Substance Abuse Child Welfare

1. Substance Abuse & Child Welfare Rethinking Assumptions Steven J. Ondersma, PhD Departments of Psychiatry & Behavioral Neurosciences and Obstetrics & Gynecology Apt question�what DO we do? Even more relevant now that hospitals are mandated to report and CPS is mandated to become involved.Apt question�what DO we do? Even more relevant now that hospitals are mandated to report and CPS is mandated to become involved.

2. Post-Presentation Message from Dr. Steve Ondersma It�s come to my attention that some attendees of my talk may have come away feeling that treatment has been proven not to work. This was not a message I intended to give, so I�m clarifying my intended �take-away� messages here. Treatment DOES work overall, but has, at best, a moderate positive effect. It is neither a panacea�even for those who complete it�nor the only way to get from disordered to safe use/abstinence. It IS more than effective enough to be recommended to persons with substance use disorders. An overall moderate positive effect means that some persons/studies will show no effect from treatment, some will show a small to moderate positive effect, and a few will show a very strong positive effect. Most persons who do move from disordered use to abstinence/safe use do so without treatment. Some, however, seem to require treatment. Brief treatment is often as effective as extended treatment (but not in every case). With respect to parenting interventions, single-focus treatment may be more effective than multi-focal treatment. Rick Barth�s study suggested that substance abuse treatment was associated with a higher likelihood of future maltreatment re-reports. These are important and baffling data, but neither he nor I take it to mean that treatment is contraindicated. It DOES mean that we don�t yet have a complete understanding of how change happens, or what its effects are. It may also mean that we perhaps should be appropriately humble in our emphasis on the importance of treatment.

3. Overview Examine the issue of prenatal substance exposure in light of scientific evidence Explore the conflict between the timetables of child development and substance dependence, in light of current science Explore what the above might mean in terms of how the courts could/should respond Keep an open mind, and objectively weigh the evidence with me. No clear answers, but there is some solid scientific data that gives important guidance.Keep an open mind, and objectively weigh the evidence with me. No clear answers, but there is some solid scientific data that gives important guidance.

4. Oklahoma Infant Parenting Program (IPP) Federally-funded demonstration project Designed around needs of drug-exposed infants and their mothers Multi-component, centralized, with emphasis on barrier reduction One year in length

5. Overview, Part I: Prenatal Exposure How should we respond to this threat? How others are responding The latest research on prenatal drug exposure The risk of prenatal drug exposure compared to that of other exposures Discussion and recommendations Keep an open mind, and objectively weigh the evidence with me. No clear answers, but there is some solid scientific data that gives important guidance.Keep an open mind, and objectively weigh the evidence with me. No clear answers, but there is some solid scientific data that gives important guidance.

6. Part I: It�s Not Easy

7. Threats to Children�s Welfare Physical abuse Sexual abuse Neglect (all types�) Violence exposure Poverty Inadequate schools Prenatal exposures: drugs, alcohol, tobacco, lead, medicine� Poor diet or exercise Parental factors often below the legal threshold Mental illness, drug or alcohol abuse Marital conflict Excessive/inappropriate TV, etc. Environmental threats Accidental injury

8. Possible Responses to These Threats Education/awareness campaigns School-based prevention Home visitation (universal, selective, indicated) Mental health and substance abuse treatment Mentoring programs Community programs Legislative efforts (e.g., sin taxes, welfare, seatbelt laws) Police efforts (e.g., alcohol-related roadblocks) CWS (all levels) Criminal court Of course, can respond in more than one way, and usually should�but there�s likely to be a primary response to most threats.Of course, can respond in more than one way, and usually should�but there�s likely to be a primary response to most threats.

9. Issues Considered in Matching Threats to Responses Relative harm Moral issues Prevalence of the threat Likelihood of success for various options Side-effects of the response Cost-benefit ratio (need to reserve strongest response for cases where it is most needed) Proportion of at-risk children reached 3 million referrals, 2 million screened in, just under 1 million substantiated (2001); 171,570 for physical abuse; NIS-3 says CPS investigated 28% of those meeting harm standard 20-40 k deaths/year due to flu; 50 million lost work days = cost of over 1 billion annually3 million referrals, 2 million screened in, just under 1 million substantiated (2001); 171,570 for physical abuse; NIS-3 says CPS investigated 28% of those meeting harm standard 20-40 k deaths/year due to flu; 50 million lost work days = cost of over 1 billion annually

10. A �Perfect� Match: CPS & Physical Abuse Relative harm is high Moral outrage is nearly universal Affects less than 1% of all children (NIS-III) CPS can rapidly increase a given child�s safety A relatively high proportion of affected children are reached Cost and other side-effects are well justified

11. Another �Perfect� Match:Smoking & Selective Prevention Relative harm is lower, both pre- and postnatally Moral concerns are present, but muted Prevalence is high: 29.6% of persons 12 and older smoke cigarettes Most affected children and their caregivers can be reached using public health methods The cost and consequences of stronger responses may not be justified by their added benefit, if any Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or An act or failure to act which presents an imminent risk of serious harm. DOESN�T MEAN WE APPROVE. So is there a perfect match for prenatal drug exposure?Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or An act or failure to act which presents an imminent risk of serious harm. DOESN�T MEAN WE APPROVE. So is there a perfect match for prenatal drug exposure?

12. Is There a Perfect Match for Prenatal Drug Exposure? Doesn�t map out perfectly onto one known primary response; perhaps most importantly, no consensus in terms of where to PUT this issue. Substance abuse, fetal rights/status, and choice all come into play. SO HOW DO WE WORK OUT WHAT TO DO? --Four things: others, risk, relative risk, associated issues. Then we�ll talk.Doesn�t map out perfectly onto one known primary response; perhaps most importantly, no consensus in terms of where to PUT this issue. Substance abuse, fetal rights/status, and choice all come into play. SO HOW DO WE WORK OUT WHAT TO DO? --Four things: others, risk, relative risk, associated issues. Then we�ll talk.

13. Part II: Examining Responses in the United States

14. Ondersma et al., CAN, 2001 Urban Counties: Two of three largest counties in each state Exceptions replaced by Census region Total N = 100 Rural Counties: Random selection of two counties with population between 10,000 and 100,000 Exceptions: CT, HI, MA, RI Total N = 100

15. Percent of Counties Receiving Referrals So, among those receiving referrals, is their anything approaching a consensus?So, among those receiving referrals, is their anything approaching a consensus?

16. % Cases Juvenile Charges Filed (Among Counties Receiving Referrals)

17. % Infants Removed--Cocaine (Among Counties Receiving Referrals) So agreement as to what to do is a problem�So agreement as to what to do is a problem�

18. Opinion of County Practice

19. Nationwide Survey of DA�s Participants: Criminal District Attorneys randomly selected from urban, urban fringe, and rural counties, 4 per state The DA most familiar with prenatal drug exposure policy or practice identified Current N = 100 (goal is 200)

20. Opinion: How Damaging Are Various Exposures? (1-7) Prenatal exposure to illicit drugs: 6.14 Postnatal exposure to drugs: 6.02 Prenatal exposure to alcohol: 5.89 Prenatal exposure to tobacco: 4.48

21. What % Of Perinatal Drug Users Should Be Prosecuted Criminally?

22. Part III: Examining Harm from an Historical Perspective

23. The Prehistorical Period Concern regarding alcohol exposure first noted in 1973, with limited public reaction Prior to the mid 1980�s, drug exposure received little attention among the scientific and lay communities Chasnoff doing opiate and other work in early 1980�sChasnoff doing opiate and other work in early 1980�s

24. The Early Period Mid 1980�s: growing concern regarding illicit drug use in America, particularly crack cocaine Research suggesting significant deleterious effects of crack cocaine exposure emerges Drug use as a crime belief is ascendant in this periodDrug use as a crime belief is ascendant in this period

25. Early Period: The Media Responds Public fear and outrage regarding illicit drugs galvanizes around the �crack baby� image This media portrayal burns lasting images into the minds of the public George Will, etc. List it all out.George Will, etc. List it all out.

26. The Courts Respond in Turn� Criminal prosecution for cocaine use during pregnancy is the first reaction in many states (Ondersma & Tatum, 2001) 1989: A hospital in South Carolina begins testing women, without their consent, and sending results to the police; 29 of 30 were African-American (leads to U.S. Supreme Court decision in Ferguson v. City of Charleston)

27. Middle Period: The Backlash 1993: Growing skepticism among scientific community culminates in a 1993 special section in Neurotoxicology & Teratology Most researchers assert that the effects of prenatal exposure to drugs have been greatly misunderstood, and emphasize need for appropriately controlled research Lag phenomenon: public opinion and lore usually many years behind science The disease model of substance abuse arises from the ashes: many begin to assert that criminalizing substance abuse is no different than locking up the mentally ill, and that criminalizing actions regarding fetuses is the first step down a slippery slope�Lag phenomenon: public opinion and lore usually many years behind science The disease model of substance abuse arises from the ashes: many begin to assert that criminalizing substance abuse is no different than locking up the mentally ill, and that criminalizing actions regarding fetuses is the first step down a slippery slope�

28. Current Period: Ostrea, Ostrea, & Simpson, Pediatrics, 1997 Meconium screening of 2,964 infants at Hutzel Hospital in Detroit, MI Data cross-checked with death registry at age 2 No association between drug exposure status (of any type) and mortality Why controlled research better than personal experience?Why controlled research better than personal experience?

29. Lester et al., Science, 1998 Meta-analysis suggests that prenatal cocaine exposure is associated with an IQ deficit of approximately 3.26 points This very small decrease, due to the increased number of children falling below 70, is estimated to lead to approximately $350 million annually in additional costs.

30. Maternal Lifestyles Study Large, multisite, prospective, masked study of prenatal cocaine exposure funded by NICHD, NIDA, ACYF, and CSAT Designed around the reality that cocaine is a marker for other drugs of abuse and compromised caregiving NICHD, NIDA, ACYF, CSATNICHD, NIDA, ACYF, CSAT

31. Lester et al., Pediatrics, 2002 Total of 1,388 infants (658 exposed infants and 730 comparison) evaluated at one month of age Cocaine exposed vs. unexposed: significant differences on 2 of 26 areas (arousal and regulation) Opiate exposed vs. unexposed: significant differences on 1 of 26 areas (hyperphonated cry)

32. Three Years Old:Messinger et al., Pediatrics, 2004 Same 572 cocaine and/or opiate-exposed infants, compared to 655 infants not exposed to cocaine or opiates, at age 3 No difference on any cognitive, motor, or behavior outcome after controlling for other factors Even when comparing highest-exposed to non-exposed What really mattered? Poverty, poor maternal care, and low birthweight.

33. Seven Years Old (Behavior Only):Bada et al., Pediatrics, 2007 Controlling for all relevant factors, a few effects were found: Cocaine (heavy use only): 3.6 points higher Tobacco: 4.4 points higher Alcohol: 4.0 points higher Scores on this measure have a mean of 100; most scores fall between 60 and 140

34. Bada et al., 2007 (Cont.) �Prenatal and postnatal exposures to tobacco and alcohol are of significant public health concern. Their combined effect on child behavior is greater than what can be attributed to cocaine. Therefore, � a call for increased effort toward prevention of tobacco and alcohol use, which is a more prevalent problem and has as great an impact on childhood behavior problems as PCE [prenatal cocaine exposure].�

35. The Case Of Attachment Several early studies, most with smaller sample sizes and incomplete blinding of examiners/raters, found high rates of disorganized attachment in exposed infants (e.g., Rodning, Beckwith, & Howard, 1989) A large-scale (N = 860), fully blinded study conducted as part of the Maternal Lifestyle Study found almost no association between prenatal exposure and attachment classification (Seifer et al., 2004)

36. But Wait�Enter Methamphetamines There are similarities between the current climate with respect to methamphetamines, and the mid-1980�s with respect to crack cocaine Prevalence is highly variable Prevalence of prenatal exposure in one major study focused on four high-methamphetamine areas was 5.2%

37. Methamphetamine and Cocaine Prevalence in Seattle, 1999-2002 King, Pierce, & Snohomish CountiesKing, Pierce, & Snohomish Counties

38. Methamphetamines Very few studies are available, most of which involve animals Results with animals replicate those with opiates, cocaine, and other drugs: inconsistent, but some deficits are nearly always present at sufficient doses Smith et al., 2003, J Dev Beh Peds: No differences in birthweight between meth-exposed and not exposed human infants

39. Prenatal Meth Exposure and Neonatal Neurobehavioral Outcome(Smith et al. 2008) Studied 166 neonates (74 methamphetamine exposed and 92 comparison) within first 5 days of life No difference in birthweight, Apgar scores; evidence of decreased arousal and increased stress was present (significant differences on 2 scales out of 19 measured) These subtle effects are consistent with those found with cocaine

40. Methamphetamines--Media A CNN report was aired repeatedly over the span of a month, showing a picture of a baby who had allegedly been exposed to methamphetamines prenatally and stating: �This is what a meth baby looks like, premature, hooked on meth and suffering the pangs of withdrawal. They don't want to eat or sleep and the simplest things cause great pain.� CNN, �The Methamphetamine Epidemic in the United States,� Randi Kaye. (Aired Feb. 3, 2005 � Mar. 10 2005).

41. Methamphetamines--Media CHICAGO TRIBUNE, Judith Graham, �Only Future Will Tell Full Damage Speed Wreaks on Kids� (�At birth, meth babies are like �dishrags��) (Mar. 7, 2004)

42. Methamphetamines--Scientists �Although research on the medical and developmental effects of prenatal methamphetamine exposure is still in its early stages, our experience with almost 20 years of research on the chemically related drug, cocaine, has not identified a recognizable condition, syndrome or disorder that should be termed �crack baby� nor found the degree of harm reported in the media and then used to justify numerous punitive legislative proposals.�

43. Methamphetamines--Scientists �In utero physiologic dependence on opiates (not addiction), known as Neonatal Narcotic Abstinence Syndrome, is readily diagnosable and treatable, but no such symptoms have been found to occur following prenatal cocaine or methamphetamine exposure.�

44. Neonatal Withdrawal Describes a constellation of symptoms commonly associated with withdrawal in the neonate; usually not immediately evident By far, withdrawal is most clearly evident in infants exposed to opiates Accumulating evidence also suggests clear withdrawal in tobacco-exposed infants (at mean cigarettes/day of 6.7; Law et al., 2003) Withdrawal from other substances is much less clear, with no agreed-upon medical response

45. Summary of Drug Effects Negative effects are clear when all drugs of abuse are considered together Negative effects of single drugs (of any type) occur in some of the most heavily exposed infants These negative effects are comparable in magnitude to those of tobacco and perhaps less than that of alcohol 1. Even studies with strongest evidence that exposure is bad find deficits in some but far from all infants, and often of small magnitude when averaged across all infants (e.g., 3.25 IQ points) 1. Even studies with strongest evidence that exposure is bad find deficits in some but far from all infants, and often of small magnitude when averaged across all infants (e.g., 3.25 IQ points)

46. Part IV: Harm in the Context of Other Prenatal Risks

47. Prenatal Alcohol Exposure Alcohol presents more risk to the fetus than any other drug of abuse Risks associated with prenatal alcohol exposure include: Intrauterine growth deficiency Facial dysmorphology CNS damage, including developmental delay (severe to undetectable), hyperactivity, and attention deficits Note that typical FAS mom has 14 drinks/day during pregnancy, 10-20 kids of alcoholic moms, worse with poor nutrition, etc. Why is it so important that most women use alcohol and tobacco also? Note that brain damage is visible on MRI/PET scan and autopsyNote that typical FAS mom has 14 drinks/day during pregnancy, 10-20 kids of alcoholic moms, worse with poor nutrition, etc. Why is it so important that most women use alcohol and tobacco also? Note that brain damage is visible on MRI/PET scan and autopsy

48. Alcohol: Baer et al., Arch Gen Psychiatry, 2003 Study of 21-year old children of pregnant women evaluated between 1974 and 1975, N = 433 Prenatal exposure to alcohol associated with increases in alcohol problems (14.1% versus 4.5%) and heavy drinking (11.7% versus 6.9%)

49. Prenatal Tobacco Exposure Dose-dependent effects on: Birthweight and mortality IQ, especially verbal ability Behavior, especially conduct disorder in boys Lung function, especially in children with asthma For example, see Ness et al., NEJM, 1999 Cocaine use: odds increase for miscarriage = 1.4 Tobacco use: odds increase for miscarriage = 1.8 Note: similar actions as cocaine (vasoconstriction, hypoxia, etc.) $263 million per year in 1995 U.S. dollars for extra NICU care alone Group from U. of Birmingham just published major study showing no long-term effects when controlling for other factorsNote: similar actions as cocaine (vasoconstriction, hypoxia, etc.) $263 million per year in 1995 U.S. dollars for extra NICU care alone Group from U. of Birmingham just published major study showing no long-term effects when controlling for other factors

50. Relative Harm Tobacco and alcohol use during pregnancy is far more common. Among pregnant women: 5.5% have used any illicit drug 18.8% have used alcohol 20.4 % have smoked cigarettes Thus, tobacco and especially alcohol are more likely to cause harm than illicit drugs

51. Lead Prenatal and postnatal exposure to lead is clearly associated with cognitive and other impairments Recent research (Canfield et al., NEJM, 2003) reported IQ decrements of 7.4 points before blood lead levels reached the official cutoff

52. Other Prenatal Factors Nutrition Prenatal Care Folic Acid Medications Violence: physical violence during pregnancy is associated 3 times the risk of hemorrhage or growth restriction, and 8 times the risk of death (Janssen et al., Am J Obstet Gynecol, 2003) Punch line: many bad things the fetus can be exposed to; none are invariably devastating, alcohol and lead stand out, the rest are similar. Punch line: many bad things the fetus can be exposed to; none are invariably devastating, alcohol and lead stand out, the rest are similar.

53. Part V: Other Issues to Consider

54. Side Effects Strong responses always have side effects; this in itself does not preclude such responses Strong responses to prenatal drug exposure have unique additional side effects: Treatment avoidance Hospital shopping Reduction of honesty with medical staff Labeling of children

55. Prevalence 2.8 million children have a parent who is dependent on drugs (7.5 million including alcohol) At least 5.5% of births are drug-exposed We �catch� only a fraction of all cases of prenatal drug exposure

56. Risk Does Not Equal Certainty Walsh et al., 2003: Major survey of 8,472 adults, questioned regarding parental substance abuse and their own maltreatment Rates of physical abuse: No parental substance abuse: 7.6% Parental substance abuse: 19.8%

57. Screening Issues: FairnessChasnoff et al., NEJM, 1990 Rates of illicit drug use similar in African-American vs. white, public vs. private African-American and poor women reported to authorities at ten times the rate of white women

58. Point out racial disparitiesPoint out racial disparities

59. Given All This:What Is An Appropriate Response?

60. Why Not Simply Err on the Conservative Side? We can only utilize the strongest responses with a limited number of cases. Thus, choosing to use the strongest response in one case means not using it in another case. Responding too strongly can put our credibility, funding, and long-term ability to protect children at risk. (Remember the sexual abuse backlash.)

61. What Fits Best? Relative harm Moral concerns Prevalence of the threat Likelihood of success for various options Side-effects of the response Cost-benefit ratio (need to reserve strongest response for cases where it is most needed) Proportion of at-risk children reached

62. #1: See It In Context Prenatal exposure to illicit drugs is only one of many prenatal risk factors Inadequate nutrition (caloric intake, folic acid, etc.) Lack of prenatal care Alcohol and tobacco Environmental toxins Natural genetic variability Specialization is FINE�we must be careful to not make exaggerated claims Highlight how it�s often number of cumulative risks that makes the differenceSpecialization is FINE�we must be careful to not make exaggerated claims Highlight how it�s often number of cumulative risks that makes the difference

63. See It In Context (Cont.) Drug use is also only one of many postnatal risk factors Poverty, homelessness Mental illness, social support, IQ Exposure to violence Poor physical health, disabilities Substance abuse may be #2 in importance

64. #2: Focus Your Attention on the Postnatal Environment The risk that postnatal substance abuse presents is much more clear Thinking in this way is more consistent with how we work with other risks

65. Greenwood (R-Pa) Amendment States must have policies and procedures for addressing infants �born and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.� Hospitals must notify CPS regarding exposed infants A plan of care for mother and infant is required, including referral for the infant to early intervention services funded under Part C of the Individuals with Disabilities Education Act, for evaluation

66. Greenwood Amendment, Cont. �Such notification shall not be construed to: Establish a definition under Federal law of what constitutes child abuse; or Require prosecution for any illegal action�

67. A Key Question Is prenatal drug exposure maltreatment, like physical abuse, or is it a risk factor, like depression? If maltreatment, we must address how and why it differs from alcohol or tobacco use. If a risk factor, risk factors alone typically do not merit the strongest responses.

68. Keeping Families and Children Safe Act of 2003 (P.L. 108-36) Child abuse and neglect defined as: Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or An act or failure to act which presents an imminent risk of serious harm.

69. Overview, Part II: Substance Abuse Treatment Children need permanence yesterday, but �addiction� is a chronic, relapsing condition. Does current science offer a perspective that may help? If you choose to, how might you as Court officials modify your policies to better fit the current science? Keep an open mind, and objectively weigh the evidence with me. No clear answers, but there is some solid scientific data that gives important guidance.Keep an open mind, and objectively weigh the evidence with me. No clear answers, but there is some solid scientific data that gives important guidance.

70. Assumptions Of The �Two Clocks� Problem Success is impossible without treatment That treatment must be: Long-term Multi-component Tough, and closely monitored by the court The presence of any substance abuse means that unacceptable risk is present

71. How Well Do These Assumptions Stack Up Against The Evidence?

72. (First, A Primer on Effect Sizes�) Research reviews often focus on statistical significance, but magnitude of effects is much more important The most common measure of effect size is Cohen�s d statistic Can be interpreted as the difference between the experimental and control conditions, expressed in standard deviation units Small = .2, Medium = .5, Large = .8 .3 to .5 is typical for efficacious treatments One recent study of Buproprion SR vs. placebo in 500 pts: d=.23One recent study of Buproprion SR vs. placebo in 500 pts: d=.23

73. (Next, a Primer on Meta-Analyses) Meta-analyses combine multiple studies (meeting certain criteria) examining the association between two or more variables Meta-analyses convert outcomes in each study to a common metric (often Cohen�s d), and combine them to yield an overall measure of the association between X and Y

74. Treatment is Crucial We think first of treatment, see it as perhaps the only possible means to success, and often behave as if treatment is always effective for those who complete itWe think first of treatment, see it as perhaps the only possible means to success, and often behave as if treatment is always effective for those who complete it

75. Perceived Need for Treatment Among Persons with Substance Use Disorders Many of this group are parents; up to 10% of children have a parent with a substance use disorder, 7.8 million have a parent meeting criteria for substance dependenceMany of this group are parents; up to 10% of children have a parent with a substance use disorder, 7.8 million have a parent meeting criteria for substance dependence

76. Treatment Status Among Mothers With Substance Abuse Problems And Children In Foster Care, 1998 84.5% NOT completed or in treatment (87% no interest, 92% no Tx) 84.5% NOT completed or in treatment (87% no interest, 92% no Tx)

77. Weak Association Between Receipt of Treatment and Sobriety Treatment IS beneficial However, treatment has�at best�a moderate positive effect Recent meta-analysis: d = .30, 57% success in treated persons vs. 42% in untreated 57% to 42%. Note, this is an important difference (about 36% improvement), but not earth-shaking.57% to 42%. Note, this is an important difference (about 36% improvement), but not earth-shaking.

78. Difficulty Replicating Efficacious Interventions in the Community Training in efficacious interventions is often only weakly associated with behavior change (e.g., Miller & Mount, 2001; Baer et al., 2004) Community providers distrust manuals, which they often see as unrealistically rigid For example, multi-systemic therapy, in a 2004 meta-analysis (Curtis et al.), had an effect size of d = .81 in efficacy studies and d = .26 in effectiveness studies.

79. Preventing Placement in Substance-Abusing Families(Dore & Doris, 1998) 138 caregivers beginning specialized substance abuse services Program provided in-home specialists, addiction treatment, emergency funds, transportation, child & respite care, etc. NO association between treatment and child placement

80. Substance Abuse Treatment & Recurrence(Barth et al., 2006) Used data from mothers of 1,101 children who: Were investigated by CPS Were in need of substance abuse treatment Then created two groups of women who were matched on 17 risk factors One group received treatment (N = 219) One group did not (N = 219)

81. Barth et al., 2006 (Cont.) Re-reporting rates 18 months later: Untreated group: 8.6% Treated group: 19.3% Huh?

82. Barth et al. (Cont.) �Although this is not an argument against substance abuse treatment, it is further evidence that we do not have an adequate understanding of what happens when child welfare clients receive intervention services.�

83. Self-Change A number of studies have followed persons with substance use disorders over time to measure change in diagnostic status Up to 50% of persons with a drug or alcohol use disorder at one point in time will NOT have that disorder 5 years later Of these changers, only a minority (approximately 25%) will have obtained professional or 12-step help

84. Treatment is Crucial? Summary: Most parents in CWS with substance use disorders are not being recognized or treated Treatment has, at best, a moderate positive effect (and just getting that is not easy) Most of those who do change, change on their own

85. Longer is Better

86. Brief Vs. Extended Interventions for Problem Alcohol Use (Moyer et al., 2002) Positive values for effect sizes vs. active Tx indicate better outcomes for extended treatment conditions Effect size = tx mean minus control mean, divided by pooled standard deviationPositive values for effect sizes vs. active Tx indicate better outcomes for extended treatment conditions Effect size = tx mean minus control mean, divided by pooled standard deviation

87. Motivational Interviewing Vs. Extended Interventions (Burke et al., 2003) Alcohol studies = 15; Drug = 5 (N = 717); Diet = 4 Effect size = tx mean minus control mean, divided by pooled standard deviationAlcohol studies = 15; Drug = 5 (N = 717); Diet = 4 Effect size = tx mean minus control mean, divided by pooled standard deviation

88. Inpatient Vs. Outpatient Treatment A number of studies and reviews have compared the efficacy of inpatient vs. outpatient treatment for alcohol use disorders The first three such reviews found no advantage for inpatient treatment (Annis, 1986; Miller & Hester, 1986; & Saxe et al., 1983) A more recent review found a slight advantage for inpatient treatment in some but not all studies (and in none that used random assignment; Finney, Hahn, & Moos, 1996)

89. Bakermans-Kranenberg et al., 2003 Meta-analysis of interventions designed to increase parental sensitivity and/or infant attachment Shorter interventions were as or more efficacious than longer interventions: Sensitivity Attachment < 5 sessions d = .42 d = .27 5-16 sessions d = .38 d = .13 > 16 sessions d = .21 d = .18 Held true for multiproblem families as wellHeld true for multiproblem families as well

90. Treatment Must Address All Risks and Needs Present (More is Better)

91. Chaffin et al., JCCP, 2004 110 parents involved with CPS due to child physical abuse Randomly assigned to: Parent-Child Interaction Therapy (PCIT) Enhanced PCIT (plus services for depression, home visits, substance abuse services, etc.) Standard community parent training Outcome: CPS re-reports at a mean follow-up of 850 days

92. Chaffin et al., JCCP, 2004

93. Meta-Analysis: Valle, Wyatt, Filene, and Boyle, 2006 Performed a meta-analysis on studies of parent interventions for child maltreatment prevention Included a total of 77 studies that included a parenting intervention and a comparison group of some kind Average sample size was 111 Programs for parent or child with developmental delay Sensorimotor stimulation therapies Interventions for feeding or other disorders of infancy Programs for parent or child with traumatic brain injury Grieving/bereavement programs Programs for parent or child with developmental delay Sensorimotor stimulation therapies Interventions for feeding or other disorders of infancy Programs for parent or child with traumatic brain injury Grieving/bereavement programs

94. Single Focus Vs. Multi-Focal Overall effect size for programs focused on parenting only = .66; the effect for enhanced programs providing multiple services = .33. This difference was statistically significant Use of a manual and doing indicated or selective prevention also associated with stronger effects.Use of a manual and doing indicated or selective prevention also associated with stronger effects.

95. Bakermans-Kranenberg et al., 2003 Treatments focusing on a specific goal did better than multi-focal interventions, regardless of how high-risk the sample Broken down by outcome: Sensitivity Attachment Single focus d = .45 d = .34 Multi-focal d = .27 d = .10 PCIT-Bev storyPCIT-Bev story

96. HOW COULD THIS BE? Brief, focused treatments may better match what most parents are actually willing and able to provide Multi-focal treatments may overwhelm and demoralize some parents Success in one area may facilitate success in another area We may have underestimated the capacity for self-change (and overestimated the importance of treatment)

97. Treatment Must Be Tough And Closely Monitored By The Court

98. In One Way, YES Persons coerced into treatment do at least as well as those who enter voluntarily Court awareness of attendance is justified and probably very helpful But what about a tough approach? What about reports of parent effort, etc.?

99. Correlation Between Therapist Empathy & Drinking Outcomes 6-8 months r = -.82 12 months r = -.71 24 months r = -.51

100. Rogerian Skill and Client OutcomesValle (1981) J Studies on Alcohol 42: 783-790

101. Predictors of Patient Drinking Outcomes Therapist Responses Confront Patient Responses Interrupt Argue Off Task Negative r = .65, p<.001 r = .65, p<.001 r = .62, p<.001 r = .58, p<.001 r = .45, p< .01

102. The Association Between Problem Recognition and Change Studies suggest that there is either no association between admitting a problem exists and change (Lemere et al., 1958; Trice, 1957) or a negative association (Orford, 1957; Polich et al., 1980) The majority of persons who do change successfully deny labels such as �alcoholic� or �addict;� they give other reasons for changing

103. Therapists And Dual Roles Many substance abuse agencies take on both therapeutic and evaluative responsibilities These roles conflict with each other Further reduces openness Reduces effectiveness in both roles Contributes to mistrust on the part of parents

104. Mullins, Suarez, Ondersma, & Page, 2004 Randomly assigned mothers of drug-exposed infants to Motivational Interviewing or treatment as usual Found no positive effects Consistent with other evidence on motivational approaches with coerced persons

105. Any Substance Abuse = Unacceptable Risk

106. Alcohol Use in 2003 Any Use (past 30 days): Binge Use (= 5 drinks): Heavy Use (= 5, x 5): 50% (119 million) 23% (54 million) 7% (16 million)

107. Use of Selected Illicit Drugs: 2003 Alcohol not on here, would be 50%....Alcohol not on here, would be 50%....

108. Substance Use Disorders Abuse: Recurrent and significant adverse consequences related to the repeated use of a substance or substances. Repeated use despite legal problems, social/ interpersonal problems, hazardous use, or problems fulfilling role obligations. Dependence: The above, plus tolerance, withdrawal, and/or compulsive seeking of the substance. Addiction roughly = dependence�Addiction roughly = dependence�

109. Dependence or Abuse of Specific Substances: 2003

110. Average Days Using Per Year: With and Without Disorder (Users Only)

111. Associations Between Substance Abuse and Child Maltreatment The strongest studies suggest a two- to three-fold increase in risk This still means that maltreatment is not present in most homes in which a parent has a substance use disorder This of course is more true in homes where non-disordered substance use takes place

112. Substance Abuse by Parents In 1996, 7.5 million children (10% of all children) had one or more parents with a substance use disorder (Huang, Cerbone, & Grfoerer, 1998) 16.1% of persons with substance abuse or dependence currently live with one or more of their children Do online�.get weighted estimateDo online�.get weighted estimate

113. What Does This Suggest?

114. The Two Clock Problem Imagine a system in which long-term, intensive treatment was emphasized less than at present. How might that change things? Where else might you focus resources? Imagine a system in which abstinence was emphasized less than at present. How might that change things? How might it change things if all parents had counselors who only provided attendance records to the court?

115. Implication 1: A Greater Emphasis On Outcomes (Vs. Process) If intensive, long-term treatment is less crucial than we have previously thought, it may mean that parents should be primarily responsible for sobriety rather than treatment If so, monitoring would need to be more valid and thorough than at present

116. Implication 2: A Greater Emphasis On Parenting (Vs. Use) If it is possible�and even common�that parents can abuse alcohol or use drugs and not maltreat their children, perhaps other outcomes should be emphasized more If so, direct measures of parenting should be emphasized

117. Implication 3: Harm Reduction Treatment or no treatment, many of the parents who come before you will continue to use substances. Can we protect children by promoting abstinence, AND by teaching parents how to limit harm?

118. Implication 4: A New Alignment Counselors need �therapeutic distance� Consider asking for attendance only Establish at least one person on the treatment team who is not coercive

119. Oklahoma Infant Parenting Program (IPP) Designed for drug-exposed infants Multi-component & intensive, with emphasis on barrier reduction; 1 year in length Utilized a substance abuse treatment agency in the community (a therapeutic community) Highly coordinated, with full reporting to the court

120. Evaluation of the IPP Goal: To examine association between service provision and outcome Method: within-subjects survival analysis using follow-up CPS reports as key outcome Participants: 142 mothers of drug-exposed infants, all of whom were in out-of-home care

121. Re-Reports:Cumulative Survival in Years

122. Association Between Program Participation and Outcome No association between extent of services received (either group minutes attended or total services received) and subsequent re-reports Some evidence of a dose-response association is a necessary (but not sufficient) condition of efficacy Chaffin et al., 2004; so what�s this about? Chaffin et al., 2004; so what�s this about?

123. Conclusions Consider carefully whether vigorous CWS and Court involvement is the ideal response to prenatal substance exposure Consider whether the emphasis we traditionally place on treatment is justified Consider whether the way we think about and utilize treatment should be modified