Nancy K. Young, Ph.D. Cathleen Otero, M.S.W., M.P.A.

1. Current Substance Abuse Issues Impacting Child Abuse and Neglect Nancy K. Young, Ph.D. Cathleen Otero, M.S.W., M.P.A. Presented at the 15th National Conference on Child Abuse and Neglect – April 2005

2. Current Substance Abuse Issues Impacting Child Abuse and Neglect • Overview of NCSACW • The Five Clocks • Potential Consequences for Children affected by parental Substance Use Disorders • Issues regarding infants prenatally exposed to substances • Issues regarding parental methamphetamine use • Identifying parental Substance Use Disorders • A Framework and Policy Tools for Practice and Policy Changes

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. Key Barriers Between Substance Abuse, Child Welfare, and the Courts • Beliefs and values • Competing priorities • Treatment gap • Information systems • Staff knowledge and skills • Lack of communication • Different mandates

5. 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

6. Biggest challenge: The Four Clocks CLOCKS STILL RUNNING

7. Clocks Still Running ASFA Timetable Timeliness of intervention versus “Call me Tuesday.”

8. Clocks Still Running ASFA Timetable 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

9. Clocks Still Running TANF Timetable Neglect is often associated with both substance abuse and poverty.

10. Clocks Still Running 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.

11. Clocks Still Running • 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

12. 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

13. 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 • Cognition and learning disabilities

14. Children Living with One or More Substance Abusing Parent In millions

15. Number of Children Prenatally Exposed to Substances State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth5,6 SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

16. Number of Children Prenatally Exposed to Substances Total births = 4,093,000 2002 10% of total births = 409,300 Total substantiated reports for children 0-1 = 142,026 2002 Total age 0-1 in OOHC = 22,957 2001 Where did they all go?

17. 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.

18. 73 million children age 0-17 409,300 estimated substance-exposed births annually 4.093 million births annually 7.3 million children born substance-exposed Estimated substance-exposed births reported to CPS: 5.6% of all SEBs = 22,957 2.5 million CPS reports annually A Graphic Overview

19. 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.2 • 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:

20. 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.7,8 • SEBs require a higher level of public spending than many other target groups

21. 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))

22. 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

23. 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

24. 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

25. Special Issue: Methamphetamine

26. Concern Regarding Children • Need to consider prenatal as well as environmental exposure • Prenatal exposure • Need for developmental interventions • Environmental exposure includes increased risk for children of cookers • Need to know child’s status • Super labs • Cookers • Traffickers • Users

27. Worker Safety Issues • Dangers associated with being in proximity to methamphetamine users and “chemists.” • Identify potential signs of methamphetamine use in child welfare clients • Identify signs that methamphetamine is being “cooked” in or around the client’s home • Ensuring the safety of the child welfare worker in settings where methamphetamine is being used or “cooked.”

28. Issues Specific to Methamphetamine • Meth users begin younger than other drugs • Meth lasts longer acting than other stimulants (cocaine/crack) • Differ from other users in their drug use pattern—they use more days • Differ in their cognition—particularly in early abstinence • Need alternative methods of imparting information

29. Women’s Issues • Females MA users are more likely to: • Live alone with their children • Use MA more days • Smoke MA rather than snort or inject the drug • Have worse psychiatric profiles • Have worse medical, employment and psychiatric composites than male MA users • Reiber, 2000

30. Average Age First Use of Substance 13yr. 15 17 19 21 23 Downers Ecstasy Alcohol Opiates Hallucinogens Tobacco Tranquilizers Marijuana PCP Crack Cocaine Inhalants Methamphetamine 97-100% have used Over 50% have used Less than 50% have used

31. Treatment Outcomes • Outcomes have not differed from other drugs of abuse treatment studies

32. Treatment Outcomes Of 10 MA-abusing women entering treatment, After treatment: 1mo. 12mo. 24mo. 48mo. Still MA-abstinent: 6 4 3 3 3 still MA-abstinent 48 mo. after treatment

33. Treatment Outcomes • Positive treatment outcomes were achieved using: • Intensive outpatient setting • Three to five visits per week of comprehensive counseling for at least the first three months • Cognitive behavioral approach • Contingency management • Reducing consequences associated with drug use • Motivational interviewing & brief intervention models • Intervening earlier and reducing cumulative harm • Attending to co-occurring mental disorders

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

35. 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:

36. Verbal Screening Tools4Ps Plus • 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 month before you knew you were pregnant, how much beer/wine/liquor did you drink? • In the month before you knew you were pregnant, how many cigarettes did you smoke?

37. 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

38. Screening for ParentalSubstance Use Disorders: UNCOPE • 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?

39. Identifying Parental Substance Use Disorders Check list for Identifying SUDs:4 • 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).

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

41. Navigating the Pathways published by CSAT1 Established: • A framework for defining elements of collaboration • Methods to assess effectiveness of collaborative work

42. Framework and Policy Tools for Systems Change • To define linkage points across systems • To describe the components of the initiative • To assess the progress in implementation • To assist sites in measuring their implementation

43. Underlying values Joint accountability and shared outcome Information systems Training and staff development Budgeting and program sustainability Elements of System Linkages • Daily practice  screening and assessment • Daily practice client engagement and retention in care • Daily practice AOD services to children • Working with related agencies • Building community supports

44. Policy Tools Policy tools to facilitate collaborative work across systems: • Collaborative Values Inventory • Collaborative Capacity Instrument • Matrix of Progress in Linking Substance Abuse and Child Welfare Services • Screening and Assessment for Family Engagement, Retention and Recovery (SAFERR) Available at http://www.ncsacw.samhsa.gov

45. Models of Improved Services • Many communities began program models in 1990s • Paired Counselor and Child Welfare Worker • Counselor Out-stationed at Child Welfare Office • Multidisciplinary Teams for Joint Case Planning • Persons in Recovery act as Advocates for Parents • Training and Curricula Development • Family Treatment Courts

46. Models of Family Drug Treatment Courts • Integrated • Both dependency matters and recovery management conducted in the same court with the same judicial officer • Dual Track • Both dependency matters and recovery management conducted in same court with same judicial officer during initial phase • If parent is noncompliant with court orders, parent may be offered DDC participation and case may be transferred to a specialized judicial officer who increases monitoring of compliance and manages only the recovery aspects of the case • Parallel • Dependency matters heard on regular family court docket • Specialized court services offered before noncompliance occurs • Compliance reviews and recovery management heard by a specialized court officer

47. The Fifth Clock URGENCY • Every 70 seconds a baby is born 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 you already know are highly at risk.

48. The Voice of a Child Nothing But Silence By Ashley G. Age 12 January 2005

49. 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 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

50. URGENCY The Fifth Clock • 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.