Nancy K. Young, Ph.D.

1
Current Substance Abuse Issues Impacting Child
Abuse and Neglect

• Nancy K. Young, Ph.D.
• Cathleen Otero, M.S.W., M.P.A.
• Presented at the 15th National Conference on
  Child Abuse and Neglect April 2005

2
Current Substance Abuse Issues Impacting Child
Abuse and Neglect

• Overview of NCSACW
• The Five Clocks
• Potential Consequences for Children affected by
  parental Substance Use Disorders
• Issues regarding infants prenatally exposed to
  substances
• Issues regarding parental methamphetamine use
• Identifying parental Substance Use Disorders
• A Framework and Policy Tools for Practice and
  Policy Changes

3

• A Program of the
• Substance Abuse and Mental Health
• Services Administration
• Center for Substance Abuse Treatment
• and the
• Administration for Children and Families
• Administration on Children, Youth and Families
• Childrens Bureau
• Office on Child Abuse and Neglect

4
Key Barriers Between Substance Abuse, Child
Welfare, and the Courts

• Beliefs and values
• Competing priorities
• Treatment gap
• Information systems
• Staff knowledge and skills
• Lack of communication
• Different mandates

5
The Five Clocks

• Temporary Assistance for Needy Families (TANF)
• 24 months work participation
• 60 month lifetime

• Adoption and Safe Families Act (ASFA)
• 12 months permanent plan
• 15 months out of 22 in out-of-home care must
  petition for TPR

• Recovery
• One day at a time for the rest of your life

• Child Development
• Clock doesnt stop
• Moves at fastest rate from prenatal to age 5

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Biggest challenge

• CLOCKS STILL RUNNING

The Four Clocks
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Clocks Still Running
ASFA Timetable
Timeliness of intervention versus Call me
Tuesday.
8
Clocks Still Running
ASFA Timetable

• CFSRs have documented
• Case reviews found parental substance use
  disorders were a factor in 16 to 48 of cases
• Need for child welfare training in addictions
• Gaps in services
• Inadequate assessment and follow up on the
  underlying needs of families, including substance
  abuse
• Substance use disorders in families with repeat
  cases

9
Clocks Still Running
TANF Timetable
Neglect is often associated with both substance
abuse and poverty.
10
Clocks Still Running
Recovery Timetable
A day at a time for the rest of your life.
Recovery is a lifelong process requiring a
disease management approach rather than emergency
care.
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Clocks Still Running
Child Development Timetable

• Interventions for children of substance abusers
  must recognize potential pre-natal and
  post-natal effects.
• Require multi-dimensional assessments and
  interventions responding to developmental status
  and special needs created by substance use
  disorders in the family.
• Alcohol-related neuro-developmental disorders
• Attachment, separation, loss, grief

12
Potential Consequences for Children

• Prenatal substance exposure
• Fetal alcohol syndrome, fetal alcohol spectrum
  disorder, neuro-developmental disorders
• Postnatal environment factors
• Violence or traumatic events
• Drug and/or alcohol seeking behaviors
• Illicit drug sales or manufacturing
• Lack of adult interpersonal support systems
• Community effects such as living in poverty
• Lack of proper health care
• Inconsistent caregivers

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Areas of Child Development Affected by Parental
Substance Use Disorders
Research has shown that these effects can
manifest themselves in multiple areas, including

• Physical health consequences
• Lack of secure attachment
• Psychopathology
• Behavioral problems
• Poor social relations and skills
• Deficits in motor skills
• Cognition and learning disabilities

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Children Living with One or More Substance
Abusing Parent
In millions
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Number of Children Prenatally Exposed to
Substances
SAMHSA, OAS, National Survey on Drug Use and
Health, 2002 and 2003 reported
Substance Used (Past Month) 1st Trimester 2nd Trimester 3rd Trimester
Any Illicit Drug 7.7 women 315,161 infants 3.2 women 130,976 infants 2.3 women 94,139 infants
Alcohol Use 19.6 women 802,228 infants 6.1 women 249,673 infants 4.7 women 192,371 infants
Binge Alcohol Use 10.9 women 446,137 infants 1.4 women 57,302 infants 0.7 women 28,651 infants

• State prevalence studies report 10-12 of infants
  or mothers test positive for alcohol or illicit
  drugs at birth5,6

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Number of Children Prenatally Exposed to
Substances
Total births 4,093,000 2002 10 of total
births 409,300 Total substantiated reports
for children 0-1 142,026
2002 Total age 0-1 in OOHC 22,957 2001
Where did they all go?
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MOST GO HOME.
80-95 are undetected and go home without
assessment and needed services.

• Many doctors and hospitals do not test, or may
  have inconsistent implementation of state
  policies
• Tests detect only very recent use
• Inconsistent follow-up for woman identified as
  AOD using or at-risk, but with no positive test
  at birth
• CAPTA legislation raises issues of testing and
  reporting to CPS

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A Graphic Overview
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Screening and Assessment of Consequences for
Children
The complexity of screening and assessment for
these children is compounded by at least two
realities

• There is no absolute profile of developmental
  outcomes based on a childs exposure to his or
  her parents substance use, abuse, or
  dependence.2
• Other problems arising in parental behavior,
  competence, and disorders interact with substance
  use, abuse, and dependence to cause multiple
  co-occurring problems in the lives of these
  children.

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The importance of identifying infants prenatally
exposed to substances

• Though a small percentage of CWS cases, these
  children are disporportionately affected by many
  lifetime conditions
• 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.7,8
• SEBs require a higher level of public spending
  than many other target groups

21
Child Abuse Prevention and Treatment Act (CAPTA)
2003 Amendments

• 2003 Keeping Families Safe Act Amendments
• Policies and procedures (including appropriate
  referrals to child protection service systems and
  for other appropriate services) to address the
  needs of infants born and identified as affected
  by illegal substance abuse or withdrawal symptoms
  resulting from prenatal drug exposure, including
  a requirement that health care providers involved
  in the delivery or care of such infants notify
  the child protective services system of the
  occurrence of such condition in such infants,
  except that such notification shall not be
  construed to (I) establish a definition under
  Federal law of what constitutes child abuse or
  (II) require prosecution for any illegal action
  (section 106(b)(2)(A)(ii))
• The development of a plan of safe care for the
  infant born and identified as being affected by
  illegal substance abuse or withdrawal symptoms
  (section 106(b)(2)(A)(iii))

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Children and Parents - Intervention Points
Pre-pregnancy awareness and substance use
Prenatal screening and assessment
Bonding supports
Parents role in child care
Family literacy and economic support
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Trends in State Policies

• Legislation that defines substance-exposed births
  as child abuse or neglect
• Legislation mandating substance exposed birth
  reports to CPS by health care professionals
  and/or mandated reporters in general
• Policies for testing mother and/or infant

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Trends in State Policies

• Leaving the judgment of child abuse or neglect to
  the discretion of the CPS worker or the health
  care provider
• Addressing alcohol and drug use/abuse during
  pregnancy, but not necessarily addressing the
  substance exposed birth
• CPS policies on how to respond to a substance
  exposed birth
• No official response

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Special Issue Methamphetamine
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Concern Regarding Children

• Need to consider prenatal as well as
  environmental exposure
• Prenatal exposure
• Need for developmental interventions
• Environmental exposure includes increased risk
  for children of cookers
• Need to know childs status
• Super labs
• Cookers
• Traffickers
• Users

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Worker Safety Issues

• Dangers associated with being in proximity to
  methamphetamine users and chemists.
• Identify potential signs of methamphetamine use
  in child welfare clients
• Identify signs that methamphetamine is being
  cooked in or around the clients home
• Ensuring the safety of the child welfare worker
  in settings where methamphetamine is being used
  or cooked.

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Issues Specific to Methamphetamine

• Meth users begin younger than other drugs
• Meth lasts longer acting than other stimulants
  (cocaine/crack)
• Differ from other users in their drug use
  patternthey use more days
• Differ in their cognitionparticularly in early
  abstinence
• Need alternative methods of imparting information

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Womens Issues

• Females MA users are more likely to
• Live alone with their children
• Use MA more days
• Smoke MA rather than snort or inject the drug
• Have worse psychiatric profiles
• Have worse medical, employment and psychiatric
  composites than male MA users

Reiber, 2000
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(No Transcript)
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Treatment Outcomes

• Outcomes have not differed from other drugs of
  abuse treatment studies

32
Treatment Outcomes

• Of 10 MA-abusing women
• entering treatment,

After treatment 1mo.
12mo. 24mo.
48mo.
Still MA-abstinent 6
4 3
3
3 still MA-abstinent 48 mo. after treatment
33
Treatment Outcomes

• Positive treatment outcomes were achieved using
• Intensive outpatient setting
• Three to five visits per week of comprehensive
  counseling for at least the first three months
• Cognitive behavioral approach
• Contingency management
• Reducing consequences associated with drug use
• Motivational interviewing brief intervention
  models
• Intervening earlier and reducing cumulative harm
• Attending to co-occurring mental disorders

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Screening for Prenatal Substance Exposure and
Parental Substance Use Disorders (SUDs)
35
Identifying Infants withPrenatal Substance
Exposure
Prenatal substance exposure can be screened for
in several ways. The most common methods, used
alone or in combination, are

• Verbal screen with mother
• Review of mothers history and medical records
• Observation of mother and/or newborn
• Drug testing (urine, blood, hair or meconium)

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Verbal Screening Tools4Ps Plus

1. Did either of your parents ever have a problem
   with drinking or using drugs?
2. Does your partner have any problem with alcohol
   or drugs?
3. Have you ever had any beer or wine or liquor?
4. In the month before you knew you were pregnant,
   how much beer/wine/liquor did you drink?
5. In the month before you knew you were pregnant,
   how many cigarettes did you smoke?

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Identifying Parental Substance Use Disorders

• Studies conducted on brief screens of six or less
  items suggest that there are a limited number of
  common constructs
• An effective screen for substance use disorders
  includes questions about
• Unintended use
• Desire to restrict use
• Consequences of use
• Concern about consequences of use

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Screening for ParentalSubstance Use Disorders
UNCOPE

• In the past year, have you ever drank or used
  drugs more than you 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?
• Have you ever found yourself preoccupied with
  wanting to use alcohol or drugs?
• Have you ever used alcohol or drugs to relieve
  emotional discomfort, such as sadness, anger, or
  boredom?

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Identifying Parental Substance Use Disorders

• Check list for Identifying SUDs4
• A report of substance use is included in the
  child protective services call or report.
• Paraphernalia is found in the home (syringe kit,
  pipes, charred spoon, foils, large number of
  liquor or beer bottles, etc).
• The home or the parent may smell of alcohol,
  marijuana, or drugs.
• A child reports alcohol and or other drug use by
  parent(s) or other adults in the home.
• A parent appears to be actively under the
  influence of alcohol or drugs (slurred speech,
  inability to mentally focus, physical balance is
  affected, extremely lethargic or hyperactive,
  etc).
• A parent shows signs of addiction (needle tracks,
  skin abscesses, burns on inside of lips, etc).
• A parent admits to substance use.
• A parent shows or reports experiencing physical
  effects of addiction or being under the
  influence, including withdrawal (nausea,
  euphoria, slowed thinking, hallucinations, or
  other symptoms).

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Introduction to a Framework and Policy Tools for
Practice and Policy Changes
Getting the Clocks in Sync
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• Navigating the Pathways
• published by CSAT1
• Established
• A framework for defining elements of
  collaboration
• Methods to assess effectiveness of
  collaborative work

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Framework and Policy Tools for Systems Change

• To define linkage points across systems
• To describe the components of the initiative
• To assess the progress in implementation
• To assist sites in measuring their implementation

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Elements of System Linkages

• Underlying values

• Joint accountability and shared outcome
• Information systems
• Training and staff development
• Budgeting and program sustainability

• Daily practice ? screening and assessment
• Daily practice ? client engagement and retention
  in care
• Daily practice ? AOD services to children

• Working with related agencies
• Building community supports

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Policy Tools

• Policy tools to facilitate collaborative work
  across systems
• Collaborative Values Inventory
• Collaborative Capacity Instrument
• Matrix of Progress in Linking Substance Abuse and
  Child Welfare Services
• Screening and Assessment for Family Engagement,
  Retention and Recovery (SAFERR)

Available at http//www.ncsacw.samhsa.gov
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Models of Improved Services

• Many communities began program models in 1990s

• Paired Counselor and Child Welfare Worker

• Counselor Out-stationed at Child Welfare Office

• Multidisciplinary Teams for Joint Case Planning

• Persons in Recovery act as Advocates for Parents

• Training and Curricula Development

• Family Treatment Courts

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Models of Family Drug Treatment Courts

• Integrated
• Both dependency matters and recovery management
  conducted in the same court with the same
  judicial officer
• Dual Track
• Both dependency matters and recovery management
  conducted in same court with same judicial
  officer during initial phase
• If parent is noncompliant with court orders,
  parent may be offered DDC participation and case
  may be transferred to a specialized judicial
  officer who increases monitoring of compliance
  and manages only the recovery aspects of the case
• Parallel
• Dependency matters heard on regular family court
  docket
• Specialized court services offered before
  noncompliance occurs
• Compliance reviews and recovery management heard
  by a specialized court officer

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The Fifth Clock
URGENCY

• Every 70 seconds a baby is born who was
  prenatally exposed to alcohol or illicit drugs.
• Every minute and a half, one of those babies goes
  home without screening or any effort to begin
  early intervention.
• A baby and a family you already know are highly
  at risk.

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The Voice of a Child
Nothing But Silence By Ashley G. Age
12 January 2005
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• People all around me
• Calling out my name
• But no I cannot hear them
• For my heart is filled with shame
• Nothing but silence
• But only till the break of dawn
• Will I be feeling sad
• For wandering out on the streets
• Are my birth mom and dad
• Whyd she do this to her and me
• With this well have to cope
• But while shes clean you never know
• There still could be hope
• But in the perfect world I know
• Theres no harmful stuff

Sitting by the widow sill A tear rolls down my
cheek Although it hurts I cant express My heart
is just too weak Nothing but ache Its funny what
one pill can do To a mother or a kid And now I
know that for a fact I wont do what she
did Nothing but ache Now I live a better
life And drugsI wouldnt dare Away from all the
harmful things With a family who cares Nothing
but love I know it hurts, it sure hurt me And
thats why Ill remain drug free Nothing but
hope
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The Fifth Clock

• The fifth clock is the one that is ticking on us.
  
• It measures how fast we get it, how rapidly we
  respond to human needs that grow larger by the
  day.
• We have to measure what we do against what needs
  doing, not against what we did last year.

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Notes

• Young, N.K. and Gardner, S.L. (2002). Navigating
  the Pathways Lessons and Promising Practices in
  Linking Alcohol and Drug Services With Child
  Welfare. SAMHSA Publication No. SMA-02-3639.
  Rockville, MD Center for Substance Abuse
  Treatment, Substance Abuse and Mental Health
  Services Administration.
• Chasnoff, I.J. (1997). Prenatal Exposure to
  Cocaine and Other Drugs Is there a Profile? In
  Accardo, P.J., Shapiro, B.K., Capute, A.J.
  (Eds.), Behavior Belongs in the Brain. Baltimore,
  MD York Press, 147-163.
• Lester, B.M., Andreozzi, L., Appiah, L. (2004).
  Substance Use During Pregnancy Time For Policy
  to Catch Up With Research. Harm Reduction
  Journal, 1(5).
• Young and Gardner, Navigating the Pathways, p.
  132.
• Vega et al (1993). Profile of Alcohol and Drug
  Use During Pregnancy in California, 1992.
• 6. SAMHSA, OAS. (2003). Results from the
  2002 National Survey on Drug Use and Health
  National findings.
• 7. NIAAA (2000). Tenth Special Report to
  Congress on Alcohol and Health.
• 8. NIDA (1998). Prenatal Exposure to Drugs
  of Abuse May Affect Later Behavior and Learning

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202 714-505-3626 fax Irvine, CA 92620
www.ncsacw.samhsa.gov