# Presentation: 144292

## Improving Outcomes for Families Affected by Substance Use Disorders

**Nancy K. Young, Ph.D., Director**
**4940 Irvine Boulevard, Suite 202**
**Irvine, CA  92620  714.505.3525**
**www.ncsacw.samhsa.gov**

**Betty Ford Conference**
**Trends and Perspectives in Women’s Addiction**
**April 13, 2004**

**Notes:**
Thank you for that nice introduction. I’m very happy to have the honor of addressing this audience today. 

## Topics 	

- NCSACW
- Some Numbers
- Some History
- Policy Framework and Tools
- Models

## 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**

**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.

## PRODUCTS:

- On-Line Training
- Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals – Now Available
- Understanding Addiction and Recovery: A Guide for Child Welfare Workers – Fall 2004
- A Guide for Judges and Dependency Court Staff – Summer 2005

## PRODUCTS:

- Program of In-Depth Technical Assistance
- Round 1 – Summer 2003 to Fall 2004
- Colorado, Florida, Michigan, Virginia
- Assistance to Develop and Implementation State’s Plan to Better Serve this Population of Families
- Round 2 – Solicitation in Fall 2004
- Seven States Offered Program, 3 States and 1 Tribe will be selected

## PRODUCTS:

- Materials
- Compendium of Training Curricula
- Understanding Substance Abuse: A Guide for Child Welfare Practitioners
- Screening and Assessment for Family Engagement, Retention and Recovery (SAFERR) – Spring 2005

## Some Numbers

**Notes:**
** it’s important to be clear about where we have come from to learn the lessons of others and to honor what has been accomplished.

## Children Living With One or More Substance Abusing Parent

**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. 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.
#s—NY State has 4.69 million children 0-17, 8.3% of them is 389,000

## California’s Children

## Foster Care Population

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

**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 Meth in Past Year

- *All persons age 12 and over

**Notes:**
** This is the same slide of the foster care population 
** with the number of new crack users overlaid by year. While we understand there are many explanations for the increase in the number of children in care, there does seem to be an interesting pattern of persons who initiated crack use and the increasing foster care population. 
** If we look at another drug epidemic that is currently influencing child welfare systems, particularly in the west and Midwest, this blue line represents the number of new methamphetamine users over the past decade. 

## Some History

**2004**

- Looking Back

**Notes:**
** it’s important to be clear about where we have come from to learn the lessons of others and to honor what has been accomplished.

## Timelines

- 1968 – Report of alcoholic mothers with babies with a distinctive, unusual appearance in France
- 1973 – Fetal Alcohol Syndrome named by a team of researchers in Seattle
- Mid 1970s
- Estimate of the number of children of heroin addicts and children of alcoholics
- Fanshel reports substance abuse is common among families in child welfare

**Beginnings**

**Notes:**
** This national effort clearly did not begin with the founding of the National Center on Substance Abuse and Child Welfare, or the five national reports that were published between 1997-1999, or even the landmark work done by the Child Welfare League in their publication, Children at the Front or by the Department of Health and Human Services’ 1999 Report to Congress, or others in the 1990’s. 
The timelines for a critical segment of our work today flow all the way back to the naming of fetal alcohol syndrome in 1973, based on work by a team of researchers in Seattle and earlier work in the late 50’s and 60’s in France. This work focused on the effects of a constellation of factors in children who had been prenatally exposed to alcohol.[i] 
In the mid 1970s then, in the aftermath of the heroin epidemic of the late 60s, we see the first estimates of the number of children affected by parental heroin addiction and those affected by alcoholism. 
In 1975, the first article on the topic in child welfare literature appears and stated that substance abuse is common among families in child welfare.

## Timelines

- Impact of crack cocaine in urban centers
- Chasnoff’s group begin to publish research on prenatal effects of cocaine
- 1983 National Institute on Drug Abuse (NIDA) College on Problems of Drug Dependence conference – First Poster Session on Children Prenatally-Exposed to Cocaine

**Early and Mid 1980s**

**Notes:**
** We move on to the devastating impact of crack cocaine in urban centers after the middle class and entertainment culture spotlighted the use of powder cocaine.
In the early and mid 80s we see the emergence of significant research efforts to better understand the effects of prenatal cocaine exposure on children. At the 1983 College on Problems in Drug Dependence Dr. Chasnoff presented the first poster session that included data on infants who had been prenatally exposed to cocaine. 

## Timelines

**Mid to Late 1980s – Initiating Responses**

- Child welfare agencies began responding to an epidemic of kids coming into care and cocaine
- Schools began their efforts to understand prenatally-exposed children
- 1987 Los Angeles Unified School District develops pilot program to understand educational impact of prenatal cocaine exposure

**Notes:**
** But clearly, the awareness of the issue and early efforts to respond to the twin epidemics of crack and kids coming into care began in this era.  
As child welfare agencies began responding to the issues, schools began to report an increased number of children needing special education services and began their efforts to understand the educational issues of these children. 

## Timelines

- National Center on Child Abuse and Neglect
- 94 programs, including Illinois, Connecticut, New Jersey
- Piloted out-stationing substance abuse counselors in child welfare offices
- NIDA research efforts
- SAMHSA Specialized women’s treatment programs
- Between 1997 and 1999
- Five National Reports on Substance Abuse and Child Welfare

**Timelines**

**1990s**

**Notes:**
** Federal support beyond research for program development began in the late 1980s and early 90s as the National Center on Child Abuse and Neglect provided support. They eventually funded 94 sites, including pilots that have been sustained in Illinois, Connecticut, and New Jersey. Those pilots initiated the out-stationing of workers with expertise in substance abuse in child welfare offices. 
NIDA’s research program including the Perinatal 20 study was important as well as SAMHSA’s efforts to increase program funding for pregnant and parenting women through their residential women and children programs. We also saw the set aside in the Substance Abuse Prevention and Treatment Block Grant requiring States to increase the minimum funding they allocated to women’s programs.
By the late 90s, we saw 5 national reports published on substance abuse and child welfare. The reports identified the barriers to collaborative efforts and made recommendations for improving practice and policies.

## Timelines

- Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (1998)
- Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers (1998)
- Healing the Whole Family: A Look at Family Care Programs (1998)
- No Safe Haven: Children of Substance-Abusing Parents (1999)
- Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (1999)

**Timelines**

**1990s – Reports on the Issues**

**Notes:**
By the late 90s, we saw 5 national reports published on substance abuse and child welfare. The reports identified the barriers to collaborative efforts and made recommendations for improving practice and policies.

## 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

## Biggest Challenges:

**Reconciling the Clocks**

**The Four Clocks**

**Notes:**
** While we can take pride in these accomplishments, let me turn now to some of the challenges that we still face.
I may need to apologize for repeating the use of a metaphor—the four clocks—that we have used now for over seven years to make a point about the timetables that affect children and families at this intersection.
But the metaphor of the four clocks has helped many people, we have been told, to grasp a central reality of the work we do across agencies and within communities. Let me use those clocks as a structure to review our challenges.

## CFSR’s have documented 
Case reviews found parental substance use disorders were a factor in 16% to 48% of cases
Need for child welfare training in addictions 
Gaps in services
Inadequate assessment and follow up on the underlying needs of families, including substance abuse
Substance use disorders in families with repeat cases

- Case reviews found parental substance use disorders were a factor in 16% to 48% of cases
- Need for child welfare training in addictions
- Gaps in services
- Inadequate assessment and follow up on the underlying needs of families, including substance abuse
- Substance use disorders in families with repeat cases

- The First Clock

- Timeliness of intervention versus “Call me Tuesday”

## National Study on Child and Adolescent Well-Being: Child Welfare Workers’ (CWW) Identification of Substance Abuse

- Of the caregivers who are alcohol dependent
- 71% are classified by the CWW as not having an alcohol problem
- Of the caregivers who are drug dependent
- 73% are classified by the CWW as not having a drug problem

- CWW’s misclassify caregivers who are substance dependent most of the time

**Notes:**
Let’s look at that issue for a minute based on findings from the Children’s Bureau’s National Study of Child and Adolescent Well Being. Dr. Barth has reported that 71% of parents who are alcohol dependent were mis-classified by the child welfare worker. Again, nearly three-quarters of parents who were drug dependent were mis-classified by child welfare workers. In this nationally representative sample of child in care, child welfare workers misclassified caregivers’ substance use disorders most of the time. 
These data clearly point to the need for training but I think also point to the need for sustained partnership between child welfare workers and substance abuse counselors with expertise in identification and intervention.

## Minnesota Data

- 2002 Report to the 2004 Legislature
- Prevalence of Family Conditions at Assessment
- 				Alternative 	Traditional
- 				Response	Response
- Alcohol Abuse	     7%	   18%
- Drug Abuse		     3%	   19%

## Timeliness of Interventions
Taking CFSR findings seriously and including remediation strategies in Program Improvement Plans

- Taking CFSR findings seriously and including remediation strategies in Program Improvement Plans

- The First Clock

**ASFA Challenges**

**Notes:**
So the ASFA challenges include not only timeliness for us but also taking the findings from the CFSR seriously and ensuring that State’s Program Improvement Plans sufficiently address these issues to reduce the gap in services and in identification.

## The Second Clock

- Poverty and low-income work affect neglect, which is the majority of all reports
- Neglect is often associated with both substance abuse and poverty
- TANF resources have been used in innovative models for this population
- Treatment aftercare focus on jobs and housing
- TANF reauthorization proposes treatment be counted as a work activity

**Notes:**
** Next, there is the TANF timetable.  As we watch the TANF reauthorization debates continue, the challenge here is to remember how poverty and low-income work affect child abuse and neglect. We know that there are considerably more families that come into care with neglect allegations. And we also know that neglect—children left alone—can be as dangerous as abuse, and that neglect is often made up of two recurring ingredients: poverty and substance abuse.  
A further aspect regarding TANF is the fact that many of those innovative programs that we discussed earlier used TANF funding as a way to address this population. So the link to TANF remains critical.  
We also recognize that treatment aftercare and child welfare post-reunification services are fundamentally about jobs and housing—and if parents are left without the support they need to get and keep a job, the risks of neglect continues. 
The proposed changes in TANF reauthorization that would provide work credit for TANF clients enrolled in short term substance abuse treatment is a major step in the right direction.

## “A day at a time for the rest of your life” Recovery is a lifelong process with a disease management approach not emergency care

- Low-dosage non-comprehensive programs do not build on what we know about effective treatment for this population

- The Third Clock

**Notes:**
** Third, there is the substance abuse recovery timetable, which we have described as a day at a time for the rest of your life, underscoring how recovery is a lifelong process of disease management, not a quick visit to an emergency room on a crisis basis. 
Again I believe there are two challenges here and they are both about time.

** If we are serious about treatment effectiveness, we need to admit that low-dosage, outpatient programs simply ignore what we have learned about what works in treatment. We worked recently in a county in which all mothers who came into the child welfare system were required to complete the same county-provided program regardless of any assessment of the need for more intensive services. 
The county expected that a 2 hour twice a week outpatient program, was going to be sufficient to meet the needs of mothers with addiction who had just lost custody of their children, who were in crisis and dealing with their own grief, loss and trauma about the child abuse or neglect of their children. 
This response may meet the letter of the law in reasonable efforts, but in consideration of what we know about this crisis for families, this does not constitute reasonable efforts or principles of effective drug treatment.
We will not improve reunification rates with low-dosage programs funded on the basis of lowest bids for the least time in treatment. Always funding the lowest bidder, regardless of quality or treatment outcomes, flies in the face of everything we have learned about dosage and intensity of services.

## The Third Clock

**Recovery Challenges**

- Comprehensive services and longer-term supports are critical
- Clinical treatment, clinical support and community supports

- Recognizing the needs of children of parents in treatment

- The changing nature of drug use patterns and epidemics

**Notes:**
** Two challenges to the treatment field include the need for comprehensive services and long-term supports addressing the full range of family needs. The Center for Substance Abuse Treatment has recently revised the women’s treatment model that was first published in the mid 90s. This revised model takes into account the need for multiple clinical services, supports for those services from other agencies and community supports for sustaining recovery.
Foremost among these are the programmatic areas that affect women and children most with co-occurring challenges: mental health, trauma, domestic violence, child development, developmental disabilities, education, and special education. 
Another critical challenge to the treatment field is to recognize and address the needs of children of parents in treatment. We know too much about the effects of living with parents who have substance use disorders to ignore their specific needs for prevention and intervention. 
We often think about children of substance abusers once they are known to the child welfare system. Our challenge is to intervene with children who we all know are at higher risk for abuse and neglect before they are in child welfare. 
Finally, it is an on-going challenge to respond to the changing nature of drug epidemics and drug use patterns.

## Children of substance abusers need in-depth assessments and interventions that respond to their developmental status and the special needs created by substance use disorders in their family 
grief, loss, separation, attachment  
Adolescents who may have begun their own substance use

- grief, loss, separation, attachment
- Adolescents who may have begun their own substance use

- The Fourth Clock

## The Fourth Clock

- Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs

**Child Development Timetable**

**Notes:**
** Finally regarding children and the developmental clock, let me share a statistic that I find chilling, and at the same time purpose-giving, because it says so much about the work we have yet to do in the developmental arena.
Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs 

## Reconciling the Clocks

## 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**

## Policy Framework and Tools

- 10 Element Framework
- 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.

## 1. Values and Common Principles

***Issues to Address***
**Who is the Client -- Parent, Child, Family?**
**Can AOD Users/Abusers/ Addicts/Alcoholics 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

## How to Begin:

**Use Tools Such As the Collaborative Values Inventory to Identify and Resolve Differences That Exist Across System**
**Ensure Conversation Happens at Policy, Supervisory and Front-line Levels**

**Notes:**
Created the CVI as a method for States and communities to have those conversations in an anonymous manner to discuss these issues and develop principles of working together and priorities for action that puts those hard issues out on the table.

## Issues to Address
Roles and Responsibilities Across Systems
Communication Paths Across Systems
Incentives for Prioritization
Missing Box Problem

**Roles and Responsibilities Across Systems**
**Communication Paths Across Systems**
**Incentives for Prioritization**
**Missing Box Problem**

**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.

## Too Often We Practice...“Don’t Ask, Don’t Tell”

** ****Nationally, we have “missing box” problems**

**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**

## 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

**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**

*How to Begin:*

**Notes:**
Whose job is it to identify substance abuse among child welfare clients?
Whose job is it to identify potential risks to children among parents entering substance abuse treatment?
How is the information communicated?
How are prenatally exposed infants identified?
How will the state implement new CAPTA requirements.
Guidance in SAFERR at back of framework summary

## 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?

## 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

**Develop Mechanism to Re-engage Clients in Care**
**Ensure AOD Treatment and CPS Practice is Responsive to Clients’ Individualized Needs**

*How to Begin:*

## 4. Daily Practice -- Services to Children

***Issues to Address***
**Prevention, Early Intervention, and Treatment Services for Children in Contact with CPS**
**Content of Independent Living Programs on Parental Substance Abuse**
***Pediatrics***** (1999) v.103:1083 – 1155, Special Topics on Children and Adolescents in Families Affected by Substance Abuse**
**http://www.pediatrics.org/cgi/content/full/103/5/SI/1083**

**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

## Develop Partnerships to Respond to Potential Neuro-Developmental Effects of Prenatal Substance Exposure
Provide Prevention and Intervention Services to Children and Adolescents
Ensure that Youth Receive Appropriate Youth Development Intervention and Activities
Ensure that ILP Teens Receive Appropriate Information Related to Risks of Substance Abuse

**Provide Prevention and Intervention Services to Children and Adolescents**
**Ensure that Youth Receive Appropriate Youth Development Intervention and Activities**
**Ensure that ILP Teens Receive Appropriate Information Related to Risks of Substance Abuse**

*How to Begin:*

## 5. Information Sharing and Data Systems

**6. Training and Staff Development**

**7. Joint Accountability and Shared   Outcomes**

**8. Budgeting, Funding and Program **
**	**** ****Sustainability**

**Other System Supportive Elements**

## We Know AOD Treatment Pays

**100 Women**
**Average cost $6,800**
**$680,000**

**150 Children**
**Average 1.5 years in out-of-home care @ $24,000 per year**
**$5.4 Million**

***Foster Care Cost Offset ***
***Pays for all 100 Women’s Treatment Nearly 2 Times Over***

**30 Women recover with one episode of treatment**

**45 Children reunify at 6 months**
**	****Saves $1.1 Million**

## 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**

## Models of Improved Services

**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.

## Jointly Funded	

- Department of Health and Human Services
- Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Services
- Administration on Children, Youth & Families, Children’s Bureau, Office on Child Abuse and Neglect
- Assistant Secretary for Planning and Evaluation
- Department of Justice
- National Institute on Justice
- Drug Court Program Office

## Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs 
Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention
A baby and a family we already know are highly at risk

- Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention
- A baby and a family we already know are highly at risk

- The Fifth Clock

***Urgency***

**Notes:**
Two statistics, one which I have already cited, make that point concrete:
Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs 
Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention—for a baby and a family we already know are highly at risk 

## The fifth clock is the one that is ticking on us...it measures how fast we get it...how rapidly we respond to human needs that grow larger by the day 
We have to measure what we do against what needs doing, not against what we did last year

- We have to measure what we do against what *needs doing*, not against what we did last year

- The Fifth Clock

***Urgency***

**Notes:**
**The fifth clock is urgency, the one that measures how fast we get it—how rapidly we respond to human needs that grow larger by the day. We have to measure what we do against what needs doing, not against what we did last year.

## http://www.arium.org/anthology/kvanbeer/kvbafas.html 
Chasnoff, I. Cocaine Use in Pregnancy, New England Journal of Medicine, 1985
Barth, R. (2003). Substance Abuse Findings from the NSCAW Presented at NCSACW Researchers’ Forum. December.
Grella, C. (2003). Presentation at the NCSACW Researchers’ Forum. December 

- Chasnoff, I. Cocaine Use in Pregnancy, New England Journal of Medicine, 1985
- Barth, R. (2003). Substance Abuse Findings from the NSCAW Presented at NCSACW Researchers’ Forum. December.
- Grella, C. (2003). Presentation at the NCSACW Researchers’ Forum. December

**Responding to Families:****Timelines, Clocks and the Future**

- Notes