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Improving Outcomes for Improving Outcomes for Families Affected by Families Affected by
Substance Use DisordersSubstance Use Disorders
Nancy K. Young, Ph.D., DirectorNancy K. Young, Ph.D., Director4940 Irvine Boulevard, Suite 2024940 Irvine Boulevard, Suite 202Irvine, CA 92620 714.505.3525Irvine, CA 92620 714.505.3525
www.ncsacw.samhsa.govwww.ncsacw.samhsa.gov
Betty Ford ConferenceBetty Ford ConferenceTrends and Perspectives in Women’s AddictionTrends and Perspectives in Women’s Addiction
April 13, 2004April 13, 2004
Topics Topics
NCSACWNCSACW Some NumbersSome Numbers Some HistorySome History Policy Framework and ToolsPolicy Framework and Tools ModelsModels
A Program of the A Program of the Substance Abuse and Mental Health Substance Abuse and Mental Health
Services AdministrationServices AdministrationCenter for Substance Abuse TreatmentCenter for Substance Abuse Treatment
and theand theAdministration on Children, Youth and FamiliesAdministration on Children, Youth and Families
Children’s BureauChildren’s BureauOffice on Child Abuse and NeglectOffice on Child Abuse and Neglect
MISSION:MISSION: To improve outcomes for families by To improve outcomes for families by
promoting effective practice, promoting effective practice, organizational, and system changes at organizational, and system changes at the local, state, and national levels bythe local, state, and national levels by Developing and implementing a Developing and implementing a
comprehensive program of information comprehensive program of information gathering and disseminationgathering and dissemination
Providing technical assistanceProviding technical assistance
PRODUCTS:PRODUCTS: On-Line TrainingOn-Line Training
Understanding Child Welfare and the Understanding Child Welfare and the Dependency Court: A Guide for Substance Dependency Court: A Guide for Substance Abuse Treatment Professionals – Now Abuse Treatment Professionals – Now AvailableAvailable
Understanding Addiction and Recovery: A Understanding Addiction and Recovery: A Guide for Child Welfare Workers – Fall 2004Guide for Child Welfare Workers – Fall 2004
A Guide for Judges and Dependency Court A Guide for Judges and Dependency Court Staff – Summer 2005Staff – Summer 2005
PRODUCTS:PRODUCTS: Program of In-Depth Technical AssistanceProgram of In-Depth Technical Assistance
Round 1 – Summer 2003 to Fall 2004Round 1 – Summer 2003 to Fall 2004 Colorado, Florida, Michigan, VirginiaColorado, Florida, Michigan, Virginia Assistance to Develop and Implementation State’s Assistance to Develop and Implementation State’s
Plan to Better Serve this Population of FamiliesPlan to Better Serve this Population of Families
Round 2 – Solicitation in Fall 2004Round 2 – Solicitation in Fall 2004 Seven States Offered Program, 3 States and 1 Tribe Seven States Offered Program, 3 States and 1 Tribe
will be selectedwill be selected
PRODUCTS:PRODUCTS: MaterialsMaterials
Compendium of Training CurriculaCompendium of Training Curricula Understanding Substance Abuse: A Guide for Understanding Substance Abuse: A Guide for
Child Welfare PractitionersChild Welfare Practitioners Screening and Assessment for Family Screening and Assessment for Family
Engagement, Retention and Recovery Engagement, Retention and Recovery (SAFERR) – Spring 2005(SAFERR) – Spring 2005
Some Numbers
Children Living With One or More Children Living With One or More Substance Abusing ParentSubstance Abusing Parent
4.5
2.8
6.2
7.5
8.3
8.4
10.6
0 2 4 6 8 10 12
Need Treatment for Illicit Drug Abuse
Dependent on Illicit Drugs
Dependent on Alcohol
Dependent on AOD
Dependent on Alcohol and/or NeedsTreatment for Illicit Drugs
Used Illicit Drug in Past Month
Used Illicit Drug in Past Year
In Millions
8.9 Million Childre
n
980,000 Children with Parent who Needs AOD Treatment
California’s ChildrenCalifornia’s Children
69,000 Substance-
exposed Births
2000 Census1999 Estimates
of 11%
1992 Estimates of ATOD exposure annually
Foster Care PopulationFoster Care Population
0
100,000
200,000
300,000
400,000
500,000
600,000
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
0
1
2
3
4
5
6
7
8
Total Children Children per 1,000
52% Increase over 6 Years
Number of Children in Foster Care on Last Day of Federal Fiscal Year
Foster Care Population and Persons Foster Care Population and Persons who First Used Crack or Meth in Past Yearwho First Used Crack or Meth in Past Year
*All persons age 12 and over
0
100000
200000
300000
400000
500000
600000
19801981 1982 19831984 1985 1986 19871988 1989 19901991 1992 1993 19941995 1996 19971998 19992000 20012002
0
100,000
200,000
300,000
400,000
500,000
600,000
Children in Foster Care New Crack Users* New Methamphetamine Users*
1968 1973 1980s 1990s
2004
Looking Back
Some History
TimelinesTimelines
Mid to Late 1980s – Initiating ResponsesMid to Late 1980s – Initiating Responses
Child welfare agencies began responding to Child welfare agencies began responding to an epidemic of kids coming into care and an epidemic of kids coming into care and cocainecocaine
Schools began their efforts to understand Schools began their efforts to understand prenatally-exposed children prenatally-exposed children 1987 Los Angeles Unified School District 1987 Los Angeles Unified School District
develops pilot program to understand develops pilot program to understand educational impact of prenatal cocaine educational impact of prenatal cocaine exposureexposure
Five National Reports on Substance Abuse and Five National Reports on Substance Abuse and Child WelfareChild Welfare Responding to Alcohol and Other Drug Problems in Child Responding to Alcohol and Other Drug Problems in Child
Welfare: Weaving Together Practice and Policy (1998)Welfare: Weaving Together Practice and Policy (1998)
Foster Care: Agencies Face Challenges Securing Stable Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers (1998)Homes for Children of Substance Abusers (1998)
Healing the Whole Family: A Look at Family Care Programs Healing the Whole Family: A Look at Family Care Programs (1998)(1998)
No Safe Haven: Children of Substance-Abusing Parents (1999)No Safe Haven: Children of Substance-Abusing Parents (1999)
Blending Perspectives and Building Common Ground: A Report Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (1999)to Congress on Substance Abuse and Child Protection (1999)
TimelinesTimelines
1990s – Reports on the Issues1990s – Reports on the Issues
Key Barriers Between Substance Key Barriers Between Substance Abuse, Child Welfare and The CourtsAbuse, Child Welfare and The Courts
Beliefs and ValuesBeliefs and Values Competing Priorities Competing Priorities Treatment GapTreatment Gap Information SystemsInformation Systems Staff Knowledge and SkillsStaff Knowledge and Skills Lack of CommunicationLack of Communication Different MandatesDifferent Mandates
Biggest Challenges:Biggest Challenges:
Reconciling the Reconciling the ClocksClocks
The Four ClocksThe Four Clocks
CFSR’s have documented CFSR’s have documented Case reviews found parental substance use disorders Case reviews found parental substance use disorders
were a factor in 16% to 48% of caseswere a factor in 16% to 48% of cases Need for child welfare training in addictions Need for child welfare training in addictions Gaps in servicesGaps in services Inadequate assessment and follow up on the Inadequate assessment and follow up on the
underlying needs of families, including substance underlying needs of families, including substance abuseabuse
Substance use disorders in families with repeat casesSubstance use disorders in families with repeat cases
The First ClockThe First Clock
ASFA TimetableASFA Timetable
Timeliness of intervention versus “Call me Tuesday”Timeliness of intervention versus “Call me Tuesday”
National Study on Child and Adolescent Well-National Study on Child and Adolescent Well-Being: Child Welfare Workers’ (CWW) Being: Child Welfare Workers’ (CWW)
Identification of Substance AbuseIdentification of Substance Abuse
Of the caregivers who are alcohol dependent Of the caregivers who are alcohol dependent 71% are classified by the CWW as not having an alcohol 71% are classified by the CWW as not having an alcohol
problemproblem
Of the caregivers who are drug dependentOf the caregivers who are drug dependent 73% are classified by the CWW as not having a drug 73% are classified by the CWW as not having a drug
problemproblem
CWW’s misclassify caregivers who are CWW’s misclassify caregivers who are substance dependent most of the timesubstance dependent most of the time
Minnesota DataMinnesota Data
2002 Report to the 2004 Legislature2002 Report to the 2004 Legislature Prevalence of Family Conditions at Prevalence of Family Conditions at
AssessmentAssessmentAlternative Alternative
TraditionalTraditional
ResponseResponseResponseResponse
Alcohol AbuseAlcohol Abuse 7% 7% 18% 18% Drug AbuseDrug Abuse 3% 3% 19% 19%
Timeliness of InterventionsTimeliness of Interventions
Taking CFSR findings seriously and Taking CFSR findings seriously and including remediation strategies in Program including remediation strategies in Program Improvement PlansImprovement Plans
The First ClockThe First Clock
ASFA ChallengesASFA Challenges
The Second ClockThe Second Clock
Poverty and low-income work affect neglect, Poverty and low-income work affect neglect, which is the majority of all reportswhich is the majority of all reports
Neglect is often associated with both Neglect is often associated with both substance abuse and povertysubstance abuse and poverty
TANF resources have been used in innovative TANF resources have been used in innovative models for this populationmodels for this population
Treatment aftercare focus on jobs and housing Treatment aftercare focus on jobs and housing TANF reauthorization proposes treatment be TANF reauthorization proposes treatment be
counted as a work activitycounted as a work activity
TANF TimetableTANF Timetable
““A day at a time for the rest of your life” A day at a time for the rest of your life” Recovery is a lifelong process with a disease Recovery is a lifelong process with a disease management approach not emergency caremanagement approach not emergency care
Low-dosage non-comprehensive programs do Low-dosage non-comprehensive programs do not build on what we know about effective not build on what we know about effective treatment for this populationtreatment for this population
The Third ClockThe Third Clock
Recovery TimetableRecovery Timetable
The Third ClockThe Third Clock
Recovery ChallengesRecovery Challenges
Comprehensive services and longer-term supports Comprehensive services and longer-term supports are criticalare critical Clinical treatment, clinical support and community Clinical treatment, clinical support and community
supportssupports
Recognizing the needs of children of parents in Recognizing the needs of children of parents in treatmenttreatment
The changing nature of drug use patterns and The changing nature of drug use patterns and epidemicsepidemics
Children of substance abusers need in-depth Children of substance abusers need in-depth assessments and interventions that respond to assessments and interventions that respond to their developmental status and the special needs their developmental status and the special needs created by substance use disorders in their family created by substance use disorders in their family grief, loss, separation, attachment grief, loss, separation, attachment
Adolescents who may have begun their own Adolescents who may have begun their own substance usesubstance use
The Fourth ClockThe Fourth Clock
Child Development TimetableChild Development Timetable
The Fourth ClockThe Fourth Clock
Every 70 seconds a baby is born in this country Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit who was prenatally exposed to alcohol or illicit drugs drugs
Child Development TimetableChild Development Timetable
Reconciling the ClocksReconciling the Clocks
Information Sharing & Information Sharing & Management Management
Training and Staff Training and Staff DevelopmentDevelopment
Budgeting and Program Budgeting and Program SustainabilitySustainability
Building Community Building Community SupportsSupports
Connecting AOD, CWS, Court Systems: Connecting AOD, CWS, Court Systems: Elements of System Linkages*Elements of System Linkages*
From CSAT Technical Assistance Publication (TAP) 27: Navigating the Pathways *Revised March 2003From CSAT Technical Assistance Publication (TAP) 27: Navigating the Pathways *Revised March 2003
Underlying ValuesUnderlying Values Screening and Screening and
AssessmentAssessment Client Engagement Client Engagement
and Retention in Careand Retention in Care AOD Services to AOD Services to
Children Children Joint Accountability Joint Accountability
and Shared Outcomesand Shared Outcomes Working with Related Working with Related Agencies and Support Agencies and Support SystemsSystems
Policy Framework and ToolsPolicy Framework and Tools
10 Element Framework10 Element Framework Collaborative Values InventoryCollaborative Values Inventory Collaborative Capacity InstrumentCollaborative Capacity Instrument Matrix of Progress in LinkagesMatrix of Progress in Linkages Screening and Assessment for Family Screening and Assessment for Family
Engagement, Retention and Recovery Engagement, Retention and Recovery -- SAFERR -- SAFERR
1. Values and Common Principles1. Values and Common Principles
Issues to AddressIssues to Address Who is the Client -- Parent, Child, Who is the Client -- Parent, Child,
Family?Family? Can AOD Users/Abusers/ Can AOD Users/Abusers/
Addicts/Alcoholics be Effective Parents?Addicts/Alcoholics be Effective Parents? What is the Goal -- Recovery, Child What is the Goal -- Recovery, Child
Safety, Family Preservation, Economic Safety, Family Preservation, Economic Self-sufficiency?Self-sufficiency?
How to Begin:How to Begin:
Use Tools Such As the Collaborative Use Tools Such As the Collaborative Values Inventory to Identify and Values Inventory to Identify and Resolve Differences That Exist Across Resolve Differences That Exist Across SystemSystem
Ensure Conversation Happens at Ensure Conversation Happens at Policy, Supervisory and Front-line Policy, Supervisory and Front-line LevelsLevels
Issues to AddressIssues to Address Roles and Responsibilities Across Roles and Responsibilities Across
SystemsSystems Communication Paths Across SystemsCommunication Paths Across Systems Incentives for PrioritizationIncentives for Prioritization Missing Box ProblemMissing Box Problem
2. Daily Practice -- Client Intake, 2. Daily Practice -- Client Intake, Screening and AssessmentScreening and Assessment
Too Often We Practice…Too Often We Practice…“Don’t Ask, Don’t Tell”“Don’t Ask, Don’t Tell”
Nationally, we have “missing box” problemsNationally, 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
Clarify Intake Procedures and Clarify Intake Procedures and AOD/Child Safety Screening AOD/Child Safety Screening ProtocolsProtocols
Decide on Team, Tool, Method, Roles Decide on Team, Tool, Method, Roles and Responsibilities to and Responsibilities to Provide AOD Expertise to Child Welfare Provide AOD Expertise to Child Welfare
Workers in Investigative/Assessment Workers in Investigative/Assessment Phases Phases
Ensure Parents Seeking Treatment Ensure Parents Seeking Treatment Receive Needed Supports for Child Receive Needed Supports for Child SafetySafety
How to Begin:How to Begin:
3. Daily Practice -- Client 3. Daily Practice -- Client Engagement and Retention in Engagement and Retention in
TreatmentTreatment
Issues to AddressIssues to Address Outreach and Engagement StrategiesOutreach and Engagement Strategies Addressing Motivation to ChangeAddressing Motivation to Change Cross-system Agreement on Approaches Cross-system Agreement on Approaches
to Relapseto Relapse Responding to Clients’ Progress in Responding to Clients’ Progress in
TreatmentTreatment
Implement Assessment and Implement Assessment and Interventions based on Readiness to Interventions based on Readiness to ChangeChange
Develop Mechanism to Re-engage Develop Mechanism to Re-engage Clients in CareClients in Care
Ensure AOD Treatment and CPS Ensure AOD Treatment and CPS Practice is Responsive to Clients’ Practice is Responsive to Clients’ Individualized NeedsIndividualized Needs
How to Begin:How to Begin:
4. Daily Practice -- Services to 4. Daily Practice -- Services to ChildrenChildren
Issues to AddressIssues to Address Prevention, Early Intervention, and Prevention, Early Intervention, and
Treatment Services for Children in Treatment Services for Children in Contact with CPSContact with CPS
Content of Independent Living Programs Content of Independent Living Programs on Parental Substance Abuseon Parental Substance Abuse
PediatricsPediatrics (1999) v.103:1083 – 1155, Special (1999) v.103:1083 – 1155, Special Topics on Children and Adolescents in Families Topics on Children and Adolescents in Families Affected by Substance AbuseAffected by Substance Abuse
http://www.pediatrics.org/cgi/content/full/103/5/SI/1083http://www.pediatrics.org/cgi/content/full/103/5/SI/1083
Develop Partnerships to Respond to Potential Develop Partnerships to Respond to Potential Neuro-Developmental Effects of Prenatal Neuro-Developmental Effects of Prenatal Substance ExposureSubstance Exposure
Provide Prevention and Intervention Services to Provide Prevention and Intervention Services to Children and AdolescentsChildren and Adolescents
Ensure that Youth Receive Appropriate Youth Ensure that Youth Receive Appropriate Youth Development Intervention and ActivitiesDevelopment Intervention and Activities
Ensure that ILP Teens Receive Appropriate Ensure that ILP Teens Receive Appropriate Information Related to Risks of Substance AbuseInformation Related to Risks of Substance Abuse
How to Begin:How to Begin:
5. Information Sharing and Data Systems5. Information Sharing and Data Systems
6. Training and Staff Development6. Training and Staff Development
7. Joint Accountability and Shared 7. Joint Accountability and Shared OutcomesOutcomes
8. Budgeting, Funding and Program 8. Budgeting, Funding and Program
SustainabilitySustainability
Other System Supportive Other System Supportive ElementsElements
We Know AOD Treatment PaysWe Know AOD Treatment Pays
100 Women100 WomenAverage cost $6,800Average cost $6,800
$680,000$680,000
150 Children150 ChildrenAverage 1.5 years Average 1.5 years
in out-of-home care in out-of-home care @ $24,000 per year@ $24,000 per year
$5.4 Million$5.4 Million
Foster Care Cost Offset Pays for all 100 Women’s Treatment Nearly 2 Times Over
30 Women recover with one episode of treatment 45 Children reunify at
6 monthsSaves $1.1 Million
Primary Health Primary Health CareCare
Domestic ViolenceDomestic ViolenceTraumaTraumaMental HealthMental HealthDental HealthDental Health
10. Working with Related Agencies10. Working with Related Agencies
TransportationTransportationChild Care Child Care MedicaidMedicaidHousingHousingEconomic SecurityEconomic SecurityEducation for Education for
Mother and Mother and ChildrenChildren
9. Developing Community Supports9. Developing Community Supports
Many communities began program models in 1990sMany communities began program models in 1990s
Models of Improved ServicesModels of Improved Services
Family Treatment CourtsFamily Treatment Courts
Training and Curricula DevelopmentTraining and Curricula Development
Persons in Recovery act as Advocates for Persons in Recovery act as Advocates for ParentsParents
Multidisciplinary Teams for Joint Case Multidisciplinary Teams for Joint Case PlanningPlanning
Counselor Out-stationed at Child Welfare Counselor Out-stationed at Child Welfare OfficeOffice
Paired Counselor and Child Welfare WorkerPaired Counselor and Child Welfare Worker
Jointly FundedJointly Funded Department of Health and Human ServicesDepartment of Health and Human Services
Substance Abuse and Mental Health Services Substance Abuse and Mental Health Services Administration, Center for Substance Abuse ServicesAdministration, Center for Substance Abuse Services
Administration on Children, Youth & Families, Administration on Children, Youth & Families, Children’s Bureau, Office on Child Abuse and NeglectChildren’s Bureau, Office on Child Abuse and Neglect
Assistant Secretary for Planning and EvaluationAssistant Secretary for Planning and Evaluation
Department of JusticeDepartment of Justice National Institute on JusticeNational Institute on Justice Drug Court Program OfficeDrug Court Program Office
Every 70 seconds a baby is born in this country Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit who was prenatally exposed to alcohol or illicit drugs drugs
Every minute and a half, one of those babies goes Every minute and a half, one of those babies goes home without screening or any effort to begin early home without screening or any effort to begin early interventionintervention A baby and a family we already know are highly at riskA baby and a family we already know are highly at risk
The Fifth ClockThe Fifth Clock
UrgencyUrgency
The fifth clock is the one that is ticking on The fifth clock is the one that is ticking on us…it measures how fast we get it…how us…it measures how fast we get it…how rapidly we respond to human needs that grow rapidly we respond to human needs that grow larger by the day larger by the day
We have to measure what we do against We have to measure what we do against what what needs doingneeds doing, not against what we did , not against what we did last yearlast year
The Fifth ClockThe Fifth Clock
UrgencyUrgency