Research, Evidence-Based Programs, and Implications of ...

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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

[email protected]

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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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Risks to Children When Parents Use Methamphetamine

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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


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


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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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Treatment for Methamphetamine

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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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Elements of System Linkages

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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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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


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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


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


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Florida protocols Recovery management approaches

– STARS– SARMS

Stages of Change and Motivational interviewing techniques

Minnesota Parent Partner Network


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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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Models and Evaluations from Across the Country

Family Treatment Drug Courts

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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

70

0.01.1

6.1

0123456789

10

Per

cent

Comparison Court Ordered NationalStandard

Recidivism Rates

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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


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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


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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


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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

Research, Evidence-Based Programs, and Implications of ...

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