ReviewFactors 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
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.
References (71)
- et al.
Stigma, discrimination and the health of illicit drug users
Drug Alcohol Depend
(2007) From surviving to thriving: Understanding reunification among African American mothers with histories of addiction
Children and Youth Services Review
(2012)- et al.
An analysis of the impact of the Strengthening Families Program on family reunification in child welfare
Children and Youth Services Review
(2012) Factors predicting placement of urban American Indian/Alaskan Natives into out-of-home care
Children and Youth Services Review
(2010)Factors associated with reunification: A longitudinal analysis of long-term foster care
Children and Youth Services Review
(2010)- et al.
Substance abuse treatment completion in child welfare: Does substance abuse treatment completion matter in the decision to reunify families?
Children and Youth Services Review
(2012) - et al.
Co-occurring problems for substance abusing mothers in child welfare: Matching services to improve family reunification
Children and Youth Services Review
(2007) - et al.
A randomized pilot study of the Engaging Moms Program for family drug court
Journal of Substance Abuse Treatment
(2010) - et al.
The social and family backgrounds of infants in South Australian out-of-home care 2000–2005: Predictors of subsequent abuse notifications
Children and Youth Services Review
(2009) - et al.
Reunification in a complete entry cohort: A longitudinal study of children entering out-of-home care in Tasmania, Australia
Children and Youth Services Review
(2013)
Accomplishing family reunification for children in care: An Australian study
Children and Youth Services Review
Maternal substance abuse and disrupted parenting: Distinguishing mothers who keep their children from those who do not
Children and Youth Services Review
Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis
Children and Youth Services Review
Substance abuse treatment entry, retention, and outcome in women: A review of the literature
Drug and Alcohol Dependence
Mothers in substance abuse treatment: Differences in characteristics based on involvement with child welfare services
Child Abuse & Neglect
Do drug treatment services predict reunification outcomes of mothers and their children in child welfare?
Journal of Substance Abuse Treatment
Management of injecting drug users admitted to hospital
Lancet
A child's-eye view of parent methamphetamine abuse: Implications for helping foster families to succeed
Children and Youth Services Review
Unintended pregnancy in opioid-abusing women
Journal of Substance Abuse Treatment
Trying to come home: Substance exposed infants, mothers, and family reunification
Children and Youth Services Review
The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature
International Journal on Drug Policy
Disproportionate representation of African-American children in foster care: Secondary analysis of the National Child Abuse and Neglect Data System, 2005
Children and Youth Services Review
Mothers’ experiences, resources and needs: The context for reunification
Children and Youth Services Review
Integrated services for families with multiple problems: Obstacles to family reunification
Children and Youth Services Review
Meeting health and psychological needs of women in drug treatment court
Journal of Substance Abuse Treatment
Integrated programs for mothers with substance abuse issues and their children: A systematic review of studies reporting on child outcomes
Child Abuse & Neglect
Comprehensive treatment for co-occurring child maltreatment and parental substance abuse: Outcomes from a 24-month pilot study of the MST-Building Stronger Families program
Child Abuse & Neglect
Women in detoxification: Loss of guardianship of their children
Children and Youth Services Review
Mothers in methadone treatment and their involvement with the child protection system: A replication and extension study
Child Abuse & Neglect
Labour Force, Australia: Labour Force Status and Other Characteristics of Families 2012
2010 National Drug Strategy Household Survey report Drug statistics series no. 25. Cat. no. PHE 145. Drug statistics series no. 25
Child protection Australia 2012–13
Effectiveness of substance abuse treatment programming for women: A review
American Journal of Drug & Alcohol Abuse
Offering incentives to drug-using women to take up contraception: The ethical and clinical issues
Addiction
Unplanned pregnancy and contraceptive use in women attending drug treatment services
Australian and New Zealand Journal of Obstetrics and Gynaecology
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