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

1. Responding to Families Affected By Substance Use Disorders in the Child Welfare System Technical Training Session on Strengthening Collaborations in Vermont May 26, 2005 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 2.Child Welfare & Substance Abuse Numbers

9. Children Living with One or More Substance Abusing Parent Vermont = 15,1201 In millions

10. Infants Exposed to Substances During Pregnancy State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth3,4 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:

11. Estimated Numbers of Children Prenatally Exposed to Substances in Vermont Births in 2003 = 6,5915 10% of total births = 659 Infants with prenatal substance exposure Substantiated reports in 2003 for children 0-1 = 846 Children less than 1 year old in Out of Home Care ~ 437 Where did they all go?

12. MOST GO HOME. • 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 80-95% are undetected and go home without assessment and needed services.

13. 137,446 age 0-17 659 estimated substance-exposed births annually 6,591 births annually 11, 203 children born substance-exposed Estimated substance-exposed births reported to CPS: 5.6% of all SEBs = 37 1447 CPS substantiated reports annually8 A Graphic Overview

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

15. 1990s – Reports on the Issues • Five National Reports on Substance Abuse and Child Welfare • 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)

16. 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

17. 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

18. Biggest challenge: The Four Clocks Syncing Clocks

19. First Clock ASFA Timetable Timeliness of intervention versus “Call me Tuesday.”

20. ASFA Timetable 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

21. 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

22. Second Clock TANF Timetable • Neglect is often associated with both substance abuse and poverty • Proposals for TANF Reauthorization count Substance Abuse Treatment toward Work Participation Rates

23. 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

24. Fourth Clock • 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

25. Potential Consequences for Children • 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

26. Areas of Child Development Affected by Parental Substance Use Disorders Research has shown that these effects can manifest themselves in multiple areas, including: • 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

27. Screening and Assessment of Consequences for Children • 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. The complexity of screening and assessment for these children is compounded by at least two realities:

28. 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))

29. Initiate plan of care & enhancement services Child Birth Responses to parents’ needs Responses to infant’s needs Identification and responses to Parents’ Needs Identification and responses to preschooler’s needs Identification and responses to parents’ needs Identification and responses to child’s needs Family economic supports Identification and responses to adolescent’s needs Identification and responses to parents’ needs FAMILY CENTERED PRACTICE Aftercare and follow-up Aftercare and follow-up Parent Children and Parents - Intervention Points Pre-pregnancy awareness and substance use Prenatal screening and assessment Bonding supports Parents’ role in child care Family literacy and economic support

30. 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

31. 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

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

33. Identifying Infants withPrenatal 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:

34. Verbal Screening Tools4Ps 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?

35. 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

36. Screening for ParentalSubstance 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?

37. Identifying Parental Substance Use Disorders 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).

38. 5. Policy Framework and Tools Getting the Clocks in Sync Introduction to a Framework and Policy Tools for Practice and Policy Changes

39. Connecting AOD, CWS, Court Systems: Elements of System Linkages15 • Underlying Values • Screening and Assessment • Client Engagement and Retention in Care • AOD Services to Children • Information Sharing & Management • Training and Staff Development • Budgeting and Program Sustainability • Building Community Supports • Joint Accountability and Shared Outcomes • Working with Related Agencies and Support Systems

40. 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?

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

42. 2. Daily Practice: Client Intake, Screening and Assessment • Issues to Address • Roles and Responsibilities Across Systems • Communication Paths Across Systems • Incentives for Prioritization • Missing Box Problem

43. 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

44. How to Begin: • 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

47. 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

48. How to Begin: • 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

49. Client Levels of CareAmerican 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

50. 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