Sobriety Treatment and Recovery Teams (START)

About This Program

Target Population: Families with at least one child under 6 years of age who are in the child welfare system and have a parent whose substance use is determined to be a primary child safety risk factor

For children/adolescents ages: 0 – 5

For parents/caregivers of children ages: 0 – 5

Program Overview

START is an intensive child welfare program for families with substance use and child abuse or neglect built on cross-system collaboration and integrated service delivery with substance use disorder (SUD) treatment services. START pairs child welfare workers trained in family engagement with family mentors (i.e., peer support employees in long-term recovery) using a system-of-care and shared decision-making approach with families, treatment providers, and the courts. Essential elements of the model include quick entry into START and rapid access to intensive SUD treatment services to safely maintain child placement in the home, when possible. Each START child welfare worker-mentor dyad has a capped caseload, allowing the team to work intensively with families, engage them in individualized wraparound services, and identify natural supports with goals of child safety, permanency, and parental recovery and capacity. Strategies in both child welfare and SUD Treatment are designed to be trauma-responsive.

Program Goals

The goals of Sobriety Treatment and Recovery Teams (START) are:

  • Ensure child safety
  • Reduce entry into out-of-home care, keeping children in the home with the parents when safe and possible
  • Achieve child permanency within the Adoptions and Safe Families Act (ASFA) timeframes, preferably with one or both parents or, if that is not possible, with a relative
  • Achieve parental sobriety in time to meet ASFA permanency timeframes
  • Improve parental capacity to care for children and to engage in essential life tasks
  • Reduce repeat child maltreatment and re-entry into out-of-home care
  • Expand behavioral health system quality-of-care and service capacity as needed to effectively serve families with parental substance use and child maltreatment issues
  • Improve collaboration to transform the system of service delivery between child welfare and SUD/mental health treatment providers

Essential Components

The essential components of Sobriety Treatment and Recovery Teams (START) include:

  • Structural Fidelity to the START Model:
    • Administered and housed within a child welfare agency
    • Built upon a collaborative governance structure including:
      • Behavioral health treatment providers supported by:
        • Cross-training
        • Team-building
        • Shared decision-making (SDM)
        • Contracts/agreements
      • Expectations for intensive communication between child welfare and treatment providers via immediate reports to child welfare of:
        • Drug test results
        • Missed appointments
        • Safety concerns
      • Written weekly reports of treatment attendance/progress
      • Monthly direct line and steering meetings
      • Monthly case reviews
      • Treatment providers who are expected to deliver approaches and therapies that have the following characteristics:
        • High-quality
        • Trauma-informed
        • Gender-specific
        • Given at the same time as a treatment for a co-occurring disorder
        • Evidence-based, when possible
    • Employs family mentors who:
      • Work within the child welfare agency
      • Receive supervision from child welfare
      • Experiencing long-term recovery from SUDs with experiences that sensitize them to child maltreatment and family SUDs
    • Pairs one family mentor with one child welfare worker as a dyad with a shared caseload
    • A maximum of 4 worker-mentor dyads form a team with a dedicated supervisor
    • Caseload with no more than 12-15 families for the mentor-worker dyad.
    • Serves the target population of families with child maltreatment and parental SUD as a primary risk factor for child safety that are new to the child welfare agency or have a closed case at the time of report/referral.
  • Implementation Fidelity to START Strategies:
    • Adheres to the START Timeline that specifies the number of business days between the initial child welfare report/referral and the parent being engaged in at least 4 SUD treatment sessions as follows:
      • Referral to START within 10 days of the initial child welfare report/referral
      • First SDM meeting with the family within 2 days of referral to START
      • Behavioral health assessment within 2 days of first SDM meeting
      • SUD treatment begins within 3 days of assessment, with minimum of 4 treatment sessions in the first 10 days of treatment
    • Adheres to the START Minimum Work Guidelines that specify the intensity of child welfare services and include:
      • At least weekly home visits by both the worker and family mentor for the first 60 and 90 days of the case, respectively
      • SDM meetings that occur at key points such as:
        • At referral to START to plan with the family for child safety and placement
        • At relapse
        • When in a crisis
        • When treatment recommendations change
        • At regular intervals
      • Frequent visits between parent and child
      • Parents have six months minimum of documented sobriety prior to reunification or case closure
      • Engages parents in SUD and Mental Health services including:
        • Holistic care
        • Trauma-informed assessments
        • Level of care placement
        • Intensive services at the level, dosage, and repetition required by the parent
    • Uses a family-centered approach and practices:
      • Family includes:
        • Children
        • Mothers
        • Fathers
        • Significant others
        • Caregivers such as foster parents and other relatives
      • Provides comprehensive services to both mothers and fathers
      • Refers parents/families to parenting supports to address parenting in recovery, bonding between parents and children, and parenting skills.
    • Ensures that children are:
      • Safe
      • Having their basic needs met
      • Screened for developmental and social-emotional delays
      • Linked with needed services
  • START must be based on principles implemented by decision making that is shared by families, child welfare staff and service providers.
  • START must be constantly evolving toward the use of best practices in child welfare and SUD treatment.
  • START respects that children optimally belong with their family, seeks to promote parent/child bonding through frequent visitation and parent coaching, and keeps children safely with family whenever possible.
  • START sites must be engaged in continuous quality improvement guided by program evaluation data.

Program Delivery

Child/Adolescent Services

Sobriety Treatment and Recovery Teams (START) directly provides services to children/adolescents and addresses the following:

  • Lack of safety and basic needs, poor well-being and mental health, delayed development

Parent/Caregiver Services

Sobriety Treatment and Recovery Teams (START) directly provides services to parents/caregivers and addresses the following:

  • Parental substance use and mental health disorders, lack of family stability, below average parenting capacity, and trauma needs
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Both mothers and fathers are served. Families, including extended family, friends, and community supports, are included in SDM meetings. Parents are linked with community recovery supports and supports for concrete needs such as housing, legal services, or child care. SUD treatment providers include extended family in family SUD education sessions. Family mentors coach all members on understanding and responding to persons with SUDs.

Recommended Intensity:

Minimum of weekly home visits by the child welfare worker and family mentor. SUD and co-occurring mental health treatment intensity as determined by qualified behavioral health professional, minimum of two SUD treatment sessions per week. Depending on behavioral health assessment, recommended level of care may include detoxification, residential, medication-assisted treatment (MAT), intensive outpatient, outpatient (individual, group, and family therapy), co-occurring mental health and trauma treatment, transitional housing, and psychiatric care. Various treatments may be concurrent or sequential and may be repeated as needed.

Recommended Duration:

Cases are open and worked on by child welfare for an average of 14 months. Behavioral health treatment duration is determined by assessment and client progress but is generally complete when the child welfare case closes. Six months of continuous, documented sobriety is required before returning children to their parent(s) or closing an in-home case.

Delivery Settings

This program is typically conducted in a(n):

  • Birth Family Home
  • Foster / Kinship Care
  • Outpatient Clinic
  • Group or Residential Care

Homework

Sobriety Treatment and Recovery Teams (START) includes a homework component:

Parents need to complete child welfare case plan activities and homework may be required by some behavioral health treatment providers.

Resources Needed to Run Program

The typical resources for implementing the program are:

  • One child welfare supervisor for every 4 worker/mentor dyads
  • Child welfare workers
  • Family mentors
  • A facilitator for SDM meetings
  • Contracts/agreements with SUD treatment providers for assessment and treatment (may include employment of a START Service Coordinator)
  • Drug testing
  • Flexible funds for wraparound needs

Education and Training

Prerequisite/Minimum Provider Qualifications

START Child Welfare Supervisor: Minimum of five years of child welfare casework experience, meets agency requirements for promotion

START Child Welfare Worker: May be new to child welfare or an experienced worker, must complete agency child welfare training prior to doing field work

START Family Mentor: High school diploma or GED, two years of work experience of some sort, at least three years of sustained recovery from SUDs, active participation in recovery supports, no current criminal justice or child welfare involvement

START Service Coordinator (if this position is included): Meets state, agency, and insurance requirements to provide assessments and case management for SUDs and co-occurring mental health disorders

Education and Training Resources

There is a manual that describes how to deliver this program, and there is training available for this program.

Program Manual Information: 

  • Willauer, T., Posze, L., & Huebner, R. A. (Eds.). (2018). The Sobriety Treatment and Recovery Teams (START) Model: Implementation Manual. Children and Family Futures.

The first chapter of the manual, that explores the model and its theoretical base, is available for download at https://www.cffutures.org/start-home/start_manual_ch1/. The full manual is available to jurisdictions with training and technical assistance contracts through Children and Family Futures.

Training Contact:
Training is obtained:

Recommended training includes:

  • Consultation and technical assistance (TA) to leaders and administrators regarding systemic changes necessary to implement the program including program evaluation strategies.
  • On-site training for front-line staff and supervisors in both child welfare and SUD treatment agencies on START strategies including hiring and working with family mentors, case management, and collaboration.
  • Ongoing consultation and TA recommended regarding implementation and how to overcome barriers
Number of days/hours:

2-4 hours/month of consultation, usually by phone 1-2 days of on-site training

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Sobriety Treatment and Recovery Teams (START) as listed below:

The second chapter of the START Implementation Manual, available from the training contact listed above upon request, is designed for those exploring the fit of START in their agency. It includes a readiness assessment and site selection checklists. Checklists help leadership determine whether key elements are currently in place to support the model, what prework might be needed, and what data are important to site selection.

Formal Support for Implementation

There is formal support available for implementation of Sobriety Treatment and Recovery Teams (START) as listed below:

Ongoing TA, coaching, and consultation can be provided to leadership and front-line staff to help navigate and work through implementation issues and barriers. Children and Family Futures (CFF), the national home of the START model, will work with sites to customize a package for consultation, training, and TA for every stage of implementation, varying budgets and needs based on the status of the site on readiness, partnerships with SUD treatment providers, the courts and other factors. The goals of the training, coaching and consultation are to:

  • Ensure that the START model is first understood and selected to match the capacity and readiness of each site, adapted to the jurisdiction with the guidance of the TA consultants, and then implemented with fidelity.
  • Reinforce and coordinate START implementation with related child welfare, court improvement efforts and other initiatives in the jurisdiction.
  • Build the capacity of leadership and practitioners to implement and sustain START independently following the consultation, training and technical assistance.
  • Support the development of a learning organization culture incorporating program evaluation principles, ongoing quality improvement, and data driven decisions.

Fidelity Measures

There are fidelity measures for Sobriety Treatment and Recovery Teams (START) as listed below:

Fidelity measures are embedded into a data collection system and ideally similar data collection systems should be developed by those adopting the model. The evaluation of fidelity includes explicit directions through process evaluation and data collection/analysis. These instructions are available from the purveyor and are included in the START Implementation Manual.

Implementation Guides or Manuals

There are implementation guides or manuals for Sobriety Treatment and Recovery Teams (START) as listed below:

A detailed implementation manual is housed with CFF and is only available in conjunction with technical assistance and training. This 220-page manual includes chapters on the stages of implementation and the essential components of START, program evaluation, family mentors, child welfare practices, working with SUD treatment providers, and essential meetings. Practice guides address topics such as drug testing and minimum work standards; sample protocols and forms are included. The reference for this manual is the same as the program manual listed above:

  • Willauer, T., Posze, L., & Huebner, R. A. (Eds.). (2018). The Sobriety Treatment and Recovery Teams (START) Model: Implementation Manual. Children and Family Futures.

The first chapter of the manual, that explores the model and its theoretical base, is available for download at https://www.cffutures.org/start-home/start_manual_ch1/. The full manual is available to jurisdictions with training and technical assistance contracts through Children and Family Futures.

Research on How to Implement the Program

Research has been conducted on how to implement Sobriety Treatment and Recovery Teams (START) as listed below:

Huebner, R. A., Hall, M. T., Smead, E., Willauer, T., & Posze, L. (2018). Peer mentoring services, opportunities, and outcomes for child welfare families with substance use disorders. Children and Youth Services Review, 84, 239-246. https://doi.org/10.1016/j.childyouth.2017.12.005

Huebner, R. A., Posze, L., Willauer, T. M., & Hall, M. T. (2015). Sobriety Treatment and Recovery Teams: Implementation fidelity and related outcomes. Substance Use & Misuse, 50(10), 1341-1350. https://doi.org/10.3109/10826084.2015.1013131

Sears, J. S., Hall, M. T., Harris, L. M., Mount, S., Willauer, T., Posze, L., & Smead, E. (2017). “Like a marriage”: Partnering with peer mentors in child welfare. Child and Youth Service Review, 74, 80-86. https://doi.org/10.1016/j.childyouth.2017.01.023

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Permanency

Huebner, R. A., Willauer, T., & Posze, L. (2012). The impact of Sobriety Treatment and Recovery Teams (START) on family outcomes. Families in Society Journal of Contemporary Social Services, 93(3), 196–203. https://doi.org/10.1606%2F1044-3894.4223

Type of Study: Pretest-posttest study with a nonequivalent control group
Number of Participants: 322 Families (531 Adults and 451 Children)

Population:

  • Age — Parents: 25-28 years, Children: Mean=2.7 years
  • Race/Ethnicity — Parents: 78% White and 22% African Americans, Children: Not specified
  • Gender — Parents and Children: Not specified
  • Status — Participants are families with co-occurring child abuse and neglect and parental substance use disorders.

Location/Institution: Four START sites in two urban, one rural and one Appalachian county

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The purpose of this outcome study was to test the impact of the Sobriety Treatment and Recovery Team (START) program on rates of parental sobriety and rates of child placement in state custody (foster or residential care). Measures utilized include risk of child abuse rating on the continuous quality assessment (CQA), in addition three data sets were used as measures, START Information Network (START-IN), investigation, and OOHC (out-of-home care). This study consisted of three groups: START-served, START-referred but not accepted, and matched comparison. Results indicate that many families, despite numerous challenges, achieved sobriety and retained custody of their children with START. Mothers in START achieved nearly twice the rates of favorable outcome, compared to similar women in the state. Fathers achieved sobriety rates much lower than mothers, suggesting that a more potent intervention is needed for fathers.  Limitations include lack of randomization, lack of follow-up, and use of administrative data. 

Length of postintervention follow-up: None.

Huebner, R. A., Willauer, T., Posze, L., Hall, M. T., & Oliver, J. (2015). Application of the evaluation framework for program improvement of START. Journal of Public Child Welfare, 9(1), 42-64. https://doi.org/10.1080/15548732.2014.983289

Type of Study: One-group pretest-posttest
Number of Participants: 420 Families (673 Parents)

Population:

  • Age — Parents: 25-28 years, Children: Mean=1.5 years
  • Race/Ethnicity — Parents: 78.6% Caucasian, 20.1% African American, and 1.3% Hispanic; Children: 69.3% Caucasian, 27.9% African American, 2.0% Hispanic, and 0.8% Other
  • Gender — Parents: 409 Female and 264 Male, Children: 53.5% Male and 46.5% Female
  • Status — Participants were families with co-occurring child abuse and neglect and parental substance use disorders.

Location/Institution: Four START sites in two urban, one rural and one Appalachian county

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study applies the Children’s Bureau program evaluation framework to the Sobriety Treatment and Recovery Team (START) program, an integrated program between child welfare and substance abuse treatment. A cluster analysis of START participants in 420 families identified three subgroups. Measures utilized include the North Carolina Family Assessment Scale for General Services (NCFAS-G) and a family mentor checklist. The study was conducted in phases. In phase one, data on child placement, parental sobriety, and parental capacity in addition to data on START process and treatment variables were used to identify three homogeneous outcome subgroups. In phase two, characteristics of the cluster subgroups were compared to identify differences that might inform program improvement. Results indicate that intact families (i.e., father, mother, and child[ren]) retained child custody throughout treatment and achieved the highest rates of sobriety. Despite similar substance use disorders and loss of parental custody, group two was mostly reunified and group three was rarely reunified. Limitations include lack of randomization of participants, lack of comparison group, lack of follow-up, and the cluster analysis does not provide causal conclusions to support that the results can be attributed to the START program.

Length of postintervention follow-up: None.

Hall, M. T., Huebner, R. A., Sears, J. S., Posze, L., Willauer, T. & Oliver, J. (2015). Sobriety Treatment and Recovery Teams in rural Appalachia: Implementation and outcomes. Child Welfare, 94(4), 119–138. https://pdfs.semanticscholar.org/6510/a1dce0f3ae67944b5110311eab75e3f400d5.pdf

Type of Study: Pretest-posttest study with a nonequivalent control group
Number of Participants: 341 families

Population:

  • Age — Parents: Mean=26.7– 29 years, Children: Median=1.3 years
  • Race/Ethnicity — Parents: 76.2% White and 22.4% African-American; Children: 67.6% Caucasian, 30% African American, and 2.4% Non-White or Hispanic
  • Gender — Parents: Not specified; Children: 53.1% Males and 46.9% Females
  • Status — Participants were families with co-occurring child abuse and neglect and parental substance use disorders.

Location/Institution: Three START sites

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study describes the implementation and outcomes of Sobriety Treatment and Recovery Team (START) in a rural Appalachian county with high rates of poverty, nonmedical prescription drug use, and child maltreatment. Measures utilized include the Collaborative Capacity Instrument (CCI) and state child welfare administrative data. Results indicate that despite a severely limited addiction treatment infrastructure at baseline, children served by START were less likely to experience recurrence of child abuse or neglect within 6 months or reenter foster care at 12 months compared with a matched control group. Limitations include lack of randomization of participants, lack of follow-up, and the study relied on administrative data.

Length of postintervention follow-up: None.

Additional References

Hall, M. T, Wilfong, J., Huebner, R. A., Posze, L, & Willauer, T. (2016). Medication-assisted treatment improves child permanency outcomes for opioid-using families in the child welfare system. Journal of Substance Abuse Treatment, 71, 63–67. https://doi.org/10.1016/j.jsat.2016.09.006

Huebner, R. A., Young, N. K., Hall, M. T, Posze, L., & Willauer, T. (2017). Serving families with child maltreatment and substance use disorders: A decade of learning, Journal of Family Social Work, 4, 288–305. https://doi.org/10.1080/10522158.2017.1348110

Willauer, T. M. (2019). Child Welfare Practices of the Sobriety Treatment and Recovery Teams (START) Model. CW 360. https://cascw.umn.edu/wp-content/uploads/2019/04/360WEB_2019.temp_.pdf

Contact Information

Tina M. Willauer, MPA
Agency/Affiliation: Children and Family Futures
Email:
Phone: (714) 505-3525

Date Research Evidence Last Reviewed by CEBC: June 2019

Date Program Content Last Reviewed by Program Staff: April 2020

Date Program Originally Loaded onto CEBC: February 2016