Gender Differences

• 45% of admissions are women
  This is a higher percentage of women admissions than for any other drug except tranquilizers
  • methamphetamine - ~ 1:1
  • cocaine - 1:2
  • heroin - 1:2+
  • marijuana & alcohol - 1:3
• Since women are often caretakers of children, more children are likely affected

Source: Vaughn, C. (2003)

Methamphetamines as Primary Substance by Gender and Pregnancy Status: 1994-2004

Source: Analysis of Treatment Episode Data Set (TEDS) Computer File

Female Treatment Admissions

States with Highest Percentage of Meth/Amphetamine as Primary Substance

Source: Analysis of Treatment Episode Data Set (TEDS) Computer File

Meth/Amphetamine Admissions

By Gender - 2004

Source: Analysis of Treatment Episode Data Set (TEDS) Computer File

Trends in Primary Substance Use

Treatment Admissions for Pregnant Females by Primary Substance 1994-2004

Source: Analysis of Treatment Episode Data Set (TEDS) Computer File

Use During Pregnancy

SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003

State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth

Vega et al (1993). Profile of Alcohol and Drug Use During Pregnancy in California, 1992.

Gender Differences and Implications for Treatment

Gender Differences and Implications for Treatment

• Co-occurring mental health problems
• Trauma
• Body image

Behavior Symptom Inventory (BSI)

Scores at Baseline

Richard Rawson, Ph.D., Presentation to SAMHSA, August 2005

Beck Depression Inventory (BDI)

Scores at Baseline

Richard Rawson, Ph.D., Presentation to SAMHSA, August 2005

Self-Reported Reasons for Starting Methamphetamine Use

Richard Rawson, Ph.D., Presentation to SAMHSA, August 2005

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

Histories of Violence among Clients Treated for Methamphetamine

• Persons in tx for meth reported high rates of violence
  • 85% women
  • 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
  • 16% men

Prevalence of Co-Occurring Problems, and Violence and Trauma

• Women in treatment 2X 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

Gender Differences and Implications for Treatment

• Screen carefully for
  • Psychological problems
  • Abuse and violence
• Recognize pervasive gender differences
• Address substance abuse and psychological problems in an integrated treatment model

Children of Parents with Substance Use Disorders

So how many are there?

Children Living with One or More Substance-Abusing Parent

Numbers indicate millions

COSAs and Child Abuse/Neglect Victims

In Millions

How Big a Problem is Methamphetamine in CWS Caseloads?

We don’t really have the numbers...

Persons who Initiated Substance Use by Year

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

How Many Parents in Treatment have Children?
How Many are “At Risk” of Child Abuse or Neglect?
How Many are involved with Child Welfare Services?

We don’t really have the numbers...

Parents Entering Publicly-Funded Substance Abuse Treatment

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

Average Age First Use of Substance

Source: M.L. Brecht, Ph.D., presented at NASADAD Annual Meeting, June 2005

Risks to Children When Parents Use Methamphetamine

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

Different Situations for Children

• 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

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

Parent Uses or Abuses Meth

Risks to safety and well-being of children:

• Parental behavior under the influence: poor judgment, confusion, irritability, paranoia, violence
• Inadequate supervision
• Inconsistent parenting
• Chaotic home life
• Exposure to second-hand smoke
• Accidental ingestion of drug
• Possibility of abuse
• HIV exposure from needle use by parent

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

Parent Is Dependent on Meth

Risks to safety and well-being of children:

• All the risks of parents who use or abuse, but the child may be exposed more often and for longer periods
• Chronic neglect is more likely
• Household may lack food, water, utilities
• Chaotic home life
• Children may lack medical care, dental care, immunizations
• Greater risk of abuse
• Greater risk of sexual abuse if parent has multiple partners

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

Parent "Cooks" Small Quantities of Meth

• All the risks of parents who use or are dependent on meth, with added risks of manufacturing:
  • Chemical exposure and toxic fumes
  • Risk of fire and explosion
• Children more at risk:
  • Higher metabolic rates
  • Developing bone and nervous systems
  • Thinner skin than adults which absorbs chemicals faster
  • Children tend to put things in their mouth and use touch to explore

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

Parent Involved in Trafficking

• Presence of weapons
• Possibility of violence
• Possibility of physical or sexual abuse by persons visiting the household
• Possibility of incarceration and permanency issues for children

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

Number of Children in Meth Labs

Source: El Paso Intelligence Center

Medical Interventions for Children

• Field medical assessment
  • A medically trained professionals determines if the child discovered at the scene of a meth lab seizure needs emergency medical care
• Immediate care protocol
  • Based on findings of the field assessment, immediate care is provided within 2-4 hours for those medical problems that cannot wait 24 hours to be treated at the baseline exam.

Source: Colorado DEC

Medical Interventions for Children

• Baseline assessment protocol
  • Conducted at a pediatric facility within 24 hours of lab seizure to ascertain a child’s general health
• Initial follow-up care protocol
  • Follow-up visit within 30 days to re-evaluate child’s health status and any latent symptoms
• Long-term follow-up care protocol
  • Follow-up visit within 12 months of baseline assessment to monitor physical, emotional and developmental health, identify any late developing problems, and provide appropriate intervention

Source: Colorado DEC

Mother Uses While Pregnant

• Scope of the problem:
  • An estimated 10% to 11% of all newborns are prenatally exposed to drugs or alcohol; this amounts to 400,000 to 480,000 newborns per year
  • 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

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

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)

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

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

Mother Uses While Pregnant

• Home environment is the critical factor in the child’s outcome
• Consequences can be mediated

Practice Models

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

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

Judicial Oversight 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

Judicial Oversight 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

Sacramento, California Model of Effective Child Welfare and Substance Abuse Services

• Comprehensive training—to understand substance abuse and dependence and acquire skills to intervene with parents
• Early Intervention Specialists—Social workers trained in motivational enhancement therapy are stationed at the family court to intervene and conduct preliminary assessments with ALL parents with substance abuse allegations at the first court hearing
• Improvements in Cross-System Information Systems—to ensure that communication across systems and methods to monitor outcomes are in place as well as management of the county’s treatment capacity

Sacramento, California Model of Effective Child Welfare and Substance Abuse Services

• Prioritization of Families in Child Protective Services—County-wide policy to ensure priority access to substance abuse treatment services
• Specialized Treatment and Recovery Services (STARS)—provides immediate access to substance abuse assessment and engagement strategies conducted by staff trained in motivational enhancement therapy. STARS provides intensive management of the recovery aspect of the child welfare case plan and routine monitoring and feedback to CPS and the court
• Dependency Drug Court—provides more frequent court appearances for ALL parents with allegations of substance use.

Treatment Discharge Status by Primary Drug Problem***

24-Month Child Placement Outcomes by Parent Primary Drug Problem

Time in Out of Home Care at 24-Months after Court Order to Participate in DDCby Parent’s Primary Drug Problem

NCSACW Products

• Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers - A short monograph for front-line workers
• On-Line Training
  • Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals
  • Understanding Addiction and Recovery: A Guide for Child Welfare Professionals
  • Coming in 2007: Understanding Substance Abuse and Child Welfare Issues: A Guide for Judicial Officers

Contact NCSACW

• www.ncsacw.samhsa.gov
  Project Director:
  Nancy Young, Ph.D.
  714-505-3525
  
• Government Project Officer:
  Sharon Amatetti, SAMHSA/CSAT
  240-276-1694
  sharon.amatetti@samhsa.hhs.gov

ANNOUNCING

• 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
    conference@cffutures.org