The SAMHSA Women, Co-Occurring Disorders

1
The SAMHSA Women, Co-Occurring Disorders
Violence (WCDVS) Childrens Subset Study

• Presented at
• Putting the Pieces Together First National
  Conference on Substance Abuse, Child Welfare
  the Dependency Court
• July 15, 2004

Vivian Brown, Ph.D. PROTOTYPES Centers for
Innovation in Health, Mental health and Social
Services
Nancy VanDeMark, MSW Arapahoe House Inc.
Lisa Russell, Ph.D. ETR Associates
Norma Finkelstein, Ph.D. Institute for
Health Recovery
2
Study Overview
3
Family Focused Approach

• Treatment to promote the well-being of the entire
  family
• Attracts retains women in treatment
• Prevention of child abuse neglect of future
  substance abuse mental health problems in
  children
• Promotes resiliency coping skills in children

4
Impact of Recovery on the Family

• Changes roles relationships among all family
  members
• Stimulates guilt remorse for past behavior
• Stimulates fear loss
• Families need a great deal of support to tolerate
  the feelings stay with it

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Childrens Subset Study Primary Goals

• For children of mothers with co-occurring
• mental health and substance use disorders
• histories of violence
• Generate empirical knowledge about the
  effectiveness of trauma-informed, age-specific
  intervention models
• Identify models of care that will prevent or
  reduce intergenerational perpetuation of violence

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Target Population

• Children, ages five to ten, of women enrolled in
  the WCDVS
• Children had at least weekly personal contact
  with mother / caregiver enrolled in WCDVS
• Only one child per family enrolled in the study

7
Childrens Study Sites

• Allies Stockton, California
• Arapahoe House- Denver, Colorado
• Prototypes Los Angeles, California
• Well Project Cambridge, Massachusetts
• Coordinating Center - Policy Research Associates

8
Baseline Characteristics of the Women
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WCDVS Demographics N2,729
Age Mean 36
Race African- American Hispanic Caucasian 27 19 50
Education Less than high school 47
Relationship Status Married/significant other Divorced/separated/widowed Never married 38 32 30
Employment Full-/part-time Disabled Below Poverty Line 13 25 73
Residence Homeless Residential SA House/apartment 3 53 36
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Parenting Status

• Percent Ever Having Children 86.7
• Mean Number of Children
• Under 18 2.04
• Percent with Custody 59.2

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Trauma Experience

• Study data show that trauma started early and
  happened often
• About ¾ of subjects (74) reported multiple types
  of abuse and repeated abuse.
• Average age of first sexual and physical abuse
  was 13
• Physical neglect reported started around 9 years
• Almost all women (92) reported physical abuse
• 90 reported sexual abuse

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Health Status
49 with any insurance 62 Medicaid 18 Medicare
Serious physical illness 48
Percent with excellent/very good physical health 15
Percent taking psychotropic medications 63
Below the poverty line 65
BSI (Mean GSI Score) 1.42
Mean ASI Drug .13
Mean ASI Alcohol .20
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Legal Status

• 27 of women were mandated to mental health
  and/or substance abuse treatment by DCF/Child
  Protection.
• 21 had been in a jail or correctional facility
  in the previous 3 months.

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Summary of Demographic Characteristics

• Data indicate that, in general study participants
  were
• not highly educated
• underemployed
• in relatively poor physical and mental health
• mostly mothers with extensive histories of
  interpersonal violence

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Service Use at Baseline
Type of Service of Respondents Reported Having Received Service of Respondents Reporting Having Received Service (Out of N2729)
Hospitalization 560 20.5
Emergency Room 980 35.9
Detox Services 592 21.7
Residential Treatment (Any type) 1,486 54.5
Homeless or Domestic Violence Shelter 353 12.9
Jail or Correctional Facility 565 20.7
Peer Support or Self-Help Services 1,810 66.3
Medical Clinic or Doctors Office 1,638 60.0
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Parenting Concerns at Baseline

• Almost a quarter (24.5) of the mothers with
  children under 18 were concerned about losing
  custody of their children.
• Less than half (46) of mothers indicated they
  felt confident in their ability to help their
  child grow and develop.
• Only 32.4 of women agreed with the statement, I
  feel my family life is under my control.
• Only 37.3 of women strongly agreed or agreed
  with the statement, I feel my service providers
  support me in my role as a parent.

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In the words of the women Parenting
groups gave me confidence that I could do it.
It showed me that I was allowed to make
mistakes. It gave me skills to feel confident
with my baby and not feel like Im going to
hurt her or screw her up, cause that was my
biggest fear. Charlene, Arapahoe
House
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Baseline Characteristics of the Children
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Characteristics of Children

• Average age - 7.28 years
• In legal custody of mother - 74.3
• Involved in child welfare system - 39
• Experiencing emotional or behavioral problems -
  67.5
• Parent convicted of a crime 79.8
• Parent treated for substance abuse 98

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Age (N253)
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Race Distribution (N253)
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Gender (N253)
23
Hispanic Ethnicity (N86)
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Rating of Childs School Performance
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Prevalence of Victimization
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Intervention Overview
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Core Values Reflected in the Intervention

• Children have a right to express themselves
  openly and to have their opinions validated.
• Services for child and parent should be
  integrated.
• Safety is of utmost importance.
• Consistency is a cornerstone of service delivery.
• Interactions should promote respect and support
  understanding, compassion, dignity and self-worth.

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Core Values Reflected in the Intervention

• Children have a right to exercise control over
  their bodies
• Interventions should encourage nurturing
  relationships with adults
• Children are entitled to share information
  confidentially except when issues of safety arise
• Families should be connected to community and
  natural supports

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Core Intervention Components

• Clinical Assessment Mother Child
• Resource/Service Coordination Advocacy
• Skills-/Resiliency-Building Group

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Clinical Assessment

• Strengths and interests
• Significant life events
• Parent and child substance use
• Medical concerns

• Mental health needs
• Educational and developmental issues
• Parenting and discipline

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Group Intervention

• Orientation Mothers and Children
• Session 1 Message Its okay to feel and express
  feelings
• Session 2 What is abuse?
• Session 3 Anger
• Session 4 Its not always happy at my house
• Session 5 Sharing personal experience with
  violence

Group Intervention was adapted from Groupwork
With Children of Battered Women, Peled and Davis,
Sage Publications, 1995
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Group Intervention

• Session 6 Touch
• Session 7 Assertiveness
• Session 8 Protective Planning
• Session 9 Review and Good-bye
• Booster Session 1 (30 days post) - Review week 2
  discussion on abuse
• Booster Session 2 (60 days post) - Review week 8
  on safety planning

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Primary Goals of the Group Intervention

• Learn self-protection skills
• Develop skill in self-soothing
• Enhance interpersonal relationships
• Strengthen self-esteem and self identity

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Resource Coordination Advocacy

• Parent and child self-determination and
  empowerment
• Strengths-focused rather than pathology- focused
• Resource coordinators as resiliency mentors
• Focused on resiliency-building activities
• Teaching parents advocacy skills

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Analysis and Results
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Primary Research Question

• Are trauma-informed, age-specific interventions
  for children more effective than usual care
  conditions in leading to increases in safety,
  self-care, positive interpersonal relationships
  and self-identity?

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Sample Overview

• N253 at Baseline
• N209 at 6 Months (82.6)
• N217 at 12 Months (85.8 Retention)
• N195 (77.1) Received Baseline, 6 Month and 12
  Month Interviews
• Intervention and Comparison Groups are
  Statistically Equivalent on Demographic
  Characteristics Across Follow-Ups

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Analysis

• Primary Outcome Variable
• Behavioral Emotional Rating Scale (BERS)
  Strength Quotient (Epstein Skaima, 1998)
• Secondary Outcome Variables
• BERS Subscales
• Tools for Improving Relationships
• Family Involvement
• Capacity for Closeness
• Positive self-identity
• Measure of Safety Knowledge
• Child knows what to do to keep self safe when
  feels threatened by another person (4 Point
  Scale)

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Analysis Plan

• Covariates Used in All Analyses
• Childs Age
• Childs Gender
• Childs Race
• Site Site by Treatment Interaction
• Mothers Outcomes (Composite Score)
• Experience of Violence in the Household
• Number of Days Since Mothers Baseline Interview

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Short Term Effects (6 months post baseline)

• Primary Outcomes
• Involvement in intervention lead to comparable,
  but not better, improvement than treatment as
  usual
• Mothers outcomes affected childrens outcomes
• Children in comparison whose mothers had negative
  outcomes did worse
• Children whose mothers had positive outcomes did
  well in both conditions

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Short-Term Effects (Six Months Post Baseline)

• Secondary Outcomes
• Enrollment in the standardized intervention
  appears to lead to improvements in positive
  interpersonal relationships, knowledge about
  safety positive self-identity.

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Longer-Term Effects(Twelve Months Post Baseline)

• Primary Outcomes
• Involvement in intervention leads to sustained
  improvement compared to children in comparison
  group
• Mothers outcomes do not play role in sustaining
  childrens positive outcomes
• Younger children show more improvement regardless
  of condition
• Children in intervention group performed
  consistently better across all age groups

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Longer-Term Effects(Twelve Months Post Baseline)

• Secondary Outcomes
• Intervention plays role in sustaining
  improvements in positive interpersonal
  relationships, knowledge re safety positive
  self-identity

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Summary of Results

• In short-term (six-months), mothers overall
  treatment outcome plays stronger role in
  childrens outcomes than involvement in the
  intervention
• In longer-term (twelve-months), participation in
  intervention leads to sustained positive
  improvement regardless of mothers outcome, with
  younger children showing a greater degree of
  positive change than older children

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Implications and Lessons Learned
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Role of CSRs Parents

• Partners in development of research and
  intervention design
• Developed consent form discussing risks and
  benefits of the group intervention
• Co-facilitated groups
• Assisted mothers in understanding importance of
  the intervention
• Acted as a bridge for trust
• Provided support for parents as they experienced
  shame, guilt and fear

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Lessons Learned

• Children can be the motivator for women to seek
  treatment.
• Treatment of the woman offers an opportunity to
  provide services to the children.
• Traumatic childhood experiences influence the
  ability to parent.
• Victimization if children triggers memories in
  the parent.
• Motherhood is both a major source of identity and
  self-worth, and a source of shame and guilt.

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Lessons Learned

• Extreme guilt and shame must be addressed in
  order to build healthy parenting relationships.
• The support of a parent who has experienced
  similar challenges is critical to overcome fear
  and guilt.
• Must have well developed working relationships
  with child welfare agencies.
• System related issues of confidentiality and
  privacy must be addressed in order to promote
  healthy boundaries.

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Implementation in Residential Settings

• Challenges
• Milieu issues and group confidentiality
• Closed groups
• Retaining child once parent leaves treatment
• Custody issues
• Perceived breaches of trust travel farther and
  faster

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Implementation in Residential Settings

• Opportunities
• Ease of access for families
• Wrap around support for family
• Support outside of groups
• Continuity across interventions (milieu,
  parenting, childrens groups, mothers trauma
  groups
• Care for younger children available

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Residential Lessons Learned

• Programs should attempt to deliver the maximum
  dosage of the childrens intervention while the
  parent it in residential treatment.
• The informal relationship of CSRs and mothers
  built in the milieu become valuable assets for
  trust building
• Children are sensitive to being left out of a
  group. Decisions about closed or semi-closed
  groups should be made with these implications in
  mind.

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Residential Lessons Learned

• Interventions for parent and child should be
  integrated. Childrens staff must be sensitive
  to what is happening in mothers treatment and in
  parenting groups.
• Helping women manage their fear of systems is an
  ongoing task and is often best addressed in
  groups.
• Maintaining group confidentiality is much more
  difficult in residential settings.

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Implementation in Outpatient Settings

• Challenges
• Trust and rapport
• Scheduling
• Location
• Transportation
• Staffing
• Child care
• Custody

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Implementation in Outpatient Settings

• Opportunities
• Parent engagement, education, and support
• Parent network building
• Potential impact on other children in family
• Child and family advocacy within the community
  system of care for children

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Outpatient Lessons Learned

• Role of consumers
• Feedback, flexibility, and responsiveness
• Connection as a theme
• Child abuse reporting

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Outpatient Lessons Learned Clinical Staff

• Working toward a family approach while taking
  into account staff members strengths in training
  experience
• Staff cross training and preparation for a
  strengths based, family centered approach
• Clinical supervision that addresses planning for
  childrens and mothers unique needs as well as
  an integrated family approach

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Implications for Practice

• Integration of childrens services into existing
  adult MH SA treatment programs
• Prevention
• Future MH, SA, Intergenerational violence
• Early Intervention
• Importance of Concurrent Services (Mother
  Child)
• Systems Collaboration
• Funding