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

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 contactus@cffutures.org

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: 4.5
(Numbers indicate millions)

COSAs and Child Abuse/Neglect Victims

Living with Alcoholic/Addict Parent: 8.3
Abuse/Neglect Reports: 3.0
Investigations: 1.8
Substantiated Victims: 0.5
Placed Out of Home Care: 0.2
(In millions)

Parent Entered Treatment

New York and U.S. Gender Split

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

Estimated New York Parents Entering Publicly-Funded Treatment – 286,000

• Had a Child under age 18: 168,700
• Had a Child Removed by CPS: 40,490
• If a Child was Removed, Lost Parental Rights: ~ 4,500

Based on CSAT TOPPS-II Project

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)
• 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 Study1992 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

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 SubstanceUse Disorders in CWS Caseloads?

We don’t really have the numbers…

Let’s look at the overall foster care population over time…

Foster Care PopulationEnd of Each Federal Fiscal Year (Chart)

Foster Care Population and Persons Who First Used Crack in Prior Year (Chart)

Foster Care Population and Persons Who First Used Crack or Methamphetamine in Prior Year (Chart)

New York State Foster CareIn Care, Admissions and Discharges (Chart)

New York Child Victims by Age Group 2003 (Chart)

Children in Foster Care by Age Group 2003 (Chart)

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%)

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

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 SubstanceUse 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 ProblemsAmong 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

How does Child Welfare Assess for the Differences?

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))

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 co-occurring problems in the lives of these children.

Five Points of Intervention for Policy and Practice with Substance Exposed Infants (Flow Chart)

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

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
• 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 programming 1970s - 80s
  • Strategies still largely based on male models
• Women 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

Level Two

Serve women and children

• Child care – often through co-op babysitting
• Treatment plan includes parenting and family relationships

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

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

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 ServicesCharacteristics 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
• 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
• 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
• 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

Elements of System Linkages

• Underlying Values
  • Colorado values statements
    • Practitioners from all systems should adopt a “screen out stance” with regard to substance use disorders
    • The team is more critical than the tool in determining the relationship between substance use and child safety or risk (but the team does need the tools)
    • During the assessment process, children’s needs should be identified and addressed
    • Sharing information appropriately is desirable, helpful, and feasible
    • Actions should have consequences that are fair, timely, and appropriate to the action
    • Consequences should apply to families and to staff; consequences should not be used solely as punishments
• Daily Practice – Screening and assessment
  • 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
  • Use of UNCOPE in Oregon and Washington
    • 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?
• Daily Practice – Client engagement and retention in care
  • Florida protocols -- NYC protocols
  • Recovery management approaches
    • STARS
    • SARMS
• Daily Practice – Services to children
  • 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, receive the same information and meet together
• Joint Accountability, Shared Outcomes and Information Systems
  • Michigan revised SACWIS to prioritize families with substance use disorders
  • CFSR and NOMS processes

The Voice of a Child

Nothing But Silence
By Ashley G.
Age 12
January 2005

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