1. NCSACW
2. Child Welfare & Substance Abuse Numbers
3. Challenges Between Substance Abuse, Child Welfare and Dependency Courts
4. Identifying Parents with Substance Use Disorders
5. Policy Framework and Tools
6. Models of Linking AOD, CW & Courts
7. Family Treatment Court Outcomes

A Program of the
Substance Abuse and Mental Health
Services Administration
Center for Substance Abuse Treatment
and the
Administration for Children and Families
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, organizational, and system changes at the local, state, and national levels by
  • Developing and implementing a comprehensive program of information gathering and dissemination
  • Providing technical assistance

PRODUCTS

• Free On-Line Training
  • Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals – Now Available
  • Understanding Addiction and Recovery: A Guide for Child Welfare Workers
  • Understanding Families with Substance Use Disorders: A Guide for Judges and Attorneys working with Families in Family/Juvenile Court

PRODUCTS

• Program of In-Depth Technical Assistance
  • Round 1 – Summer 2003 to Fall 2004
    • Colorado – Licensing/certification of providers who specialize in child welfare population and protocol for improving services
    • Florida – Regional contracts to ensure local-level system linkages and preferred practice model
    • Michigan – Revised SACWIS to prioritize SUDs
    • Virginia – Comprehensive 5-year plan
  • Round 2 – Winter 2005 to Spring 2006
    • Arkansas, Massachusetts, Minnesota and Squaxin Island Tribe at Puget Sound

PRODUCTS

• Materials
  • Compendium of Training Curricula
  • Understanding Substance Abuse: A Guide for Child Welfare Practitioners
  • Draft White Paper on Funding Substance Abuse and Child Welfare Services
  • Draft White Paper on Implementing the 2004 Substance Abuse Amendment in the Child Abuse Prevention and Treatment Act (CAPTA)

2. Child Welfare & Substance Abuse Numbers

Children Living With One or More Substance Abusing Parent

(In Millions)

Number of Children Prenatally Exposed to Substances

SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

State and local prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth^5,6

Estimated Numbers of Children Prenatally Exposed to Substances in Vermont

Births in 2003 = 6,5915
10% of total births = 659 Infants with prenatal substance exposure
Substantiated reports in 2003 for children 0-1 = 846
Children less than 1 year old in Out of Home Care ~ 437

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
• Child Abuse Prevention and Treatment Act (CAPTA) Amendments of 2003 raises issues of identifying infants and reporting to Child Protective Services

A Graphic Overview

137,446 age 0-17
11, 203 children born substance-exposed
6,591 births annually

659 estimated substance-exposed births annually
Estimated substance-exposed births reported to CPS: 5.6% of all SEBs = 37
1447 CPS substantiated reports annually8

3. Challenges Between Substance Abuse, Child Welfare and Dependency Courts

1990s – Reports on the Issues

• Five National Reports on Substance Abuse and Child Welfare
  • Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (1998)
  • Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers (1998)
  • Healing the Whole Family: A Look at Family Care Programs (1998)
  • No Safe Haven: Children of Substance-Abusing Parents (1999)
  • Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (1999)

Key Barriers Between Substance Abuse, Child Welfare, and the Courts

• Competing priorities
• Beliefs and values
• Treatment gap
• Information systems
• Staff knowledge and skills
• Lack of communication
• Different mandates

The Five Clocks

• Temporary Assistance for Needy Families (TANF)
  • 24 months work participation
  • 60 month lifetime
• Adoption and Safe Families Act (ASFA)
  • 12 months permanent plan
  • 15 months out of 22 in out-of-home care must petition for TPR
• Recovery
  • One day at a time for the rest of your life
• Child Development
  • Clock doesn’t stop
  • Moves at fastest rate from prenatal to age 5

Biggest challenge: Syncing Clocks

The Four Clocks

First Clock

ASFA Timetable

Timeliness of intervention versus “Call me Tuesday.”

CFSR’s have documented

• Case reviews found parental substance use disorders were a factor in 16% to 48% of cases
• Need for child welfare training in addictions
• Gaps in services
• Inadequate assessment and follow up on the underlying needs of families, including substance abuse
• Substance use disorders in families with repeat cases

National Study on Child and Adolescent Well-Being: Child Welfare Workers’ (CWW) Identification of Substance Abuse

• Of the caregivers who are alcohol dependent
  • 71% are classified by the CWW as not having an alcohol problem
• Of the caregivers who are drug dependent
• 73% are classified by the CWW as not having a drug problem
• CWW’s misclassify caregivers who are substance dependent most of the time

Second Clock

TANF Timetable

• Neglect is often associated with both substance abuse and poverty
• Proposals for TANF Reauthorization count Substance Abuse Treatment toward Work Participation Rates

Third Clock

Recovery Timetable

“A day at a time for the rest of your life”

Recovery is a lifelong process requiring a disease management approach rather than emergency care

Fourth Clock

Child Development Timetable

• Interventions for children of substance abusers must recognize potential pre-natal and post-natal effects
• Require multi-dimensional assessments and interventions responding to developmental status and special needs created by substance use disorders in the family
  • Alcohol-related neuro-developmental disorders
  • Attachment, separation, loss, grief

Potential Consequences for Children

• Prenatal substance exposure
  • Fetal alcohol syndrome, fetal alcohol spectrum disorder, neuro-developmental disorders
• Postnatal environment factors
  • Violence or traumatic events
  • Drug and/or alcohol seeking behaviors
  • Illicit drug sales or manufacturing
  • Lack of adult interpersonal support systems
  • Community effects such as living in poverty
  • Lack of proper health care
  • Inconsistent caregivers

Areas of Child Development Affected by Parental Substance Use Disorders

Research has shown that these effects can manifest themselves in multiple areas, including:

• Physical health consequences
• Lack of secure attachment
• Psychopathology
• Behavioral problems
• Poor social relations and skills
• Deficits in motor skills
• Language delays
• Cognition and learning disabilities

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.⁹
• Other problems arising in parental behavior, competence, and disorders interact with substance use, abuse, and dependence to cause multiple co-occurring problems in the lives of these children.

The importance of identifying infants prenatally exposed to substances

• Though a small percentage of CWS cases, these children are disporportionately affected by many lifetime conditions
• Prenatal exposure to alcohol is the leading cause of mental retardation
• Special education classrooms contain a disproportionate number of children who were prenatally exposed to drugs.10,11
• SEBs require a higher level of public spending than many other target groups

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))

Children and Parents - Intervention Points

Trends in State Policies

1. Legislation that defines substance-exposed births as child abuse or neglect
2. Legislation mandating substance exposed birth reports to CPS by health care professionals and/or mandated reporters in general
3. Policies for testing mother and/or infant
4. Leaving the judgment of child abuse or neglect to the discretion of the CPS worker or the health care provider
5. Addressing alcohol and drug use/abuse during pregnancy, but not necessarily addressing the substance exposed birth
6. CPS policies on how to respond to a substance exposed birth
7. No official response

4. Screening for Prenatal Substance Exposure and Parental Substance Use Disorders (SUDs)

Identifying Infants withPrenatal Substance Exposure

Prenatal substance exposure can be screened for in several ways. The most common methods, used alone or in combination, are:

• Verbal screen with mother
• Review of mother’s history and medical records
• Observation of mother and/or newborn
• Drug testing (urine, blood, hair or meconium)

Verbal Screening Tools4Ps Plus¹²

1. Did either of your parents ever have a problem with drinking or using drugs?
2. Does your partner have any problem with alcohol or drugs?
3. Have you ever had any beer or wine or liquor in the past?
4. In the month before you knew you were pregnant, how much beer/wine/liquor did you drink?
5. In the month prior to when you knew you were pregnant, how many cigarettes did you smoke?

Identifying Parental Substance Use Disorders

• Studies conducted on brief screens of six or less items suggest that there are a limited number of common constructs
• An effective screen for substance use disorders includes questions about:
  • Unintended use
  • Desire to restrict use
  • Consequences of use
  • Concern about consequences of use

Screening for ParentalSubstance Use Disorders: UNCOPE¹³

• 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?

Identifying Parental Substance Use Disorders

Check list for Identifying SUDs:¹⁴

• A report of substance use is included in the child protective services call or report.
• Paraphernalia is found in the home (syringe kit, pipes, charred spoon, foils, large number of liquor or beer bottles, etc).
• The home or the parent may smell of alcohol, marijuana, or drugs.
• A child reports alcohol and or other drug use by parent(s) or other adults in the home.
• A parent appears to be actively under the influence of alcohol or drugs (slurred speech, inability to mentally focus, physical balance is affected, extremely lethargic or hyperactive, etc).
• A parent shows signs of addiction (needle tracks, skin abscesses, burns on inside of lips, etc).
• A parent admits to substance use.
• A parent shows or reports experiencing physical effects of addiction or being under the influence, including withdrawal (nausea, euphoria, slowed thinking, hallucinations, or other symptoms).

5. Policy Framework and Tools

Getting the Clocks in Sync

Introduction to a Framework and Policy Tools for Practice and Policy Changes

Connecting AOD, CWS, Court Systems: Elements of System Linkages¹⁵

• Underlying Values
• Screening and Assessment
• Client Engagement and Retention in Care
• AOD Services to Children
• Joint Accountability and Shared Outcomes
• Information Sharing & Management
• Training and Staff Development
• Budgeting and Program Sustainability
• Building Community Supports
• Working with Related Agencies and Support Systems

1. Values and Common Principles

• Issues to Address
  • Who is the Client -- Parent, Child, Family?
  • Can AOD Users/Abusers/ Addicts/Alcoholics be Effective Parents?
  • What is the Goal -- Recovery, Child Safety, Family Preservation, Economic Self-sufficiency?
• How to Begin:
  • Use Tools Such As the Collaborative Values Inventory to Identify and Resolve Differences That Exist Across System
  • Ensure Conversation Happens at Policy, Supervisory and Front-line Levels

2. Daily Practice: Client Intake, Screening and Assessment

• Issues to Address
  • Roles and Responsibilities Across Systems
  • Communication Paths Across Systems
  • Incentives for Prioritization
  • Missing Box Problem

  Too Often We Practice…“Don’t Ask, Don’t Tell”

  Nationally, we have “missing box” problems

  Welfare and Child Welfare Agencies have far less information than they need on substance abuse among their clients

  Alcohol and Drug Treatment Agencies have far less information than they need about the children of their treatment clients

  How to Begin:

  • 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 Investigative/Assessment Phases
    • Ensure Parents Seeking Treatment Receive Needed Supports for Child Safety

  Pathways of Communication Template

  Michigan Communication Protocal Blueprint

3. Daily Practice -- Client Engagement and Retention in Treatment

• Issues to Address
  • Outreach and Engagement Strategies
  • Addressing Motivation to Change
  • Cross-system Agreement on Approaches to Relapse
  • Responding to Clients’ Progress in Treatment
• How to Begin:
  • 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 and Needed Level of Care

  Client Levels of CareAmerican Society of Addiction Medicine¹⁶

  • Level I– Outpatient Treatment
  • Level II – Intensive Outpatient/Partial Hospitalization
  • Level III – Medically Monitored Intensive Inpatient Treatment
  • Level IV – Medically Managed Intensive Inpatient Treatment

4. Daily Practice -- Services to Children

• Issues to Address
  • Prevention, Early Intervention, and Treatment Services for Children in Contact with CPS
  • Content of Independent Living Programs on Parental Substance Abuse
  • Pediatrics (1999) v.103:1083 – 1155, Special Topics on Children and Adolescents in Families Affected by Substance Abuse¹⁷
• How to Begin:
  • Develop Partnerships to Respond to Potential Neuro-Developmental Effects of Prenatal Substance Exposure
  • Provide Prevention and Intervention Services to Children and Adolescents
  • Ensure that Youth Receive Appropriate Youth Development Intervention and Activities
  • Ensure that ILP Teens Receive Appropriate Information Related to Risks of Substance Abuse

Other System Supportive Elements

5. Information Sharing and Data Systems
6. Training and Staff Development
7. Joint Accountability and Shared
Outcomes
8. Budgeting, Funding and Program Sustainability

9. Developing Community Supports
10. Working with Related Agencies

• Primary Health Care
• Domestic Violence
• Trauma
• Mental Health
• Dental Health
• Transportation
• Child Care
• Medicaid
• Housing
• Economic Security
• Education for Mother and Children

Policy Framework and Tools

• 10 Element Framework
• Collaborative Values Inventory
• Collaborative Capacity Instrument
• Matrix of Progress in Linkages
• Screening and Assessment for Family Engagement, Retention and Recovery -- SAFERR

6. Models of Linking AOD, CW & Courts

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

7. Family Treatment Court Outcomes

Five Components of Sacramento County’s Comprehensive Systems’ Reform

1. Comprehensive cross-system joint training
   • Three Levels of Training
     • AOD basics for all staff – 4 days required
       • AOD screening, brief intervention, motivational enhancement and AOD treatment – 4 days required of all case carrying workers
       • Group intervention skills – 4 days required of all ADS staff and voluntary for any CPS division staff
2. Substance Abuse Treatment System of Care
   • Managed Wait List
   • Immediate Access to Substance Abuse Services
   • Group Services Expansion and Implementation of Pre-Treatment Groups
3. Early Intervention Specialists
   • Review of every court petition to determine if substance use disorders may be present
   • Immediate access to intervention and assessment at court hearings
   • Immediate authorization of publicly-funded treatment services
4. Recovery Management Specialists (STARS)
   • Motivational enhancement
   • Gender-specific services
   • Immediate access to recovery management and treatment services
   • Provider orientation of providing hope and accountability
   • Compliance monitoring—Twice monthlies
5. Dependency Drug Court
   • Parallel system to dependency petition
   • 30, 60 and 90-day compliance hearings
   • Structured incentives for compliance and sanctions for non-compliance
   • Voluntary participation in on-going services

PARENTS AND CHILDREN IN THE EVALUATION (Chart)

CHILD DEMOGRAPHIC CHARACTERISTICS

• 52% Girls
• 48% Boys

• 1.6 % American Indian/Alaskan
• 2.0% Asian Pacific Islander
• 27.4% African American
• 20.3% Hispanic
• 48.7% Caucasian*

• Average Age of 6.5*

PARENTS

• 111 Comparison parents, 847 Court-Ordered parents
• Over 69% were women
• Average age was 32
• 54% were Caucasian, about 21% African American and 17% Hispanic
• Methamphetamine was the primary drug problem for 52% of participants
• Generally have low education attainment and are largely unemployed
• Almost 29% reported a disability at treatment entry and almost 28% reported a history of chronic mental illness

PARENT GENDER (Chart)

RACE/ETHNICITY OF PARENTS (Chart)

*p<.05

PARENT BASELINE CHARACTERISTICS (Chart)

*p<.05

PRIMARY DRUG PROBLEM*** (Chart)

***p<.001

PERCENT OF MOTHERS AND FATHERS BY PRIMARY DRUG PROBLEM** (Chart)

**p<.01

TREATMENT ADMISSION RATES*** (Chart)

Comparison: 50.5%
Court Ordered: 86.4%

***p<.001

MEAN NUMBER OF TREATMENT ADMISSIONS*** (Chart)

Comparison: 1.3
Court Ordered: 2.4

***p<.001

TREATMENT MODALITY*** (Chart)

***p<.001

PERCENT OF MOTHERS AND FATHERS BY TREATMENT MODALITY** (Chart)

TREATMENT DISCHARGE STATUS (Chart)

D.S.

TREATMENT DISCHARGE STATUS BY MOTHERS AND FATHERS (Chart)

D.S.

24-MONTH CHILD PLACEMENT OUTCOMES*** (Chart)

***p<.001

TIME TO REUNIFICATION (Chart)

***p<.001

24-MONTH COST SAVINGS DUE TO INCREASED REUNIFICATION RATES

• 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
• 42.1% - Reunification rate for court-ordered DDC group children
• 63 Additional DDC children reunified

• 33.1 – Average months in out-of-home care for comparison group children
• 8.6 - Average months to reunification for court-ordered DDC children
• 24.5 month differential

• $2,953,639 Estimated Savings in Out-of-Home care costs

We Know AOD Treatment Pays

• 100 Women
  • Average cost $6,800
• $680,000

30 Women recover with one episode of treatment

• 150 Children
  • Average 1.5 years in out-of-home care @ $24,000 per year
• $5.4 Million

45 Children reunify at 6 months saves $1.1 Million

Foster Care Cost Offset Pays for all 100 Women’s Treatment Nearly 2 Times Over

The Fifth Clock

Urgency

• The fifth clock is the one that is ticking on us…it measures how fast we get it…how rapidly we respond to human needs that grow larger by the day
• We have to measure what we do against what needs doing, not against what we did last year
• Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs
• Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention
  • A baby and a family we already know are highly at risk

The Voice of a Child

References

1. U.S. Census Data 2000 – Vermont Births. Accessed: http://www.childwelfare.com/vermont.htm
2. SAMHSA, OAS. (2003). Results from the 2002 National Survey on Drug Use and Health: National findings.
   Ibid.
3. Vega et al. (1993). Profile of Alcohol and Drug Use During Pregnancy in California, 1992.
4. NCHS – FASTATS. (2003). http://www.cdc.gov/nchs/fastats/popup_vt.htm.
5. U.S. DHHS, Administration on Children, Youth and Families. (2005). Child Maltreatment 2003. Table 3-9.
6. U.S. House of Representatives, Committee on Ways and Means. (2004). 2004 Green Book.
7. U.S. DHHS, Administration on Children, Youth and Families. (2005). Child Maltreatment 2003.
8. Chasnoff, I.J. (1997). Prenatal Exposure to Cocaine and Other Drugs: Is there a Profile? In: Accardo, P.J., Shapiro, B.K., & Capute, A.J. (Eds.), Behavior Belongs in the Brain. Baltimore, MD: York Press, 147-163.
9. NIAAA. (2000). Tenth Special Report to Congress on Alcohol and Health.
10. NIDA. (1998). Prenatal Exposure to Drugs of Abuse May Affect Later Behavior and Learning.
11. McGourty, R. F., & Chasnoff, I. J. (2003). Power Beyond Measure: A Community-Based Approach to Developing
12. Integrated Systems of Care for Substance Abusing Women and their Children. Chicago, IL: NTI Publishing.
13. Evince Clinical Assessment. UNCOPE screening tool is available as a downloadable pdf file from the website: www.evinceassessment.com.
14. Young, N.K. and Gardner, S.L. (2002). Navigating the Pathways: Lessons and Promising Practices in Linking Alcohol and Drug Services With Child Welfare. Technical Assistance Publication No. 27. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
15. Ibid.
16. American Society of Addiction Medicine (ASAM). (1996). Patient Placement Criteria for the Treatment of Substance-Related Disorders, 2nd ed. Chevy Chase, MD: ASAM.
17. Pediatrics (1999) Special Topics on Children and Adolescents in Families Affected by Substance Abuse. Accessed: http://www.pediatrics.org/cgi/content/full/103/5/SI/1083.