Improving Outcomes for Families Affected by Substance Use Disorders Presented at 9 th Annual Conference of the Association of Alcoholism and Substance.

Improving Outcomes for Families Affected by Substance Use Disorders Presented at 9 th Annual Conference of the Association of Alcoholism and Substance Abuse Providers of New York State STRENGTHENING FAMILIES AND EMPOWERING COMMUNITIES January 31, 2006

N ational C enter on S ubstance A buse and C hild W elfare www.ncsacw.samhsa.gov 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

 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 Mission

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 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 Understanding Substance Use Disorders, Treatment and Family Recovery: A Guide for Child Welfare ProfessionalsVisitwww.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 YorkTexas Four Sites with a less intensive level of support Four Sites with a less intensive level of support

 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 Pre-conference symposium on substance-exposed infants with Dr. Ira Chasnoff  January 31 to February 2, 2007 National Conference National Conference  Disneyland Hotel, Anaheim California Sign up for information at Sign up for information at contactus@cffutures.org contactus@cffutures.org ANNOUNCING

Children of Parents with Substance Use Disorders So how many are there? Living with parent Mother used while pregnant Parent entered treatment

Children Living with One or More Substance-Abusing Parent Numbers indicate millions 500,000 NY Children Living with Parent About 33,000 in Out-of-Home Care for Child Abuse/Neglect in 2003

COSAs and Child Abuse/Neglect Victims In Millions 0 2 4 6 8 10

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 18168,700  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 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 45% of Persons Admitted

Mother Used While Pregnant Last Statewide Study 1992 in California

Use During Pregnancy Substance Used (Past Month) 1st Trimester 2nd Trimester 3rd Trimester Any Illicit Drug Alcohol Use Binge Alcohol Use SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data 7.7% women 19,481 infants 19.6% women 49,588 infants 10.9% women 27,577 infants

Use During Pregnancy Substance Used (Past Month) 1st Trimester 2nd Trimester 3rd Trimester Any Illicit Drug Alcohol Use Binge Alcohol Use SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data 7.7% women 19,481 infants 19.6% women 49,588 infants 10.9% women 27,577 infants 3.2% women 8,100 infants 6.1% women 15,400 infants 1.4% women 3,500 infants

Use During Pregnancy Substance Used (Past Month) 1st Trimester 2nd Trimester 3rd Trimester Any Illicit Drug Alcohol Use Binge Alcohol Use SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data 2.3% women 5,800 infants 4.7% women 11,900 infants 0.7% women 1,800 infants 7.7% women 19,481 infants 19.6% women 49,588 infants 10.9% women 27,577 infants 3.2% women 8,100 infants 6.1% women 15,400 infants 1.4% women 3,500 infants State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth

Use During Pregnancy Substance Used (Past Month) 1st Trimester 2nd Trimester 3rd Trimester Any Illicit Drug Alcohol Use Binge Alcohol Use SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data 2.3% women 5,800 infants 4.7% women 11,900 infants 0.7% women 1,800 infants 7.7% women 19,481 infants 19.6% women 49,588 infants 10.9% women 27,577 infants 3.2% women 8,100 infants 6.1% women 15,400 infants 1.4% women 3,500 infants

Parent is alcohol dependent or need treatment: About 25,000 New York infants affected per year Mother uses while pregnant: About 500,000 New York children affected New York Children Affected Parents in Treatment: About 168,000 New York Treatment Admissions Were parents of minor children

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 50% Increase over 6 Years

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

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

New York State Foster Care In Care, Admissions and Discharges Source: New York State Monitoring and Analysis Profiles (2003)

New York Child Victims by Age Group 2003 Source: Child Maltreatment 2003

Children in Foster Care by Age Group 2003 Source: New York MAPS (2003)

Past Year Substance Use by Youth Age 12 to 17 Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care 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%)

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 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 Definition of substance abuse Population (rural versus urban) Population (rural versus urban) Sample (in-home versus out of home) 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 “cooks” small quantities of meth Parent involved in super lab Parent involved in super lab  Parent involved in trafficking  Mother uses while pregnant

 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 “cooks” small quantities of meth Parent involved in super lab Parent involved in super lab  Parent involved in trafficking  Mother uses while pregnant  Parent is dependent on drugs and/or alcohol  Mother uses while pregnant Risks for Children How does Child Welfare Assess for the Differences?

Substance Exposed Infants

Total births 253,000 10% of total births 25,300 Total child victims under age 1 year 6,300 Total age 0-2 years in OOHC = 2,400 Where did they all go? 2003 Estimated Number of Children Prenatally Exposed to Substances in New York 25%

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))

 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. The complexity of screening and assessment for these children is compounded by at least two realities: Screening and Assessment of Consequences for Children

5. Identify and respond to the needs of ● Infant ● Preschooler ● Child ● Adolescent ParentChild Five Points of Intervention for Policy and Practice with Substance Exposed Infants Identify and respond to family’s needs Initiate enhanced prenatal services 3. Identification at Birth 4. Ensure infant’s safety and respond to infant’s needs 2. Prenatal screening and assessment 1. Pre-pregnancy awareness of substance use effects System Linkages Respond to family’s needs System Linkages

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

 Many communities began program models in 1990s Models of Improved Services  Family Treatment Courts  Training and Curricula Development  Persons in Recovery act as Advocates for Parents  Multidisciplinary Teams for Joint Case Planning  Counselor Out-stationed at Child Welfare Office  Paired Counselor and Child Welfare Worker

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) Integrated (e.g., Santa Clara, Reno, Suffolk) Both dependency matters and recovery management conducted in the same court with the same judicial officer Both dependency matters and recovery management conducted in the same court with the same judicial officer Dual Track (e.g., San Diego) Dual Track (e.g., San Diego) Dependency matters and recovery management conducted in same court with same judicial officer during initial phase 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 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) Parallel (e.g., Sacramento) Dependency matters are heard on a regular family court docket Dependency matters are heard on a regular family court docket Specialized court services offered before noncompliance occurs Specialized court services offered before noncompliance occurs Compliance reviews and recovery management heard by a specialized court officer Compliance reviews and recovery management heard by a specialized court officer Cross-Court Team (e.g., Orange County, CA) Cross-Court Team (e.g., Orange County, CA) Dependency and recovery matters are heard by same court Dependency and recovery matters are heard by same court Recovery management, child welfare services, legal representation assigned to a team Recovery management, child welfare services, legal representation assigned to a team Team works in six courts with separate judges/commissioners Team works in six courts with separate judges/commissioners

Emergence of Family Based Treatment… Models are not Not Yet Reformed Systems

 Women’s programming 1970s - 80s Strategies still largely based on male models Strategies still largely based on male models  Women and children 1990s Increased recognition of specific needs for women – Trauma and Co-occurring disorders Increased recognition of specific needs for women – Trauma and Co-occurring disorders  Children’s intervention needs – Early 2000s Significant therapeutic needs of children Significant therapeutic needs of children Poor parenting skills and minimal attachment ability Poor parenting skills and minimal attachment ability Emergence of Family Based Treatment

Moving Toward Family Based Treatment  Challenges Defining who is the family member Defining who is the family member How many and ages of children in programs How many and ages of children in programs Logistics, milieu and clinical reasonsLogistics, milieu and clinical reasons Incorporating fathers in treatment milieu Incorporating fathers in treatment milieu Preventing further trauma of family divisions and separationsPreventing 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 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 Continuum of Family Based Treatment

Comprehensive Family Based Services Characteristics and Principles  Safety comes first For each family member For each family member  Comprehensive Clinical treatment, clinical supports and community supports 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 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

  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 Framework and Policy Tools for Systems Change

 Underlying values  Joint accountability and shared outcome  Information systems  Training and staff development  Budgeting and program sustainability Elements of System Linkages  Daily practice  screening and assessment  Daily practice  client engagement and retention in care  Daily practice  AOD services to children  Working with related agencies  Building community supports Visit www.ncsacw.samhsa.govwww.ncsacw.samhsa.gov for Examples from States to Implement these Elements

Elements of System Linkages  Underlying Values Colorado values statements Colorado values statements Practitioners from all systems should adopt a “screen out stance” with regard to substance use disordersPractitioners 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)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 addressedDuring the assessment process, children’s needs should be identified and addressed Sharing information appropriately is desirable, helpful, and feasibleSharing information appropriately is desirable, helpful, and feasible Actions should have consequences that are fair, timely, and appropriate to the actionActions 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 punishmentsConsequences should apply to families and to staff; consequences should not be used solely as punishments

Elements of System Linkages  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 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: An effective screen of substance use disorders includes questions about: Unintended useUnintended use Desire to restrict useDesire to restrict use Consequences of useConsequences of use Concern about consequences of useConcern about consequences of use

In the past year, have you ever drank or used drugs more than you meant to?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 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?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?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 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?Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger, or boredom? Elements of System Linkages  Daily Practice – Screening and assessment Use of UNCOPE in Oregon and Washington Use of UNCOPE in Oregon and Washington

Elements of System Linkages  Daily Practice – Client engagement and retention in care Florida protocols -- NYC protocols Florida protocols -- NYC protocols Recovery management approaches Recovery management approaches STARSSTARS SARMSSARMS

Elements of System Linkages  Daily Practice – Services to children Screening project for FASD among the children of the Santa Clara County Family Drug Treatment Court (California) 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 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 togetherFour groups – adolescents, pre-adolescents, children and parents – meet separately, receive the same information and meet together

Elements of System Linkages  Joint Accountability, Shared Outcomes and Information Systems Michigan revised SACWIS to prioritize families with substance use disorders Michigan revised SACWIS to prioritize families with substance use disorders CFSR and NOMS processes 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 Nothing But Silence

Improving Outcomes for Families Affected by Substance Use Disorders Presented at 9 th Annual Conference of the Association of Alcoholism and Substance.

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Improving Outcomes for Families Affected by Substance Use Disorders Presented at 9 th Annual Conference of the Association of Alcoholism and Substance.

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Presentation on theme: "Improving Outcomes for Families Affected by Substance Use Disorders Presented at 9 th Annual Conference of the Association of Alcoholism and Substance."— Presentation transcript:

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