Responding to Families: Timelines, Clocks and the Future Nancy K. Young, Ph.D., Director July 14, 2004 Baltimore, MD.

Responding to Families:Responding to Families:Timelines, Clocks and the FutureTimelines, Clocks and the Future

Nancy K. Young, Ph.D., DirectorNancy K. Young, Ph.D., Director

July 14, 2004July 14, 2004Baltimore, MDBaltimore, MD

Responding to Families:Responding to Families:Timelines, Clocks and the FutureTimelines, Clocks and the Future

A Sense of SatisfactionA Sense of Satisfaction

A Sense of UrgencyA Sense of Urgency

We have much to feel good about in our efforts to We have much to feel good about in our efforts to combine forces to help children and families affected combine forces to help children and families affected by substance use disorders and child abuse or neglectby substance use disorders and child abuse or neglect

At the same time, we need a much greater sense of At the same time, we need a much greater sense of urgency in building on these victories to enter into the urgency in building on these victories to enter into the next phase of getting serious and getting to scalenext phase of getting serious and getting to scale

Two Opposing Ideas:Two Opposing Ideas:

1968 1973 1980s 1990s

2004

Timelines

Looking Back

TimelinesTimelines

1968 – Report of alcoholic mothers with babies 1968 – Report of alcoholic mothers with babies with a distinctive, unusual appearance in with a distinctive, unusual appearance in FranceFrance

1973 – Fetal Alcohol Syndrome named by a 1973 – Fetal Alcohol Syndrome named by a team of researchers in Seattleteam of researchers in Seattle

Mid 1970s Mid 1970s Estimate of the number of children of heroin addicts Estimate of the number of children of heroin addicts

and children of alcoholicsand children of alcoholics Fanshel reports substance abuse is common among Fanshel reports substance abuse is common among

families in child welfarefamilies in child welfare

BeginningsBeginnings

TimelinesTimelines

Impact of crack cocaine in urban centersImpact of crack cocaine in urban centers Chasnoff’s group begin to publish research on Chasnoff’s group begin to publish research on

prenatal effects of cocaine prenatal effects of cocaine 1983 National Institute on Drug Abuse (NIDA) 1983 National Institute on Drug Abuse (NIDA)

College on Problems of Drug Dependence College on Problems of Drug Dependence conference – First Poster Session on Children conference – First Poster Session on Children Prenatally-Exposed to CocainePrenatally-Exposed to Cocaine

Early and Mid 1980sEarly and Mid 1980s

Number of children in foster care escalatesNumber of children in foster care escalates

TimelinesTimelines

Mid to Late 1980sMid to Late 1980s

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*

TimelinesTimelines

Mid to Late 1980sMid to Late 1980s 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

Federal Grant Support BeganFederal Grant Support Began National Center on Child Abuse and Neglect National Center on Child Abuse and Neglect

94 programs, including Illinois, Connecticut, New Jersey 94 programs, including Illinois, Connecticut, New Jersey Piloted out-stationing substance abuse counselors in child Piloted out-stationing substance abuse counselors in child

welfare officeswelfare offices

NIDA research effortsNIDA research efforts SAMHSA Specialized women’s treatment programsSAMHSA Specialized women’s treatment programs

Between 1997 and 1999 Between 1997 and 1999 Five National Reports on Substance Abuse and Five National Reports on Substance Abuse and

Child WelfareChild Welfare

TimelinesTimelines

1990s1990s

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 Aubsers (1998)Homes for Children of Substance Aubsers (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

1990s1990s

Many communities began program modelsMany communities began program models

TimelinesTimelines

1990s1990s

Family Treatment CourtsFamily Treatment Courts

Training and Curricula DevelopmentTraining and Curricula Development

Persons in Recovery act as Advocates for ParentsPersons in Recovery act as Advocates for Parents

Multidisciplinary Teams for Joint Case PlanningMultidisciplinary Teams for Joint Case Planning

Counselor Out-stationed at Child Welfare OfficeCounselor Out-stationed at Child Welfare Office

Paired Counselor and Child Welfare WorkerPaired Counselor and Child Welfare Worker

TimelinesTimelines

1990s1990s Efforts by members of Congress and advocacy Efforts by members of Congress and advocacy

groups to ensure that substance abuse issues groups to ensure that substance abuse issues were addressed in the Adoption and Safe were addressed in the Adoption and Safe Families Act (ASFA)Families Act (ASFA)

TimelinesTimelines

Looking at our Achievements

1990s1980s

2004

1.1. Active working relationships and multiple Active working relationships and multiple models of connectionmodels of connection

Courts, Child Welfare Agencies and Treatment Courts, Child Welfare Agencies and Treatment ProvidersProviders

Leadership provided by NCSACW consortium Leadership provided by NCSACW consortium member organizations: member organizations: American Public Human Services Association - APHSAAmerican Public Human Services Association - APHSA Child Welfare League of America - CWLA Child Welfare League of America - CWLA National Association of State Alcohol and Drug Abuse National Association of State Alcohol and Drug Abuse

Directors - NASADADDirectors - NASADAD National Council of Juvenile and Family Court Judges - National Council of Juvenile and Family Court Judges -

NCJFCJ NCJFCJ National Indian Child Welfare Association - NICWANational Indian Child Welfare Association - NICWA

Our Biggest AchievementsOur Biggest Achievements

TimelinesTimelines

2. Leadership of the Federal Government2. Leadership of the Federal Government 1999 Blending Perspectives report, in 1999 Blending Perspectives report, in

response to ASFAresponse to ASFA 1999 Stakeholders forum called for a 1999 Stakeholders forum called for a

central focal point for these effortscentral focal point for these efforts 2000-2001 Regional forums held around 2000-2001 Regional forums held around

the nation the nation 2002 Funding of the National Center on 2002 Funding of the National Center on

Substance Abuse and Child WelfareSubstance Abuse and Child Welfare

Our Biggest AchievementsOur Biggest Achievements

TimelinesTimelines

3. Progress in the Dependency Courts3. Progress in the Dependency Courts Judge McGee in Reno and Judge Parham in Judge McGee in Reno and Judge Parham in

Pensacola Florida apply principles and strategies of Pensacola Florida apply principles and strategies of adult drug courts to dependency proceedings. adult drug courts to dependency proceedings.

Judge Milliken in San Diego initiated the first county-Judge Milliken in San Diego initiated the first county-wide approach to parental substance use disorderswide approach to parental substance use disorders

Our Biggest AchievementsOur Biggest Achievements

TimelinesTimelines

Courts increasingly document their effectivenessCourts increasingly document their effectiveness

The NCJFCJ and NADCP have provided strong The NCJFCJ and NADCP have provided strong foundations for expansion of model courts and foundations for expansion of model courts and development of family treatment courts development of family treatment courts

4. Advances in the accountability agenda4. Advances in the accountability agenda Children’s Bureau’s Child and Family Service Children’s Bureau’s Child and Family Service

Review (CFSR) process Review (CFSR) process

SAMHSA’s Plan to Transition the Substance SAMHSA’s Plan to Transition the Substance Abuse Prevention and Treatment Block Grant Abuse Prevention and Treatment Block Grant (SAPTBG) to a Performance Environment(SAPTBG) to a Performance Environment

TimelinesTimelines

Our Biggest AchievementsOur Biggest Achievements

Missing boxes versus data protocolsMissing boxes versus data protocols

5. Development of a Comprehensive 5. Development of a Comprehensive Framework and Policy ToolsFramework and Policy Tools

10 Element Framework10 Element Framework

Our Biggest AchievementsOur Biggest Achievements

TimelinesTimelines

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: 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

Underlying ValuesUnderlying Values

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

Working with Related Working with Related Agencies and Support Agencies and Support SystemsSystems

Connecting AOD, CWS, Court Systems: 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

Underlying ValuesUnderlying Values

5. Development of a Comprehensive 5. Development of a Comprehensive Framework and Policy ToolsFramework and Policy Tools

10 Element Framework10 Element Framework

Our Biggest AchievementsOur Biggest Achievements

TimelinesTimelines

Collaborative Values InventoryCollaborative Values Inventory Collaborative Capacity InstrumentCollaborative Capacity Instrument Screening and Assessment for Family Screening and Assessment for Family

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

Biggest Challenges:Biggest Challenges:

Clocks still runningClocks still running

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

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, 4-hour a week outpatient Low-dosage, 4-hour a week outpatient programs do not build on what we know about programs do not build on what we know about effective treatment for this populationeffective treatment 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

Findings from TOPPS II Findings from TOPPS II on Status of Childrenon Status of Children

61% of women coming into treatment live with a child less than 18 years old

Among women with children, 31% had a child removed from home due to a child protection court order

Among women who had children removed from home, 41% had parental rights terminated to 1 or more child

8 out of every 100 women had their parental rights terminated

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

CommunicationCommunication – a critical factor in all four of – a critical factor in all four of the systems represented by the four clocks, the systems represented by the four clocks, and in several others that affect these children and in several others that affect these children and familiesand families Frontline workersFrontline workers Program managersProgram managers

Policy officialsPolicy officials

Putting the Four Clocks in SyncPutting the Four Clocks in SyncCommunication, Linkages and PrioritiesCommunication, Linkages and Priorities

Putting the Four Clocks in SyncPutting the Four Clocks in SyncCommunication, Linkages and PrioritiesCommunication, Linkages and Priorities

CommunicationCommunication: Who needs to know what when: Who needs to know what when Communication strategies, protocols, supports and Communication strategies, protocols, supports and

policy that clarifies communication pathwayspolicy that clarifies communication pathways

LinkageLinkage points across systems points across systems 10 elements of system linkages10 elements of system linkages

Confidentiality is usually not about legal barriers, but Confidentiality is usually not about legal barriers, but often more about trustoften more about trust

Encouraging the flow of informationEncouraging the flow of information

Collaboration takes timeCollaboration takes time

PriorityPriority – Community-wide agreement that – Community-wide agreement that these families receive the services they needthese families receive the services they need

Putting the Four Clocks in SyncPutting the Four Clocks in SyncCommunication, Linkages and PrioritiesCommunication, Linkages and Priorities

Real reform is more than a collaboration meeting Real reform is more than a collaboration meeting every monthevery month

Getting clocks connected to each other requires Getting clocks connected to each other requires genuine collaboration… which takes timegenuine collaboration… which takes time

Future TrendsFuture Trends

Four Trends: Pushing the Timeline Four Trends: Pushing the Timeline into the Futureinto the Future

1968 1973 1980s 1990s

2004

1. 1. Substance-Exposed BirthsSubstance-Exposed Births

We are learning more about the enormous costs of We are learning more about the enormous costs of letting most of these babies go home without helpletting most of these babies go home without help

We are learning how powerful early intervention We are learning how powerful early intervention can be in improving the life chances of these can be in improving the life chances of these childrenchildren

We are learning more about how to prevent We are learning more about how to prevent substance-exposed births substance-exposed births

CAPTA AmendmentsCAPTA Amendments

We need a national debate on both “upstream” We need a national debate on both “upstream” prenatal screening and universal screening at birthprenatal screening and universal screening at birth

Future TrendsFuture Trends

2.2. Growth of Family Drug Treatment CourtsGrowth of Family Drug Treatment Courts

Courts and their communities will need to decide Courts and their communities will need to decide how large-scale their interventions need to behow large-scale their interventions need to be

How timely their interventionHow timely their intervention

How to adapt family treatment court strategies to How to adapt family treatment court strategies to prevent child removal among families receiving child prevent child removal among families receiving child welfare serviceswelfare services

Future TrendsFuture Trends

3.3. The Pressures for AccountabilityThe Pressures for Accountability

Only child welfare agencies and treatment providers Only child welfare agencies and treatment providers that develop their capacity to measure their impact that develop their capacity to measure their impact will survive the continuing hard fiscal climate will survive the continuing hard fiscal climate

When resources are scarce, allocating them to When resources are scarce, allocating them to ineffective programs has moral implications and real ineffective programs has moral implications and real consequences for those children and familiesconsequences for those children and families

Redefining “reasonable efforts” based on CFSR Redefining “reasonable efforts” based on CFSR findings that substance abuse services are not findings that substance abuse services are not available for reunification efforts in many states may available for reunification efforts in many states may heighten the focus on the array of available servicesheighten the focus on the array of available services

Future TrendsFuture Trends

4. Family-Centered Policy and Practice4. Family-Centered Policy and Practice

Intervening with families before children need to be Intervening with families before children need to be removed is good economics and good practiceremoved is good economics and good practice

Pew Commission’s recommendations for changing the Pew Commission’s recommendations for changing the financing of the child welfare system to remove incentives financing of the child welfare system to remove incentives for foster care underscore the need for front-end reformsfor foster care underscore the need for front-end reforms

As child welfare links to reforms in home visiting, As child welfare links to reforms in home visiting, family support programs, and school-based family support programs, and school-based interventions, these need to be measured against interventions, these need to be measured against what they have done for the children living with what they have done for the children living with parents with substance use disorders parents with substance use disorders

Future TrendsFuture Trends

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

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

Listening to the voice of a childListening to the voice of a child

““I Have a Dream”I Have a Dream”

Responding to Families:Responding to Families:Timelines, Clocks and the FutureTimelines, Clocks and the Future

This is the Fifth ClockThis is the Fifth Clock