In fiscal years 1993-95, the Center for Substance Abuse Treatment (CSAT) awarded 50 grants under its Residential Women and Children (RWC) and Pregnant and Postpartum (PPW) programs. These 5-to-6 year grants provided funding for development of facilities providing long-term (6-12 month) residential substance abuse treatment for pregnant and postpartum women with children under one year old (through PPW) or women with children over one year of age (through RWC). Funded projects were required to provide:

• gender-specific and culturally appropriate treatment services;
  
  
• on-site residential care for clients' infants or young children, to enable clients to maintain supervised parenting relationships throughout their treatment; and
  
  
• comprehensive services for both clients and their infants/children - substance abuse treatment, prenatal, pediatric, medical, mental health, vocational, parenting, legal, nursery/preschool, transportation, etc.

CSAT initiated these demonstration programs to expand existing capacities for residential treatment of pregnant and parenting women with serious substance abuse problems, and particularly low income and minority women for whom access to appropriate treatment was especially limited. A second CSAT purpose was to develop model programs that could provide a basis for evaluation of the effectiveness of comprehensive, long-term residential treatment for pregnant and parenting women.

The 50 RWC/PPW projects were diverse in many ways. They were dispersed across all regions of the country (list attached). Many were located in large or mid-size urban areas; others were located on Indian reservations or in other rural areas. Some targeted clients from specific racial/ethnic groups, while others served ethnically diverse clienteles. Some targeted pregnant and postpartum women, while others focused on women with older children. Projects also differed in admissions criteria, planned length of stay, treatment philosophy or approach, and types of featured ancillary and aftercare services.

In addition to the 50 individual project grants, CSAT funded a separate study of the effectiveness of the interventions provided through the RWC/PPW program. The contract for this cross-site study was awarded to Caliber Associates of Fairfax, Virginia. This cross-site study collected extensive data about providers' treatment approaches and about their clients' characteristics and outcomes. Client outcomes were assessed by examining pre-post change, comparing information about client activities and experiences in the 6 months after discharge to similar information about her situation before treatment began. Cross-site data were collected from fall 1996 to summer 2001.

This paper highlights cross-site study findings on four important topics:

• the RWC/PPW projects and clients;
  
  
• pregnancy outcomes, including estimates of program impacts in reducing harm to infants;
  
  
• client outcomes, as indicated by pre-treatment vs. post-treatment differences in areas such as drug use, criminal involvement, self-sufficiency, and parenting status; and
  
  
• project outcomes, as indicated by their success in obtaining funding support for continued operation once the CSAT demonstration grant ended.

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Projects. Most of the 50 RWC/PPW projects were small: 70% had 10-20 beds; only 5% had more than 30 beds. Once they became operational, most projects ran at close to full capacity: two-thirds (66%) had daily bed use rates of 80 percent or higher.

About half of the projects targeted pregnant or postpartum women, with the remainder targeting women with children over one year of age. About half of the projects had a planned length of stay of 6 months; the rest had a planned length of stay of 12 months. Some projects targeted specific racial/ethnic groups: 30% targeted African Americans, 22% Latinas, and 14% Native Americans or Alaskan Natives.

Mental health problems and abuse victimization are widespread among women with histories of chronic substance abuse, and some RWC/PPW projects actively targeted such clients: 30% targeted dually diagnosed women with both substance abuse and mental health problems, and 16% targeted abused women. Some projects (28%) targeted women involved with the criminal justice system. Projects generally accepted women without regard to their particular drug(s) of addiction.

Clients. The cross-site study assembled data for 5,110 women who were admitted to RWC/PPW projects. These women are distinctive in many ways:

• Age. The median age at admission was 30.3. Few clients were younger than 21 (4%).
  
  
• Race/ethnicity. A majority of the clients were members of targeted racial/ethnic minority groups: African-Americans (46%), Hispanics/Latinas (10%), or Native Americans or Alaskan Natives (9%); 30% were non-Hispanic whites, and the remaining 5% were of other, multiple, or unknown race/ethnicity.
  
  
• Partner status. Over half of the clients (65%) lived with a spouse or domestic partner at some time during the 12 months prior to treatment entry.
  
  
• Pregnancy/parenting status. 27% of RWC/PPW clients were pregnant at treatment entry; an additional 26% were postpartum in that they brought an infant under 1 year of age into treatment; the remaining 47% were parents of older children. Most women brought at least one child into treatment; however, because of legal or other obstacles, 15% did not have any of their children admitted into treatment. Among women who brought children into treatment, the average was 2.0 children per client; 35% of the children were infants under 1 year of age; 36% were age 1-4, 20% were age 5-8, and the remaining 9% were age 9 or older.
  
  
• Alcohol and drug abuse history. Nearly all RWC/PPW clients (96%) were chronic substance abusers in that they had used alcohol or drugs for at least 5 years prior to this treatment episode. Clients' mean number of years of substance use was 15.3. Most clients (75%) had prior substance abuse treatment episodes, and 44% had previously received residential treatment. The primary substances of abuse were most often crack (46%), alcohol (15%), powder cocaine (12%), or heroin (7%); all other substances were cited by fewer than 7% of clients as being their primary problem.
  
  
• Treatment motivation. At treatment entry, most clients had high scores on measures of motivation for treatment. On a series of 7-point scales of treatment readiness, for example, clients' average score was 6.0.
  
  
• Related problems. Most clients brought multiple problems with them into treatment in addition to their chemical dependency. Other common problems included: unemployment (92%), lack of high school diploma or GED (51%), physical disorders (64%), mental health disorders (50%), history of abuse by parents (57%) or by others (76%), current problems with the criminal justice system (50%), current or past problems with Child Protective Services agencies (61%), problems with alcohol- or drug-involved parents (56%) or spouse/partner (42%), etc. On an inventory of 14 problem areas, including the above, clients' average number of problems at treatment entry was 7.4.

In summary, it is easy to see why RWC/PPW clients were referred for long-term residential substance abuse treatment. Most had long-standing problems of compulsive, out-of-control substance abuse, usually coupled with other significant problems -- histories of physical/sexual abuse victimization, poor educational/vocational preparation, and significant health or mental health problems, among other major life crises.