# Presentation: 679266

## Child Welfare and Substance Abuse:Current Issues and Innovations

**National Association of State Alcohol and Drug Abuse Directors Annual Meeting****Miami, Florida**
**June 2005**
**Nancy K. Young, M.S.W., Ph.D.**

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

## A Sense of Satisfaction	

***A Sense of Urgency***

**We have much to feel good about in our efforts to combine forces to help children and families affected by substance use disorders and child abuse or neglect**

**At the same time, we need a much greater sense of urgency in building on these victories to enter into the next phase of getting serious and getting to scale**

- Two Contrasting Ideas:

## Topics 	

- NCSACW
- Children with Prenatal Substance Exposure
- Children of Substance Abusers who are also Victims of Child Abuse and/or Neglect
- Children in the Child Welfare System with their own Substance Use Disorder
- Future Trends

## 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
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
- 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

- Free On-Line Training with CEUs
- 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
- Understanding Families with Substance Use Disorders: A Guide for Judges and Attorneys working with Families in Family/Juvenile Court

## PRODUCTS

- Program of In-Depth Technical Assistance
- Round 1 – Summer 2003 to Fall 2004
- Colorado – Licensing/certification of providers who specialize in child welfare population and protocol for improving services
- Florida – Regional contracts to ensure local-level system linkages and preferred practice model
- Michigan – Revised SACWIS to prioritize SUDs
- Virginia – Comprehensive 5-year plan
- Round 2 – Winter 2005 to Spring 2006
- Arkansas, Massachusetts, Minnesota and Squaxin Island Tribe at Puget Sound

## 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.

## PRODUCTS

- Materials
- Compendium of Training Curricula
- Understanding Substance Abuse: A Guide for Child Welfare Practitioners
- Draft White Paper on Funding Substance Abuse and Child Welfare Services
- Draft White Paper on Implementing the 2004 Substance Abuse Amendment in the Child Abuse Prevention and Treatment Act (CAPTA)

## PRODUCTS we’re working on...

- State Policies regarding Substance Exposed Infants
- Guidance to States and Communities on:
- Screening and Assessment for Family Engagement, Retention and Recovery (SAFERR)
- Methamphetamine and child risk and safety assessments
- The use of drug testing in child welfare practice
- Medication assisted treatment for opiate dependence and implications for child welfare

## 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. 

## Children with Prenatal Substance Exposure

**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.

## Number of Children Prenatally Exposed to Substances 

| Substance Used (Past Month) |  |  | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  |  | 2.3% women          94,139 infants |
| Alcohol Use |  |  | 4.7% women               192,371 infants |
| Binge Alcohol Use |  |  | 0.7% women                28,651 infants |

- SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

**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           130,976 infants | 2.3% women          94,139 infants |
| Alcohol Use |  | 6.1% women                249,673 infants | 4.7% women               192,371 infants |
| Binge Alcohol Use |  | 1.4% women                 57,302 infants | 0.7% women                28,651 infants |

- SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

**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 and local prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth5,6

- State and local prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth5,6

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug | 7.7% women         315,161 infants | 3.2% women           130,976 infants | 2.3% women          94,139 infants |
| Alcohol Use | 19.6% women             802,228 infants | 6.1% women                249,673 infants | 4.7% women               192,371 infants |
| Binge Alcohol Use | 10.9% women                  446,137 infants | 1.4% women                 57,302 infants | 0.7% women                28,651 infants |

- SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

**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)	

## Infants with pre-natal substance        ~410,000 

- exposure

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

- Number of Children Prenatally Exposed to Substances

- Total child victims under 1 year old     **~****86,000**

- Total children under 1 year old	     **~****41,000 **entering out-of-home-care

## Most Go Home

- 	90%+ 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
- Child Abuse Prevention and Treatment Act (CAPTA) Amendments of 2003 raises issues of identifying infants and reporting to Child Protective Services

**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.

## 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

- Child

- Aftercare and follow-up

- Identification and responses to parents’ needs

- Responses to infant’s needs

- Identification and responses to needs of
-  Preschooler
-  Child
-  Adolescent

- Aftercare and follow-up

- Responses to parents’ needs

- Initiate plan of care & enhancement services

-  Children and Parents - Intervention Points

- Prenatal screening and assessment

- Pre-pregnancy awareness and substance use

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

## 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
- Language delays and communication disorders
- Psychopathology
- Behavioral problems
- Poor social relations and skills
- Deficits in motor skills
- 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.

## Children of Substance Abusers who are also Victims of Child Abuse and/or Neglect

**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**

**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

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

- 73% of caregivers who are drug dependent are classified by the CWW as not having a drug problem

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

- Documenting Substance Use Disorders in Child Welfare

- Children and Family Service Reviews (CFSRs)
- Parental substance use disorders were a factor in 16% to 48% of cases

**Notes:**
CA AFCARS – Adoption and Foster Care Analysis and Reporting System. 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.

## Children in the Child Welfare System with their own Substance Use Disorder

## 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 – Few Independent Living Programs under Chafee Bill include prevention or intervention for children of substance abusers aging out of foster care

- grief, loss, separation, attachment
- Adolescents who may have begun their own substance use – Few Independent Living Programs under Chafee Bill include prevention or intervention for children of substance abusers aging out of foster care

- Children in the Child Welfare System with their own SUD

## Youths who have ever been in foster care had higher rates of any illicit drug use than youths who have never been in foster care (33.6 vs. 21.7 percent)
Youths aged 12 to 17 who were in need of substance abuse treatment in the past year were more likely to have received treatment if they have ever been in foster care 

- Youths aged 12 to 17 who were in need of substance abuse treatment in the past year were more likely to have received treatment if they have ever been in foster care

- Children in the Child Welfare System with their own SUD

## Future Trends

## TANF Opportunities

- Treatment aftercare focus on jobs and housing
- TANF reauthorization proposes treatment be counted as a work activity
- Does your state define the child welfare population as a “needy family” under TANF
- Can use TANF to pay for treatment

**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.

## Models of Cross-system funding for joint initiatives
Title IV-E Waiver projects

- Title IV-E Waiver projects

- Funding Opportunities

## Taking CFSR findings seriously and including remediation strategies in Program Improvement Plans
New round of CFSRs begin this summer – contact your state’s child welfare lead to get involved

- New round of CFSRs begin this summer – contact your state’s child welfare lead to get involved

- Child and Family Service Reviews

**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.

## Early recognition of Substance Use Disorders
Timeliness of Interventions
“Call me Tuesday”
“Your life has just begun”

- Timeliness of Interventions
- “Call me Tuesday”
- “Your life has just begun”

- Timeliness of Interventions

- 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.

## Four Components of System Reform 

- Comprehensive cross-system joint 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
- Early Intervention Specialists
- Immediate access to intervention and assessment at the court hearings

## Recovery Management Specialists
Motivational enhancement
Immediate access to recovery management and treatment services
Compliance monitoring
Dependency Drug Court
30, 60 and 90-day compliance hearings
Structured incentives for compliance and sanctions for non-compliance
Voluntary participation in on-going services

- Motivational enhancement
- Immediate access to recovery management and treatment services
- Compliance monitoring
- Dependency Drug Court
- 30, 60 and 90-day compliance hearings
- Structured incentives for compliance and sanctions for non-compliance
- Voluntary participation in on-going services

- Four Components of System Reform

## Early recognition of Substance Use Disorders
Timeliness of Interventions
“Call me Tuesday”
“Your life has just begun”

- Timeliness of Interventions
- “Call me Tuesday”
- “Your life has just begun”

- Timeliness of Interventions

- ASFA Challenges

*A timely message of hope*

**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 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

- Nothing But Silence

## 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.

## Child Welfare and Substance Abuse: 

- 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.
- Office of Applied Studies. (2004). Results from the 2003 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 04–3964, NSDUH Series H–25). Rockville, MD: Substance Abuse and Mental Health Services Administration. _[http://oas.samhsa.gov/2k5/FosterCare/FosterCare.htm](http://oas.samhsa.gov/2k5/FosterCare/FosterCare.htm)_
- Office of Applied Studies. (2003). *Results from the 2002 National Survey on Drug Use and Health: National findings* (DHHS Publication No. SMA 03–3836, NHSDA Series H–22). Rockville, MD: Substance Abuse and Mental Health Services Administration at _[http://oas.samhsa.gov/2k3/pregnancy/pregnancy.htm](http://oas.samhsa.gov/2k3/pregnancy/pregnancy.htm)_
- Office of Applied Studies. (2002). *Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of national findings* (DHHS Publication No. SMA 02-3758, NHSDA Series H-17). Rockville, MD: Substance Abuse and Mental Health Services Administration. _[http://www.drugabusestatistics.samhsa.gov/2k3/children/children.htm](http://www.drugabusestatistics.samhsa.gov/2k3/children/children.htm)_
- Hamilton BE, Martin JA, Sutton PD. (2003) Births: Preliminary data for 2002. _National vital statistics reports_, 51 (11), Hyattsville, Maryland: National Center for Health Statistics at _[http://www.cdc.gov/nchs/data/nvsr/nvsr51/nvsr51_11.pdf](http://www.cdc.gov/nchs/data/nvsr/nvsr51/nvsr51_11.pdf)_

- Child Welfare and Substance Abuse:
- Current Issues and Innovations

## Child Welfare and Substance Abuse: 

- National Institute on Alcoholism and Alcohol Abuse. (2000). *Tenth Special Report to Congress on Alcohol and Health*. Washington, DC: Department of Health and Human Services at _[http://www.niaaa.nih.gov/publications/10report/intro.pdf](http://www.niaaa.nih.gov/publications/10report/intro.pdf)_
- National Institute of Drug Abuse. (1998). Prenatal Exposure to Drugs of Abuse May Affect Later Behavior and Learning.  NIDA Notes, 13 (4) at http://www.drugabuse.gov/NIDA_Notes/NNVol13N4/Prenatal.html

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- Child Welfare and Substance Abuse:
- Current Issues and Innovations