Improving Outcomes for Improving Outcomes for Families Affected by Families Affected by

Substance Use DisordersSubstance Use Disorders

Nancy K. Young, Ph.D., DirectorNancy K. Young, Ph.D., Director4940 Irvine Boulevard, Suite 2024940 Irvine Boulevard, Suite 202Irvine, CA 92620 714.505.3525Irvine, CA 92620 714.505.3525

www.ncsacw.samhsa.govwww.ncsacw.samhsa.gov

Betty Ford ConferenceBetty Ford ConferenceTrends and Perspectives in Women’s AddictionTrends and Perspectives in Women’s Addiction

April 13, 2004April 13, 2004

Topics Topics

NCSACWNCSACW Some NumbersSome Numbers Some HistorySome History Policy Framework and ToolsPolicy Framework and Tools ModelsModels

A Program of the A Program of the Substance Abuse and Mental Health Substance Abuse and Mental Health

Services AdministrationServices AdministrationCenter for Substance Abuse TreatmentCenter for Substance Abuse Treatment

and theand theAdministration on Children, Youth and FamiliesAdministration on Children, Youth and Families

Children’s BureauChildren’s BureauOffice on Child Abuse and NeglectOffice on Child Abuse and Neglect

MISSION:MISSION: To improve outcomes for families by To improve outcomes for families by

promoting effective practice, promoting effective practice, organizational, and system changes at organizational, and system changes at the local, state, and national levels bythe local, state, and national levels by Developing and implementing a Developing and implementing a

comprehensive program of information comprehensive program of information gathering and disseminationgathering and dissemination

Providing technical assistanceProviding technical assistance

PRODUCTS:PRODUCTS: On-Line TrainingOn-Line Training

Understanding Child Welfare and the Understanding Child Welfare and the Dependency Court: A Guide for Substance Dependency Court: A Guide for Substance Abuse Treatment Professionals – Now Abuse Treatment Professionals – Now AvailableAvailable

Understanding Addiction and Recovery: A Understanding Addiction and Recovery: A Guide for Child Welfare Workers – Fall 2004Guide for Child Welfare Workers – Fall 2004

A Guide for Judges and Dependency Court A Guide for Judges and Dependency Court Staff – Summer 2005Staff – Summer 2005

PRODUCTS:PRODUCTS: Program of In-Depth Technical AssistanceProgram of In-Depth Technical Assistance

Round 1 – Summer 2003 to Fall 2004Round 1 – Summer 2003 to Fall 2004 Colorado, Florida, Michigan, VirginiaColorado, Florida, Michigan, Virginia Assistance to Develop and Implementation State’s Assistance to Develop and Implementation State’s

Plan to Better Serve this Population of FamiliesPlan to Better Serve this Population of Families

Round 2 – Solicitation in Fall 2004Round 2 – Solicitation in Fall 2004 Seven States Offered Program, 3 States and 1 Tribe Seven States Offered Program, 3 States and 1 Tribe

will be selectedwill be selected

PRODUCTS:PRODUCTS: MaterialsMaterials

Compendium of Training CurriculaCompendium of Training Curricula Understanding Substance Abuse: A Guide for Understanding Substance Abuse: A Guide for

Child Welfare PractitionersChild Welfare Practitioners Screening and Assessment for Family Screening and Assessment for Family

Engagement, Retention and Recovery Engagement, Retention and Recovery (SAFERR) – Spring 2005(SAFERR) – Spring 2005

Some Numbers

Children Living With One or More Children Living With One or More Substance Abusing ParentSubstance Abusing Parent

4.5

2.8

6.2

7.5

8.3

8.4

10.6

0 2 4 6 8 10 12

Need Treatment for Illicit Drug Abuse

Dependent on Illicit Drugs

Dependent on Alcohol

Dependent on AOD

Dependent on Alcohol and/or NeedsTreatment for Illicit Drugs

Used Illicit Drug in Past Month

Used Illicit Drug in Past Year

In Millions

8.9 Million Childre

n

980,000 Children with Parent who Needs AOD Treatment

California’s ChildrenCalifornia’s Children

69,000 Substance-

exposed Births

2000 Census1999 Estimates

of 11%

1992 Estimates of ATOD exposure annually

Foster Care PopulationFoster Care Population

0

100,000

200,000

300,000

400,000

500,000

600,000

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

0

1

2

3

4

5

6

7

8

Total Children Children per 1,000

52% Increase over 6 Years

Number of Children in Foster Care on Last Day of Federal Fiscal Year

Foster Care Population and Persons Foster Care Population and Persons who First Used Crack or Meth in Past Yearwho First Used Crack or Meth in Past Year

*All persons age 12 and over

0

100000

200000

300000

400000

500000

600000

19801981 1982 19831984 1985 1986 19871988 1989 19901991 1992 1993 19941995 1996 19971998 19992000 20012002

0

100,000

200,000

300,000

400,000

500,000

600,000

Children in Foster Care New Crack Users* New Methamphetamine Users*

1968 1973 1980s 1990s

2004

Looking Back

Some History

TimelinesTimelines

Mid to Late 1980s – Initiating ResponsesMid to Late 1980s – Initiating Responses

Child welfare agencies began responding to Child welfare agencies began responding to an epidemic of kids coming into care and an epidemic of kids coming into care and cocainecocaine

Schools began their efforts to understand Schools began their efforts to understand prenatally-exposed children prenatally-exposed children 1987 Los Angeles Unified School District 1987 Los Angeles Unified School District

develops pilot program to understand develops pilot program to understand educational impact of prenatal cocaine educational impact of prenatal cocaine exposureexposure

Five National Reports on Substance Abuse and Five National Reports on Substance Abuse and Child WelfareChild Welfare Responding to Alcohol and Other Drug Problems in Child Responding to Alcohol and Other Drug Problems in Child

Welfare: Weaving Together Practice and Policy (1998)Welfare: Weaving Together Practice and Policy (1998)

Foster Care: Agencies Face Challenges Securing Stable Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers (1998)Homes for Children of Substance Abusers (1998)

Healing the Whole Family: A Look at Family Care Programs Healing the Whole Family: A Look at Family Care Programs (1998)(1998)

No Safe Haven: Children of Substance-Abusing Parents (1999)No Safe Haven: Children of Substance-Abusing Parents (1999)

Blending Perspectives and Building Common Ground: A Report Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (1999)to Congress on Substance Abuse and Child Protection (1999)

TimelinesTimelines

1990s – Reports on the Issues1990s – Reports on the Issues

Key Barriers Between Substance Key Barriers Between Substance Abuse, Child Welfare and The CourtsAbuse, Child Welfare and The Courts

Beliefs and ValuesBeliefs and Values Competing Priorities Competing Priorities Treatment GapTreatment Gap Information SystemsInformation Systems Staff Knowledge and SkillsStaff Knowledge and Skills Lack of CommunicationLack of Communication Different MandatesDifferent Mandates

Biggest Challenges:Biggest Challenges:

Reconciling the Reconciling the ClocksClocks

The Four ClocksThe Four Clocks

CFSR’s have documented CFSR’s have documented Case reviews found parental substance use disorders Case reviews found parental substance use disorders

were a factor in 16% to 48% of caseswere a factor in 16% to 48% of cases Need for child welfare training in addictions Need for child welfare training in addictions Gaps in servicesGaps in services Inadequate assessment and follow up on the Inadequate assessment and follow up on the

underlying needs of families, including substance underlying needs of families, including substance abuseabuse

Substance use disorders in families with repeat casesSubstance use disorders in families with repeat cases

The First ClockThe First Clock

ASFA TimetableASFA Timetable

Timeliness of intervention versus “Call me Tuesday”Timeliness of intervention versus “Call me Tuesday”

National Study on Child and Adolescent Well-National Study on Child and Adolescent Well-Being: Child Welfare Workers’ (CWW) Being: Child Welfare Workers’ (CWW)

Identification of Substance AbuseIdentification of Substance Abuse

Of the caregivers who are alcohol dependent Of the caregivers who are alcohol dependent 71% are classified by the CWW as not having an alcohol 71% are classified by the CWW as not having an alcohol

problemproblem

Of the caregivers who are drug dependentOf the caregivers who are drug dependent 73% are classified by the CWW as not having a drug 73% are classified by the CWW as not having a drug

problemproblem

CWW’s misclassify caregivers who are CWW’s misclassify caregivers who are substance dependent most of the timesubstance dependent most of the time

Minnesota DataMinnesota Data

2002 Report to the 2004 Legislature2002 Report to the 2004 Legislature Prevalence of Family Conditions at Prevalence of Family Conditions at

AssessmentAssessmentAlternative Alternative

TraditionalTraditional

ResponseResponseResponseResponse

Alcohol AbuseAlcohol Abuse 7% 7% 18% 18% Drug AbuseDrug Abuse 3% 3% 19% 19%

Timeliness of InterventionsTimeliness of Interventions

Taking CFSR findings seriously and Taking CFSR findings seriously and including remediation strategies in Program including remediation strategies in Program Improvement PlansImprovement Plans

The First ClockThe First Clock

ASFA ChallengesASFA Challenges

The Second ClockThe Second Clock

Poverty and low-income work affect neglect, Poverty and low-income work affect neglect, which is the majority of all reportswhich is the majority of all reports

Neglect is often associated with both Neglect is often associated with both substance abuse and povertysubstance abuse and poverty

TANF resources have been used in innovative TANF resources have been used in innovative models for this populationmodels for this population

Treatment aftercare focus on jobs and housing Treatment aftercare focus on jobs and housing TANF reauthorization proposes treatment be TANF reauthorization proposes treatment be

counted as a work activitycounted as a work activity

TANF TimetableTANF Timetable

““A day at a time for the rest of your life” A day at a time for the rest of your life” Recovery is a lifelong process with a disease Recovery is a lifelong process with a disease management approach not emergency caremanagement approach not emergency care

Low-dosage non-comprehensive programs do Low-dosage non-comprehensive programs do not build on what we know about effective not build on what we know about effective treatment for this populationtreatment for this population

The Third ClockThe Third Clock

Recovery TimetableRecovery Timetable

The Third ClockThe Third Clock

Recovery ChallengesRecovery Challenges

Comprehensive services and longer-term supports Comprehensive services and longer-term supports are criticalare critical Clinical treatment, clinical support and community Clinical treatment, clinical support and community

supportssupports

Recognizing the needs of children of parents in Recognizing the needs of children of parents in treatmenttreatment

The changing nature of drug use patterns and The changing nature of drug use patterns and epidemicsepidemics

Children of substance abusers need in-depth Children of substance abusers need in-depth assessments and interventions that respond to assessments and interventions that respond to their developmental status and the special needs their developmental status and the special needs created by substance use disorders in their family created by substance use disorders in their family grief, loss, separation, attachment grief, loss, separation, attachment

Adolescents who may have begun their own Adolescents who may have begun their own substance usesubstance use

The Fourth ClockThe Fourth Clock

Child Development TimetableChild Development Timetable

The Fourth ClockThe Fourth Clock

Every 70 seconds a baby is born in this country Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit who was prenatally exposed to alcohol or illicit drugs drugs

Child Development TimetableChild Development Timetable

Reconciling the ClocksReconciling the Clocks

Information Sharing & Information Sharing & Management Management

Training and Staff Training and Staff DevelopmentDevelopment

Budgeting and Program Budgeting and Program SustainabilitySustainability

Building Community Building Community SupportsSupports

Connecting AOD, CWS, Court Systems: Connecting AOD, CWS, Court Systems: Elements of System Linkages*Elements of System Linkages*

From CSAT Technical Assistance Publication (TAP) 27: Navigating the Pathways *Revised March 2003From CSAT Technical Assistance Publication (TAP) 27: Navigating the Pathways *Revised March 2003

Underlying ValuesUnderlying Values Screening and Screening and

AssessmentAssessment Client Engagement Client Engagement

and Retention in Careand Retention in Care AOD Services to AOD Services to

Children Children Joint Accountability Joint Accountability

and Shared Outcomesand Shared Outcomes Working with Related Working with Related Agencies and Support Agencies and Support SystemsSystems

Policy Framework and ToolsPolicy Framework and Tools

10 Element Framework10 Element Framework Collaborative Values InventoryCollaborative Values Inventory Collaborative Capacity InstrumentCollaborative Capacity Instrument Matrix of Progress in LinkagesMatrix of Progress in Linkages Screening and Assessment for Family Screening and Assessment for Family

Engagement, Retention and Recovery Engagement, Retention and Recovery -- SAFERR -- SAFERR

1. Values and Common Principles1. Values and Common Principles

Issues to AddressIssues to Address Who is the Client -- Parent, Child, Who is the Client -- Parent, Child,

Family?Family? Can AOD Users/Abusers/ Can AOD Users/Abusers/

Addicts/Alcoholics be Effective Parents?Addicts/Alcoholics be Effective Parents? What is the Goal -- Recovery, Child What is the Goal -- Recovery, Child

Safety, Family Preservation, Economic Safety, Family Preservation, Economic Self-sufficiency?Self-sufficiency?

How to Begin:How to Begin:

Use Tools Such As the Collaborative Use Tools Such As the Collaborative Values Inventory to Identify and Values Inventory to Identify and Resolve Differences That Exist Across Resolve Differences That Exist Across SystemSystem

Ensure Conversation Happens at Ensure Conversation Happens at Policy, Supervisory and Front-line Policy, Supervisory and Front-line LevelsLevels

Issues to AddressIssues to Address Roles and Responsibilities Across Roles and Responsibilities Across

SystemsSystems Communication Paths Across SystemsCommunication Paths Across Systems Incentives for PrioritizationIncentives for Prioritization Missing Box ProblemMissing Box Problem

2. Daily Practice -- Client Intake, 2. Daily Practice -- Client Intake, Screening and AssessmentScreening and Assessment

Too Often We Practice…Too Often We Practice…“Don’t Ask, Don’t Tell”“Don’t Ask, Don’t Tell”

Nationally, we have “missing box” problemsNationally, we have “missing box” problems

Welfare and Child Welfare Agencies have far less information than they need on substance abuse among their clients

Alcohol and Drug Treatment Agencies have far less information than they need about the children of their treatment clients

Clarify Intake Procedures and Clarify Intake Procedures and AOD/Child Safety Screening AOD/Child Safety Screening ProtocolsProtocols

Decide on Team, Tool, Method, Roles Decide on Team, Tool, Method, Roles and Responsibilities to and Responsibilities to Provide AOD Expertise to Child Welfare Provide AOD Expertise to Child Welfare

Workers in Investigative/Assessment Workers in Investigative/Assessment Phases Phases

Ensure Parents Seeking Treatment Ensure Parents Seeking Treatment Receive Needed Supports for Child Receive Needed Supports for Child SafetySafety

How to Begin:How to Begin:

3. Daily Practice -- Client 3. Daily Practice -- Client Engagement and Retention in Engagement and Retention in

TreatmentTreatment

Issues to AddressIssues to Address Outreach and Engagement StrategiesOutreach and Engagement Strategies Addressing Motivation to ChangeAddressing Motivation to Change Cross-system Agreement on Approaches Cross-system Agreement on Approaches

to Relapseto Relapse Responding to Clients’ Progress in Responding to Clients’ Progress in

TreatmentTreatment

Implement Assessment and Implement Assessment and Interventions based on Readiness to Interventions based on Readiness to ChangeChange

Develop Mechanism to Re-engage Develop Mechanism to Re-engage Clients in CareClients in Care

Ensure AOD Treatment and CPS Ensure AOD Treatment and CPS Practice is Responsive to Clients’ Practice is Responsive to Clients’ Individualized NeedsIndividualized Needs

How to Begin:How to Begin:

4. Daily Practice -- Services to 4. Daily Practice -- Services to ChildrenChildren

Issues to AddressIssues to Address Prevention, Early Intervention, and Prevention, Early Intervention, and

Treatment Services for Children in Treatment Services for Children in Contact with CPSContact with CPS

Content of Independent Living Programs Content of Independent Living Programs on Parental Substance Abuseon Parental Substance Abuse

PediatricsPediatrics (1999) v.103:1083 – 1155, Special (1999) v.103:1083 – 1155, Special Topics on Children and Adolescents in Families Topics on Children and Adolescents in Families Affected by Substance AbuseAffected by Substance Abuse

http://www.pediatrics.org/cgi/content/full/103/5/SI/1083http://www.pediatrics.org/cgi/content/full/103/5/SI/1083

Develop Partnerships to Respond to Potential Develop Partnerships to Respond to Potential Neuro-Developmental Effects of Prenatal Neuro-Developmental Effects of Prenatal Substance ExposureSubstance Exposure

Provide Prevention and Intervention Services to Provide Prevention and Intervention Services to Children and AdolescentsChildren and Adolescents

Ensure that Youth Receive Appropriate Youth Ensure that Youth Receive Appropriate Youth Development Intervention and ActivitiesDevelopment Intervention and Activities

Ensure that ILP Teens Receive Appropriate Ensure that ILP Teens Receive Appropriate Information Related to Risks of Substance AbuseInformation Related to Risks of Substance Abuse

How to Begin:How to Begin:

5. Information Sharing and Data Systems5. Information Sharing and Data Systems

6. Training and Staff Development6. Training and Staff Development

7. Joint Accountability and Shared 7. Joint Accountability and Shared OutcomesOutcomes

8. Budgeting, Funding and Program 8. Budgeting, Funding and Program

SustainabilitySustainability

Other System Supportive Other System Supportive ElementsElements

We Know AOD Treatment PaysWe Know AOD Treatment Pays

100 Women100 WomenAverage cost $6,800Average cost $6,800

$680,000$680,000

150 Children150 ChildrenAverage 1.5 years Average 1.5 years

in out-of-home care in out-of-home care @ $24,000 per year@ $24,000 per year

$5.4 Million$5.4 Million

Foster Care Cost Offset Pays for all 100 Women’s Treatment Nearly 2 Times Over

30 Women recover with one episode of treatment 45 Children reunify at

6 monthsSaves $1.1 Million

Primary Health Primary Health CareCare

Domestic ViolenceDomestic ViolenceTraumaTraumaMental HealthMental HealthDental HealthDental Health

10. Working with Related Agencies10. Working with Related Agencies

TransportationTransportationChild Care Child Care MedicaidMedicaidHousingHousingEconomic SecurityEconomic SecurityEducation for Education for

Mother and Mother and ChildrenChildren

9. Developing Community Supports9. Developing Community Supports

Many communities began program models in 1990sMany communities began program models in 1990s

Models of Improved ServicesModels of Improved Services

Family Treatment CourtsFamily Treatment Courts

Training and Curricula DevelopmentTraining and Curricula Development

Persons in Recovery act as Advocates for Persons in Recovery act as Advocates for ParentsParents

Multidisciplinary Teams for Joint Case Multidisciplinary Teams for Joint Case PlanningPlanning

Counselor Out-stationed at Child Welfare Counselor Out-stationed at Child Welfare OfficeOffice

Paired Counselor and Child Welfare WorkerPaired Counselor and Child Welfare Worker

Jointly FundedJointly Funded Department of Health and Human ServicesDepartment of Health and Human Services

Substance Abuse and Mental Health Services Substance Abuse and Mental Health Services Administration, Center for Substance Abuse ServicesAdministration, Center for Substance Abuse Services

Administration on Children, Youth & Families, Administration on Children, Youth & Families, Children’s Bureau, Office on Child Abuse and NeglectChildren’s Bureau, Office on Child Abuse and Neglect

Assistant Secretary for Planning and EvaluationAssistant Secretary for Planning and Evaluation

Department of JusticeDepartment of Justice National Institute on JusticeNational Institute on Justice Drug Court Program OfficeDrug Court Program Office

Every 70 seconds a baby is born in this country Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit who was prenatally exposed to alcohol or illicit drugs drugs

Every minute and a half, one of those babies goes Every minute and a half, one of those babies goes home without screening or any effort to begin early home without screening or any effort to begin early interventionintervention A baby and a family we already know are highly at riskA baby and a family we already know are highly at risk

The Fifth ClockThe Fifth Clock

UrgencyUrgency

The fifth clock is the one that is ticking on The fifth clock is the one that is ticking on us…it measures how fast we get it…how us…it measures how fast we get it…how rapidly we respond to human needs that grow rapidly we respond to human needs that grow larger by the day larger by the day

We have to measure what we do against We have to measure what we do against what what needs doingneeds doing, not against what we did , not against what we did last yearlast year

The Fifth ClockThe Fifth Clock

UrgencyUrgency