# Presentation: 144289

## Improving Outcomes for Families Affected by Substance Use Disorders: Policy and Practice Framework and Tools

- Nancy K. Young, Ph.D.
- Director, NCSACW

- Presented at
- Adolescents, Families, and Addiction: Family-Centered Approaches to Services
- April 20, 2006

## 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. 

## MISSION
To improve outcomes for families by promoting effective practice, organizational, and system changes at the local, state, and national levels by
Developing and implementing a comprehensive program of information gathering and dissemination
Providing technical assistance

- To improve outcomes for families by promoting effective practice, organizational, and system changes at the local, state, and national levels by
- Developing and implementing a comprehensive program of information gathering and dissemination
- Providing technical assistance

- www.ncsacw.samhsa.gov

**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.

## Consortium Approach
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)

- 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)

## Foundation of the Policy and Practice Framework and Tools

## Where We’ve Been

- 1960s and early 1970s
- Recognition and naming of Fetal Alcohol Syndrome
- Heroin epidemic
- Hughes Act: Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970

- Beginnings – 30 + Years

## Where We’ve Been

- Impact of crack cocaine in urban centers
- Chasnoff’s group begin to publish research on prenatal effects of cocaine
- Number of children in foster care escalates

- Early and Mid 1980s – Forefront of Media Attention and Beginning of Research Efforts

## Foster Care Population

**Number of Children in Foster Care on Last Day of Federal Fiscal Year**

**ASFA**

**Notes:**
nearly doubling from 1980 to the current caseloads of over one-half million. 
Much has been said about the co-occurrence of the crack cocaine epidemic and the escalation of children in out of home during the six year period between 1986 and 1992. Let’s look at those numbers for a moment.

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

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

## Where We’ve Been

- Mid to late 1990s – Practice Models

- 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

## Where We’ve Been

- Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy
- Young, Gardner & Dennis; Child Welfare League of America
- Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers
- General Accounting Office
- Healing the Whole Family: A Look at Family Care Programs
- Children’s Defense Fund

- Late 1990s

## Where We’ve Been

- No Safe Haven: Children of Substance-Abusing Parents
- Center on Addiction and Substance Abuse Columbia University
- Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection
- Department of Health and Human Services

- Late 1990s

## Identified Barriers
1. 	Differences in values and perceptions of primary client
2. 	Timing differences in service systems
3. 	Knowledge gaps
4.	Lack of tools for effective engagement in services
5. 	Intervention and prevention needs of children
6. 	Lack of effective communication
7. 	Data and information gaps
8. 	Categorical and rigid funding streams as well as treatment gaps

- 1. 	Differences in values and perceptions of primary client
- 2. 	Timing differences in service systems
- 3. 	Knowledge gaps
- 4.	Lack of tools for effective engagement in services
- 5. 	Intervention and prevention needs of children
- 6. 	Lack of effective communication
- 7. 	Data and information gaps
- 8. 	Categorical and rigid funding streams as well as treatment gaps

- Where We’ve Been

- Summary of the Five National Reports

## Identified Barriers
1. 	Differences in values and perceptions of primary client
2. 	Timing differences in service systems
3. 	Knowledge gaps
4. 	Lack of tools for effective engagement in services
5. 	Intervention and prevention needs of children
6.	Lack of effective communication
7. 	Data and information gaps
8. 	Categorical and rigid funding streams as well as treatment gaps

- Summary of the Five National Reports

- Identified Barriers
- 1. 	Differences in values and perceptions of primary client
- 2. 	Timing differences in service systems
- 3. 	Knowledge gaps
- 4. 	Lack of tools for effective engagement in services
- 5. 	Intervention and prevention needs of children
- 6.	Lack of effective communication
- 7. 	Data and information gaps
- 8. 	Categorical and rigid funding streams as well as treatment gaps

## Suggested Strategies
1.	Develop principles for working together
2.	Create on-going dialogues and efficient communication
3.	Develop cross-training opportunities
4.	Improve screening, assessment and monitoring practice and protocols
5.	Develop funding strategies to improve timely treatment access
6.	Expand prevention services to children
7.	Develop improved cross-system data collection

- Suggested Strategies
- 1.	Develop principles for working together
- 2.	Create on-going dialogues and efficient communication
- 3.	Develop cross-training opportunities
- 4.	Improve screening, assessment and monitoring practice and protocols
- 5.	Develop funding strategies to improve timely treatment access
- 6.	Expand prevention services to children
- 7.	Develop improved cross-system data collection

- Summary of the Five National Reports

## Suggested Strategies
1.	Develop principles for working together
2.	Create on-going dialogues and efficient communication
3.	Develop cross-training opportunities
4.	Improve screening, assessment and monitoring practice and protocols
5.	Develop funding strategies to improve timely treatment access
6.	Expand prevention services to children
7.	Develop improved cross-system data collection

- Suggested Strategies
- 1.	Develop principles for working together
- 2.	Create on-going dialogues and efficient communication
- 3.	Develop cross-training opportunities
- 4.	Improve screening, assessment and monitoring practice and protocols
- 5.	Develop funding strategies to improve timely treatment access
- 6.	Expand prevention services to children
- 7.	Develop improved cross-system data collection

- Summary of the Five National Reports

## Five National Goals Established
Building Collaborative Relationships
Assuring Timely Access to Comprehensive Substance Abuse Treatment Services
Improving our Ability to Engage and Retain Clients in Care and to Support Ongoing Recovery
Enhancing Children’s Services
Filling Information Gaps

- Building Collaborative Relationships
- Assuring Timely Access to Comprehensive Substance Abuse Treatment Services
- Improving our Ability to Engage and Retain Clients in Care and to Support Ongoing Recovery
- Enhancing Children’s Services
- Filling Information Gaps

- Leadership of the Federal Government

- Blending Perspectives and Building Common Ground (Report to Congress in response to ASFA)

## 1999 Stakeholders forum called for a central focal point for these efforts
2000-2001 Regional forums of state teams
2002 Funding of the National Center on Substance Abuse and Child Welfare

- 2000-2001 Regional forums of state teams
- 2002 Funding of the National Center on Substance Abuse and Child Welfare

- Leadership of the Federal Government

## Improvements and Revisions in CFF’s Comprehensive Framework and Policy Tools
10 Element Framework

- 10 Element Framework

- CFF and NCSACW Products

## Connecting AOD, CWS, Court Systems: 

- Training and Staff Development
- Budgeting and Program Sustainability
- Building Community Supports

**Connecting AOD, CWS, Court Systems: **
**Elements of System Linkages***

**From CSAT Technical Assistance Publication (TAP) 27: Navigating the Pathways *Revised March 2003**

- Underlying Values
- Screening and Assessment
- Client Engagement and Retention in Care
- AOD Services to Children

- Joint Accountability and Shared Outcomes

- Working with Related Agencies and Support Systems

## 1. Values and Common Principles

- Issues to Address
- Who is the client -- Parent, Child, Family?
- Can AOD users/abusers be effective parents?
- What is the goal -- Recovery, child safety, family preservation, economic self-sufficiency?

**Notes:**
Tell a story about how often we’ve heard, “but we have different clients.” Try not to yawn when we hear this over and over.
Then in one state the AOD director said, I really want our interventions to focus on the mother who has just lost custody. The ASFA clock has kicked in and we have to get interventions in place quickly. The CWS Director said, yes, that important. But, my highest risk case is the family in which one of my workers has investigated, knows something is going on in the family but has decided the risk is not there to remove the child. Once ASFA kicks in, those are my lowest risk cases. I need to figure out how to deal with those high risk cases in which children are still at home.
This was a whole new conversation about parent, child and family—and every community in the country needs to have that conversation to talk about priorities, families and how we look at the whole family as our client and how we put programs in place to work with the whole family

## 1. Values and Common Principles

- Common Strategies
- Identify and resolve differences that exist across system
- Ensure conversation happens at policy, supervisory and front-line levels
- Develop common principles for working together
**NCSACW Product**
- Collaborative Values Inventory

**Notes:**
Tell a story about how often we’ve heard, “but we have different clients.” Try not to yawn when we hear this over and over.
Then in one state the AOD director said, I really want our interventions to focus on the mother who has just lost custody. The ASFA clock has kicked in and we have to get interventions in place quickly. The CWS Director said, yes, that important. But, my highest risk case is the family in which one of my workers has investigated, knows something is going on in the family but has decided the risk is not there to remove the child. Once ASFA kicks in, those are my lowest risk cases. I need to figure out how to deal with those high risk cases in which children are still at home.
This was a whole new conversation about parent, child and family—and every community in the country needs to have that conversation to talk about priorities, families and how we look at the whole family as our client and how we put programs in place to work with the whole family

## 1. Values and Common Principles

- Massachusetts Family Recovery Collaborative Acccomplishments
- State level Memorandum of Understanding between agency partners and tribe
- Statement of Shared Values and Guiding Principles

**Notes:**
Tell a story about how often we’ve heard, “but we have different clients.” Try not to yawn when we hear this over and over.
Then in one state the AOD director said, I really want our interventions to focus on the mother who has just lost custody. The ASFA clock has kicked in and we have to get interventions in place quickly. The CWS Director said, yes, that important. But, my highest risk case is the family in which one of my workers has investigated, knows something is going on in the family but has decided the risk is not there to remove the child. Once ASFA kicks in, those are my lowest risk cases. I need to figure out how to deal with those high risk cases in which children are still at home.
This was a whole new conversation about parent, child and family—and every community in the country needs to have that conversation to talk about priorities, families and how we look at the whole family as our client and how we put programs in place to work with the whole family

## Issues to Address
Roles and responsibilities across systems
Communication paths across systems
Incentives for prioritization
Missing box problem
Welfare and child welfare agencies have far less information than they need on substance abuse among their clients
Alcohol and drug treatment agencies have far less information than they need about the children of their treatment clients

- Roles and responsibilities across systems
- Communication paths across systems
- Incentives for prioritization
- Missing box problem
- Welfare and child welfare agencies have far less information than they need on substance abuse among their clients
- Alcohol and drug treatment agencies have far less information than they need about the children of their treatment clients

- 2. Daily Practice -- Client Intake, Screening and Assessment

**Notes:**
Whose job is it to screen for substance use among child welfare families? How do hospitals screen for a substance exposed birth? How do they report it now? How will the State implement new CAPTA law regarding medical personnel reporting?
Whose job is it to screen for risks to children among parents entering the substance abuse treatment system? 
Do we ask? Do we record it in the case file? Do we record it in a data base? Do we share that information with the other system?
Monograph that is in draft SAFERR – recommendations for practice in the summary of the framework.

## 2. Daily Practice -- Client Intake, Screening and Assessment

- Common Strategies
- Clarify intake procedures and AOD/child safety screening protocols
- Decide on team, tool, method, roles and responsibilities to
- Provide AOD expertise to Child Welfare Workers in investigative/assessment phases
- Ensure parents seeking treatment receive needed supports for child safety

**Notes:**
Whose job is it to screen for substance use among child welfare families? How do hospitals screen for a substance exposed birth? How do they report it now? How will the State implement new CAPTA law regarding medical personnel reporting?
Whose job is it to screen for risks to children among parents entering the substance abuse treatment system? 
Do we ask? Do we record it in the case file? Do we record it in a data base? Do we share that information with the other system?
Monograph that is in draft SAFERR – recommendations for practice in the summary of the framework.

## 3. Daily Practice -- Client Engagement and Retention in Treatment

- Issues to Address
- Outreach and engagement strategies
- Addressing motivation to change
- Cross-system agreement on approaches to relapse
- Responding to clients’ progress in treatment

**Notes:**
One of the components that all of the sites that we looked at had in common was some sort of bridge between CWS and AOD agencies. 
Sometimes it was peer support—a mentor or as Illinois calls them and recovery coach; sometimes it is enhanced case management like in San Diego (SARMS). Sometimes it is AOD counselor trained in motivational interviewing that is stationed at the dependency court like in Sacramento County. 

Every community has to ask itself if giving a phone number or list of treatment agencies to a parent who has just lost custody of his or her is family centered, does it foster engagement, is it reasonable?

## 3. Daily Practice -- Client Engagement and Retention in Treatment

- Common Strategies
- Implement assessment and interventions based on readiness to change
- Develop mechanism to re-engage clients in care
- Ensure AOD treatment and CPS practice is responsive to clients’ individualized needs

**Notes:**
One of the components that all of the sites that we looked at had in common was some sort of bridge between CWS and AOD agencies. 
Sometimes it was peer support—a mentor or as Illinois calls them and recovery coach; sometimes it is enhanced case management like in San Diego (SARMS). Sometimes it is AOD counselor trained in motivational interviewing that is stationed at the dependency court like in Sacramento County. 

Every community has to ask itself if giving a phone number or list of treatment agencies to a parent who has just lost custody of his or her is family centered, does it foster engagement, is it reasonable?

## Client Intake, Screening, Assessment, Engagement and Retention in Treatment

- NCSACW Product
*Screening and Assessment for Family Engagement, Retention and Recovery (SAFERR): Guidance for States and Communities Serving Families with Substance Use Disorders in Child Welfare Services and Dependency Courts*
- Current practice and key factors and processes for child welfare, alcohol and drug services and dependency court systems
- Guidance on developing collaborative efforts to improve outcomes for families.

## Client Intake, Screening, Assessment, Engagement and Retention in Treatment

- Massachusetts Family Recovery Collaborative Accomplishments
- Draft Protocol on Screening, Assessment, and Communication
- Family Engagement Program Concept Paper and Proposal

## 4. Daily Practice -- Services to Children

- Issues to Address
- Prevention, early intervention, and treatment services for children in contact with CPS
- Independent Living Programs’ content on substance abuse

**Notes:**
Need to look developmentally at issues for children
Prenatal exposure and neurodevelopmental effects
Early attachment and bonding
School readiness
Special education services
Pre-adolescent prevention strategies
Transitions to teenage years
Supports and transitions in Independent Living Programs

## 4. Daily Practice -- Services to Children

- Common Strategies
- Develop partnerships to respond to potential neuro-developmental effects of prenatal substance exposure
- Provide prevention and intervention services to children and adolescents
- Provide youth with appropriate youth development intervention and activities
- Ensure that ILP teens receive appropriate information related to risks of substance abuse
- NCSACW Product
- Substance Exposed Infants Report
- SAFERR Appendix on children of substance abusers

**Notes:**
Need to look developmentally at issues for children
Prenatal exposure and neurodevelopmental effects
Early attachment and bonding
School readiness
Special education services
Pre-adolescent prevention strategies
Transitions to teenage years
Supports and transitions in Independent Living Programs

## 5. Training and Staff Development

- NCSACW Products
*The Child Welfare-Substance Abuse Connection: A Compendium of Training Curricula and Resources*
*Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers*
- On-line self-tutorials
- 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
- Substance Use Disorders, Mental Disorders and Co-Occurring Disorders Training Package

## 6. Information Sharing and Data Systems7. Joint Accountability and Shared Outcomes	■ SAFERR	■ Consortium Workgroup Data Inventory

- 8. Budgeting, Funding and Program Sustainability
- 	■ White Paper on Funding Comprehensive 	Services for Families with Substance Use 	Disorders in Child Welfare and Dependency 	Courts

- Other System Supportive Elements

## Primary Health Care
Domestic Violence
Trauma
Mental Health
Dental Health	

- Domestic Violence
- Trauma
- Mental Health
- Dental Health

- 10. Working with Related Agencies

- Transportation
- Child Care
- Medicaid
- Housing
- Economic Security
- Education for Mother and Children

- 9. Developing Community Supports

## Development of a Comprehensive Framework and Policy Tools
10 Element Framework

- 10 Element Framework

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

- NCSACW Products

## NCSACW Products

- A self-assessment by County (and/or State) alcohol and drug and child welfare service agencies
- Designed to elicit discussion among and within agencies about their readiness for collaborative work
- Scale Rating
- Disagree 			= 1
- Somewhat Agree 		= 2
- Agree 				= 3
- Not Sure/Don’t know	Not included in mean

## CCI SUMMARY SCORES: Pre-IDTA

## CCI SUMMARY SCORES: Post-IDTA

## Massachusetts – pre/post CCI

## Massachusetts Family Recovery Collaborative Accomplishments

- State level Memorandum of Understanding between agency partners and tribe
- Statement of Shared Values and Guiding Principles
- Draft Protocol on Screening, Assessment, and Communication
- Family Engagement Program Concept Paper and Proposal

**Notes:**
Products Developed:  State level Memorandum of Understanding between agency partners and tribe
Practice Elements Impacted:  Values and Principles of Collaborative Relationships

Products Developed:  Statement of Shared Values and Guiding Principles
Practice Elements Impacted:  Values and Principles of Collaborative Relationships

Products Developed:  Draft Protocol on Screening, Assessment, and Communication
Practice Elements Impacted:  Daily Practice: Screening, Assessment, Client Engagement and Retention in Care

Products Developed:  Family Engagement Program Concept Paper and Proposal
Practice Elements Impacted:   Daily Practice: Screening, Assessment, Client Engagement and Retention in Care