Trust and Safety:How to Manage a Kinship Caregiver
Relationship with Parents with
Substance Use Disorders
Nancy K. Young, Ph.D.
Director, Children and Family Futures
National Center on Substance Abuse
and Child Welfare
11th Annual Kinship Conference
Burlington, VT
September 2015
TEXT PAGE
3
A Program of the
Substance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment
and the
Administration on Children, Youth and FamiliesChildren’s Bureau
Office on Child Abuse and Neglect
The FDC TTA Program is supported by:The Office of Juvenile Justice and Delinquency Prevention Office of Justice
Programs (2013-DC-BX-K002)
Family Drug Court Training and
Technical Assistance Program
The Mission - to improve outcomes for children and families by providing TTA that supports planning and implementation of comprehensive FDCs.
• FDC TTA Needs Assessment• FDC Guidelines• FDC Learning Academy Webinar Series• FDC Peer Learning Program• FDC Orientation Materials
• Setting the Stage with some Data
• Understanding Substance Use Disorders, Treatment and
Recovery
• Understanding Risks to Children
• Impact on Kinship Care: Family Dynamics, Children’s Needs,
Caregiver’s Needs and Parent’s Needs
• Safety and Achieving Balance: A Team Effort
Agenda
Vermont Department for Children and Families, Family Services Division, 2014 Report on Child Protection in Vermonthttp://dcf.vermont.gov/sites/dcf/files/pdf/fsd/2014-CP-Report.pdf
Child Abuse and Neglect Intakes and Accepted Reports by Year
Vermont
21%27%
31% 30% 32% 30% 29% 30%
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
2007 2008 2009 2010 2011 2012 2013 2014
Intakes Accepted Reports Percent
Vermont
Source: Wolcott, Cindy. S.9/Act 60 Implementation (PowerPoint). State of Vermont, Cross Leadership Meeting. September 17, 2015.
8
Vermont—Children in Care by Quarter
2013-2015 saw a 36% increase
Source: Wolcott, Cindy. S.9/Act 60 Implementation (PowerPoint). State of Vermont, Cross Leadership Meeting. September 17, 2015.
15%
0%
10%
20%
30%
40%
50%
60%
70%
AL
(N=7
,44
3)
AK
(N
=2,8
42
)
AZ
(N=2
3,8
54
)
AR
(N
=7,4
11
)
CA
(N
=85
,11
4)
CO
(N
=10,
54
2)
CT
(N=5
,80
3)
DE
(N=1
,16
0)
DC
(N
=1,9
31
)
FL (
N=3
3,2
70
)
GA
(N
=13
,54
2)
HI (
N=2
,05
4)
ID (
N=2
,43
8)
IL (
N=2
1,9
57
)
IN (
N=1
8,6
95
)
IA (
N=1
0,5
70
)
KS
(N=9
,84
5)
KY
(N=1
2,1
73
)
LA (
N=7
,38
4)
ME
(N=2
,44
1)
MD
(N
=7,0
61
)
MA
(N
=13
,63
9)
MI (
N=2
2,2
61
)
MN
(N
=11
,11
4)
MS
(N=
6,0
72
)
MO
(N
=16
,18
6)
MT
(N=3
,39
7)
NE
(N=7
,74
2)
NV
(N
=8,0
28
)
NH
(N
=1,2
82
)
NJ
(N=1
2,0
82
)
NM
(N
=3,7
46
)
NY
(N=3
0,9
81
)
NC
(N
=13
,40
1)
ND
(N
=1,9
23
)
OH
(N
=21,
43
5)
OK
(N
=15
,09
6)
OR
(N
=12,
22
6)
PA
(N
=22,
93
8)
RI (
N=2
,90
2)
SC (
N=5
,98
9)
SD (
N=2
,29
6)
TN (
N=1
4,3
91
)
TX (
N=4
6,2
86
)
UT
(N=4
,87
7)
VT
(N=1
,60
5)
VA
(N
=7,1
83
)
WA
(N
=15
,22
2)
WV
(N
=7,9
06
)
WI (
N=1
0,8
52
)
WY
(N=1
,89
0)
PR
(N
=4,8
36
)
Source: AFCARS Data, 2013
National Average: 31%
Parental Substance Use as Reason for Removal
Across States, 2013
Vermont: 15%
Age of Children in Care
In 2015, young children (ages 0-5) surpassed all other groups
Source: Wolcott, Cindy. S.9/Act 60 Implementation (PowerPoint). State of Vermont, Cross Leadership Meeting. September 17, 2015.
Percent of Children Removed from Parents’ Custody with
Parental Alcohol and/or Drug Use
as a Reason for Removal by Age, 2013
27.1
13.3
0
10
20
30
40
50
60
70
80
AK
(N
=2,8
42
)
AL
(N=7
,44
3)
AR
(N
=7,4
11
)
AZ
(N=2
3,8
54
)
CA
(N
=85
,11
4)
CO
(N
=10,
54
2)
CT
(N=5
,80
3)
DC
(N
=1,9
31
)
DE
(N=1
,16
0)
FL (
N=3
3,2
70
)
GA
(N
=13
,54
2
HI (
N=2
,05
4)
ID (
N=2
,43
8)
IA (
N=1
0,5
70
)
IL (
N =
N/A
)
IN (
N=1
8,6
95
)
KS
(N=
9,84
5)
KY
(N=1
2,1
73
)
LA (
N=7
,38
4)
MA
(N
=13
,63
9)
MD
(N
=7,0
61
)
ME
(N=
2,4
41
)
MI (
N=2
2,2
61
)
MN
(N
=11
,11
4)
MO
(N
=16
,18
6)
MS
(N=6
,07
2)
MT
(N=3
,39
7)
NC
(N
=13
,40
1)
ND
(N
=1,9
23
)
NE
(N=7
,74
2)
NH
(N
=1,2
82
)
NJ
(N=1
2,0
82
)
NM
(N
=3,7
46
)
NV
(N
=8,0
28
)
NY(
N=3
0,9
81
)
OH
(N=2
1,4
35)
OK
(N
=15
,09
6)
OR
(N
=12,
22
6)
PA
(N
=2
2,9
38
)
RI (
N=2
,90
2)
SC (
N=
5,9
89
)
SD (
N=2
,29
6)
TN (
N=1
4,3
91
)
TX (
N=4
6,2
86
)
UT
(N=4
,87
7)
VT
(N=
1,6
05
)
VA
(N
=7,1
83
)
WA
(N
=15
,22
2)
WI (
N=1
0,8
52
)
WV
(N
=7,9
06
)
WY
(N=1
,89
0)
PR
(N
=4,8
36
)
Under Age 1 Age 1 and Older
VERMONT
Under Age 1: 27%
Age 1 and Older: 13%
N= Total number of children removed by StateSource= AFCARS 2013 Foster Care File
People treated for opioid addiction in the
Vermont treatment system has dramatically shifted
Alcohol: 72% in 2000; 40% in 2014 Opioids: 5% in 2000; 42% in 2014
Source: Substance Abuse Treatment Information System (SATIS) Source: Foldand, Tony. PowerPoint. State of Vermont, Cross Leadership Meeting. September 17, 2015.
The number of individuals using heroin at treatment admission
is increasing faster than for other opioids/synthetics
Source: Substance Abuse Treatment Information System (SATIS) Source: Foldand, Tony. PowerPoint. State of Vermont, Cross Leadership Meeting. September 17, 2015.
Understanding
Substance Use
Disorders, Treatment and
Recovery
• No child writes their essay on what they want to be is an alcoholic
or drug addict
• No one wakes up one day and says … today’s a great day to
develop a brain disorder that risks my health, family, job, future,
freedom and possibly life
• Yet – in the time we are together today, 180 people will die of
addiction
Substance use Disorders are Complex
and Generally Begin Early in Life!
TEXT PAGE
It is also a Developmental Disorder
• The vast majority of addiction begins in adolescence as teens
experiment, and for a critical few, begin a progression of changed
neurochemistry with life-long consequences
• The changing circuitry of teenagers' brains appears to leave them
especially vulnerable to the effects of drugs and alcohol
17
WWW.NIDA.NIH.GOV
WWW.NIDA.NIH.GOV
WWW.NIDA.NIH.GOV
WWW.NIDA.NIH.GOV
Nucleus accumbensVentral tegmental Area (VTA)
Dopamine release
Cortex
MesolimbicSystem
http://www.vivitrol.com/opioidrecovery/howvivitrolworks
When the receptors are unlocked, they release neurotransmitters including dopamine in the brain. Dopamine gives you
a good feeling to reward you for doing something you enjoy. This reward is what makes you want to repeat these
behaviors.http://www.vivitrol.com/opioidrecovery/howvivitrolworks
When that activity is something you enjoy, your brain releases chemicals called endorphins that make you feel good.
Endorphins attach to receptors – much like a key fitting into a lock – and unlock the receptors.
http://www.vivitrol.com/opioidrecovery/howvivitrolworks http://www.vivitrol.com/opioidrecovery/howvivitrolworks
WWW.NIDA.NIH.GOV
Natural Rewards Elevate Dopamine Levels
0
50
100
150
200
0 60 120 180
Time (min)
% o
f B
asal D
A O
utp
ut
NAc shell
Empty
Box Feeding
Source: Di Chiara et al.
FOOD
100
150
200
DA
Co
ncen
trati
on
(%
Baseli
ne)
MountsIntromissionsEjaculations
15
0
5
10
Co
pu
latio
n F
req
uen
cy
Sample
Number
1 2 3 4 5 6 7 8 9 1011121314151617
ScrScrBasFemale 1 Present
ScrFemale 2 Present
Scr
Source: Fiorino and Phillips
SEX
Effects of Drugs on Dopamine Levels
0100200300400500600700800900
10001100
0 1 2 3 4 5 hr
Time After Amphetamine%
of
Bas
al R
ele
as
e
DADOPACHVA
Accumbens AMPHETAMINE
0
100
200
300
400
0 1 2 3 4 5 hrTime After Cocaine
% o
f B
as
al R
ele
as
e
DADOPACHVA
AccumbensCOCAINE
0
100
150
200
250
0 1 2 3 4 5hrTime After Morphine
% o
f B
as
al R
ele
as
e Accumbens
0.51.02.510
Dose (mg/kg)
MORPHINE
0
100
150
200
250
0 1 2 3 hrTime After Nicotine
% o
f B
as
al R
ele
as
e
AccumbensCaudate
NICOTINE
Source: Di Chiara and Imperato
When you take opioids such as heroin or opioid pain medications (e.g. VICODIN®, Percocet® and OxyContin®), they attach to a particular type of receptor. This results in the release of greater amounts of dopamine, which creates a pleasure response or reward. VICODIN® is a registered trademark of Abbott Laboratories; Percocet® is a registered trademark of Endo Pharmaceuticals;
http://www.vivitrol.com/opioidrecovery/howvivitrolworks
• Brain imaging studies show physical changes in areas of the brain
that are critical to
– Judgment
– Decision making
– Learning and memory
– Behavior control
• These changes alter the way the brain works, and help explain
the compulsion and continued use despite negative
consequences
A chronic, relapsing brain disease
Substance Use Disorders are similar to other diseases, such as heart disease. Both diseases disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, are preventable, treatable, and if left untreated, can result in premature death
TEXT PAGE
A treatable disease
• Substance use disorders are preventable and is a treatable
disease
• Discoveries in the science of addiction have led to advances in
drug abuse treatment that help people stop abusing drugs and
resume their productive lives
• Similar to other chronic diseases, addiction can be managed
successfully
• Treatment enables people to counteract addiction's powerful
disruptive effects on brain and behavior and regain areas of life
function
These images of the dopamine transporter show the brain’s remarkable
potential to recover, at least partially, after a long abstinence from drugs -
in this case, methamphetamine.
TEXT PAGE
Diagnosing Substance Use Disorders:
DSM 5 Criteria
1. Impaired Control
Larger amounts or over a longer time
than originally intended
Persistent desire to cut down
A great deal of time spent obtaining
the substance
Intense craving
2. Social Impairment
Failure to fulfill work or school
obligations
Recurrent social or interpersonal
problems
Withdraw from social or recreational
activities
3. Risky Use
Recurrent use in situations physically
hazardous
Continued use despite persistent physical
or psychological problem that is likely to
have been caused or exacerbated by use
4. Pharmacological Criteria
Tolerance: Need for markedly increased
dose to achieve the desired affect
Withdrawal: Syndrome that occurs when
blood or tissue concentrations of a
substance decline in an individual who
had maintained prolonged heavy use
Mild
2-3 Criteria
Moderate
4-5 Criteria
Severe
6+ Criteria
Principles of Effective Drug Addiction Treatment:
A Research Based Guide
1. Addiction is a complex but treatable disease that affects brain function and behavior
2. No single treatment is appropriate for everyone
3. Treatment needs to be readily available
4. Effective treatment attends to multiple needs of the individual
5. Remaining in treatment for an adequate period of time is critical
6. Behavioral therapies are the most commonly used forms of drug abuse treatment
7. Medications are an important element of treatment for many
patients, especially when combined with counseling and other
behavioral therapies8. An individual’s treatment and services plan must be continually assessed and modified
9. Many drug-addicted individuals also have other mental disorders
10. Medically assisted detoxification is only the first stage of addiction treatment
11. Treatment does not need to be voluntary to be effective
12. Drug use during treatment must be monitored continuously as lapses do occur
13. Treatment programs should test patients for infectious diseases
34National Institute on Drug Abuse (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Retrieved from http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-
research-based-guide-third-edition/acknowledgments on September 18, 2014
http://www.drugabuse.gov/publications/principles-drug-addiction-treatment
http://www.vivitrol.com/opioidrecovery/howvivitrolworks
TEXT PAGE
• Medications are an important element of treatment for many
patients, especially when combined with counseling and
other behavioral therapies
– National Institute on Drug Abuse, Principles of Drug Addiction
Treatment
Recent review by American Society of Addiction Medicine and National Institute on
Drug Abuse
Advancing Access to Addiction Medications: Implications for Opioid Addiction Treatment
http://www.asam.org/docs/advocacy/Implications-for-Opioid-Addiction-Treatment
Medication-Assisted Treatment (MAT)
MEDICATIONS USED TO TREAT TOBACCO DEPENDENCE
MEDICATION PRIMARY USE FORMULATION TREATMENT SETTING ADMINISTRATION
Nicotine replacementtherapies(Nicotine)
•Replace nicotine from smoking and reduce withdrawal symptoms
•Gum
•Lozenge
•Inhaler
•Nasal Spray
•Patch
•Gum: Over the counter (OTC)
•Lozenge: OTC
•Inhaler: prescription
•Nasal Spray: prescription
•Patch: OTC and prescription
•Gum: 1-2 pieces/hour; no more than 20 pieces/day
•Lozenge: n/a
•Inhaler: As directed by physician
•Nasal Spray: As directed by physician
•Patch: Single patch worn daily
Bupropion sustained-release(Zyban®)
•Blocks brain receptors and interferes with the dopamine reward pathway
•Tablet •Prescribed •Twice a day
Varenicline tartrate(Chantix®)
•Partial agonist and antagonist—Blocks nicotine receptor sites
•Tablet •Prescribed •Once or twice daily
Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465757/pdf/nihms59469.pdf
MEDICATIONS USED TO TREAT ALCOHOL USE DISORDERS
MEDICATION PRIMARY USE FORMULATION TREATMENT SETTING ADMINISTRATION
Disulfiram(Antabuse®)
•Inhibits production of an enzyme (acetaldehyde)that allows the body to absorb alcohol
•Acetaldehyde builds up and causes unpleasant effects—flushing, nausea and palpitations
•Tablet •Physician prescribed
•Supervised ingestion is preferred as a key component of treatment plan
•Daily
Oral Naltrexone(Revia®)
•Antagonist—Blocks effects of opioids
•Tablet •Prescribed •Daily
Extended-Release Injectable Naltrexone (Vivitrol®)
Antagonist—Blocks effects of opioids
•Injection •Administered by medical professional
•Monthly
TEXT PAGE
ADDITIONAL MEDICATIONS USED TO TREAT ALCOHOL USE DISORDERS
MEDICATION PRIMARY USE FORMULATION TREATMENT SETTING ADMINISTRATION
Acamprosate(Campral®)
•Reduces symptoms related to abstaining from alcohol—insomnia, anxiety, restlessness, and unpleasant changes in mood
•Tablet •Prescribed •Three times daily
Center for Substance Abuse Treatment. Incorporating Alcohol Pharmacotherapies into Medical Practice: A Review of the Literature. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 09-4380. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.
MEDICATIONS USED TO TREAT OPIOID USE DISORDERS
MEDICATION PRIMARY USE FORMULATIONTREATMENT
SETTING
MAXIMUM
CLIENT
CAPACITY
ADMINISTRATION
Methadone(Dolophine®, Methadose®)
•Agonist—Suppresses cravings and withdrawals
•Detoxification
•Maintenance
•Liquid
•Tablet/Diskette
•Powder
•SAMHSACertified Opioid Treatment Program (OTP)
---- •Daily at OTP
•Some individuals may qualify for take-home prescriptionslasting up to 30 days
Buprenorphine(Subutex®)
•Partial Agonist—Suppresses cravings and withdrawals; partial stimulation of brain receptors
•Detoxification
•Tablet •Physicians or psychiatrists granted a DATA waiver
•Some SAMHSA Certified OTPs
•100 •Daily
•Individuals can be prescribed a supply to be taken outside of the treatment setting
Buprenorphine-Naloxone Combination(Suboxone®;Zubsolv)
•Maintenance •Sublingual Tablets
•Prescription ---- •Daily
TEXT PAGE
ADDITIONAL MEDICATIONS USED TO TREAT OPIOID USE DISORDERS
MEDICATION PRIMARY USE FORMULATIONTREATMENT
SETTING
MAXIMUM
CLIENT
CAPACITY
ADMINISTRATION
Naloxone(Narcan®)
•Antagonist—Displaces opiates from brain receptors and reverses respiratory depression
•Reverse overdose
•Injection •First Responders ---- •When overdose is suspected or signs of overdose are observed
Naltrexone Extended-Release
(Vivitrol®)
•Antagonist—Blocks effects of opioids
•Maintenance
•Injection (primarily)
•Any healthcare provider licensed to prescribe medications
---- •Monthly, following medically supervised detoxification
Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 13-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Retrieved from https://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.pdf
Substance Abuse and Mental Health Services Administration. Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide.. HHS Publication No. (SMA) 14-4892R. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Retrieved from http://store.samhsa.gov/shin/content/SMA14-4892/SMA14-4892.pdf
Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
Summary Points
Each medication varies in its ability to:
Prevent or reduce withdrawal symptoms
Prevent or reduce drug craving
Medical doctors determine the appropriate type of
medication, dosage and duration based on each
person’s:
Biological makeup
Addiction history and severity
Life circumstances and needs
OTP Certification Guidelines
Medical Director licensed to practice medicine and has
experience in addiction medicine. Responsible for monitoring
and supervising all medical services.
Provision of adequate medical, counseling, vocational,
educational, and other assessment and treatment services.
Special services for pregnant patients, including priority access
and provision of or referral for prenatal care and other gender
specific services.
Risks to Children
*Approximately 4 million (3,952,841) live births in 2012
Estimates based on: National Survey on Drug Use and Health, 2012; Martin, Hamilton, Osterman, Curtin & Mathews. Births: Final Data for 2012. National Vital Statistics Report, Volume 62, Number 9; Patrick, Schumacher, Benneyworth, et al. NAS and Associated Health Care
Expenditures. Journal of the American Medical Association (JAMA) 2012; 307(18):1934-1940. doi: 10.1001/jama.2012.3951; May, P.A., and Gossage, J.P.(2001).Estimating the prevalence of fetal alcohol syndrome: A summary.Alcohol Research & Health 25(3):159-167. Retrieved October
21, 2012 from http://pubs.niaaa.nih.gov/publications/arh25-3/159-167.htm
Estimated Number of Infants* Affected by Prenatal Exposure, by Type of Substance and Infant Disorder
640,00015.9%
340,0008.5%
240,0005.9%
108,0002.7%
12,0000.3%
30,000(0.5-7 per 1,000 births)
13,000(3.3 per 1,000
births)
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
Tobacco Alcohol Illicit Drugs Binge Drinking Heavy Drinking FAS/ARND/ARBD NAS
Includes nine categories of illicit drugs, including heroin and the nonmedical use of prescription medications.
Past Month Substance Use by Pregnant Women Incidence of Infant Disorder
TEXT PAGE
Prenatal Exposure and Postnatal Environment
in Vermont
Prenatal Exposure Postnatal Environment
~6,500 births per year
8.3 million children in the nation have a parent
who needs treatment
11% of children in the country
~13,500 children of parent who needs treatment
~2,200 (33.4%) prenatally exposed birth
~1,000 [16%] tobacco prenatal exposure per year
~750 [12%] alcohol prenatal exposure per year
~400 [6%] illicit drugs, including heroin and nonmedical
use of prescription medications, prenatal exposure
per year in Vermont
Impact of Prenatal Exposure
47
Tobacco Exposure• Low birth weight
• Brainstem (respiratory and autonomic functions) abnormalities
• 2nd hand exposure and asthma
Fetal Alcohol Spectrum Disorders: Range of disorders related to growth deficiencies, physical anomalies, and
central nervous system (CNS) dysfunctions
• Fetal Alcohol Syndrome (FAS):
• Growth deficiency
• Unique cluster of minor facial anomalies (small eyes, smooth philtrum, thin upper lip)
• Severe CNS dysfunctions
• Partial FAS:
• Some growth deficiency and facial anomalies
• Severe CNS dysfunctions
• Alcohol Related Neurodevelopmental Disorder (ARND):
• Range of disabilities in behavior, adaptive skills, executive functioning, and self-regulation
TEXT PAGE
• An expected and treatable condition that
follows prenatal exposure to opioids
• Symptoms begin within 1-3 days after birth, or
may take 5-10 days to appear
• Symptoms include blotchy skin; difficulty with
sleeping and eating; trembling, irritability and
difficult to soothe; diarrhea; slow weight gain;
sweating; hyperactive reflexes; increased
muscle tone
• Timing of onset is related to characteristics of
drug used by mother and time of last dose
• Most opioid exposed babies are exposed to
multiple substances
Neonatal Abstinence Syndrome (NAS)
The American College of Obstetricians and Gynecologists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076. U.S. National Library of Medicine, National Institutes of Health. Neonatal Abstinence Syndrome. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007313.htm on July 24, 2014Hudak, M.L., Tan, R.C. The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012, 129(2): e540Jansson, L.M., Velez, M., Harrow, C. The Opioid Exposed Newborn: Assessment and Pharmacological Management. Journal of Opioid Management. 2009; 5(1):47-55
NAS occurs with notable variability,
with 55-94% of exposed infants
exhibiting symptoms
Medication is required in
approximately 50% of cases
Neonatal Abstinence Syndrome—Treatment
• Non-Pharmacological Treatment
• Swaddling
• Breastfeeding
• Calm, low-stimulus environment
• Rooming with mother
American Academy of Pediatrics, Committee on Drugs (1998). Neonatal Drug Withdrawal. Pediatrics, 101(6), 1079-1088.Hudak, M.L., Tan, R.C. The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012, 129(2): e540Jansson, L.M., Velez, M., Harrow, C. The Opioid Exposed Newborn: Assessment and Pharmacological Management. Journal of Opioid Management. 2009; 5(1):47-55Jones, H., Kaltenbach, K., Heil, S., Stine, S., Coyle, M., Arria, A., O’Grady, K., Selby, P., Martin, P., Fischer, G. (2010). Neonatal Abstinence Syndrome After Methadone or Buprenorphine Exposure. New England Journal of Medicine, 363(24):2320-2331
The overarching goal of treatment is
to soothe the newborn’s discomfort
and promote mother-infant bonding
and attachment.
• Pharmacological Treatment
• Individualized based on the severity of withdrawal symptoms
• Scoring tool to measure severity of withdrawal symptoms should be adopted
• Based on an assessment of the risks and benefits of pharmacologic therapy
• Type of medication should match the type of agent causing withdrawal
• 80% of children can be successfully weaned from methadone completely within 5-10 days
• Mean length of hospital stay for newborns: Methadone = 9.9 days; Buprenorphine = 4.1 days
Different Populations of Women Can Give Birth to Infants with NAS Symptoms
Chronic pain or other medical
conditions maintained on
medication
Actively abusing or dependent on
heroin
Misuse of own prescribed medication
Misuse of non-prescribed medication
In recovery from opioid addiction & maintained on methadone or buprenorphine
(e.g. medication assisted
treatment)
Adapted from Dr. Cece Spitznas, White House Office of National Drug Control Policy 9;307(18):1934-40.
Opioids during Pregnancy
The American Congress of Obstetricians and Gynecologists:
Withdrawal from Opioids During Pregnancy
• Withdrawal or the abrupt discontinuation
of opioids in an opioid-dependent
pregnant woman is not recommended as
it can result in preterm labor, fetal
distress, or fetal demise
• Medically supervised withdrawal can be
accomplished in some instances and
should be undertaken by a physician
experienced in perinatal addiction
treatment
The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics &
Gynecology, 119(5), 1070-1076.
The American Congress of Obstetricians and Gynecologists:
Treatment of Opioid Dependence During Pregnancy
• The current standard of care for pregnant women with opioid dependence is
opioid assisted therapy with methadone
• Buprenorphine is an effective option for pregnant women who are new to
treatment or maintained on buprenorphine pre-pregnancy.
• Maternal outcomes, pain management considerations and breastfeeding
recommendations are similar between the medications used in the treatment
of opioid dependence
The American Congress of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics &
Gynecology, 119(5), 1070-1076.
Hendree Jones, Presented at the NADCP Annual meeting, May 28, 2014, Anaheim, CA.
Jones, H., O’Grady, K., Malfi, D., & Tuten, M. (2008). Methadone maintenance vs. methadone taper during pregnancy: Maternal and neonatal outcomes. American Journal on Addictions, 17(5), 372-386
Opioid relapse rate in pregnant women with opioid use disorder is between 41-96%
As part of a comprehensive treatment program,
MAT has been shown to:
• Increase retention in treatment
• Decrease illicit opiate use
• Decrease criminal activities
• Decrease drug-related HIV risk behaviors
• Decrease obstetrical complications
Fullerton, C.A., et al. November 18, 2013. Medication-Assisted Treatment with Methadone: Assessing the Evidence. Psychiatric Services in Advance; doi: 10.1176/appi.ps.201300235The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076.
Long-Term Impact
• Studies demonstrate cognitive development to be within the
normal range up to age 5
• Advances in the field call for additional studies on the long-term
impact of opioid prenatal exposure
• Family characteristics, improved prenatal care, exposure to
multiple substances, and other medical and psychosocial factors
have a significant impact on long-term outcomes
The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076. Emmalee, S. B. et al. (2010) Prenatal Drug Exposure: Infant and Toddler Outcomes. Journal of Addictive Diseases, 29(2), 245-258.Baldacchino, A., et al. (2014). Neurobehavioral consequences of chronic intrauterine opioid exposure in infants and preschool children: a systematic review and meta-analysis. BMC Psychiatry, 14(104).
Parenting and Family Factors that Increase Risk
• Single family households—larger family size as well as single-family
households at greater risk
• Family history of interpersonal violence—correlated with increase
risk of physical child abuse but weaker for sexual abuse and neglect
• Issues affecting parenting ability
- Severe/abusive tactics
- Dysphoria
- Stress
- Poor coping mechanisms
- High reactivity (impulsivity, affect)
Child Factors that Increase Risk
• Age—younger children (under age 6)
• Special needs—vs. non-special need children
• Gender—mixed results, but girls may be at higher risk of sexual
abuse than boys
• Younger children in family—younger children are at higher risk
than older children; infants under age 1 are the highest risk group
• Child health and behavior
• Positive toxicology report—children born with positive
toxicology
Parent Factors that Increase Risk
• Substance abuse/mental health issues—most frequent risk
factor for maltreatment
• Age—younger parent, the higher risk of maltreating
• History of foster care themselves
• Lower educational levels
• Paternal experience of abuse in childhood
• Social isolation and lack of social support
• Maternal employment
• Paternal factors—more research needed
No intervention In-Home Services Removal
No Use
Mild
Moderate
Severe
Low Risk
Low NeedHigh Risk
Low Need
Low Risk
High Need
High Risk
High Need
Alternative Response
DS
M 5
Dia
gn
osis
Child Welfare Intervention
TEXT PAGE
Children Go Home, Stay Home…
or Find Home
1 Children’s Bureau. Child Welfare Outcomes 2008-2011, Report to Congress. U.S. Department of Health and Human Services, Administration for Children and Families, Administration of
Child Youth and Families.
Annually, there are approximately 740,000
instances of child maltreatment in the United
States.1
Approximately 65% of these children
will remain at home.
Another 20% to 25% will
be returned home
following a removal.
Total of 80% to
85% of children
remaining at or
returning
home.
“I wish you helped my mom.”
Impact on Kinship Care:
Family Dynamics,
Children’s Needs,
Caregiver’s Needs and
Parent’s Needs
Child’s Desire for Visitation
Promotes healthy attachment
and reduces the negative effects
of separation for the child
Establishes and strengthens
the parent-child relationship
Eases the pain of separation, loss
and abandonment for the child
Improves child well-being
Keeps hope alive for the
parents and enhances parents’
motivation to change
Involves parents in their child’s everyday activities and development
Helps parents gain confidence in their
ability to care for their child and allows
parents to learn and practice new skills
Parent’s Right to Visitation
Eases the pain of
separation, loss and
abandonment for the parent
Promotes healthy attachment and reduces the
negative effects of separation for the parent
Allows kinship and foster caregivers
to support birth parents
Opportunity for kinship and foster caregivers
to model positive parenting skills
Caregiver’s Opportunity
for Engagement
American Bar Association, Visitation with Infants and Toddlers in Foster Care: What Judges and Attorneys Need to Know;http://www.americanbar.org/content/dam/aba/administrative/child_law/visitation_brief.authcheckdam.pdfNRC for Family Centered Practice and Permanency, Information Packet: Parent-Child Visiting; http://www.hunter.cuny.edu/socwork/nrcfcpp/downloads/information_packets/Parent-Child_Visiting.pdf
Provides a setting for the caseworker
to observe and suggest how to improve
parent-child interactions
Provides information to the court and
caseworker on the family’s progress
Social Worker’s Opportunity for
Observation and Engagement
Family TimeShorter stays in out of home care
Increased reunification
Successful reunification
Honoring a Child’s Desire to Know Their Parents
• Start with a contract – contingency contracting
• Be open to parents’ growth and change
• Plan for and anticipate difficult visitation situations
– Parent is under the influence
– Parent has a lapse or relapse
– Child is maltreated
– Parent is not engaged or doesn’t show to visitation
• Developmentally appropriate
• Bonding and attachment is critical for newborns and infants
It’s easy when the parent is compliant.
What will you do in the difficult situations?
Contracting Considerations
Describe the target
behavior change in
the parent’s own
words.
Incentives can be
included to
reinforce positive
behaviors
The signature is
a meaningful
ritual!
1. Contracting on goals supportive of recovery lead
to better outcomes than those more directly
related to substance use
2. The severity of the consequences for breaking a
contract positively affects the adherence to the
contracts terms
Considerations for Visitation:
Developmental Tasks, Ages 0-5
• Newborn and Infants:
– Establish a sense of trust
– Make needs known and have them met
– Develop attachment to at least one primary caregiver
– Breastfeeding and Neonatal Abstinence Syndrome: Promote bonding and
soothes infant
• Toddlers
– Increased self-awareness and self-regulation
– Continue attachment bonding with caregiver(s)
Visitations should be frequent and long enough to
enhance the parent-child relationship.
Consistent, Routine &
Predictable
Safe location
Transitional objects
Adapted from: http://www.courts.mo.gov/hosted/circuit11/Documents/Parental%20guide%20to%20visitation.pdf
Considerations for Visitation:
Developmental Tasks, Ages 6-11
School Age:
• Development of self-esteem, self-worth, moral development
and personal security
• Development of relationships with peers and adults
• Aware of parents’ as individuals
• Aware of parents’ substance use and recovery
• May feel anger towards parent
• May blame self
Help the child understand the parents’ substance use and that the child is not the cause.
I didn’t Cause It
I can’t Cure it
I can’t Control it
I can Care for myself by
Communicating
my feelings,
Making healthy Choices
And
By Celebrating myself
NACOA – National Association for Children of Alcoholics
Teach the 7 C’s
Considerations for Visitation:
Developmental Tasks, Ages 12-18
Pre-Adolescents, Teens and Transitional Age Youth:
• Establish identity
• Establish sense of independence
• Establish peer group
• Separation from family
• Mourn childhood
Help the adolescent normalize the experience of having a parent with a substance use disorder through peer connections.
Provide an opportunity for youth to share
experiences with each other
• Partner with a treatment agency
• Provide space at CW office
• Celebrating Families! Curricula
NACOA – National Association for Children of Alcoholics
" Assure frequency or length of visits
will not be used as punishment or
reward, but is a right of all family members unless
child safety is jeopardized.“
Strengthening the parent-child bond through visitation may be a more effective motivator for a parent to address their substance use.
“Continued contact between the child and his family is essential to maintaining and
strengthening family bonds. Changes in visitation arrangements shall be directly related to the ongoing risk and family assessment.”
What Children Need
• Listening and helping to identify feelings
• Providing information about substance use and mental disorders
• Providing ongoing support to keep them safe and help them recover!
• Following through on screenings to ensure they receive the
counseling and support they need!
• Helping them to understand they are not to blame!
“You are not the reason your parent has a disorder.”
“Your parents addiction is a disease that may cause them to lose control or do things that do
not keep you safe or cared for.”
“Who can you trust who you might talk with about your concerns – a teacher, close friend, an adult in your family?”
“There are a lot of kids like you. You are not alone – and there’s no reason to feel embarrassed.”
What Caregivers Need
Self Care is the
heart of the Kinship
Balancing Act
Where do you find support?
What do you do to refuel?
Setting the Boundary: Maintaining Hope
Tolerance
Safety
Hope
But be prepared for
children to seek out
their birth parents,
regardless of the
limits you set…..
Continuum of Trust Levels in Kinship Care
A Shared History…
Clear expectations, transparency, openness to change, & healthy boundariesare the keys to rebuilding trust.
No Trust
• Rigid boundaries with parent, won’t be flexible to meet parents’ needs
Codependent
• Overly trusting of parent, allows inappropriate access to child
Balanced
• Understands needs of child and parent, balances child safety with bonding needs
Safety and Achieving
Balance: A Team Effort
Child
Caregiver
Parent
Social Worker
Trust & Transparency
Shared Information
Key Information
• Treatment progress
• Child well-being
• Changes in visitation
• Changes in case plan goals
• Decisions on child’s health, education, etc.
TEXT PAGE
Types of Kinship Care: Resources
Informal Kinship Care
Permanent Guardianship Adoption
Guardianship Assistance
Foster Care Payments
Subsidized Guardianship
Temporary Assistance for Needy
Families (TANF): Income Based
Eligibility
TANF-Child Only Benefit
Federal Title IV-E Adoption Assistance
State Adoption Assistance
Additional Resources
Supplemental Nutrition Assistance
Program
Child’s Health Insurance: Medicaid or Children’s Health Insurance Program
Respite Care
Foster Care Custody; Guardianship
Educational
Supports
• Remain in home school if appropriate
• Eligible for educational surrogate parent to help navigate
educational issues
• Reimbursement for transportation to school
• Remain in home school until disposition: otherwise only if
relative lives in the same town or school agrees
• Not eligible
• None
Other Benefits
for Child
• Eligible for Medicaid
• Free hot lunch
• Child care in licensed facility (100% covered
• Eligible for Medicaid or Dr. Dynasaur if eligible for Child
Only Research up grant
• Free hot lunch if eligible for Child Only Reach Grant
• Childcare if a proven need; covered up to maximum
allowed, not typically 100%
Other Supports
for child, parent
and family
• Social worker or contracted agency assistance for support,
negotiating family issues, parent visitation, etc.
• Help for parents to reunite with the child and/or to
experience safe contact
• Access to Family Services (FS) contracted services
• Legal support for court proceedings, including TPR
• Permanency planning for the child: Reunification,
TPR/adoption, permanent guardianship
• None unless ordered by court
• None unless ordered by court or DCF open case
• Only at Commissioner's discretion and dependent on
available funding
• None once DCF is no longer involved (except OCS)
• Permanency planning when reunification is the goal: legal
custody or guardianship unless the child’s attorney or
relative petitions for TPR; cost of legal representation is
usually the relative’s
Other
• Reimbursement of mileage to doctor’s, counseling, other
appointments of child
• Respite services so the family has a break and can come
back together renewed
• Trainings available for foster parents to be better parents
and to better understand child’s trauma and needs
• None (some exceptions with Medicaid eligibility)
• From VKAP or Agencies on Aging if caregiver is 55+
• Some trainings
Supports for Foster Care or Kinship Caregivers—VERMONT SPECIFIC
Contact Information
Nancy K. Young, PhD, MSW
Director, Children and Family Futures
Director, National Center on Substance Abuse and Child Welfare
1-866-493-2758
www.cffutures.org
www.ncsacw.samhsa.gov/default.aspx
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