# Presentation: 207126

## Methamphetamine and Child Welfare: Trends, Lessons and Practice Implications

**SAMHSA, Center for Substance Abuse Treatment**
**Nancy K. Young, Ph.D., Director**
**National Center on Substance Abuse and Child Welfare **
**Jay Wurscher, Director**
**Oregon Child Welfare Addiction Services**

**Methamphetamine and Child Welfare: ****Trends, Lessons and Practice Implications**

**Presented at CWLA National Conference**
**March 1, 2006**

## Part I

**Background and Context**

## Scope of the Problem

## Meth use has increased
Use has spread from the West
Accounts for a small percentage of the total number of people affected by drug and alcohol problems
The impact of meth use on child welfare varies widely among States and among Counties

- Use has spread from the West
- Accounts for a small percentage of the total number of people affected by drug and alcohol problems
- The impact of meth use on child welfare varies widely among States and among Counties

**Scope of the Problem**

## Meth/Amphetamine Treatment Admission Rate Per 100,000 Population Aged 12 or Older - 1993-2003

- Source: Treatment Episode Data Set (TEDS)

**Meth/Amphetamine Treatment Admission Rate**** **Per 100,000 Population Aged 12 or Older - 1993-2003

## Eastward Spread of Methamphetamine

**Eastward Spread of Methamphetamine**

**Admissions per 100,000 population**

**Notes:**
Admissions per 100,000 people. For the United States as a whole, methamphetamine admission rates increased by 420 
percent between 1992 and 2002, from 10 per 100,000 population aged 12 and over
 to 52 per 100,000. Rates were generally highest in the West, 
particularly in the Pacific States, AND spreading east into the Midwest and South. 

## Eastward Spread of Methamphetamine

**Eastward Spread of Methamphetamine**

**Admissions per 100,000 population**

**Notes:**
Admissions per 10,000 people. By 2002, 19 States reported rates of 50 or more admissions per 100,000;
 in 13 of these, rates were 100 or more admissions per 100,000. 

## Alcohol 	     	  				42%

Heroin/Other Opiates			18%

Marijuana					15%

Cocaine						14%

Meth/Amphetamine and			  7%
	Other Stimulants				

- Heroin/Other Opiates			18%
- Marijuana					15%
- Cocaine						14%
- Meth/Amphetamine and			  7%
- 	Other Stimulants

**Treatment Admissions by Primary Substance - 2003**

- Source: Treatment Episode Data Set (TEDS)

**Notes:**
Heavy alcohol use is drinking five or more drinks on the same occasion in each of 5 or more days in the past 30 days.

## Methamphetamine is affecting communities that have not experienced prior stimulant drug problems

Child welfare agencies are dealing with more cases involving methamphetamine

- Child welfare agencies are dealing with more cases involving methamphetamine

**Impact of Increasing ****Methamphetamine Use**

## Smoked Cocaine/Crack and Meth/Amphetamine Treatment Admissions by Race/Ethnicity

- Source: Treatment Episode Data Set (TEDS)

## Meth/Amphetamine & Cocaine Treatment Admissions According to Census Division 2003              RATE per 100,000 

**Rate per 100,000**

- Source: Treatment Episode Data Set (TEDS)

## 47% of admissions are women
	     This is a higher percentage of women  
       admissions than for any other drug except 
       tranquilizers
 methamphetamine -  ~ 1:1                                      
 cocaine - 1:2  
 heroin - 1:2+
 marijuana & alcohol - 1:3 

Since women are often caretakers of children, more children are likely affected

**	****     **This is a higher percentage of women
-        admissions than for any other drug except
-        tranquilizers
-  methamphetamine -  ~ 1:1
-  cocaine - 1:2
-  heroin - 1:2+
-  marijuana & alcohol - 1:3
**Since women are often caretakers of children, more children are likely affected**

**Gender Differences**

- Source: Vaughn, C. (2003)

## Self-Reported Reasons for Starting Methamphetamine Use 

**Self-Reported Reasons for Starting Methamphetamine Use**** **

- Richard Rawson, Ph.D., Presentation to SAMHSA, August 2005

**Notes:**
These differences explain why so many women use meth.

## Treatment Admissions Meth/Amphetamine as Primary Substance by Gender

- Source: Treatment Episode Data Set (TEDS)

**Notes:**
Women are more likely than men to report meth/amphetamines as their primary substance at admission. This trend has remained constant over the years.  

## Meth/Amphetamine Admissions By Gender - 2003

- Source: Treatment Episode Data Set (TEDS)

**Notes:**
Unlike other drugs, the gender breakdown for meth/amphetamine admissions is nearly equal among men and women.  However, when you look at teens, the picture is much more disturbing, with females representing the majority of such admissions.

## Female Treatment Admissions States with Highest % of Meth/Amphetamine as Primary Substance

- Source: Treatment Episode Data Set (TEDS)

**Notes:**
This slide takes a closer look at the female treatment admissions.  It shows that the percentage for which meth/amphetamine is the primary substance at admission is strikingly higher in many western and midwestern States. The national average was 10% in 2002.  These States far exceed that number.  Next 4 highest States were: 7. Iowa, 8. Oregon, 9. Arkansas and 10. Oklahoma

## Trends in Primary Substance UseTreatment Admissions for Pregnant Females by Primary Substance 1995-2003 

**Trends in Primary Substance Use**Treatment Admissions for Pregnant Females by Primary Substance 1995-2003** **

**Percent of Women’s Admissions for**** ****Meth/Amphetamine**** ****and**** ****Marijuana**** ****Nearly Doubled over 8 Years**

- Source: Treatment Episode Data Set (TEDS)

**Notes:**
Background/context: The percentage of females pregnant at admission has remained relatively constant at about 4%.  For 2003, the total number of females pregnant at admission was 19,179.
The graph shows an interesting trend:  from 1995 to 2003, alcohol and cocaine as primary substance for pregnant women at admission has gone down, while marijuana and methamphetamine have increased.  Heroin has remained relatively constant.
In addition (not reflected in any graph), if you look at all pregnant female admissions with meth/amphetamines/other stimulants as the primary substance, the percentage who are 18-24 years old has increased from 39% in 1995 to 46% in 2003 – so providers are dealing with more younger pregnant females who use meth.

## Natural Rewards Elevate Dopamine Levels

**Natural Rewards Elevate Dopamine Levels**

## Effects of Drugs on Dopamine Levels

***Source: Di Chiara and Imperato***

**Effects of Drugs on Dopamine Levels**

## Effects of Methamphetamine Addiction

## Short-Term Effects of Methamphetamine

_**PSYCHOLOGICAL**_
**Confidence**
**Alertness**
**Mood**
**Sex drive**
**Energy**
**Talkativeness**
**Boredom**
**Loneliness**
**Timidity**

_**PHYSICAL**_**	**
**Heart rate**
**Respiration**
**Blood pressure**
**Pupil size**
**Sensory acuity**
**Energy**
**Appetite**
**Sleep **
**Reaction time**

- Source: Judith Cohen, Ph.D., Presentation to NASADAD, June 2005

**Notes:**
People like MA
Addictive—time varies, from immediate to years

Initially get a surge.  Accentuate the positive, eliminate the negative

## MethamphetamineChronic Physical Effects

- Tremors
- Weakness
- Headaches
- Sweating
- Coughing

- Dry Mouth
- Oily skin/complextion
- Burned lips/sore nose
- Dental
- Weight Loss/Anorexia

**Notes:**
As time goes on, picture changes

Feel poorly, ingestion causes burns, hurts gums

Loose a lot of weight.  One of reasons women use initially.

## MethamphetamineChronic Psychological Effects

- Confusion
- Concentration
- Hallucinations
- Fatigue
- Memory loss
- Insomnia

- Source: Richard Rawson, Ph.D., Presentation to SAMHSA, August 2005

- Irritability
- Paranoia
- Panic reactions
- Depression
- Anger
- Psychosis

**Notes:**
Not only do you not feel well, your thinking and cognitive processes are impacted.

One of reasons women use, to help with depression, now is made worse.

## Decreased ability to:
Recognize and recall words and pictures
Make inferences
Manipulate information
Ignore irrelevant information
Learn from experience

Users and people in early recovery may find it difficult to:
Pay attention
Comprehend spoken and written information
Remember information

- Recognize and recall words and pictures
- Make inferences
- Manipulate information
- Ignore irrelevant information
- Learn from experience
- Users and people in early recovery may find it difficult to:
- Pay attention
- Comprehend spoken and written information
- Remember information

**Cognitive Effects**

- Source: Simon (1999)

**Notes:**
Think about what you need from an individual to bring about change in behavior:

Need to pay attention
Understand you
Remember what you told them to do

All of these will be difficult.

## Rate of recovery is associated with severity of abuse and days of abstinence.
Study documented significant recovery with Meth abusers who were able to stay drug free for at least 9 months.
After 4 years of abstinence, no deficits in:
Memory
Learning
Attention
Executive function
Motor function

- Study documented significant recovery with Meth abusers who were able to stay drug free for at least 9 months.
- After 4 years of abstinence, no deficits in:
- Memory
- Learning
- Attention
- Executive function
- Motor function

**Cognitive Effects**

- Sources: Lundahl et al. (2004); Volkow et al. (2001)

**Notes:**
But with time, person can regain their capacity to function and “have a life in the community.”

## Risks to Children When Parents Use Methamphetamine

## Foster Care Population and Persons Who First Used Crack or Methamphetamine in Prior Year 

## Six Different Situations for Children

- Parent uses or abuses methamphetamine
- Parent is dependent on methamphetamine
- Mother uses meth while pregnant
- Parent “cooks” small quantities of meth
- Parent involved in trafficking
- Parent involved in super lab

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

## Each situation poses different risks and requires different responses
Child welfare workers need to know the different responses required
The greatest number of children are exposed through a parent who uses or is dependent on the drug 
Relatively few parents “cook” the drug

- Child welfare workers need to know the different responses required
- The greatest number of children are exposed through a parent who uses or is dependent on the drug
- Relatively few parents “cook” the drug

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

**Six Different Situations for Children**

## Parent Uses or Abuses Meth

- Risks to safety and well-being of children:
- Parental behavior under the influence: poor judgment, confusion, irritability, paranoia, violence
- Inadequate supervision
- Inconsistent parenting
- Chaotic home life
- Exposure to second-hand smoke
- Accidental ingestion of drug
- Possibility of abuse
- HIV exposure from needle use by parent

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

## Parent Is Dependent on Meth

- Risks to safety and well-being of children:
- All the risks of parents who use or abuse, but the child may be exposed more often and for longer periods
- Chronic neglect is more likely
- Household may lack food, water, utilities
- Chaotic home life
- Children may lack medical care, dental care, immunizations
- Greater risk of abuse
- Greater risk of sexual abuse if parent has multiple partners

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

## Mother Uses Meth While Pregnant

- Risk to child depends on frequency and intensity of use, and the stage of pregnancy
- Risks include birth defects, growth retardation, premature birth, low birth weight, brain lesions
- Problems at birth may include difficulty sucking and swallowing, hypersensitivity to touch, excessive muscle tension (hypertonia)
- Long term risks may include developmental disorders, cognitive deficits, learning disabilities, poor social adjustment, language deficits

- Sources: Anglin et al.  (2000); Oro & Dixon, (1987); Rawson & Anglin (1999); Dixon & Bejar (1989); Smith et al. (2003); Shah (2002)

## Mother Uses Meth While Pregnant

- Observed effects may be due to other substances, or combination of substances, used by the mother
- For example, if the mother also smokes, growth retardation may be significant
- Observed effects may be complicated by other conditions, such as the health, environmental, or nutritional status of the mother

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

## Mother Uses While Pregnant

- Scope of the problem:
- An estimated 10% to 11% of all newborns are prenatally exposed to drugs or alcohol; this amounts to 400,000 to 480,000 newborns per year
- Only about 5% of prenatally exposed newborns are placed in out-of-home care; the rest go home without assessment and services

- Sources: Vega; SAMHSA, OAS, National Survey of Alcohol and Drug Use During Pregnancy, 2002 and 2003

## Mother Uses While Pregnant

**	**
- Home environment is the critical factor in the child’s outcome
- Consequences can be mediated

- Shah, R.** **(2005, June). From NASADAD presentation

**Notes:**
The home environment depends on the parent’s engagement and success in treatment.  The home environment is the critical factor for the child.  In addition the child’s social, emotional, developmental and psychological needs must also be addressed.   Address the child’s need has an impact on the parent’s treatment as well because coping with the issues of recovery and the challenges of a child with unmet or undetected special needs can pose barriers for parents trying to maintain a safe and stable home for their child. 

## Parent “Cooks” Small Quantities of Meth

- All the risks of parents who use or are dependent on meth, with added risks of manufacturing the drug:
- Chemical exposure
- Toxic fumes
- Risk of fire and explosion

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

**Notes:**
While the number of parent’s who cook is relatively small compared to the number that use, living in a meth lab is extremely dangerous, especially for children.

## Environmental Methamphetamine Exposure and Risks

- Toxic effects of manufacturing
- Children more at risk:
- Higher metabolic rates
- Developing bone and nervous systems
- Thinner skin than adults which absorbs chemicals faster
- Children tend to put things in their mouth and use touch to explore

- Source: Mason (2004)

## Parent Involved in Trafficking

- Presence of  weapons
- Possibility of violence
- Possibility of physical or sexual abuse by persons visiting the household

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

**Notes:**
The lifestyle that goes with trafficking is very dangerous.

## Parent Involved in Super Lab

- Lower likelihood of children on the site

- Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

## Number of Children in Meth Labs

|  | 2000  | 2001  | 2002  | 2003  |
| --- | --- | --- | --- | --- |
| Number of incidents 
 | 8,971  | 13,270  | 15,353  | 14,260  |
| Incidents with children present 
 | 1,803  | 2,191  | 2,077  | 1,442  |
| Percent with children present | 20%  | 16.5% | 13.5% | 10% |
|  |  |  |  |  |
| Children taken into protective custody  | 353 | 778  | 1,026  | 724  |

**Number of Children in Meth Labs**

- Source:  El Paso Intelligence Center

**4 years = 2,881; all children ~1,200,000**

**Notes:**
Labs include small home labs and large scale superlabs.

The data is trending down, but we don’t know if that is because of a shift in the resources to finding the labs, or something else.

May be more consolidation of super labs supplying more people.  Children less likely to be present at Super labs.

## National Alliance of Drug Endangered Children (DEC)

- Formed in October 2003
- Provides multi-disciplinary training for communities interested in starting or expanding DEC programs
- _[www.nationaldec.org](http://www.nationaldec.org/)_

## Multidisciplinary DEC TEAMS

**Medical and Mental Health Services**
- trained in diagnosing and treating children exposed to neglect and abuse, possible chemical hazards, and trauma
**Child Protective Services**
- determine the course of the child welfare investigation and share information with law enforcement officers, district attorneys’ offices, and health care and mental health agencies.
**Law Enforcement**
- must act to ensure the immediate safety of the children present, ensure that children are placed in a safe environment with a responsible caretaker.

## DEC Team (cont.)

**Public Safety**
- Fire department personnel and hazardous materials professionals, play a key role in documenting conditions of child endangerment, including the potential for fire or explosion, presence of hazardous materials, improper storage of chemicals, and poor ventilation.
**Prosecution**
- Prosecutors are responsible for filing and supporting charges of child endangerment. In cases in which one parent or caregiver is not charged with endangerment but lesser charges are levied, the prosecutor can play an important role in safeguarding the child’s welfare by influencing the terms of probation. These terms often include ***drug treatment***, parenting classes, and other rehabilitative measures.

## Treatment for Methamphetamine

## CSAT’s Methamphetamine Treatment Project

- Largest randomized clinical trial of treatment for meth dependence
- Intensive outpatient setting
- Three to five visits per week of comprehensive counseling for at least the first three months
- Cognitive behavioral approach
- Contingency management

## Matrix Model Treatment Outcomes 

**Of 10 MA-abusing persons entering treatment **
**(UA results):**

**6 still MA-abstinent**
** ****12 months after treatment**** **

**After treatment:               DC         ****	****	****6mo.               ****	****12mo.                                  ****  **

**Still MA-abstinent:            6.5                ****	****   6.9                ****	****    5.9      **

- Source: Rick Rawson, Ph.D. Presentation to SAMHSA, August 2005

**Notes:**
Women’s outcomes were not as good as groups that were mixed.

40% vs. 55-60% at 12 months.

## Similar Outcomes

- Treatment outcomes do not differ from other drugs of abuse
- Treatment outcomes have more to do with the quantity and quality of treatment than type of drug abused

## Gender Differences and Implications for Treatment

- Co-occurring mental health problems
- Trauma
- Body image

## Scores at Baseline 

**Behavior Symptom Inventory (BSI)**
**Scores at Baseline**** **

- Richard Rawson, Ph.D., Presentation to SAMHSA, August 2005

**Notes:**
Women have higher scores on mental health problems than men at time of entry to treatment for meth.

## Histories of Violence among Clients Treated for Methamphetamine

- Persons in treatment for methamphetamine reported high rates of violence
- 85% women
- 69% men
- The most common source of violence:
- For women, was a partner (80%)
- For men, was strangers (43%)
- History of sexual abuse and violence:
- 57% women
- 16% men

- Source: Cohen, J. (2003)

## Prevalence of Co-Occurring Problems, and Violence and Trauma 

- Women in treatment 2 times more likely to have history of sexual and physical abuse than general population
- Women who are dependent on meth usually have more severe problems than their male counterparts in many areas of their life
- Speaks to the need for comprehensive, and trauma-related services

- Source:  CSAT TIP 36

## Gender Differences and Implications for Treatment

- Sexual behavior linked to methamphetamine is a significant clinical issue that needs to be addressed in women-only groups
- Co-occurring mental health issues complicate treatment and require longer duration for treatment
- Violence linked to meth use is related to trauma and safety needs which must be addressed in treatment
- Body image and nutrition need to be addressed

## Threats of violence and reduced cognitive capacity to manage activities of daily living suggest that a period of residential treatment or referral to safe houses or supervised housing may be indicated.
Intensive outpatient treatment should be coupled with additional supports such as transportation, meals, child care.
Gender specific treatment is indicated given women’s histories of trauma and violence 

- Intensive outpatient treatment should be coupled with additional supports such as transportation, meals, child care.
- Gender specific treatment is indicated given women’s histories of trauma and violence

**Gender Differences and Implications for Treatment**

## What Predicts Longer Abstinence?

- Longer time in treatment (e.g. those with 4 or more mo. of treatment have more than double the rate of 24-48 mo. abstinence)
- More sessions per month of individual counseling
- Treatment, intervention and case planning need to account for short-term effects, especially cognitive deficits and verbal communication
- Drug Court involvement
- Family involvement

- M.L. Brecht, Ph.D., et al. (2005)

- Longer abstinence following treatment for women with:

## Summary

## Summary

- Methamphetamine is a dangerous drug with serious physical, cognitive, and health consequences
- The effects of long-term use are reversible with prolonged abstinence
- Treatment for methamphetamine is as effective as treatment for other drugs

## A high percentage of methamphetamine users are women of child-bearing age

Meth accounts for 7% of treatment admissions nationally, but in some States 30- 44% of women admitted were admitted for methamphetamine 

- Meth accounts for 7% of treatment admissions nationally, but in some States 30- 44% of women admitted were admitted for methamphetamine

**Summary**

## Scope of the problem:
The number of meth users is small compared to other drugs and alcohol 

Admissions increased through 2003

Communities that have not experienced prior drug problems may lack the resources to handle a meth problem

Meth use may be leveling off

- The number of meth users is small compared to other drugs and alcohol
- Admissions increased through 2003
- Communities that have not experienced prior drug problems may lack the resources to handle a meth problem
- Meth use may be leveling off

**Summary**

## Parents’ use of methamphetamine puts their children at risk

The best outcome for both child and parent is achieved when:

The parent receives immediate, effective treatment and comprehensive services

The child receives immediate assessment and services, as well as follow-up services

- The best outcome for both child and parent is achieved when:
- The parent receives immediate, effective treatment and comprehensive services
- The child receives immediate assessment and services, as well as follow-up services

**Summary**

## Child welfare workers must distinguish between

  		Children whose parents use meth, and 
		Children whose parents manufacture 	meth

They must learn the established medical protocols for children present in meth labs

-   		Children whose parents use meth, and
- 		Children whose parents manufacture 	meth
- They must learn the established medical protocols for children present in meth labs

**Summary**

## We need early diagnosis and intervention for children affected by meth before and after birth

We need comprehensive, timely, and state-of-the-art treatment for parents referred to treatment as a condition of keeping or reunifying with their children

We need information systems that capture the necessary data to support effective approaches

- We need comprehensive, timely, and state-of-the-art treatment for parents referred to treatment as a condition of keeping or reunifying with their children
- We need information systems that capture the necessary data to support effective approaches

**Summary**

## For Further Information

## SAMHSA Resources

**Treatment Improvement Protocols (TIP 33)**
- Best Practice Guidelines for Treatment of Substance Abuse
- Researched, Drafted, and Reviewed by Substance Use Disorder Professionals

## KAP Keys & Quick Guide

Developed to accompany the TIP Series

Based entirely on TIP #33

Designed to meet the needs of busy clinicians for concise, easily accessed “how-to” information 

http://www.samhsa.gov 

**KAP Keys & Quick Guide**
- Developed to accompany the TIP Series
- Based entirely on TIP #33
- Designed to meet the needs of busy clinicians for concise, easily accessed “how-to” information
- _[http://www.samhsa.gov](http://www.samhsa.gov/)__ _

**SAMHSA Resources**

## SAMHSA Resources

**SAMHSA’s Addiction Technology Transfer Centers (ATTC)**
- Pacific Southwest ATTC
- 	_[http://](http://www.psattc.org/events/cates/I/presentations/index.html)__[www.psattc.org/events/cates/I/presentations/index.html](http://www.psattc.org/events/cates/I/presentations/index.html)_
- Methamphetamine 101: Etiology and Physiology of an Epidemic

## ATTC’s Introduction to Evidence-Based Treatments for Methamphetamine

- CD-ROM Learning Tools
- DVD Training Module
- Produced by: Applied Behavioral Health Policy at the University of Arizona for the Pacific Southwest ATTC
*web* _[www.psattc.org](http://www.psattc.org/)_

## 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

- 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

**Notes:**
** I’d like to take just a moment to introduce to you the National Center on Substance Abuse and Child Welfare. We are coming up on our 2 year anniversary next month and we are quite pleased with the progress that is underway. 
Many of you may know that we are co-funded by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment and the Administration for Children, Youth and Families’ Children’s Bureau, Office on Child Abuse and Neglect. 

## To improve outcomes for families by promoting effective practice, and organizational and system changes at the local, state, and national levels

Developing and implementing a comprehensive program of information gathering and dissemination

Providing technical assistance

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

**NCSACW Mission**

**Notes:**
You have a handout in your materials on our technical assistance program and how to reach us as well as an announcement of our first on-line curricula. 
This on-line training is directed to substance abuse counselors and explains child welfare services and the dependency court. It takes about 4 hours to complete, it is free of charge and comes with 4 hours of CEUs for those that are interested. Our second on-line curricula will be released in a few months and targets child welfare workers and explains addiction and recovery.
You can visit our website and leave us your email address if you are not currently on our distribution list to receive announcements of our products and activities and we look forward to hearing more from you.

## American Public Human Services Association (APHSA)
Child Welfare League of America (CWLA)
National Association of State Alcohol and Drug Abuse Directors (NASADAD)
National Council of Juvenile and Family Court Judges (NCJFCJ)
National Indian Child Welfare Association (NICWA)

- Child Welfare League of America (CWLA)
- National Association of State Alcohol and Drug Abuse Directors (NASADAD)
- National Council of Juvenile and Family Court Judges (NCJFCJ)
- National Indian Child Welfare Association (NICWA)

**NCSACW Consortium**

## Recent NCSACW Products

*Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers*
- 	(A short monograph for front-line workers)
- On-Line Training – Now Available
- Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals
- Understanding Substance Use Disorders, Treatment and Family Recovery: A Guide for Child Welfare Professionals

**Notes:**
Publication and on-line training.  Free of charge.

## Contact NCSACW

- _[www.ncsacw.samhsa.gov](http://www.ncsacw.samhsa.gov/)_
**	****Project Director:**
**	****Nancy Young, Ph.D.**
**	****714-505-3525**
**Government Project Officer:**
**	****Sharon Amatetti, SAMHSA/CSAT**
**	****240-276-1694**
**	**_[sharon.amatetti@samhsa.hhs.gov](mailto:sharon.amatetti@samhsa.hhs.gov)__ _

## Part II

**Model Programs**

## Signs of Use and Warning Signs for Workers

## Euphoria 
Grinding of teeth 
Rapid breathing 
Sweating
Hyperactivity 
Tremor - shaking hands 
Rapid or pressured speech 
Depression - when drug wears off 
Irritability, paranoia, suspiciousness 
Hallucinations 
Presence of drug paraphernalia 

- Grinding of teeth
- Rapid breathing
- Sweating
- Hyperactivity
- Tremor - shaking hands
- Rapid or pressured speech
- Depression - when drug wears off
- Irritability, paranoia, suspiciousness
- Hallucinations
- Presence of drug paraphernalia** **

**Signs of Methamphetamine Use ****and Use of Other Stimulants**

- Source: Crowell & Webber (2001)

## Warning Signs for Workers

- Client is extremely irritable, suspicious, or argumentative, or there is an escalation of irritability
- Regular client does not appear to know who worker is
- Evidence of paranoid thinking, delusions
- Client verbalizes implicit or explicit threat against worker

- Source: Crowell & Webber (2001)

## Scratch marks or scabs, particularly on client’s hands and arms - may be evidence of tactile hallucinations and indicate a prior episode of stimulant psychosis
Severe damage to teeth and gums
Drawn face and underweight 
Strong chemical odor - may indicate manufacturing of meth

- Severe damage to teeth and gums
- Drawn face and underweight
- Strong chemical odor - may indicate manufacturing of meth

**Other Severe Signs of Meth Use **

- Source: Crowell & Webber (2001)

**Notes:**
Severe signs.  Will not see these in all instances.

## Methamphetamine: Implications for Workers

## Denial = Super-memory Imprinting

- Memory imprinting increases in power as dopamine activity increases.
- Addicts remember the “good-times” and fail to remember the “bad-times”.

## Research on Cognitive Impairments of MA addicts

- Ability to manipulate information (multi-relational or “synthesis”).
- Ability to make inferences.
- Ability to ignore irrelevant information.
- Ability to learn new or recall information.

- Hippocampus?

- implications?

## “Methamphetamine: Snapshot Phenomenon”   Wurscher & Martin

- Criminal

- Psycho-case

- Sad-case

- wants
- recovery

- Doesn't
- want
- recovery

## Oregon’s Response

## Oregon Child Welfare 1997-99

- 60%  of CW families A&D involved
- 54%  of CW families DRUG involved
- 68%  of CW DRUG families METH
- #1 reason for termination –
- No recovery  - 46%  METH

## Oregon Child Welfare 2004

- 875,790 children  ages 0-18
- 46,524 reports of suspected abuse
- 10,622 FOUNDED abuse cases
-   9.6%  ^  over previous year
- 73.8%  ^  since 1994
-   9.4%  ^  in POPULATION since 1994
-   50%  of removals METH related

## Current Oregon Issues

- Meth Labs almost eliminated
- Meth Addiction Higher than ever
- 2003 - 30% reduction in A&D TX
- Foster Care Population Growing
- Meth cases most CHAOTIC

## What Labs ARE NOT

-  Chernobyl
- 	– Meth Labs are not radioactive.
-  Fatal to CPS Workers
- 	– Meth Labs will not kill you.

## Oregon METH Response

- Collaborate & Integrate
- Separation of issues – Labs & Addiction
- Governor’s METH Task Force
- Drug Endangered Child Response
- DEC Teams & OADEC
- Addiction Recovery Teams - ART
- Family Involvement Team - FIT

## DEC - Drug Endangered Child Team Partners

- DHS Child Welfare
- Local Law Enforcement
- Meth Lab Law Enforcement
- Criminal Prosecuting District Attorneys
- Child Welfare Attorneys
- Local Medical Staff - Hospitals

## DEC Collaboration Issues

- LEA will seek evidence for charges and arrest.
- DA’s will seek prosecution on both drug charges and child maltreatment.
- DEC Collaboration requires CPS to play active role in this process while advocating for the best outcomes for children.
- Can be conflicts in process.

## CPS Requirements – On Site

- Focus - on Your CPS Safety Assessment
- Gather Info from Site Safety Officer
- Determine De-Contamination Need/Plan
- Focus - Be the Social Worker, not the Police Officer.
- Stay Behind the Police Barriers
- Transport Children Safely

## Addiction Recovery Teams

- DHS & Contract Collaboration
- DHS staff person assigned to A&D
- Contracted A&D Counselor
- Contracted Outreach Worker
- Other Integrated Services
- Must be on site at child welfare

## Family Involvement Team 

- FIT Team
- Portland – Multnomah County
- A&D CW Services at the court
- On site DHS & A&D at all times
- On site transport & child visit
- Treatment Program Case Managers
- ASFA attentive & accountable

## ADVANTAGES – ART & FIT

- All providers believe in RECOVERY
- Immediate focus on A&D TX needs
- Tracking clients toward recovery
- Relapse response with Outreach
- FIT – services offered at court
- FIT – TX site case management

## ADVANTAGES – ART & FIT

- Parent focused service
- Caseworkers feel supported
- Treatment programs OK with CW
- Clients stick with TX
- Recovery modeled – Parent Mentors
***Reunited*** video    asfavideo.org

## ADVANTAGES ART - FIT

- Defense bar buys in
- Judges recommend & mandate services
- Negates punitive casework
- Promotes clinical approaches
- Drug testing seen as intervention
- Recovery is modeled to caseworkers

## Oregon Resource People

- Jay Wurscher
- 	Alcohol & Drug Services Coordinator
- 	OR Dept of Human Services
- 	Salem OR
- 	503-945-6634
- 	jay.m.wurscher@state.or.us

- Samantha Byers
- 	Family Involvement Team/Parent Mentors
- 	OR Dept of Human Services
- 	Portland, OR
- 	503-988-5464, Ext-126693
- 	samantha.byers@state.or.us

## Sacramento County’s Response

**Sacramento County’s Response**

## Program Context

- Sacramento County population: 1.5 million
- In 2004, there were approximately 7,000 substantiated child abuse/neglect referrals, in Sacramento1.
- An estimated 70 to 80% of child welfare cases involve families affected by substance use

- Source: Center for Social Services Research, University of California at Berkeley

**Notes:**
Beginning in 1997, following several highly publicized deaths, a concerted effort was made to remove children who were living with parents using drugs.  

## Sacramento County Prior to STARS and Dependency Drug Court

- Reunification rate about 20-25%
- Parents unable to access AOD treatment
- Social workers, attorneys, courts often uninformed on parent progress
- Drug testing not uniform and results often delayed

## Sacramento County After STARS and Dependency Drug Court

- Reunification rates at 40–45 percent
- Reunification is occurring faster
- Parents truly have “treatment on demand”
- All parties involved in the case are informed at every stage of treatment
- All parents receive random observed “instant” drug testing

## Comprehensive cross-system joint training
Substance Abuse Treatment System of Care
Early Intervention Specialists
Recovery Management Specialists (STARS)
Dependency Drug Court
	Reforms have been implemented over the past eleven years

- Substance Abuse Treatment System of Care
- Early Intervention Specialists
- Recovery Management Specialists (STARS)
- Dependency Drug Court
- 	Reforms have been implemented over the past eleven years

**Five Components of Sacramento County’s Comprehensive Reform **

## Five Components of Sacramento County’s Comprehensive Reform 

*1.  Comprehensive cross-system joint training*
** **
- 	Three Levels of Training
- AOD basics for all staff – 4 days required
- AOD screening, brief intervention, motivational enhancement and AOD treatment – 4 days required of all case carrying workers
- Group intervention skills – 4 days required of all ADS staff and voluntary for any CPS division staff

## 2.  Substance abuse treatment system of care

Managed wait list

Immediate access to substance abuse services

Group services expansion and implementation of pre-treatment groups

- Managed wait list
- Immediate access to substance abuse services
- Group services expansion and implementation of pre-treatment groups

**Five Components of Sacramento County’s Comprehensive Reform**

## 3.  Early Intervention Specialists

Review of every court petition to determine if substance use disorders may be present
Immediate access to intervention and assessment at court hearings
Immediate authorization of publicly-funded treatment services

- Review of every court petition to determine if substance use disorders may be present
- Immediate access to intervention and assessment at court hearings
- Immediate authorization of publicly-funded treatment services

**Five Components of Sacramento County’s Comprehensive Reform**

## 4.  Recovery Management Specialists (STARS)
Motivational enhancement
Gender-specific services
Immediate access to recovery management 
and treatment services
Provider orientation of providing hope and accountability 
Compliance monitoring—twice monthlies

- Motivational enhancement
- Gender-specific services
- Immediate access to recovery management
- and treatment services
- Provider orientation of providing hope and accountability
- Compliance monitoring—twice monthlies

**Five Components of Sacramento County’s Comprehensive Reform**

## 5.  Dependency Drug Court

Parallel system to dependency petition
30, 60 and 90-day compliance hearings
Structured incentives for compliance and sanctions for non-compliance
Voluntary participation in on-going services

- Parallel system to dependency petition
- 30, 60 and 90-day compliance hearings
- Structured incentives for compliance and sanctions for non-compliance
- Voluntary participation in on-going services

**Five Components of Sacramento County’s Comprehensive Reform**

**4940 Irvine Boulevard, Suite 202**
**Irvine, CA  92620**
**714.505.3525**
**Fax 714.505.3626**
**www.cffutures.org**

**Sacramento County****Dependency Drug Court****Evaluation Findings**

## Parents and Children in Evaluation

## Total Mothers and Fathers in DDC Evaluation

**73.4%**

**26.6%**

## Primary Drug Problem*

***p<.001**

## Percent of Mothers and Fathersby Mental Illness at Admission*

*** p<.001**

## Percent of Mothers and Fathers by Treatment Modality*

*** p<.01**

## Treatment Admission Rates*

***p<.001**

## Percent of Mothers and Fathersby Treatment Completion

**n.s.**

## 24-Month Placement Outcomes*

***Significantly more Court Ordered Year 1 children reunified at 24 months than comparison children. Significantly more Year 1 children were in continued FR/FC at 12 months (with less in long term placement or guardianship) than the comparison groups.**

## Time to Reunification

**Notes:**
The Year 2 cohort had a similar time to reunification as the comparison group.  Although the reunification rate was similar to the other court ordered group, the Year 2 cohort appeared to take longer to reunify.  This may be due to the change in demographics (i.e., homelessness) that we saw for this group.  It also may be due to a change in the types of parents that entered the DDC following B13.

## 24-Month Cost Savings

- 27.2% - Reunification rate for comparison group children
- 42.1% - Reunification rate for court-ordered DDC group children
- 63 Additional DDC children reunified
- 33.1 – Average months in out-of-home care for comparison group children
- 8.6  - Average months to reunification for court-ordered DDC children
**$2,953,639 estimated savings in out-of-home care costs**

## Anglin, M., Burke, C., Perrochet, B., Stamper, E. & Dawud-Noursi, S. (2000). History of the methamphetamine problem. Journal of Psychoactive Drugs, 32(2), 137-141.
Brecht, M.-L., M. D. Anglin, et al. (2005). "Coerced Treatment for Methamphetamine Abuse: Differential Patient Characteristics and Outcomes." The American Journal of Drug and Alcohol Abuse 31(2): 337.
Brecht, M.L.(2004) Women and Methamphetamine: Characteristics, Treatment Outcomes. Presentation to the Center
        For Substance Abuse Treatment, State Systems Development Conference. August 13.
Cohen, Judith, Ph.D. Presentation to NASADAD, June 2005.
Colorado DEC. Retrieved from  www.colodec.org/decpapers/Documents/DEC%20Medical%20Protocol.pdf
Crowell and Webber, 2004. Retrieved from www.drugfreeinfo.org/PDFs/strengthensupervision.pdf.
Dixon, S.D., & Bejar, R. (1989). Echoencephalographic findings in neonates associated with maternal cocaine and methamphetamine use: Incidence and clinical correlates. Journal of Pediatrics, 115(5 Pt 1), 770-778.
Ferguson, T. (2001). Overview of medical toxicology and potential exposures to clandestine drug laboratories in California. Paper presented to the Minnesota Department of Health.
Lundahl, L.H., Keenan, P., Schuster, C.R., & Johanson, C.E. (2004, June). Neurocognitive function in chronic high dose methamphetamine abusers following long term abstinence. Poster session presented at the 66th Annual Scientific Meeting of the College on Problems of Drug Dependence, San Juan, Puerto Rico. 
Mason, A. P. 2004. Methamphetamine labs. Presented at the annual conference of the North Carolina Family-Based, Services Association.
Obert, J.L., London, E.D., & Rawson, R.A. (2002). Incorporating brain research findings into standard treatment: An example using the Matrix Model. Journal of Substance Abuse Treatment, 23(2), 107-113.
Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS).
Office of Applied Studies, Substance Abuse and Mental Health Services Administration, National Survey of Alcohol and Drug Use During Pregnancy, 2002 and 2003.

- Brecht, M.-L., M. D. Anglin, et al. (2005). "Coerced Treatment for Methamphetamine Abuse: Differential Patient Characteristics and Outcomes." The American Journal of Drug and Alcohol Abuse 31(2): 337.
- Brecht, M.L.(2004) Women and Methamphetamine: Characteristics, Treatment Outcomes. Presentation to the Center
-         For Substance Abuse Treatment, State Systems Development Conference. August 13.
- Cohen, Judith, Ph.D. Presentation to NASADAD, June 2005.
- Colorado DEC. Retrieved from  _[www.colodec.org/decpapers/Documents/DEC%20Medical%20Protocol.pdf](http://www.colodec.org/decpapers/Documents/DEC%20Medical%20Protocol.pdf)_
- Crowell and Webber, 2004. Retrieved from _[www.drugfreeinfo.org/PDFs/strengthensupervision.pdf](http://www.drugfreeinfo.org/PDFs/strengthensupervision.pdf)_.
- Dixon, S.D., & Bejar, R. (1989). Echoencephalographic findings in neonates associated with maternal cocaine and methamphetamine use: Incidence and clinical correlates. *Journal of Pediatrics, 115*(5 Pt 1), 770-778.
- Ferguson, T. (2001). *Overview of medical toxicology and potential exposures to clandestine drug laboratories in California*. Paper presented to the Minnesota Department of Health.
- Lundahl, L.H., Keenan, P., Schuster, C.R., & Johanson, C.E. (2004, June). *Neurocognitive function in chronic high dose methamphetamine abusers following long term abstinence*. Poster session presented at the 66th Annual Scientific Meeting of the College on Problems of Drug Dependence, San Juan, Puerto Rico.
- Mason, A. P. 2004. *Methamphetamine labs*. Presented at the annual conference of the North Carolina Family-Based, Services Association.
- Obert, J.L., London, E.D., & Rawson, R.A. (2002). Incorporating brain research findings into standard treatment: An example using the Matrix Model. *Journal of Substance Abuse Treatment*, *23*(2), 107-113.
- Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS).
- Office of Applied Studies, Substance Abuse and Mental Health Services Administration, National Survey of Alcohol and Drug Use During Pregnancy, 2002 and 2003.

- References

- Oro, A.S., & Dixon, S.D. (1987). Perinatal cocaine and methamphetamine exposure: Maternal and neonatal correlates. *Journal of Pediatrics*, 571-578.
- Rawson, Richard, Ph.D., Presentation to SAMHSA, August 2005.
- Rawson, R., & Anglin, M.D. (1999, June). *Methamphetamine: New knowledge, new treatments*. Retrieved April 2004, from the UCLA Integrated Substance Abuse Programs Web site: http://www.uclaisap.org/slides/Index46/index.htm
- Simon, S. (1999). *Cognitive impairment in individuals currently using methamphetamine*. Retrieved April 2004, from the UCLA Integrated Substance Abuse Programs Web site: http://www.uclaisap.org/slides/Index46/sld034.htm
- Smith, L., Yonekura, M.L., Wallace, T., Berman, N., Kuo, J., & Berkowitz, C. (2003). Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. *Journal of Developmental and Behavioral Pediatrics, 24*(1):17-23.
- Shah, R.** **(2005, June). From NASADAD presentation
- Thompson, P.M., Hayashi, K.M., Simon, S.L., Geaga, J.A., Hong, M.S., Sui, Y., et al. (2004). Structural abnormalities in the brains of human subjects who use methamphetamine. *Journal of Neuroscience, 24*(26), 6028-6036.
- Vaughn, C. (2003). Get up to speed on methamphetamine use. *NCADI Reporter*. Retrieved from _[http://www.health.org/newsroom/rep/215.aspx](http://www.health.org/newsroom/rep/215.aspx)_
- Vega et al (1993), Profile of Alcohol and Drug Use During Pregnancy in California, 1992.
- Volkow, N.D., Chang, L, Wang, G.J., Fowler, J.S., Leonido-Yee, M., Franceschi, D., et al. (2001b). Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. *American Journal of Psychiatry, 158*, 377-382.
- Young, Nancy K., Ph.D. Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005.
- Zickler, P. (2000). Brain imaging studies show long-term damage from methamphetamine abuse. *NIDA Notes, 15*(3).

- References