Parental Substance Abuse & Child Parental Substance Abuse & Child MaltreatmentMaltreatment

Evaluation Results From Evaluation Results From Project First Step: New Hampshire’s Project First Step: New Hampshire’s

IV-E Waiver DemonstrationIV-E Waiver Demonstration

NCSACW First National Conference on Substance Abuse, NCSACW First National Conference on Substance Abuse, Child Welfare and the Dependency CourtChild Welfare and the Dependency Court

July 2004July 2004

Barriers to effective treatmentBarriers to effective treatment

Limited servicesWait lists for in-patient and out-patient

Focus on the substance abuse recovery doesn’t address family and parenting issues

Client MinimizationReadiness to ChangeCo-Morbidity

Original project Original project assumptionsassumptions

Better initial risk & safety assessments by CPS.

Direct assessment/counseling available to the family.

Interventions to address child maltreatment in the context of the substance abuse

Eventual decrease in child’s stay in temp. foster care.

New Hampshire Health & Human Services, Division for Children, Youth & families

 Vision Statement

 We envision a state in which every child lives in a nurturing family and plays and goes to school in communities that are safe and cherish children.

 Mission Statement

 We are dedicated to assisting families in the protection, development, permanency,

and well-being of their children and

the communities in which they live.

DCYF Comprehensive

Child & Family Services Plan, 2000-2004

Initial selection at IntakeInitial selection at Intake

Call Received

Intake Assessment

Credible Report + Identified Substance Abuse

Screened Out

Credible Report: No Identified Substance Abuse

Family Research LabFamily Research Lab

Involved in client selection

CPS Intake screens in eligible family

FRL staff makes random assignment to standard/ enhanced groups, takes client id info

Group assignment noted when family is referred to targeted district office for CPS assessment

Enhanced ServicesEnhanced Services

Consult with L.A.D.A.C. and supervisorCPS + consultant meet with family

Goal for Enhanced ServicesGoal for Enhanced Services

In CPS cases involving parental substance abuse– Better assessments of safety for children– Better plans for children in placement– Less frequent/shorter periods of time in foster

care– Improved permanency plans– Costs for children in temporary

foster care may decrease

Benefits to the communityBenefits to the community

Strengthened ties between the Treatment community & the CPS office

Education for the Treatment providers about substance abuse treatment needs in CPS cases

Additional outreach resource

For people awaiting treatmentFor people awaiting treatment

Individual counselingOn-going contact with counselor

– Treatment Window extended 60 days– Treatment Provider connections

For families receiving servicesFor families receiving services

Consultant participates in case planningKeep focus on parent issuesInclude parenting in treatment goalsAftercare with focus on parenting

Benefits to CPS during Benefits to CPS during assessmentassessment

Regular Consultation Preliminary screening (SASSI) of

parental substance abuseImpact of parental substance abuse on

safety and risk of harm to childrenRecommendations for

services and treatment

“[The Counselor’s] involvement provides all concerned with a better understanding of what is needed, what has been provided, how receptive parents are, what has or has not been accomplished. This is done in a way that seems entirely consistent with the legal protections accorded patients in substance abuse programs. … To a large extent, I think this is a matter of much better coordination between the folks who treat substance abuse and the folks who protect children. I do think the project is providing better outcomes for the children and their parents, by making necessary info more readily available.”

Communication from NH DCYF attorney, on Project First Step, 6/2003

Benefits for CPS cases when Benefits for CPS cases when children are in out-of-home carechildren are in out-of-home care

Comprehensive assessment with DXAssistance with goal specific case

planningContinued consultationRecommendations for

parents and children

Current Evaluation StatusCurrent Evaluation Status

Since 11/15/99…– 437 families eligible

212 baseline interviews (49%) 151 follow-up interviews (73%)

– 132 SA assessments of Enhanced clients by LADACs (59%)

Percentage of Families Completed Percentage of Families Completed SASSI by SiteSASSI by Site

66%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge

of

Fa

mili

es

Co

mp

lete

d

SA

SS

I

Site

Manchester

Nashua

Status of SA Assessment among Status of SA Assessment among Enhanced ClientsEnhanced Clients

Enhanced Clients assessed = 132 (59% of total assigned)

Equivalent to engagement of client/ or an overestimate?

36% HI DEF . – True extent of engageability or readiness to change

may be more like a third of clients (those assessed and not minimizing). (1/2 x 2/3=1/3 all clients engageable )

– May be the first time anyone has confronted them with assertions of SA.

Study Sample Characteristics: Study Sample Characteristics: Trauma & Co-MorbidityTrauma & Co-Morbidity

Co-MorbidityCo-Morbidity

1/3 of those assessed by SA consultants fall in “High Prob.” range of Substance Dependence Disorder

45% of “high-prob” have a prior diagnosis of mental illness.

Within interview sample, 45% of “high prob.” have clinical levels of depression

16% prior hx of mental illness was documented in initial record data.

Evaluation interviews reveal 45% Clinically Depressed using CESD measure.

Domestic Violence in Initial CPS Domestic Violence in Initial CPS Study ReferralsStudy Referrals

Over half (58%) had a prior Order of Protection at some time

Over 1/3 report DV in current year19% got a protective order on current

partner in the past

Victimization & Trauma Hx. Of AdultVictimization & Trauma Hx. Of Adult

0 20 40 60 80

Physical Attack Stranger

Physical Attack Know

Sexual Assault Know

Sex Assault stranger

Unwanted Sex Know

Mugged

Witness Killing

Chld. Phys. Ab.

Emotional Abuse

Ty

pe

Vic

tim

iza

tio

n

Percent of Respondents

Alcohol Abuse History in Initial CPS Alcohol Abuse History in Initial CPS Referrals (Interview Sample)Referrals (Interview Sample)

 40% of respondents reported drinking 4 > drinks at a time. 1/3> of partners had a history of binge/bender drinking

patterns & a history of aggressive behavior when drinking. Avg. MAST score= 2.2 (range 0-11)

40% attended AA 41% fights while drinking 22% arrested for DUI 28% prior RX history for drinking problem

 

Respondents’ Past Year Drug Use Respondents’ Past Year Drug Use (N=139)(N=139)

0 4 8 12 16 20 24 28

Heroin

Cocaine or Crack

Tranquilizers

Barbiturates

Amphetamines

Marijuana

Ty

pe

of

Dru

g U

se

d

Percent of Respondents that Have Used

DispositionsDispositions

Preliminary Outcomes by GroupPreliminary Outcomes by Group

Enhanced

(n=222)

Standard

(n=215)

Founded Problem Resolved 1.8% 5.1%

Unfounded Closed 86.5% 84.6%

Founded New Case (Court)/ B-Case w/ Services

11.3% 9.3%

Incomplete 0.0% 0.9%

Unfounded, Voluntary Case Opened

0.5% 0.0%

Preliminary Outcomes of Initial Referrals by Group & SitePreliminary Outcomes of Initial Referrals by Group & SiteEnhanced

(n=222) Standard(n=215)

Founded-Problem Resolved Manchester Nashua

0.9%2.6%

5.4%4.8%

B Case Opened, Founded Manchester Nashua

4.7%0.9%

0.9%1.9%

DCYF Founded, Court Dismissed Manchester Nashua

0.0%0.9%

0.9%1.0%

Unfounded, Voluntary Services Manchester Nashua

0.9%0.0%

0.0%0.0%

Founded-New Case Opened Manchester Nashua

11.3%6.0%

6.3%9.6%

Unfounded-Closed Manchester Nashua

82.1%89.7%

85.6%81.7%

Percent of Initial Referrals Founded Percent of Initial Referrals Founded by Groupby Group

13.1% 14.6%0%

50%

100%

Pe

rce

nt

of

Fa

mil

ies

Founded Dispositions

Enhanced

Standard

Final Founded Dispositions of Initial Final Founded Dispositions of Initial Referrals by Group & SiteReferrals by Group & Site

17.1% 12.7% 9.5% 16.5%0%

20%

40%

60%

80%

100%

Pe

rce

nt

of

Fa

mili

es

Manchester Nashua

Enhanced

Standard

Correct Assignment of Subsequent Correct Assignment of Subsequent Referrals by Group & SiteReferrals by Group & Site

92.6%

99.1%

78.3%

88.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Manchester Nashua

Enhanced

Standard

Percentage of Cases Ever Open by Percentage of Cases Ever Open by Group & SiteGroup & Site

22.2%19.3% 19.3%

23.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge

of

Ca

se

s O

pe

ne

d

Manchester Nashua

Enhanced

Standard

Percentage of Cases Open on Percentage of Cases Open on Subsequent Referral by GroupSubsequent Referral by Group

41.7% 46.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f C

as

es

Enhanced

Standard

Enhanced

(n= 228)

Standard

(n= 219)

ANY SUBSEQUENT REFERRALS

MEAN # SUBSEQUENT REFERRALS (“0” INCLUDED)

42.5%

0.94

45.2%

1.03

% & # CASES OPENED ON SUBSEQUENT REFERRALS

7.0% (16) 9.13% (20)

% & # SUBSEQUENT REFERRALS FOUNDED

11% (34) 14.6% (43)

Subsequent Referrals by GroupSubsequent Referrals by Group

Subsequent Referrals by Group & SiteSubsequent Referrals by Group & Site

Enhanced Standard

Manchester Nashua Manchester Nashua

ANY SUBSQ. REFERRALS

MEAN # SUBSQ. REFERRALS,

(“0” INCLUDED)

45.4%

0.95

40.0%

0.93

44.7%

1.08

45.7%

0.98

% & # CASES OPENED ON SUBSQ. REFERRALS

4.6%

(5)

9.2%

(11)

8.8%

(10)

9.5%

(10)% & # SUBSQ. REFERRALS FOUNDED

8.3%

(13)

13.6% (21)

14.9%

(21)

14.3% (22)

Characteristics of Characteristics of Child PlacementsChild Placements

In-Home Services for Families with In-Home Services for Families with Cases by GroupCases by Group

IN-HOME SERVICES* Enhanced Standard

% FAM. ANY IN-HOME SERVICE

MEAN # FAM W/ IN-HOME SERVICE

(“0” INCLUDED)

# OF FAM. RECEIVING IN-HOME SERVICES W/ A VOLUNTARY/B-CASE

12.5%

0.15

2

12.8%

0.13

0

* There are 8 families, in which one child received In-Home Services and was not removed, but another child within that same family was removed.

Out of Home Placement (OHP) Out of Home Placement (OHP) Types by GroupTypes by Group

Enhanced Standard

KIN CARE % FAM. ANY KIN CARE MEAN # FAM. W/ KIN CARE (“O” INCLUDED)

18.7%0.30

17.0%0.21

FOSTER CARE % FAM. ANY FOSTER CARE MEAN # FAM W/ FOSTER CARE (“0” INCLUDED)

58.3%1.67

63.8%2.72

OTHER OHP % FAM. ANY OHP MEAN # FAM W/ OHP (“0” INCLUDED)

22.9%0.77

25.5%0.68

Mean Number of Days in Placement Mean Number of Days in Placement per Family (Includes all Children) by per Family (Includes all Children) by

Group & SiteGroup & Site

825.9941.6 1040.9

1057.1

0

200

400

600

800

1000

1200

Me

an

# o

f D

ay

s

Manchester Nashua

Enhanced

Standard

Mean # of Days in Placement per Mean # of Days in Placement per Family (Includes all Children) by Family (Includes all Children) by LADAC Engaged Groups & SiteLADAC Engaged Groups & Site

941.6

900.5

266.5

1057.1

1039.6

1043.7

0

200

400

600

800

1000

1200

Me

an

# o

f D

ay

s

Manchester Nashua

Standard

Enhanced w/SASSI

Enhanced w/No SASSI

Mean Number of Placements per Mean Number of Placements per Family by Group & SiteFamily by Group & Site

6.29

3.94 4.613.56

0

1

2

3

4

5

6

7

8

9

10

Me

an

# o

f P

lac

em

en

ts

Manchester Nashua

Standard

Enhanced

Mean Number of Placements per Family Mean Number of Placements per Family by LADAC Engaged Groups & Siteby LADAC Engaged Groups & Site

6.29

4.2

2

4.61

2.83

5

0

1

2

3

4

5

6

7

Me

an

# o

f P

lac

em

en

ts

Manchester Nashua

Standard

Enhanced w/ SASSI

Enhanced w/ No SASSI

Mean Number of Children in Mean Number of Children in Placement per Family by LADAC Placement per Family by LADAC

Engaged Groups & SiteEngaged Groups & Site

2.14

1.47

2 1.94 1.92 1.83

0

0.5

1

1.5

2

2.5

3

# o

f C

hild

ren

Manchester Nashua

Standard

Enhanced w/ SASSI

Enhanced w/ No SASSI

Percentage of Families with Children Percentage of Families with Children in Placement by LADAC Engaged in Placement by LADAC Engaged

Groups & SiteGroups & Site

63.6%

71.4%

66.7%

72.0%

75.0%

75.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f F

am

ilie

s in

Pla

ce

me

nt

Manchester Nashua

Standard

Enhanced w/ SASSI

Enhanced w/ No SASSI

Mean Number of Placements per Mean Number of Placements per Child in Placement by LADAC Child in Placement by LADAC

Engaged Groups & SiteEngaged Groups & Site

32.63

1

2.051.65

2.39

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

# o

f P

lac

em

en

ts

Manchester Nashua

Standard

Enhanced w/ SASSI

Enhanced w/ No SASSI

Percentage of Families with TPR by GroupPercentage of Families with TPR by Group

16.7% 8.5%0%

20%

40%

60%

80%

100%

% o

f F

am

ilie

s

Enhanced

Standard

Percentage of Families with TPR by Percentage of Families with TPR by Group & SiteGroup & Site

12.5%

9.1%

20.8%

8.0%

0%

5%

10%

15%

20%

25%

% o

f F

am

ilie

s

Manchester Nashua

Enhanced

Standard

Mean Length to TPR by GroupMean Length to TPR by Group

682.3 783

0

100

200

300

400

500

600

700

800

# o

f D

ay

s

Enhanced

Standard

Mean Length to TPR by Group & SiteMean Length to TPR by Group & Site

600.33

998

731.4568

0

100

200

300

400

500

600

700

800

900

1000

# o

f D

ay

s

Manchester Nashua

Enhanced

Standard

Child OutcomesChild Outcomes

Preliminary Child Outcomes Preliminary Child Outcomes for Index Children ages 4-17for Index Children ages 4-17

CBCL Scores (Caregiver Reports): Mean problem scores decreased for all

subscales, among both Enhanced and Standard Groups

Children in Enhanced Groups had greater declines in 5 of 8 problem categories: – Anxiety & Depression– Withdrawn/Depressed– Somatic Problems– Attention Problems– Aggressive Behavior

Cost NeutralityCost Neutrality

Population measured includes all children Population measured includes all children involved in “Founded/Open” Casesinvolved in “Founded/Open” Cases

Total children in open cases, by group and quarter.

020406080

100120

Standard Open Enhanced/Open

Enhanced/Standard group costs

$-$100,000.00$200,000.00$300,000.00$400,000.00$500,000.00$600,000.00$700,000.00

CUMULATIVE (CUM.) CTRL. - GROSS TOTAL

CUM. EXPER. GRP. CNL - GROSS TOTAL

Treatment Utilization Treatment Utilization & Caretaker & Caretaker OutcomesOutcomes

Wave 2 Counseling & Treatment Wave 2 Counseling & Treatment Utilization Ever-Open Cases: Utilization Ever-Open Cases:

Interview SampleInterview Sample

Referral Made

Attended >1X

%Referrals Completed/

Ongoing RX

Counseling

Standard Enhanced

70% (7/10)

63% ( 12/19)

86% (6/7)

67% (8/12)

50% (5/10)

67% (8/12)

Substance Abuse RX

Standard

Enhanced40% (4/10)

59% (10/17)

100% (4/4)

88% (10/17)

30% (3/10)

50% (5/10)

W1 & W2 RX Utilization by Groups: W1 & W2 RX Utilization by Groups: Interview Sample, Self ReportsInterview Sample, Self Reports

Enhanced Standard

% Resp. attend AA

W1 (ever)

W2 (past yr.)

40% (45/112)

69% (19/28)

43% (43/100)

45% (10/22)

% Resp. help for drinking

W1 (ever)

W2 (past yr.)

25% (28/112)

48% (11/23)

32% (32/100)

43% (6/14)

% Resp. hosp. for drinking

W1 (ever)

W2 (past yr.)16% (18/112)

27% (4/15)

18% (18/100)

11% (1/9)

W1 & W2 RX Utilization by Groups: W1 & W2 RX Utilization by Groups: Interview Sample, R. Reports on PartnerInterview Sample, R. Reports on Partner

Enhanced Standard

% Part. attend AA

W1 (ever)

W2 (past yr.)

31% (20/65)

62% (8/13)

44% (25/57)

46% (6/13)

% Part. help for drinking

W1 (ever)

W2 (past yr.)

25% (16/64)

25% (2/8)

22% (12/65)

43% (6/10)

% Part. hosp. for drinking

W1 (ever)

W2 (past yr.)

16% (9/64)

27% (4/15)

18% (8/54)

11% (1/9)

W1 & W2 Parent Outcomes: W1 & W2 Parent Outcomes: Interview Sample, Self ReportsInterview Sample, Self Reports

Enhanced Standard

% Clinically Depressed

W1

W2

38.2%

34.2

43.8%

34.4

% Heavy Drinking

W1

W2

27%

33%

53%

44%

% Past Year Hard Drug Use

W1

W2

45%

16%

55%

19%

W1 & W2 Parent Outcomes:W1 & W2 Parent Outcomes: Interview Sample, Self ReportsInterview Sample, Self Reports

Enhanced Standard

% Employed FT

W1

W2

33.3%

39.7

30.3%

25.7%*

%Enrolled Educ/Voc. Program

W2 28.2% 16.2%*

Next StepsNext Steps

Apply First Step model to additional district offices– Via IV-E waiver model, or– Alternate funding source

Develop statewide protocol that addresses co-occurrence of child maltreatment & substance abuse

Engage in training/awareness building among essential partners

Parental Substance Abuse and Child Parental Substance Abuse and Child Maltreatment: Evaluation Results From Maltreatment: Evaluation Results From

Project First StepProject First Step

Thank You for your advocacy

and service!