Improving Outcomes for Families Affected by Substance Use Disorders

1. Improving Outcomes for Families Affected by Substance Use Disorders Betty Ford Conference Trends and Perspectives in Women’s Addiction April 13, 2004 Nancy K. Young, Ph.D., Director 4940 Irvine Boulevard, Suite 202 Irvine, CA 92620 714.505.3525 www.ncsacw.samhsa.gov

2. Topics • NCSACW • Some Numbers • Some History • Policy Framework and Tools • Models

3. 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

4. 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

5. 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

6. 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

7. 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

8. Some Numbers

9. In Millions Children Living With One or More Substance Abusing Parent

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

11. 52% Increase over 6 Years Foster Care Population Number of Children in Foster Care on Last Day of Federal Fiscal Year

12. Foster Care Population and Persons who First Used Crack or Meth in Past Year *All persons age 12 and over

13. Some History 1968 1973 1980s 1990s 2004 Looking Back

14. 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

15. Timelines 1990s – Reports on the Issues • Five National Reports on Substance Abuse and Child Welfare • 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)

16. 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

17. Biggest Challenges: The Four Clocks Reconciling the Clocks

18. ASFA Timetable The First Clock • 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 • Timeliness of intervention versus “Call me Tuesday”

19. 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

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

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

22. TANF Timetable 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

23. Recovery Timetable The Third Clock • “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

24. 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

25. Child Development Timetable The Fourth Clock • 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

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

27. Reconciling the Clocks

28. Connecting AOD, CWS, Court Systems: Elements of System Linkages* • Underlying Values • Screening and Assessment • Client Engagement and Retention in Care • AOD Services to Children • Information Sharing & Management • Training and Staff Development • Budgeting and Program Sustainability • Building Community Supports • Joint Accountability and Shared Outcomes • Working with Related Agencies and Support Systems From CSAT Technical Assistance Publication (TAP) 27: Navigating the Pathways *Revised March 2003

29. 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

30. 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?

31. 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

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

33. Too Often We Practice…“Don’t Ask, Don’t Tell” • 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

34. How to Begin: • 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

35. 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

36. How to Begin: • 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

37. 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 http://www.pediatrics.org/cgi/content/full/103/5/SI/1083

38. How to Begin: • 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

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

40. 100 Women Average cost $6,800 $680,000 150 Children Average 1.5 years in out-of-home care @ $24,000 per year $5.4 Million We Know AOD Treatment Pays • 30 Women recover with one episode of treatment • 45 Children reunify at 6 months • Saves $1.1 Million Foster Care Cost Offset Pays for all 100 Women’s Treatment Nearly 2 Times Over

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

42. Models of Improved Services • Many communities began program models in 1990s • Paired Counselor and Child Welfare Worker • Counselor Out-stationed at Child Welfare Office • Multidisciplinary Teams for Joint Case Planning • Persons in Recovery act as Advocates for Parents • Training and Curricula Development • Family Treatment Courts

43. 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

44. The Fifth Clock • 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 Urgency

45. The Fifth Clock • 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 Urgency