KIDS NOW PlusSubstance Abuse and Pregnancy Initiative

Kentucky Division of Behavioral HealthFran Belvin, MA, LPAT

Funded in part by Tobacco Settlement dollars through the Kentucky Early Childhood Development Funding Authority

KIDS NOW Early Childhood Development Authority

Other KIDS NOW Programs: • Immunizations• Newborn Hearing Screening • Eye Examinations• Folic Acid• Public health home visitation (0-2)• Early childhood mental health (0-5)• Child care subsidy, quality rating system

Competitive Grants Awarded to 8 Community Mental Health Regions

(36 counties served)

FUNDING$900,000 Tobacco Settlement 151, 890 KY Div. of Behavioral Health$ 951,890 Total FY 2011

PERSONNELCase managers 13 FTE Prevention specialists 6.5 FTEState-level administrator 1 FTE

KIDS NOW PlusSubstance Abuse and Pregnancy Program

MISSION: to reduce harm to Kentucky children from maternal substance use during and after pregnancy.

Yes, and…Because pregnant women using alcohol and drugs often have complex challenges including mental health problems and victimization, and because these challenges also contribute to poor birth outcomes, the KIDS NOW Plus program includes assessment and linkage with other needed services.

• Ambivalence about giving up substance– Substance abuse/dependence– Self-medicating a mental illness

• Shame/stigma• Fear of losing custody• Fear of prosecution

Common Barriers to Seeking Help: Why Pregnant Women are a “Difficult Population to Reach”

More Barriers to Seeking Help During Pregnancy

• Influence of family & friends• Coercion from

boyfriend/husband• Domestic violence• Lack of readily available

services• Cost of treatment• Transportation

Unintentional Barriers set up in the Health Care Setting

• We don’t ask, • How we ask - “You don’t use alcohol or drugs,

do you?”• Fast pace of clinic• Our own discomfort• Our judgmental attitude • Resistance (Lack of skill -- we have gotten

“ahead of her” in the change process)

Referrals to KIDS NOW Plus

– Health Departments– Local Physicians– High School Youth Service Centers– Department for Community Based Services– Drug Courts– Spouse Abuse Shelters– Pregnancy Crisis Centers– Internal Mental Health Center referrals

KIDS NOW PlusSubstance Abuse and Pregnancy Initiative

Pregnant women have varying levels of risk for ATOD use in combination with other risk factors, so a continuum of care is needed:

• OUTREACH• SCREENING• SUBSTANCE ABUSE PREVENTION CLASSES• ASSESSMENT• INTENSIVE CASE MANAGEMENT• REFERRALS TO TREATMENT

Collaboration with Community Partners

• Health departments• Private physicians• Department for Community Based

Services (child protection)• Drug Courts• Domestic violence shelters• Pregnancy crisis centers• High schools• Etc.

Referrals

• Prevention Specialist participates in boards and advisory groups

• Provider incentives• Training for referral sources on screening and

brief intervention protocols• Follow-up with referral sources• Memoranda of Understanding (MOUs)

Screening Identifies Risk

• Self-report screening is effective• Determines whether a referral is needed• Should be universal• Should be repeated multiple times during

pregnancy• May be integrated into health history• Opportunity to educate all pregnant patients

about the risks of substance use

Screening Tool:Level 1: Substance Use and Pregnancy

Health Risk Questionnaire*

• Friends, family, partner SA problem• Mental health symptoms• Alcohol, drug, and tobacco use

– “Before you knew you were pregnant”– “Past 30 days”

• Domestic violence

* Completed by medical provider or KN+ worker

Negative screen (all “no” responses)

• Reinforce healthy decisions• Provide

brochure/fact sheet • Invite to universal

prevention class

Positive screen (any “yes” responses)

BRIEF INTERVENTION:• Ask permission to discuss her responses• Review them with her• State your concern• Advise abstinence• Ask if she is willing to accept help: If yes, refer to

KN+• If not, what step is she willing to take?• Follow up at every prenatal visit

Levels of Prevention ServicesUniversal –

For any pregnant womanRisks associated with alcohol, tobacco or another drug use during pregnancy and lactation, including risks to a fetus, such as low birth weight and fetal alcohol syndrome.

Selective – For women who are not using ATOD during pregnancy but are at risk for substance abuse problems later in life

• Family AOD history• Significant others w/AOD problems• Mental health problems• Victims of physical, sexual and emotional abuse

Levels of Prevention Services

Indicated – For pregnant women who have received a substance abuse assessment, and assessment indicates:

• AOD use during pregnancy at a sub-clinical level or • Have exhibited problems associated with AOD use

prior to pregnancy

Meet with woman at OB office, health department, home visit, office

Assist with housing, finances, baby items etc. Complete Baseline screen to identify areas of risk:

substance use, stress, victimization, mental health problems

Create individualized service plan based on Baseline screen Appropriate level of contact Use incentives to increase engagement “Pretreatment” - to increase motivation for treatment Support attendance at prenatal appointments Follow woman through pregnancy and 6 weeks postpartum

whether in treatment or not

Outreach Case Management Services

1. Medical provider completes Level 1 Screen

Screen is Negative

2. Medical provider gives patient educational brochure & invitation to substance abuse universal prevention class

2. Medical provider delivers

Brief Intervention & refers to KIDS NOW Plus

3. KIDS NOW Plus reviews Level 1 Screen and offers prevention and/or case management services

Screen is Positive

KIDS NOW Plus Services

4. KIDS NOW Plus case manager:• Engages through traditional case management

and incentives• Completes in-depth screen• Refers to SA, MH, DV, smoking cessation services• Builds readiness for accepting referrals• Encourages abstinence (MI)• Supports attendance at prenatal appointments

Evidence-Based Practices

• Universal Screening Cannot tell who is using by appearances

• Brief InterventionMedical provider

• Intensive Case ManagementTo address complexity of needs

• Motivational InterviewingEmpathy, collaboration, autonomy

• Motivational IncentivesIncentivize target behaviors

Gender Specific Treatment

• Trauma Informed Care• Parenting education• Family services• Health services• Educational and vocational

services• Case management

Pregnant women are considered a priority population by the Federal SA Block Grant: requires that services are offered within 48 hours of initial contact.

FY 2009 DATAWomen Served

1,366 – Received Universal prevention 171 – Received Selective or Indicated prevention 667 – Received case management services 360 – Received baseline assessments 195 – Received postnatal follow-up assessments

4,551 face-to-face case management contacts(average 3.33 visits per client)

Mental Health Problems Reported at Baseline (n=360)

Depression

Thoughts

of hurti

ng ...

Irrita

ble

Worri

ed excessi

vely

Witn

essed tr

aumati

c ...

58.6%

5.8%

35.3%

66.9%

54.7%

DSM-IV Diagnoses (n = 360)

Learning

Retardation

Other psychotic and developmental

Abuse

Behavioral

Personality

Other non-psychotic

Anxiety

V Codes

Mood

Substance abuse

1.1%

1.4%

1.9%

2.5%

4.7%

6.1%

6.4%

14.2%

18.9%

23.3%

38.9%

Partner Violence in the Past Year Reported at Baseline (n=360)

27.5%

14.4%

23.9%

14.2%

4.4%

Psychological abuse

Physicalabuse

Extremejealousy

Harrassingbehavior

Forcedsex

Percent of Clients Reporting Substance Use Prior to Knowledge of Pregnancy (n = 360)

Cigarettes Alcohol Illegal drugs Prescription drugs

76.1%

33.3%26.4%

22.0%

Changes in mental health from baseline to postnatal and rate of change (n = 195)

61.5%

6.2%

43.1%

53.3%

19.5%

72.8%

50.3%

4.1%

24.6%

36.4%

16.9%

52.8%

Baseline Postnatal

Depression Thoughts of hurting self

Irritable Others notice irritability

Full of self Excessively anxious

↓ 13.3%*

↓ 33.9%

↓ 42.9%**

↓ 31.7%***

↓ 13.3%

↓ 27.5%***

*** p < .001, ** p < .01, * p < .05a time frames used at baseline and follow-up are not necessarily the sameb Significance established using z-test for proportions

Percent of clients reporting partner victimization from baseline to postnatal and rate of change (n = 195)

15.4%

29.2%26.7%

13.8%

2.6%1.0%

7.2% 6.2%

1.5%0.0%

Baseline Postnatal

Psychological abuse

Physicalabuse

Extremejealousy

Harrassingbehavior

Forcedsex

↓ 93.5%***

↓ 73.5%***↓ 76.8%***

↓ 89.1%***

↓ 100.0%*

Percent of Follow-up Clients Reporting Substance Use: (1)Prior to Knowledge of Pregnancy; (2) at Baseline; and (3) at Postnatal and Rate of Change Between (1) and (2) (n = 195)

Cigarettes Alcohol Illegal drugs Prescription drug misuse

76.9%

32.8%26.2%

18.5%

64.6%

4.6%

13.3% 9.7%

67.2%

16.4%

4.1% 3.6%

Baseline During Postnatal↓ 16.0%**During

↓ 86.0%***During ↓ 49.2%*

During ↓ 47.6%*During

Percent of Follow-up Clients Reporting Specific Illegal Drug Use Among Those Reporting Illegal Drug Use: (1) Prior to

Knowledge of Pregnancy; (2) at Baseline; and (3) at Postnatal and Rate of Change between (1) and (2) (n = 51)

92.2%

19.6%

7.8% 3.9%

47.1%

9.8%2.0% 0.0%

15.7%

0.0% 0.0% 0.0%

Baseline During Postnatal

Marijuana Cocaine Methamphetamine Amphetamine

↓48.9%*** During

D

↓50.0% During ↓74.4%

During↓100% During

Percent of clients reporting specific prescription drug use prior to and during pregnancy among those reporting prescription drug use at prior and rate of change (n = 36)

Hyrdocodone

Percocet

Oxycontin

Valium

Xanax

0.0%

2.8%

0.0%

2.8%

0.0%

0.0%

2.8%

0.0%

2.8%

0.0%

50.0%

16.7%

19.4%

8.3%

30.6%

Baseline During Postnatal

↓100%*** During

↓66.3% During

↓100%** During

↓83.2%* During

↓100%*** During

Birth Outcomes Compared to Matched Group and General Population

(n=189)

• Comparison group matched on: – Age– Race– Education– County of residence

DemographicsKids Now clients

(n = 189)Comparison group

(n = 189)General population

(n = 189)

Race*White 94.2% 95.2% 87.8%Black 4.2% 4.2% 6.9%Other 1.6% 0.5% 5.3%

Education***No high school degree 33.7% 33.9% 16.9%High school graduate or GED 43.9% 43.4% 27.0%College 22.5% 22.8% 56.1%

Avg. age*** 24.2 24.2 26.1

Married*** 35.6% 52.4% 55.0%

Urban/rural status***Metro 35.3% 35.3% 57.8%Non metro 49.5% 49.7% 34.4%Very rural 15.2% 15.0% 7.8%

Source of pay for birth of baby

Self-pay

Champus/Tricare

Unknown

Other

Private insurance

Medicaid

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

0.0%

0.0%

0.0%

3.7%

5.9%

90.4%

3.7%

0.5%

0.5%

4.2%

25.9%

65.1%

4.2%

0.0%

0.0%

3.2%

43.4%

47.6%

General population (n = 189)Comparison group (n = 189)KIDS NOW Plus (n = 189)

Average birth weight (in grams)

Series1 3,100

3,120

3,140

3,160

3,180

3,200

3,220

3,240

3,260

3,280

3,300

3,200

3,159

3,274

KIDS NOW Plus (n = 189)Comparison group (n = 189)General population (n = 189)

Percent of babies with low birth weight (< 2500 grams)

Series10.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.9%

10.1%

8.5%

KIDS NOW Plus (n = 189)Comparison group (n = 189)General population (n = 189)

Percent of premature births(less than 37 weeks gestation)

Series10.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

11.1%

13.8%12.2%

KIDS NOW Plus (n = 189)Comparison group (n = 189)General population (n = 189)

Gestational weeks for KIDS NOW Plus a comparison group, and the general population

23 25 26 27 28 29 30 31 32 33 34 35 360

2

4

6

8

10

12

14

KIDS NOW Plus Comparison Group

Final APGAR scores

4 5 6 7 8 9 100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Kids Now Plus clients (n = 189) Comparison group (n = 189)

General population (n = 189)

KIDS NOW PlusKY Division of Behavioral HealthFran Belvin fran.belvin@ky.gov