Child Welfare and Substance Abuse: Current Issues and Innovations National Association of State Alcohol and Drug Abuse Directors Annual Meeting Miami, Florida June 2005 Nancy K. Young, M.S.W., Ph.D.

A Sense of Satisfaction A Sense of Urgency We have much to feel good about in our efforts to combine forces to help children and families affected by substance use disorders and child abuse or neglect At the same time, we need a much greater sense of urgency in building on these victories to enter into the next phase of getting serious and getting to scale Two Contrasting Ideas:

Topics NCSACW Children with Prenatal Substance Exposure Children of Substance Abusers who are also Victims of Child Abuse and/or Neglect Children in the Child Welfare System with their own Substance Use Disorder Future Trends

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, 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

PRODUCTS  Free On-Line Training with CEUs  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

 Information Sharing & Management  Training and Staff Development  Budgeting and Program Sustainability  Building Community Supports Connecting AOD, CWS, Court Systems: Elements of System Linkages* From CSAT Technical Assistance Publication (TAP) 27: Navigating the Pathways *Revised March 2003  Underlying Values  Screening and Assessment  Client Engagement and Retention in Care  AOD Services to Children  Joint Accountability and Shared Outcomes  Working with Related Agencies and Support Systems

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

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)

PRODUCTS we’re working on…  State Policies regarding Substance Exposed Infants  Guidance to States and Communities on:  Screening and Assessment for Family Engagement, Retention and Recovery (SAFERR)  Methamphetamine and child risk and safety assessments  The use of drug testing in child welfare practice  Medication assisted treatment for opiate dependence and implications for child welfare

Foster Care Population 52% Increase over 6 Years Number of Children in Foster Care on Last Day of Federal Fiscal Year

Foster Care Population and Persons who First Used Crack or Meth in Past Year *All persons age 12 and over

Children with Prenatal Substance Exposure

Number of Children Prenatally Exposed to Substances Substance Used (Past Month) 3rd Trimester Any Illicit Drug2.3% women 94,139 infants Alcohol Use4.7% women 192,371 infants Binge Alcohol Use 0.7% women 28,651 infants SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

Number of Children Prenatally Exposed to Substances Substance Used (Past Month) 2nd Trimester3rd Trimester Any Illicit Drug3.2% women 130,976 infants 2.3% women 94,139 infants Alcohol Use6.1% women 249,673 infants 4.7% women 192,371 infants Binge Alcohol Use 1.4% women 57,302 infants 0.7% women 28,651 infants SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

Number of Children Prenatally Exposed to Substances State and local prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth 5,6 Substance Used (Past Month) 1st Trimester2nd Trimester3rd Trimester Any Illicit Drug7.7% women 315,161 infants 3.2% women 130,976 infants 2.3% women 94,139 infants Alcohol Use19.6% women 802,228 infants 6.1% women 249,673 infants 4.7% women 192,371 infants Binge Alcohol Use 10.9% women 446,137 infants 1.4% women 57,302 infants 0.7% women 28,651 infants SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

Infants with pre-natal substance ~ 410,000 exposure Where did they all go? Number of Children Prenatally Exposed to Substances Total child victims under 1 year old ~ 86,000 Total children under 1 year old ~ 41,000 entering out-of-home-care

Most Go Home 90%+ 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

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))

Child Aftercare and follow-up Identification and responses to parents’ needs Responses to infant’s needs Identification and responses to needs of Preschooler Child Adolescent Aftercare and follow-up Responses to parents’ needs Initiate plan of care & enhancement services Parent Children and Parents - Intervention Points Birth Prenatal screening and assessment Pre-pregnancy awareness and substance use

 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 Potential Consequences for Children

Areas of Child Development Affected by Parental Substance Use Disorders  Physical health consequences  Lack of secure attachment  Language delays and communication disorders  Psychopathology  Behavioral problems  Poor social relations and skills  Deficits in motor skills  Cognition and learning disabilities Research has shown that these effects can manifest themselves in multiple areas, including:

Children of Substance Abusers who are also Victims of Child Abuse and/or Neglect

Children Living With One or More Substance Abusing Parent In Millions

 71% of caregivers who are alcohol dependent are classified by the CWW as not having an alcohol problem  73% of caregivers who are drug dependent are classified by the CWW as not having a drug problem  CWW’s misclassify caregivers who are substance dependent most of the time Documenting Substance Use Disorders in Child Welfare  Children and Family Service Reviews (CFSRs)  Parental substance use disorders were a factor in 16% to 48% of cases

Children in the Child Welfare System with their own Substance Use Disorder

 Children of substance abusers need in-depth assessments and interventions that respond to their developmental status and the special needs created by substance use disorders in their family  grief, loss, separation, attachment  Adolescents who may have begun their own substance use – Few Independent Living Programs under Chafee Bill include prevention or intervention for children of substance abusers aging out of foster care Children in the Child Welfare System with their own SUD

 Youths who have ever been in foster care had higher rates of any illicit drug use than youths who have never been in foster care (33.6 vs percent)  Youths aged 12 to 17 who were in need of substance abuse treatment in the past year were more likely to have received treatment if they have ever been in foster care Children in the Child Welfare System with their own SUD

Future Trends

TANF Opportunities  Treatment aftercare focus on jobs and housing  TANF reauthorization proposes treatment be counted as a work activity  Does your state define the child welfare population as a “needy family” under TANF  Can use TANF to pay for treatment

 Models of Cross-system funding for joint initiatives  Title IV-E Waiver projects Funding Opportunities

 Taking CFSR findings seriously and including remediation strategies in Program Improvement Plans  New round of CFSRs begin this summer – contact your state’s child welfare lead to get involved Child and Family Service Reviews

 Early recognition of Substance Use Disorders  Timeliness of Interventions  “Call me Tuesday”  “Your life has just begun” Timeliness of Interventions ASFA Challenges

Four Components of System Reform  Comprehensive cross-system joint 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  Early Intervention Specialists  Immediate access to intervention and assessment at the court hearings

 Recovery Management Specialists  Motivational enhancement  Immediate access to recovery management and treatment services  Compliance monitoring  Dependency Drug Court  30, 60 and 90-day compliance hearings  Structured incentives for compliance and sanctions for non-compliance  Voluntary participation in on-going services Four Components of System Reform

 Early recognition of Substance Use Disorders  Timeliness of Interventions  “Call me Tuesday”  “Your life has just begun” Timeliness of Interventions ASFA Challenges A timely message of hope

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 But 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 And that’s why I’ll remain drug free Nothing… but hope Nothing But Silence

 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 The Fifth Clock Urgency

  Chasnoff, I. Cocaine Use in Pregnancy, New England Journal of Medicine, 1985  Barth, R. (2003). Substance Abuse Findings from the NSCAW Presented at NCSACW Researchers’ Forum. December.  Office of Applied Studies. (2004). Results from the 2003 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 04–3964, NSDUH Series H–25). Rockville, MD: Substance Abuse and Mental Health Services Administration.  Office of Applied Studies. (2003). Results from the 2002 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 03–3836, NHSDA Series H–22). Rockville, MD: Substance Abuse and Mental Health Services Administration at  Office of Applied Studies. (2002). Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of national findings (DHHS Publication No. SMA , NHSDA Series H-17). Rockville, MD: Substance Abuse and Mental Health Services Administration.  Hamilton BE, Martin JA, Sutton PD. (2003) Births: Preliminary data for National vital statistics reports, 51 (11), Hyattsville, Maryland: National Center for Health Statistics at Child Welfare and Substance Abuse: Current Issues and Innovations

 Vega, W., Noble, A., Kolody, B., Porter, P., Hwang, J. and Bole, A. (1993). Profile of Alcohol and Drug Use During Pregnancy in California, 1992: Perinatal Substance Exposure Study General Report. Sacramento, CA: CA Dept of Alcohol and Drug Programs  National Institute on Alcoholism and Alcohol Abuse. (2000). Tenth Special Report to Congress on Alcohol and Health. Washington, DC: Department of Health and Human Services at  National Institute of Drug Abuse. (1998). Prenatal Exposure to Drugs of Abuse May Affect Later Behavior and Learning. NIDA Notes, 13 (4) at Irvine Blvd, # Irvine, CA Child Welfare and Substance Abuse: Current Issues and Innovations