Review
Factors that influence mother–child reunification for mothers with a history of substance use: A systematic review of the evidence to inform policy and practice in Australia

https://doi.org/10.1016/j.drugpo.2015.05.025Get rights and content

Highlights

  • A review of mothers with substance use disorders with children in out of home care.

  • Mothers had multiple co-occurring problems and many had mental health issues.

  • Mothers who used heroin had lower reunification rates.

  • Sexual and reproductive health is an area that requires further research.

  • A one-stop-shop primary health care model may improve outcomes.

Abstract

Background

An estimated 60–70% of Australian children in out of home care have a parent with a substance use disorder (SUD). The assessment of a parent's history and needs and the design of supportive interventions, particularly for mothers who are often the primary carers of children, are important considerations in deciding whether or not family reunification is desirable and possible. It is not clear from the research how the needs of families can be best met. There are no systematic reviews that provide evidence to inform the development of preventative and remedial interventions and related policy options. We undertook a systematic review to examine maternal characteristics and program features that facilitate or pose a barrier to mother–child reunification in contexts where mothers have a SUD.

Methods

A structured search of nine databases was undertaken to identify peer reviewed literature in English between 2004 and 2014 and examine factors that influenced mother–child reunification in mothers with SUD. We employed a narrative synthesis design to analyse the findings sections of all papers as the methods of the various studies did not permit the pooling of data.

Results

A total of 11 studies were included in this review. Findings show that factors such as timeliness of treatment entry, treatment completion and the receipt of matched services, and programs that provided a greater level of integrated care are positively related to reunification. The presence of a mental health disorder, use of opiates and having a greater number of children were barriers to reunification.

Conclusion

Women with SUD who have a child in out of home care appear to have multiple unmet needs. Accessible, stigma free and comprehensive integrated care services, as well as greater access to primary health care that address social and medical issues must be considered to improve the physical and psycho-social outcomes of these women and their children.

Introduction

Child abuse and neglect are of both international (EMCDDA, 2012) and national concern. Currently in Australia there are increasing numbers of children at risk are being reported to authorities, placing statutory child protection services under pressure (Commonwealth of Australia, 2009). Children and young people up to the age of 18 in the state of New South Wales (NSW) who are unable to live with their birth families are provided with out-of-home care (OOHC) services. In June 2013, 40,539 Australian children were living in OOHC. These numbers have increased in recent years from 7.3 children per 1000 in 2011 to 7.8 per 1000 in 2013. Aboriginal and Torres Strait Islander children are 10.6 times as likely to be living in OOHC than non-Indigenous children (AIHW, 2014). Disparate rates of children in OOHC care similarly seen in other minority groups such as Native American Indian and African American children (Carter, 2010, Knott and Donovan, 2010).

The misuse of substances such as alcohol, illicit and prescription only medicines in Australia, as in many other countries, is commonly cited as a factor associated with a parent having a child in OOHC (Delfabbro et al., 2009, Delfabbro et al., 2013). It is estimated that approximately 60–70% of Australian children in OOHC were removed from households where at least one parent had a substance use disorder (SUD) (Fernandez & Lee, 2013). Recent work by Taplin and Mattick (2013) found that of 171 women who were all receiving opiate substitution therapy, almost one third (32.7%) had a child living in OOHC. Whilst maternal (or paternal) substance use does not necessarily lead to poor parenting (Street, Harrington, Chiang, Cairns, & Ellis, 2004), it is strongly linked to child maltreatment and neglect (Blakey, 2012). Mothers with a history of a SUD are often highly involved with the child protection system, highlighting the vulnerabilities of these family units (Schilling et al., 2004, Taplin and Mattick, 2013). Whilst it is recognised that maternal substance use does not equate to automatic child removal, nor is substance use is rarely the only contributing factor for child removal, (Marcenko, Lyons, & Courtney, 2011) substance use is a significant concern in Australia, where it is implicated in serious health and social outcomes that were estimated to cost the nation $55.2 billion dollars between 2004/2005 (Collins & Lapsley, 2008).

There are differences in patterns of drug and alcohol use among men and women in Australia (AIHW, 2011) that, when considered in the light of household composition, can affect parents and their children in different ways. For example, the majority (84%) of single parent households in Australia as of June 2012 were headed by women and increasing rates of illicit drug use have been found among single parent households (ABS, 2012).

In Australia, reunification of parent/s and child/ren, when and where possible, is the primary goal after a child has been placed in OOHC (AIHW, 2014). This goal is in line with the United Nations Convention on the Right of the Child Article 7, which states that ‘… as far as possible, [the child has] the right to know and be cared for by his or her parent’ (OHCHR, 2014). Reunification is the ‘…the movement of children from the substitute care setting into the biological family home’ (Choi, Huang & Ryan 2012, p. 1642). Within the child welfare context, reunification is a process of services that are provided to families who have a child placed in OOHC, with the intention of returning the child back to their family of origin (Carnochan, Lee, & Austin, 2013). When, this does not occur, the child is placed into alternative care, such as kinship care or adoption (Maluccio, Abramczyk, & Thomlison, 1996). Kinship care is particularly important for Aboriginal and Torres Strait Islander communities where there is a cultural tradition of providing care to other family members’ children if the care cannot be provided by the biological parent. Aboriginal and Torres Strait Islander children experience lower rates of reunification than other populations (AIHW, 2014). Reasons for lower reunification rates may include high levels of poverty, morbidity and mortality rates, parental substance abuse and domestic violence, as well as discrimination within the child protection system (Delfabbro et al., 2003, Delfabbro et al., 2009).

Children who come from households where substance use is present have been shown to have lower rates of reunification compared to families where substance use is not an issue (McGlade et al., 2009, Sarkola et al., 2011, Schaeffer et al., 2013). It is not known specifically why reunification rates are lower when substance use is involved, and there are no systematic reviews that provide insight into these factors. In addition, research that focuses solely on mothers with SUD and programs to facilitate reunification are limited (Grella, Needell, Shi, & Hser, 2009). It is therefore not clear how mothers needs can be best supported to facilitate mother–child reunification. A focus on mothers is important as women are usually the primary carer for children and are the parent most likely to receive them when they are returned from OOHC (Douglas & Walsh, 2009).

We undertook a systematic review to address these gaps in the empirical literature and to provide evidence to inform the development of preventative and remedial interventions to support mothers whose children may have been or are at risk of being removed to OOHC. The aim of this review is therefore to determine the factors that influence mother–child reunification, including programs and/or strategies that have been found to facilitate reunification in circumstances where mothers have a history of SUD. This paper will provide a clearer understanding of how, when and if reunification processes can be instigated and how mothers can be best supported.

Section snippets

Methods

An initial scoping exercise of relevant databases revealed research studies with a range of methodologies that did not allow for the pooling of statistical data. In order to analyse and synthesise findings from qualitative and quantitative studies, a narrative synthesis was selected as the most appropriate method for this review. This enabled the exploration of relationships within and across the research studies by analysing and describing findings (Popay et al., 2006).

Findings

A total of 11 studies are included in this review. All studies are from the United States of America (USA). Nine papers are quantitative studies (Choi et al., 2012, Choi and Ryan, 2007, Dakof et al., 2009, Grant et al., 2011, Green et al., 2006, Grella et al., 2009, Huang and Ryan, 2011, McCann et al., 2010, Twomey et al., 2011). One qualitative study (Einbinder, 2010) and one multiple embedded case history (Blakey, 2012) were also included.

Several papers use data from the same intervention

Discussion

The review demonstrates the ongoing barriers and challenges faced by mothers to address their substance dependence and gain custody of their children where possible. Whilst many of the studies reported on outcomes of comprehensive programs and intensive case management for these women, reunification rates varied. Even when mothers were provided with matched service provision for co-occurring problems, uptake and reunification rates were generally low (Choi & Ryan, 2007). However, tailored and

Conclusion

Women with SUD are a vulnerable group of women with complex and often unmet needs. This is compounded by the effects of having a child removed and taken into OOHC and presents further challenges for these women, their children and health care providers. More comprehensive and integrated care services, as well as greater access to PHC must be considered if we are to improve outcomes and address issues for these women, as well as their children and potential future generations.

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