Transcript Arizona - Philadelphia University

Improving Outcomes for
Families Affected by
Substance Use Disorders
Presented at 9th Annual Conference of the
Association of Alcoholism and Substance Abuse
Providers of New York State
STRENGTHENING FAMILIES AND
EMPOWERING COMMUNITIES
January 31, 2006
www.ncsacw.samhsa.gov
National Center on Substance Abuse
and Child Welfare
Power Point at
www.cffutures.org
Children and Family Futures
A Program of the
Substance Abuse and Mental Health
Services Administration
Center for Substance Abuse Treatment
and the
Administration on Children, Youth and Families
Children’s Bureau
Office on Child Abuse and Neglect
Mission

To improve outcomes for families by promoting
effective practice, and organizational and
system changes at the local, state, and national
levels


Developing and implementing a
comprehensive program of information
gathering and dissemination
Providing technical assistance
Recent Products

Understanding Substance Abuse and Facilitating
Recovery: A Guide for Child Welfare Workers
(A short monograph for front-line workers)

On-Line Training – Now Available
 Understanding Child Welfare and the Dependency
Court: A Guide for Substance Abuse Treatment
Professionals
 Understanding Substance Use Disorders, Treatment
and Family Recovery: A Guide for Child Welfare
Professionals
Visit
www.ncsacw.samhsa.gov
Program of In-Depth Technical Assistance

Fifteen months of in-depth work with a State
Team to develop practice protocols and
policies that improve outcomes for families
 Round 1 – 2003/2004
Colorado Florida Michigan Virginia

Round 2 – 2004/2006
Arkansas Massachusetts Minnesota
Squaxin Island Tribe

Round 3 – 2006/2007
New York
Texas
Four Sites with a less intensive level of support
Program of In-Depth Technical Assistance

Fifteen months of in-depth work with a State
Team to develop practice protocols and
policies that improve outcomes for families
 Round 1 – 2003/2004
Colorado Florida Michigan Virginia

Round 2 – 2004/2006
Arkansas Massachusetts Minnesota
Squaxin Island Tribe

Round 3 – 2006/2007
New York
Texas
Four Sites with a less intensive level of support
ANNOUNCING

Putting the Pieces Together for Children and Families:
Second National Conference on Substance Abuse, Child
Welfare and the Courts

January 30, 2007
Pre-conference symposium on substance-exposed
infants with Dr. Ira Chasnoff


January 31 to February 2, 2007


National Conference
Disneyland Hotel, Anaheim California

Sign up for information at
[email protected]
Children of Parents with
Substance Use Disorders
So how many are there?
Living with parent
Parent entered treatment
Mother used while pregnant
Children Living with One or More
Substance-Abusing Parent
500,000 NY Children Living with Parent
About 33,000 in Out-of-Home Care for Child Abuse/Neglect in 2003
Used Illicit Drug in Past Year
10.6
Used Illicit Drug in Past Month
8.4
Dependent on Alcohol and/or Needs
Treatment for Illicit Drugs
8.3
Dependent on AOD
7.5
Dependent on Alcohol
6.2
Dependent on Illicit Drugs
2.8
Need Treatment for Illicit Drug Abuse
Numbers indicate millions
4.5
0
2
4
6
8
10
12
COSAs and Child Abuse/Neglect Victims
Living with
Alcoholic/Addict
Parent
8.3
Abuse/Neglect
Reports
3.0
1.8
Investigations
Substantiated
Victims
Placed in Out of
Home Care
In Millions
0.5
0.2
0
2
4
6
8
10
Parent Entered Treatment
New York and U.S. Gender Split
80%
70%
60%
75%
70%
50%
40%
30%
20%
25%
30%
10%
0%
Male
New York
Female
United States
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
Based on CSAT TOPPS-II Project
10%
Estimated New York Parents Entering
Publicly-Funded Treatment – 286,000

Had a Child under age 18

Had a Child Removed by CPS

If a Child was Removed, Lost
Parental Rights
Based on CSAT TOPPS-II Project
168,700
40,490
~ 4,500
New York Data on Children
Family History Variable

Marital Status 􀂉 Married 􀂉 Never Married 􀂉
Living as Married 􀂉 Separated 􀂉 Divorced 􀂉
Widowed

Child of Alcoholic/Substance Abuser 􀂉 No 􀂉
Both 􀂉 Child of Alcoholic(s) 􀂉 Child of
Substance Abuser(s)
45% of Persons Admitted

No. of children ___



No. of children living with Client ___
No. of Children living in Foster Care ___
Case with Child Protective Services 􀂉 Yes 􀂉 No
Mother Used While Pregnant
Last Statewide Study
1992 in California
Use During Pregnancy
SAMHSA, Office of Applied Studies, National Survey on Drug Use
and Health, 2002 and 2003, applied to New York 2003 birth data
Substance Used
(Past Month)
1st Trimester
Any Illicit Drug
7.7% women
19,481 infants
Alcohol Use
19.6% women
49,588 infants
Binge Alcohol
Use
10.9% women
27,577 infants
2nd Trimester
3rd Trimester
Use During Pregnancy
SAMHSA, Office of Applied Studies, National Survey on Drug Use
and Health, 2002 and 2003, applied to New York 2003 birth data
Substance Used
(Past Month)
1st Trimester
2nd Trimester
Any Illicit Drug
7.7% women
19,481 infants
3.2% women
8,100 infants
Alcohol Use
19.6% women
49,588 infants
6.1% women
15,400 infants
Binge Alcohol
Use
10.9% women
27,577 infants
1.4% women
3,500 infants
3rd Trimester
Use During Pregnancy
SAMHSA, Office of Applied Studies, National Survey on Drug Use
and Health, 2002 and 2003, applied to New York 2003 birth data
Substance Used
(Past Month)
1st Trimester
2nd Trimester
3rd Trimester
Any Illicit Drug
7.7% women
19,481 infants
3.2% women
8,100 infants
2.3% women
5,800 infants
Alcohol Use
19.6% women
49,588 infants
6.1% women
15,400 infants
4.7% women
11,900 infants
Binge Alcohol
Use
10.9% women
27,577 infants
1.4% women
3,500 infants
0.7% women
1,800 infants
State prevalence studies report 10-12% of infants or
mothers test positive for alcohol or illicit drugs at birth
Use During Pregnancy
SAMHSA, Office of Applied Studies, National Survey on Drug Use
and Health, 2002 and 2003, applied to New York 2003 birth data
Substance Used
(Past Month)
1st Trimester
2nd Trimester
3rd Trimester
Any Illicit Drug
7.7% women
19,481 infants
3.2% women
8,100 infants
2.3% women
5,800 infants
Alcohol Use
19.6% women
49,588 infants
6.1% women
15,400 infants
4.7% women
11,900 infants
Binge Alcohol
Use
10.9% women
27,577 infants
1.4% women
3,500 infants
0.7% women
1,800 infants
New York Children Affected
Parent is alcohol dependent or need treatment:
About 500,000 New York children affected
Parents in Treatment:
About 168,000 New York Treatment Admissions
Were parents of minor children
Mother uses while pregnant:
About 25,000 New York infants affected per year
How Big a Problem are Substance
Use Disorders in CWS Caseloads?
 We
don’t really have the numbers…
Let’s look at the overall foster care
population over time…
Foster Care Population
End of Each Federal Fiscal Year
ASFA
600,000
500,000
400,000
300,000
200,000
100,000
0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Children in Foster Care
Foster Care Population and Persons Who First
Used Crack in Prior Year
600,000
600,000
500,000
500,000
400,000
400,000
300,000
300,000
200,000
200,000
100,000
100,000
0
0
1985198619871988198919901991199219931994199519961997199819992000200120022003
Children in Foster Care**
New Crack Users*
Foster Care Population and Persons Who First
Used Crack or Methamphetamine in Prior Year
600,000
600,000
500,000
500,000
400,000
400,000
300,000
300,000
200,000
200,000
100,000
100,000
0
0
1985198619871988198919901991199219931994199519961997199819992000200120022003
Children in Foster Care**
New Crack Users*
New Methamphetamine Users*
New York State Foster Care
In Care, Admissions and Discharges
50000
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
1999
2000
2001
In Care
Source: New York State Monitoring and Analysis Profiles (2003)
2002
Admissions
2003
New York Child Victims by Age Group 2003
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
Age 0-3
Source: Child Maltreatment 2003
Age 4-7
Age 8-11
Age 12-15
Age 16-17
Children in Foster Care by Age Group 2003
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Age <2
Age 2-5
Age 6-9
New York State
Source: New York MAPS (2003)
Age 10-13
Age 14-17
New York City
Age 18+
Past Year Substance Use
by Youth Age 12 to 17
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%)
40
35
30
37.8
33.6
34.4
25
20
21.7
15
10
5
0
Alcohol
Ever in Foster Care
Illicit Drug
Not in Foster Care
Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care
Percent of Youth Ages 12 to 17
Needing Substance Abuse Treatment
by Foster Care Status
18
16
17.4
14
12
10
8
13.1
10.4
8.8
6
4
5.9
5.3
2
0
Need for Alcohol Need for Illicit Need for Alcohol
Treatment
Drug Treatment
or Illicit 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
How Big a Problem are Substance
Use Disorders in CWS Caseloads?
 We
don’t have good data…
 The
“missing box” problem means data is
not readily available in most states and
communities
 Most
practitioners agree, and federal
government reported that at least 1/3 of
referrals and 2/3 of removals involve
families with a substance use disorder
Estimates of AOD Problems
Among Parents in Child Welfare
 Research
studies vary based on:

Definition of substance abuse

Population (rural versus urban)

Sample (in-home versus out of home)
Risks for Children
 Parent
uses or abuses drugs and/or alcohol
 Parent
is dependent on drugs and/or alcohol
 Special
circumstances involving
methamphetamine and manufacturing


Parent “cooks” small quantities of meth
Parent involved in super lab
 Parent
involved in trafficking
 Mother
uses while pregnant
Risks for Children
How does Child Welfare Assess for the Differences?
 Parent
uses or abuses drugs and/or alcohol
 Parent
is dependent on drugs and/or alcohol
 Special
circumstances involving
methamphetamine and manufacturing


Parent “cooks” small quantities of meth
Parent involved in super lab
 Parent
involved in trafficking
 Mother
uses while pregnant
Substance Exposed Infants
2003 Estimated Number of Children Prenatally
Exposed to Substances in New York
Total births
253,000
10% of total births
25,300
Total child victims
under age 1 year
6,300 25%
Total age 0-2 years in OOHC =
2,400
Where did they all go?
MOST GO HOME.
80-95% are undetected and go home
without assessment and needed services.
 Many doctors and hospitals do not test, or may have
inconsistent implementation of state policies
 Tests detect only very recent use
 Inconsistent follow-up for woman identified as AOD using
or at-risk, but with no positive test at birth
 CAPTA legislation raises issues of testing and reporting
to CPS
Child Abuse Prevention and Treatment Act
(CAPTA) 2003 Amendments
2003 Keeping Families Safe Act Amendments
 Policies and procedures (including appropriate referrals to child
protection service systems and for other appropriate services) to address
the needs of infants born and identified as affected by illegal
substance abuse or withdrawal symptoms resulting from prenatal
drug exposure, including a requirement that health care providers
involved in the delivery or care of such infants notify the child
protective services system of the occurrence of such condition in
such infants, except that such notification shall not be construed to (I)
establish a definition under Federal law of what constitutes child abuse;
or (II) require prosecution for any illegal action (section 106(b)(2)(A)(ii));
 The development of a plan of safe care for the infant born and identified
as being affected by illegal substance abuse or withdrawal symptoms
(section 106(b)(2)(A)(iii))
Child Abuse Prevention and Treatment Act
(CAPTA) 2003 Amendments
2003 Keeping Families Safe Act Amendments
 Policies and procedures (including appropriate referrals to child
protection service systems and for other appropriate services) to address
the needs of infants born and identified as affected by illegal
substance abuse or withdrawal symptoms resulting from prenatal
drug exposure, including a requirement that health care providers
involved in the delivery or care of such infants notify the child
protective services system of the occurrence of such condition in
such infants, except that such notification shall not be construed to (I)
establish a definition under Federal law of what constitutes child abuse;
or (II) require prosecution for any illegal action (section 106(b)(2)(A)(ii));
 The development of a plan of safe care for the infant born and identified
as being affected by illegal substance abuse or withdrawal symptoms
(section 106(b)(2)(A)(iii))
Screening and Assessment of
Consequences for Children
The complexity of screening and assessment for these
children is compounded by at least two realities:

There is no absolute profile of developmental
outcomes based on a child’s exposure to his or her
parents’ substance use, abuse, or dependence.

Other problems arising in parental behavior,
competence, and disorders interact with substance
use, abuse, and dependence to cause multiple cooccurring problems in the lives of these children.
Five Points of Intervention for Policy and Practice
with Substance Exposed Infants
1. Pre-pregnancy awareness of
substance use effects
2. Prenatal screening
and assessment
Child
4. Ensure infant’s safety and
respond to infant’s needs
5. Identify and respond
to the needs of
●
Infant
● Child
● Preschooler
●
Adolescent
3. Identification
at Birth
Initiate enhanced
prenatal services
Parent
System
Linkages
Respond to family’s
needs
System
Linkages
Identify and respond
to family’s needs
Key Barriers Between Substance
Abuse, Child Welfare, and the Courts

Beliefs and values

Competing priorities

Treatment gap

Information systems

Staff knowledge and skills

Lack of communication

Different mandates
Models of Improved Services
 Many communities began program models in
1990s
 Paired Counselor and Child Welfare Worker
 Counselor Out-stationed at Child Welfare Office
 Multidisciplinary Teams for Joint Case Planning
 Persons in Recovery act as Advocates for Parents
 Training and Curricula Development
 Family Treatment Courts
More Advanced Models of Team Efforts

Workers out-stationed in collaborative settings: at
courts, at CWS agencies, at treatment agencies

Increased recovery management and monitoring
of recovery progress

New methods and protocols on sharing
information

Increased judicial oversight and family drug
treatment courts

New priorities for treatment access for child
welfare-involved families

New responses to children’s needs
Lessons and Challenges of
Out-stationed Substance Abuse Counselors
Roles and Responsibilities
1. Referral and Brokering
2. Clinical Consultation and
Interpretation
3. Engaging Clients in Treatment
4. Cross-training
5. Creating Awareness
Lessons and Challenges of
Out-stationed Substance Abuse Counselors
Environment and Context
 Who Is the Customer?
 Specific Qualifications
 Clear Policies, Protocols and Location
 Clear Supervisory Relationships
 Clear Functions for the Substance
Abuse and Child Welfare Agencies
and/or the Overall County
Family Drug Treatment Court Models
•
Integrated (e.g., Santa Clara, Reno, Suffolk)
•
•
Both dependency matters and recovery management
conducted in the same court with the same judicial
officer
Dual Track (e.g., San Diego)
•
•
Dependency matters and recovery management
conducted in same court with same judicial officer
during initial phase
If parent is noncompliant with court orders, parent may
be offered DDC participation and case may be
transferred to a specialized judicial officer who
increases monitoring of compliance and manages only
the recovery aspects of the case
Family Drug Treatment Court Models
•
Parallel (e.g., Sacramento)
•
•
•
•
Dependency matters are heard on a regular family
court docket
Specialized court services offered before
noncompliance occurs
Compliance reviews and recovery management heard
by a specialized court officer
Cross-Court Team (e.g., Orange County, CA)
•
•
•
Dependency and recovery matters are heard by same
court
Recovery management, child welfare services, legal
representation assigned to a team
Team works in six courts with separate
judges/commissioners
Models are not Not Yet Reformed Systems
Emergence of Family Based Treatment…
Emergence of Family Based Treatment
 Women’s

Strategies still largely based on male models
 Women

programming 1970s - 80s
and children 1990s
Increased recognition of specific needs for
women – Trauma and Co-occurring disorders
 Children’s


intervention needs – Early 2000s
Significant therapeutic needs of children
Poor parenting skills and minimal attachment
ability
Moving Toward Family Based Treatment
 Challenges


Defining who is the family member
How many and ages of children in programs
• Logistics, milieu and clinical reasons

Incorporating fathers in treatment milieu
• Preventing further trauma of family divisions and
separations
Continuum of Family Based Treatment
Level One
Serve women
•Family relationships framework is built into
service delivery
Continuum of Family Based Treatment
Level Two
Serve women and children
•Child care – often through co-op
babysitting
•Treatment plan includes parenting and
family relationships
Continuum of Family Based Treatment
Level Three
Serve women and children
•Therapeutic needs of children are
recognized
•Parenting and family relationships are part
of treatment plan
•For families in child welfare services, dual
role of supporting recovery and ensuring
health and safety of children
Continuum of Family Based Treatment
Level Four
Serve women and children
•Therapeutic needs of children are
recognized and they have own
treatment/therapeutic goals
•Fathers and/or significant others receive
services in support of the woman’s
recovery
Continuum of Family Based Treatment
Level Five
Serve women, children and family members
they define as their family
•All members of family unit have individualize
treatment plans
•Focus is on family members and the family
system as a whole
•Community supports including domestic
violence, employment and re-entry services
are addressed
Comprehensive Family Based Services
Characteristics and Principles

Safety comes first


For each family member
Comprehensive

Clinical treatment, clinical supports and community
supports

Family members are defined by the participant
 Based on unique needs and resources of
individual families
 Treatment is dynamic

Not everyone comes together for pre-determined
length of treatment episode
Comprehensive Family Based Services
Characteristics and Principles
 Conflict
is inevitable but resolvable
 Substance use disorders are viewed as
chronic, but treatable
 Treatment content acknowledges and
focuses on the importance of attachment
and relationships to others while helping
family to function as a whole
 Services are gender responsive and
specific
 Services are culturally competent
Comprehensive Family Based Services
Characteristics and Principles
 Requires
an array of staff professionals in
an environment of mutual respect and
shared training
 Treatment supports creation of healthy
family systems with appropriate roles and
good communication
 REQUIRES CROSS-SYSTEM
COLLABORATIVE RELATIONSHIPS
Navigating the Pathways
TAP 27 published by CSAT
Established:
 A framework for defining elements of
collaboration
 Methods to assess effectiveness of
collaborative work
Framework and Policy Tools for
Systems Change
 To define linkage points across systems
 To describe the components of the
initiative
 To assess the progress in implementation
 To assist sites in measuring their
implementation
Framework and Policy Tools for
Systems Change
 10 Element Framework
 Collaborative Values Inventory
 Collaborative Capacity Instrument
 Matrix of Progress in Linkages
 Screening and Assessment for Family
Engagement, Retention and Recovery -SAFERR
Elements of System Linkages

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
Visit www.ncsacw.samhsa.gov
for Examples from States to Implement these Elements
The Voice of a Child
Nothing But Silence
By Ashley G.
Age 12
January 2005
Nothing But Silence
People all around me
Calling out my name
But no I cannot hear them
For my heart is filled with shame
Nothing but silence
But only till the break of dawn
Will I be feeling sad
For wandering out on the streets
Are my birth mom and dad
Why’d she do this to her and me
With this we’ll have to cope
But while she’s clean you never know
There still could be hope
But in the perfect world I know
There’s no harmful stuff
Now I’ve come to realize
It’s just a bunch of bluff
Nothing but silence
Sitting by the widow sill
A tear rolls down my cheek
Although it hurts I can’t express
My heart is just too weak
Nothing but ache
It’s funny what one pill can do
To a mother or a kid
And now I know that for a fact
I won’t do what she did
Nothing but ache
Now I live a better life
And drugs…I wouldn’t dare
Away from all the harmful things
With a family who cares
Nothing but love
I know it hurts, it sure hurt me
That’s why I’ll remain drug free
Nothing… but hope