# Presentation: 839153

## Data Issues Across Systems and Filling Information Gaps

- Presented by
- Will Hornsby, MSW		Sharon Boles, Ph.D.
- Children’s Bureau 		National Center on Substance
- ACYF				Abuse and Child Welfare

- Methamphetamine: The Child Welfare Impact and Response
- May 9, 2006

## Child and Family Services Review – CFSR

- Assesses State performance related to child welfare outcomes and systemic factors.  Assessment is based on:
- Statewide assessment
- State child welfare data
- Case record review and interviews
- Interviews with stakeholders

## CFSR - Review Concepts

- Outcomes of services provided to children and families served
- Safety
- Permanency
- Child and family well-being

## CFSR - Review Concepts – cont.

- Systemic Factors
- Training
- Quality Assurance
- Foster and adoptive homes
- Case review
- Statewide Information System
- Agency responsiveness
- Service array

## Reviews completed for all States

- No State met all outcomes assessed
- Substance Use Disorders (SUDs) can impact all outcome areas

**Child and Family Services Review – CFSR**

## Program Improvement Plans - PIPs 

- Each State creates a plan to address the areas needing improvement identified in the CFSRs
- Plans are negotiated with and approved by the Children’s Bureau
- Plans are monitored
- All States have an approved PIP

## Child and Family Service Plan - CFSP

**CFSP -** A required five-year comprehensive plan outlining programs and initiatives the State will follow in administering programs and services to promote the safety, permanency and well-being of children and families
**Annual Progress and Services Report (APSR) -** A yearly report which discusses progress made by the States in accomplishing the goals and objectives cited in the State's CFSP

## 	Role of Substance Use Disorders and Methamphetamine

## Sources of Information

- Child and Family Services Reviews (CFSR) related documents
- Statewide Assessment
- Final Report
- Program Improvement Plan (PIP)
- Child and Family Services Plan related documents
- CFSP
- APSR

## Sources of Information – cont.

- It should be noted that the CFSR process does not systematically review for methamphetamine-related issues

## Role of Substance Use Disorders and Methamphetamine

- Most frequently cited primary reasons for case opening
- Neglect (33.1%)
- Physical Abuse (15.6%)
- Substance Abuse by Parents (11.8%)
- 43 PIPs mention substance abuse issues
- Increasing awareness of the impact of methamphetamine

## Methamphetamine specifically mentioned:
7 Statewide Assessments
5 CFSR Final Reports
2 CFSR PIPs
9 CFSPs
22 APSRs

- 7 Statewide Assessments
- 5 CFSR Final Reports
- 2 CFSR PIPs
- 9 CFSPs
- 22 APSRs

**Role of Substance Use Disorders and Methamphetamine**

## Methamphetamine mentioned in the following ways:
9 States mentioned methamphetamine in the Annual Progress and Services Report, but it is not mentioned in any other documents 
7 States mentioned methamphetamine in the Statewide Assessment and/or included in the CFSR Final Report, but not mentioned in their PIP or CFSP

- 9 States mentioned methamphetamine in the Annual Progress and Services Report, but it is not mentioned in any other documents
- 7 States mentioned methamphetamine in the Statewide Assessment and/or included in the CFSR Final Report, but not mentioned in their PIP or CFSP

**Role of Substance Use Disorders and Methamphetamine**

## Gaps in Service
Substance abuse services were identified as an important gap in services
Lack of substance abuse services contrasted with more readily available services, such as parenting classes and family counseling
Rural settings have unique concerns with treatment resources and transportation

- Substance abuse services were identified as an important gap in services
- Lack of substance abuse services contrasted with more readily available services, such as parenting classes and family counseling
- Rural settings have unique concerns with treatment resources and transportation

**      ****Issues in CFSR Process**

## Assessment and Follow-up Issues
References to assessments by child welfare staff not addressing substance abuse as an underlying issue and risk assessment tools not adequate to identify families’ Substance Use Disorders
Waiting lists create barriers to timely access to treatment
Lack of follow through when referrals are made

- References to assessments by child welfare staff not addressing substance abuse as an underlying issue and risk assessment tools not adequate to identify families’ Substance Use Disorders
- Waiting lists create barriers to timely access to treatment
- Lack of follow through when referrals are made

**       ****Issues in CFSR Process**

## Entry and re-entry into foster care
A Statewide Assessment identified methamphetamine use and parents involved in meth labs as contributing to increases in substantiated reports and first-time foster care entries
Identified reasons by stakeholders for re-entry included: 
Parents relapsing due to drug and alcohol use, including methamphetamine
Lack of post-reunification supports, particularly in cases where relapse may be an issue

- A Statewide Assessment identified methamphetamine use and parents involved in meth labs as contributing to increases in substantiated reports and first-time foster care entries
- Identified reasons by stakeholders for re-entry included:
- Parents relapsing due to drug and alcohol use, including methamphetamine
- Lack of post-reunification supports, particularly in cases where relapse may be an issue

**       ****Issues in CFSR Process**

## Moving to Permanency
Stakeholders identified issue of competing timelines for treatment completion, recovery and permanency per Adoption and Safe Families Act (ASFA) guidelines 
Stakeholders in one state report that parents struggling with methamphetamine may face serious challenges in working towards reunification, compounded by lack of treatment services and post-treatment support services
Stakeholders identified lack of access to treatment as cause for  failing to make “reasonable efforts”

- Stakeholders identified issue of competing timelines for treatment completion, recovery and permanency per Adoption and Safe Families Act (ASFA) guidelines
- Stakeholders in one state report that parents struggling with methamphetamine may face serious challenges in working towards reunification, compounded by lack of treatment services and post-treatment support services
- Stakeholders identified lack of access to treatment as cause for  failing to make “reasonable efforts”

**       ****Issues in CFSR Process**

**Notes:**
Permanency goal of adoption being established before parents have sufficient opportunity to work toward reunification, particularly when parents are struggling with methamphetamine addiction and there are insufficient treatment services or post-treatment supportive services.

## Other Issues
Example of Substance Abuse Workers accompanying Child Welfare Workers to home
Stakeholders in one state identified specialized training for caregivers related to methamphetamine as a need
PIP strategies regarding training on substance use disorders and service system for child welfare workers 

- Example of Substance Abuse Workers accompanying Child Welfare Workers to home
- Stakeholders in one state identified specialized training for caregivers related to methamphetamine as a need
- PIP strategies regarding training on substance use disorders and service system for child welfare workers

**       ****Issues in CFSR Process**

## Improving the data collection around cases involving methamphetamine to determine the needed resources and responses
Need for wider implementation of medical protocols for children who may have been exposed to toxic chemicals
Need to identify types of resources available to families with an infant prenatally exposed to methamphetamine and understand which interventions are successful

- Need for wider implementation of medical protocols for children who may have been exposed to toxic chemicals
- Need to identify types of resources available to families with an infant prenatally exposed to methamphetamine and understand which interventions are successful

**             ****Issues in CFSPs**

## Developed specialized training on methamphetamine
Some focused on children exposed to toxic chemicals from meth labs and implementation of Drug Endangered Children (DEC) programs
Expansion of the use of Multi-Disciplinary Teams

- Some focused on children exposed to toxic chemicals from meth labs and implementation of Drug Endangered Children (DEC) programs
- Expansion of the use of Multi-Disciplinary Teams

**           ****Strategies in CFSPs**

## Addressing Substance Use Disorders and Methamphetamine

**Identified strengths and opportunities **
- PIP strategies addressing partnerships with substance abuse treatment agencies and other public health providers
- Formalizing relationships with Memoranda of Understanding
- PIP strategies creating substance use disorder and/or methamphetamine specialists
- Family drug courts seen as a strength in some states as a tool that ensures access to treatment and closer monitoring of clients

**Sacramento County****Dependency Drug Court:**
**Overview and Findings**

## Program Context

- Sacramento County population: 1.5 million
- In 2004, there were approximately 7,000 substantiated child abuse/neglect referrals, in Sacramento1.
- Approximately 60% of child welfare cases in Sacramento involve families affected by substance use

- 1. Needell, B., Webster, D., Armijo, M., Lee, S., Cuccaro-Alamin, S., Shaw, T., Dawson, W., Piccus, W., Magruder, J., Exel, M., Conley, A., Smith, J., Dunn, A., Frerer, K., Putnam Hornstein, E., & Kaczorowski, M.R., (2006). *Child Welfare Services Reports for California*. Retrieved May 1, 2006, from University of California at Berkeley Center for Social Services Research website. URL: <http://cssr.berkeley.edu/CWSCMSreports/>

**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 Dependency Drug Court

- 18.5% reunification rate
- Parents unable to access AOD treatment
- Social workers, attorneys, courts often uninformed on parent progress
- Drug testing not uniform and results often delayed

## Five Components of Reform

	1.		Comprehensive cross-system joint training
	2.		Substance Abuse Treatment System of Care
	3.		Early Intervention Specialists
	4.		Recovery Management Specialists (STARS)
	5.		Dependency Drug Court

Reforms have been implemented over the past eleven years

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

**Sacramento County’s Comprehensive Reform**

## Five Components of Sacramento County’s Comprehensive Reform 

- 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

**1.  Comprehensive cross-system joint training**

## 2.  Substance abuse treatment system of care

Child welfare clients have priority access to treatment
Immediate access to substance abuse services

Group services expansion and implementation of pre-treatment groups

- Child welfare clients have priority access to treatment
- 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
Non-adversarial approach
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
- Non-adversarial approach
- 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 **

## Sacramento County Dependency Drug Court Model

## Participant Groups

**Comparison -  **Selected from all cases with AOD in petition that entered CPS Division between February and May 2001, prior to EIS and STARS implementation and met DDC criteria
**Dependency Drug Court Treatment Group** – “Court Ordered” parents who entered the dependency system and were court-ordered to receive DDC supervision – 4 cohorts
**Year 1 **-**  **Oct 2001 - Sep 2002 – 324 Parents, 432 Children
**Year 2 **-**  **Oct 2002 - Sep 2003 – 249 Parents, 429 Children
**Year 3 **-**  **Oct 2003 - Sep 2004 – 274 Parents, 485 Children
**Year 4 **-**  **Oct 2004 - Sep 2005 – 444 Parents, 751 Children

## Parents and Children in the Evaluation

**24**
**Mos**

**12**
**Mos**

**24**
**Mos**

**24**
**Mos**

## Child Demographic Characteristics

- 2270 children:  173 comparison, 2097 DDC
- Overall, 52% were girls and 48% were boys
- 48.2% Caucasian
- 28.2% African American
- 19.4% Hispanic
- 2.3% Asian Pacific Islander
- 1.9 % American Indian/Alaskan
- There were no cohort differences in terms of gender or race/ethnicity of the children

**Notes:**
The Year 3 child demographic data may change slightly when the new cohort is confirmed.

## Parent Demographic Characteristics

- 1402 participants: 111 comparison, 1291 DDC
- Overall, 70.0% of the participants were women, approximately 32 years of age
- 54.2% Caucasian
- 20.4% African American
- 17.2% Hispanic
- 3.4% American Indian
- 2.5% Asian
- 2.2% “other”
- There were no cohort differences in terms of gender or race/ethnicity

## Parent Baseline Characteristics

- 83.5% were unemployed,
- 46.4% had less than a high school education
- 17.0% were pregnant at treatment admission
- 31.9% reported a disability impairment
- 30.7% reported being diagnosed with chronic mental illness
- 45.4% were homeless at treatment admission
- There were no cohort differences in any of these variables
- Significant cohort differences were found in terms of those with a primary heroin problem

## Primary Drug Problem

***p<.05**

## Primary Drug Problem by Gender

***p<.05; **p<.01**

## Baseline Characteristics with Significant Gender Differences

****p<.01; ***p<.001**

## Treatment Admission Rates***

*****p<.001**

## Treatment Discharge Status by Primary Drug Problem***

*****p<.001**

## 12-Month Child Placement Outcomes

***p<.05; ***p<.001**

## 12-Month Child Placement Outcomes by Parent Primary Drug Problem

**12-Month Child Placement Outcomes ****by Parent Primary Drug Problem**

**   *****p<.05**
*****p=.000**

## 24-Month Child Placement Outcomes***

***p<.05; ***p<.001**

## 24-Month Child Placement Outcomes by Parent Primary Drug Problem

***p<.05**

## Total Time in Out of Home Care

## Time in Out of Home Care by Parent’s Primary Drug Problem

## Recidivism Rates

## 24-Month Cost Savings Due to Increased Reunification Rates

- Takes into account the reunification rates, time of out-of-home care, time to reunification, and cost per month
- 27.2% - Reunification rate for comparison group children
- 42.0% - Reunification rate for court-ordered DDC group children
- 128 Additional DDC children reunified
- 33.1 – Average months in out-of-home care for comparison group children
- 9.4  - Average months to reunification for court-ordered DDC children
- 23.7 month differential
**$5,823,208 Estimated Savings in Out-of-Home care costs**

**Notes:**
This calculation is similar to the third, only using the 18 month figures.