Barry M. Lester, PhD Brown Center for the Study of Children at Risk

1. The Vulnerable Infants Program Barry M. Lester, PhD Brown Center for the Study of Children at Risk The impact on children and families of parental drug use, particularly methamphetamine Werry Center, Auckland, New Zealand July 2008

2. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys In the 1980s, early reports on prenatal cocaine effects created a public frenzy about “unfit to parent” women and their damaged “crack babies."

3. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys Based on insufficient and inaccurate information, society over-reacted. Women were prosecuted, children were removed from their birth mothers, families were split up.

4. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys By the mid 1990s, the number of children in foster care reached an all-time high of over 500,000. Many of these children suffered emotional problems from multiple foster care placements.

5. Policy Responses 2 parallel policy responses towards drug use by women Punitive Treatment

6. Problems With Punitive Approach • Fear of being reported drives women away from health care system (e.g. prenatal care) • Denies the opportunity to parent for those who can/want to parent

7. Problems With Punitive Approach • Overburdens foster care system • Child’s ability to form attachments is jeopardized by multiple foster placements

8. “What gets me angry is that these patients come in & they demand a lot of attention & a lot of work & then in some respects it takes away from the medical care that the other patients get who did the right thing… & everyone is, like, being drawn away to help some drug addict who rolls in off the street in stress because she got high on crack & never went to clinic. Sometimes I think ‘the hell with her.’ I want to take care of the other patients.” (Obstetric Resident)

9. Treatment • Drug use by pregnant women viewed as a mental health (medical) issue • Harm reduction • Reproductive health care, substance abuse and mental health treatment, relationship with child

10. State Laws Vary • In regards to law, there is no national uniformity • State laws vary widely in their approach towards maternal drug abuse

11. Number Of States By Type Of Substance Abuse Statue 18 16 14 12 10 8 6 4 2 0 Term. Of Test/ Child Treatment Alcohol Rights Rep./ID Abuse Lester, Andriozzi & Appiah, J. Harm Reduction, 2004

12. State Laws: Some Examples “It is presumed that a newborn child is abused or neglected and that the child cannot be protected from further harm without being removed from the custody of the mother upon proof that a blood or urine test of the child at the time of birth or the mother at birth shows the presence of any amount of a controlled substance or the metabolite of a controlled substance not administered by medical treatment…” (South Carolina)

13. “A person mandated to report [substance exposure in an infant] shall immediately report to the local welfare agency if the person knows or has reason to believe that a woman is pregnant and has used a controlled substance for a nonmedical purpose during pregnancy. The local welfare agency shall immediately conduct an appropriate assessment and offer services, including but not limited to, chemical dependency services, a referral for chemical dependency treatment, and a referral for prenatal care.”(Minnesota)

14. Conflicting Policies A general problem in this field is that policies for the pregnant women/mother may be in conflict with policies for the fetus/child

15. Examples Of Conflicting Policies • Drug using mothers lose insurance • Fear of being reported keeps pregnant women away from health care system (e.g. prenatal care) • Treatment drugs for the mother can cause withdrawal in the baby (methadone) • Child’s ability to form attachments is jeopardized by multiple foster placements

16. Addiction Can Be Treated: Partial Recovery of Brain Dopamine Transporters in Methamphetamine Abuser After Protracted Abstinence 3 0 ml/gm METH Abuser (1 month detox) Normal Control METH Abuser (24 months detox) Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.

17. 50 to 70% 50 to 70% 40 to 60% 30 to 50% Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses Addiction Treatment Does Work 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 20 10 0 Drug Dependence Type I Diabetes Hypertension Asthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

18. Successful Treatment with Mothers CSAT PPWI Demonstration Program: Reduced positive tox at delivery; increased prenatal care CSAT study of 50 residential programs: Reduction in premature births, low birth weight, infant mortality SAMHSA review of 38 projects: Improved retention, increased prenatal care, improved birth outcomes, less alcohol & drug use Perinatal-20: Legal/CPS sanctions improved recruitment and retention. Long term adherence to treatment Options For Recovery: Court ordered treatment improved completion. Decreased CPS; increased reunification Residential treatment with children: Improved self-esteem, parenting skills, attachment to child

19. Effective Treatment • Start treatment during pregnancy • Length of treatment: residential or outpatient • Comprehensive treatment • Home-based treatment • Motivational interviewing and contingency management • Emphasis on the mother-infant relationship • Family treatment drug court (Lester and Twomey 2008)

20. Model Programs • Family Centered • Comprehensive • Interdisciplinary Staff • Nonjudgmental, Nonpunitive, Nurturing, Culturally and Linguistically Appropriate • Parenting Programs • Mental Health and Women’s Issues • Child Care • Transportation ( Lester, Andriozzi & Appiah, J. Harm Reduction, 2004)

21. Translating Research To Policy The changing view of drug abuse as a mental health/ medical illness leads to treatment and prevention instead of sanctions by the criminal justice system and the child protection system An example of the mental health approach is VIP (Vulnerable Infants Program) and Family Treatment Drug Court, that are specifically designed for perinatal substance users and their families The Providence Journal March 11, 2000

22. VulnerableInfants Program of Rhode Island (VIP-RI) The purpose of the program is to facilitate the ability of the Rhode Island Family Court to comply with the Adoption and Safe Families Act (ASFA) of 1997; Public Law 105-89 regarding the placement of drug exposed newborn infants in the State of Rhode Island.

23. Vulnerable Infants Program (VIP) VIP is a statewide hospital based program for women who have used illegal drugs and/or alcohol during pregnancy, their infants and families VIP (Women and Infants Hospital) Family Treatment Drug Court CPS

24. VIP was developed because in RI: • Too many babies were boarding in hospital beyond medical necessity because of issues surrounding placement • Concerns about how placement decisions were being made • Too many infants were placed in foster care (in 1995, RI had the 2nd highest rate of out of home placement in the US) • RI Court was having trouble complying with the 1997 Adoption and Safe Families Act (ASFA)

25. Foster Care Dramatic increase in number of children in foster care from late 1980’s through 1990’s Due in large part to increased drug use among women, particularly cocaine use among pregnant women

26. Foster Care • National concern with increased number of children in foster care lead to 1997 passage of Adoption and Safe Families Act (ASFA) • ASFA requires a permanency hearing in Family Court 12 months after the child enters foster care

27. VIP was established in 2000 based on: • The model of substance abuse as a treatable mental health disorder • Evidence based research showing that: • drug exposed infants can recover • treatment for drug using mothers and their infants is effective

28. Family Treatment Drug Court (FTDC) • FTDC established in 2003 • Specifically designed for perinatal substance users and their families • Facilitate permanency placements for substance exposed infants • Ensure parents receive substance use treatment and ancillary services to increase opportunities for reunification

29. VIP Provides • Evaluation of mother for substance use disorder, mental health, parenting, life skills, family resources, support, and evaluation of infant using standardized assessments. • Recommendation to CPS and Court for placement • Development of treatment plan for mother to keep or be reunified with baby • Case management to implement treatment plan, liaison with Court to follow ASFA guidelines

30. Components of VIP • Administrative • Education/Training • Service/Linkage

31. Administrative • Develop an infrastructure to work with Court and Child Protective Services (DCYF) to facilitate compliance with ASFA , provide linkages with other state and community agencies • DCYF-VIP partnership with standardized hospital protocol • Partner with Family Court to develop Family Treatment Drug Court

32. Education/Training • Provide an education program for the Court, state and community agencies in relevant substance abuse issues to help more informed decisions regarding placement of drug exposed infants

33. Service/Linkage Standardized testing determines treatment needs Treatment referrals & ancillary services facilitated Collaboration with CPS Attend FDTC hearings, provide input, monitor progress, until permanent placement

34. In-Hospital Component • Birth – MD Records Drug Exposure • VIP-RI enrolls patient, completes intake and administers assessments • VIP-RI shares assessments results, make referral’s to treatment and services • VIP-RI meets with CPS to share assessments, currents services and placement for infant • Enroll in Family Treatment Drug Court

35. Assessment Tools • Substance Abuse Subtle Screening Inventory (SASSI) • identifies substance dependence • Brief Symptom Inventory (BSI) • identifies psychological symptoms • Adult-Adolescent Parenting Inventory (AAPI-2) • identifies high-risk parenting & child rearing attitudes

36. Assessment Tools • Family Support Scale • – measures available family support • The NICU Network Neurobehavioral Scale (NNNS) designed for drug exposed infants, measures development • including neurological • integrity, behavioral • function, and sign of • stress or withdrawal • in the infant

37. Family Treatment Drug Court (FTDC) • One of a small number of drug courts focused on perinatal substance users and their families • Primary purpose is to comply with ASFA guidelines for permanent placement, working with parents to promote the likelihood of reunification

38. Rhode Island FTDC (cont) • Employs a therapeutic not adversarial approach • Collaboration among multiple social service agencies to achieve timely permanent placement for infants • VIP-RI provides care coordination for FTDC participants

39. Philosophy of FTDC • Early identification • Intervention with intensive case monitoring • Frequent court reviews • Facilitates more informed judicial decisions regarding child placement and timely permanent placement decisions

40. Drug Court Phases • Four Phases I-V • Movement from one phase to another is determined by the Drug Court team. • As participant progresses, Court hearings are less frequent. • Incentives are given when participants enter a new phase. • Sanctions are given for non-compliance of FTDC contract.

41. Phases Cont. • Length of FTDC program averages from 8 months to 15 months. • Graduation occurs after participants successfully completes all four phases. • Graduation ceremony at the Courthouse. • Child Protective Service case is closed at graduation.

42. Total Enrolled 217 Mothers 176 (81%) Fathers 41 (23%) Court Involved Children 284 Includes 182 Infants 1 Child 29 (27%) 2 - 3 Children 48 (45%) 4 -5 Children (22%) 23 6 (6%) 6 + Children Average Number of Children = 3 *

43. Mother’s Substance Abuse Previous Substance Abuse Treatment Primary Drug of Choice (n=105) 48 46% Cocaine 26 25% Opiates 75% 100% 30 29% Marijuana 1 1% Alcohol 80% 60% Substance Abuse Subtle Screen Data 40% • High Probability for Substance Abuse Disorder - 20% 0% 60% (56 out of 94)

44. Mother’s Mental Health Status Previous Mental Health Treatment 100% 90% 80% 70% 53% 60% 50% Percentage of Clients 40% 30% 20% 10% 0%

45. Hospital Length of Stay For Drug Exposed Infants Days

46. Placement

47. Improved Maternal Psychological Symptoms

48. Mothers with one or more high risk scores on the Adult Adolescent Parenting Inventory Expectations, Empathy Discipline, Family Roles, Power/Control

49. More Infants Are Being Placed With Their Families With Family Treatment Drug Court Treatment Court (n=64) Family Court (n=81) (~60% reduction foster care placement)

50. Average Time to Reunification with Mother 100% Family Court (Standard) Total 90% FTDC (Specialty) Total" 80% 73% 70% 60% Percentage of Clients Reunified 50% 39% 40% 33% 30% 20% 20% 11% 7% 10% 6% 6% 6% 0% 0% 0% 0% 0 - 3 months 4 - 6 months 7 - 9 months 10 - 12 months 13 - 15 months 16 - 18 months Number of Months to Reunification