Improving Outcomes for Families Affected by Substance Use ... · Round 2 Summary Findings • Lkf i...

National Center on Substance Abuse and Child Welfarehttp://www.ncsacw.samhsa.gov 1

Improving Outcomes for Families Affected

by Substance Use Disorders:Disorders:

Trends, Lessons and Practice Implications

Ken DeCerchio, MSW, CAPFlorida 2010 Dependency Summit

August 26 2010

A Program of theSubstance Abuse and Mental Health Services

AdministrationCenter for Substance Abuse TreatmentCenter for Substance Abuse Treatment

&the Administration on Children, Youth and Families

Children’s BureauOffice on Child Abuse and Neglect

NCSACW Mission:

To develop knowledge and provide technical assistance to Federal, State, local agencies andassistance to Federal, State, local agencies and

Tribes to improve outcomes for families with substance use disorders in the child welfare and

family court systems


Where We’ve Been

• Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy Young, Gardner & Dennis; CWLA

• Foster Care: Agencies Face Challenges Securing Stable Homes for Children of

3

Securing Stable Homes for Children of Substance Abusers General Accounting Office

• Healing the Whole Family: A Look at Family Care Programs Children’s Defense Fund

Where We’ve Been

• No Safe Haven: Children of Substance-Abusing Parents Center on Addiction and Substance Abuse Columbia

University

• Blending Perspectives and Building

4

Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection Department of Health and Human Services


Identified barriersIdentified barriers1. Differences in values and perceptions of primary

li t

Summary of the Five National Reports

client

2. Timing differences in service systems

3. Knowledge gaps

4. Lack of tools for effective engagement in services

5. Intervention and prevention needs of children

6 Lack of effective communication6. Lack of effective communication

7. Data and information gaps

8. Categorical and rigid funding streams as well as treatment gaps

5

Leadership of the Federal Government onSubstance Abuse and Child Welfare Issues

1999 Report to Congress: Blending Perspectives and Building Common Ground

2000 – 2001 Regional State Team Forums

2002 ‐ 2007 National Center on Substance Abuse and Child Welfare

TEXT PAGE

2007 – 2012 Re‐funding National Center on Substance Abuse and Child Welfare

2007 – 2012 Regional Partnership Grants

6


Leadership of the Federal Government

• Five National Goals Established Building Collaborative Relationships

Assuring Timely Access to Comprehensive Substance Abuse Treatment Services

Improving our Ability to Engage and Retain Clients in Care and to Support Ongoing Recovery

Enhancing Children’s Services

Filling Information Gaps7

NCSACW In‐Depth Technical Assistance Sites Children’s Bureau Regional Partnership Grants

OJJDP Family Drug Courts

US DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services AdministrationAdministration for Children and Familieswww.samhsa.gov

NCSACW IDTA Sites = 20 Sites

16 States

3 Tribal Communities

1 County

14 OJJDP Sites


Good ThingsGood Things Going on in

Florida

9

Good Things Going on in Florida

• 25 Family Drug Courts

• SA/CW Collaboration/Family Intervention Specialists

Reductions in Out of Home Care• Reductions in Out-of Home Care

• Chapter 39, Part 1. SA Services. Goals:

– To ensure the safety of children

– To prevent and remediate the consequences of substance abuse on families involved in or at risk of entering child welfare

TEXT PAGE

– To expedite permanency for children and reunify healthy, intact families when appropriate

– To support families in recovery

10


• Quality Improvement Plan for CFSR– Innovation Sites

Good Things Going on in Florida

– Family Centered Practice

– TA request to the NCSACW

• Family Preservation Protocol

• Services Integration Training

• Trauma Informed Services

TEXT PAGE

• Co-Occurring Disorders Initiative

• Local partnerships through CBCs, Regional Offices and Treatment Agencies

• National model on interventions for substance-exposed infants 11

The Hard Questions:Topics for Discussion

Prevalence: How widespread is substance abuse in the child welfare caseload?

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

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

Treatment and Beyond: Is treatment effective for parents who are at risk or involved with the child welfare system? What services and supports should be given to infants, children and youth of substance-abusing parents in the child welfare system?

Outcomes: Do positive treatment outcomes assure positive reunification outcomes?

Technical Assistance Resources

Tools for Collaborative Practice


How widespread is substance abuse insubstance abuse in

the child welfare caseload?

How Many Children?

• 8,300,000 children living with alcohol or drug-dependent parents

• 700,000 children in the child welfare system affected by substance abuse

• 500,000 prenatally exposed infants each year

• 9,000,000 prenatally exposed 0-18 year olds


Children Living with One or More Substance-Dependent Parent

10.6

~460,870 Florida Children

6.2

7.5

8.3

8.4

TEXT PAGE

4.5

2.8

0 5 10 15Numbers indicate millions

15

Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection Washington, DC: Department of Health and Human Services. 1999

The Annie E. Casey Foundation, Kids Count Data Center. Accessed 7.20.10

Child Maltreatment By Age Group, 2006Child Maltreatment By Age Group, 2006

United States Florida

Rate per Rate perAge Group of Victims Number

Rate per 1,000

NumberRate per

1,000

Age < 1 100,142 24.4 14,089 60.4

Age 1-3 172,940 14.2 28,490 42.5

Age 4-7 213,194 13.5 32,611 38.0

Age 8-11 170 944 10 8 25 582 29 9Age 8-11 170,944 10.8 25,582 29.9

Age 12-15 170,635 10.2 24,783 27.0

Age 16-17 54,029 6.3 8,995 18.7

Total 881,884* 12.1 134,550 33.5

* Total U.S. number does not include additional 3,110 children whose ages were unknown.Source: U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2006. (Washington, DC: U.S. Government Printing Office, 2008). Tables 3‐3, 3‐9.

16


Child Welfare Caseload Snapshot

As of April 201029 839 children on caseload– 29, 839 children on caseload• 11, 197 in-home• 18, 642 out-of-home

– Estimate of parents caregivers with SAMH needs: 7,500 to 13,000

– About 55,000 adult SA treatment admissions

Substance Abuse Prevalence in Statewide Assessment

• A 2003-2004 updated survey to determine progress indicated (Statewide Assessment):progress indicated (Statewide Assessment): – 1999 - 52% of Florida’s protective supervision

cases required substance abuse treatment in the case plan for one or more caregivers; 47.6% of these cases documented participation in treatment.p p

– 2004 - 50.5% of protective supervised case plans documented caretaker substance abuser treatment needs. 45% were admitted and 68% successfully completed treatment.


Substance Abuse Prevalence in Statewide Assessment

• The Child Welfare Integrated Quality Assurance (CWIQA) reviews that were conducted from February to June 2005 revealed that (Statewide Assessment):– Approximately 44% of the case files reviewed contained

requirements for one or more parents to obtain substance abuse treatment.

– Documentation in case files indicating that the parent either completed treatment or was receiving treatment at the time of the review was diverse. (Percentage of “yes” ranges from 36% to 94%) The overall QWICA sample performance was 50%.

– Generally there was more success with mothers than fathers in their commitment to enter and complete treatment.

Substance Abuse Prevalence in Round 2 CFSR

• Primary reason for opening case (Final Report):Substance abuse by parent(s)– Substance abuse by parent(s)• 12 (29%) of out of home cases (N=41)• 5 (21%) of in home cases (N=24)

– Substance abuse by child• 0 of out of home cases (N=41)( )• 1 (4%) of in home cases (N=24)


Round 2 CFSR Summary Findings

• Substance abuse by parents was reported to impact repeat maltreatment and prevent reunification and permanencyp p y

• Conflicting timelines for parents entering and completing substance abuse treatment programs and meeting the requirements of the court.

– Parents required to complete substance abuse programs may not be able to complete these programs within the time period (12 months and less) required by the case plan

d t (Fi l R t)and courts (Final Report).

• Need for additional staff training on substance abuse and understanding its impact on families affected by substance use disorders

Source: Statewide Assessment and CFSR Final Report

Round 2 Summary Findings

L k f i f t h t l h lth• Lack of services for parents, such as mental health services, substance abuse treatment, affordable day care, and services for persons with a dual diagnosis, are not as developed nor as comprehensive as the service array for children.

– Other services that maintain a wait list are wraparound services, substance abuse services for adults and youth, and mental health services (Statewide Assessment).

• Issues with family assessments not detecting problems such as domestic violence and substance abuse at an early stage.

Source: Statewide Assessment and CFSR Final Report


Florida 2007 AFCARS

Alcohol Abuse Parent

No Yes Total

Florida National Florida National Florida NationalFlorida National Florida National Florida National

Count 44,346 673,795 2,983 53,435 47,329 727,230

Percent 93.7% 92.7% 6.3% 7.3% 100.0% 100.0%

Drug Abuse Parent No Yes Total

Florida National Florida National Florida National

Count 29,310 558,024 18,019 169,207 47,329 727,231

Percent 61.9% 76.7% 38.1% 23.3% 100.0% 100.0%

Percent and Number of Children in Florida with Terminated Parental Rights

by Reason for Removal -- 2007

Physical Abuse (n=7,452)

Neglect (n=15,026)

Parent Alcohol or Drug Abuse (n=19,893)

Child Behavior (n=1,096)

Child Alcohol or Drug Abuse (n=1,103)

Parent Unable to Cope (n=1,923)

Sexual Abuse (n=1,936)

Parent Incarceration (n=3,738)

Abandonment (n=4,440)

Inadequate Housing (n=5,946)

0 10 20 30 40 50 60 70 80 90 100

Child Disability (n=88)

Reliquishment (n=360)

Parent Death (n=568)

Source: Boles, S. (2010). Data analysis of the 2007 Adoption and Foster Care Analysis and Reporting System (AFCARS) data set. Unpublished data.


50

60

70

Parental AOD as Reason for Removal in Florida 1995‐2007

20

30

40

50

Percent

0

10

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Source: AFCARS Data Files

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

• Each situation poses different risks and requires different responses

• Child welfare workers need to know the different responses required

• The greatest number of children are exposed through a parent who uses or is dependent on athrough a parent who uses or is dependent on a substance

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

Risks to Children:Different Situations for Children

• 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


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 Not in Foster Care

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

25%

10.4%13.1%

17.4%

5.9% 5.3%

8.8%

5%

10%

15%

20%

TEXT PAGE

0%

Need for Alcohol Treatment

Need for Illicit Drug Treatment

Need for Alcohol or Illicit Drug Treatment

Ever in Foster Care Not in Foster Care

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


Use During Pregnancy

Substance Used

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

Applied to 2008 Florida birth data: 231,395

Substance Used (Past Month)

1st Trimester 2nd Trimester 3rd Trimester

Any Illicit Drug

Alcohol Use

2.3% women5,300 infants


7.0% women 16, 200 infants




TEXT PAGE

Binge Alcohol Use

State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth




National Vital Statistics Report, Births, Marriages, Divorces, and Deaths: Provisional Data for 2008, Volume 57, Number 19. Accessed July 20, 2010.

Why should families affected by parental y p

substance use in the child welfare system be given priority access to

treatment?


Intergenerational Effects

Substance use disorders What we knoware family diseases

Affected children• Children we remove• Children we send

back home

What we know

California sample

F il t d• Children we leave at home

Family centered treatment works

Developmental Effects

Five levels of impact on younger children

CAPTA

What we know

80-95% of prenatally

d

Prenatal exposure

effects can

amended in 2003

exposed children are not identified at birth and

just go home

effects can be reduced

through early identification

and early intervention


Examples of Priority Access

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

– Arizona Executive Order

– Sacramento

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

Why must substance abuse b bi d ith t lbe combined with mental

health, family violence, poverty or other influences on child abuse

and neglect?


Health and Hospitals

Domestic Mental Health

Schools and Special

EducationDevelopmental

Disabilities

Domestic Violence

Child Development

Juvenile Justice

Family Income Support

Courts

Comprehensive Approaches

• Integrated treatment coordinates substance abuse and t l h lth i t ti t t t th h l f ilmental health interventions to treat the whole family

more effectively

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

C l d d C lif i h d l d d l f li k• 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 i l d ith th hildor involved with the child welfare system? What

are the issues about the quality of treatment for

families in the child welfare system?

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?

• Are prevention services provided?

• Are services to children provided?


Spectrum of Substance Use Disorders

Experiment Experiment

TEXT PAGE

ppand and UseUse

AbuseAbuse

DependenceDependence41

Compliance with Medical Treatment

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

• > 50% of medical patients are dishonest about compliance

TEXT PAGE

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.


Reasons for Disease Re-Occurrence

#1: Lack of Compliance

#2: Socioeconomic Factors

#3: Family Support

#4: Psychiatric Co-morbidity

AOD Treatment - Predictors of OutcomeEmployment

Family SupportPsychiatric Status

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.

Beyond Treatment: Early Intervention

• What is the Connection Between Prenatal Exposure, Learning and Behavior?p g

– Affects childhood development

– Lifetime impact

• The Importance of Identifying Infants Prenatally Exposed to Substances. Although a small percentage of child welfare cases:welfare cases:

– 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.


Prenatal Exposure Belongs to No One Agency

• Prenatal Exposure is:– a school readiness issue

– a maternal and child health issue

– a developmental disability issue

– a substance abuse prevention issue

– a child welfare issue

– a family support issue

• Therefore, taking this problem seriously requires uncommon interagency efforts and accountability for annually reported results

Effects of Child Maltreatment and Parental Substance Abuse on Children and Youth

• The effects of substance use disorders on children and families are significant and well documentedg

• Research shows that children of parents who abuse drugs are more at risk than their peers for delinquency, depression, poor school performance, and alcohol and drug use.

• Research has found that maltreated children were also at increased risk of other interrelated problems inat increased risk of other interrelated problems in adolescence including drug use, poor academic performance, teen pregnancy, serious and violent delinquency, and emotional and mental health disorders.


Women’s Treatment With Family

Involvement

Women’s Treatment With Children

Present

Child

Women’s and Children’s Services

Children

Family Services

Children

Family-Centered Treatment

Continuum of Family-Based Services

Services for women with substance

use disorders. Treatment

plan includes family

issues, family

Children accompany women to treatment. Children

participate in child care but

receive no therapeutic

services. Only women have

Children accompany women to treatment.

Women and attending children

have treatment plans and receive

appropriate

Children accompany women to treatment;

women and children

have treatment

plans. Some services

provided to other family

Each family member has a treatment plan and receives individual and

family services.

y involvement

Goal: improved outcomes for women

treatment plans

Goal: improved outcomes for women

appropriate services.

Goals: improved

outcomes for women and

children, better parenting

other family members

Goals: improved outcomes for women and

children, better parenting

Goals: improved outcomes for

women, children, and other

family members; better parenting

and family functioning

Clinical Treatment and Support Services for Children

men

t Ser

vice

s • Screening • Intake• Assessment • Medical care and services• Mental health• Residential care (in residential

settings) ort S

ervi

ces • Onsite or nearby

child care • Mental health and

remediation services• Prevention services

TEXT PAGE

Clin

ical

Tre

atm settings)

• Case management• Case planning • Substance abuse education

and prevention• Mental health and trauma

services• Therapeutic child care and

development

Clin

ical

Sup

po • Recreational services

• Educational services • Advocacy • Recovery community

support services


Do positive treatment poutcomes assure

positive reunification outcomes?

Understanding the Outcomes

MonitoredMonitored by CFSR process

Need to prove that treatment works for

What we know

Reunifications linked to

substance

Baselines for reunification vs.

baselines for substance-child

welfare cases

substance abuse

substance-affected children


The Child and Family Services Reviews

• Safety

• Permanency

• Well-Being

TEXT PAGE

Purpose

• Enables the Children's Bureau to:

– (1) ensure conformity with Federal child welfare requirements;

(2) determine what is actually happening to children and families– (2) determine what is actually happening to children and families as they are engaged in child welfare services; and

– (3) assist States to enhance their capacity to help children and families achieve positive outcomes.

• The Federal Government conducts the reviews in partnership with State child welfare agency staff; consultant reviewers supplement the Federal Reviewconsultant reviewers supplement the Federal Review Team.

• The reviews are structured to help States identify strengths and areas needing improvement within their agencies and programs.


Assessment

• Examines Child Welfare performance and systemic factors– Analysis of performance on Federal data indicators

– Review policy and practice per safety, permanency, and well-being outcomes

• Assessment is based on:– Statewide assessment

– State child welfare data

– Case record review and interviews

– Interviews with stakeholders

Seven Outcome Areas

Safety PermanencyChild and

Family Well‐Being

• Children are, first and foremost, protected from abuse and neglect.

• Children are safely maintained in their homes whenever possible and appropriate.

• Children have permanency and stability in their living situations.

• The continuity of family relationships and connections is preserved for families.

• Families have enhanced capacity to provide for their children's needs.

• Children receive appropriate services to meet their educational needs.

• Children receive adequate services toadequate services to meet their physical and mental health needs.

54


Seven Systemic Factors

TrainingQuality

Foster and adoptiveTraining

Q yAssurance

adoptive homes

Case reviewStatewide Information System

Agency responsiveness

Service array


The Review ProcessBegins at least 6 months before

Onsite Review

One week period

30 days after the Onsite Review

Over 2‐5 years after the Onsite Review

Over 2‐5 years after the O it R i

TEXT PAGESupporting Improvements in Child Welfare Systems Through the Child and Family Services Reviews: A Resource for State Legislators Children’s

Bureau, US Department of Health and Human Services

Review

90 days after Onsite Review

Onsite Review

Data Indicators: CFSR and NOMS

REDUCED MORBIDITY Outcome: Abstinence from drug/alcohol use

EMPLOYMENT/EDUCATIONOutcome: Increased/ Retained Employment or

SAFETY• Children are, first and foremost, protected from

abuse and neglect.Child f l i t i d i th i hOutcome: Increased/ Retained Employment or

Return to/Stay in school

CRIME AND CRIMINAL JUSTICE Outcome: Decreased Criminal Justice Involvement

STABILITY IN HOUSING Outcome: Increased Stability in Housing

SOCIAL CONNECTEDNESS Outcome: Increased Social Supports/ Social Connectedness

ACCESS/CAPACITY

• Children are safely maintained in their homes whenever possible and appropriate.

• Children receive adequate services to meet their physical and mental health needs.

PERMANENCY• Children have permanency and stability in their

living situations.• The continuity of family relationships and

connections is preserved for families.

CHILD AND FAMILY WELL‐BEINGACCESS/CAPACITY Outcome: Increased access to Services (Service Capacity)

RETENTION Outcome: Increased Retention in Substance Abuse Treatment

PERCEPTION OF CARE Outcome: Client Perception of Care

• Families have enhanced capacity to provide for their children's needs.

• Children receive appropriate services to meet their educational needs.

NOMS Domain and Outcomes

CFSR Domains and Outcomes


Improving Outcomes

Percent of Children Reunified within 12 Months of the Child Entering Foster Care

69.9 %71

69.9 %

65.5 %

64

65

66

67

68

69

70

Percent

63

64

National Florida


Re-entry to Foster Care within 12 Months of Family Reunification

10.5 %10.510.6

9.9 %

9 79.89.910

10.110.210.310.4

Percent

9.69.7

National Florida

Median Length of Stay in Foster Care among Children who Reunified

12

6.5 %

9.6 %

2

4

6

8

10

Months

0

National Florida


Drop off Points

15,029 cases referred

for assessment

11,469 received assessment

(24% drop off = 3,560)

Number referred to treatment = 7,022

Number made it to treatment = 2,744 (61% treatment 2,744 (61%

drop off)

844 successfully completed tx*

How many children reunify ? 63

* Some clients still in tx & may yet successfully complete

Engaging Moms Dependency Drug Court Model

Th E i M P (EMP) D d• The Engaging Moms Program (EMP) Dependency Drug Court is a gender-specific and family-basedintervention program designed to support mothers in their mission to remain drug-free, cultivate effective parenting skills, and navigate through the court system.

• Implemented in 2001 at the Eleventh Judicial Circuit in Miami-Dade County, Florida.


What Makes the EMP Model Unique?

• Caseworkers work intensely with the mother in integrated individual and family sessions (e.g., individual sessions with the mother, individual

sessions with family/partner, family and couple sessions, etc.).

Th b i f thi d l i f d d• The basis of this model is founded on:Six core areas of change

organized into sequence of three stages

EMP’s Theory of Change believes that change in all six core areas

is essential to the mother’s success in sobriety and the care of her children.

Six Core Areas of Change:1. Motivation and commitment to succeed in drug

court and permanently change her life;2. The emotional attachment between the mother

and her children;3. Relationships between mother and her family of

i iorigin;4. Parenting skills;5. Mother’s romantic relationships;6. Emotional regulation, problem solving, and

communication skills


Three Stages of Intervention

• Stage 1: Building an alliance with the mother and cultivating motivation

• Stage 2: Behavioral Change – taking a closer look at motherhood and other relationships, learning how to make choice that reflect the best interest for the family.

• Stage 3: Launch to independence - creating a realistic and effective routine that supports the mother in a life of independence.

A Closer Look at Engaging Moms Program Results

• The study compared the results of the Engaging Moms Program (EMP) with case management services (CMS).

• The study analyzed extant court record data on child welfare outcomes on mothers enrolled in drug court prior to and then after the program changed from CMS to EMP.

• This study is a natural experiment of 80 consecutive admissions into the dependency drug court.

Dakof, Gayle A., Judge Jeri B. Cohen, and Eliette Duarte. "Increasing Family Reunification for Substance‐Abusing Mothers and Their Children: Comparing Two Drug Court Interventions in Miami." Juvenile and Family Court Journal 60.4 (2009): 11‐23.


Comparing EMP and CMS Results

• In this study, the only difference between the EMP group and the CMS group was the intensity of the relationship between the drug court caseworker and the mothers as a result of the implementation of EMP; all other aspects of the

thprograms were the same.

ResultsEMP Participants had significantly more success than CMS

*Reunification rates at 15‐months after entry in the dependency drug court


• The 72% drug court graduation rates for EMP g gcompare favorably with drug court graduation rates generally which average about 47%.

• The 15-month family reunification rates of 70% compare favorably with family reunification rates p y yamong drug-using and child welfare-involved mothers which have historically been under 25%.

Implications of Engaging Moms

• This study finds that Engaging Moms Dependency Drug Court Model holds the p y gpotential to improve a mother’s chances for reunification with her children, consistent with AFSA timelines and regardless of the challenges of substance abuse, poverty, mental health issues, and trauma.

• The impact on an under-served population may be considerable and could promote a stronger and more effective partnership among judiciary, child welfare caseworkers, and treatment providers.


Sacramento Family Dependency Drug Court

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

Critical components of DDC:

intervention specialist workers

• 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 alcoholcompliance and ensure accountability for all parents with alcohol and drug problems (Phase I - mandatory);

• 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.

78 084.3

100

Parent Characteristics at Baseline

78.0

47.5

32.225.4

21.7

50.844.7

31.434.6

20.1

38.5

20

40

60

80

Per

cen

t

TEXT PAGE

0Unemployed Less than a

High School Education

Disability Impairment

Chronic Mental Illness

Pregnant at Admission

Homeless

Comparison Court Ordered

Not Significant

Source: CalOMSThere is no difference in parent baseline characteristics between DDC and Comparison groups


100

Admission Rates*** (Ever been in AOD treatment)

53.2

85.7

40

60

80

Pe

rce

nt

TEXT PAGE

0

20

Comparison Court Ordered***p<.001 Comp n=111; DDC n=2422 Source: CalOMS

100

Treatment Outcomes:Discharge Status

56.8

43.2

65.9

34.1

20

40

60

80

Per

cen

t

TEXT PAGE

0

Satisfactory Unsatisfactory


P<.05 Source: CalOMSComp n=111; DDC n=2814


36 Month Child Placement Outcomes

100

26.033.5

12.71.7

17.38.7

47.7

25.2

7.62.3 4.4

12.7

0

20

40

60

80

Per

cen

t

TEXT PAGE

0Reunification*** Adoption* Guardianship* FR Services Long-Term

Placement***Other

Comparison Court-Ordered

*p<.05; ***p<.001 Comp n=173; DDC n=2817 Source: CWS/CMS

Time to Reunification at Among Children Reunifying by 36 Months

32

36

10.4 9.8

4

8

12

16

20

24

28

Mo

nth

s

TEXT PAGE

0

4


Not SignificantComp n=173; DDC n=2814 Source: CWS/CMS


DDC Graduation Criteria

For 180 consecutive days, parent must:

• Produce negative drug tests

• Attend all required group and individual treatment

sessions

• Attend all scheduled Recovery Specialist (STARS)

meetings

• Attend at least 3 support / 12-step meetings weekly

• Attend all required DDC appearances

• Complete all requirements of the court

Parents DDC Graduation Status

100

33.6

24.7

41.8

20

40

60

80

Per

cen

t

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0

Graduated (n=964) 90 Day Certificate (n=709)

Neither Landmark (n=1200)

Source: STARS


100

Reasons for Not Completing DDC (n=868)

70.3

40

60

80

Percent

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3.15.3 4.7

8.4

2.9 0.94.4

0

20

Failure to Appear (n=610)

Mental Health (n=27)

Incarcerated (n=46)

Out of County (n=41)

Services Terminated

(n=73)

Prop 36 (n=25)

Adult Drug Court (n=8)

Timed Out of Level 2 (n=38)

100

Child Reunification Rates by DDC Graduation Status Over Time

26 0

62.2

74.3

45.6

52.5

25 1

40

60

80

Per

cen

t

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19.1

26.0

1925.1

0

20

12 Months 36 MonthsComparison Graduated 90 Day Certificate Neither Landmark


60

Re-Entry to Foster Care Rates

15.012.1

19.7

5 3

14.720

40

Percent

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5.3

0

Federal (median)

California Sacramento Comparison DDC

Comp n=173; DDC n=2086 Source: CFSR, CWS/CMS

Recurrence of MaltreatmentRates Within 6 Months

60

20

40

Percent

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5.48.2 9.4

5.2 3.6

0

Federal California Sacramento Comparison DDC

Comp n=173; DDC n=2814 Source: CFSR, CWS/CMS


Cost Offset

• Between 2003-2007, it is estimated that the DDC has saved $17,572,290 in foster care costs alone, due to the higher 24 month reunification rate of court-ordered children relative to the comparison group.

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Common Ingredients of Family Treatment Courts

• System of early identification of families

• Earlier access to assessment and treatment services

• Increased management of recovery services and compliance

• System of incentives and sanctions

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y

• Increased judicial oversight


Wh C ll b t ?Why Collaborate?The 10 Elements of System Linkages and

Models of Collaboration

• Needs of families are more complex and require multiple tsystem responses

• Achieve better outcomes with families that have multiple needs

• Broaden the base of community support for children andBroaden the base of community support for children and families


ChangingThe System

Getting Better at Getting Along: Four Stages of Collaboration

ChangingThe Rules

The System

Existing Funding

External Funding

TEXT PAGE

InformationExchange

JointProjects

Beyond Collaboration to Results, Sid Gardner, 1996 89

Summary: Neither agency can achieve its mission with its own resources alone

Short-term benefits Longer-range benefits

Child welfare systems

CWS can make faster, better decisions about parents with

Lifelong child well-being can be improved if children in the CWsystems decisions about parents with

substance use disorders if it has closer links to better screening and effective treatment

improved if children in the CW system receive developmental services at the earliest possible moment linked to their parents’ receiving effective treatment and aftercare

Treatment systems Treatment would more effective if clients were

The long-term intergenerational effects of addiction would be

engaged based on assurances that their children will receive quality care and services, rather than ignoring children as in most treatment programs

reduced for high-risk children in the CW system if they were identified early and provided services for as long as they need them—so that they do not become clients of the treatment system in the next generation

90


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

91

Elements of System LinkagesThe Ten Key Bridges

Mission

1. Underlying Values and Priorities

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

TEXT PAGE 92

Outcomes

10. Shared Outcomes and Systems Reforms

Syste e e ts

6. Information Systems 7. Training and System Tools

8. Budget and Sustainability

9. Working with Other Agencies


10 Element Framework Underlying Values

Collaborative Capacity Instrument ( CCI)

Collaborative Values Inventory (CVI)Instrument ( CCI)

• Anonymous way to assess strengths and challenges in working across systems

• Matrix of Progress provides a description of the characteristics in

Inventory (CVI)

• Anonymous way to discuss common values and beliefs that can act as barriers between systems

• Results used to develop common principles of

communities with basic and advanced collaborative practice

collaborative work

10 Element FrameworkUnderlying Values

• Practitioners should systematically inquire about potential involvement with the other systemsinvolvement with the other systems

• The team is more critical than the tool in determining the relationship between substance use and child safety or risk (but the team does need the tools)

• During the assessment process, children’s needs should be identified and addressed

• Sharing information appropriately is desirable helpful and feasible• Sharing information appropriately is desirable, helpful, and feasible

• Actions should have consequences that are fair, timely, and appropriate to the action

• Consequences should apply to families and to staff; visitation should not be used as a consequence


10 Element Framework, Daily Practice:Screening and Assessment

UNCOPE – Washington and Maine

• In the past year, have you ever drank or used drugs more than you meant to?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?

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• Have you ever found yourself preoccupied with wanting to use alcohol or drugs?

• Have you ever used alcohol or drugs to relieve emotionaldiscomfort, such as sadness, anger, or boredom?

Source: Norm Hoffman, Ph.D. ‐ Evince

10 Element Framework, Daily Practice:Engagement and Retention

• Out-stationing staff

• Use motivational enhancement

• Ensure AOD treatment and CPS practice is responsive to clients’ individualized needs

• Strengths-based, supportive relationships, trauma-informed, culturally competent, accessible

• Parent Partners

• Recovery management approaches

– STARS

– SARMS


Screening and Assessment for Family Engagement, Retention and Recovery

• Screening and Assessment for F il E t R t tiFamily Engagement, Retention and Recovery (SAFERR)– Provides screening and

assessment tools

– Includes guidelines for communication and collaboration across the systems responsible

TEXT PAGE

for helping families

– Available at: www.ncsacw.samhsa.gov

It’s the Team not the Tool

10 Element Framework, Daily Practice:Services to Children

• Screening project for FASD among the children of the Santa Clara County Family Drug Treatment Court (California)

• Developmental Screening and intervention (Linda Ray Center, Miami)

• Use of Celebrating Families! or Strengthening F ili i l t d t f ili b t thFamilies curricula to educate families about the impact of substance dependence on families


Substance Exposed Infants

This document provides an assessment of State policy from the broadest perspective: prevention, intervention, identification, and treatment of prenatal substance exposure, including immediate and ongoing services for the infant, the mother, and the family.

Order Free Copies

This publication may be downloaded or ordered at www.samhsa.gov/shin. Or, please call SAMHSA's Health Information Network at 1‐877‐SAMHSA‐7Health Information Network at 1 877 SAMHSA 7 (1‐877‐726‐4727) (English and Español). In addition, this publication can be ordered from the Child Welfare Information Gateway at 1‐800‐394‐3366.Available online: http://www.ncsacw.samhsa.gov/files/Substance-Exposed-Infants.pdf

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 problemsp

• Poor social relations/skills

• Deficits in motor skills

• Cognition and learning disabilities


Policy and Practice Framework: Five Points of Intervention

Initiate enhanced2. Prenatal screening and

1. Pre‐pregnancy awareness of substance use effects

ParentChild

Initiate enhanced prenatal services

3. Identification at Birth

4. Ensure infant’s safety and d t i f t’ d

2. Prenatal screening and assessment

Respond to parents’ needsSystem k

Identify and respond to parents’ needs

respond to infant’s needs

5. Identify and respond to the needs of

● Infant ●Preschooler● Child ● Adolescent

System Linkages

Linkages

10 Element Framework Joint Accountability, Shared Outcomes, and

Information Systems

• Filling in “missing boxes” for prevalence of – Substance abuse in child welfare cases– Substance abuse in child welfare cases

– Prevalence of effects among children of substance abusers (abuse, neglect, developmental delays)

– Extent of newborn prenatal substance exposure

• Michigan revised SACWIS to prioritize case planning for families with substance use p gdisorders

• Developing communication protocols

• CFSR (SIP) and NOMS processes


10 Element Framework Training and Staff Development

• Common Strategies

– Creating a training plan

– Develop an inventory of current training efforts

– Developing opportunities for cross training and joint training


Understanding Substance Abuse and Facilitating Recovery:

A Guide for Child Welfare Workers

• Discusses the relationship of alcohol and drugs to families in the child welfare system

• Provides information on the biological, psychological, and social processes of alcohol and drug addiction to help staff recognize when substance abuse is a risk factor in their cases

TEXT PAGE

• Describes strategies to facilitate and support alcohol and drug treatment and recovery for families affected by substance use disorders

Available online at www.ncsacw.samhsa.gov



• On-Line Training: Available at http://www.ncsacw.samhsa.gov

– Understanding Child Welfare and the Dependency Court: A g p yGuide for Substance Abuse Treatment Professionals

– Understanding Substance Use Disorders, Treatment and Family Recovery: A Guide for Child Welfare Professionals

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

• Child Welfare Training Toolkit : Available at

TEXT PAGE

Child Welfare Training Toolkit : Available at http://www.ncsacw.samhsa.gov

– Helping Child Welfare Workers Support Families with Substance Use, Mental, and Co-Occurring Disorders

– 6 Modules, each containing a PowerPoint presentation, training script and plan, and handouts

10 Element FrameworkFunding and Program Sustainability

• Funding and Program Sustainability– Two types of sustainability:

• Financial

• Political and Community Support

• So an inventory of existing and potential funding streams is a critical need

I t t ll b ti ti i t “h d• Integrate collaborative practice into “how we do business.”


Technical AssistanceAssistance Resources

Levels of Technical Assistance

Information and Sharing of Models

Expert Consultation and

Research

Development of Issue‐ Specific

Products

Strategic Planning, Training Resources and Facilitation

108


Types of TA Products

• Collaborative practice and policy tools

• Information and sharing of models• Information and sharing of models

• Expert consultation and research

• Development of issue-specific products

Monographs, white papers, fact sheets

• Training resources and collaborative facilitationg

On-line courses, training materials

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

109

Types of TA Products

• Collaborative practice and policy tools

• Information and sharing of modelsInformation 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

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

110


How do I access Technical Assistance?

• Visit our Website:

http://ncsacw.samhsa.gov

• E-mail Us:

[email protected]

• Call Us:

1-866-493-2758

111

Ken DeCerchio MSW CAP

Contact Information

Ken DeCerchio, MSW, CAPChildren and Family Futures

Regional Partnership Grant ProgramProgram Director

Phone: 1‐866‐493‐2758Email: [email protected]

TEXT PAGE112

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