1. Introduction and Background
Mothers Making a Change (MMAC) is a public program serving mothers with a substance abuse problem in Cobb and Douglas counties in Georgia. MMAC came to our attention during a discussion with the Foster Care Unit Manager in the Social Services Section of the Division of Family and Children Services (DFCS) in Atlanta. The program was recommended for review due to the special and innovative nature of reunification services it provides.(1) For contextual information, an overview of state and county information is presented.
MMAC is a comprehensive substance abuse and reunification program in Cobb and Douglas counties that includes community outreach, early intervention, family preservation and support services, comprehensive outpatient treatment services, and residential services for women with substance abuse problems. The goal of the program is to provide comprehensive treatment for pregnant and postpartum substance abusing or chemically dependent women with young children, with a main focus to promote a drug-free environment and family stability. Services include residential substance abuse treatment, day treatment services for substance abuse, outpatient treatment, outreach services, and early intervention services.
Background information on state and county policy and service structure is helpful in understanding how MMAC fits into the continuum of reunification services in Cobb and Douglas counties. This report first outlines information on the child welfare system in the state and counties and key policies affecting child welfare and specifically reunification. Following this information, a detailed description of MMAC is presented to provide specifics on implementation, staffing, services, the relationship MMAC has with coordinating agencies, barriers encountered in delivering services, program success, and funding. The report ends with conclusions on why MMAC is unique in the continuum of reunification services provided in Cobb and Douglas counties in Georgia.
1.1 State and County Information
Cobb and Douglas counties are just outside of Atlanta, Georgia. Cobb County is suburban with approximately 566,000 people, while Douglas County is a smaller rural county currently going through a transition of sprawl and growth, with approximately 90,000 people.(2) In FY 1999, the two counties together investigated about 2,100 CPS cases (1,668 in Cobb; 526 in Douglas), and Cobb County placed 445 children in foster care while Douglas County placed about 150 children. The county-level information provided in this report focuses primarily on Cobb County.(3)
The State of Georgia child welfare system is state-supervised and county-administered. Policy for children in foster care is established at the state-level. Field Coordinators supervise County Directors, who oversee DFCS at the county level. The DFCS manages a unit that provides consultation and support to each county and provide mentors to train new DFCS supervisors. Within each county is a Child Protective Services (CPS) unit, a treatment unit (that manages cases other than long-term foster care cases), and a foster care unit that manages long-term, ongoing cases.
In 1996, Georgia passed a law instituting permanency time frames for children in foster care and emphasizing non-reunification plans for children in care for more than 12 months. This began the process of expediting children who had been lingering in the foster care system into the adoption process. In 1998, Georgia passed State Law 440 to bring the state into full compliance with Adoption and Safe Families (ASFA) provisions.
There is a trend in Georgia to move away from an emphasis on reunification, according to one state administrator we spoke to. Media attention on child fatalities across the state, and the perception that DFCS was not focusing sufficiently on child safety, has prompted an unfriendly climate for reunification. In addition, the new legislation limiting the time children spend in foster care gave emphasis to a shift from reunification to adoption. Between July 1998 and June 1999, approximately 2,100 children exited the Georgia child welfare system. Of that number, about 1,150 (55%) children were adopted, and of those adopted, 85 percent were adopted by their foster parents. Prior to the passage of the 1996 and ASFA laws, the state foster care system was heavily loaded with long-term cases waiting for reunification. However, despite the importance of expediting permanency for children under the new legislation, the state still uses reunification as a child's primary permanency option after placement.
According to the state administrator with whom we spoke, Georgia's 1996 legislation and ASFA prompted changes for DFCS. First, relatives now play a more prominent role in child welfare services since ASFA. When a child enters foster care, as part of the initial assessment, DFCS staff try to identify relatives to see if they can help meet the needs of the child(ren). In any given month, according to the state administrator, DFCS has approximately 2,100 children (19%) statewide placed with relatives, out of approximately 12,000 children in state custody. DFCS looks to relatives to provide permanent homes for children, either through a transfer of custody of the child, or by being foster parents with an ultimate goal of adoption. If a relative becomes a foster parent, he or she must complete the foster parent program (MAPP) in order to receive a per diem foster care payment. DFCS uses relatives for temporary custody situations but limits the amount of time for temporary custody before pursuing a permanent situation. In temporary custody cases, home studies are completed prior to placement, and kin receive TANF payments.(4)
Because of the emphasis on kin care, the state is examining options to provide more support for relatives. DFCS is hoping that legislation recently introduced in the state will provide financial help to kin caregivers. The legislation would allow kin who provide temporary custody to receive a payment equivalent to about 80 percent of the foster care board rate (more than the current TANF rate). Despite the emphasis by state and county administrators on the use of and increase in relative care, Cobb County DFCS reported only a few cases of permanent relative placement over the last few years.
ASFA has made DFCS look closely at its processes for permanency. DFCS has developed training for staff on enhanced family assessment early in a case. The state provides First Placement, Best Placement, a statewide public/private initiative(5), where counties work with a team of professionals to better identify the strengths and needs of families and children. As part of this initiative, DFCS has developed rules and procedures for assessment and follows a detailed assessment system for families. Professionals, such as psychologists, are contracted from the private sector to do assessments on parents and children and take part in the multidisciplinary teams which meet to plan for the child and family. The state hopes that this process will result in better case plans. The state has also developed staff education on utilizing family conferencing. This training has taken place in all counties as of December 2000. Some counties have embraced the concept and done well with it, while others have chosen not to utilize the practice. The hope is that putting effort into the development of assessment and family conferencing practices across the state will show that effort put into the "front end" of a case will result in better outcomes for families on the "back end."
DFCS has begun to develop and closely examine concurrent planning. Its focus is on a clearer understanding of what it means to plan concurrently rather than sequentially. The state administrator told us that more training is needed with staff on this concept in terms of how to operationalize concurrent planning. Training is also needed for foster parents who play a role in the concurrent process. DFCS has a group of foster parents who are successfully working with birth parents, and this group is training other foster parents in the skills and importance of working with birth parents.
The state is also looking closely at reviewing reasonable efforts and compelling reasons for terminating parental rights (TPR). It is getting a clearer notion of what it means to provide compelling reasons to continue reunification efforts under ASFA. The state is becoming more skilled in determining when termination of rights is appropriate for each child and family.
Overall, the state administrator said that ASFA has helped DFCS realize that changes were needed in its permanency practices across the board regardless of whether the child is with a birth, foster, or adoptive family. Moreover, time limits have emphasized the importance of teaching case managers to think about what is best for each individual child rather than simply reacting to problems in a case.
The DFCS in Cobb County has a mission to "help families provide the care, protection and experiences essential to their well-being."(6) Permanency options for children in foster care are established by state policy, and include reunification, relative placement, TPR/adoption, and long-term foster care (for independent living services and emancipation). The primary goal of most children entering foster care in the county is reunification. A Cobb County Administrator reported that reunification is the primary objective and first consideration for every family and child who enter care.
DFCS is mandated to investigate all allegations of abuse and neglect against children 0 to 17 years of age. Calls come in to CPS through a phone intake system. From intake, cases go to a supervisor who determines if criteria establishing abuse and neglect are met or if it is a non-abuse/neglect case. DFCS uses a 23-category, validated risk assessment system that includes a written assessment form. If the assessment shows that the case is not abuse or neglect then the family is referred for privately provided services. Services for these cases are voluntary, and the county pays for a worker to make 10 visits to the family to resolve their issues. If the abuse and neglect criteria are met for a case, it is assigned. A face-to-face visit between a DFCS worker and the family will occur within 24 hours if the case deals with severe neglect or abuse (e.g., sexual abuse, severe physical abuse, child fearful at home) or will occur within 5 days for less severe cases.
DFCS has 30 days to investigate and reach a decision on substantiation. Cases needing services but no foster care placement are transferred to an ongoing unit. If the abuse and neglect are substantiated and the child is in need of removal, then the case will go to Family Court, and law enforcement may be called in for protective custody. If a child is removed from a home by a police officer and placed in a shelter or foster home, the child must appear before the Juvenile Court within 24 hours (or the next business day). The court hearing determines whether the child should remain in care; if not, the child is returned to the parent's custody, and DFCS has 30 days to file a petition for abuse and neglect and 60 days before the next hearing. At the 60-day hearing, the judge will review abuse and neglect evidence and decide whether the child should remain in the home or return to state custody. The judge also reviews a parent's alcohol and drug assessment and decides whether the family needs services, including substance abuse treatment (see the MMAC program description for more details on the referral process for clients in need of substance abuse treatment). If at the 24-hour hearing, the child remains in the custody of child welfare, DFCS has 5 days to file a petition for abuse and neglect and a follow-up hearing is scheduled within 10 days to determine services. Currently, substance abuse is the number one reason for child placement in Georgia.
Cobb County DFCS workers carry a caseload of approximately 40 children per worker. Workers do not provide direct services to families but act as case managers. Direct services to families are contracted out to private providers in the county or region.
Cobb County DFCS provides a variety of reunification services to families. The county is one of the seven demonstration sites for a state reunification initiative called First Placement, Best Placement. In this initiative, counties work with a team of professionals to better identify the strengths and needs of families, and to ensure that children are placed in the setting that best meets their particular needs, thereby decreasing the number of times a child changes placements and increasing stability for the child. The initiative also provides flexible spending of funds for concrete services and was reported by one county administrator to be the first time the county has had money to help families obtain furniture, pay bills, pay rent, and obtain deposits required to work toward their goals. The county also has the Homestead Program, which provides intensive in-home family preservation services to families.
In addition, there are three main programs in the county that specifically focus on treating parents and children with substance abuse problems (MMAC, Georgia Recovery, and MG Counseling). There is also a statewide program focused on the transition of reunification called The Prevention of Unnecessary Out-of-Home Placement program (PUP) which offers family preservation-type in-home services for CPS clients whose children are ready to return home, encouraging a smooth reunification transition. In hopes of increasing the number of visitations between parents and their children, there is a "Starting Over" program, run by St. Julian's in the county, providing extended evening and weekend morning hours to accommodate parent's work schedules and encourage visitation several times per week.(7)
According to the Cobb County Juvenile Court Presiding Judge, the county has increased the number of TPR actions primarily due to the backlog of foster care cases moved toward adoption. Moreover, Cobb County seems to do more TPR cases than other parts of the state. The court has gone through a significant amount of training since ASFA, and judges are writing orders to comply with ASFA requirements. The new state and federal regulations push the court to look at terminations sooner and to consider terminations for cases dealing with older children as well. The judge stated that he has become less tolerant of parents experiencing drug relapse and has been quicker to terminate parental rights in such cases. According to Georgia law, a parent having an uncontrollable substance abuse problem is grounds for TPR.
After a parent's rights are terminated, the state is required by law to look first for a family member or blood relative who might provide permanency for the child. The court can also order or recommend that mediation take place for decisionmaking about the child's placement. Mediation might be recommended when there are a number of family members who do not agree about the appropriate home for the child and do not particularly want to reveal details of private family matters in court. State mediators are used for the process, and mediation often speeds up decisions and allows the child to acquire permanency sooner. According to the judge, greater use of mediation is expected in the future.
2. Mothers Making A Change Program
Within the context of the Cobb County child welfare service system, MMAC is a program that provides comprehensive substance abuse services to women in the community. The MMAC program is operated under the Cobb and Douglas Counties Community Services Boards, a public agency established by law under the Georgia State Department of Human Resources, that primarily provides mental health, substance abuse, and mental retardation services in the community (i.e., adolescent counseling, family preventive services, men's substance abuse treatment) to the community. The Community Service Board is considered part of the state's mental health system and not within the CPS organizational arm of DHR.
MMAC was established in the early 1990s in response to an increase in the number of women delivering crack cocaine-addicted infants. There was a scarcity of substance abuse services in the area for women; in particular, there were limited services for women abusing substances and few places to house women with high-risk problems. The area lacked residential programs for substance abuse services, especially programs willing to take the risk of serving a pregnant woman and provide the additional maternal health services needed. At about the same time, there was a highly publicized court case in Cobb County involving the prosecution of a woman who delivered a cocaine-positive baby. The woman, in her defense, claimed there were no substance abuse treatment services for her and other women who were pregnant and had a drug addiction. As a result, Cobb County set up a Task Force, under the auspices of the Department of Public Health (DPH), to study the problem. The Task Force discovered that the DPH, DFCS, and CPS were serving the same families and addressing the same substance abuse problems. Focus groups were set up in the county to address the problems of women with substance abuse problems. It was determined that the county's "traditional" model used by child welfare and public health services to serve substance abusers was ineffective in addressing women's substance abuse problems, particularly for those women who were pregnant. In the end, it was decided that DPH and DFCS would collaborate to form services to address women's substance abuse in the county. In the summer of 1992, the idea for women's services was developed. By November 1992, the specific needs of both Cobb and Douglas counties were identified and MMAC was established.
Services were initiated in January 1993, and the program has evolved through a number of changes. Services originally included substance abuse services, counseling, and assessment. The focus was to deliver healthy babies to women at risk of substance abuse by providing street outreach and substance abuse treatment targeted to pregnant women and mothers who were at risk. The program worked closely with the Cobb DFCS Parent Education and Training program (PET), assisting the program with substance-abusing women having high dropout rates and incidents of child abuse and neglect. MMAC worked closely with PET and came onsite to provide substance abuse services for PET consumers. MMAC, co-located with DFCS PET program, also provided parent training and educational services to county clients.
In 1994, MMAC began focusing more attention and efforts on CPS cases. The program expanded services and began providing day treatment services to CPS clients. Women and their children received 6 hours of service per day including treatment for substance abuse, domestic abuse, women's issues, low self-esteem, anger management, rape issues, parenting, education, and child support. The program encountered confounding issues along the way, and changes in the program developed based on those issues. For example, when MMAC administrators realized that almost three-quarters of the women they served were homeless, and client homelessness was a major problem interfering with reunification, the program developed a residential component to the program so women and their children could live together while the mother received substance abuse treatment.
Today, MMAC is a comprehensive program that includes community outreach, early intervention, family preservation and support services, comprehensive outpatient treatment services, and residential services for women with substance abuse problems in Cobb and Douglas counties. The goal of the program has expanded from its inception in 1994 and includes providing comprehensive treatment for pregnant and postpartum substance abusing or chemically dependent women with young children, with a main focus to promote a drug-free environment and family stability.
MMAC's services are based on a non-threatening treatment model that is family centered, community based, and encompasses a holistic approach to treatment. MMAC recognizes that substance abuse is one of multiple family problems and addresses the addiction, as well as the education, health access, housing, and employment needs in a holistic fashion. Moreover, the program recognizes that to keep a parent and child together requires resolving the problems of the parent. Therefore, services are mother and family focused rather than child focused.
In addition to providing direct services to women, MMAC provides extended services to other public agencies and the courts. The program provides liaison services to DFCS including drug assessments, toxicology screening, panel review hearings, case reviews, as well as case plan consultation and recommendations on CPS cases. In addition, MMAC provides similar services to TANF offices. MMAC staff also provide liaison services to the Juvenile Court by appearing at hearings and making recommendations regarding child placement and service interventions and participates in staffings for high-risk clients at the county hospital. Evident from their many links to social service agencies and the juvenile courts, MMAC staff are perceived as experts among their peer agencies and have an excellent working relationship within the social agency and court communities.
Communication and collaboration between MMAC and DFCS staff run smoothly. This is supported by having a MMAC staff member stationed at the Cobb County DFCS division office for consultation and liaison services and a CPS staff member stationed at MMAC to work collaboratively on cases. Likewise, judges seem to have a good working relationship with MMAC and reported using the program frequently because they believe it works. In fact, despite our best efforts to find any antagonistic feelings in peer agencies and the community, we failed to find anyone less than impressed by MMAC staff and services.
2.1 Target Population, Eligibility and the Referral Process
The MMAC target population for services is low-income, substance-abusing, pregnant or postpartum women with young children, who are residents of Cobb or Douglas counties. The population primarily consists of low-income, single females, with a long history of substance abuse. Women served are generally in their early 20s. The ethnic makeup of clients varies but seems to be about 50 percent Caucasian and 50 percent ethnic minority. The majority of children served by the program are under the age of 5. The director of women's services for the program commented on some recent changes in population characteristics. She reported serving a population of adult women who are much younger than in past years and also reported serving a higher percentage of Hispanics currently than in the past.
MMAC referral criteria include the following: any woman who is pregnant or within 12 months postpartum and has young children if she meets the following criteria: 1) self- reports of any drug or alcohol use, 2) positive toxicological screening of the mother, or 3) positive toxicological screening of the infant shortly after birth. Most clients must be TANF eligible if not already on TANF (due to funding requirements - see the funding section for details) and also must have and maintain rights to their children or be eligible to petition for rights to their children, even if they do not currently have custody. MMAC will work with women going through the TPR process with one child, as long as the mother still has rights to a second child. At the time of referral, all clients must sign a release statement and consent form for services. If women referred do not meet these criteria, they are referred to basic outpatient services provided by the county.
MMAC averages about 70-80 clients per month, including an average of 6 pregnant clients. Referrals primarily come from CPS, which on average refers approximately 50-60 clients per month, or 75 percent of monthly referrals, for screening assessments and treatment. Referrals can also come from hospitals, the courts, the criminal justice system, and other social service agencies such as DPH. Referrals can be voluntary or mandatory, and there is some preference for mandatory cases because this gives MMAC a little more leverage with the client. Currently, cases are 50 percent reunification clients and 50 percent family preservation clients. Most of the other cases referred from DFCS come from the TANF employment program.
Most cases from CPS are from investigations (intake), but cases may also come from ongoing and foster care cases. For a CPS referral, a DFCS caseworker reviews the intake or ongoing case with his/her supervisor, and upon determination that MMAC would be appropriate for the client, the worker faxes a referral to MMAC for consideration. The MMAC director of women's services reports that the referral process with CPS is relatively simple. Prior to a decision to refer, DFCS can also call and request a client screening. With an MMAC administrator on site at DFCS, client screenings or drug testing can be done on the day a client is in the office during investigation. This way, clients do not have a chance to hide their problems prior to testing. MMAC then provides a recommendation to DFCS on placement and treatment based on the mother's level of commitment to change.
Referrals from the hospital can come to the program prior to CPS involvement with a call from the hospital regarding a patient at risk and meeting the criteria for the program. There is no existing CPS law to intervene during pregnancy. Women who are suspected of drug use or test positive for drugs prior to delivery are immediately eligible for the MMAC program, and in fact, state law requires that priority for the program be given to pregnant women. The implicit threat to the mother is that the child will be removed if the baby is born drug-positive. If successful in the program, the family may never become a DFCS case. However, if babies in the county are delivered at the hospital with a positive toxicology, CPS policy is to remove the child from the parent, the case is mandated to go to court, and MMAC may become involved at that point.
The juvenile court refers cases to MMAC by a court-order for MMAC reunification services. However, despite a court order recommending services (especially residential placement), MMAC might decide after assessment that the client is not appropriate and recommend an alternate treatment plan. This decision is based on client assessment, need, risk of the family, and when the client does not feel she can abide by the structure of the residential facility. Referrals from criminal justice generally come from the parole office staff. If a female parolee has a severe problem with relapse or parole violation related to substance abuse, the parole chief will refer to MMAC. This is done at an administrative parole hearing and will include a directive remanding the parolee to MMAC or jail if she does not comply.
Criminal justice also occasionally uses MMAC as part of a parole plan for inmates planning to leave the correction system who are at high risk and have no home. The parole office chief in Douglas County appreciates MMAC for its therapeutic approach in cases. Clients can also be returned to jail or enrolled in a program run by parole, but the Chief felt that the corrections staff tended to be too authoritative and not as therapeutic in its services. Referrals from other sources are few and can generally be made informally.
With all the multiple roles of MMAC staff (as placement/treatment consultant, drug screeners, liaisons, etc.) and their work with many agencies, staff members often become aware of probable clients prior to any referral for services, and in some cases they actually participate in the pre-referral screening process. The result is a uniquely collaborative and less formal referral process between MMAC and other public agencies.
2.2 Staffing and Services
MMAC employs approximately 19 full- and part-time staff in both the Cobb County and Douglas facilities. MMAC staff interviewed seemed well educated with a considerable number of years of experience in their areas of work, although some had worked with MMAC for less than a year.(8) Staff working in the residential facilities and the program nurse are available 7 days per week, 24 hours per day if needed. Overall, staff seem very motivated, and dedicated to the success of clients. In addition to program staff, mothers who have completed the program come back and volunteer their time to assist with current clients. These women babysit children and attend sessions for clients and discuss their addiction and treatment.
Upon referral, MMAC's goal is to get women into the program for service within 12 to 24 hours. Once the client arrives, staff begin a lengthy orientation and comprehensive assessment performed by the program coordinator and other program staff. This assessment, done for every client, can take up to 2 hours and involves an evaluation that includes a complete physical and medical, psychosocial and substance abuse assessment using the Addiction Severity Index (female ASI) of psychosocial status. Nearly 100 percent of the women entering the program meet the American Society of Addiction Medicine patient placement criteria for treatment of substance abuse disorders. After the assessment process, a decision is made to determine the appropriate level of services needed -- either residential, day treatment, or outpatient services. The assessment team considers the level of treatment based on whether the client is an intensive addict who needs to work toward recognition of her problem and getting clean of drugs (recommended for residential treatment with no passes), a serious drug user who recognizes the problem and wants to cooperate with treatment (recommended for residential treatment with fewer restrictions), or an occasional drug user (generally recommended for the day treatment program). The assessment should be complete, and a meeting involving the client and family (if possible) takes place after 48 hours from the time of intake to the program. In the family meeting, the program coordinator, client, and family members discuss the client's placement in the program.
In addition to the general assessment, the coordinator of nursing services also provides a comprehensive health assessment and examination to all clients including a TB skin test, urinalysis for drug screening, and, with the client's consent, tests for syphilis, HIV, a Pap smear, and mammogram (these services are optional). Pregnant mothers are assessed for pre-natal care. If the drug screening is positive, and they determine that the client needs to be treated for detoxification, this takes priority over all other needs, especially if the woman is pregnant. The top priority at the program is that women deliver healthy and drug-free babies in order to deter CPS placement of the child once he or she is born. If detoxification is required, they quickly refer the client to the Detoxification Crisis Stabilization Center, where doctors, nurses, and psychiatrists provide 24-hour-a-day, 7-day-per-week services and support. Further referrals for neurologists or internists can be made if the client has special health problems such as seizures, depression, or diabetes. The nurse told us she places major emphasis on providing medical services that expedite reunification of families. She contributes to the assessment team that makes recommendations to DFCS and the court on the extent of recovery and health compliance of a client and whether reunification is possible.
Children entering the program with their parent also receive a health assessment to determine the status of immunizations and any special health needs. If any child lacks immunizations, he or she is referred to receive them. A client's child who is not residing in the program may be referred for health services to MMAC's Child and Adolescent Program. It is often the case that while the child may have health coverage, the mother may not due to unemployment, homelessness, or drug addiction. Therefore, MMAC assists the client in completing a form to qualify for Medicaid or other health coverage at the indigent clinic.
The nurse also is responsible for coordinating transportation services for clients to ensure that medical appointments are kept and visits the residential facilities at least once a week. She makes daily sick calls as needed Monday through Friday and is on call 24 hours a day, 7 days a week for emergencies. The nurse is also careful to note any medical needs in the discharge plans for a client.
Treatment and case plans are written by a multidisciplinary team based on their assessments of the client. The team includes the case manager, the client, the site supervisor, nurse, and other interested agencies. A client is informed about the shortened timetables under ASFA and that if she does not recover within that timeline, parental rights might be terminated. Concurrent planning is determined by DFCS, so it is possible that the foster care worker has a concurrent plan for the family. However, concurrent planning is not done at MMAC. While case management for the family remains with DFCS, DFCS often uses the MMAC case plan to assist in writing its plan due to the richness of information provided by MMAC. MMAC staff work closely with DFCS workers to create reasonable and realistic case planning for a family, although there may be differences of opinion on these points. If there are major differences between established DFCS and MMAC plans, MMAC and DFCS staff meet to discuss and resolve differences to establish realistic and attainable goals for a client. Case updates by MMAC to DFCS are done at the time of regularly scheduled case reviews. Otherwise, communication is open, and DFCS and MMAC staff may discuss a case at any time, on a case-by-case basis.
MMAC provides a variety of services through outpatient treatment, residential treatment, day treatment, health care services, and child care. The most common presenting problems of clients entering the MMAC are substance abuse, homelessness, lack of resources, and limited family support. The most commonly provided services are substance abuse treatment and housing. Since MMAC is considered a mental health program, it falls under the authority of a state HMO-type entity that dictates the length of time and type of treatment for state mental health and substance abuse patients. Although there was no indication by the director of women's services that this authority caused problems in serving clients, she did say that the state is in the process of changing the women's treatment program authorization protocol for substance abuse services, to give more flexibility for treatment in the MMAC program. Services are generally specified for a minimum of 6 months, and most clients receive services for 12-15 months, although the program may serve a client for up to 2 years.(9) MMAC believes that women who are able to stay longer in the program have more success in substance abuse treatment, which results in successful reunifications. High-risk families are served through a Family Preservation/Support Grant under the Adoption and Safe Families Act.
Residential Substance Abuse Treatment
The hallmark of the MMAC program is its residential substance abuse treatment services. The program runs two facilities, one each in Cobb and Douglas counties. The location in Douglas County is a seven-unit, gated apartment complex that was purchased through grant monies. The Cobb County facility consists of apartments rented by the program within an existing complex. Staff at both complexes are located on site 24 hour per day, 7 days per week to intervene, monitor, refer, and handle emergencies. There is also a doctor on call after hours for any mental health or substance abuse crises after hours. Each program has a nurse assigned who is also available 24 hours, 7 days per week. The residential program can house a maximum of 35 families, depending on the number of children in each family. The Cobb County program is more intensive in nature, and most services are on site. Stays in this location are from 6 to 12 months. After a successful stay in the Cobb County location, clients may be transferred to the Douglas facility, where their stay can be longer if the family is homeless. Clients at the Douglas facility stay an average of 9 months but can stay up to 2 years. The Douglas County program sends clients to the their day program for services.
The residential program is coordinated to provide services in three phases. The first phase (90 days of services at the Cobb County facility), known as the Ready to Work Program, focuses on overcoming the client's severe addiction. This first phase of intensive services to conquer addiction involves counselors being straight with clients about the realities of addiction and providing "tough love" guidance through spirituality and a 12 step drug recovery program. The first 60 days deal primarily with the client's denial behavior and teaching skills to enhance the development of recovery tools.
The second phase of the residential program lasts 4 to 6 months and involves substance abuse treatment, relapse prevention, self development, and skills building. This phase also focuses on family reunification. Services provided are primarily targeted toward enhancing life skills and include an array of substance abuse counseling, anger management, child development, parental skills, nutrition, and education, all provided at the Cobb County MMAC offices for outpatient services. Transportation for services, appointments for doctors and nurses, probation appointments, and court hearings are provided, and a random urine drug screening is conducted to ensure the client remains drug-free throughout treatment. Mothers receive information on the effects of substance abuse on babies. They view videos about babies born to drug-addicted mothers and learn about the different behavior these children may exhibit, such as withdrawal and passiveness. This information also illustrates to the mothers that many of the babies are able to outgrow their addiction and become healthy children, despite the fact that some may suffer lifetime emotional or neurological disorders. During this phase of treatment, the clients also take part in a family setting with other mothers and their children that provides a sense of belonging and support and prepares mothers to reunify with their children. Community activities include arts and crafts, field trips, monthly potluck meals, and "I Can" award celebrations to acknowledge client progress. Clients are also required to prepare personal journals and asked to complete at least three pages per week in the journal. Assistance and tutoring are available for those who need help reading or writing.
As stated earlier, the primary goal of the second phase is to reunify clients with their children and establish skills to preserve the family. Most women in the program are reunified with their children during this phase. MMAC then takes the responsibility of child care and transporting the child to school and health appointments. It is important to point out that once a child is reunified in the residential program with his/her parent, the parent acquires physical custody of the child, with the state maintaining legal custody of the child. The uniqueness in MMAC is that the parent and child are reunified while the mother is in residential treatment. For women not reunified, children are permitted to visit on weekends and overnight. MMAC understands how stressful visitation and the process of reunification can be on a mother. The program facilitates a total of 12-17 visitations per month for all clients and their children. Visitation is conducted as a gradual process and usually begins in hourly sessions, then overnight visits, 2-day visits, and so on. For women with multiple children, MMAC increases the number of children per visitation gradually as well. Clients also may be eligible for passes during the second phase of the program and are able to leave the facility for shopping or visits with relatives but must report back to their residence by a designated time.
Educational services are provided through MMAC's Education Program, run by one full-time staffer. The curriculum is designed as a self-help program, tailored for the individual to progress at her own pace. This program is detailed later under Day Treatment Services.
The third and final phase of the residential program consists of 6 months of after care that focus on support to avoid or minimize substance abuse relapses and finding employment for the client. The after-care phase involves very close monitoring of the parent's interaction with her children by MMAC's case manager and continued drug screenings, family enhancing, and educational and job activities. Transportation is provided for court or probation appointments, health care, employment training, and to work.
Day Treatment Services
The non-residential, day treatment program provides a variety of services to women and their families from 9 a.m. to 2 p.m., including substance abuse treatment, meals, transportation, case management, day care, parenting classes, health care and mental health services, substance abuse relapse prevention, education and GED courses, and employment services. Services are provided at the Cobb County offices. Individualized services can include therapy (individual and group); support groups; stress management; budgeting; team management; family education groups; exercise, self-esteem, anger, and domestic violence services; health education; nutrition; personal hygiene; and HIV education.
Educational services are provided on a 4-day class schedule. Monday and Wednesday are devoted to educational enrichment; Tuesday and Thursday focus on activities necessary to complete the GED; Friday is devoted to light educational games and fun learning activities. Clients' assignments are graded and homework assignments are given in GED-level coursework. The program is entitled "Reach and Teach" and is broken down into two separate components. The Reach component serves between 8 and 12 clients at one time, per group, and focuses on motivation, self-esteem and maintaining attention span. Incentives are provided to motivate students and self-esteem is cultivated by having students tutor their peers. Attention span activities include required-reading articles posted on a community bulletin board and reading articles from newspapers. Clients are also trained to use computers for word-processing and Internet access including how to use search engines. Students also volunteer for various activities.
The Teach component of the program has three tracks: 1) GED preparation, 2) Enrichment, and 3) Advanced. The GED preparation track includes instruction in language, math, spelling, algebra, and computer skills. Students practice on old GED tests and preparatory tests. Homework is assigned. To date, 99 percent of clients in this track have achieved their GEDs. The Enrichment track is for those clients who already have a high school diploma and want to learn additional skills or enhance existing skills. They receive instruction in reading, English, math, typing and word processing, as well as Internet skills. Assignments are graded. The Advanced track is for the few clients who have some college education or a college degree. The program utilizes students as peer tutors and provides instruction on topics of personal interest. One recent student learned to design a web page and received an award for her work. As part of the educational program, students also perform community services at senior center facilities, children's hospitals, or homeless shelters. It is interesting to note that around 30 former clients at MMAC facilities are currently employed with MMAC training and assistance, or with the County Community Service Board.
In addition to coursework, students are actively involved in planning "We Can" events to honor and celebrate their accomplishments. They plan celebrations such as luncheons and award ceremonies. Each has a theme. At the award ceremonies, students are recognized for various achievements, and a "Student of the Quarter" is chosen. The women find these activities exciting and look forward to the opportunity to have parents, children, and relatives attend. At the celebration events, themes dealing with cultural diversity are the focus, and activities have included a fashion show where clients wear apparel from different countries to a food court where clients make dishes from various parts of the world and explain the culture and food.
The educational program also sponsors general enrichment activities for clients during the week and weekends. Clients are encouraged to interact with their children at the onsite child care, attend substance abuse recovery meetings, and got to the library or purchase a book.
Outpatient Services
Outpatient services provide treatment for clients who meet the diagnostic criteria for substance-related disorder as defined by the DSM-IV. MMAC has two levels of outpatient services -- Level I, which includes assessment and individual, group, and family support services for less than 6 hours weekly, and Level II, which is more intensive and provides the same services for 9 or more hours per week. The length of services is based on individual needs, the client's treatment plan, and needed support. Services include individual therapy, group therapy, psychiatric assessment, medication monitoring, family therapy/support, nursing assessment, and family education/support. These services are geared toward women with children in foster care placement or at risk of TPR because they are most likely to enter the residential treatment program.
Outreach Services
MMAC also provides outreach services in the community. Outreach is an extension of MMAC services to the community. In recognition that many cultural groups, communities, and specialized populations will not readily seek a treatment facility, MMAC has staff who have established themselves in the community. Services are provided to pregnant women or women with young children, women with numerous hospital admissions, and women in shelters and other community agencies. MMAC hopes to accomplish education in the community, to encourage all cultural groups to enter services, and reduce and minimize barriers to treatment for groups and communities. This service is provided on a continuous basis 7 days a week and when there is a crisis that requires assistance.
Also a part of outreach services is providing substance abuse education to the community when requested. This may include speakers and participation in local health fairs to promote and increase awareness of substance abuse and related issues. Additionally, MMAC staff collaborate with community agencies to help enhance and coordinate the quality of care provided to the community.
Early Intervention Services
MMAC began providing early intervention services in June 2000. These services are provided to women at risk of developing substance related problems and are designed to explore and address risk factors that appear to be related to substance abuse and teach the client how to recognize harmful consequences of inappropriate substance use. The program is psycho-educational based and consists of components on the medical aspects of addiction, the dynamics of addiction, cross addiction, and coping skills. Services are prepaid at a cost of $125, which includes the group meetings and urine drug screenings. Appropriate clients include those referred to MMAC for assessment where the extent of abuse or addiction is unknown, those with a suspected history of substance use but in denial of active substance use, and cases in which assessment staff are unable to aptly diagnose under the DSM-IV guidelines.
Other Services
Health services are an important part of the comprehensive services provided by MMAC, with help and coordination from the DPH. Health services include basic health screening, family planning services, an early intervention program for infants in a high-risk population for developmental delay, a WIC program that provides food and nutritional counseling, and prenatal and postnatal care.
Child care services are also provided to clients and their families on site while the client attends treatment services. The availability of child care on site reduces a major barrier to treatment and reunification and provides a supervised site for the mother to develop and enhance her parenting skills.
Additional services that MMAC generally provides to clients include family education, community education and prevention services, and Beginning Alcohol and Addiction Basic Education Studies (BABES) for children of dysfunctional and substance-abusing families.
2.3 Barriers to Reunification
The director of women's services for MMAC reports that finding good, affordable, and safe permanent housing for families is the most difficult barrier encountered to reunification. Located outside Atlanta, Cobb County is a middle-class suburban area with a lack of affordable housing. Many clients entering the program are homeless, and given the high cost of rent, women fear having to go back to the same unsafe environments they lived in prior to their substance abuse recovery and reunification. Wait lists for section 8 housing in the county are very long. Child care for clients leaving the program can also be a problem, however many client's child care is provided through TANF services. The strongest predictor to re-entry into the CPS system for a family is lack of community and family support. MMAC staff hope to have instilled self-esteem and a sense of community belonging to clients served in its program. In addition, the program's coordination with services in the community helps to provide resources for clients leaving the program.
The decision of whether to make a recommendation for reunification is based on an assessment made by a multi-member team of MMAC staff. Members of the team include the residential site coordinator, site supervisor, clinical staff personnel, a physician, the program nurse, the child care staff, and a CPS worker. Members come together to assess and work up a proposal for CPS review, then the group of MMAC staff and the CPS worker come together to develop a plan. Once again, the close relationship that MMAC staff have with DFCS workers plays a key role in coordination of a decision on reunification. Reunification recommendations are based on the assessment of a client's compliance with treatment and willingness to work toward case goals, random urine screening results, how long the parent has been clean, observed interaction with the children, and how well the parent is likely to cope with reunification once it takes place. If the client is placed in residential treatment, staff also consider the client's observance of facility rules. After all these factors are considered and if the recommendation is made for reunification, MMAC staff will go to court and recommend reunification and support the client in these efforts. CPS, with MMAC input, makes the final decision as to when a case will close. However, MMAC may maintain contact and support once a case is closed.
2.4 Relationship with Juvenile Court
The court takes a very active role in determining the length and scope of services a MMAC client will receive. In addition, it can also order certain conditions of treatment, such as leaving a residential facility for visits or walks. MMAC may appear in court but always on behalf of the parent. If a parent (former client) has relapsed or not succeeded in her program, state and federal confidentiality laws pertaining to mental health services required for drug treatment restrict staff's ability to testify on grounds for TPR. In TPR cases, MMAC will comply with a subpoena, and the director will appear with a copy of the case record, but staff will not testify in court against a client. MMAC ensures that appropriate releases are signed that meet federal confidentiality law requirements.
Judges from both the Douglas and Cobb counties Juvenile Courts had great praise for MMAC staff and services. One judge reported that the MMAC program works because it is comprehensive. It addresses substance abuse problems, job readiness skills, GED, employability, parenting skills, and housing needs. It allows mothers to live where they are not dependent on someone who has the ability and probability of using and abusing the children. The judge uses the MMAC program frequently and felt that MMAC had a much higher success rate than other drug treatment programs, because other programs are not adequate to handle this population, specifically lacking services for women and their families.(10)
MMAC fills the important gaps for treatment, especially transportation, which is important in a rural county.
The Cobb County judge reported that he used MMAC because it was affordable and easily accessible to families. He also mentioned that he frequently uses MMAC staff for assessment of substance abuse.
2.5 Funding of Services
Funding for MMAC services comes from two main sources -- state Grant in Aid Block Grant monies (30%) and TANF funds (70%). The grant, managed by the state office, includes Safe and Stable Families monies used to fund reunification in the state. The TANF definition was recently broadened to "needy families," and clients must be receiving one DFCS service. Cases are 50 percent reunification clients and 50 percent family preservation clients. According to the director of women's services 49 of 90 (54%) DFCS referrals each month are CPS cases. Most of the other cases referred from DFCS come from the TANF employment program.
In addition to block grant and TANF funding, MMAC has received federal and state family preservation and support monies for about 4 years, and the program also received a minimum $75,000 state grant for family preservation services. These funds are utilized for housing, case management, or 6-month follow-up services for DFCS families and support dollars for other non-DFCS families served. It receives limited money from Medicaid reimbursement and about 5 percent from client fees.
3. Conclusions
A great deal stands out about the MMAC program and the services it offers. First, the fact that MMAC is part of the mental health system and not the CPS system (although they are both under the auspices of the DHR) seems to be an important factor, giving a sense of autonomy within the arena of child welfare and which also provides MMAC with access to resources not typically CPS. The result is a major benefit to clients who have the advantage of a service provider that can draw from a wealth of resources from mental health and child welfare. MMAC also benefits from being under the administration of DHR, which provides MMAC an advantage in its collaboration with other DHR branches like TANF and CPS. This seems to make communication, planning, and cooperation in setting service priorities much easier for MMAC staff.
MMAC also seems unique in the thoroughness of the design and development of its programs. The history of the program (i.e., the task force and focus groups utilized) demonstrates that a great deal of thought and planning went into the development and planning of the program. Moreover, each program component has a clear and defined population and goals, and the services strongly emphasize every detail of the client's needs. Perhaps, since MMAC is a substance abuse program coming from a medical/psychological perspective, the program takes a methodical and detailed approach to development and planning of services. Of course, this type of planning, development, and service cannot take place without strong leadership, and the current director of women's services seems to be responsible for the leadership that defines MMAC. She was hired at the beginning of program development, has developed a great deal of the criteria for the program herself, and has since been at the forefront of program implementation. Credit must also be given to DHR and other decision makers at the public agency level who were a part of the planning and development of this program.
MMAC attracted our attention due to the mother and family focus of the program, distinct from the trend toward child-focused and child-protection focused reunification services. MMAC recognizes that keeping a parent and child together requires resolving the problems of the parent. As a mental health program, MMAC sees the family issue from a "parent mental health problem" approach, rather than a "child protection" approach. Therefore, the goal is to solve the parental problem to preserve the family, not simply to protect the child from the parent.
The intensive and comprehensive nature of services provided by MMAC also is unique. The blending of substance abuse services that address addiction and social services that address the social and economic needs of clients makes well-rounded treatment for mothers and their children. MMAC staff spend a great deal of time providing intensive, hands-on attention and services to clients, particularly those in the residential treatment program. Moreover, MMAC perceives a parent's substance abuse problem as one of multiple family problems and takes the time to address each problem individually and completely. The holistic approach to services makes the services offered quite unique. Every facet of the client's needs seems to have been carefully thought out and met through services. Services are carefully structured to resolve not only addiction but build self-esteem, establish community and support, build parenting skills and restructure the child/parent relationship. It is evident that the staff of the program are dedicated and committed to delivering both complete mental health services and social services, supporting clients in their goals, and believe very strongly in family reunification. In the words of one client,
"I had the tools [to complete drug treatment] but I didn't know what to do with them. All they told me was to go to meetings and read your books, but nobody told me what to do if I ran into old friends or what to do for stress management. MMAC did all this and much more, every single day."(11)
Finally, MMAC appears to have a unique relationship with the courts and peer agencies it works with. Our discussions with DFCS, criminal justice, and court personnel clearly showed that MMAC administrators and staff have established themselves as experts in the field of substance abuse treatment and are valued resources on the issue within the child welfare and judicial community. The liaison relationships and communication routines MMAC staff have established with these agencies have been an enormous benefit to the courts and agencies, to the community as a whole, and to the success of MMAC programs and services.
Endnotes
1. The program was visited in November 2000.
2. Georgia Department of Human Resources, Division of Family and Children Services, Evaluation and Reporting Section, as cited from 1998 U.S. Census Bureau population projects.
3. Our county-level phone and personal interview discussions took place with DFCS officials from Cobb County, therefore the county-level background information in this report will focus on Cobb County although much of the information is likely relevant to Douglas County as well.
4. As of April 2001, relatives willing to assume permanent custody until the child's 18th birthday could receive a relative subsidy. The subsidy is $10 per day and is paid for using TANF funds. Children in this arrangement will have their plans reviewed by the counties each year, and the court will review the custody status every 3 years.
5. First Placement, Best Placement began as an initiative in 7 demonstrations sites across the state (including Cobb County). As of February 2000, the initiative is statewide.
6. Cobb County Department of Family and Children Services. Philosophy and Values. Retrieved January 10, 2000, from the World Wide Web: www.cobbdfcs.state.ga.us/
7. The state requires visitation twice a month between parent and child. One judge we spoke to felt this was insufficient to foster reunification.
8. Interviews were conducted with the following MMAC staff: Director of Women's Services, Program Coordinator, Site Supervisor for Residential Programs, Coordinator for the Education Program, a case manager, and Coordinator of Nursing Services.
9. Clients served past the ASFA timelines are exceptions granted by the court. If the client and child are placed together in a residential program they are considered reunified by the county.
10. Presently, MMAC is not tracking recidivism rates of children that leave their program; however it is beginning to do 6 month follow-up tracking on families that exit the program. Currently, DFCS reports the recidivism rate to be 10-15 percent for children in the program.
11. Atlanta Journal/Atlanta Constitution. "Forsaking Drugs, Embracing Life." Jan. 30, 1997, p. C8.