Substance Abuse, Child Welfare and the courts: what's the ... · Substance Abuse, Child Welfare and...

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Substance Abuse, Child Welfare and

the Courts: What’sthe Courts: What s the Connection?

Pamela Petersen-Baston, MPA, CAP, CPP

Presented at the:

Children’s Law Conference

November 5, 2010

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7 1 47 1 4 -- 5 0 55 0 5 -- 3 5 2 53 5 2 5n c s a c w @ c f f u t u r e s . o r g n c s a c w @ c f f u t u r e s . o r g

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A Program of the

Substance Abuse and Mental Health

Services AdministrationCenter for Substance Abuse

Treatmentand the

Administration on Children, Youth and Families

Children’s Bureau

TEXT PAGE

Children s BureauOffice on Child Abuse and Neglect

2

Overview

• What is the connection?

• Strategies for collaboration

TEXT PAGE

What’s theWhat s the Connection?

3

The Hard Questions

How widespread is substance abuse in the child welfare caseload?

Why should substance abusing parents in the child welfare system be given priority in access to treatment?

Why must substance abuse be combined with mental health, family violence, poverty and other influences on child abuse and neglect?

Is treatment effective for parents who are at risk or involved with the child welfare system? What are the issues about the quality of treatment for parents in the child welfare system?

Do positive treatment outcomes assure positive reunification outcomes?

How widespread is

substancesubstance abuse in the child welfare

caseload?

4

• Practitioners often cite estimates of 40% to 80% of child welfare-involved families have substanceinvolved families have substance abuse problems.

• Report to Congress estimated between one third and two thirds of children in child welfare were affected by parental substance abuse.

(Semidei, Radel, & Nolan, 2001; Young, Gardner, & Dennis, 1998; USDHHS, 1999)

Children Living with One or Children Living with One or More More

SubstanceSubstance--Abusing ParentAbusing Parent

10.6

127,000 children in South Carolina

6.2

7.5

8.3

8.4

11%

TEXT PAGE

4.5

2.8

0 5 10 15

Numbers indicate millions

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Children Living with One or Children Living with One or More More

SubstanceSubstance--Abusing ParentAbusing Parent

Lived with a parent who was dependent

on or abusedParent Gender

TEXT PAGENational Survey on Drug Use and Health (2009)

Alcohol Illicit Drug

Father Mother

Treatment Admissions and Child Maltreatment Data

Summary, 2008

United States

South CarolinaStates Carolina

Number

Percent

Number

Percent

Total Treatment Admissions

2,016,077

100%

27,193

100%

Alcohol834,4

6241.4%

14,621

53.8%

All Other 1 181 58 6 12 57 46 2

TEXT PAGE

All Other Drugs

1,181,615

58.6%

12,572

46.2%

Child Maltreatment Victims*

758,289

20.9%

12,549

30.3%

Child Victimization Rate

9.5 11.4

1) U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2008 (Washington, DC: U.S. Government Printing Office, 20010). Tables 3.1, 3.32) Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS) Highlights - - 2008 National Admissions to Substance Abuse Treatment Services. Tables 2a, 6a. OAS Series #S-40, DHHS Publication No. (SMA) 08-4313, Rockville, MD, 2008.

*Includes those with disposition of substantiated, indicated or alternative response victim. Percentage is number of maltreatment cases out of total number of children who received a CPS investigation.

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Parents Entering Publicly-Funded

Substance Abuse Treatment

59%• Had a

child under age 18

22%• Had a

child removed by CPS

10%• If a child

was removed, lost parental rights

Based on CSAT TOPPS-II Project

Risks to Children:Different Situations for

Children

• Parent uses or abuses a substance

• Parent is dependent on a psubstance

• Special considerations when Methamphetamine production is involved

– Parent involved in a home lab or super lab

• Parent involved in trafficking

• Mother uses a substance while pregnant

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

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Past Year Substance Use by Youth Age 12 to 17

50%

Compared to African-American Youth, Caucasian Youth were more likely to use alcohol (41.4% versus 29.8%)

and illicit drugs (36.2% versus 26.7%)

Compared to African-American Youth, Caucasian Youth were more likely to use alcohol (41.4% versus 29.8%)

and illicit drugs (36.2% versus 26.7%)

37.8%34.4%33.6%

21.7%

10%

20%

30%

40%

50%

TEXT PAGE

0%

10%

Alcohol Illicit Drug

Ever in Foster Care

Source: Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care

Percent of Youth Ages 12 to 17 Needing Substance Abuse Treatment by Foster

Care Status

TEXT PAGE

Source: Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care

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Use During Pregnancy

SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2004-2005

Annual Average, Applied to 2008 South Carolina birth data: 63,001

Substance Used (Past Month)

1st Trimester

2nd Trimester

3rd Trimester

Any Illicit Drug

2.3% women1,449 infants


7.0% women 4,410 infants

20.6% women



Alcohol Use

Binge Alcohol UseState prevalence studies report 10-12% of infants or

mothers test positive for alcohol or illicit drugs at birth


12,978 infants



Number of Children Prenatally Exposed to Substances

South Carolina total live births = 63 001 (2008)63,001 (2008)

12% of total live births = 7,560

Total child victims under age 1 year = 1,544

(2008)

Where did they all go?

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

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

TEXT PAGE

but with no positive test at birth

• CAPTA legislation raises issues of testing and reporting to CPS

How Many Children in South Carolina?

• 127,000 children living with alcohol or drug-dependent parents

• 9,400 children in the child welfare system affected by parental substance abuse

• 2,500 children taken into out of home care each year affected by parental substance abuse

• 7,560 prenatally exposed infants each year

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Why should substance

abusing parents in the child welfare system be given

priority in access to treatment?

Intergenerational Effects

Substance use disorders are What we knowdisorders are

family diseases

Affected children• Children we

remove• Children we

send back home• Children we

What we know

California sample

Family • Children we leave at home

ycentered treatment

works

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Developmental Effects

Five levels of

impact on younger children

CAPTA

What we know

80-95% of prenatally

Prenatal exposure CAPTA

amended in 2003

prenatally exposed

children are not identified at birth and

just go home

peffects can be reduced

through early identification

and early intervention

Models of Priority Access

• A few states and jurisdictions have made child welfare parents a priority in accessing treatmentpriority in accessing treatment.

– Arizona Executive Order

– Sacramento

– Santa Clara

• Federal 48-hr requirement, but not reported or monitored annuallyp y

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Why must substance b b bi dabuse be combined with mental health,

family violence, poverty or other

influences on child abuse and neglect?

Health and Hospitals

Mental Health

Schools and Special Education

Developmental Disabilities

Domestic Violence

Child Development

Juvenile Justice

Family Income Support

Courts

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Comprehensive Approaches

• Integrated treatment coordinates substance abuse and mental health interventions to treat the whole person pmore effectively

• Recognizes the importance of ensuring that entry into any one system can provide access to all needed systems

• Colorado and California have developed models of links between family income support programs and child welfare

Is treatment effective for

parents who are at risk or involved

ith th hildwith the child welfare system?

What are the issues about the

quality of treatment for

parents in theparents in the child welfare

system?

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Key Questions

• Are family treatment services provided?

• Is treatment the right dose and duration?

• Does comprehensive treatment include treatment for co-occurring disorders?

• Are recovery support services available for the family?

Compliance with Medical Treatment

• > 50% of “re-occurrence” was due to lack of compliance

• > 50% of medical patients lie about compliance

TEXT PAGE

Source: McLellan, A., Metzger, D. A., Alterman, A. I., Woody, G. E., Durell, J., & O’Brien, C. P. (1995). Is addiction treatment “worth it”? Public health expectations, policy-based comparisons. Philadelphia, PA: The Penn-VA Center for Studies on Addiction and the Treatment Research Institute.

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Reasons for Disease Re-Occurrence

#1 - Lack of Compliance

#2 - Socioeconomic Factors

#3 - Family Support

#4 - Psychiatric Co-morbidity

AOD Treatment - Predictors of OutcomeOutcome

EmploymentFamily Support

Psychiatric Status

Source: McLellan, A., Metzger, D. A., Alterman, A. I., Woody, G. E., Durell, J., & O’Brien, C. P. (1995). Is addiction treatment “worth it”? Public health expectations, policy-based comparisons. Philadelphia, PA: The Penn-VA Center for Studies on Addiction and the Treatment Research Institute.

Do positive treatmenttreatment outcomes

assure positive reunification

outcomes?

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Understanding the Outcomes

Monitored by CFSR process

Need to prove that

treatment works for

What we know

Reunifications linked to

substance b

Baselines for reunification vs.

baselines for substance-

child welfare cases

abuse substanceaffected children

Research Findings

• Mothers with more employment and psychiatric problems were less likely to be reunified with their children

• Completion of 90 or more days in treatment approximately doubled their likelihood of reunification

• Mothers who were treated in programs providing a “high” level of family-related or education/employment services were approximately twice as likely to reunify

TEXT PAGE

pp y y ywith their children as those who were treated in programs with “low” levels of these services

Source: Journal of Substance Abuse Treatment, Volume 36, Issue 3, Pages 278-293 C. Grella, B. Needell, Y. Shi, Y. Hser

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Sacramento Family Dependency Drug Court

• Immediate identification of alcohol and drug problems by early intervention specialist workers

Critical components of DDC:

• Prompt assessment and placement in treatment services, usually within 2-5 working days;

• A full continuum of alcohol and drug treatment services; Intensive recovery management provided by the STARS program;

• Drug Court hearings at 30,60,and 90 day intervals to monitor compliance and ensure accountability for all parents with alcohol and drug problems (Phase I - mandatory); p ( y);

• More frequent drug court hearings for parents who are in need of additional support and monitoring in order to succeed (Phase II and III -voluntary); and,

• Timely use of incentives and progressive sanctions.

Child Placement Outcomes at 36 Months

**p<.01; ***p< 001

Comp n=173; DDC n=2086

Source: CWS/CMS

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Child Reunification Rates by DDC

Graduation Status – Over Time

TEXT PAGE

Source: STARS; CWS/CMS

The Reunification Gap: A State-level Example

Case Study:

• 63% of reunifications occur within 12 th12 months

(3,255 of 5,166 children in care)

• Per the National target of 75.2%, this state’s 12 month reunification goal should be 3,885.

• Therefore, the gap between the current and target reunification rate gis 630 children.

• 630 children 454 parents– Child-parent ratio conversion = .72

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• 454 parents need to complete treatment to meet the National Target reunification rate.

The Reunification Gap: A State-level Example

g

• To have 454 parents complete treatment, an additional 1,261 treatment spaces are necessary.– Assume 36% of parents who enter

treatment successfully complete the treatment episode

• 1,261 new treatment spaces , prepresents 4.7% of the state’s total treatment admissions (assuming no overlap).– State has 27,000 annual treatment

admissions

Tools for Collaboration:

10 Element Framework

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The Five Clocks

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

Adoption and Safe Families Act (ASFA)

• 12 months permanency plan

• 15 of 22 months in out-of-home care must petition for Termination of Parental Rights (TPR)

RecoveryO d t ti f th t f

TEXT PAGE

• One day at a time for the rest of your life

Child Development• Clock doesn’t stop

• Moves at the fastest rate from prenatal to age 5

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The Most Important Clock

• The 5th Clock: The one that’s ticking on us

H l d h t t if• How long do we have to act if

our families have

• 24 months to work and

• 12 months to reunify?

• Taking this clock seriously meansthat we take aggressive action t il th l k hild

TEXT PAGE

to reconcile the clocks on children and families

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Why Collaborate?

• Avoid duplication of effort

• Problem solving opportunities

• Exchange knowledge

• Build relationships

• Increase communication

• Improve outcomes

ChangingThe System

Getting Better at Getting Along:

Four Stages of Collaboration

ChangingThe Rules

Existing Funding

External Funding

InformationExchange

JointProjects

Sid Gardner, 1996Beyond Collaboration to Re

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Navigating the PathwaysPublished by CSAT

• A framework for defining elements of collaboration

To define linkage points across systems: where are the most important bridges we need to build?

• Methods to assess effectiveness of collaborative work

To assess differing values

To assist sites in measuring their implementation

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Mission

1. Underlying Values and Priorities

Elements of System LinkagesElements of System LinkagesThe Ten Key BridgesThe Ten Key Bridges

System Elements

Children, Family, Tribal, and Community Services

2. Screening and Assessment

3. Engagement and Retention

4. Services for Children

5. Community and Family Support

Outcomes

10. Shared Outcomes and Systems Reforms

6. Information Systems

7. Training and System Tools

8. Budget and Sustainability

9. Working with Other Agencies

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Collaborative Practice and PolicyTools

Ten Element Framework – A method to organize collaborative activities in specific practice and policy areas

Collaborative Values Inventory – An anonymous way to explore values and beliefs to facilitate the development of common principles using web‐based data collection

Collaborative Capacity Instrument – An anonymous way to assess the strengths and challenges in each of the areas of system linkages using web‐based data collection

i f i S i k i b dMatrix of Progress in System Linkages – A practice‐based approach that specifies characteristics of advance collaboration practice in the elements of system linkages

Screening and Assessment for Family Engagement, Retention and Recovery — SAFERR ‐‐ A guidebook to develop effective communication across systems while engaging families in services

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Mission


Elements of System LinkagesThe Ten Key Bridges

System Elements






Outcomes






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Underlying Values and Principles of Collaboration

Tools and Resources

• Collaborative Values Inventory

• Synthesis of Cross System Values and Principles: A National Perspective

Models

• IDTA Memoranda of Understanding and statements of shared valuesand statements of shared values and principles

Mission



System Elements






Missing Boxes

Outcomes






25

DropoffDropoff PointsPoints

50,000 Children with Substantiated Abuse/Neglect 33,000 Parents

60% of Parents Need Assessment 60% of Parents Need Assessment 19,800

50% Go for Assessment 9,900

80% Need Treatment 7,920

50% Go to First Session 3,960

30% Complete 90 Days – 1,188

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50% Reunify or Stay with Parents 594

Screening and Assessment

Tools and Resources

• SAFERR-Screening and Assessment for Family Engagement, Retention and Recovery

Models • Arizona – Families

F.I.R.S.T. Model• Washington –

GAIN-SS and CDPs statewide

• Maine-

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Mission



System Elements






Call Me Tuesday

Outcomes






Engagement and Retention

Tools and Resources• SAFERR- Screening and

Assessment for FamilyAssessment for Family Engagement, Retention and Recovery

• SAS- Substance Abuse Specialist Paper

Models • Arizona – Families F I R S T Model• Arizona – Families F.I.R.S.T. Model• Sacramento- STARS• Cuyahoga County- START

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Mission



System Elements






Outcomes






10 Element FrameworkServices to Children

• Complex interchange of biological, psychological and sociological eventsevents

• Screening is complicated by:– 1. There is no absolute profile of

developmental outcomes

– 2. Other issues in parental behavior, competence, and disorders

interact which may lead to multiple co-poccurring problems for children

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Daily Practice – Services to Children

Multiple Opportunities for Intervention

• Commonly noted consequences for children– Fetal Alcohol Syndrome (FAS)Fetal Alcohol Syndrome (FAS)– Alcohol-related neuro-developmental

disorders (ARND)• Physical health consequences• Lack of secure attachment• Psychopathology• Behavioral problems• Poor social relations/skills• Deficits in motor skills• Cognition and learning disabilities• Cognition and learning disabilities

Services to Children

Tools and Resources

• Substance-Exposed Infants: State Responses to the Problem

Models • Washington State• Research Triangle

I tit tInstitute• RPG Children's

Cluster• Miami Zero to Two

Court• Strengthening

FamiliesCelebrating

In Process, review of children’sIn the SAPTBG

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Mission



System Elements






What is the role of the RecoveryCommunity in Child Welfare Prac

Outcomes






Mission



System Elements






Outcomes






30

Joint Accountability, Shared Outcomes and Information

Systems

Tools and Resources• RPG Data codebook• Webinars on linkagesWebinars on linkages• Analysis of “what it takes to move the

CFSR needle”

Models • Michigan revised SACWIS to prioritize

families with substance use disorders• CFSR and NOMS processes

C lif i C lOMS t k 7500• California CalOMS now tracks 7500 CW parents in treatment and knows which had positive outcomes [36%]

Mission



System Elements






Outcomes






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Training and Staff Development

Tools and Resources

• NCSACW online tutorials

• Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers

• Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals

• Understanding Substance Use Disorders, Treatment and Family Recovery: A Guide for Legal Professionals

Online Training

Available at no charge at http://ncsacw.samhsa.gov

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Implementing Online Tutorials

Available at no charge at http://ncsacw.samhsa.gov

Training and Related Products

• On-Line Training

– Available at no cost

– Upon completion of the tutorial:Upon completion of the tutorial:

• Certificate awarded

• CEUs and CLEs are available

• Child Welfare Training Toolkit: Helping Child Welfare Workers Support Families with Substance Use, Mental, and Co-Occurring Disorders http://www.ncsacw.samhsa.gov/training/toolkit/olkit/

• State Legislator information resources web-pages (in development)

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Mission



System Elements






Outcomes






Budget and Sustainability

Tools and Resources

• White Paper on Funding Comprehensive Services for Families with Substance Use Disorders in Child Welfare and Dependency Courts

• Funding Family-Centered Treatment for Women With Substance Use Disorders– Detailed tables of Federal funding sources for

comprehensive services

• Sustainability discussion guide for Regional Partnership Grants and webinars

• IDTA State strategic plans for continued efforts

Models

• Milwaukee Courts Integrated Funding System

• Cost Studies in Sacramento and Sonoma

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Mission



System Elements






Outcomes






Working with Other Agencies

Partnership most frequently cited as necessary:

• Mental health services for adults• Mental health services for adults.

• Mental health services for children.

• Domestic Violence

• Housing

• Income Support (TANF, Vocational Training, Employment)

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Working with Other Agencies

Tools and Resources• Family Centered Treatment for

WomenWomen• A Review of Alcohol and Drug

Issues in the States’ Child and Family Service Reviews and Program Improvement Plans regarding Service Array

ModelsModels • Shields for Families,

PROTOTYPES, Meta House • Other multiservice agencies

Mission



System Elements






Outcomes






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Shared Outcomes System Reforms

Tools and Resources

• SAFERR communication protocols

• IDTA State communication protocols and

examples of data system improvements

• RPG Logic Model

• A Review of Alcohol and Drug Issues in the

States' Child and Family Service Reviews and

Program Improvement Plans

Models

• Guide to Cross-System Data Sources for State

and Tribal Child Welfare, Substance Abuse

Treatment and Court Systems (In Development)Treatment, and Court Systems (In Development)

• May 16, 2008: Connecting the Dots: How States

and Counties Have Used Existing Data Systems

to Create Cross System Data Linkages

– http://www.cffutures.com/webinars.shtml#May

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Levels of Technical Assistance

Level One:

Information and Sharing of Models

Level Two:

Expert Consultation and Research

Level Three:

Development of Issue‐Specific Products

Level Four:

Strategic Planning, Training Resources

and Facilitation

16 States3 Tribes1 County

53 Grantees

10 Pre‐IDTA

247 requests

366 requests

1077 requests

September 2001 through June 2009 72

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Types of TA Products

• Collaborative practice and policy tools

• Information and sharing of models

• Expert consultation and research

• Development of issue-specific products

Monographs, white papers, fact sheets

• Training resources and collaborative

facilitation

On-line courses, training materials, g

• Longer-term strategic planning and development of protocols and practice models

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National Center on Substance Abuse and Child

Welfare

• How do I access technical assistance?

– Visit the NCSACW website for resources and products at http://ncsacw.samhsa.gov

– Complete the contact form on the website

– Email us at [email protected]

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