1. Engaging Moms Program for Dependency Court
Judge Jeri B Cohen, 11th Circuit Judicial Court
Gayle A Dakof, University of Miami Miller School of Medicine

2. Families with Drug Dependent Parents Have Poor Outcomes
Increased re-referral to child welfare
Greater placement instability
Longer stays in foster care
Increased number of out of home placements
Termination of parental rights

3. Research Indicates That:
Strengthening parents so they can provide a safe and healthy environment for their children is the best way to protect and nurture children

4. Engaging Moms Program Is Designed To:
Help Drug and Child Welfare Involved Mothers To Provide a Safe and Healthy Family Environment for Their Children
Prevent Termination of Parental Rights
Reduce Number and Length of Foster Care Placements
Influenced by MDFT

5. Engaging Moms Program Not A Substance-Abuse Treatment
but A Family-Based Intervention That Supports Treatment and Facilitates Recovery by Improving Family Relationships and Familial Role Functioning

6. Background On EMP
Originally designed to enroll and retain drug addicted mothers of infants into substance abuse treatment, but not to retain in treatment
Very activist approach with family and in-home
Only worked with family for 8 weeks

7. EMP: Substance Abuse Enrollment & Retention Version (Dakof, Quille, Tejeda, Alberga, Bandstra & Szapocznik, Enrolling and Retaining Mothers of Substance-Exposed Infants in Drug Abuse Treatment. JCCP, 2003)
NIDA-funded study
103 Black non-treatment seeking mothers of drug exposed infants
Randomized to EMP or Community Service As Usual
Therapeutic Goals: Enroll in Substance Abuse Treatment within 8 weeks, Retain in Treatment for at least 4 weeks

8. Enrollment In Substance Abuse Treatment
As you can see from this graph, more mothers randomly assigned to
EMP enrolled in treatment. 88% of moms randomly assigned to emp versus 46% of moms assigned to community services as usual enrolled in substance abuse treatment.

9. 4 Week Retention
Also, significantly more mothers randomly assigned to emp were retained in treatment for at least 4 weeks—67% versus 38%

10. Bringing EMP to DDC
Given the success of EMP with enrolling and retaining drug addicted mothers into substance abuse treatment, we decided to expand the goals of EMP and bring the intervention to dependency drug court
At 90 days, the control group and the EM group both showed 30% retention
What was going on in the treatment facilities: not gender specific; confrontational

11. EMP In Dependency Drug Court
Develops Original EMP by:
Expanding goal from enrollment & initial retention in treatment to longer term outcomes (recovery & reunification)
Length of intervention increased from 12 weeks to length of stay in drug court (12 – 15 months)
Goal Is To Help Mothers Succeed In Dependency Drug Court

12. Engaging Moms In Dependency Drug Court: Pilot study /Quasi-Experimental Dakof, Cohen & Duarte (2009). Increasing family reunification for substance abusing mothers and their children: Comparing two drug court interventions, Juvenile and Family Court Journal.
80 consecutive enrollments in dependency drug court
All women received drug court services
The first 37 enrollments received DDC with standard case management and the subsequent 43 enrollments received DDC with Engaging Moms Program
This is a quasi experimental design

13. Percent of mothers Reunified
70% who received engaging moms were reunified 15 months after drug court enrollment in comparison to 40% reunification for those receiving standard (not intensive, but standard) case management services.
This is very encouraging for drug court with the engaging moms approach, and a little discouraging for standard case management given that 40% re-unification is lower than what has been reported in exemplary dependency drug courts (remember re-unification rate between 42% and 57%). I think our rate is lower because this was the first year of drug court, and the case management was the very basic broker style (assessment, monitoring, referral to service).
But the main thing is that it encouraged us to do further work on developing the engaging moms drug court approach.

14. EMP in Dependency Drug Court: Randomized Study: Pilot Study 2
Intervention Development Study (NIDA Funded)
Randomized longitudinal Design: EMP vs. Intensive Case Management
Intent to treat; blinded judge
Sample Size = 62 (underpowered not enough statistical power)
Data Collection at Intake; 3, 6, 9, 12, 18 months
This one is a pilot study despite the randomized longitudinal design because it has a small sample size, thus it is what we call an underpowered study: not enough statistical power due to small sample size to find significantly significant findings. However, if we find medium to large effect sizes, Cohen’s d, (which we did), this tells us that the chances are very high that with a larger sample size we would have significantly significant findings.

15. Participant Characteristics
42% Black, 35% Hispanic, 23% White,
Non-Hispanic
Average age = 30
Monthly median income = $561
57% less than high school education
55% victims of child physical abuse
3 lifetime arrests
80% with co-morbid mental health problems

16. Comparing Drug Court EMP to Drug Court ICMS
In all domains of functioning, families assigned to EMP showed improvement that was equal to or better than families assigned to ICMS ( family functioning, parenting, violence, children’s mental health, drug use and employment).
Since sample size was small, effect sizes became very important

17. Child Welfare Outcomes: EMP vs. ICMS
48% of ICM cases filed for TPR versus 23% of EMP cases
77% of EMP had positive child welfare outcomes (reunification or perm guardianship) compared to 52% of ICM.
23% of EMP cases went to TPR in comparison to 48% of ICM. You see the huge difference between emp and icm in perm guardianship outcomes. I think this is fascinating, given how emp deal more directly with the family of origin. And it also raises issues of how one defines positive child welfare outcomes.

18. EMP Participants, In Comparison to ICMS, Showed Equal or Better Outcome on All Variables
Evaluate difference between the 2 groups by using a statistical test called the, Cohen’s d.
This test indicates the strength of the effect from small, medium to large. The larger the effect the better the results, with most scientists thinking that medium to large effects are meaningful. .50 is considered a medium effect and .80 or greater is considered a large effect.
Alcohol and family functioning measured by the ASI
Parenting practices and non violent discipline practices measured by the Conflict Tactics Scale

19. EMP Participation Associated With Better Outcomes than ICMS
Greater decrease in alcohol use (d = 1.45) (ASI)
Greater improvement in mental health (d = .50)(Brief Symptom Inventory)
Greater decreased risk of child abuse (d = .51) (Child Abuse Potential Inventory)
Greater improvement in family functioning (d = .63) (ASI)
No differences on mother’s drug use with both groups showing significant improvements
Alcohol and family functioning measured by the ASI
Parenting practices and non violent discipline practices measured by the Conflict Tactics Scale

20. Mothers showed significant improvement from DDC enrollment through 18 month follow-up
Reduced drug and alcohol use
Improved mental health
Improved family functioning
Decreased risk for child abuse
Decreased mental health problems in children 20 20

21. EMP versus ICMS
Mother’s in the EMP group reported a significantly stronger therapeutic alliance with the drug court counselor than did mothers in ICMS
Mothers in the EMP group received more counseling sessions that included their family of origin
Alcohol and family functioning measured by the ASI
Parenting practices and non violent discipline practices measured by the Conflict Tactics Scale

22. Summary of Results
In Dependency Drug Court, the Engaging Moms Program appears to increase the likelihood of positive outcomes in comparison to Intensive Case Management
Remember: all parents had intensive drug court services
National average even with recovery coaches: 8-25%
Important to recognize that the original drug court judge (Cohen) was not the judge in this study. Judge was competent but was new to dependency court and not dedicated or committed to drug court. Also, she was blind to intervention condition.

23. Core EMP Interventions
Build & Strengthen Therapeutic Alliance with Mother & Family
Enhance Mother and Family Motivation to Change
Strengthen Mother’s Emotional Attachment With Children
Involve Family of Origin-Repair Relationships/Seek Support
Improve Parenting Practices
Improve Romantic Relationships
Conduct Shuttle Diplomacy Between Mother & Service Providers/Courts/Child Welfare
Deal With Relapses, Setback and Mistakes in a Therapeutic Manner (non punitive)
Launch To Independent Life: Planning In Excruciating Detail/Prepare for Bumps in the Road

24. Alliance Building-Being a Strong Advocate
“I am behind you 150%!”
Compliment, Praise, & Agree
Empower & Validate
Build Confidence In The Program
Seek Strengths
Be Loving & Nurturing

25. Enhancing Motivation Help Mother and Family Recognize:
Distress & Despair:
Unhappiness, Guilt, Shame, Have A Lot To Lose
Positive Expectations & Hope:
Have A Lot To Gain

26. Enhance Bonding With Children
Focus on Emotional Aspect of Parenting:
They Need You.
You Need Them
Emphasize & Enhance Love & Connection Between Mother & Children
(Attachment Relationship)

27. Involve Family Of Origin
Engage family
Repair relationships
Seek emotional and practical help

28. Examine Romantic Relationships
Relationship Life Review-The Good, The Bad & The Ugly
Self – Examination: Men, Relationships, Parenting- Wants and Conflicts
Help Mother Make Thoughtful Decisions & Choices

29. Shuttle Diplomacy Between Mother & Service Providers
Be Proactive: Prevent Problems With Substance Abuse Treatment and Other Service Providers
Resolve Any Problems and Conflicts Immediately

30. Deal With Relapse & Mistakes, & Other Setbacks in a Non-punitive Manner
Discuss Ambivalence of Change
Action—Means We Need To Work Harder, Do Something Different
Explore Relapse Fully (Antecedents, Experience, Consequences)
Renew Commitment
Collaborate On Action Plan

31. Facilitating Therapeutic Jurisprudence in The Courtroom
Prepare Mother For Court Appearances
Use The Theater of the Court to Enhance Therapeutic Aims
Advocate in front of the Judge

32. Launch To Post Drug Court Life: Planning In Excruciating Detail
Develop a Routine for Everyday Life.
Address How Will Balance Self Care, Children, Work
Outline and Plan For Dealing With Common Emergencies with Children & Families
Relapse Prevention Plan
Bumps In Road: What Are They/Plan To Address

33. Partnership with University of Miami Linda Ray Intervention Center
Interventions to strengthen the emotional bond between mother-child
Part C responds to the developmental issues for the children
Once mothers are engaged in recovery they can focus on the needs of their children
Parenting programs are improved

34. Ages & Stages (ASQ) Developmental Screenings for Dependent Children
100 screenings completed as of 2001 with University grant funding
Children ranged from 04 months- 48 months
72% children showed delays as compared to the 10%-20% expected w/in general population
Court sample reflected LRIC sample and a partnership opportunity was created

35. One half of the children in foster care show developmental delay that is approximately four to five times the rate of delay found in children in the general population. (Dicker and Gordon, 2000)

36. Intervention protocol developed for Dependency screenings
Child within normal range in all domains, no need to refer at this time, Plan to re-screen 3-6 months/case worker should note re-screen date
2. Child falls on the cusp for developmental delays. Plan to re-screen in 3-6 months/case worker schedules

37. Follow-Up Value to the Court
Early intervention programs serve the babies until age 36 months and monitor children’s progress, plan for transitions after age three into Pre-K and Head Start programs then transition to kindergarten. Process continues many times after case is closed
Reports are submitted to judges, lawyers, case managers, court specialist, medical and home visiting resource agencies
Goal of unbroken continuum of care is maintained

38. Outcomes for Children
Parents and children alike receive wrap around services early on with greatest chance of impact continually engaged
The appropriate use of a screening protocol serves as a window to determine necessity of further Part C assessments in an established sequence
Coordinated continuum of care incorporating early intervention results in more positive child outcomes at age 5

39. Funded by the Florida Legislature
Infant and Young Children’s Mental Health Pilot Project: Miami-Dade County Juvenile Court Site
Funded by the Florida Legislature

40. Infant Mental Health Program
Comprehensive baseline assessments to establish existing quality of adult-child relationship and child’s developmental needs and need for program
Child-Parent Psychotherapy (CPP, Lieberman) dyadic therapy is provided for child and mother/father for average of 25 sessions by trained infant mental health clinicians to heal the relationship and support child development
Child-parent pairs are re-assessed at completion of the sessions and outcomes are examined for both child and the relationship
Reports forwarded to judges at benchmarks in the process for incorporation into decision-making process for permanency: Have the risks been reduced/ameliorated sufficiently?
There is a difference between early intervention for language and cognitive deficits and infant mental health, child in a relationship

41. Changes observed in the child post treatment in CPP
Increased enthusiasm
More persistence
Increased emotional and behavioral responsiveness
More positive emotions
Less withdrawal
Less depression
Less irritability
Less anger
More compliance

42. Parents’ Reports of Satisfaction
95% saw improved relationship with baby
83% identified positive changes in child
77% improved parenting
73% improved family life
Caregiver Satisfaction with Treatment Services
The data indicated that the caregivers reported significant improvement in all areas, including their relationship with their baby, positive changes in their babies, improvements in parenting, and help with the difficulties they had been having with their children. 42

43. Additional Benefits
Of the first 59 children involved in this project, it is important to note the potential extended impact into the family
mothers had a total of 156 children
fathers had a total of 138 children.

44. Outcomes: for those that completed treatment
No further abuse or neglect reports in 100% of the cases at 6 months post-treatment
100% rate of reunification for dyads who successfully completed the model

45. Next Goals for IMH integrated systems: Miami spearheads Infant Mental Heath-Court-Early Intervention collaborative
Increased judicial awareness and knowledge of the impact of child emotional development, family violence on children and families, and the effectiveness of child-parent psychotherapy;
2) Expanded Partnerships between the judiciary and clinical providers that systematize timely court-ordered referrals for comprehensive developmental evaluation and child-parent psychotherapy;
Implementation of a collaborative approach– initiated, led, and supervised by the judge –to ensure the child’s emotional well-being is at the forefront of judicial decision-making and permanency planning. Engagement of the family continues.
(CDC/RTI/UM Translating Research to Practice 2010)

46. Need for evidence-based parenting programs in Miami
Existing system for parenting programs was focused on attendance not content
The Dependency Drug Court partnered with the UM Linda Ray Center to obtain research-based parenting skills program
Goal was to provide empirically-based parenting services which would respond to the issues of substance abuse, neglect, family violence, and negative impact on children’s development.
Funded by Department of Human Services, Substance Abuse Mental Health Services Administration, Family Strengthening Initiative. 46

47. Core Components Emerged
Evidence Based Curriculums
Pre/Post Behavioral Observations with inter-rater reliability
AAPI-2 pre/post data gathered
Standardized Reporting Templates for Court

48. Miami Sample Parenting Report
DEPENDENCY PARENTING PROVIDER INITIATIVE
FINAL REPORT
By:
This report summarizes the progress made by the parent named below at the completion of this agency’s parenting
program and includes the POST-service behavioral observation (with children ages 0-5) (if applicable) and the POST-
service Adult-Adolescent Parenting Inventory (AAPI-2).
Start date:       Completion date:      
ATTENDANCE, PARTICIPATION & PROGRESS:
Please note that the following information is an overall assessment that pertains to the parent’s participation throughout the course of the parenting program.
The parent has attended       out of       sessions offered.
Overall, the parent (check one) Has attended the sessions on time/Has not attended the sessions on time.
During the parent group sessions, the parent (check one):
Actively participated Participated with prompting Did not participate
Participated inappropriately
As evidenced by:      
During the parent-child interactive segment (if applicable), the parent demonstrated appropriate parenting (circle one):
Most of the time Some of the time None of the time Not applicable
BEHAVIORAL OBSERVATION INFORMATION (only for children ages 0-5):
The Behavioral Observation rating scales were developed for children ages birth to five years old by Dr. Joy Osofsky-Louisiana State University and Dr. Anne
Hogan- Florida State University Center for Prevention and Early Intervention as an adaptation of their clinical version. The parenting facilitator who completed
this report, was trained by experienced clinicians that were trained directly by Dr. Osofsky in the procedural methods. The PRE-SERVICE behavioral
observation provides a window into the strengths and weaknesses of the parent-child interactions/communications, etc. that will need to be addressed in the
parenting classes at the onset.

49. Continued Sample Parenting Report
Behavioral observation Completed Yes No
If no, (check one) No children 0-5
No contact permitted between parent and child(ren) in age range
The POST-service Behavioral Observation of the above-named parent and
(child’s name)      who was       year(s) and month(s) old took place on      
POST-Service behavioral Observation Summary
    
*Mutual positive engagement:      
*Quality of play:      
*Caregiver rejection:      
*Child’s negativity towards caregiver:      
*Caregiver teaching/helpfulness with clean up and awareness of child’s developmental needs:      
*Description of reunion/separation with caregiver and child:  
Summary of changes observed PRE to POST
*Description of reunion/separation with caregiver and child:      
ADULT ADOLESCENT PARENTING INVENTORY AAPI-2 (description attached):
The adult adolescent parenting inventory designed to assess the parenting and child rearing attitudes of adults and adolescent parents and pre parent populations. Based on the known parenting and child rearing behaviors of abusive parents, responses to the inventory provide an index for practicing behaviors known to be attributable to child abuse and neglect. Responses to the AAPI-2 provide and index of risk in five specific parenting and child rearing behaviors:

50. Continued Sample Parenting Report
Construct A- Inappropriate Expectations of Children
Construct B- Parental Lack of Empathy Towards Children’s Needs
Construct C- Strong Parental Belief in the Use of Corporal Punishment
Construct D- Reversing Parent-Child Family Roles
Construct E- Oppressing Children’s Power and Independence
The POST-service AAPI was completed on:      
POST-Service Adult-Adolescent Parenting Inventory Summary:
Construct A- Inappropriate Expectations of Children:      
Construct B - Parental Lack of Empathy Towards Children’s Needs:      
Construct C - Strong Parental Belief in the Use of Corporal Punishment:      
Construct D - Reversing Parent-Child Family Roles:      
Construct E - Oppressing Children’s Power and Independence:   
   
SUMMARY of changes noted on the AAPI-2 from PRE to POST:
Construct E - Oppressing Children’s Power and Independence:      
Additional Comments:      
SUMMARY of parent-child current functioning from weekly facilitator notes as well as the structured behavioral observations, the parenting inventories, participation levels and the quality of the parent-child(ren) interactions:      
ADDITIONAL SERVICE AND/OR TREATMENT NEEDS:
THE FOLLOWING ARE ONLY RECOMMENDATIONS AND SHOULD BE EVALUATED IN THE CONTEXT OF THE CASE PLAN AND THE SERVICES

51. Sample Adult Adolescent Parenting Inventory – 2 (AAPI-2)