Family-Based Recovery:Home-based Treatment for
Families Affected by Parental Substance Abuse
Managing Risk in the Best Interest of the Child
Presentation Collaborators
Yale Child Study Center
Jean Adnopoz, M.P.H.
Karen E. Hanson, L.C.S.W.
Dale Saul, Ph.D.
Jeffrey J. Vanderploeg, Ph.D.
The State of Connecticut
Department of Children And Families
Peter Panzarella, M.A.
Connecticut
• Population - 3,409,549– Approximately 750,000 under age 18
• No County Government (169 Town Governments)
• CT Department of Children and Families is a consolidated Children’s Agency with mandates:– Child Welfare– Children’s Behavioral Health– Juvenile Justice– Prevention
Connecticut Department of Children and Families
• DCF serves at any point in time 36,000 children and 16,000 families across mandates
• DCF with Department of Social Services (Medicaid) carved out Behavioral Health and manage the Connecticut Behavioral Health Partnership
• DCF Behavioral Health develops and implements policy, programs and services in the community
• DCF has developed a broad array of intensive in-home behavioral health services
Drug Use in Connecticut • In Connecticut during 2005-2006 (average),
9.2% of men and women ages 12 and older reported using illicit drugs in the past month, compared to 8.2% overall in the U.S.
• In Connecticut in 2008, a study of women of childbearing age (18-44 years) revealed that:– 18.7% of women of reported smoking, compared to
20.0% of women overall in the U.S.– 16.0% of women reported binge drinking in the past
month, compared to 14.8% overall in the U.S.
Source: Peristats March of Dimes
Connecticut Substance Abuse Screening GAIN Short Screen Data for Protective
Services
Family-Based Recovery: History
• Stages of Community Readiness– No Awareness– Denial– Vague Awareness– Preplanning– Preparation– Initiation– Stabilization
(From: National Implementation Research Network) http://www.fpg.unc.edu/~nirn/resources/publications/Monograph/index.cfm
Family-Based Recovery:Community Readiness
• 2005 Conference and Report (Funded by AIA/DCF)
• Disseminated the latest research on substance-exposed infants and their families in a report Attachment & Recovery: Caring for Substance Affected Families
http://aia.berkeley.edu/media/pdf/attachment_recovery.pdf• Explore systems collaboration strategies and
participate in the development of regional collaborative networks to best serve the needs of Connecticut families
Family-Based Recovery Recommendations 2005
• Comprehensive community based care for child and family
• Importance of attachment theory in service design
• Co-occurring problems and housing needs
• Implement best practices
Family-Based Recovery 2006 • Re-design of DCF funded Substance
Abusing Parents/ Children at RISK programs combined funding with In-Home Behavioral Health
• DCF, Yale Child Study Center and Johns Hopkins University collaborated on model development
• Infrastructure developed for the needed Quality Assurance and Consultation (Family-Based Recovery Services)
• Request for Proposal was released in 2006 for five service providers
Family-Based Recovery
• DCF contracted with 6 providers• Yale Child Study Center – provides
QA• DCF developed a MOA with the
University CT Health Center on independent evaluation – Qualitative Analysis of FBR
Implementation– Quantitative Analysis of (Matched
Group Design)
FBR: Opportunity
• Family-Based Recovery (FBR) integrates two treatment modalities to focus on attachment, parenting, substance abuse recovery and psychotherapy.– Coordinated Intervention for Women and
Infants (CIWI), an attachment-based parent-child therapeutic approach (Yale Child Study Center)
– Reinforcement-Based Treatment (RBT), a contingency management substance abuse treatment model (John Hopkins University)
FBR Mission
The mission of FBR is
1) to ensure that children develop optimally in drug-free, safe and stable homes with their parent/s
2) to develop a replicable, evidence-based practice model
FBR Key Constructs
• Attachment critical for healthy development
• Substance abuse treatment works
• Risk management for stability and permanence
FBR Key Constructs
FBR draws on the wish of most adults to be recognized as competent to engage them in substance abuse recovery and promote adequate parenting behaviors
The FBR Way
FBR is more than a treatment for parents who are using substances: it is a way of engaging, treating and being with a client and his/her children. The FBR approach incorporates good clinical skills, motivational interviewing techniques with lessons learned about home-based work.
The FBR Way
Once the risk for relapse and child neglect/abuse decreases, the work expands to address other client-identified goals. The FBR team supports and encourages the client’s efforts towards change in all aspects of their life: education, relationships, parenting. There are no limits to success for FBR clients.
The ABC’s of FBR
• Acceptance
• Building Trust
• Commitment to Engagement
Acceptance
• Staff need to accept clients where they are in order to promote change and allow clients to determine their own goals
• Staff will be exposed to family systems and environments that might differ from their own experiences and values– Differences can cause discomfort
– Individuals vary in their ability to conduct in-home work
Building Trust
Trust is an essential element of effective intervention: building trust requires a commitment to the process of engagement and a willingness to endure testing, rejection, frustration and hostility
Commitment to Engagement
Key values are:– Respect– Patience – Persistence– Willingness to allow families to lead
the intervention– Early success offering concrete
service can enhance initial engagement
Putting it together
CIWI RBT
DCFFBR
The FBR Team
FBR Teams is composed of:• 2 Full-Time Master’s level clinicians
– 1 Clinician provides parent-child related interventions to six families
– 1 Clinician provides sobriety-related interventions to six families
• 1 Full-Time Bachelor’s level Family Support Specialist
• A Half-Time Supervisor• A Part-Time Psychiatrist
FBR Clients
• A parent who is actively abusing substances and/or has a recent history of substance abuse (w/in 30 days)
• A child who is:–under the age of 24 months– resides with the index parent at the
time of referral, or– in foster care with a plan for
imminent reunification
Parent-Infant Intervention
Complex Families
• FBR families: – Often come to parenting with legacy
of childhood emotional neglect and abuse, loss, abandonment
– Problematic relationships in adulthood– Emotion regulation more challenging
with neglect/abuse hx, and for those modulating emotion with substance use
Emotion Regulation• Parenting that requires emotion
regulation can easily overwhelm/be a source of disconnection
• Goal: “Overriding” first response of anger or hopelessness, and reflecting on what is going on with this child at this moment
• FBR listens, observes, reflects with parents, contains the moment
Infant Mental Health and Attachment
• Infant Mental Health: the developing capacity of the very young child to experience, regulate and express emotion; form close, secure interpersonal relationships; explore and learn—all in the context of family, community and cultural expectations
Attachment
• Attachment theorist Bowlby stated that for infants to survive, – They must behave in ways that help
keep parents close and communicate in ways that get parents to respond
– Their parents must be able to understand them
Attachment
• A young child’s relationship with the primary caregiver is key to healthy development in socio-emotional, cognitive and health domains
• Parents’ perceptions of being parented affects how they parent and how they see their child
Attachment-based Work
• Fosters change in maladaptive attachment relationships
• Targets Internal Working Model of the relationship for both parent and child
Infant Mental Health Approach
• FBR uses an Infant Mental Health approach:– Encourages parent to identify and
explore feelings re parenting– Focuses on the infant’s feelings:
“speaking for the baby”– Focuses parent on the needs of the
child– Links past with current caregiving
experiences
Infant Mental Health Approach
Not parent education:FBR uses everyday moments—
feeding, bathing, reciprocal play, singing, talking, touch-- to help parents make connections between feelings, action, and consequences of acting on feelings in the parent-child relationship.
What behaviors frighten the parent or child, what brings them close?
Competent Parents, Competent Babies
• We use the opportunity of a baby to help parents resolve issues with early caregivers (“Ghosts in the Nursery”) that are interfering with the capacity to parent and establish secure attachments
• Our task: to help parents feel competent and be a “secure base” from which their children can explore the world; for babies to feel understood and safe in their parents’ care
Reflective Functioning
• RF: seeing from the child’s perspective, or being able to make sense of the child’s behavior, emotion, feelings
• FBR uses natural parent-child interaction as opportunity for intervention: moment of anticipating/understanding a need; moment of shared delight or when parent can soothe child; staying present with child despite stress
Reflective Functioning
• Techniques to enhance RF:– Helping parent identify what emotions
are baby’s and what are parent’s – Helping parent see baby as separate
being, developing with age-appropriate behaviors and needs
– Helping parent feel her/his unique importance to this child
Parent-Child Measures
• Measures that inform and guide the parent-child work are:– Parent Stress Inventory –Short Form– Edinburgh Postnatal Depression Scale– Postpartum Bonding Questionnaire– Genogram– Ages and Stages (ASQ and ASQ-Social
Emotional) Questionnaires
Substance AbuseTreatment
Reinforcement-based Treatment
• Reinforcement-based Treatment (RBT) is an evidence-based behavioral approach to substance abuse treatment.
• RBT incorporates:– Community Reinforcement Approach
(Budney & Higgins, 1998)
– Motivational Interviewing (Miller & Rollnick, 1992).
FBR: Basic Principles
Positive reinforcement is the most effective means of producing behavior change.
– The best way to eliminate an individual’s drug use is to offer competing reinforcers that can take the place of drug use
– Competing reinforcers: People, Places and Things that can take the place of drug use
– FBR believes that the infant/child is the primary positive reinforcer
FBR Tools for Treating Substance Abuse
• Functional Assessments
• Contracts
• Graphs
• Feedback Report
• Drug Testing/Vouchers
Functional Assessment
The Functional Assessment (FA) is a clinical instrument that structures the gathering of information on a client’s drug use at intake and after each relapse. Information is organized into categories:– Internal and external triggers– Behavior (route of use, amount)– Short-term positive consequences– Consequences
Contracts
Contracts are used throughout treatment• Whenever there is a need to emphasize a
behavioral goal: “critical time points”
• Early on in treatment as an agreement to “sample” abstinence
– Sobriety Sampling Contract signed as initial contract at intake
• Clients might “break the contract” and use, but hope contract will make the individual stop and ponder this choice
A clinical tool that: • Makes abstinence and abstinence-
related goals salient to the client• Helps clients understand the ongoing
relationship between substitution behaviors and abstinence
• Provides a concrete way for the clinician to reinforce (both socially and tangibly) progress towards goals
• Helps clinician predict relapses
Graphs
Days Clean Graph_______'s Days Clean from _____________
0123456789
10111213141516171819202122232425262728293031
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Day of Month _____________
To
tal
days c
lean
Isabel PCP
Congratulations to me!
Refused testing
August
Isabel’s PCP
Mood Graph
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
__Isabel_'s Daily Mood
Day of Month _____________
Kids removed due to PCP use
Visit with kids
Feedback ReportFeedback is a technique that has been shown effective in getting clients to think about change.– Similar to how patients in the medical
setting view results of cholesterol testing, blood pressure
– Feedback is tailored to the individual and provides specific scientific results that carry weight
Social Club
A weekly group for clients and their children during which the clients:
• Receive peer and staff acknowledgement (reinforcement) and support for parenting and abstinence
• Practice interacting with other non-drug using parents in a non-drug environment
• Provide some continuity after graduation from FBR
Social Club
• Whatever the topic or activity, a goal of Social Club is for the conversation to ultimately link to issues of parenting and/or recovery.
• It is the role of FBR staff to link the group topic/activity to parenting and/or substance use.
• As the group process evolves and membership stabilizes this time will generally be client-led.
Drug Testing
• The team conducts substance abuse screening (urine and/or breathalyzer) at each home visit
• An 8-panel urine dip stick yields results in 5 minutes
• Clients receive a $10 gift card for each clean screen during the first part of treatment
• Clients can earn up to $720
Family-Based Recovery Services
FBR Services
• FBR Services provides:– Weekly 1 hour consultation with each
site– Weekly ½ hour consultation for each
supervisor– Quarterly network trainings– Quarterly QA reports to sites and DCF– Annual credentialing – Manual
Quality Assurance Approach and Goals
Goals of Quality Assurance:• Data collection that is accurate and timely
• Monitor adherence to clinical services inherent to FBR model (e.g., FBR Tools and Measures)
• Provide quarterly reports to DCF that describe FBR client population and programmatic adherence measures
– One network (aggregated) report– One report for each site on adherence data
FBR Network Case, Caregiver and
Index Child Characteristics
FBR Network Cases/Clients Served
Site Active Cases Active Clients
New Intakes
New Discharges
Site 1 14 28 5 4
Site 2 13 27 2 4
Site 3 17 35 7 6
Site 4 18 41 7 9
Site 5 16 36 7 4
Site 6 14 28 3 3
Quarter Total 92 195 31 30
Program to Date
316 680 316 254
FBR Network: Referral Source
91%
1%
7%
DCFOtherMissing
FBR Network: Family Makeup
15%
82%
3%
CouplesMother onlyFather only
FBR Network: Mother’s Age
13%
38%
29%
10%10%
17-2021-2526-3031-3536+
FBR Network: Maternal Marital Status
74%
8%12%
1%
0% 6%Single, never marriedDivorced/separatedMarriedWidowedOtherMissing/unknown
FBR Services: Maternal Education
35%
33%3%
15%
2%
11%Some High SchoolHS Grad/GEDTrade/VocationalSome CollegeCollege Grad. or GreaterMissing
FBR Network: Father’s Age
7%
30%
23%14%
25%
17-2021-2526-3031-3536+
FBR Network: Paternal Marital Status
57%
9%
23%
11%
Single, never marriedDivorced/separatedMarriedWidowedOtherMissing/unknown
FBR Services: Paternal Education
34%
36%2%
29%
Some High SchoolHS Grad/GEDSome CollegeMissing
FBR Network: Child Demographics
1%
62%11%
12%
14% 1%
Child’s Age
In Utero
0-6 months
7-12 months
13-18 months
19+ months
Missing
52%48%
Child’s Gender
BoysGirls
FBR Network: Child Race/Ethnicity
31%
0%
14%38%
14%2%
African-AmericanAsianBiracialCaucasianHispanicMissing
FBR Services: Child Placement at Intake
4%
87%
8% 1% 0%
Child’s Living Situation
Foster CareHome with Bio. ParentsWith RelativesOtherMissing
Parental Substance Use and Clinical
Characteristics
Maternal Risk Factors
Psych
iatri
c Illness
Physical A
buse
Sexual
Abuse
Domes
tic V
iole
nce
Sold D
rugs
Prostit
ution
Crimin
al Convi
ction
Probat
ion/P
arole
0
20
40
60
80
100
46
23 25
43
10 6
35
15
1017 17 13 17 16 12 9
Yes Unknown/Missing
Paternal Risk Factors
Psych
iatri
c Ill
ness
Physic
al A
buse
Sexual
Abuse
Domes
tic V
iole
nce
Sold D
rugs
Prost
itutio
n
Crimin
al C
onvict
ion
Probat
ion/P
arole
0
20
40
60
80
100
23 2011 16
29
0
48
2520 21 27 23 27
18 23 21
Yes Unknown/Missing
Index Child Clinical and Risk Characteristics
Child Risk Characteristics
N Mean Range
Gestational Age
212 37.9 weeks (s.d. = 3.1 weeks)
27 - 42 wks.
Birth Weight 198 6.3 lbs (s.d. = 1.3 lbs.) 2.2 – 9.4 lbs.
Case Outcomes
Duration of Services
• Kaplan-Meier survival curve plots estimated LOS based on all available data (open and closed cases)
• Using this method, the median length of time in the program is 6.2 months
• Among discharged cases (236), only 7% have been discharged in less than one month after referral
FBR Tox Screen Data
• Total of 17,298 screens program to date• Among the 17,298 screens to date, 77% have been
clean, 23% have been positive for one or more substances– 71% of positive screens were for marijuana– 9% cocaine – 9% prescription drugs– 9% PCP– 6% opiates– 3% other
Clean Tox Screens
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 1
0
Week 1
1
Week 1
2
Week 1
3
Week 1
4
Week 1
50%
10%20%30%40%50%60%70%80%90%
100%
43%
58%65%
69% 71% 73% 73% 74%
70%
75% 75%79% 78% 79% 79%
Percent of Clients with Clean Urine Screen, by Weeks in Program (N=228)
Clean Screen
Child Placement at Discharge
72%
12%
10%2% 4%
Home with Bio. Parents
Relative's Care
Foster Care
Other
Missing
Clinical MeasuresMeasures
NPre-Test Score
Post-Test Score
Change Score and
Significance
Edinburgh Depression Scale 255
Total Score 5.95 5.05 -0.90 **
Parenting Stress Index-Short Form
112
Total Score 67.62 60.89 -6.73 **
Parenting Distress 26.05 22.30 -3.75 **
Parent-Child Dysfunctional Interaction 18.89 16.86 -1.93 **
Difficult Child 22.44 21.18 -1.26 NS (p=.06)
Parental Bonding Questionnaire 100
Total Score 5.89 4.04 -1.85 **
Impaired Bonding 3.53 2.49 -1.04 **
Rejection-Anger 0.77 0.53 -0.24 NS
Anxiety-Care 1.57 1.02 -0.55 **
Risk of Abuse 0.04 0.00 -0.04 NS
AcknowledgementsYale UniversityJean AdnopozKaren E. HansonChristian M. ConnellDale SaulJeffrey J. Vanderploeg Jeanette RadawichAmy Myers
Johns Hopkins/U. of Maryland
Michelle TutenCindy SchaefferJennifer Ertel
Dept. of Children & FamiliesRobert PlantPeter PanzarellaFrancis GregoryTere Foley
University of ConnecticutJo HawkeKaren Steinberg