What can we learn from family treatment courts about improving practice for families affected by substance use disorder?

This brief is part of a series on family treatment courts (FTCs) developed in partnership with Children and Family Futures. Additional briefs on this topic provide an overview of family treatment courts and their role as a catalyst for systems change. For more information about FTCs, please consult the Family Treatment Court Best Practice Standards, or contact Children and Family Futures at FDC@cffutures.org.

Family treatment courts (FTCs) have proven to support positive outcomes for families affected by parental substance use disorder, including improved recovery for adults, safety for children, and timely permanency for families.1 However, not all jurisdictions have secured the funding for implementation of this model, including the hiring of an FTC coordinator, one of the primary program expenses. 

Many of the strategies that FTCs employ to achieve these outcomes — such as early substance use disorder identification and timely access to treatment, peer recovery coaches, intensive case management, frequent and supportive engagement with participants, and a commitment to family time — are not exclusive to FTCs or other specialty courts. In fact, each of these effective strategies can and should be implemented in any child and family well-being system and in all family courts, in collaboration with community partners. Making these strategies “business as usual” could have the additional benefit of making it easier to budget for associated costs and eliminate sustainability concerns because separate funding and support is not needed.

Bridget Bauman, director of the Children’s Court Improvement Program in Wisconsin, notes that some counties in her state have successfully implemented FTC principles without a formal program coordinator in place. “It would be ideal to have the full FTC model,” she observes, “but it is still helpful to incorporate elements such as having more informal discussion among partners, meeting with families more frequently, and taking a trauma-informed approach.”

In one study of FTCs in a Regional Partnership Grant program, families of color experienced similar outcomes to white families. However, the study found that some children of color, including African Americans, still were underrepresented in the FTC programs. While the reasons for this should be examined, incorporating more of these strategies throughout the system may serve to increase equity. 

My drug court team helped me realize my full potential and become a better mother. The compassion they have toward parents with substance use disorder is very heartfelt. I believe in myself a lot more because of this program.

– Family Treatment Court Participant, Travis County, Texas

Early identification and timely access to treatment

Jurisdictions with FTCs seek to ensure that all families involved with the child welfare system are promptly and systematically screened for the presence of parental substance use disorder to facilitate timely treatment. Ideally, this screening occurs in the initial stages of the investigation when substance use is identified as a factor — and before a decision is made about whether to separate children from their parents — to ensure that the family obtains access to treatment services and other supports as quickly as possible. FTCs that use standardized assessment tools for eligibility — with objective, documented criteria based on the best available evidence rather than subjective criteria such as caseworkers’ impressions of parents’ motivation to change or readiness for treatment — achieve significantly better treatment completion and reunification rates.2

Once parents’ needs are assessed, FTCs seek to facilitate timely, family-centered treatment at an appropriate level of care. Long wait times are associated with a reduced likelihood of completing treatment.3 One statewide longitudinal study found that the sooner mothers with child welfare involvement entered substance use disorder treatment after their children’s placement in out-of-home care, the more likely their families were to reunify.4

Screening and assessment for substance use disorder should occur in conjunction with early assessments of other challenges that may affect the family, including collateral legal issues. For more information about preventive legal support, see How can pre-petition legal representation help strengthen families and keep them together?

When inpatient treatment is indicated, family-centered residential treatment programs that allow children to remain with their parent are more successful in engaging and retaining parents in treatment.5 Residential treatment programs for mothers and their children also promote positive parent and child outcomes, such as enhanced bonding, improved communication, and greater maternal sensitivity to the child’s needs. These programs provide a natural opportunity to assess parenting skills and parent-child attachment, and to provide therapy or intensive parenting interventions. The Family First Prevention Services Act allows state child welfare agencies to claim Title IV-E foster care maintenance payments to support children remaining with a parent in family-based residential treatment for up to 12 months, although some implementation challenges exist in taking full advantage of this option. 

Facilitating timely access likely requires monitoring service access and delivery to better understand the barriers and challenges encountered by parents seeking substance use disorder treatment. FTC teams frequently help resolve community-based barriers that prevent participants from obtaining needed services, including treatment, by collaborating closely with the child welfare system, community-based substance use treatment providers, and other community providers to ensure comprehensive family-centered care is available and provided.

Milwaukee County’s FTC benefits from the presence of four residential providers serving women and three serving men. Two of these providers also can accommodate children. Although wait lists still exist for residential treatment, FTC providers always are able to connect a client with at least outpatient care right away, and have successfully reduced time to residential program enrollment.

In the past, referrals to substance use screening were made after the client’s first dependency court hearing. Observing that a significant number of clients slipped through the cracks by missing follow-up calls or screening appointments, the FTC began inviting screeners to meet with parents onsite at the children’s court while parents wait for their initial hearing. If they consent, parents can be screened, contacted by a recovery support coordinator, and scheduled for a treatment intake at the provider of their choice, all within 48 hours.

The Milwaukee FTC program significantly increases the likelihood of family reunification. Eligible families that do not enter the program experience a 12% reunification rate, but for those who stay in the program five months or longer, the rate of reunification increases to 55%.

Source: Interview with Milwaukee County FTC staff on 2/1/2021. 

Peer recovery coaches

Many successful FTCs employ peer recovery coaches or recovery support specialists who have lived experience with substance use treatment and are in recovery, often former participants of that FTC. These professionals often are some of the first people to connect with participants and can serve as a bridge between participants and their service teams, particularly early in the program while the team is building rapport and trust. 

The peer recovery coach’s role is to guide participants in their recovery, helping them build informal networks within the recovery community that will continue offering support once the formal system steps away. Peer recovery coaches also often function as advocates for participants during case staffings and hearings, ensuring that the team understands the perspective of a person in recovery.

Peer recovery coaches can do and say things that other professionals on the team can’t. They can have real, transparent conversations, and the participants will often listen to them when they won’t listen to anyone else because peer recovery coaches have been where they are. Their work has had a huge impact, not just on family treatment court cases, but on other cases as well.

– Karla Nelson, Protective Services Court Manager, Excel Dependency Court, Fairfield County, Ohio

Intensive case management and case coordination

Families involved with both the child welfare system and substance use disorder treatment may have multiple, complex needs and be involved with numerous services, providers, and agencies. One study found that, on average, parents involved concurrently with the child welfare system and substance use disorder treatment had nine weekly service event requirements in their reunification case plans, compared to five for parents without substance use disorders.6

Parents with child welfare involvement and substance use disorders benefit from intensive case management services, with smaller caseloads and greater frequency and intensity of contact than traditional models of case management. Compared with practice as usual, intensive case management for individuals with substance use disorders improves outcomes such as retention in treatment, decreased substance use, and increased family functioning.7 One study of families with parental substance use disorders involved in the child welfare system found that parents receiving intensive case management engaged with treatment at a significantly higher rate and were more likely to achieve stable reunification than those who did not receive such services.8

Case plan coordination is a key element of intensive case management. Coordinated case plans address the strengths and needs of each participant as well as whole family functioning, with special attention to coordinating children’s services with those of the parents. Children, parents, and other family members (as defined by the family) also are active partners in case planning. 

Due to funding and staffing considerations, some FTCs split case management responsibilities between two (or more) positions that coordinate closely. In Fairfield County, Ohio, the team relies on clearly defined roles: the child protective services case manager focuses on everything related to the child’s needs (including parenting time and the protective services case plan), while the FTC case manager supports the parent on all other needs, including housing, employment, appointments, and coordination of case plans.

The Fairfield County, Ohio Excel Dependency Court has made great strides in recent years to incorporate a more incentive-based, family-centered approach. The court employs an integrated model, meaning one magistrate hears both the dependency and FTC cases for a single participant. Prior to weekly hearings, the court’s program coordinator provides a written update about each participant. This results in more focused staffing meetings and prevents the magistrate from having to make on-the-spot decisions during hearings. Team members are in frequent contact outside of the staff meetings as well.

Due to these in-depth pre-court conversations, the magistrate is able to spend the bulk of time in hearings conversing directly with participants about parenting, their children, and their own recovery. The tone is informal, positive, and encouraging — in virtual hearings during COVID, the magistrate used a “cheering” phone app to replace the applause frequently heard after good news is relayed in an open courtroom. Conversation among the other professionals is limited to positive feedback or problem-solving to help remove any barriers to treatment or case plan progress. The court’s new approach has decreased parents’ median time to permanency from 292 days in 2018 (before the changes were implemented) to 151 days in 2020. By comparison, in traditional cases, median time to permanency was 668 days in the same county in 2018.

Source: email correspondence with Fairfield County, Ohio Excel Dependency Court staff on February 26, 2021

Rapport and trust through supportive engagement

Long gaps between dependency hearings may pose a challenge for parents with a substance use disorder, as they benefit most from frequent, supportive engagement. In the FTC model, avoidance of long gaps is under the purview of the judge, who convenes review hearings for all participants at least monthly, and as frequently as every week for new participants. 

Research involving adult drug courts found that when a judge spends an average of just three minutes (or more) with each participant, outcomes are improved. Prior to each hearing, the judge and other operational team members receive information about participant engagement and progress, to inform the court’s responses. At FTC hearings, the judge speaks directly to each participant about his or her participation and engagement in services, child welfare case plan requirements, services for his or her children, and any barriers the family is encountering. The judge builds rapport with parents by being engaging, supportive, and encouraging, and emphasizes the participant’s strengths and the importance of continued engagement in treatment and services. 

We wanted to make our court less sanction-based and more family-centered. Instead of ‘Why didn’t you …’ we ask, ‘What barriers can we help remove?’ and ‘What do you need?’ We want to be the voice in their head that says, ‘Yes, you can do this!’

– Michelle Edgar, Magistrate, Excel Dependency Court, Fairfield County, Ohio

FTCs take a unique approach to motivation and accountability. They use a phased approach to support behavior change and completion of case plans, where advancement is based on achievement of realistic, clearly defined behavioral objectives associated with sustained recovery, stable reunification, and safety, well-being, and permanency for children. Criteria for advancement through the phases are clearly communicated. 

FTCs recognize that personal change in general, and substance use disorder recovery in particular, are complex processes. When responding to participant setbacks, effective FTC teams avoid harsh sanctions such as jail time, and never use decreased family time (visitation) as a sanction. Instead, they consider the cause underlying the behavior as well as the effect of the therapeutic response on the parent, the parent’s children and family system, and the parent’s engagement in treatment and supportive services. If inconsistent or noncompliant behavior is due to a barrier, teams respond by providing additional supports. 

The Tompkins County, N.Y., FTC has operated since 2001 under the supervision of Judge John Rowley. In 2014, the FTC team implemented system improvements that dramatically improved program outcomes. Program graduation rates for adults engaged in treatment have grown from 20% to 45%. Voluntary relinquishments of parental rights dropped from 45% to 16%, and relative custody rose from 10% to 41%.

To make the process more family-focused, the team added a parent-child services coordinator position and implemented two evidence-based programs that promote healthy parent-child relationships. SafeCare supports families moving toward reunification with home visits from public health nurses. It has the benefit of providing an additional set of eyes on family well-being during this challenging period. The Strengthening Families Program is offered to all participants and provides families an opportunity for extra parenting time on top of (not in place of) regular visits — a strategy that has incentivized parental engagement.

Based in part on feedback from program graduates, Judge Rowley also made changes in his courtroom, moving agency representatives out of the jury box and seating them alongside clients. The judge also comes down from his bench to interact with participants from a podium on the courtroom floor. Parents, who used to be called forward to a podium to speak, now interact with the judge from the relative comfort of their seats.

Sources: Capacity Building Center for States Podcast: How we partner with the community to improve services options (Podcast episode 7: Collaborating to Create Family-Focused Courts) and The Prevention and Family Recovery Initiative: Case Study – Tompkins County, NY

Family time and connection

Effective FTCs recognize the importance of high-quality, well-resourced, face-to-face family time and reunification services when the child is in out-of-home placement. Family time is a fundamental right for all children in foster care and their families. It should never be used as an incentive or sanction for recovery progress. Decisions about family time should be based only on the child’s best interests — in most cases, frequent contact with parents, siblings, and other kin results in fewer behavior problems and greater well-being for children. 

FTCs also can encourage positive relationships between foster or kin caregivers and parents. Research shows that when foster parents demonstrate empathy and acceptance of a child’s family, children feel a greater sense of belonging to both families. “We know that the child and parents both do better when they have a good relationship with the foster caregiver,” says Judge Laura Crivello, Presiding Judge of the Children’s Court in Milwaukee County, Wisc. “I encourage foster caregivers as much as I can by showing gratitude and recognition in the courtroom.”

Family treatment court is about relationships and creating a bond — trusting people and having them trust you. It’s not just about encouragement, it’s about using words of change, helping participants learn from past mistakes, and motivating them to be as healthy as they can be.

– Laura Crivello, Presiding Judge, Children’s Court, Milwaukee County, Wisc

1 This brief was informed through interviews with Laura Crivello, Presiding Judge, and Rebecca Foley-Cramer, Coordinator, Children’s Court of Milwaukee County, Wisc., and Bridget Bauman, Director, Wisconsin Children’s Court Improvement Program on Feb. 1, 2021; Michelle Edgar, Magistrate, and Mikaila Tussing, Special Programs Coordinator, Fairfield County (Ohio) Juvenile Court on Jan. 5, 2021; Karla Nelson, Protective Services Court Program Manager, Fairfield County Juvenile Court; Stacey Bergstrom, Family Services Manager, and Sarah Fortner, Assistant Deputy Director for Protective Services, Fairfield County Job and Family Services on Jan. 5, 2021; and Aurora Martinez Jones, Presiding Judge, 126th District Court, Travis County, Texas, on Jan. 22, 2021.
2 Koetzle Shaffer D, Hartman JL, Johnson Listwan S, Howell T, Latessa EJ. (2010). Outcomes among drug court participants: does drug of choice matter? International Journal of Offender Therapy and Comparative Criminology, 55(1),155–74. van Wormer J, Hsieh M-L. (2016). Healing families: outcomes from a family drug treatment court. Juvenile and Family Court Journal, 67(2), 49–65
3 Chawdhary A, Sayre SL, Green C, Schmitz JM, Grabowski J, Mooney ME. (2007). Moderators of delay tolerance in treatment-seeking cocaine users. Addictive Behaviors, 32(2), 370–6; Hoffman KA, Ford JH, Tillotson CJ, Choi D, McCarty D. (2011). Days to treatment and early retention among patients in treatment for alcohol and drug disorders. Addictive Behaviors, 36(6), 643–7.
4 Green BL, Rockhill A, Furrer C. (2007). Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis. Children and Youth Services Review. 29(4): 60–73.
5 Chen X, Burgdorf K, Dowell K, Roberts T, Porowski A, Herrell JM. (2004). Factors associated with retention of drug abusing women in long-term residential treatment. Evaluation Program Plan, 27(2), 205–12.
6 D’Andrade AC, Chambers RM. (2012). Parental problems, case plan requirements, and service targeting in child welfare reunification. Children and Youth Services Review, 34(10), 2131–8.
7 Vanderplasschen W, Rapp RC, Wolf JR, Broekaert E. (2004). The development and implementation of case management for substance use disorders in North America and Europe. Psychiatric Services, 55(8), 913–22. Penzenstadler L, Machado A, Thorens G, Zullino D, Khazaal Y. (2017). Effect of case management interventions for patients with substance use disorders: a systematic review. Front Psychiatry, 8, 1–9; Rapp RC, Van Den Noortgate W, Broekaert E, Vanderplasschen W. (2014). The efficacy of case management with persons who have substance abuse problems: a three-level meta-analysis of outcomes. Journal of Consulting and Clinical Psychology, 82(4), 605–18.
8 Ryan JP, Victor BG, Moore A, Mowbray O, Perron BE. (2016). Recovery coaches and the stability of reunification for substance abusing families in child welfare. Children and Youth Services Review, 70, 357–63.