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The SAMHSA Women, Co-Occurring Disorders & Violence (WCDVS) Children’s Subset Study Presented at: Putting the Pieces Together: First National Conference.

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Presentation on theme: "The SAMHSA Women, Co-Occurring Disorders & Violence (WCDVS) Children’s Subset Study Presented at: Putting the Pieces Together: First National Conference."— Presentation transcript:

1 The SAMHSA Women, Co-Occurring Disorders & Violence (WCDVS) Children’s Subset Study Presented at: Putting the Pieces Together: First National Conference on Substance Abuse, Child Welfare & the Dependency Court July 15, 2004 Norma Finkelstein, Ph.D. Institute for Health & Recovery Vivian Brown, Ph.D. PROTOTYPES Centers for Innovation in Health, Mental health and Social Services Nancy VanDeMark, MSW Arapahoe House Inc. Lisa Russell, Ph.D. ETR Associates

2 Study Overview

3 Family Focused Approach Treatment to promote the well-being of the entire family Treatment to promote the well-being of the entire family Attracts & retains women in treatment Attracts & retains women in treatment Prevention of child abuse & neglect; of future substance abuse & mental health problems in children Prevention of child abuse & neglect; of future substance abuse & mental health problems in children Promotes resiliency & coping skills in children Promotes resiliency & coping skills in children

4 Impact of Recovery on the Family Changes roles & relationships among all family members Changes roles & relationships among all family members Stimulates guilt & remorse for past behavior Stimulates guilt & remorse for past behavior Stimulates fear & loss Stimulates fear & loss Families need a great deal of support to tolerate the feelings & stay with it Families need a great deal of support to tolerate the feelings & stay with it

5 Children’s Subset Study Primary Goals For children of mothers with co-occurring mental health and substance use disorders & histories of violence: Generate empirical knowledge about the effectiveness of trauma-informed, age-specific intervention models Generate empirical knowledge about the effectiveness of trauma-informed, age-specific intervention models Identify models of care that will prevent or reduce intergenerational perpetuation of violence Identify models of care that will prevent or reduce intergenerational perpetuation of violence

6 Target Population Children, ages five to ten, of women enrolled in the WCDVS Children, ages five to ten, of women enrolled in the WCDVS Children had at least weekly personal contact with mother / caregiver enrolled in WCDVS Children had at least weekly personal contact with mother / caregiver enrolled in WCDVS Only one child per family enrolled in the study Only one child per family enrolled in the study

7 Children’s Study Sites Allies – Stockton, California Allies – Stockton, California Arapahoe House- Denver, Colorado Arapahoe House- Denver, Colorado Prototypes – Los Angeles, California Prototypes – Los Angeles, California Well Project – Cambridge, Massachusetts Well Project – Cambridge, Massachusetts Coordinating Center - Policy Research Associates Coordinating Center - Policy Research Associates

8 Baseline Characteristics of the Women

9 WCDVS Demographics N=2,729 AgeMean36 Race African- American HispanicCaucasian27%19%50% Education Less than high school 47% RelationshipStatus Married/significant other Divorced/separated/widowed Never married 38%32%30% EmploymentFull-/part-timeDisabled Below Poverty Line 13%25%73% ResidenceHomeless Residential SA House/apartment 3% 3%53%36%

10 Parenting Status Percent Ever Having Children86.7 Percent Ever Having Children86.7 Mean Number of Children Mean Number of Children Under Percent with Custody59.2 Percent with Custody59.2

11 Trauma Experience Study data show that trauma started early and happened often: Study data show that trauma started early and happened often: About ¾ of subjects (74%) reported multiple types of abuse and repeated abuse. About ¾ of subjects (74%) reported multiple types of abuse and repeated abuse. Average age of first sexual and physical abuse was 13 Average age of first sexual and physical abuse was 13 Physical neglect reported started around 9 years Physical neglect reported started around 9 years Almost all women (92%) reported physical abuse Almost all women (92%) reported physical abuse 90% reported sexual abuse 90% reported sexual abuse

12 Health Status 49% with any insurance 62% Medicaid 18% Medicare Serious physical illness 48% Percent with excellent/very good physical health 15% Percent taking psychotropic medications 63% Below the poverty line 65% BSI (Mean GSI Score) 1.42 Mean ASI Drug.13 Mean ASI Alcohol.20

13 Legal Status 27% of women were mandated to mental health and/or substance abuse treatment by DCF/Child Protection. 27% of women were mandated to mental health and/or substance abuse treatment by DCF/Child Protection. 21% had been in a jail or correctional facility in the previous 3 months. 21% had been in a jail or correctional facility in the previous 3 months.

14 Summary of Demographic Characteristics Data indicate that, in general study participants were: Data indicate that, in general study participants were: not highly educated not highly educated underemployed underemployed in relatively poor physical and mental health in relatively poor physical and mental health mostly mothers with extensive histories of interpersonal violence mostly mothers with extensive histories of interpersonal violence

15 Service Use at Baseline Type of Service # of Respondents Reported Having Received Service % of Respondents Reporting Having Received Service (Out of N=2729) Hospitalization Emergency Room Detox Services Residential Treatment (Any type) 1, Homeless or Domestic Violence Shelter Jail or Correctional Facility Peer Support or Self-Help Services 1, Medical Clinic or Doctor’s Office 1,

16 Parenting Concerns at Baseline Almost a quarter (24.5%) of the mothers with children under 18 were concerned about losing custody of their children. Almost a quarter (24.5%) of the mothers with children under 18 were concerned about losing custody of their children. Less than half (46%) of mothers indicated they felt confident in their ability to help their child grow and develop. Less than half (46%) of mothers indicated they felt confident in their ability to help their child grow and develop. Only 32.4% of women agreed with the statement, “I feel my family life is under my control.” Only 32.4% of women agreed with the statement, “I feel my family life is under my control.” Only 37.3% of women strongly agreed or agreed with the statement, “I feel my service providers support me in my role as a parent.” Only 37.3% of women strongly agreed or agreed with the statement, “I feel my service providers support me in my role as a parent.”

17 In the words of the women… “Parenting [groups] gave me confidence that I could do it. It showed me that I was allowed to make mistakes. It gave me skills to feel confident with my baby and not feel like I’m going to hurt her or screw her up, cause that was my biggest fear.” Charlene, Arapahoe House

18 Baseline Characteristics of the Children

19 Characteristics of Children Average age years Average age years In legal custody of mother % In legal custody of mother % Involved in child welfare system - 39% Involved in child welfare system - 39% Experiencing emotional or behavioral problems % Experiencing emotional or behavioral problems % Parent convicted of a crime – 79.8% Parent convicted of a crime – 79.8% Parent treated for substance abuse – 98% Parent treated for substance abuse – 98%

20 Age (N=253)

21 Race Distribution (N=253)

22 Gender (N=253)

23 Hispanic Ethnicity (N=86)

24 Rating of Child’s School Performance

25 Prevalence of Victimization

26 Intervention Overview

27 Core Values Reflected in the Intervention Core Values Reflected in the Intervention Children have a right to express themselves openly and to have their opinions validated. Children have a right to express themselves openly and to have their opinions validated. Services for child and parent should be integrated. Services for child and parent should be integrated. Safety is of utmost importance. Safety is of utmost importance. Consistency is a cornerstone of service delivery. Consistency is a cornerstone of service delivery. Interactions should promote respect and support understanding, compassion, dignity and self-worth. Interactions should promote respect and support understanding, compassion, dignity and self-worth.

28 Children have a right to exercise control over their bodies Children have a right to exercise control over their bodies Interventions should encourage nurturing relationships with adults Interventions should encourage nurturing relationships with adults Children are entitled to share information confidentially except when issues of safety arise Children are entitled to share information confidentially except when issues of safety arise Families should be connected to community and natural supports Families should be connected to community and natural supports Core Values Reflected in the Intervention Core Values Reflected in the Intervention

29 Core Intervention Components Clinical Assessment – Mother & Child Clinical Assessment – Mother & Child Resource/Service Coordination & Advocacy Resource/Service Coordination & Advocacy Skills-/Resiliency-Building Group Skills-/Resiliency-Building Group

30 Strengths and interests Strengths and interests Significant life events Significant life events Parent and child substance use Parent and child substance use Medical concerns Medical concerns Mental health needs Mental health needs Educational and developmental issues Educational and developmental issues Parenting and discipline Parenting and discipline Clinical Assessment

31 Group Intervention Orientation: Mothers and Children Session 1: Message: It’s okay to feel and express feelings Session 2: What is abuse? Session 3: Anger Session 4: It’s not always happy at my house Session 5: Sharing personal experience with violence Group Intervention was adapted from Groupwork With Children of Battered Women, Peled and Davis, Sage Publications, 1995

32 Group Intervention Session 6: Touch Session 7: Assertiveness Session 8: Protective Planning Session 9: Review and Good-bye Booster Session #1 (30 days post) - Review week 2 discussion on abuse Booster Session #2 (60 days post) - Review week 8 on safety planning

33 Primary Goals of the Group Intervention Learn self-protection skills Learn self-protection skills Develop skill in self-soothing Develop skill in self-soothing Enhance interpersonal relationships Enhance interpersonal relationships Strengthen self-esteem and self identity Strengthen self-esteem and self identity

34 Resource Coordination & Advocacy Parent and child self-determination and empowerment Parent and child self-determination and empowerment Strengths-focused rather than pathology- focused Strengths-focused rather than pathology- focused Resource coordinators as “resiliency mentors” Resource coordinators as “resiliency mentors” Focused on resiliency-building activities Focused on resiliency-building activities Teaching parents advocacy skills Teaching parents advocacy skills

35 Analysis and Results

36 Primary Research Question Primary Research Question Are trauma-informed, age-specific interventions for children more effective than usual care conditions in leading to increases in safety, self-care, positive interpersonal relationships and self-identity?

37 Sample Overview N=253 at Baseline N=253 at Baseline N=209 at 6 Months (82.6%) N=209 at 6 Months (82.6%) N=217 at 12 Months (85.8% Retention) N=217 at 12 Months (85.8% Retention) N=195 (77.1%) Received Baseline, 6 Month and 12 Month Interviews N=195 (77.1%) Received Baseline, 6 Month and 12 Month Interviews Intervention and Comparison Groups are Statistically Equivalent on Demographic Characteristics Across Follow-Ups Intervention and Comparison Groups are Statistically Equivalent on Demographic Characteristics Across Follow-Ups

38 Analysis Primary Outcome Variable Behavioral & Emotional Rating Scale (BERS) Strength Quotient (Epstein & Skaima, 1998) Behavioral & Emotional Rating Scale (BERS) Strength Quotient (Epstein & Skaima, 1998) Secondary Outcome Variables BERS Subscales BERS Subscales Tools for Improving Relationships Tools for Improving Relationships Family Involvement Family Involvement Capacity for Closeness Capacity for Closeness Positive self-identity Positive self-identity Measure of Safety Knowledge Child knows what to do to keep self safe when feels threatened by another person (4 Point Scale) Child knows what to do to keep self safe when feels threatened by another person (4 Point Scale)

39 Analysis Plan Covariates Used in All Analyses Covariates Used in All Analyses Child’s Age Child’s Age Child’s Gender Child’s Gender Child’s Race Child’s Race Site & Site by Treatment Interaction Site & Site by Treatment Interaction Mother’s Outcomes (Composite Score) Mother’s Outcomes (Composite Score) Experience of Violence in the Household Experience of Violence in the Household Number of Days Since Mother’s Baseline Interview Number of Days Since Mother’s Baseline Interview

40 Short Term Effects (6 months post baseline) Primary Outcomes Involvement in intervention lead to comparable, but not better, improvement than treatment as usual Involvement in intervention lead to comparable, but not better, improvement than treatment as usual Mother’s outcomes affected children’s outcomes Mother’s outcomes affected children’s outcomes Children in comparison whose mothers had negative outcomes did worse Children in comparison whose mothers had negative outcomes did worse Children whose mothers had positive outcomes did well in both conditions Children whose mothers had positive outcomes did well in both conditions

41 Short-Term Effects (Six Months Post Baseline) Secondary Outcomes Enrollment in the standardized intervention appears to lead to improvements in positive interpersonal relationships, knowledge about safety & positive self-identity. Enrollment in the standardized intervention appears to lead to improvements in positive interpersonal relationships, knowledge about safety & positive self-identity.

42 Longer-Term Effects (Twelve Months Post Baseline) Primary Outcomes Involvement in intervention leads to sustained improvement compared to children in comparison group Involvement in intervention leads to sustained improvement compared to children in comparison group Mothers’ outcomes do not play role in sustaining children’s positive outcomes Mothers’ outcomes do not play role in sustaining children’s positive outcomes Younger children show more improvement regardless of condition Younger children show more improvement regardless of condition Children in intervention group performed consistently better across all age groups Children in intervention group performed consistently better across all age groups

43 Secondary Outcomes Intervention plays role in sustaining improvements in positive interpersonal relationships, knowledge re: safety & positive self-identity Intervention plays role in sustaining improvements in positive interpersonal relationships, knowledge re: safety & positive self-identity Longer-Term Effects (Twelve Months Post Baseline)

44 Summary of Results In short-term (six-months), mother’s overall treatment outcome plays stronger role in children’s outcomes than involvement in the intervention In short-term (six-months), mother’s overall treatment outcome plays stronger role in children’s outcomes than involvement in the intervention In longer-term (twelve-months), participation in intervention leads to sustained positive improvement regardless of mother’s outcome, with younger children showing a greater degree of positive change than older children In longer-term (twelve-months), participation in intervention leads to sustained positive improvement regardless of mother’s outcome, with younger children showing a greater degree of positive change than older children

45 Implications and Lessons Learned

46 Role of CSR’s & Parents Partners in development of research and intervention design Partners in development of research and intervention design Developed consent form discussing risks and benefits of the group intervention Developed consent form discussing risks and benefits of the group intervention Co-facilitated groups Co-facilitated groups Assisted mothers in understanding importance of the intervention Assisted mothers in understanding importance of the intervention Acted as a bridge for trust Acted as a bridge for trust Provided support for parents as they experienced shame, guilt and fear Provided support for parents as they experienced shame, guilt and fear

47 Lessons Learned Children can be the motivator for women to seek treatment. Children can be the motivator for women to seek treatment. Treatment of the woman offers an opportunity to provide services to the children. Treatment of the woman offers an opportunity to provide services to the children. Traumatic childhood experiences influence the ability to parent. Traumatic childhood experiences influence the ability to parent. Victimization if children triggers memories in the parent. Victimization if children triggers memories in the parent. Motherhood is both a major source of identity and self-worth, and a source of shame and guilt. Motherhood is both a major source of identity and self-worth, and a source of shame and guilt.

48 Lessons Learned Extreme guilt and shame must be addressed in order to build healthy parenting relationships. Extreme guilt and shame must be addressed in order to build healthy parenting relationships. The support of a parent who has experienced similar challenges is critical to overcome fear and guilt. The support of a parent who has experienced similar challenges is critical to overcome fear and guilt. Must have well developed working relationships with child welfare agencies. Must have well developed working relationships with child welfare agencies. System related issues of confidentiality and privacy must be addressed in order to promote healthy boundaries. System related issues of confidentiality and privacy must be addressed in order to promote healthy boundaries.

49 Implementation in Residential Settings Challenges Challenges Milieu issues and group confidentiality Milieu issues and group confidentiality Closed groups Closed groups Retaining child once parent leaves treatment Retaining child once parent leaves treatment Custody issues Custody issues Perceived breaches of trust travel farther and faster Perceived breaches of trust travel farther and faster

50 Implementation in Residential Settings Opportunities Opportunities Ease of access for families Ease of access for families Wrap around support for family Wrap around support for family Support outside of groups Support outside of groups Continuity across interventions (milieu, parenting, children’s groups, mother’s trauma groups Continuity across interventions (milieu, parenting, children’s groups, mother’s trauma groups Care for younger children available Care for younger children available

51 Residential Lessons Learned Programs should attempt to deliver the maximum dosage of the children’s intervention while the parent it in residential treatment. Programs should attempt to deliver the maximum dosage of the children’s intervention while the parent it in residential treatment. The informal relationship of CSR’s and mothers built in the milieu become valuable assets for trust building The informal relationship of CSR’s and mothers built in the milieu become valuable assets for trust building Children are sensitive to being “left out” of a group. Decisions about closed or semi-closed groups should be made with these implications in mind. Children are sensitive to being “left out” of a group. Decisions about closed or semi-closed groups should be made with these implications in mind.

52 Residential Lessons Learned Interventions for parent and child should be integrated. Children’s staff must be sensitive to what is happening in mother’s treatment and in parenting groups. Interventions for parent and child should be integrated. Children’s staff must be sensitive to what is happening in mother’s treatment and in parenting groups. Helping women manage their fear of systems is an ongoing task and is often best addressed in groups. Helping women manage their fear of systems is an ongoing task and is often best addressed in groups. Maintaining group confidentiality is much more difficult in residential settings. Maintaining group confidentiality is much more difficult in residential settings.

53 Implementation in Outpatient Settings Challenges Challenges Trust and rapport Trust and rapport Scheduling Scheduling Location Location Transportation Transportation Staffing Staffing Child care Child care Custody Custody

54 Implementation in Outpatient Settings Opportunities Opportunities Parent engagement, education, and support Parent engagement, education, and support Parent network building Parent network building Potential impact on other children in family Potential impact on other children in family Child and family advocacy within the community system of care for children Child and family advocacy within the community system of care for children

55 Outpatient Lessons Learned Role of consumers Role of consumers Feedback, flexibility, and responsiveness Feedback, flexibility, and responsiveness Connection as a theme Connection as a theme Child abuse reporting Child abuse reporting

56 Outpatient Lessons Learned: Clinical Staff Working toward a family approach while taking into account staff members’ strengths in training & experience Working toward a family approach while taking into account staff members’ strengths in training & experience Staff cross training and preparation for a strengths based, family centered approach Staff cross training and preparation for a strengths based, family centered approach Clinical supervision that addresses planning for children’s and mother’s unique needs as well as an integrated family approach Clinical supervision that addresses planning for children’s and mother’s unique needs as well as an integrated family approach

57 Implications for Practice Integration of children’s services into existing adult MH & SA treatment programs Integration of children’s services into existing adult MH & SA treatment programs Prevention Prevention Future MH, SA, Intergenerational violence Future MH, SA, Intergenerational violence Early Intervention Early Intervention Importance of Concurrent Services (Mother & Child) Importance of Concurrent Services (Mother & Child) Systems Collaboration Systems Collaboration Funding Funding


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