Improving Outcomes for Families Affected by Substance Use Disorders Nancy K. Young, Ph.D., Director 4940 Irvine Boulevard, Suite 202 Irvine, CA Betty Ford Conference Trends and Perspectives in Women’s Addiction April 13, 2004

Topics  NCSACW  Some Numbers  Some History  Policy Framework and Tools  Models

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 by  Developing and implementing a comprehensive program of information gathering and dissemination  Providing technical assistance

PRODUCTS:  On-Line Training  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 – Fall 2004  A Guide for Judges and Dependency Court Staff – Summer 2005

PRODUCTS:  Program of In-Depth Technical Assistance  Round 1 – Summer 2003 to Fall 2004  Colorado, Florida, Michigan, Virginia  Assistance to Develop and Implementation State’s Plan to Better Serve this Population of Families  Round 2 – Solicitation in Fall 2004  Seven States Offered Program, 3 States and 1 Tribe will be selected

PRODUCTS:  Materials  Compendium of Training Curricula  Understanding Substance Abuse: A Guide for Child Welfare Practitioners  Screening and Assessment for Family Engagement, Retention and Recovery (SAFERR) – Spring 2005

Some Numbers

Children Living With One or More Substance Abusing Parent In Millions

8.9 Million Children 980,000 Children with Parent who Needs AOD Treatment California’s Children 69,000 Substance- exposed Births 2000 Census 1999 Estimates of 11% 1992 Estimates of ATOD exposure annually

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

s 1990s 2004 Looking Back Some History

Timelines  1968 – Report of alcoholic mothers with babies with a distinctive, unusual appearance in France  1973 – Fetal Alcohol Syndrome named by a team of researchers in Seattle  Mid 1970s  Estimate of the number of children of heroin addicts and children of alcoholics  Fanshel reports substance abuse is common among families in child welfare Beginnings

Timelines  Impact of crack cocaine in urban centers  Chasnoff’s group begin to publish research on prenatal effects of cocaine  1983 National Institute on Drug Abuse (NIDA) College on Problems of Drug Dependence conference – First Poster Session on Children Prenatally-Exposed to Cocaine Early and Mid 1980s

Timelines Mid to Late 1980s – Initiating Responses  Child welfare agencies began responding to an epidemic of kids coming into care and cocaine  Schools began their efforts to understand prenatally-exposed children  1987 Los Angeles Unified School District develops pilot program to understand educational impact of prenatal cocaine exposure

 Federal Grant Support Began  National Center on Child Abuse and Neglect  94 programs, including Illinois, Connecticut, New Jersey  Piloted out-stationing substance abuse counselors in child welfare offices  NIDA research efforts  SAMHSA Specialized women’s treatment programs  Between 1997 and 1999  Five National Reports on Substance Abuse and Child Welfare Timelines1990s

 Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (1998)  Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers (1998)  Healing the Whole Family: A Look at Family Care Programs (1998)  No Safe Haven: Children of Substance-Abusing Parents (1999)  Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (1999) Timelines 1990s – Reports on the Issues

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

Biggest Challenges: Reconciling the Clocks The Four Clocks

 CFSR’s have documented  Case reviews found parental substance use disorders were a factor in 16% to 48% of cases  Need for child welfare training in addictions  Gaps in services  Inadequate assessment and follow up on the underlying needs of families, including substance abuse  Substance use disorders in families with repeat cases The First Clock ASFA Timetable  Timeliness of intervention versus “Call me Tuesday”

National Study on Child and Adolescent Well-Being: Child Welfare Workers’ (CWW) Identification of Substance Abuse  Of the caregivers who are alcohol dependent  71% are classified by the CWW as not having an alcohol problem  Of the caregivers who are drug dependent  73% are classified by the CWW as not having a drug problem  CWW’s misclassify caregivers who are substance dependent most of the time

Minnesota Data  2002 Report to the 2004 Legislature  Prevalence of Family Conditions at Assessment Alternative Traditional ResponseResponse  Alcohol Abuse 7% 18%  Drug Abuse 3% 19%

 Timeliness of Interventions  Taking CFSR findings seriously and including remediation strategies in Program Improvement Plans The First Clock ASFA Challenges

The Second Clock  Poverty and low-income work affect neglect, which is the majority of all reports  Neglect is often associated with both substance abuse and poverty  TANF resources have been used in innovative models for this population  Treatment aftercare focus on jobs and housing  TANF reauthorization proposes treatment be counted as a work activity TANF Timetable

 “A day at a time for the rest of your life” Recovery is a lifelong process with a disease management approach not emergency care  Low-dosage non-comprehensive programs do not build on what we know about effective treatment for this population The Third Clock Recovery Timetable

The Third Clock Recovery Challenges  Comprehensive services and longer-term supports are critical  Clinical treatment, clinical support and community supports  Recognizing the needs of children of parents in treatment  The changing nature of drug use patterns and epidemics

 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 The Fourth Clock Child Development Timetable

The Fourth Clock  Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs Child Development Timetable

Reconciling the Clocks

 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

1. Values and Common Principles  Issues to Address  Who is the Client -- Parent, Child, Family?  Can AOD Users/Abusers/ Addicts/Alcoholics be Effective Parents?  What is the Goal -- Recovery, Child Safety, Family Preservation, Economic Self-sufficiency?

How to Begin:  Use Tools Such As the Collaborative Values Inventory to Identify and Resolve Differences That Exist Across System  Ensure Conversation Happens at Policy, Supervisory and Front-line Levels

 Issues to Address  Roles and Responsibilities Across Systems  Communication Paths Across Systems  Incentives for Prioritization  Missing Box Problem 2. Daily Practice -- Client Intake, Screening and Assessment

Too Often We Practice… “Don’t Ask, Don’t Tell” Ü Nationally, we have “missing box” problems Welfare and Child Welfare Agencies have far less information than they need on substance abuse among their clients Alcohol and Drug Treatment Agencies have far less information than they need about the children of their treatment clients

 Clarify Intake Procedures and AOD/Child Safety Screening Protocols  Decide on Team, Tool, Method, Roles and Responsibilities to  Provide AOD Expertise to Child Welfare Workers in Investigative/Assessment Phases  Ensure Parents Seeking Treatment Receive Needed Supports for Child Safety How to Begin:

3. Daily Practice -- Client Engagement and Retention in Treatment  Issues to Address  Outreach and Engagement Strategies  Addressing Motivation to Change  Cross-system Agreement on Approaches to Relapse  Responding to Clients’ Progress in Treatment

 Implement Assessment and Interventions based on Readiness to Change  Develop Mechanism to Re-engage Clients in Care  Ensure AOD Treatment and CPS Practice is Responsive to Clients’ Individualized Needs How to Begin:

4. Daily Practice -- Services to Children  Issues to Address  Prevention, Early Intervention, and Treatment Services for Children in Contact with CPS  Content of Independent Living Programs on Parental Substance Abuse  Pediatrics (1999) v.103:1083 – 1155, Special Topics on Children and Adolescents in Families Affected by Substance Abuse

 Develop Partnerships to Respond to Potential Neuro-Developmental Effects of Prenatal Substance Exposure  Provide Prevention and Intervention Services to Children and Adolescents  Ensure that Youth Receive Appropriate Youth Development Intervention and Activities  Ensure that ILP Teens Receive Appropriate Information Related to Risks of Substance Abuse How to Begin:

5. Information Sharing and Data Systems 6. Training and Staff Development 7. Joint Accountability and Shared Outcomes 8. Budgeting, Funding and Program Sustainability Sustainability Other System Supportive Elements

We Know AOD Treatment Pays  100 Women  Average cost $6,800  $680,000  150 Children  Average 1.5 years in out-of-home $24,000 per year  $5.4 Million Foster Care Cost Offset Pays for all 100 Women’s Treatment Nearly 2 Times Over 30 Women recover with one episode of treatment 45 Children reunify at 6 months Saves $1.1 Million

 Primary Health Care  Domestic Violence  Trauma  Mental Health  Dental Health 10. Working with Related Agencies  Transportation  Child Care  Medicaid  Housing  Economic Security  Education for Mother and Children 9. Developing Community Supports

 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

Jointly Funded  Department of Health and Human Services  Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Services  Administration on Children, Youth & Families, Children’s Bureau, Office on Child Abuse and Neglect  Assistant Secretary for Planning and Evaluation  Department of Justice  National Institute on Justice  Drug Court Program Office

 Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs  Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention  A baby and a family we already know are highly at risk The Fifth Clock Urgency

 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, Barth, R. (2003). Substance Abuse Findings from the NSCAW Presented at NCSACW Researchers’ Forum. December. 4.Grella, C. (2003). Presentation at the NCSACW Researchers’ Forum. December Responding to Families: Timelines, Clocks and the Future Notes