# Presentation: 681321

## 

Technical Training Session on
Strengthening Collaborations in Vermont
May 26, 2005

- Technical Training Session on
- Strengthening Collaborations in Vermont
- May 26, 2005

**Responding to Families Affected By Substance Use Disorders in the Child Welfare System**

**Nancy K. Young, M.S.W., Ph.D.**
**4940 Irvine Boulevard, Suite 202**
**Irvine, CA 92620**
**714.505.3525  Fax 714.505.3626**
**www.ncsacw.samhsa.gov**** **

## Topics 	

- NCSACW
- Child Welfare & Substance Abuse Numbers
- Challenges Between Substance Abuse, Child Welfare and Dependency Courts
- Identifying Parents with Substance Use Disorders
- Policy Framework and Tools
- Models of Linking AOD, CW & Courts
- Family Treatment Court Outcomes

## A Program of the 
Substance Abuse and Mental Health 
Services Administration

Center for Substance Abuse Treatment

and the

Administration for Children and Families

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 for Children and Families
- 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 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. We’re just beginning our third year. 

## 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
- A Guide for Judges and Dependency Court Staff

## 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
- Policy and Practice products on NCSACW website
- Round 2 – Winter 2005 to Spring 2006
- Arkansas, Massachusetts, Minnesota, Squaxin Island Tribe

## 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) – 2005

## 2. Child Welfare & Substance Abuse 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

- In millions

- Vermont = 15,1201

**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 defined – parent used in past  year, etc.
The one I think is important is this 8.3 million children that live with a parent who is dependent on alcohol or needs treatment for drugs. This translates to 11% of the kids in our country or 1 million kids in CA.  If 11% of kids, 3 out of every elementary school classroom, are going home to a parent who is alcoholic or needs treatment for drug abuse, how does 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 a 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 have different opinions about what those standards should be, but these are certainly issues that we need to take that into account when we are devising policies and practices that work for these families.
CA in July 2003 has 9,485,676 children 0-17, 11% of them is 1,043,424

## Number of Children Prenatally Exposed to Substances 

| Substance Used (Past Month) |  |  | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  |  | 2.3% women          152 infants |
| Alcohol Use |  |  | 4.7% women               310 infants |
| Binge Alcohol Use |  |  | 0.7% women                46 infants |

- SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported national percentage of substance use by trimester; those percentages applied to Vermont births:

**Notes:**
SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003
Applied to survey percentages to 4,093,000 births in 2002
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)	

## Number of Children Prenatally Exposed to Substances 

| Substance Used (Past Month) |  | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  | 3.2% women           211 infants | 2.3% women          152 infants |
| Alcohol Use |  | 6.1% women                402 infants | 4.7% women               310 infants |
| Binge Alcohol Use |  | 1.4% women                 92 infants | 0.7% women                46 infants |

- SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported national percentage of substance use by trimester; those percentages applied to Vermont births:

**Notes:**
SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003
Applied to survey percentages to 4,093,000 births in 2002
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)	

## State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth3,4

- State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth3,4

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug | 7.7% women         508 infants | 3.2% women           211 infants | 2.3% women          152 infants |
| Alcohol Use | 19.6% women             1292 infants | 6.1% women                402 infants | 4.7% women               310 infants |
| Binge Alcohol Use | 10.9% women                  718 infants | 1.4% women                 92 infants | 0.7% women                46 infants |

- SAMHSA, OAS, National Survey on Drug Use and Health2, 2002 and 2003 reported national percentage of substance use by trimester; those percentages applied to Vermont births:

**Notes:**
SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003
Applied to survey percentages to 4,093,000 births in 2002
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)	

## Estimated Numbers of Children Prenatally Exposed to Substances in Vermont

- Births in 2003 = **6,591**5
- 10% of total births = **659 **Infants with prenatal substance exposure**	****	**
- Substantiated reports in 2003 for children 0-1 = **84**6
- Children less than 1 year old in Out of Home Care ~ **43**7**	**

***Where did they all go?***

- Estimated Numbers of Children Prenatally Exposed to Substances in Vermont

## MOST GO HOME.

- 	80-95% are undetected and go home without assessment and needed services.

- Many doctors and hospitals do not test, or may have inconsistent implementation of state policies
- Tests detect only very recent use
- Inconsistent follow-up for woman identified as AOD using or at-risk, but with no positive test at birth
- CAPTA legislation raises issues of testing and reporting to CPS

**Notes:**
The answer is of course that...
These issues are now being raised with changes to the Child Abuse Prevention and Treatment Act (CAPTA) within the Keeping Families Safe Act of 2003.  These changes include a requirement that states have policies and procedures requiring health care providers to notify CPS of “infants born and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.”  States must also develop a “plan of safe care” for such infants.  The law does not require reporting of children prenatally exposed to legal substances such as alcohol and tobacco.  Nothing in the law, however, prevents states from requiring such reporting.
Whatever side of the debate you sit on regarding testing and reporting of substance exposed births, I would expect that we can agree on the need for a comprehensive response – whether the lead be taken by child welfare, public health or AOD services – because, even though these kids may go home and miss becoming part of the system at birth, we continue to find that these kids come back into one of several systems later.

## A Graphic Overview

**Notes:**
CPS reports or substantiated???

## 3. Challenges Between                 Substance Abuse, Child Welfare and Dependency Courts

## 1990s – Reports on the Issues

- 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)

**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

- Competing priorities
- Beliefs and values
- 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

## The Five Clocks

-  Temporary Assistance for Needy Families (TANF)
- 24 months work participation
- 60 month lifetime

** **Adoption and Safe Families Act (ASFA)
- 12 months permanent plan
- 15 months out of 22 in out-of-home care must petition for TPR

** **Recovery
- One day at a time for the rest of your life

** **Child Development
- Clock doesn’t stop
- Moves at fastest rate from prenatal to age 5

## Biggest challenge:

- Syncing Clocks

**The Four Clocks**

## First Clock

- ASFA Timetable

- Timeliness of intervention
- versus “Call me Tuesday.”

## First Clock continued

- 	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

## 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.

## TANF Timetable

- Second Clock

- Neglect is often associated with both substance abuse and poverty
- Proposals for TANF Reauthorization count Substance Abuse Treatment toward Work Participation Rates

## Third Clock

- Recovery Timetable

- 	“A day at a time for the rest of your life”
- 	Recovery is a lifelong process requiring a disease management approach rather than emergency care

## Interventions for children of substance abusers must  recognize potential pre-natal and post-natal effects

Require multi-dimensional assessments and interventions responding to developmental status and special needs created by substance use disorders in the family

Alcohol-related neuro-developmental disorders
Attachment, separation, loss, grief

- Interventions for children of substance abusers must  recognize potential pre-natal and post-natal effects
- Require multi-dimensional assessments and interventions responding to developmental status and special needs created by substance use disorders in the family
- Alcohol-related neuro-developmental disorders
- Attachment, separation, loss, grief

- Child Development Timetable

- Fourth Clock

## Prenatal substance exposure
Fetal alcohol syndrome, fetal alcohol spectrum disorder, neuro-developmental disorders

Postnatal environment factors 
Violence or traumatic events
Drug and/or alcohol seeking behaviors
Illicit drug sales or manufacturing
Lack of adult interpersonal support systems
Community effects such as living in poverty
Lack of proper health care
Inconsistent caregivers

- Fetal alcohol syndrome, fetal alcohol spectrum disorder, neuro-developmental disorders
- Postnatal environment factors** **
- Violence or traumatic events
- Drug and/or alcohol seeking behaviors
- Illicit drug sales or manufacturing
- Lack of adult interpersonal support systems
- Community effects such as living in poverty
- Lack of proper health care
- Inconsistent caregivers

- Potential Consequences for Children

## Areas of Child Development Affected by Parental Substance Use Disorders

- Physical health consequences
- Lack of secure attachment
- Psychopathology
- Behavioral problems
- Poor social relations and skills
- Deficits in motor skills
- Language delays
- Cognition and learning disabilities

- Research has shown that these effects can manifest themselves in multiple areas, including:

**Notes:**
Could be an effect of postnatal environment, but could be compounded by prenatal exposure
While it is crucial that the parents are screened, assessed and engaged in treatment, it is also critical that the child’s social, emotional, developmental and psychological needs are addressed. Without intervention, the child’s unaddressed needs may impede a parent’s recovery or interfere with the timely resolution of the child’s permanent plan. Coping with the issues of recovery and the challenges of a child with unmet or undetected special needs can pose barriers for parents trying to maintain a safe and stable home for their child. Identifying and addressing the needs of these children will support parents in this effort. In addition to the time limits on reunification under ASFA, the Federal legislation’s "fast track" provision gives States the option of bypassing efforts to reunify families in certain egregious situations. Depending on how a State views parental SUDs, there is a potential to fast track the termination of parental rights for these families, particularly those in which an infant has been prenatally exposed to illicit drugs.

## There is no absolute profile of developmental outcomes based on a child’s exposure to his or her parents’ substance use, abuse, or dependence.9  

Other problems arising in parental behavior, competence, and disorders interact with substance use, abuse, and dependence to cause multiple co-occurring problems in the lives of these children. 

- Other problems arising in parental behavior, competence, and disorders interact with substance use, abuse, and dependence to cause multiple co-occurring problems in the lives of these children.

- The complexity of screening and assessment for these children is compounded by at least two realities:

- Screening and Assessment of Consequences for Children

**Notes:**
To understand the forces influencing the futures of children exposed to alcohol and drugs, it is necessary to assess many different factors that affect their lives. The consequences of alcohol and drug use are the products of a complex interchange of biological, psychological, and sociological events. 

## The importance of identifying infants prenatally exposed to substances

- Though a small percentage of CWS cases, these children are disporportionately affected by many lifetime conditions
- Prenatal exposure to alcohol is the leading cause of mental retardation
- Special education classrooms contain a disproportionate number of children who were prenatally exposed to drugs.10,11
- SEBs require a higher level of public spending than many other target groups

## Child Abuse Prevention and Treatment Act (CAPTA) 2003 Amendments

- 2003 Keeping Families Safe Act Amendments
- Policies and procedures (including appropriate referrals to child protection service systems and for other appropriate services) to address the needs of **infants born and identified as affected by illegal substance abuse** or **withdrawal symptoms resulting from prenatal drug exposure**, including a requirement that health care providers involved in the delivery or care of such infants **notify the child protective services system of the occurrence of such condition in such infants**, except that such notification shall not be construed to (I) establish a definition under Federal law of what constitutes child abuse; or (II) require prosecution for any illegal action (section 106(b)(2)(A)(ii));
- The development of **a plan of safe care** for the infant born and identified as being affected by illegal substance abuse or withdrawal symptoms (section 106(b)(2)(A)(iii))

**Notes:**
CAPTA amendments put a spotlight on the identification and referral of SEIs

## Child Abuse Prevention and Treatment Act (CAPTA) 2003 Amendments

- 2003 Keeping Families Safe Act Amendments
- Policies and procedures (including appropriate referrals to child protection service systems and for other appropriate services) to address the needs of **infants born and identified as affected by illegal substance abuse** or **withdrawal symptoms resulting from prenatal drug exposure**, including a requirement that health care providers involved in the delivery or care of such infants **notify the child protective services system of the occurrence of such condition in such infants**, except that such notification shall not be construed to (I) establish a definition under Federal law of what constitutes child abuse; or (II) require prosecution for any illegal action (section 106(b)(2)(A)(ii));
- The development of **a plan of safe care** for the infant born and identified as being affected by illegal substance abuse or withdrawal symptoms (section 106(b)(2)(A)(iii))

**Notes:**
CAPTA amendments put a spotlight on the identification and referral of SEIs

##  Children and Parents - Intervention Points

-  Children and Parents - Intervention Points

- Prenatal screening and assessment

- Pre-pregnancy awareness and substance use

**Family literacy and economic**
** ****support**

**Bonding supports**

**Parents’ role in **
**child care**

**Notes:**
But the identification and referral of SEIs must be considered in the larger context, which requires partnerships between several agencies

## Trends in State Policies

- Legislation that defines substance-exposed births as child abuse or neglect
- Legislation mandating substance exposed birth reports to CPS by health care professionals and/or mandated reporters in general
- Policies for testing mother and/or infant

## Trends in State Policies

- Leaving the judgment of child abuse or neglect to the discretion of the CPS worker or the health care provider
- Addressing alcohol and drug use/abuse during pregnancy, but not necessarily addressing the substance exposed birth
- CPS policies on how to respond to a substance exposed birth
- No official response

## 4. Screening for Prenatal Substance Exposure and Parental Substance Use Disorders (SUDs)

## Identifying Infants withPrenatal Substance Exposure

- Verbal screen with mother
- Review of mother’s history and medical records
- Observation of mother and/or newborn
- Drug testing (urine, blood, hair or meconium)

- Prenatal substance exposure can be screened for in  several ways. The most common methods, used alone or in combination, are:

## Verbal Screening Tools4Ps Plus12

- Did either of your parents ever have a problem with drinking or using drugs?
- Does your partner have any problem with alcohol or drugs?
- Have you ever had any beer or wine or liquor in the past?
- In the month before you knew you were pregnant, how much beer/wine/liquor did you drink?
- In the month prior to when you knew you were pregnant, how many cigarettes did you smoke?

## Identifying Parental Substance Use Disorders

- Studies conducted on brief screens of six or less items suggest that there are a limited number of common constructs
- An effective screen for substance use disorders includes questions about:
- Unintended use
- Desire to restrict use
- Consequences of use
- Concern about consequences of use

**Notes:**
Important that an effective screen must be institutionalized and consistent.  That is, you have to decide that you will do a screen, you have to decide when you will administer the screen, and then you have to be sure to be consistent about administering the screen at the designated time.  May not be appropriate to use a screening tool during an ER, but it would certainly be useful during an investigation.

## Screening for ParentalSubstance Use Disorders: UNCOPE13

- In the past year, have you ever drank or **used** drugs more than you meant to?
- Have you ever **neglected** some of your usual responsibilities because of using alcohol or drugs?
- Have you felt you wanted or needed to **cut down** on your drinking or drug use in the last year?
- Has anyone **objected** to your drinking or drug use?
- Have you ever found yourself **preoccupied** with wanting to use alcohol or drugs?
- Have you ever used alcohol or drugs to relieve **emotional** discomfort, such as sadness, anger, or boredom?

##   Check list for Identifying SUDs:14
A report of substance use is included in the child protective services call or report.
Paraphernalia is found in the home (syringe kit, pipes, charred spoon, foils, large number of liquor or beer bottles, etc).
The home or the parent may smell of alcohol, marijuana, or drugs.
A child reports alcohol and or other drug use by parent(s) or other adults in the home.
A parent appears to be actively under the influence of alcohol or drugs (slurred speech, inability to mentally focus, physical balance is affected, extremely lethargic or hyperactive, etc).
A parent shows signs of addiction (needle tracks, skin abscesses, burns on inside of lips, etc).
A parent admits to substance use.
A parent shows or reports experiencing physical effects of addiction or being under the influence, including withdrawal (nausea, euphoria, slowed thinking, hallucinations, or other symptoms).

- A report of substance use is included in the child protective services call or report.
- Paraphernalia is found in the home (syringe kit, pipes, charred spoon, foils, large number of liquor or beer bottles, etc).
- The home or the parent may smell of alcohol, marijuana, or drugs.
- A child reports alcohol and or other drug use by parent(s) or other adults in the home.
- A parent appears to be actively under the influence of alcohol or drugs (slurred speech, inability to mentally focus, physical balance is affected, extremely lethargic or hyperactive, etc).
- A parent shows signs of addiction (needle tracks, skin abscesses, burns on inside of lips, etc).
- A parent admits to substance use.
- A parent shows or reports experiencing physical effects of addiction or being under the influence, including withdrawal (nausea, euphoria, slowed thinking, hallucinations, or other symptoms).

- Identifying Parental Substance Use Disorders

**Notes:**
A system of setting up the investigation and identification of substance abuse issues

## Introduction to a Framework and Policy Tools for Practice and Policy Changes

- 5. Policy Framework and Tools
- Getting the Clocks in Sync

## 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**15

**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**

## 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**15

**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/ 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

## 
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

- 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

**How to Begin:**

**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

## Slide 50

## Slide 51

## 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 and Needed Level of Care

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

**How to Begin:**

## Client Levels of CareAmerican Society of Addiction Medicine16

- Level I– Outpatient Treatment
- Level II – Intensive Outpatient/Partial Hospitalization
- Level III – Medically Monitored Intensive Inpatient Treatment
- Level IV – Medically Managed Intensive Inpatient Treatment

## 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 Abuse17

**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

- 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

**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**

## 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**

## 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.

## 6. Models of Linking AOD, CW & Courts

## 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.

## 7. Family Treatment Court Outcomes

## Five Components of Sacramento County’s Comprehensive Systems’ Reform 

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

## 
2. Substance Abuse Treatment System  
    of Care
Managed Wait List
Immediate Access to Substance Abuse Services
Group Services Expansion and Implementation of Pre-Treatment Groups

**2. Substance Abuse Treatment System  **
**    ****of Care**
- Managed Wait List
- Immediate Access to Substance Abuse Services
- Group Services Expansion and Implementation of Pre-Treatment Groups

**Five Components of Sacramento County’s Comprehensive Systems’ 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

**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

**Five Components of Sacramento County’s Comprehensive Systems’ 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 Systems’ Reform**

## 
5. Dependency Drug Court
Parallel system to dependency petition
30, 60 and 90-day compliance hearings
Structured incentives for compliance and sanctions for non-compliance
Voluntary participation in on-going services

**5. Dependency Drug Court**
- Parallel system to dependency petition
- 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 Systems’ Reform**

## PARENTS AND CHILDREN IN THE EVALUATION

**Notes:**
The number of Year 3 parents and children may change slightly once they are matched.  These numbers are preliminary.

## CHILD DEMOGRAPHIC CHARACTERISTICS

- 52% Girls
- 48% Boys
-  1.6 % American Indian/Alaskan
-  2.0% Asian Pacific Islander
-  27.4% African American
-  20.3% Hispanic
-  48.7% Caucasian*
-  Average Age of 6.5*

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

## PARENTS

- 111 Comparison parents, 847 Court-Ordered parents
- Over 69% were women
- Average age was 32
- 54% were Caucasian, about 21% African American and 17% Hispanic
- Methamphetamine was the primary drug problem for 52% of participants
- Generally have low education attainment and are largely unemployed
- Almost 29% reported a disability at treatment entry and almost 28% reported a history of chronic mental illness

## PARENT GENDER

**PARENT GENDER**

## RACE/ETHNICITY OF PARENTS

***p<.05**

**Notes:**
Demographic data will be added for the Year 3 cohort as soon as new CADDS data is received.

There appears to be an increase in Caucasian parents and decrease in African American parents over time.  It will be important to attempt to identify why these changes are occurring such as a change in the census demographics for Sacramento, different types of parents entering court, etc.

## PARENT BASELINE CHARACTERISTICS

***p<.05**

**Notes:**
Demographic data will be added for the Year 3 cohort as soon as new CADDS data is received.

There appears to be an increase in Caucasian parents and decrease in African American parents over time.  It will be important to attempt to identify why these changes are occurring such as a change in the census demographics for Sacramento, different types of parents entering court, etc.

## PRIMARY DRUG PROBLEM***

*****p<.001**

## PERCENT OF MOTHERS AND FATHERS BY PRIMARY DRUG PROBLEM**

****p<.01**

## TREATMENT ADMISSION RATES***

*****p<.001**

## MEAN NUMBER OF TREATMENT ADMISSIONS***

*****p<.001**

## TREATMENT MODALITY***

*****p<.001**

## PERCENT OF MOTHERS AND FATHERS BY TREATMENT MODALITY**

****p<.01**

## TREATMENT DISCHARGE STATUS

**n.s.**

## TREATMENT DISCHARGE STATUS BY MOTHERS AND FATHERS

**n.s.**

## 24-MONTH CHILD PLACEMENT OUTCOMES***

*****p<.001**

## TIME TO REUNIFICATION

*****p<.001**

**Notes:**
The Year 2 cohort had a similar time to reunification as the comparison group.  Although the reunification rate was similar to the other court ordered group, the Year 2 cohort appeared to take longer to reunify.  This may be due to the change in demographics (i.e., homelessness) that we saw for this group.  It also may be due to a change in the types of parents that entered the DDC following B13.

## 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
- 42.1% - Reunification rate for court-ordered DDC group children
- 63 Additional DDC children reunified
- 33.1 – Average months in out-of-home care for comparison group children
- 8.6  - Average months to reunification for court-ordered DDC children
- 24.5 month differential
**$2,953,639 Estimated Savings in Out-of-Home care costs**

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

## 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**

## 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***

## 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***

## The Voice of a Child

**Nothing But Silence**
**By Ashley G.**
**Age 12**
**January 2005**

## 
People all around me
Calling out my name
But no I cannot hear them
For my heart is filled with shame
Nothing but silence

But only till the break of dawn
Will I be feeling sad
For wandering out on the streets
Are my birth mom and dad

Why’d she do this to her and me
With this we’ll have to cope
But while she’s clean you never know
There still could be hope

But in the perfect world I know
There’s no harmful stuff
But now I’ve come to realize
It’s just a bunch of bluff

Nothing but silence

- People all around me
- Calling out my name
- But no I cannot hear them
- For my heart is filled with shame
- Nothing but silence
- But only till the break of dawn
- Will I be feeling sad
- For wandering out on the streets
- Are my birth mom and dad
- Why’d she do this to her and me
- With this we’ll have to cope
- But while she’s clean you never know
- There still could be hope
- But in the perfect world I know
- There’s no harmful stuff
- But now I’ve come to realize
- It’s just a bunch of bluff
- Nothing but silence

- Sitting by the widow sill
- A tear rolls down my cheek
- Although it hurts I can’t express
- My heart is just too weak
- Nothing but ache
- It’s funny what one pill can do
- To a mother or a kid
- And now I know that for a fact
- I won’t do what she did
- Nothing but ache
- Now I live a better life
- And drugs...I wouldn’t dare
- Away from all the harmful things
- With a family who cares
- Nothing but love
- I know it hurts, it sure hurt me
- And that’s why I’ll remain drug free
- Nothing... but hope

## References

- U.S. Census Data 2000 – Vermont Births. Accessed: _[http://www.childwelfare.com/vermont.htm](http://www.childwelfare.com/vermont.htm)_
- SAMHSA, OAS. (2003). *Results from the 2002 National Survey on Drug Use and Health: National findings. *
- Ibid.
- Vega et al. (1993).  *Profile of Alcohol and Drug Use During Pregnancy in California*, 1992.
- NCHS – FASTATS. (2003). _[http://](http://www.cdc.gov/nchs/fastats/popup_vt.htm)__[www.cdc.gov/nchs/fastats/popup_vt.htm](http://www.cdc.gov/nchs/fastats/popup_vt.htm)_.
- U.S. DHHS, Administration on Children, Youth and Families. (2005). *Child Maltreatment 2003.* Table 3-9.
- U.S. House of Representatives, Committee on Ways and Means. (2004). 2004 Green Book.
- U.S. DHHS, Administration on Children, Youth and Families. (2005). Child Maltreatment 2003.
- Chasnoff, I.J. (1997). Prenatal Exposure to Cocaine and Other Drugs: Is there a Profile? In: Accardo, P.J., Shapiro, B.K., & Capute, A.J. (Eds.), *Behavior Belongs in the Brain.* Baltimore, MD: York Press, 147-163.
- NIAAA. (2000). *Tenth Special Report to Congress on Alcohol and Health. *
- NIDA. (1998). *Prenatal Exposure to Drugs of Abuse May Affect Later Behavior and Learning.*
- McGourty, R. F., & Chasnoff, I. J. (2003). *Power Beyond Measure: A Community-Based Approach to Developing Integrated Systems of Care for Substance Abusing Women and their Children*. Chicago, IL: NTI Publishing.
- Evince Clinical Assessment. UNCOPE screening tool is available as a downloadable pdf file from the website: _[www.evinceassessment.com](http://www.evinceassessment.com/)_.
- Young, N.K. and Gardner, S.L. (2002). Navigating the Pathways: Lessons and Promising Practices in Linking Alcohol and Drug Services With Child Welfare. Technical Assistance Publication No. 27. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
- Ibid.
- American Society of Addiction Medicine (ASAM). (1996). Patient Placement Criteria for the Treatment of Substance-Related Disorders, 2nd ed. Chevy Chase, MD: ASAM.
- Pediatrics (1999) *Special Topics on Children and Adolescents in Families Affected by Substance Abuse. *Accessed:* *_*[http://www.pediatrics.org/cgi/content/full/103/5/SI/1083](http://www.pediatrics.org/cgi/content/full/103/5/SI/1083)*_.