# Presentation: 502567

## Building FASD State Systems Fetal Alcohol Spectrum Disorders Center for Excellence 

***Promising Practices for FASD Prevention and Intervention***
- May 6, 2004

**Therese Grant, Ph.D.**
**granttm@u.washington.edu**
**University of Washington School of Medicine**
**Director, Washington State Parent-Child Assistance Program**

## WHEN CASE MANAGEMENT ISN’T ENOUGH

***Parent-Child Assistance Program *****(PCAP)**

**A 3-year home visitation **
**intervention program**
**for high risk mothers who abuse**
**alcohol and/or drugs during pregnancy**

## Client Picture

## Primary Goal

**To prevent future births **
**of alcohol and drug exposed children.**

***Primary Goal***

**Parent-Child Assistance Program**

## The Formula for Preventing Alcohol/Drug Exposed Births

**Motivate women to stop drinking or using drugs before and during pregnancy.**
**- OR -**
**Help women who can’t stop drinking or using drugs avoid becoming pregnant.**

## History of the Program

**1991-95      Federally funded demonstration: Seattle**
**1996-98      Philanthropist provides interim funding**
**1996-97      Governor funds replication in Tacoma**
**1997-98      Follow-up study, original cohort: Seattle**
**1997-05      WA State funding:  Seattle and Tacoma**
**1999-05      Expanded WA State funding:  ****	****	****Spokane, Yakima, Grant County**
**1998-04      Replication sites: ****	****	****	****	****Minnesota, N.Carolina, Alaska, Texas, Canada**

**Parent-Child Assistance Program**

## PCAP Theoretical Framework 

**     ****Relational Theory**
**       ****A woman’s sense of connectedness to ****	****others is central to her growth, ****	****development, definition of self**
**   ****Intervention**
**       ****Long term, positive interpersonal ****	****relationship with advocate**

## PCAP Advocate Characteristics

**• ****Have experienced some of the same ****	****types of adverse life circumstances as ****	****clients, but seldom to same degree**
**• ****Have subsequently achieved success in ****	****important ways**
**• ****Are positive role models and offer clients ****	****hope and motivation from a realistic ****	****perspective **

## Advocate Quote #1

*“**I've lived through the things they've been through, so I'm not afraid or intimidated.  I've lived with domestic violence.  For someone to tell a client in a domestic violence situation to just up and go, it’s not that easy.  There are lots of plans to think about.  I understand when someone says, 'I can't just leave right now.'  But I can help plan a strategy, because I've lived it.”** *
***	******	******	******	******— *****PCAP Advocate**

## PCAP Theoretical Framework

**Stages of Change**** **
**      ****Clients will be at different stages of readiness for change.  Motivation is a process for change that ****	****occurs within the context of interpersonal relationships.**
**Intervention**
**       ****Motivational Interviewing**
**	****•  ****acknowledge client’s perception of situation**
**	****•  ****encourage her to explore + and – aspects**

## PCAP Theoretical Framework

**  ****Harm Reduction**** **
**     ****Addiction and associated risks are on a continuum.  The goal is to reduce harmful consequences of the habit for mother and her child.**
**  ****Intervention**
**      ****Any steps toward decreased risk are steps in the right direction.**

## PCAP: A Two-Pronged Approach

**Advocate**

**Community Service Providers**

**Clients & **
**Families**

**Notes:**
Ratio 15:1, work with all members of family, client never kicked out
Regular case conferencing

## The Scope of Advocacy

**Community Providers**

**Juvenile **
**Justice**

**Probation**

**Alcohol/Drug**
**Tx**

**Mental Health**
**Tx**

**Health Care**

**Family**
**Planning**

**Job **
**Training**

**Schools**

**Bio**
** ****Mom**

**Bio**
**Dad**

**Siblings**

**Friends**

**Partners**

**Children**

**Neighbors**

**Extended**
**Family**

**Care-**
**takers**

**Notes:**
Mother identifies her own goals that we coordinate with program goals
Client-centered

## PCAP Outcomes Over Time

***PCAP has demonstrated***
***improved FASD prevention outcomes between original demonstration ******	******	******(1991-1995) and current replication programs******.***

***How do we account for this?***

***Good things happen when the State implements strong policy, and communities implement effective programs***

**Systems**** ****Working Together**

## Parent-Child Assistance Program Treatment & Abstinence Outcomes

| 3-Year PCAP Outcomes | Original CSAP
1991-1995
N=60  | Seattle PCAP
1996-2003
N=76 | Tacoma PCAP
1996-2003
N=80 |
| --- | --- | --- | --- |
| 
Follow up rate  

Inpatient or Outpatient Tx  	completed or in progress

Longest abstinence ≥ 1 yr
Longest abstinence ≥ 2 yrs

Abstinent at exit for ≥ 6 mo
Abstinent at exit for ≥ 1 yr
 | 
92%

52% 

37% 
13%

28%
17%

 |  
84% 

76%

59%
22%

43%
34%
 |  
85%

73%

46% 
24%

39%
33%

 |

## Systems Working Together

**•**   **DASA i****ncreased treatment beds for ****	****women (55 in 1991; 149 in 2004)**
**•**   **FAS Diagnostic and Prevention ****	****Network (1995 – 2004)**

**Systems**** ****Working Together**

**Notes:**
Lawmaker ed includes regular reports to State – strong eval component – invite leg.s to staff mtgs – successful clients present testimony at hearings

## Parent-Child Assistance ProgramFamily Planning Outcomes 

| 3-Year Outcomes | Original CSAP
1991-1995
N=60  | Seattle PCAP
1996-2003
N=76  | Tacoma PCAP
1996-2003
N=80 |
| --- | --- | --- | --- |
| 
Using birth control at intake
Using birth control at exit
    More reliable method*

Subsequent birth, (% women)
    Abstinent entire pregnancy
    Entered Tx during pregnancy
    Follow up tubal, IUD | 
3%
73%
43%

28%
18%
47%
- | 
13%
74%
49%

29%
32%
50%
25% | 
16%
71%
53%

25%
60%
40%
32%
 |

*** Tubal ligation, consistent DepoProvera, IUD, Norplant**

## Systems Working Together

**•**   **DSHS First Steps improved ****family ****	****planning ****	****education and access to ****	****services and supplies (1989 – 2004)****	**

**Systems**** ****Working Together**

**Notes:**
Lawmaker ed includes regular reports to State – strong eval component – invite leg.s to staff mtgs – successful clients present testimony at hearings

## Systems Working Together

**PCAP CONTINUES TO IMPLEMENT AN EFFECTIVE PROGRAM**
** ****Maintains high-quality program, trained staff**
** ****Evaluates program**
** ****Demonstrates consistent positive outcomes ****	****to sustain funding**
** ****Builds acceptance, recognition in community**
** ****Participates in legislative task forces**
** ****Educates community & legislature to solve ****	****problems**

**Notes:**
Lawmaker ed includes regular reports to State – strong eval component – invite leg.s to staff mtgs – successful clients present testimony at hearings

## Are mothers who lose custody of their children more likely to have a subsequent exposed pregnancy?

***"I'm going to keep having babies until they let me keep one."***

## Risk for Subsequent Alcohol/Drug Exposed Pregnancy (N = 174)

| Target Child Living with Mother Always*
 | 0.38  (0.16-0.87)
 | .02 |
| --- | --- | --- |

| Factor  | Adjusted Model  |  |
| --- | --- | --- |
|  | HR (95% CI)  | P  |

- ***Adjusted for age, race, education, parity, and mental health diagnosis**

- What are the policy implications?

**Notes:**
Adjusted point estimate indicates 60% less risk if the TC is living w/mom always

## Client Quote

**“*****Before PCAP I never thought about goals.  They showed me the right direction.  They showed me that I am responsible.  That no matter who I am or what I do, I am somebody.  It is never too late.”***		-- PCAP Client at Graduation