That is correct?
    Ms. Ogletree. Yes, it is.
    Mr. McCrery. So, is the babysitter provided by the 
transitional home----
    Ms. Ogletree. Transitional home----
    Mr. McCrery [continuing]. Or provided by----
    Ms. Ogletree. No, the babysitter is not provided by the 
transitional home. The babysitter is in a program that works 
with drugs and alcohol. And she was willing to work with me, as 
long as I was doing what was expected of myself as far as my 
recovery. And you don't find too many people like that, so I 
guess I could say I was fortunate.
    Mr. McCrery. Yes. So are you paying the babysitter?
    Ms. Ogletree. Yes, sir. I am paying them out of my pocket, 
yes.
    Mr. McCrery. So when you are out of the transitional home, 
what are your plans? Are you going to be able to afford a place 
to live and a babysitter? Are you going to try to find a place 
closer to your work, or what is your plan?
    Ms. Ogletree. Well, my plan is by--well, I have up to 2 
years in my transitional house; and within that time, I have 
plans to transitional out into a regular setting where I can 
afford my own place, get the experience on my job that I need 
to transitional out into a regular apartment, affordable 
housing, that I can afford and affordable day care for my kids.
    Mr. McCrery. OK. Well, good luck.
    Ms. Ogletree. Thank you.
    Mr. McCrery. Thank you very much for your testimony.
    Mr. Batty, how is your program funded?
    Mr. Batty. It is privately funded.
    Mr. McCrery. What does that mean?
    Mr. Batty. Individual contributions, businesses and 
churches provide the bulk of that support, as opposed to a 
government subsidy.
    Mr. McCrery. OK.
    Dr. Satel, you have testified that you think we ought to 
link welfare payments--I presume you mean TANF payments, cash 
welfare payments----
    Dr. Satel. Right.
    Mr. McCrery [continuing]. For compliance with treatment 
programs.
    Dr. Satel. Yes.
    Mr. McCrery. And then you mentioned that some other places 
are linking things such as SSI payments on a voluntary basis. 
The folks in treatment voluntarily give their SSI payments over 
to the treatment center?
    Dr. Satel. Right.
    Mr. McCrery. And they give them back if they are 
successful. So, would you recommend tying some other 
entitlement programs to compliance with treatment programs, 
like SSI benefits or food stamps or----
    Dr. Satel. Yes. We had an interesting model for this called 
DA&A, drug abuse and alcoholism. Until 1995 the Social Security 
Administration considered addiction to be a disease, and 
addicts were given benefits just like everyone else who was 
disabled. There was a lot of trouble with the DA&A Program. As 
you remember, few people went to treatment; a lot of that money 
ended up subsidizing addiction. There was a linkage formed 
between SSA and treatment programs but that legislation was 
reversed about 1 year after it went into effect. Nevertheless, 
that was a model for making benefits contingent upon compliance 
with treatment.
    Here, I am talking about a much more--I guess I could say a 
more micromanaged form of that, ideally at the level of the 
treatment program. A colleague of mine has been collaborating 
with the State of New Jersey trying to help the State to come 
up with some creative ideas. For example, for compliance with 
work requirements and treatment if the person needed it, the 
State could give them improved housing vouchers. And also food 
stamps are important to control, because if the person is 
actively using drugs, again they are converted into cash and 
sold and used to buy drugs.
    Mr. McCrery. OK. Thank you. Thank you all for your 
testimony.
    Chairman Shaw. Thank you, Mr. McCrery.
    I might add that the States can do that with the TANF 
payments if--if they can.
    Mr. Levin.
    Mr. Levin. Just quickly, so others can join in, the States 
have the discretion. So let me ask you, how do you, with TANF, 
how--let's say that, with drug addicts, there is kind of an up 
and down--not off in a straight line.
    So let's say for a few months, the person hasn't used 
drugs. And then the person does for 1 month, the fourth month, 
and has two children. How do you--you have to link these two 
creatively, don't you? I mean you can't just----
    Dr. Satel. Right.
    Mr. Levin [continuing]. Have a mechanical linkage.
    Dr. Satel. In the written testimony, I went into that a 
little bit. If a recipient started to deteriorate badly, you 
would give her the--you could give people a lot of choices; but 
one choice could be residential care--obviously, a person can't 
be maintained as an outpatient if she is heavily using drugs. 
Her children aren't safe; she is using.
    I wouldn't stop the clock either; I agree with Mr. Zill on 
that. One of my key points here is that the reason why people 
drop out of treatment at such high rates and why compliance 
with treatment is so poor is because there are no consequences. 
Ultimately, if they violate every rule and expectation 
associated with welfare or with the treatment program, I 
suppose they could run out of safety nets. If they did land on 
the street and if they did--as Professor Reuter was saying 
earlier, they would likely resort to crime, but we have 
something called drug courts which are wonderful innovations. 
And they take people who have been arrested for drug crimes, 
misdemeanors, or felonies. There is one in the District of 
Columbia, and it is a diversionary program where offenders are 
sent to treatment instead of jail. And there are very, very 
clear consequences for not keeping up with the treatment 
program, ultimately ending up with the person having to fulfill 
a jail sentence. Not that many people have to do that. And if 
they comply with the treatment and finish it, then their 
offense gets expunged at the end.
    In fact, if I could just add, the District of Columbia drug 
court did a very interesting demonstration project a few years 
ago where they had one cohort in treatment and another just 
getting sanctions. These people were told, if your urine is 
dirty, you are going to go to jail for a night. If it is dirty 
the second time, 2 nights and so on, progressively.
    And the group with just the sanctions were told, If you 
think you need some treatment, go to AA, get it on your own, 
but we are just looking at the urines. And this is what is 
going to happen to you if your urines are positive, so you know 
up front.
    That group did better than the group in treatment. And that 
has a lot to do with the unaccountable way that particular 
treatment program worked. And it is very similar, 
unfortunately, to the average treatment program out there.
    Mr. Levin. OK. I think others should question.
    Thank you.
    Chairman Shaw. Mr. Coyne.
    Mr. Coyne. I have no questions.
    Chairman Shaw. Mr. Rangel.
    Mr. Rangel. I have none.
    Chairman Shaw. I would like to make an observation here 
with regard to Ms. Ogletree and Ms. Saler and going back to 
what Charlie Rangel was saying and then, Mr. Batty, from your 
standpoint, it appears here that there is a common thread. If 
somebody is getting into a job or looking or training for a 
job, the cure rate is much better. Or if it is a spiritual 
awakening, it is much better.
    I think what we are doing, where Charlie was talking 
about--put me in jail, so what; my family name, so what--I 
think it is more a question of self-worth, self-dignity, and 
feeling good about yourself and having some expectations of 
yourself than other people having expectations of you.
    Ms. Saler, you used a statistic, you put the two back to 
back, and I may have missed them, but did you say--what is the 
correlation between people who find a job and those that are 
successful in the completion of your program?
    Ms. Saler. With the--in the study that was done, what was 
important was that those who completed treatment at the time 
that the independent followup was done, 85 percent of them were 
employed. One of the connections that we were able to make in 
this is that we were able to actually see people who had made 
lifestyle changes that supported their recovery, and the 
converse of that, their completed treatment supported making 
those changes.
    So what we spend a lot of time with internally in treatment 
is looking daily, weekly, quarterly at a minimum, for an 
overall picture, who is not staying in treatment. When are they 
leaving? What can we do differently? What needs to be done 
better? What is missing for this group at this time? And 
spending a lot of time. And I would say that many of my 
colleagues in the field do the same thing, looking at what it 
is we can do.
    And knowing the consequences is important. I would just 
mention in regard to part of that, just a few weeks ago, we 
sponsored a conference for women in Maryland who are in 
treatment; 150 women from around the State of Maryland came. 
And the theme of the conference was ``Welfare Reform: What Does 
It Mean to You.'' And officials from the State of Maryland, 
folks in recovery, all came together and presented two women 
who are going through the process in varieties of programs 
around the State, what it is that all of this meant and how it 
impacted them. And if they didn't think it was real, they had 
better get with it pretty quickly.
    And it was very interesting to--Judy was there and a lot of 
other women. And they both felt they had the information they 
needed. They also felt empowered because it was very clear to 
them what the State was willing to do to help them, what the 
treatment programs were willing to do to help them, and what 
was expected of them. And I would throw that out as one other 
type of thing that is going on. And it is a tool in working 
with folks that are going through this.
    Frequently, just sitting down and giving folks the 
information and letting them know what the consequences are and 
making sure we follow through on the consequences are really 
important.
    Chairman Shaw. Ms. Ogletree, let me ask you a question. If 
you had come out of the program and just gone home and received 
benefits and not gone to work, would it have been harder for 
you to stay clean?
    Ms. Ogletree. Yes, it would have. When I first came out of 
the program, I wasn't working; I was unemployed. And I did 
receive benefits for 2 months after I left treatment. I then 
got a job at Second Genesis as a receptionist. I was still 
looking for employment.
    And I had some of the job skills. And it was just more 
incentive to want to get off welfare reform, welfare system 
with the reform going on and everything like that. And I knew I 
always had it in me to go back to work and be the responsible 
adult that I should be.
    So after treatment, I did stay on welfare for 2 months.
    Chairman Shaw. I appreciate all of your testimony today. I 
think it is----
    Mr. McCrery. Mr. Chairman.
    Chairman Shaw. Yes.
    Mr. McCrery. If you would allow me.
    Chairman Shaw. Surely. Go ahead.
    Mr. McCrery. I would like to ask Ms. Saler a question. How 
many employees do you have?
    Ms. Saler. At Second Genesis?
    Mr. McCrery. Yes.
    Ms. Saler. Approximately 110 right now.
    Mr. McCrery. And how many of those are women with small 
children; do you know, offhand?
    Ms. Saler. One-third.
    Mr. McCrery. One-third?
    Ms. Saler. That would be a rough guess, one-third to one-
half.
    Mr. McCrery. I gather you don't provide any child care for 
your employees?
    Ms. Saler. We have at our women and children's program, we 
have it onsite, but no, we don't, we--it is a problem. It is an 
issue for us for bringing--we do hire a lot of single mothers, 
working mothers, and that is an issue. It continues to be an 
issue. And it--and as we return more and more women to the 
workforce, child care is becoming a major issue.
    I will sit--and when I get into talking about people 
getting back to work at vocations, I'll say there is vocational 
counseling, child care, skills training and child care, and 
housing and child care; and how are we going to handle it?
    Mr. McCrery. Have you looked at providing onsite child care 
for your employees?
    Ms. Saler. Yes, we have.
    Mr. McCrery. And what is the obstacle?
    Ms. Saler. Cost.
    Mr. McCrery. Cost.
    Chairman Shaw. Is liability a part of that? I hear that 
also.
    Ms. Saler. We have actually at our women's and children's 
program, we already have children onsite, and that has not been 
an issue. I am less worried about the liability.
    One of the issues becomes, in the current climate, getting 
the funding for treatment. We work--we do work with public 
dollars, and what we are getting paid for treatment is far 
below what the private for-profit sector is paid on average in 
our--most of our regular programs we get paid about $55 a day. 
The women and children's program, we get about $125 a day to 
work with the entire family. So----
    Mr. McCrery. Your total funding comes from public sources?
    Ms. Saler. Public and private. We work--we do work on 
contract with the States and the local jurisdictions, and then 
we--we do some work with private insurance companies, employee 
assistance programs, things like that.
    Chairman Shaw. Again, I want to thank this panel.
    Mr. Pearlstein, good luck with your daughter and your 
coming adoption.
    Mr. Pearlstein. Thank you very much.
    Chairman Shaw. And we are adjourned.
    [Whereupon, at 5:15 p.m., the hearing was adjourned.]
    [Submissions for the record follow:]

Statement of Child Welfare League of America, Inc.

    The Child Welfare League of America (CWLA) welcomes this 
opportunity to submit testimony. We commend the subcommittee 
for its efforts to examine the links between substance abuse 
and child abuse and neglect. Our comments focus on substance 
abuse as a factor in the placement of children into foster 
care, and highlight the need for and examples of interventions 
that keep children safe and help families recover.
    CWLA's 900-member public and private agencies across the 
country work everyday to improve conditions for children and 
families at risk and in crisis. Serving over 2.5 million 
children and their families each year, CWLA member agencies 
provide a wide array of services including child protective 
services, family preservation, family support, adoption, family 
foster care, treatment foster care, residential group care, 
adolescent pregnancy prevention, child day care, emergency 
shelter care, substance abuse treatment, independent living, 
and youth development.

                 Need for Protection and Care Increases

     In 1996, an estimated 3,126,000 children were 
reported to child protective services agencies as alleged 
victims of child maltreatment.\1\ From 1987 to 1996, the total 
number of children reported abused or neglected increased 
45%.\2\ The number of reports substantiated has increased by 
approximately 14% over the same period.
---------------------------------------------------------------------------
    \1\ National Committee for the Prevention of Child Abuse (NCPCA). 
Current Trends in Child Abuse Reporting and Fatalities: NCPCA's 1996 
Annual Fifty State Survey, Chicago, IL: NCPCA Publications.
    \2\ 2 NCPCA, 1996.
---------------------------------------------------------------------------
     In 1996, nearly one million children were 
confirmed victims of child maltreatment.\3\
---------------------------------------------------------------------------
    \3\ 3 NCPCA, 1996.
---------------------------------------------------------------------------
     Last year, an estimated 1,046 children, or three 
children per day, died as a result of child abuse and neglect; 
82% of the victims are under the age of five, and 42% are less 
than one year old at the time of their death.\4\
---------------------------------------------------------------------------
    \4\ 4 NCPCA, 1996.
---------------------------------------------------------------------------
     When child protective services determines that a 
child cannot be safely cared for at home the child is removed 
to a safer place. Preliminary estimates indicate that 502,000 
children in the U.S. lived in out-of-home care--family foster 
care, kinship care, or residential care--at the end of 1996.\5\
---------------------------------------------------------------------------
    \5\ Tatara, T., American Public Welfare Association. Research 
Notes. (1997, March).
---------------------------------------------------------------------------

      Substance Abuse Highly Involved in Abuse and Neglect Reports

    The use of drugs and abuse of alcohol among families is a 
pervasive and disturbing trend that continues to have a 
devastating impact on the safety and well-being of children. 
Although it is difficult to quantify a causal relationship 
between alcohol and other drug (AOD) use and child 
maltreatment, experts agree there is a high correlation between 
parental chemical dependency and child abuse and neglect.
     Nearly eighty percent of states report that 
parental substance abuse is one of the top two problems 
exhibited by families reported for maltreatment.\6\
---------------------------------------------------------------------------
    \6\ 6 NCPCA, 1996.
---------------------------------------------------------------------------
     Drug testing of families with abused and neglected 
children in the District of Columbia Family Court in 1995 
revealed that two in three parents tested positive for cocaine 
and one in seven tested positive for heroin and other 
opiates.\7\
---------------------------------------------------------------------------
    \7\ Newmark, L. (November 15, 1995).''Parental drug testing in 
child abuse and neglect cases: Major findings.'' Presented at the 46th 
Annual Meeting of the American Society of Criminology. Washington, DC: 
The Urban Institute.
---------------------------------------------------------------------------
    Identifying family members who are chemically involved and 
assessing how AOD use affects their ability to provide a safe, 
nurturing living environment are critical steps in determining 
risk of maltreatment for children. Once substance abusing 
caregivers are identified, child welfare professionals struggle 
to find and provide appropriate treatment. Even if treatment 
services are available, the timeframes for effective treatment 
may exceed timeframes to achieve permanency for children. A 
wait for residential AOD treatment for women with children may 
be close to 10 months in some parts of the country.

        CWLA'S 1997 AOD Survey Reveals Great Need, Few Resources

    In 1997, CWLA surveyed state public child welfare agencies 
in order to obtain a baseline measure of the types of policies, 
programs and data collection efforts in place to support 
chemically involved families, with a special emphasis on 
children and youths in out-of-home care. Survey respondents 
estimated that:
     67% of parents involved with the child welfare 
system need AOD treatment;
     Child welfare agencies could only provide services 
for 31% of those parents in need;
     Less than half of all states report that training 
on recognizing and dealing with AOD problems is available for 
foster parents;
     Only 9 states (of 47 states responding) provide 
similar training for kinship care providers yet 30 percent of 
all children currently in out-of-home care are in kinship care 
living with a relative;
     83% could not provide the number of youth in out-
of-home care whose parents are chemically dependent;
     Only 11% believe that children and parents with 
AOD problems can be treated in a timely manner (less than 1 
month);
     42% rely on school-based education drug prevention 
programs as the only form of prevention services available for 
youth in out-of-home care;
     94% could not provide the number of youth in out-
of-home care known to abuse AOD themselves.

   Effective Treatment Exists; Supply and Access Remain Very Limited

    Treatment is a cost-effective strategy for intervening to 
stop the cycle of destruction and despair that substance abuse 
inflicts on children and families. Programs providing 
comprehensive services and attending to the continuing 
treatment needs of women are most beneficial. The U.S. 
Department of Health and Human Services' Center for Substance 
Abuse Treatment recently reported on women's outcomes for their 
grantees providing comprehensive programs targeted to post-
partum women and their infants.\8\
---------------------------------------------------------------------------
    \8\ 8 U.S. Department of Health and Human Services, Center for 
Substance Abuse Treatment. (1995). Study of grantees administered by 
the Women's and Children's Branch. Rockville, MD: author.
---------------------------------------------------------------------------
    Of the women in treatment:
     95% reported uncomplicated, drug-free births;
     81% were referred by the criminal justice system 
and had no new charges following treatment;
     75% who successfully completed treatment remained 
drug-free; and
     40% eliminated or reduced their dependence on 
welfare.
    Of their children:
     65% were returned from foster care; and
     84% who participated in treatment with their 
mothers improved their school performance.
    As noted earlier, such interventions are in short supply. 
In general, traditional substance abuse treatment services have 
been tailored to male addicts not to women. Very few substance 
abuse treatment programs provide child care or adequate 
alternatives for women who seek treatment, creating a 
significant barrier for women who need help. A 1993 survey of 
drug treatment programs in five cities found that most accept 
pregnant women (83% of outpatient and 70% of residential 
programs), but only 20% both accept pregnant women and provide 
child care. In three of the five cities surveyed, no 
residential programs accepted pregnant women and provided child 
care.\9\
---------------------------------------------------------------------------
    \9\ Breitbart, V, Chavkin, W, and Wise, PH (1994). Accessibility of 
drug treatment for pregnant women: A survey of programs in five cities. 
American Journal of Public Health, 84(10), 1658-1661.
---------------------------------------------------------------------------
    The most effective and responsive solution to the chemical 
dependency/child abuse dynamic is preventing the problem in the 
first place. We must educate the public on the devastating 
health consequences of AOD abuse and the emotional and physical 
hazards of growing up in a chemically involved household. We 
must develop better means to identify and provide a continuum 
of treatment and support services to chemically involved 
families. Without additional prevention and treatment 
resources, the child welfare system will continue to wage a war 
against substance abuse that it cannot win.
    We again applaud the efforts of this subcommittee to 
investigate the difficult and complex links between substance 
abuse and child abuse and neglect. We look forward to 
continuing to work with you to help children stay safe.
      

                                

Statement of Ray Soucek, Haymarket Center, Chicago, Illinois

    Mr. Chairman, I am writing on behalf of Haymarket Center, a 
comprehensive drug treatment center located on the West side of 
Chicago, in reference to your Subcommittee's recent hearing on 
Substance Abuse in Welfare Families. Established in 1975, 
Haymarket is the third largest substance abuse treatment center 
in the State of Illinois, providing services to more than 
13,000 people annually. Our organization is deeply concerned 
with the effect of welfare reform on recipients with drug and 
alcohol abuse problems.
    The link between substance abuse and welfare recipients is 
significant. A study conducted by Aid to Families with 
Dependent Children (AFDC) of drug and alcohol use among adult 
recipients found that between 15-20% of welfare recipients have 
drug and alcohol problems. Another study conducted by 
researchers at the National Institute on Alcohol Abuse and 
Alcoholism (NIAAA) based on data from the 1992 National 
Longitudinal Alcohol Epidemiologic Survey, estimated that 17.9% 
of welfare recipients are dependent on alcohol and drugs, 
compared to 8.9% of non-recipients. Put simply, welfare 
recipients report a higher rate of drug and alcohol abuse than 
non-recipients do.
    Mr. Chairman, it is our belief that States must address the 
issue of dependency in order to prepare more welfare recipients 
to enter the workforce. With the new Welfare-to-Work 
stipulations, States must pay for the effects of substance 
abuse regardless of whether they pay for treatment. Ignoring 
the problem will result in States having an estimated 20% of 
their workforce with a major job-readiness impediment, causing 
heavy financial burden for the State. The new welfare law 
mandates that work participation rates amongst recipients rise 
from 25-50% between 1997 and 2002, with States receiving fines 
for non-compliance. An even more expensive consequence having 
to take over when untreated alcohol and drug abuse problems 
prevent recipients from leaving welfare within the designated 
time limit.
    There are two subgroups within the welfare population that 
pose significant challenges to Welfare-to-Work self-sufficiency 
efforts: abusers with co-occurring disorders, and substance 
abusing welfare mothers.

What is the effect of co-occurring disorders on diagnosis and 
treatment?

    Co-occurring disorders are a common problem among all 
people with substance abuse disorders. It is estimated that 
half of all people with substance abuse problems have co-
occurring disorders, involving psychiatric as well as substance 
abuse disorders. Often one problem can be considered primary 
and the other secondary, but more often, the patient is 
disabled by both disorders and requires integrated treatment. 
These people often fall victim to inadequate or ineffective 
treatment services, and lack of insurance coverage for their 
problems.
    According to M. Susan Ridgeley, J.D., M.S.W., Associate 
Professor, Department of Mental Health and Law policy at the 
University of Florida, there are numerous aspects of co-
occurring disorders that make the problem more debilitating to 
the patient and the system:
     Patients often suffer from more severe psychiatric 
symptomatology
     High rates of relapse and rehospitalization
     Worse course in treatment of the psychiatric 
disorder
     More admissions to emergency rooms and 
noncompliance with treatment interventions
     Increased acting out suicidal and criminal 
behavior
     Less able to carry out activities needed to manage 
their lives
    Mr. Chairman, this last characteristic common to patients 
with co-occurring disorders is especially significant to the 
self-sufficiency goals of the Welfare-to-Work program, and in 
reducing the incidence of drug abuse among welfare recipients. 
With increased pressure from the new laws to get welfare 
recipients into the workforce, less time is likely to be spent 
getting to the root of the problem. Co-occurring patients are 
expensive to the system because they often are not properly 
diagnosed. The solution is providing incentives for physicians 
and counselors to make diagnosis and treatment for co-occurring 
disorders the ônormö rather than the exception.

Why do dependent welfare mothers often not receive treatment?

    According to a September 1997 study produced by the Legal 
Action Center (LAC), titled Making Welfare Reform Work: Tools 
for Confronting Drug and Alcohol Problems Among Welfare 
Recipients, there are many common barriers to treatment for 
women with children. And according to the Department of Health 
and Human Services, in 1991 it was estimated that 5.6 million 
mothers with children living at home had used drugs during the 
past six months. The LAC study said these women face unique 
obstacles in receiving treatment, including:
    1. Stigma: Studies have discussed the multitude of self-
deprecating feelings women with substance abuse problems have 
experienced. According to the LAC, ``these emotions can lead to 
an immobilizing sense of depression and isolation and 
ultimately prevent women from asking for help.''
    2. Lack of Child Care: A 1996 survey in Substance Abuse 
Report reported that few substance abuse treatment centers 
provide child care, often acting as a deterrent for welfare 
mothers from seeking treatment, according to William Walden, 
Commissioner of the New Jersey Department of Human Services. 
Ther to meet increased demand for child care services. The 
problem of lack of quality child care for all welfare 
recipients is compounded for those with substance abuse 
problems. Before welfare mothers need quality child care while 
they are working, they need quality child care while in 
treatment, making centers that do provide child care and 
clinical child services more appealing.
    3. Fear of Losing Custody of Their Children: Since many 
States take punitive action against mothers with drug problems, 
women often are afraid to admit their addiction and seek 
treatment.
    4. Fear of Prosecution: In State v. Whitner the South 
Carolina Supreme Court ruled that women can be held criminally 
liable for their actions during pregnancy. The fear of 
prosecution by those welfare mothers who use drugs while 
pregnant coincides with fear of losing custody of children.
    5. Victims of Violence: Women with substance abuse problems 
have high rates of being victimized by violence, a problem that 
affects their recovery from addiction.
    6. Safe Housing: Drug-free safe housing is important for 
many recovering women. However, safe housing has become more 
and more difficult to obtain due to The Housing Opportunity 
Extension Act of 1996, which permits authorities to deny 
housing to former drug and alcohol abusers due to the potential 
threat they pose to other residents.
    Mr. Chairman, States must overcome these barriers by 
identifying welfare mothers with substance abuse problems and 
providing them with proper treatment. It is clear that the 
consequences for ignoring the problems are severe. Child 
welfare and foster care costs are increasing dramatically. 
Alcohol and drug abuse are among the top factors for children 
entering welfare and foster care. According to a 1994 GAO 
study, almost 80% of young children who entered foster care in 
1991 in California, New York, and Pennsylvania, had at least 
one parent with a drug or alcohol addiction. The cost of 
placing a child in the welfare or foster care system is 2 to 16 
times more than the cost of individual federally funded drug 
treatment. According to a LAC study, ``Providing alcohol and 
drug treatment prevention services for [welfare] families could 
protect children, reduce welfare caseloads, and produce 
significant savings for the federal and state governments.''
    The reformed welfare system must recognize the needs of 
recipients wif recipients are expected to achieve self-
sufficiency and job-readiness. Investments in treatment, 
especially for those with co-occurring disorders and welfare 
mothers, will be much more cost effective for the system and 
beneficial to recipients in the long run.
      

                                

Statement of Gwen Rubinstein, M.P.H., Deputy Director of National 
Policy, Legal Action Center, Washington, DC

    Welfare reform, now unfolding, presents states with many 
opportunities and challenges. It will not be long before we 
know whether this experiment will succeed in its key mission of 
moving many Americans from welfare to work.
    Reform of the child welfare and foster care systems will 
also be enacted soon. That initiative will present a set of new 
challenges to states, which are already grappling with many 
other complex reform initiatives inside and outside of the 
welfare system.
    We commend the Subcommittee on Human Resources of the House 
Committee on Ways and Means for calling this hearing, and we 
appreciate the opportunity to provide written testimony for the 
record. Alcoholism and drug dependence often are major barriers 
to self-sufficiency for welfare recipients, and we welcome 
discussion of how our national policy can confront thisproblem 
humanely, productively, and cost-effectively.
    The Legal Action Center is a law and policy organization 
focusing on alcohol, drug, and HIV/AIDS issues. The Center also 
represents the National Coalition of State Alcohol and Drug 
Treatment and Prevention Associations, a coalition of 34 state 
treatment and prevention associations in 30 states around the 
country. These associations represent providers on the front 
lines of treatment and prevention who daily confront the 
dramatic need to maintain and strengthen services for 
individuals and families with drug and alcohol problems.
    A key component to the success of both of these reforms, we 
believe, is the adoption of a balanced and comprehensive 
approach to addressing alcohol and drug problems among all 
Americans, but particularly low-income Americans. If reforms 
are to succeed, they must make a steadfast commitment to 
identifying children and adults who have or are on the brink of 
an alcohol or drug problem and providing them appropriate 
alcohol and drug treatment and prevention services.
    The Legal Action Center recently completed a major study 
for the Annie E. Casey Foundation entitled ``Making Welfare 
Reform Work: Tools for Confronting Alcohol and Drug Problems 
Among Welfare Recipients'' (copy attached). This statement 
incorporates some of our study's leading findings and 
recommendations. We request that the entire study be included 
in the record.

                Alcoholism, Drug Dependence, and Welfare

    Several national studies have attempted to determine how 
many welfare recipients have alcohol and drug problems; all 
have concluded that between 15 and 20 percent of welfare 
recipients do.\1\  This could translate nationally into between 
400,000 and 800,000 adult welfare recipients needing treatment 
to move into recovery, off welfare, and into jobs.
---------------------------------------------------------------------------
    \1\ Entities that have published studies include: Assistant 
Secretary for Planning and Evaluation, U.S. Department of Health and 
Human Services: National Center on Addiction and Substance Abuse at 
Columbia University; and National Institute of Alcohol Abuse and 
Alcoholism, National Institutes of Health.
---------------------------------------------------------------------------
    Few states, however, know the prevalence of alcoholism and 
drug dependence in their welfare caseloads. Earlier this year, 
the Legal Action Center surveyed state welfare officials and 
state alcohol and drug officials to gauge their knowledge and 
plans concerning welfare reform and addiction. Our report found 
that only five states had any data on the number of welfare 
recipients with drug or alcohol problems.\2\
---------------------------------------------------------------------------
    \2\ Those States included Kansas, which reported that 20 to 50 
percent of its caseload would fail a drug test, North Carolina, which 
said 35 percent of its welfare clients were at risk for alcohol or drug 
problems, and Oregon, which estimated that 50 to 60 percent of its 
welfare caseload was alcohol or drug related.
---------------------------------------------------------------------------
    This lack of information will undoubtedly hamper state and 
local planning and reduce the likelihood that alcohol and drug 
problems will be confronted with enough thought to be handled 
most effectively.

             Alcoholism, Drug Dependence, and Child Welfare

    Abuse and neglect associated with parental alcohol and drug 
abuse are among the most common reasons for entering the child 
welfare system, and drug-and alcohol-related foster care 
placements have been increasing. Almost 80 percent of young 
children who entered foster care in 1991 in California, New 
York, and Pennsylvania had at least one parent who was abusing 
drugs or alcohol, compared to 52 percent in 1986.\3\
---------------------------------------------------------------------------
    \3\ General Accounting office, Foster Care: Parental Drug Abuse Has 
Alarming Impact on Young Children, 1994, p. 7.
---------------------------------------------------------------------------
    In Washington State, 41 percent of infants placed in out-
of-home care in 1995 were born to 1mothers who abused alcohol 
or other drugs during their pregnancy.\4\ In New York, crack 
cocaine alone was blamed for a three-fold increase in the 
city's child abuse and neglect cases in the late 1980s.\5\
---------------------------------------------------------------------------
    \4\ Washington State Department of Social and health Services, 
``Chemical Dependence Among DHS Clinets: A Departmental problem,'' 
October 31, 1996, p. 10.
    \5\ Brandeis University, institute for Health Policy, Substance 
Abuse: The Nation's Number One Health Problem--Key Indicators for 
Policy, 1993.
---------------------------------------------------------------------------
    Out-of-home placements for children whose parents have 
alcohol or drug problems have contributed to skyrocketing 
foster care costs. Federal expenditures on foster care 
increased 300 percent between 1986 and 1991--from $637 million 
to more than $2.2 billion.\6\ In Illinois, the added medical 
and related costs of caring for 2,500 cocaine-affected infants 
in child welfare custody were $60 million in 1991.\7\
---------------------------------------------------------------------------
    \6\ Ibid.
    \7\ Child Welfare League of America, ``Through the Eyes of a Child: 
A National Agenda for Addressing Chemical Dependency,'' (Working 
Draft), 1992, p. 27.
---------------------------------------------------------------------------
    Providing adequate alcohol and drug treatment and 
prevention services for these families would protect children, 
reduce child welfare caseloads, and produce significant savings 
for the federal and state government. Foster care costs in 1994 
ranged from $4,800 per year for placement in family foster care 
to $36,500 per year for placement in group care.\8\ This is two 
to 16 times more than the cost per person for federally funded 
drug treatment.\9\
---------------------------------------------------------------------------
    \8\ U.S. House of Representatives, 1996 Green Book: Background 
Materials and Data on Programs Within the Jurisdiction of the Committee 
on Ways and Means, 1996, pp. 714-724.
    \9\ Substance Abuse and Mental health Services Administration, FY 
98 Budget Justification.
---------------------------------------------------------------------------
    Yet legislation passed in House this spring and in the 
Senate over the weekend to speed up adoption of children in 
foster care virtually ignores the relationship between 
addiction and child welfare. In fact, the Senate version of the 
bill, at the last moment, lost three important provisions to 
address that issue: a General Accounting Office study to 
explore the relationship between child welfare placement and 
alcoholism and drug dependence, allowance for foster care 
funding (under Title IV-E of the Social Security Act) to help 
pay for residential treatment in the case of children being 
reunited with a parent in treatment, and a new priority in the 
Substance Abuse Block Grant for parents in families involved in 
the child welfare system.
    These problems can be overcome, but not if they are 
ignored. In a recent study of 475 New York child welfare cases 
that received a range of preventive services (including alcohol 
and drug treatment), 98 percent of the families avoided foster 
care placement, domestic violence decreased in 93 percent of 
the families, child physical and sexual abuse decreased in 100 
percent of the families, and 48 percent of the families 
sustained abstinence from alcohol and drugs.\10\
---------------------------------------------------------------------------
    \10\ National Development and Research Institutes, ``Preventive 
Services Outcome Assessment: A Survey of Contracted Agencies, 
Preliminary Results,'' March 1995.
---------------------------------------------------------------------------

                 Treatment Is Effective But Underfunded

    Empirical research has shown that after alcohol and drug 
treatment, women reduce their reliance on welfare and increase 
their employment.\11\ \12\ We believe these findings support 
public policy that promotes treatment for welfare recipients 
with alcohol and drug problems as a way of helping them find 
and keep jobs and leave the welfare rolls. (I have attached a 
copy of the National Treatment Improvement Evaluation Study and 
ask that it be included in the record.)
---------------------------------------------------------------------------
    \11\ Dean R. Gerstein, et. al, ``Alcohol and Other Drug Treatment 
for Patents and Welfare Recipients: Outcomes, Costs, and Benefits,'' 
January 1997, p. 29.
    \12\ Center for Substance Abuse Treatment, ``The National Treatment 
Improvement Evaluation Study--The President Effects of Substance Abuse 
Treatment, One Year Later,'' September 1996, p. 11.
---------------------------------------------------------------------------
    Individual recovery stories also demonstrate the 
effectiveness of treatment:
     CD is a 38-year-old woman who has been in recovery 
for two years, since she entered residential treatment at 
Project Return in New York City for crack abuse. She has three 
children--ages 12, 7, and 6 years old--who had been in kinship 
foster care with her mother while CD was abusing drugs. After 
treatment, CD was reunited with all of her children. CD is a 
former welfare recipient who has been employed for nearly one 
year as a nurse's assistant.
     SS is a 38-year-old white woman who had lost 
custody of her three children due to her long history of 
substance abuse when she entered Par Village in St. Petersburg, 
Florida, for treatment. Her drug use included crack cocaine, 
alcohol, and heroin. Between 1992 and 1994, SS participated in 
treatment and was able to regain custody of her children one by 
one. She has worked diligently to develop and practice her 
recovery and vocational skills. After treatment, SS established 
a home for her and her children and enrolled in St. Petersburg 
Junior College, where she continues her studies and is employed 
by the Work Study Program. SS and her children are very 
involved in the worship and activities at their church in 
Clearwater, Florida, and she is an active participant in 12-
step programs throughout Pinellas County.
    These success stories are occurring all over America, yet 
publicly funded treatment programs such as Project Return or 
PAR Village are not always readily available in many 
communities. Waiting lists are common, and the most difficult 
treatment to find in virtually any community is a residential 
program for women and children.
    The main source of federal funding for alcohol and drug 
treatment, the Substance Abuse Prevention and Treatment Block 
Grant, has been stagnant. It will be allocated $1.36 billion in 
FY 98, the same as in FY 97. According to our study, only nine 
states plan to increase their own appropriations for alcohol 
and drug treatment for welfare families.
    Drug and alcohol treatment services are also not well 
covered under state Medicaid plans because they are optional. 
And reimbursement is expressly disallowed for all Medicaid-
covered services provided to recipients between 22 and 64 years 
of age in residential treatment facilities classified as 
Institutions for Mental Diseases (IMDs).\13\
---------------------------------------------------------------------------
    \13\ The IMD exclusion, originally drafted to prevent funding of 
large mental hospitals, has been extended to include even cost-
efficient substance abuse treatment programs. IMDs are facilities with 
more than 16 treatment beds.
---------------------------------------------------------------------------
    Finally, about 20 states are likely to deny cash welfare 
and food stamps to individuals with drug felony convictions, 
thus reducing funds that have been available for alcohol and 
drug treatment. Cash welfare and food stamps have helped to pay 
for room and board in residential alcohol and drug treatment 
programs for women with children. But the new federal welfare 
law prohibits giving these benefits to individuals with drug 
felony convictions, unless states ``opt out.''
    Treatment programs serving women are, predictably, 
concerned about these trends. Our study found that most expect 
welfare reform to decrease their revenue but increase their 
caseload.

                         Policy Recommendations

    The Legal Action Center submits the following policy 
recommendations to the Subcommittee for addressing alcohol and 
drug problems among welfare recipients and families involved in 
the child welfare system:

Identify Welfare Recipients and Families Involved in the Child 
Welfare System Who Have Alcohol and Drug Problems.

    The first step in breaking the cycle that keeps addicted 
people and later generations dependent on welfare or involved 
with the child welfare system is identifying, easily and cost-
effectively, welfare recipients who have alcohol and drug 
problems.
     Conduct Screening and Refer Welfare Recipients and 
Families Involved with the Child Welfare System Identified as 
Having Alcohol or Drug Problems for Treatment; Penalize Only 
Those With Alcohol and Drug Problems Who Refuse to Enter 
Available Treatment.
    Many short and simple screening tools--both written and 
verbal--are available for identifying individuals with drug and 
alcohol problems. They can easily be integrated into the 
existing welfare intake process, as some states and localities 
(such as New York, Oregon, and Utah) have already done, or 
child welfare intake process (as Sacramento County has done). 
Those identified as having alcohol and drug problems can then 
be referred for further clinical assessment and appropriate 
treatment, if needed.
     Reject Drug Testing as a Method of Identifying 
Individuals With Alcohol and Drug Problems.
    Limited resources should not be invested in drug testing 
because it yields little useful information at too high a 
cost.f screening and assessment described above is far more 
effective at a fraction of the cost.
     Train Welfare and Child Welfare Caseworkers to 
Administer Screening Protocols and Refer Clients for Services.
    The knowledge and skills of welfare and child welfare 
caseworkers are of critical importance in helping welfare 
recipients overcome both their short-and long-term barriers to 
working, including alcohol and drug problems. If caseworkers 
are in as much denial as their clients are about these 
problems, even the most well-designed state initiative is 
doomed to fail.

Promote and Encourage Treatment and Recovery Among Welfare 
Recipients.

    Helping individuals who are dependent both on welfare and 
alcohol and drugs enter treatment and overcome their addiction 
is an effective way to move them from welfare to work and 
reduce child abuse and neglect.
     Provide Treatment to Welfare Recipients Whose 
Addiction Prevents Them from Working, and Encourage Their 
Participation in Treatment by Not Counting Time Spent in 
Treatment Toward Their Time Limit on Welfare.
    Ideally, welfare recipients identified as having alcohol 
and drug problems should have ready access to treatment. 
National, state, and local policies should make every effort to 
increase the availability of treatment for welfare recipients 
needing it, particularly treatment designed for women with 
children, and make it more attractive by exempting individuals 
in treatment from the welfare time limits.
     Draw on All Possible Sources of Treatment Funding.
    The new welfare reform and adoption reform laws provide no 
new funding for alcohol and drug treatment. But treatment can 
still be funded by increasing federal appropriations for the 
Substance Abuse Block Grant, state allocation of welfare 
savings to treatment, state transfer of welfare money to the 
Social Services Block Grant, and Federal or state expansion of 
Medicaid reimbursement for treatment.
     Define Appropriate Work Components of Treatment as 
a Work or Community Service Under the Welfare Law, and Ensure 
that Work and Treatment Are Coordinated.
    Some work activities (as defined in the new welfare law) 
are integral parts of some alcohol and drug treatment programs. 
Counting them as work--whether by contracting with treatment 
programs to provide them or coordinating treatment with other 
work activities--will ensure that states have more welfare 
recipients to count toward their minimum work participation 
rates (so they will avoid penalties) and that welfare 
recipients striving toward recovery will gain work experience 
within the suoportive context of their treatment program.
     Eliminate the Felony Drug Conviction Ban.
    The federal government should eliminate the welfare law's 
ban on welfare and food stamps for individuals convicted of 
drug felonies. The drug felony conviction ban shrinks available 
treatment resources, strips the criminal justice system of 
resources it needs for mandatory drug and alcohol treatment, 
and shreds the safety net for individuals who have been in 
recovery, worked, and paid taxes, and their families.

Promote Prevention and Early Intervention for Welfare 
Recipients and Their Children.

    Addiction and welfare can both be inter-generational; 
effective prevention and intervention can break the cycle for 
many families forever.
     Integrate Prevention and Early Intervention 
Services into Welfare Reform.
    Preventing parents and children on welfare from developing 
alcohol and drug problems--or intervening early in the 
process--can keep families together, maintain safe environments 
for children, and help more families make a successful 
transition from welfare to work. All of these would decrease 
welfare and child welfare caseloads and save states money. The 
benefits to individuals, families, and communities would be 
great.
     Draw On All Available Sources of Prevention 
Funding.
    Prevention activities can be funded both inside and outside 
of the new welfare law and at the national, state, and local 
levels. Key federal sources of funding that should be increased 
include the Substance Abuse Block Grant and programs under the 
Center for Substance Abuse Prevention and Safe and Drug-Free 
Schools and Communities Act.

                               Conclusion

    Many welfare recipients have alcohol and drug problems. 
Their children (and many adult welfare recipients) are 
themselves at high risk for becoming dependent on or abusing 
alcohol or drugs. To succeed, welfare reform must confront this 
problem in a balanced and effective way that includes alcohol 
and drug treatment and prevention services.
    Many families involved in the child welfare system also 
have alcohol and drug problems, putting both children and 
parents at risk. The child welfare system must confront this 
problem in a balanced and effective way that includes alcohol 
and drug treatment and prevention services.
    Adopting a reasoned and comprehensive approach can 
simultaneously meet the goals of welfare reform, reduce alcohol 
and drug addiction and abuse, and improve the lives of our 
children, families, and communities.
      

                                

Statement of William D. McColl, Director of Government Relations; on 
Behalf of National Association of Alcoholism and Drug Abuse Counselors, 
Arlington, Virginia

    On behalf of the National Association of Alcoholism and 
Drug Abuse Counselors (NAADAC), please accept the following 
comments regarding protecting children from the prevalence and 
impact of substance abuse on families receiving welfare. 
NAADAC, with more than 18,000 members, is the largest national 
organization representing the interests of alcoholism and drug 
abuse treatment and prevention professionals across the United 
States.
    Research has clearly shown that children are highly 
affected by alcoholism and drug addiction within the family. 
Families on welfare face additional pressures from joblessness 
and poverty. Nevertheless, these issues are not insoluble. 
NAADAC reiterates three fundamental principles to deal with 
alcoholism and drug addiction, applicable not only to welfare, 
but also to society at large. First, alcoholism and other drug 
dependency must be addressed primarily as a public health 
problem. Second, access to appropriate care, delivered by 
credentialed professionals, must be provided to persons 
dependent on alcohol and other drugs. Finally, public and 
private funding must be significantly increased and policies 
improved to provide adequate levels of care for persons 
dependent on alcohol and other drugs.
    By following these fundamental principles, our nation can 
begin to reduce the tremendous burden faced by victims of the 
diseases of alcoholism and drug addiction. Treating these 
diseases will result in safer children, restored families and 
inproved communities. NAADAC adds the following specific 
program solutions below, designed to enhance the nation's 
ability to help those children caught in the difficult position 
of being on welfare with one or more parents who have the 
disease of alcoholism or drug addiction.

   Treatment Must Be a Fundamental Part of Federal and State Welfare 
                           Programs--Welfare

    In 1996, Congress fundamentally changed the federal welfare 
law to require that states move people from public assistance 
to work. As states begin to implement the new welfare 
requirements, the National Association of Alcoholism and Drug 
Abuse Counselors (NAADAC) supports policies and legislation 
which acknowledge the vital role of alcohol and drug treatment 
in helping individuals who are addicted to alcohol and other 
drugs to find employment and achieve self-sufficiency.
    State policymakers must be made aware that treatment 
positively affects the ability of this population to move into 
employment. According to one recent study, 5.2% of adults in 
Aid to Families With Dependent Children (AFDC) households are 
so severely impaired by alcoholism and/or drug addiction 
problems that they are unable to participate in immediate 
employment or training activities.\1\ This group must receive 
treatment if they are to become capable of work. An additional 
11.2% of AFDC adults are somewhat impaired and may require 
alcoholism and drug addiction treatment concurrent with work or 
training activities.\2\
---------------------------------------------------------------------------
    \1\ Gerstein, Dean R. et. al., U.S. Department of Health and Human 
Services, Office of the Assistance Secretary for Planning and 
Evaluation, Alcohol and Other Drug Treatment for Parents and Welfare 
Recipients: Outcomes, Costs and Benefits, January 1997.
    \2\ Ibid.
---------------------------------------------------------------------------
    Alcoholism and drug addiction treatment is capable of cost-
effectively moving clients from the ranks of the unemployment 
to work. The National Treatment Improvement Evaluation Study 
showed that people who complete treatment increased the rate of 
past year employment by 18.7% while decreasing income received 
from welfare programs by 10.7%.2 In addition state governments 
will save significant public funds by reducing the medical 
costs that result from this disease, helping people to live 
independently from welfare and public assistance, reducing the 
number of crimes committed by people who are addicted, and 
lowering the cost of incarceration.\3\
---------------------------------------------------------------------------
    \3\ Center for Substance Abuse Treatment, National Treatment 
Improvement Evaluation Study, September 1996.
---------------------------------------------------------------------------
    Much of the funding of the welfare system is in block grant 
form which allows each state a substantial opportunity to 
decide how they will spend their funds. NAADAC recommends that 
states place a portion of welfare funding into alcohol and drug 
treatment to help ensure success in moving people into jobs. 
State treatment agencies and treatment advocates must educate 
state legislatures, executives, policy makers, and welfare 
agencies to ensure that those most responsible for implementing 
welfare requirements clearly understand the need for treatment.

                    Changes to the 1996 Welfare Law

    NAADAC urges one significant change to the 1996 welfare 
reform law. The law currently makes any individual convicted of 
a drug-related felony ineligible for food stamps and Temporary 
Assistance to Needy Families (TANF), previously AFDC. This 
provision unnecessarily sanctions people who are suffering from 
the diseases of alcoholism and drug addiction. The loss of food 
stamps and TANF reduces families' total allotments by the 
amount of funding which would have gone to the ineligible 
person. This may jeopardize an entire family's well-being 
because benefits support entire families, not just the 
individuals who use them. Children are particularly vulnerable 
to these reductions. Moreover, many treatment providers use 
TANF and food stamp benefits to help support the costs of room 
and board associated with residential treatment. Loss of access 
to even this meager funding source may cause a patient to lose 
treatment opportunities.
    Patients who complete treatment require stability and 
continuing care to ensure a successful transition to drug free 
life. There is no provision for restoration of benefits in the 
new welfare law upon an individuals entrance into recovery. 
Consequently the stability that this source of funding could 
bring to people in recovery is lost. We urge Congress to repeal 
this lifetime ban. Short of repeal, Congress should take steps 
to mitigate possible damage from this provision by exempting 
persons who are seeking treatment, have completed treatment, 
are pregnant, or who are otherwise disabled. NAADAC notes that 
states are currently allowed to opt out of this provision. They 
should do so.

                    Drug Testing and the Welfare Law

    The welfare law now allows states to require that welfare 
recipients be tested for drug use and to apply sanctions for 
positive tests. NAADAC again reiterates its position that ``the 
purpose of drug testing must be rehabilitative and not 
punitive.'' \4\ We are concerned that blanket drug testing 
programs will be accomplished at high cost to the state without 
leading to effective treatment people addicted to drugs. 
Testing will not effectively address the alcohol and 
prescription pharmaceutical addiction problems of welfare 
recipients, and will not, by itself, adequately identify people 
who are addicted to those illegal drugs which are most commonly 
tested. To correctly identify persons addicted to drugs, state 
welfare agencies must professionally assess and screen 
recipients in addition to, or in place of, drug testing. Upon 
positively identifying an individual who is suffering from 
alcoholism or drug addiction, agencies must provide access to 
an adequate level of alcohol and drug addiction treatment from 
licensed or certified alcohol and drug treatment counselors.
---------------------------------------------------------------------------
    \4\ Ibid.
---------------------------------------------------------------------------

                               Conclusion

    In summation, the best way to help people who are on 
welfare and who suffer from alcoholism or addiction to drugs is 
to provide them with treatment. Treatment is the most cost-
efficient and effective means of ensuring that welfare 
recipients suffering from these diseases are able to move from 
dependence on cash assistance to employment and self-
sufficiency. NAADAC supports efforts to reform the welfare law 
to ensure that persons who are suffering from the diseases of 
alcoholism and drug addiction do not suffer from 
discrimination.\5\ In particular, provisions barring persons 
convicted of drug-related felonies from receiving food stamps 
and TANF are onerous and make treatment inaccessible to those 
who are most in need of this service. Finally, NAADAC 
encourages states to make every effort to ensure that drug 
testing is rehabilitative and not punitive. If drug testing is 
used, states should provide adequate access and funding for 
treatment by certified and licensed counselors.
---------------------------------------------------------------------------
    \5\ NAADAC, Position Statement, Drug Testing, March 1996. NAADAC, 
Position Statement, Drug Screens, April 15, 1987.
---------------------------------------------------------------------------
      

                                

Statement of Hon. Jim Ramstad, a Representative in Congress from the 
State of Minnesota

    Mr. Chairman, thank you for calling this hearing to discuss 
the impacts of substance abuse on families receiving welfare. I 
would also like to thank you for inviting Dr. Mitch Pearlstein, 
my friend from the Center of the American Experiment in 
Minnesota, to testify today.
    I know many of the people speaking today will explain that 
alcoholism and drug addition are painful, destructive 
occurrences with staggering public costs. We all know 
addictions cause health care costs to rise and contribute to 
the overwhelming amount of crime, violence and domestic abuse 
in our nation today.
    Despite these facts, I couldn't agree more with Dr. 
Pearlstein's assessment that this nation ``seems to be in a 
haze, numbed to the pervasiveness and destructiveness of 
drugs.'' That's why this hearing, to shed light on the 
devastation all drugs can create, is so important.
    The most important costs, of course, are the personal 
costs. Alcoholism and drug addiction permeate all races and all 
income levels. They afflict both the abuser and his/her 
family--most dramatically, the children. Dr. Pearlstein gives 
an emotional personal account of how it has affected his 
family, especially his adopted daughter.
    As one who has been sober for 16 years, I know treatment 
works. I also realize that many factors affect treatment 
success, and just like chemotherapy and radiation for cancer 
victims, traditional treatment programs cannot have a 100% 
success rate.
    We should look at alternative programs, as Dr. Pearlstein 
suggests in his testimony. Frankly, I believe we should 
consider anything that will effectively help a person fight 
addictive tendencies. I am glad to learn through today's 
witnesses about the kinds of treatment programs that are 
working across this nation so we can try to replicate them for 
others.
    And for those who won't or can't fight addiction, Mr. 
Pearlstein is absolutely correct--we must remove the children 
from their care and get the children into a stable, loving and 
nurturing family as soon as possible.
    Certainly, any welfare/foster care system that keeps just 
one child in harms way or away from a loving family just one 
day longer than necessary needs improvement. Unfortunately, 
more than one child is severely neglected by our system every 
year. Dr. Pearlstein tells of 2,000 infants and young children 
in the U.S. who die from neglect and abuse by parents and 
caregivers every year. We also know that over 500,000 children 
linger in our foster care system awaiting adoption.
    Because alcoholism and drug addition are so pervasive and 
destructive and can most greatly harm the most vulnerable in 
our society--our children--I would like to thank you again, Mr. 
Chairman, for calling this hearing. I look forward to the 
testimony of today's witnesses and learning more about ways we 
can fight addiction and improve the lives of America's children 
and families.

                                   -