# Presentation: 335301

## Intervention as Prevention: Working Effectively with Mothers Who Abuse Alcohol and Drugs During Pregnancy

**Clinical Director, Parent Child Assistance Program (PCAP)**
**University of Washington**
**Seattle, Washington**
** ****American Native Women's Health and Maternity Care Conference**
**August 15-17, 2007**
**Albuquerque, New Mexico**

**Intervention as Prevention: Working Effectively with Mothers Who Abuse Alcohol and Drugs During Pregnancy**

##  Workshop Objectives

**Strategies used by the  Parent-Child Assistance Program (PCAP) in working with high-risk women to prevent future alcohol and drug exposed births.**
**The importance of caring for the care-giver staff, networking and day-to-day support. **
**“****How to’s” in building a system which supports these values.  **

**Participants will learn about:**

## The Problem

** ****Possible effects of prenatal exposure on the ****	****child’s health**
** ****Likelihood of a compromised home ****	****environment**
** ****Likelihood that these mothers will have ****	****more exposed, affected children**

***These problems are costly to society and are completely preventable***

***Maternal alcohol and drug use ******	******	******	******	******puts children at risk because of:***

## WHEN CASE MANAGEMENT ISN’T ENOUGH

**An intensive, 3-year home visitation and case management intervention for high-risk **
**alcohol and/or drug abusing mothers **

***WHEN CASE MANAGEMENT ISN’T ENOUGH***

## Primary Goal:

**of Alcohol and Drug Exposed Children**

**Primary Goal:**

## PCAP Background

**1991-present**
**   ****WA State: King, Pierce, Yakima, Grant, Spokane, ****	****Cowlitz, Skagit Counties **
**   ****Replication sites: MN, NC, AK, TX, NV, LA, PA; **
**	****multiple sites with Health Canada First Nations ****	****Inuit Health Branch (FNIHB)**** **** **
**We thank our funders:**
**	****SAMHSA (CSAP)**
**	****WA State Dept. Social and Health Services **
**	****      ****(Division of Alcohol and Substance Abuse)**
**	****March of Dimes**
**	****Nesholm Family Foundation**
**	****Private Philanthropy**

## PCAP Enrollment Criteria

**  ****Used alcohol/drugs heavily during ****	****pregnancy**
**  ****Not effectively engaged with ****	****community resources**
**  ****Are currently pregnant, up to six ****	****months postpartum**

**-or-**
**Have delivered a child with a diagnosis of FAS/E**

## PCAP: A Two-Pronged Approach

**Community **
**Service **
**Providers**

**Clients & **
**Families**

**PCAP: A Two-Pronged Approach**

## Core Components of the Intervention

**PCAP is a 3-year home visitation model implemented by well-trained, supervised case managers.   **
**Caseload recommendation: 15-16 active client families.**
**Case managers:**

** ****Assess client’s strengths, needs.**
** ****Help clients identify goals and “baby” steps to meet ****	****goals  (every 4 months) using “The Difference Game”.**
** ****Develop a network among client’s service providers to ****	****facilitate effective treatment planning.**
** ****Link clients with appropriate community services *****and *****	*****assure clients receive services*****. **
** ****Provide advocacy for all family members as needed.**_** **_
** ****Clients are not asked to leave PCAP because of relapse ****	****or setbacks.**

## The Scope of Advocacy

**Community Providers**

**Juvenile **
**Justice**

**Probation**

**Alc/Drug**
**Tx**

**Mental Health**
**Tx**

**Health Care**

**Family**
**Planning**

**Job **
**Training**

**Schools**

**Bio Dad**

**Room-**
**mates**

**Friends**

**Partners**

**Neighbors**

**Extended**
**Family**

**Caretakers**

**Children**

**CPS**

**Siblings**

## The Formula for Preventing Alcohol/Drug Exposed Births

**•   ****Motivate women to stop drinking or ****	****using drugs before and during ****	****pregnancy**

**•   ****Help women who can’t stop drinking ****	****or using drugs to avoid becoming ****	****pregnant**

**– ****OR – **

## Results: Treatment & Abstinence

| 3-Year Outcomes | Original
N=60
(’91 -’95) | Seattle PCAP
N=76 
(’96 -’03) | Tacoma PCAP
N=80
(’96 -’03) |
| --- | --- | --- | --- |
| 
Follow up rate  

Inpatient or Outpatient Tx complete or in progress

Abstinent at exit for ≥ 6 mo
Abstinent at exit for ≥ 1 yr

Longest abstinence in PCAP ≥ 1 yr 
Longest abstinence in PCAP ≥ 2 yrs
 | 
92.3%

52% 

28%
17%

37%
13% |  
85% 

76%

43% 
34%

59%
22%  | 
 85%

73%

39%
33%

46%
24%
 |

_**American Journal of Drug and Alcohol Abuse, 2005**_

## Results: Family Planning

| 3-Year Outcomes | Original
N=60
(’91 -’95) | Seattle PCAP
N=76 
(’96 -’03) | Tacoma PCAP
N=80
(’96 -’03) |
| --- | --- | --- | --- |
| 
Family planning at intake
Family planning at exit
  	More reliable method

Subsequent birth, (% women)
  	Clean & sober throughout 
  	Entered treatment during 	 | 
3%
73%
43%

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

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

25%
40%
55%
 |

**Results:**** Family Planning**

_**American Journal of Drug and Alcohol Abuse, 2005**_

##  Results: Preventing Future Alcohol- Exposed Births

**At PCAP replication sites, 78 women were binge ****	****drinkers  (**_**>**_**5 drinks/occasion) during the index ****	****pregnancy.  **
**At PCAP exit, 51 (66%) were no longer at present ****	****risk of having another alcohol exposed ****	****pregnancy:**
**   ****•  ****24 (31%) using reliable contraception;**
**   •**  **18 (23%) abstinent from alcohol/drugs >= 6 months;**
**   •**    **9 (12%) both reliable contraceptive and abstinent.**

## Results: Preventing Future Alcohol- Exposed Births

**Without PCAP about 30% (or 23) of 78 drinking ****	****	****mothers would have had another highly ****	****	****	****exposed birth.**
**We reduced that by 66%, preventing about 15 ****	****	****alcohol-exposed births.**
**Incidence of FAS is estimated at 4.7% to 21% ****	****	****among heavy drinkers. **
**Therefore we estimate PCAP prevented at least one and up to 3 new cases of FAS.  **

## Results: Cost Savings

**The average lifetime cost for an individual with ****	****FAS is $1.5 million.**
**PCAP costs about $15,000 / client for 3 years ****	****(intervention, administration, evaluation).  **
**If we prevented just **_**one**_** new case of FAS, the ****	****estimated lifetime cost savings = cost of ****	****PCAP for 102 women.  **

## Lessons Learned: Strategies for Preventing Alcohol/Drug Exposed Births

**	****Alcohol/Drug Treatment**
**	****Family Planning**

## Lessons Learned:Alcohol & Drug Treatment

**	****Mandated treatment may be necessary**
**	****Seek women-only treatment setting**
**	****Seek treatment where children can stay or ****	****arrange for child visitation**
**	****Arrange for post-treatment, transitional ****	****housing**
**	****Introduce client to relevant support groups**

## Lessons Learned: Family Planning

** ****Does NOT mean never having ****	****another baby**
** ****DOES mean having more control ****	****over whether, and when, to have ****	****another child**

## Family Planning Strategies

***Education***

** ****Basic anatomy, how pregnancy occurs**
** ****How various family planning methods work**
** ****Possible contraindications**
** ****Consider lifestyle and health status**
** ****Consider cognitive and functional status**

## Family Planning Strategies

** ****Encourage clients to discuss, acknowledge ****	****previous experiences**
** ****Motivational Interviewing: Help client identify ****	****pros and cons of having another child; ****	****revisit this topic**
** ****Reestablish client goals every 4 months. How ****	****will having another child affect achieving ****	****goals?**

## Caring for the
 care-giver staff is critical. 

“How to’s” for building a system 
which supports these values...  

** ****care-giver staff is critical. **
**“****How to’s” for building a system **
**which supports these values...  **

##  Relational Theory  says

**A woman’s sense of connectedness to others ****	****is central to her growth, development, ****	****definition of self.**
**In response, our intervention is**
**Long term, positive interpersonal relationship ****	****with case manager and PCAP team.**

**Tip #1:   ****Develop a Theoretically-Based Model**** ****That Gives Staff Meaning to the Work They Do**

## Relational Theory

**Positive relationships within the intervention, treatment, and recovery setting are critical.**
**The quality of interpersonal relationships:**
** **
**	****• ****may determine whether or not a woman ****	****remains in an intervention**
**	****• ****may be more important to improvement than ****	****concrete services received**

## Case Manager 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**

## Theoretical Framework

***Stages of Change*****  theory says**
**Clients will be at different stages of readiness for change. A “cookbook” approach doesn’t make sense.**
**In response, our intervention is **
**Motivational Interviewing:**
**	****Acknowledge client’s perception of situation**
**	****Encourage her to explore + and – aspects**
**	****Promote self-efficacy: ****a client’s expectations about ****	****herself are influenced **_**most**_** powerfully by her own ****	****history of accomplishment**

## Slide 27

## Tip #2: Individual Supervision

**Supervisor meets individually with each case manager every other week to:****	**
** ****	****Review every case**
**	****Make recommendations**
**	****Listen for common issues/problems that ****	****should be addressed with the group in ****	****weekly staffing **
**	****Discuss how the focus can be re-directed to ****	****the Big Picture and client goals, and away ****	****from small crises the client can handle**

## Tip #3: Weekly Group Staffings

** ****Weekly 2-hour problem–solving sessions intended to ****	****leave staff in a positive frame of mind for challenges ****	****they face**
** ****During individual supervisions, supervisor listens for ****	****common problems that can be addressed in staffing **
** ****Maintain a balance: case managers staff clients,  **
**	****share info about services/providers, discuss project ****	****business, but also need to keeping meetings flexible ****	****and ****	****interesting**

## Tip #4: Develop Protocols

**As a team (*****including all front line staff)*****, identify the issue and brain-storm best practices for managing it**
**Develop a written protocol, and review it at annual “Refresher” trainings to avoid program “drift”**
**Revise protocols periodically as necessary, and as new ideas arise**
**Example:  PCAP Boundaries and Standards ****	****	****(a hallmark of our quality control)**

**Problems, questions, issues always arise. Take the time to thoughtfully develop standardized (but not iron-clad) protocols: **

## Tip #5: Team Support

** ****Annual statewide retreat focused on issues of concern ****	****to case managers:  work-session with invited trainer, ****	****time to share best practices, social time**
**  ****Opportunities for staff to present at conferences, ****	****meetings**
** “****Courtesy visits” when a client is in treatment in ****	****another county**
** ****Client transfers to other state programs sites**
** ****Quarterly meetings/potluck with supervisors, ****	****evaluator, director**
** ****Ongoing consultation and support among the ****	****supervisor team (enrollment decisions, personnel ****	****problems, service provider referrals)**

## Tip #6: Ongoing Training Opportunities

**In-service training (32 hours per year)**
** ****Annual 2-day “Refresher” work session on PCAP ****	****model and protocols**
** ****Periodic multi-site staff trainings on topics of interest ****	****(e.g. Motivational Interviewing)**
** ****Trainings conducted periodically by specialists at ****	****staff meeting or local service provider agencies**
**Ongoing outside training (up to 32 hours per year)**
** ****Training topics are determined by case manager’s ****	****needs and interests, and as recommended by ****	****clinical supervisor **

## Tip #7: Evaluation Feedback Loop

**Program Evaluator attends site staff meetings annually to:**
**Give case managers and the team updates on **
**	****	****- client characteristics**
**	****	****- specific client outcomes**
** ****Identify areas for improvement **
**	**** ****	****	****	****  ****	**
***Individualized feedback helps staff see their outcomes relative to others, and encourages them to learn improvement strategies from others***

## Ongoing Challenge: Maternal Alcohol Use During PregnancyIt’s not “just alcohol ”

## February 21, 2005U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy 

**Women who are pregnant or who may become pregnant should abstain from alcohol consumption in order to eliminate the chance of giving birth to a baby with any of the harmful effects of the Fetal Alcohol Spectrum Disorders (FASD).**

**This updates a 1981 Surgeon General's Advisory.**** **

## If I’m pregnant, can I ...

**...****have a beer?**
**“****The Centers for Disease Control says “no level of alcohol...has been determined safe,” but some doctors feel limited drinking – no more than a pint a day, suggests Dr. Gibb – after the first trimester is okay.”**

**- ****People Magazine, April 17, 2006, pp 102-107**