research, evidence-based programs, and implications of
TRANSCRIPT
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Research, Evidence-Based Programs, and Implications of Parental Substance Use Disorders on Child Welfare Practice
Children 2007: Raising Our Voices for Children
February 25, 2007Washington, D.C.
Nancy K. Young, Ph.D.National Center on Substance Abuse and Child Welfare
4940 Irvine Blvd., Suite 202Irvine, Ca 92620
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EXPERIMENT AND USE
ABUSEDEPENDENCE
A Problem for Child Welfare and Court Officers: The most frequently used marker of substance abuse problems
in child welfare and family court does not tell you anything about the individual’s place on the spectrum
SPECTRUM OF ADDICTION
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Persons who Initiated Substance Use by Year
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Children in Foster Care New Cocaine UsersNew Crack Users New Methamphetamine UsersNew Heroin Users
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What is the Relationship?
It is not solely the use of a specific substance that affects the child welfare system; it is a complex relationship between – The substance use pattern– Variations across States and local jurisdictions
regarding policies and practices– Knowledge and skills of workers – Access to appropriate health and social
supports for families
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Key Questions
– How many child welfare cases involve a caregiver with a substance use disorder? (40-80%)
– How many parents in treatment have children?How many are “at risk” for child abuse
or neglect?How many have open cases?
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Parents Entering Publicly-Funded Substance Abuse Treatment
Had a Child under age 18 59%
Had a Child Removed by CPS 22%
If a Child was Removed, Lost Parental Rights 10%
Based on CSAT TOPPS-II Project
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Past Year Substance Use by Youth Age 12 to 17
37.833.6 34.4
21.7
0
5
10
15
20
25
30
35
40
Alcohol Illicit Drug
Ever in Foster Care Not in Foster Care
Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care
Compared to African-American Youth, Caucasians were more likely to use alcohol (41.4% versus 29.8%) and illicit drugs (36.2% versus 26.7%)
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Percent of Youth Ages 12 to 17 Needing Substance Abuse Treatment by Foster Care Status
10.4
5.9
13.1
5.3
17.4
8.8
02
46
8
1012
1416
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Need for AlcoholTreatment
Need for Illicit DrugTreatment
Need for Alcohol orIllicit Drug Treatment
Ever in Foster Care Not in Foster Care
Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care
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Different Situations for Children
Parent uses or abuses methamphetamine
Parent is dependent on methamphetamine
Parent “cooks” small quantities of meth
Parent involved in trafficking
Parent involved in super lab
Mother uses meth while pregnant
Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005
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Each situation poses different risks and requires different responses
Child welfare workers need to know the different responses required
The greatest number of children are exposed through a parent who uses or is dependent on the drug
Relatively few parents “cook” the drug
Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005
Different Situations for Children
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2000 2001 2002 2003*
Number of incidents 8,971 13,270 15,353 14,260
Incidents with children present
1,803 2,191 2,077 1,442
Children residing in labs 216 976 2,023 1,447
Children affected** 1,803 2,191 3,167 3,419
Children exposed totoxic chemicals
345 788 1,373 1,291
Children taken into protective custody
353 778 1,026 724
Children injured 12 14 26 44
Children killed 3 0 2 3
4 years = 2,881; all children ~1,000,000
Number of Children in Meth Labs2004 2005
3,088 1,647
13 11
3 2
*The 2003 number of incidents is calendar year, while the remaining data in the column are for fiscal year**Data for 2000 and 2001 may not show all children affected
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Mother Uses While Pregnant
Scope of the problem:
– An estimated 10% to 11% of all newborns are prenatally exposed to drugs or alcohol, which is approximately 50,000 infants per year in California
– Only about 5% of prenatally exposed newborns are placed in out-of-home care; the rest go home without assessment and services
Sources: Vega; SAMHSA, OAS, National Survey of Alcohol and Drug Use During Pregnancy, 2002 and 2003
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Substance Abuse Pattern of Pregnant Methamphetamine Users
Women who use meth/cocaine in the first trimester are more likely to use during the third trimester
Nicotine use is universal among drug-using pregnant women
Marijuana and alcohol are secondary drugs, used in 60% of the group
Source: Dr. Rizwan Shah, presented at NASADAD Annual Meeting, June 2005
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Mother Uses Meth While Pregnant
Risk to child depends on frequency and intensity of use, and the stage of pregnancy
Risks include birth defects, growth retardation, premature birth, low birth weight, brain lesions
Problems at birth may include difficulty sucking and swallowing, hypersensitivity to touch, excessive muscle tension (hypertonia)
Long term risks may include developmental disorders, cognitive deficits, learning disabilities, poor social adjustment, language deficits
Sources: Anglin et al. (2000); Oro & Dixon, (1987); Rawson & Anglin (1999); Dixon & Bejar (1989); Smith et al. (2003); Shah (2002)
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Mother Uses Meth While Pregnant
Observed effects may be due to other substances, or combination of substances, used by the mother
– For example, if the mother also smokes, growth retardation may be significant
Observed effects may be complicated by other conditions, such as the health, environmental, or nutritional status of the mother
Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005
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Mother Uses While Pregnant
Shah, R. (2005, June). From NASADAD presentation
Home environment is the critical factor in the child’s outcome
Consequences can be mediated
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Alcohol
MarijuanaTobacco
Inhalants
Downers
HallucinogensPCP
CocaineMethamphetamine
OpiatesTranquilizers
Ecstasy
Crack
Source: M.L. Brecht, Ph.D., presented at NASADAD Annual Meeting, June 2005
Average Age First Use of Substance
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Histories of Violence among Clients Treated for Methamphetamine
Persons in treatment for methamphetamine reported high rates of violence85% women vs. 69% men
The most common source of violence:For women, was a partner (80%)For men, was strangers (43%)
History of sexual abuse and violence:57% women vs. 16% men
Source: Cohen, J. (2003)
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7
36
62
29
64
84
0 20 40 60 80 100
Sexual Abuse***
PhysicalAbuse***
Emotional Abuse
% Men % Women
*** significant difference between women and men p < .001Judith Cohen, Ph.D. Presentation to NASADAD June 2005
Abuse During Lifetime from a Women’s Treatment Population
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Prevalence of Co-Occurring Problems, and Violence and Trauma
Women in treatment 2 times more likely to have history of sexual and physical abuse than general population
Women who are dependent on meth usually have more severe problems than their male counterparts in many areas of their life
Speaks to the need for comprehensive, and trauma-related services
Source: CSAT TIP 36
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Gender Differences and Implications for Treatment
Co-occurring mental health issues complicate treatment and require longer duration for treatment
Violence linked to meth use is related to trauma and safety needs which must be addressed in treatment
Body image and nutrition need to be addressed
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Matrix Model
– Intensive outpatient setting
– Three to five visits per week of comprehensive counseling for at least the first three months
– Cognitive behavioral approach
– Contingency management
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Similar Outcomes
Treatment outcomes do not differ from other drugs of abuse
Treatment outcomes have more to do with the quantity and quality of treatment than type of drug abused
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A framework for defining elements of collaboration
To define linkage points across systems
To describe the components of the initiative
Methods to assess effectiveness of collaborative work
To assess the progress in implementation
To assist sites in measuring their implementation
Navigating the Pathwayspublished by CSAT
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In-Depth Technical Assistance
Round 1– Colorado– Florida– Michigan– Virginia
Round 2– Arkansas– Massachusetts– Minnesota– Squaxin Island Tribe
Round 3– New York ‒ Texas ‒ Maine (partial)
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Framework and Policy Tools for Systems Change
– 10 Element Framework– Matrix of Progress in Linkages– Collaborative Values Inventory– Collaborative Capacity Instrument– Screening and Assessment for
Family Engagement, Retention and Recovery -- SAFERR
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Framework and Policy Tools for Systems Change
– 10 Element Framework– Matrix of Progress in Linkages– Collaborative Values Inventory– Collaborative Capacity Instrument– Screening and Assessment for
Family Engagement, Retention and Recovery -- SAFERR
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10 Element Framework
Underlying values Daily practice −
screening and assessment
Daily practice − client engagement and retention in care
Daily practice − AOD services to children
Joint accountability and shared outcome
Information systems Training and staff
development Budgeting and
program sustainability Working with related
agencies Building community
supports
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Issues to Address Who is the client -- Parent, Child, Family?
Can AOD users/abusers be effective parents?
What is the goal -- Recovery, child safety, family preservation, economic self-sufficiency?
10 Element FrameworkUnderlying Values
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Common Strategies Identify and resolve differences that exist
across system
Ensure conversation happens at policy, supervisory and front-line levels
Develop common principles for working together
10 Element FrameworkUnderlying Values
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Studies conducted on brief screens of six or less items suggest that there are a limited number of common constructs
An effective screen of substance use disorders includes questions about:– Unintended use– Desire to restrict use– Consequences of use– Concern about consequences of use
10 Element FrameworkDaily Practice – Screening and Assessment
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Issues to Address Time, Time, Time – reconcile the clocks
Roles and responsibilities across systems Key role of parent’s attorney
Communication paths across systems
Incentives for prioritization
Missing box problem
10 Element FrameworkDaily Practice – Screening and Assessment
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10 Element FrameworkDaily Practice – Screening and Assessment
Common Strategies Clarify intake procedures and AOD/child safety
screening protocols
Decide on team, tool, method, roles and responsibilities to– Provide AOD expertise to Child Welfare Workers
in investigation/assessment– Ensure parents seeking treatment receive
needed supports for child safety
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• In the past year, have you ever drank or used drugs more than you meant to?
• Have you ever neglected some of your usual responsibilities because of using alcohol or drugs?
• Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
• Has anyone objected to your drinking or drug use?• Have you ever found yourself preoccupied with wanting to
use alcohol or drugs?• Have you ever used alcohol or drugs to relieve emotional
discomfort, such as sadness, anger, or boredom?
Use of UNCOPE in Oregon, Washington and Maine
10 Element FrameworkDaily Practice – Screening and Assessment
Norm Hoffman, Ph.D. - Evince
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Issues to Address Time, Time, Time
Outreach and engagement strategies
Addressing motivation to change
Cross-system agreement on approaches to relapse
Responding to clients’ progress in treatment
10 Element FrameworkDaily Practice – Engagement and Retention
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Common Strategies Re-configure staffing patterns
Implement assessment and interventions based on readiness to change
Develop mechanism to re-engage clients in care
Ensure AOD treatment and CPS practice is responsive to clients’ individualized needs
10 Element FrameworkDaily Practice – Engagement and Retention
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Florida protocols Recovery management approaches
– STARS– SARMS
Stages of Change and Motivational interviewing techniques
Minnesota Parent Partner Network
10 Element FrameworkDaily Practice – Engagement and Retention
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Screening project for FASD among the children of the Santa Clara County Family Drug Treatment Court (California)
Use of Celebrating Families! curriculum to educate families about the impact of substance dependence on families– Four groups – adolescents, pre-adolescents,
children and parents – meet separately, but receive the same information
10 Element FrameworkDaily Practice – Services to Children
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Joint Accountability, Shared Outcomes and Information Systems– Michigan revised SACWIS to prioritize
families with substance use disorders– CFSR and NOMS processes
10 Element Framework
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Framework and Policy Tools for Systems Change
– 10 Element Framework– Matrix of Progress in Linkages– Collaborative Values Inventory– Collaborative Capacity Instrument– Screening and Assessment for
Family Engagement, Retention and Recovery -- SAFERR
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Framework and Policy Tools for Systems Change
– 10 Element Framework– Matrix of Progress in Linkages– Collaborative Values Inventory– Collaborative Capacity Instrument– Screening and Assessment for
Family Engagement, Retention and Recovery -- SAFERR
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Family Drug Treatment Court Models
Integrated (e.g., Santa Clara, Reno, Suffolk)
Dual Track (e.g., San Diego)
Parallel (e.g., Sacramento)
Cross-Court Team (e.g., Orange County, CA)
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Common Ingredients of Family Treatment Courts
System of identifying families Earlier access to assessment and
treatment services Increased management of recovery
services and compliance System of incentives and sanctions Increased judicial oversight
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FTDC Evaluation – NPCImplications
Entry time – time to FTDC entry and time to treatment entry meant increased likelihood of FTDC graduation, longer treatment stays and treatment completion
Completion – FTDC graduation, longer stays in treatment, and treatment completion meant more likely to reunify and less likely to TPR
Implications – engagement and retention of parents in FTDC and treatment is critical
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Five Components of Reform
1. Comprehensive cross-system joint training2. Substance Abuse Treatment System of Care3. Early Intervention Specialists4. Recovery Management Specialists (STARS)5. Dependency Drug Court
Reforms have been implemented over the past eleven years
Sacramento County’s Comprehensive Reform
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Jurisdiction& Disposition
Hearings
Detention Hearing
Child in Custody
STARSVoluntary
Participation
STARSCourt OrderedParticipation
Level 1DDC
Hearings30
Days60
Days90
Days
Level 3Monthly Hearings
Level 2
Weekly or Bi-Weekly Hearings
180 DaysGraduation
Early Intervention Specialist (EIS) Assessment &Referral to STARS
Court Ordered to
STARS & 90 Days of DDC
Sacramento County Dependency Drug Court Model
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53.2
84.8
0
20
40
60
80
100
Pe
rce
nt
Comparison (n=111) DDC (n=1738)
***p<.001
Treatment Admission Rates***
65***p<.001
50.3
71.366.1
60.2 61.9
49.7
28.733.9
39.8 38.1
0
20
40
60
80
Perc
ent
Satisfactory Unsatisfactory
Heroin (n=181) Alcohol (n=623)Methamphetamine (n=2039) Cocaine/Crack (n=465)Marijuana (n=465)
Treatment Discharge Status by Primary Drug Problem***
66
27.2
43.6
31.822.6
13.34.5 1.7
14.018.5
3.3
0
20
40
60
80
Pe
rce
nt
Reunification*** Adoption** Guardianship*** ContinuedReunificationServices***
Long-TermPlacement***
Comparison (n=173) DDC (n=1346)**p<.01; ***p<.001
24-Month Child Placement Outcomes
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300.7280.8
0
50
100
150
200
250
300
350
Day
s
Comparison (n=47) DDC (n=587)
n.s.
Time to Reunification at 24 Months
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24-Month Cost Savings Due to Increased Reunification Rates
Preliminary Findings
Takes into account the reunification rates, time of out-of-home care, time to reunification, and cost per month
27.2% - Reunification rate for comparison group children 43.6% - Reunification rate for court-ordered DDC group children 221 Additional DDC children reunified
33.1 – Average months in out-of-home care for comparison group children
9.4 - Average months to reunification for court-ordered DDC children
23.7 month differential
$10,049,036 Estimated Savings in Out-of-Home care costs
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Models and Evaluations from Across the Country
Substance Abuse Specialists in Child Welfare and the Courts
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Mid to late 1990s – Practice Models
Many communities began program models
ᅳ Paired Counselor and Child Welfare Worker
ᅳ Counselor Out-stationed at Child Welfare Office
ᅳ Multidisciplinary Teams for Joint Case Planning
ᅳ Persons in Recovery act as Advocates for Parents
ᅳ Training and Curricula Development
ᅳ Family Treatment Courts
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Mid to late 1990s – Practice Models
Many communities began program models
ᅳ Paired Counselor and Child Welfare Worker
ᅳ Counselor Out-stationed at Child Welfare Office
ᅳ Multidisciplinary Teams for Joint Case Planning
ᅳ Persons in Recovery act as Advocates for Parents
ᅳ Training and Curricula Development
ᅳ Family Treatment Courts
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Substance Abuse Title IV-E Waiver Project Evaluations
Focused on early identification of parental substance use disorders and service referrals – Delaware – co-located staff– Maryland – Family Support Service Teams– New Hampshire – CD contracted staff on-site
Emphasized the recovery of caregivers not yet in treatment but whose children had already been removed– Illinois – Recovery Coaches
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Challenges– Referrals and enrollment– Inadequate worker training and education
and staff turnover Training, tools and appropriate interventions
– Service coordination, strong managerial support, and consistent cross-system communication
– Information tracking systems
Substance Abuse Title IV-E Waiver Project Evaluations
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Challenges– Permanency and reunification outcomes
were more difficult to affect than treatment access, engagement and retention outcomes
– Differences in system management styles and professional philosophies
– Improved identification must be accompanied by access to adequate and appropriate substance abuse treatment resources
Substance Abuse Title IV-E Waiver Project Evaluations
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Successes– Illinois had the highest success in connecting
parents to treatment (73% vs. 50%)– Delaware CPS units in which supervisors took
an active role in reviewing cases and in directly referring cases to substance abuse counselors had the smoothest, most consistent referral process.
– Delaware and Illinois demonstrated positive effects on length of time in foster care placement
Substance Abuse Title IV-E Waiver Project Evaluations
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Lessons and ChallengesProgram Structure
Purpose Roles
– Referral and Brokering– Clinical Consultation and Interpretation– Engaging Clients in Treatment– Cross-training– Creating Awareness
Setting
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Underlying values and principles Funding
– Budgeting and program sustainability Outcomes and evaluation
– information systems– joint accountability – shared outcomes
Training and staff development
Lessons and ChallengesCollaborative Structure
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The four questions:
1. Where are the data that tells the story? Begin to monitor the population in all three
information systems – CWS, ADS, Court
2. Who do we need to succeed? Find one key partner who’s not at the table now
3. Where’s the real money? Get a redirection agenda
4. Who are the champions? Recruit policy leaders who will endorse the effort