# Presentation: 231109

## Improving Outcomes for Families Affected by Substance Use Disorders

**Presented at 9****th**** Annual Conference of the **
**Association of Alcoholism and Substance Abuse **
**Providers of New York State**
**STRENGTHENING FAMILIES AND **
**EMPOWERING COMMUNITIES**
**January 31, 2006**

## National Center on Substance Abuse
and Child Welfare

- and Child Welfare

**www.ncsacw.samhsa.gov**

**Power Point at**
- _[www.cffutures.org](http://www.cffutures.org/)_
**C****hildren and ****F****amily ****Futures**

## Slide 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

- 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

- 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.

## Recent 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**
**Visit**
**www.ncsacw.samhsa.gov**** **

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

## Program of In-Depth Technical Assistance

**Fifteen months of in-depth work with a State Team to develop practice protocols and policies that improve outcomes for families**
**Round 1 – 2003/2004**
**	****	****Colorado   Florida   Michigan   Virginia**
**Round 2 – 2004/2006**
**	****	****Arkansas   Massachusetts   Minnesota****	**
**	****	****	****Squaxin Island Tribe**
**Round 3 – 2006/2007**
**	****	****New York****	****Texas**
**     ****Four Sites with a less intensive level of support**

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

## Program of In-Depth Technical Assistance

**Fifteen months of in-depth work with a State Team to develop practice protocols and policies that improve outcomes for families**
**Round 1 – 2003/2004**
**	****	****Colorado   Florida   Michigan   Virginia**
**Round 2 – 2004/2006**
**	****	****Arkansas   Massachusetts   Minnesota****	**
**	****	****	****Squaxin Island Tribe**
**Round 3 – 2006/2007**
**	****	****New York****	****Texas**
**     ****Four Sites with a less intensive level of support**

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

## Putting the Pieces Together for Children and Families: 
Second National Conference on Substance Abuse, Child Welfare and the Courts

January 30, 2007
 Pre-conference symposium on substance-exposed infants with Dr. Ira Chasnoff

January 31 to February 2, 2007
 National Conference

Disneyland Hotel, Anaheim California
 Sign up for information at  
    contactus@cffutures.org

**Second National Conference on Substance Abuse, Child Welfare and the Courts**
- January 30, 2007
-  Pre-conference symposium on substance-exposed infants with Dr. Ira Chasnoff
- January 31 to February 2, 2007
-  National Conference
- Disneyland Hotel, Anaheim California
-  Sign up for information at
-     **contactus@cffutures.org**

- ANNOUNCING

## Children of Parents with Substance Use Disorders

** **

**So how many are there?**

**Living with parent**

**Mother used while pregnant**

**Parent entered treatment**

## Children Living with One or More Substance-Abusing Parent

**500,000 NY Children Living with Parent **

**About 33,000 in Out-of-Home Care for Child Abuse/Neglect in 2003**

**Notes:**
I always start with this slide – it points out one of the fundamental problems for child welfare
This is from the Report to Congress – Blending Perspectives and Building Common Ground. It shows the variety of ways that “Children of Substance Abusers” can be define – parent used in past  year, etc.
The one I think is import – hit bar again and box comes up around the 8.3 million, that translates to 11% of the kids in our country. The one I think is important is this 8.3 million children that live with a parent who is dependent on alcohol or needs treatment for drugs. This translates to 11% of the kids in our country or 500,000 kids in NY. (NY 2003 Child population was 4,532,748 * 11% = 498,602 children living with a parent)
If 11% of kids, 3 out of every elementary school classroom are going home to a parent who is alcoholic or needs treatment for illicit drug abuse, how do child welfare handle this issue when that same family comes to their attention due to abuse or neglect..
What’s the right standard for when the child should be removed in the context of parental addiction? What’s the right standard for when a child can be returned home in the context of 11% of the children?
We might not like that so many of our children are living in these environments, but that is the environment that we are working in and we need to take that into account when we are devising policies and practices that work with these families.

## COSAs and Child Abuse/Neglect Victims

**In Millions**

**0         2          4         6          8         10**

## Parent Entered Treatment

## New York and U.S. Gender Split

## Parents Entering Publicly-Funded Substance Abuse Treatment

**Had a Child under age 18****	****	****     59%**
**Had a Child Removed by CPS****	****     22%**
**If a Child was Removed, Lost      **
**	****Parental Rights****	****	****	**** ****	****     10%**

- Based on CSAT TOPPS-II Project

## Estimated New York Parents Entering Publicly-Funded Treatment – 286,000

**Had a Child under age 18****	****	****168,700**
**Had a Child Removed by CPS****	****  40,490**
**If a Child was Removed, Lost      **
**	****Parental Rights****	****	****	**** ****	**** ~ 4,500**

- Based on CSAT TOPPS-II Project

## New York Data on Children Family History Variable

**Marital Status **􀂉 Married 􀂉 Never Married 􀂉 Living as Married 􀂉 Separated 􀂉 Divorced 􀂉 Widowed
**Child of Alcoholic/Substance Abuser **􀂉 No 􀂉 Both 􀂉 Child of Alcoholic(s) 􀂉 Child of Substance Abuser(s)
**No. of children** ___
- No. of children living with Client ___
- No. of Children living in Foster Care ___
- Case with Child Protective Services 􀂉 Yes 􀂉 No

**45% of Persons Admitted**

## Mother Used While Pregnant

- Last Statewide Study1992 in California

## Use During Pregnancy

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  |  |  |
| Alcohol Use |  |  |  |
| Binge Alcohol Use |  |  |  |

- SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data

**Notes:**
253,001 live births in NY in 2003
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)

## Use During Pregnancy

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  |  |  |
| Alcohol Use |  |  |  |
| Binge Alcohol Use |  |  |  |

- SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data

**Notes:**
253,001 live births in NY in 2003
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)

## Use During Pregnancy

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  |  |  |
| Alcohol Use |  |  |  |
| Binge Alcohol Use |  |  |  |

- SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data

- State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth

**Notes:**
253,001 live births in NY in 2003
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)

## Use During Pregnancy

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  |  |  |
| Alcohol Use |  |  |  |
| Binge Alcohol Use |  |  |  |

- SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003, applied to New York 2003 birth data

**Notes:**
253,001 live births in NY in 2003
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)

## Parent is alcohol dependent or need treatment:

- About 25,000 New York infants affected per year

- Mother uses while pregnant:

- About 500,000 New York children affected

**New York Children Affected**

- Parents in Treatment:

- About 168,000 New York Treatment Admissions
- Were parents of minor children

**Notes:**
253,001 live births in NY in 2003 = 25,300 at 10% or 22,770 at 9%

## How Big a Problem are SubstanceUse Disorders in CWS Caseloads?

- We don’t really have the numbers...

**Let’s look at the overall foster care **
**population over time...**

## Foster Care PopulationEnd of Each Federal Fiscal Year

- ASFA

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

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

## New York State Foster CareIn Care, Admissions and Discharges

- Source: New York State Monitoring and Analysis Profiles (2003)

**Notes:**
Substantiated and indicated

## New York Child Victims by Age Group 2003

- Source: Child Maltreatment 2003

## Children in Foster Care by Age Group 2003

- Source: New York MAPS (2003)

**Notes:**
Point-in-time number of children in foster care on 12/31/03

## Past Year Substance Use by Youth Age 12 to 17

- Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care

**Compared to African-American Youth, Caucasians were more likely to use alcohol (41.4% versus 29.8%) and illicit drugs (36.2% versus 26.7%)**

## Percent of Youth Ages 12 to 17 Needing Substance Abuse Treatment by Foster Care Status

- Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care

## How Big a Problem are SubstanceUse Disorders in CWS Caseloads?

- We don’t have good data...
- The “missing box” problem means data is not readily available in most states and communities
- Most practitioners agree, and federal government reported that at least 1/3 of referrals and 2/3 of removals involve families with a substance use disorder

## Estimates of AOD ProblemsAmong Parents in Child Welfare

- Research studies vary based on:
- Definition of substance abuse
- Population (rural versus urban)
- Sample (in-home versus out of home)

## Risks for Children

- Parent uses or abuses drugs and/or alcohol
- Parent is dependent on drugs and/or alcohol
- Special circumstances involving methamphetamine and manufacturing
- Parent “cooks” small quantities of meth
- Parent involved in super lab
- Parent involved in trafficking
- Mother uses while pregnant

## Parent uses or abuses drugs and/or alcohol

Parent is dependent on drugs and/or alcohol

Special circumstances involving methamphetamine and manufacturing
Parent “cooks” small quantities of meth
Parent involved in super lab

Parent involved in trafficking

Mother uses while pregnant

- Parent is dependent on drugs and/or alcohol
- Special circumstances involving methamphetamine and manufacturing
- Parent “cooks” small quantities of meth
- Parent involved in super lab
- Parent involved in trafficking
- Mother uses while pregnant

- Parent is dependent on drugs and/or alcohol
- Mother uses while pregnant

**Risks for Children**

**How does Child Welfare Assess for the Differences?**

## Substance Exposed Infants

## Where did they all go?

- Total births  				**253,000**
- 10% of total births  			  **25,300****	****	****	**
- Total child victims **	****	**
- 	under age 1 year  		    **6,300 ****	****   **
- Total age 0-2 years in OOHC = 	    **2,400**

***Where did they all go?***

- 2003 Estimated Number of Children Prenatally Exposed to Substances in New York

**25%**

## MOST GO HOME.

- 	80-95% are undetected and go home without assessment and needed services.

- Many doctors and hospitals do not test, or may have inconsistent implementation of state policies
- Tests detect only very recent use
- Inconsistent follow-up for woman identified as AOD using or at-risk, but with no positive test at birth
- CAPTA legislation raises issues of testing and reporting to CPS

**Notes:**
The answer is of course that...
These issues are now being raised with changes to the Child Abuse Prevention and Treatment Act (CAPTA) within the Keeping Families Safe Act of 2003.  These changes include a requirement that states have policies and procedures requiring health care providers to notify CPS of “infants born and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.”  States must also develop a “plan of safe care” for such infants.  The law does not require reporting of children prenatally exposed to legal substances such as alcohol and tobacco.  Nothing in the law, however, prevents states from requiring such reporting.
Whatever side of the debate you sit on regarding testing and reporting of substance exposed births, I would expect that we can agree on the need for a comprehensive response – whether the lead be taken by child welfare, public health or AOD services – because, even though these kids may go home and miss becoming part of the system at birth, we continue to find that these kids come back into one of several systems later.

## Child Abuse Prevention and Treatment Act (CAPTA) 2003 Amendments

- 2003 Keeping Families Safe Act Amendments
- Policies and procedures (including appropriate referrals to child protection service systems and for other appropriate services) to address the needs of **infants born and identified as affected by illegal substance abuse** or **withdrawal symptoms resulting from prenatal drug exposure**, including a requirement that health care providers involved in the delivery or care of such infants **notify the child protective services system of the occurrence of such condition in such infants**, except that such notification shall not be construed to (I) establish a definition under Federal law of what constitutes child abuse; or (II) require prosecution for any illegal action (section 106(b)(2)(A)(ii));
- The development of **a plan of safe care** for the infant born and identified as being affected by illegal substance abuse or withdrawal symptoms (section 106(b)(2)(A)(iii))

**Notes:**
CAPTA amendments put a spotlight on the identification and referral of SEIs

## Child Abuse Prevention and Treatment Act (CAPTA) 2003 Amendments

- 2003 Keeping Families Safe Act Amendments
- Policies and procedures (including appropriate referrals to child protection service systems and for other appropriate services) to address the needs of **infants born and identified as affected by illegal substance abuse** or **withdrawal symptoms resulting from prenatal drug exposure**, including a requirement that health care providers involved in the delivery or care of such infants **notify the child protective services system of the occurrence of such condition in such infants**, except that such notification shall not be construed to (I) establish a definition under Federal law of what constitutes child abuse; or (II) require prosecution for any illegal action (section 106(b)(2)(A)(ii));
- The development of **a plan of safe care** for the infant born and identified as being affected by illegal substance abuse or withdrawal symptoms (section 106(b)(2)(A)(iii))

**Notes:**
CAPTA amendments put a spotlight on the identification and referral of SEIs

## There is no absolute profile of developmental outcomes based on a child’s exposure to his or her parents’ substance use, abuse, or dependence.  

Other problems arising in parental behavior, competence, and disorders interact with substance use, abuse, and dependence to cause multiple co-occurring problems in the lives of these children. 

- Other problems arising in parental behavior, competence, and disorders interact with substance use, abuse, and dependence to cause multiple co-occurring problems in the lives of these children.

- The complexity of screening and assessment for these children is compounded by at least two realities:

- Screening and Assessment of Consequences for Children

**Notes:**
To understand the forces influencing the futures of children exposed to alcohol and drugs, it is necessary to assess many different factors that affect their lives. The consequences of alcohol and drug use are the products of a complex interchange of biological, psychological, and sociological events. 

## Five Points of Intervention for Policy and Practice

**Parent**

**Child**

- with Substance Exposed Infants

**Identify and respond to family’s needs**

**Initiate enhanced prenatal services**

**4. Ensure infant’s safety and respond to infant’s needs**

**2. Prenatal screening and assessment**

**1. Pre-pregnancy awareness of substance use effects**

**Respond to family’s needs**

**Notes:**
This model depicts the points in time that health and social service systems often come into contact with families affected by a substance use disorder. 
We normally think about substance exposed newborns at the time of birth but we would suggest that a policy and practice model needs to start way before the birth event and address the pre-pregnancy public health messages that women and their partners receive about substance use in the critical first trimester of pregnancy
Increasingly we find that efforts are working during pregnancy to ensure that expectant mothers receive the prenatal care they need and to ensure that they recognize the risks to their child from substance use. For those mothers identified as needed substance abuse services, a referral to enhanced prenatal care including substance abuse services is warranted.
At the birth event, and CAPTA reminds us, that we have some obligations to provide for safe care for the child and we would suggest to ensure that the parents have access to services when needed.
If we haven’t identified a substance exposed infant earlier in his/her development, we recognize that are multiple opportunities as children grow and develop to provide the kinds of prevention and intervention services that they may need to ameliorate their risks. And connecting children and parents together in this intervention model suggest the need for strong collaborative efforts to fully address this population.

## 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

**Notes:**
In Summarizing those reports, we found they typically mention several key barriers between the systems

Beliefs and values that workers come with
Competing priorities for innovations 
A very real treatment gap that means clients compete with each other for treatment space as do workers compete with each other to get their clients into too scarce slots
Information systems that can’t talk to each other and few formal systems in how workers should or could be communicating 
Staff knowledge and skills to work with these families
A very real communication gap about families who need services and how they are doing in care
Different mandates of what each system is funded to do

## Models of Improved Services

**Family Treatment Courts**

**Training and Curricula Development**

**Persons in Recovery act as Advocates for Parents**

**Multidisciplinary Teams for Joint Case Planning**

**Counselor Out-stationed at Child Welfare Office**

**Paired Counselor and Child Welfare Worker**

**Notes:**
** This work and efforts in other sites began to draw on the expertise of people in recovery to act as advocates for parents in the child welfare system. 
I have to tell you that in 1996, Laura Feig Radel who many of you know from the Office of the Assistant Secretary for Planning and Evaluation, and I sat in a meeting passing back and forth a piece of paper with a list of program models that we could name that were putting initiatives together to better address the child welfare and substance abuse issues. Probably not a very scientific method of classification but at that time, we named about 7 models and about 20 locations with programs up and running. 
For example, Delaware paired a substance abuse counselor with a child welfare worker; many communities, including the state of New Jersey established a system of outstationed substance abuse counselors in child welfare offices who acted as technical advisors to child welfare workers; 
Many communities also established multidisciplinary case planning efforts; sites began to draw on the recovery community for its expertise; 

there was much emphasis on developing training and curricula to train front-line practitioners and finally, family treatment courts emerged.
These innovators and leaders provided the lessons with two common themes in their programs: experimenting with staffing patterns and drawing on persons in recovery who provided some type of increased case management and recovery management for parents.

## More Advanced Models of Team Efforts

- Workers out-stationed in collaborative settings: at courts, at CWS agencies, at treatment agencies
- Increased recovery management and monitoring of recovery progress
- New methods and protocols on sharing information
- Increased judicial oversight and family drug treatment courts
- New priorities for treatment access for child welfare-involved families
- New responses to children’s needs

## Lessons and Challenges of Out-stationed Substance Abuse Counselors

_**Roles and Responsibilities**_
**Referral and Brokering**
**Clinical Consultation and Interpretation**
**Engaging Clients in Treatment**
**Cross-training**
**Creating Awareness**

## Lessons and Challenges of Out-stationed Substance Abuse Counselors

_**Environment and Context**_
**Who Is the Customer?**
**Specific Qualifications**
**Clear Policies, Protocols and Location**
**Clear Supervisory Relationships**
**Clear Functions for the Substance Abuse and Child Welfare Agencies and/or the Overall County**

## Family Drug Treatment Court Models 

- Integrated  (e.g., Santa Clara, Reno, Suffolk)
- Both dependency matters and recovery management conducted in the same court with the same judicial officer
- Dual Track (e.g., San Diego)
- Dependency matters and recovery management conducted in same court with same judicial officer during initial phase
- If parent is noncompliant with court orders, parent may be offered DDC participation and case may be transferred to a specialized judicial officer who increases monitoring of compliance and manages only the recovery aspects of the case

## Family Drug Treatment Court Models 

- Parallel (e.g., Sacramento)
- Dependency matters are heard on a regular family court docket
- Specialized court services offered before noncompliance occurs
- Compliance reviews and recovery management heard by a specialized court officer
- Cross-Court Team (e.g., Orange County, CA)
- Dependency and recovery matters are heard by same court
- Recovery management, child welfare services, legal representation assigned to a team
- Team works in six courts with separate judges/commissioners

## 
Emergence of Family Based Treatment...

- Emergence of Family Based Treatment...

- Models are not Not Yet Reformed Systems

## Women’s programming 1970s - 80s
Strategies still largely based on male models
Women and children 1990s
Increased recognition of specific needs for women – Trauma and Co-occurring disorders
Children’s intervention needs – Early 2000s
Significant therapeutic needs of children
Poor parenting skills and minimal attachment ability

- Strategies still largely based on male models
- Women and children 1990s
- Increased recognition of specific needs for women – Trauma and Co-occurring disorders
- Children’s intervention needs – Early 2000s
- Significant therapeutic needs of children
- Poor parenting skills and minimal attachment ability

- Emergence of Family Based Treatment

## Moving Toward Family Based Treatment

- Challenges
- Defining who is the family member
- How many and ages of children in programs
- Logistics, milieu and clinical reasons
- Incorporating fathers in treatment milieu
- Preventing further trauma of family divisions and separations

## Continuum of Family Based Treatment

_**Level One**_
- Serve women
- Family relationships framework is built into service delivery

## Continuum of Family Based Treatment

- Serve women and children
- Child care – often through co-op babysitting
- Treatment plan includes parenting and family relationships

## Continuum of Family Based Treatment

- Serve women and children
- Therapeutic needs of children are recognized
- Parenting and family relationships are part of treatment plan
- For families in child welfare services, dual role of supporting recovery and ensuring health and safety of children

## Continuum of Family Based Treatment

- Serve women and children
- Therapeutic needs of children are recognized and they have own treatment/therapeutic goals
- Fathers and/or significant others receive services in support of the woman’s recovery

## Continuum of Family Based Treatment

- Serve women, children and family members they define as their family
- All members of family unit have individualize treatment plans
- Focus is on family members and the family system as a whole
- Community supports including domestic violence, employment and re-entry services are addressed

## Comprehensive Family Based ServicesCharacteristics and Principles

- Safety comes first
- For each family member
- Comprehensive
- Clinical treatment, clinical supports and community supports
- Family members are defined by the participant
- Based on unique needs and resources of individual families
- Treatment is dynamic
- Not everyone comes together for pre-determined length of treatment episode

## Comprehensive Family Based ServicesCharacteristics and Principles

- Conflict is inevitable but resolvable
- Substance use disorders are viewed as chronic, but treatable
- Treatment content acknowledges and focuses on the importance of attachment and relationships to others while helping family to function as a whole
- Services are gender responsive and specific
- Services are culturally competent

## Comprehensive Family Based ServicesCharacteristics and Principles

- Requires an array of staff professionals in an environment of mutual respect and shared training
- Treatment supports creation of healthy family systems with appropriate roles and good communication
- REQUIRES CROSS-SYSTEM COLLABORATIVE RELATIONSHIPS

## Navigating the Pathways 
TAP 27 published by CSAT

Established:

	A framework for defining elements of 	collaboration 

	Methods to assess effectiveness of 	collaborative work

- TAP 27 published by CSAT
- Established:
- 	A framework for defining elements of 	collaboration
- 	Methods to assess effectiveness of 	collaborative work

## To define linkage points across systems
To describe the components of the initiative
To assess the progress in implementation
To assist sites in measuring their implementation 

- To describe the components of the initiative
- To assess the progress in implementation
- To assist sites in measuring their implementation

- Framework and Policy Tools for Systems Change

## Framework and Policy Tools for Systems Change

- Collaborative Values Inventory
- Collaborative Capacity Instrument
- Matrix of Progress in Linkages
- Screening and Assessment for Family Engagement, Retention and Recovery  -- SAFERR

**Notes:**
** And so today, part of our achievement is a set of policy tools to assist states and communities in improving the linkages across all these agencies. Using a collaborative values inventory and a tool for assessing collaborative capacity among agencies, several dozen states and counties have taken the lead in using these tools to prioritize and monitor real change. 
These tools are on our website and are available for your use with electronic data collection. We have worked with four states now in our program of in-depth technical assistance on these system linkages as well as introduced our work that is underway in providing guidance on Screening and Assessment for Family Engagement, Retention and Recovery.

## Underlying values

- Joint accountability   and shared outcome
- Information systems
- Training and staff development
- Budgeting and program sustainability

- Elements of System Linkages

- Daily practice  screening and assessment
- Daily practice  client engagement and retention in care
- Daily practice  AOD services to children

- Working with related agencies
- Building community supports

**Visit   **_[www.ncsacw.samhsa.gov](http://www.ncsacw.samhsa.gov/)__    _
**for Examples from States to Implement these Elements**

## Elements of System Linkages

- Underlying Values
- Colorado values statements
- Practitioners from all systems should adopt a “screen out stance” with regard to substance use disorders
- The team is more critical than the tool in determining the relationship between substance use and child safety or risk (but the team does need the tools)
- During the assessment process, children’s needs should be identified and addressed
- Sharing information appropriately is desirable, helpful, and feasible
- Actions should have consequences that are fair, timely, and appropriate to the action
- Consequences should apply to families and to staff; consequences should not be used solely as punishments

## Elements of System Linkages

- Daily Practice – Screening and assessment
- Studies conducted on brief screens of six or less items suggest that there are a limited number of common constructs
- An effective screen of substance use disorders includes questions about:
- Unintended use
- Desire to restrict use
- Consequences of use
- Concern about consequences of use

## 
In the past year, have you ever drank or used drugs more than you meant to?
Have you ever neglected some of your usual responsibilities because of using alcohol or drugs?
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Has anyone objected to your drinking or drug use?
Have you ever found yourself preoccupied with wanting to use alcohol or drugs?
Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger, or boredom? 

- In the past year, have you ever drank or **used** drugs more than you meant to?
- Have you ever **neglected** some of your usual responsibilities because of using alcohol or drugs?
- Have you felt you wanted or needed to **cut down** on your drinking or drug use in the last year?
- Has anyone **objected** to your drinking or drug use?
- Have you ever found yourself **preoccupied** with wanting to use alcohol or drugs?
- Have you ever used alcohol or drugs to relieve **emotional** discomfort, such as sadness, anger, or boredom?

- Elements of System Linkages

- Daily Practice – Screening and assessment
- Use of UNCOPE in Oregon and Washington

## Elements of System Linkages

- Daily Practice – Client engagement and retention in care
- Florida protocols -- NYC protocols
- Recovery management approaches
- STARS
- SARMS

## Elements of System Linkages

- Daily Practice – Services to children
- Screening project for FASD among the children of the Santa Clara County Family Drug Treatment Court (California)
- Use of *Celebrating Families!* curriculum to educate families about the impact of substance dependence on families
- Four groups – adolescents, pre-adolescents, children and parents – meet separately, receive the same information and meet together

## Elements of System Linkages

- Joint Accountability, Shared Outcomes and Information Systems
- Michigan revised SACWIS to prioritize families with substance use disorders
- CFSR and NOMS processes

## The Voice of a Child

**Nothing But Silence**
**By Ashley G.**
**Age 12**
**January 2005**

## People all around me
Calling out my name
But no I cannot hear them
For my heart is filled with shame
Nothing but silence

But only till the break of dawn
Will I be feeling sad
For wandering out on the streets
Are my birth mom and dad

Why’d she do this to her and me
With this we’ll have to cope
But while she’s clean you never know
There still could be hope

But in the perfect world I know
There’s no harmful stuff
Now I’ve come to realize
It’s just a bunch of bluff

Nothing but silence

- Calling out my name
- But no I cannot hear them
- For my heart is filled with shame
- Nothing but silence
- But only till the break of dawn
- Will I be feeling sad
- For wandering out on the streets
- Are my birth mom and dad
- Why’d she do this to her and me
- With this we’ll have to cope
- But while she’s clean you never know
- There still could be hope
- But in the perfect world I know
- There’s no harmful stuff
- Now I’ve come to realize
- It’s just a bunch of bluff
- Nothing but silence

- Sitting by the widow sill
- A tear rolls down my cheek
- Although it hurts I can’t express
- My heart is just too weak
- Nothing but ache
- It’s funny what one pill can do
- To a mother or a kid
- And now I know that for a fact
- I won’t do what she did
- Nothing but ache
- Now I live a better life
- And drugs...I wouldn’t dare
- Away from all the harmful things
- With a family who cares
- Nothing but love
- I know it hurts, it sure hurt me
- That’s why I’ll remain drug free
- Nothing... but hope

- Nothing But Silence