Final Evaluation of the Title IV-E Waiver Child Welfare Demonstration in New Hampshire Ninth Annual Child Welfare Demonstration Projects Meeting June 2005 Glenda Kaufman Kantor, University of New Hampshire Bernie Bluhm, NH DCYF

State of New Hampshire Study Sample Sites

Challenges of NH Environment

Baseline Status of Substance Abuse in NH

History: Higher Incidence of Problem Drinking NH Women Than National Average

Current Status of NH Substance Abuse (2002) 31% Past Month Illicit Drug Use – (18-25 yrs)– 2 nd Highest in U.S. 50% Past Month Binge Alcohol Use – (18-25 yrs)- 3 rd Highest in U.S. 21% Past Month Binge Alcohol Use – (26 yrs>) (National Average) 300 children <17 living under court order in secure facilities due to D/A charges, related crimes (2001)

Since 1994, less than 15% of NH CPS assessments completed each year have been substantiated (Founded).

Key Project Aims  Identify & Address Parental Substance Abuse Problems co-occurring with suspected child abuse or neglect.  Better Decision-Making about Safety  Reduce Substance Abuse Risk Behaviors of Parents  Fewer Subsequent Founded Referrals  Prevent or Shorten Placement of Children in Foster Care  Improve Stability and Adjustment of Children  Cost Neutrality/Savings of Project

Project Design

Target Population Credible report of suspected CA/N Substance Abuse Current Risk Factor Related to CA/N Reside in Hillsborough Co area covered by the Manchester/Nashua D.Os. No Open Case at Intake into Study Accessible to DCYF CPSW

LADC Role Engage Client at Time of Assessment of Allegation Immediate Screening & Assessment by LADC Immediate individual treatment for AODA Immediate and ongoing consultation for CPSW

For people awaiting treatment Individual counseling On-going contact with counselor – Treatment window extended 60 days from CPS assessment or case closure – Treatment provider connections

For Families Receiving Services Consultant participates in case planning Keep focus on parent issues Include parenting in treatment goals Aftercare with focus on parenting Support to relative caregivers

Benefits to CPS During Assessment Regular Consultation Preliminary Screening (SASSI) of Parental Substance Abuse Impact of Parental Substance Abuse on Safety and Risk of Harm to Children Recommendations for Services and Treatment

Benefits for CPS Cases When Children Are In Out-Of-Home Care Comprehensive assessment with DX Assistance with goal specific case planning Continued consultation Recommendations for parents and children

Evaluation

Evaluation Design Experimental Model with True Randomized Design to Standard/Enhanced Services at 2 District Offices Standard group received the usual services provided by NH DCYF Parallel Data Collection for Standard and Enhanced Process & Outcomes SACWIS Data Interviews at Baseline & Follow-up Cost Benefit

Final Evaluation Status Conducted 11/15/99 through 10/15/04 – 437 families eligible 212 baseline interviews (49%) 156 follow-up interviews (74%)

Study Sample Demographics: Primary Caregiver Enhanced Group (n=222): Mean Age: 33 Years % White: 92% Any Employment: 59% Relationship of Alleged Perp. to Child Bio. Mother 69% Mean Family Size Total Adults: 1.83 Total Children: 2.80 Standard Group (n=215): Mean Age: 33 Years % White: 90% Any Employment: 63% Relationship of Alleged Perp. to Child Bio. Mother: 72% Mean Family Size Total Adults: 1.85 Total Children: 2.84

Study Sample Demographics: Child Enhanced Group (n=222) Female: 51% Mean Age: 8 yrs. Median: 9 yrs. Range: 0-17 yrs. Ethnicity: White: 87% Black: 6% Latino/Hispanic: 5% Other: 2% Standard Group (n=215) Female: 51% Mean Age: 8 yrs. Median: 8 yrs. Range: 0-17 yrs. Ethnicity: White: 89% Black: 6% Latino/Hispanic: 2% Other: 3%

Maltreatment & CPS Factors Enhanced Group (n=222) CPS Factors Prior Referrals * 44% High Risk at Entry 11% Type of Maltreatment Physical Abuse 25% Phys. Abuse & Negl. 13% Neglect: 52% Sexual Abuse: 3% Psychological Abuse: 1% Standard Group (n=215) CPS Factors Prior Referrals 51% High Risk at Entry 14% Type of Maltreatment Physical Abuse: 21% Phys. Abuse & Negl: 9% Neglect: 56% Sexual Abuse: 5% Psychological Abuse: 2%

Family Risk Factors Enhanced (n=222) Domestic Violence: 33% Adult Mental Illness: 18% Adult Phys. Disability: 4% Homeless: 17% Incarceration (Case Level): 32% Standard (n=215) Domestic Violence: 33% Adult Mental Illness: 20% Adult Phys. Disability: 7% Homeless: 14% Incarceration (Case Level): 28%

Child Risk Factors Enhanced Group (n=222) Mental Illness: 6% Phys. Disability: 3% Learning Disabled 11% Neonatal Addiction: 2% Severe Behavior Prob. 5% JPPO* Involvement at Case Level 26% Standard Group (n=215) Mental Illness: 7% Phys. Disability: 5% Learning Disabled: 13% Neonatal Addiction: 1% Severe Behavior Prob. 9% JPPO* Involvement at Case Level 24% * DHHS Division for Juvenile Justice Services Juvenile Probation & Parole Officers, involved due to child status offenses or delinquency.

Co-Morbidity in Interview Sample

Victimization & Trauma Hx. Of Adult

Probability of Having a Substance Dependence Disorder

Co-Morbidity 45% of “high-probability” have prior diagnosis of mental illness. 45% of “high probability” have clinical levels of depression 18% prior hx of mental illness documented in initial record data. 45% Clinically Depressed using CESD measure.

Domestic Violence in Initial CPS Study Referrals Over half (58%) had a prior Order of Protection at some time Over 1/3 report DV in current year 19% got a protective order on current partner in the past

PROCESS EVALUATION

Implementation Challenges Engagement of Client & Timing Randomization of LADC Services within Sites District Office Cultures Different Therapist Effects Attrition of LADC & CPSWs Need to build consensus between co-located systems – Information sharing/confidentiality – Focus on “Primary Client” – Treatment recommendations from different points of view – ASFA 12 month clock vs recovery clock

LADC: Challenges of Engagement

Challenges of Engagement

Correct Assignment of Subsequent Referrals by Group & Site

Percentage of Families Completed SASSI by Site

Percent of Initial Referrals Founded by Group

Final Founded Dispositions of Initial Referrals by Group & Site

Client Satisfaction w/ LADC Manchester (n=27) Overall Satisfaction Satisfied: 52% Overall Satisfaction by Substantiation – No Case Ever Opened Satisfied: 40% – Case Opened Satisfied: 67% Nashua (n=19) Overall Satisfaction Satisfied: 90% Overall Satisfaction by Substantiation – No Case Ever Opened Satisfied: 92% – Case Opened Satisfied: 86%

Mean Therapist Referrals for Clients After Initial Eval. by Site: 1,2,3,4 statistical significance found between sites: ANOVA p >

Treatment Utilization

Treatment Utilization by Group

LADC: Networking

Outcomes

Outcomes: Substance Abuse & Assessment

Preliminary Findings on System Status 1999: Substance Abuse Incidence & Case Outcome Review of NH Cases for 1 month= 640 Cases 546 cases completed assessments Substance Abuse documented as a factor in completed assessments =159/546 or 29% Proportion of substance abuse referrals founded as cases=35/159 (22%)

Project First Step: Substance Abuse as a Factor in Completed Assessments 1999 : Substance Abuse documented as a factor in completed assessments – 159/546 or 29% 2004: Substance Abuse documented as a factor in completed assessments – 66% of Enhanced Group *** – 47% of Standard Group

Substantiation by High Probability of Having a Substance Dependence Disorder * Significant statistical difference found between substantiation: Chi Sq 9.51, 1df,p=.002 Cases opened for continued services and/or placement directly supervised or paid by DCYF

Percentage of Cases Open on Subsequent Referral by Group & Site *Significant statistical difference found between groups within Manchester: Chi Sq. 1-Sided p (.036) >.05

Enhanced (n= 228) Standard (n= 219) % CASES FOUNDED ON SUBSEQUENT REFERRALS MEAN # SUBSEQUENT REFERRALS 46% % 1.20 Subsequent Referrals* by Group *Referral: Report to NH DCYF based on a suspicion of child abuse or neglect. All NH citizens are mandated reporters.

Characteristics of Child Placements

In-Home Services for Families with Cases by Group IN-HOME SERVICES*EnhancedStandard % FAM. ANY IN-HOME SERVICE MEAN # FAM W/ IN-HOME SERVICE # OF FAM. RECEIVING IN-HOME SERVICES W/ A VOLUNTARY/B-CASE 12% % * “In home services” means services paid for and/or supervised by DCYF in founded cases after due process was provided or afforded. There are 8 families, in which one child received In-Home Services and was not removed, but another child within that same family was removed.

Out of Home Placement (OHP) Types by Group EnhancedStandard KIN CARE % FAM. ANY KIN CARE MEAN # FAM. W/ Children in KIN CARE 22% % 0.24 FOSTER CARE % FAM. ANY FOSTER CARE MEAN # Child Placements for FAM W/ FOSTER CARE Placements 63% % 2.72 OTHER OHP % FAM. ANY OHP MEAN # FAM W/ Children in OHP 26% % 0.68

Mean Number of Children in Placement per Family by Group & Site

Mean length of placement (days) per child in placement by group & site

Mean Number of Placements per Child in Placement by Group & Site

Percentage of Families with TPR by Group

Percentage of Families with TPR by Group & Site

Mean Length to TPR by Group

ADULT OUTCOMES

W1 & W2 RX Utilization by Groups: Interview Sample, Self Reports EnhancedStandard % Resp. attend AA W1 (ever) W2 (past yr.) 40% (45/112) 69% (19/28) 43% (43/100) 45% (10/22) % Resp. help for drinking W1 (ever) W2 (past yr.) 25% (28/112) 48% (11/23) 32% (32/100) 43% (6/14) % Resp. hospitalization for drinking W1 (ever) W2 (past yr.) 16% (18/112) 27% (4/15) 18% (18/100) 11% (1/9)

W1 & W2 RX Utilization by Groups Interview Sample: Reports on Partner EnhancedStandard % Partner attend AA W1 (ever) W2 (past yr.) 31% (20/65) 62% (8/13) 44% (25/57) 46% (6/13) % Part. help for drinking W1 (ever) W2 (past yr.) 25% (16/64) 25% (2/8) 22% (12/65) 43% (6/10) % Part. hosp. for drinking W1 (ever) W2 (past yr.) 16% (9/64) 27% (4/15) 18% (8/54) 11% (1/9)

W1 & W2 Parent Outcomes: Interview Sample, Self Reports EnhancedStandard % Clinically Depressed W1 W2 39% 36% 40% 32% % Heavy Drinking W1 W2 29% 35% 53% 42% % Hard Drug Hx W1 W2 43% 44% 47% 48%

W1 & W2 Parent Outcomes: Interview Sample, Self Reports EnhancedStandard % Employed FT W1 W2 32% 38% 32% 24%* %Enrolled Educ/Voc. Program W228%16%

Child Outcomes

Child Outcomes for Index Children ages 4-17 Children in Enhanced Groups had greater declines in 7 of 8 problem categories: –Anxiety & Depression –Withdrawn/Depressed –Somatic Problems –Attention Problems –Aggressive Behavior

Child School & Health Outcomes Enhanced Group – Repeated Grade* 10% – Academic/Other School Problems 39% – MD concerns re: health 11% Standard Group – Repeated Grade* 29% – Academic/Other School Problems 43% – MD concerns re: health 14%

Cost Analysis

Shortfall EXPER. GRP. EXPEND. IN EXC. OF CNL - FFP TOTAL (B7d(e)) $280, (IV-E funds)

IV: Cost-Benefit Analysis - Costs to date $1,569, Major funding streams Title IV-E

What Contributed to Higher Costs? Few differences between standard and enhanced Prior referrals significantly higher among enhanced high cost group JPPO referrals significantly greater among enhanced high cost group More child mental health problems identified at intake for enhanced group

Cost Benefits Analysis by Group Including LADC Costs Avg. Cost/Child 1 Savings – Child Not Removed 2 Savings – Kin Care 3 Total Avg. Cost/Child 4 Total Avg. Savings 5 Enhanced$23,709 $5,952$23,709$29,660 Standard$20,951 $4,920$20,951$25,871

Conclusions Key Outcomes – Significant Effects of Assessment – Strengths of Effects Diminished by Site Differences – More Long-Term Substance Abuse Treatment of Adults – Child Safety Outcomes: fewer subsequent founded reports, more stability, decrease in time to TPR – Improved Well Being for Adults & Children

LADC: Closing

Finale: LADAC clip