Collaborative Interventions for Newborns and Parents Affected by Substance Abuse

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Collaborative Interventions for Newborns and
Parents Affected by Substance Abuse
Jean Twomey, Ph.D. Brown Center for the Study of
Children at Risk Brown Alpert Medical School
Abandoned Infants Assistance Resource
Center National Center on Substance Abuse Child
Welfare Substance Exposed Newborns
Collaborative Approaches to a Complex Issue Old
Town Alexandria, VA June 24, 2010
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Overview

• Perinatal substance use
• child welfare involvement
• How to meet the needs of
• Parents
• Infants
• Social service agencies
• Collaborative Interventions
• Vulnerable Infants Program of Rhode Island
  (VIP-RI)
• Rhode Island Family Treatment
• Drug Court (RI FTDC)

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Perinatal Substance Use and Child Welfare
InvolvementParents, Infants, Social Services
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Perinatal Substance Use Child Welfare
Involvement

• Associated with growing numbers of infants in
  child welfare system
• Crack epidemic in 1980s
• Substance-exposed infants admitted to foster care
  rose from 7 (1987) to 29 (1992) (Goerge
  Harden, 1993)
• Policy practice about how to safeguard
  substance-exposed infants vary from state to
  state
• No uniform standards or philosophy on how best to
  intervene

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Substance Use during Pregnancy

• Major public health social problem
• 5 of pregnant women use illicit drugs
  (National Household Survey on Drug Use Health
  2006-2007)
• Extent of concern reflected in involvement of
  multiple social service systems

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Current Conceptualizations of Drug Use

• Chronic brain disease
• Indicator of multiple problem areas
• Cannot be treated as a discrete diagnosis
• Comprehensive, multidimensional treatment needed
• Effective treatment continuing care
  monitoring (McLellan, Lewis, OBrien, Kleber,
  2000)

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Public Policies Matter

• Approaches influenced by public policy public
  perception
• impact of prenatal exposure
• reactions to pregnant substance users
• Punitive actions do not advance maternal, fetal
  or child health interests (Flavin Paltrow,
  2010)
• Policies need to promote reinforce help seeking
  behaviors

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Treatment Works

• Evidenced-based research effectiveness of
  multiple treatment approaches
• Mothers more likely to successfully complete
  treatment when programs recognize importance of
  parent-child relationship
• Help parent to be emotionally responsive
  nurturingnot just how to manage child behaviors

Focus on mother-infant relationship
Collaboration among social service systems
Home visitation Residential Motivational
interviewing contingency management
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Perinatal Substance Use Parents

• Associated risk factors add to concerns about
  parenting abilities
• Lack of role models for how to be a nurturing
  parent
• Parents can be attached to their babies not
  want to lose them even when they are not able to
  take care of them (Lederman Osofsky, 2004)

Co-occurring psychiatric disorders Domestic
violence Lack social supports
Trauma Unaddressed medical needs Limited
vocational educational experiences
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Barriers to Treatment

• Limited availability of programs for pregnant
  parenting women
• Stigma
• Concerns about separation from children
• Fears about losing custody
• Lack of resources
• Insurance, transportation, child care
• Addressing basic needs may be priority
• Housing, food, transportation, heat

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Perinatal Substance Use Infants

• Mandated reporting ensuring infant safety often
  leads to out-of-home placement
• Longer time in care, less likely to be reunified,
  more likely to be re-reported
• Disruptions in attachment
• Increased risk for psychological, developmental,
  behavioral, physical problems
• Stress trauma associated with separation loss

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Optimizing Outcomes for Infants in Placement

• Monitor case closely
• Focus on childs physical psychological health
  development
• Ameliorate effects of disruptions in
  relationships by ensuring consistent, nurturing
  caregiving
• Consider childs established psychological ties
• Reunify or if removal likely to be permanent, act
  quickly
• Frequent contact with parents needed to establish
  sustain relationship
• Minimize lengthy separations multiple moves

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Pressures Faced by Social Service Agencies

• More global expectations
• Growing awareness of complex parental needs
• Immediate and long-term concerns about
  substance-exposed infants
• Increased accountability
• Mandated time frames for permanency
• Budget staff cuts

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Importance of How Social Services Agencies
Function

• Impact treatment permanency outcomes
• Without attention to families multiple needs
  reunification unlikely or, if occurs, unlikely to
  remain permanent
• Complementary approaches that address parent
  infant needs

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Collaborative Interventions Vulnerable Infants
Program of Rhode Island (VIP-RI)
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Vulnerable Infants Program of Rhode Island
(VIP-RI)

• Federal demonstration grant to work with child
  welfare system family court to
• Secure permanency for substance-exposed infants
  within Adoption Safe Families Act (ASFA)
  guidelines
• Optimize parents opportunities for reunification
• Care coordination program
• Improving ways social service systems deliver
  services and interface will positively impact
  families

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Adoption and Safe Families Act (ASFA)

• Purpose expedite permanency, reduce foster
  care drift
• Shift from prioritizing reunifying families in
  almost all circumstances
• Makes health safety of children a priority
• Permanency hearings within 12 months of foster
  care placement
• Termination of parental rights if in foster care
  15 of prior 22 months
• Mandates concurrent permanency planning

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Overview of VIP-RI

• Criteria for participation
• Involvement in child welfare because of substance
  use during pregnancy
• Referrals
• Majority from maternity hospital
• Community agencies, self-referral
• Available to partners
• Infants followed until permanency
• When reunification not feasible, work with
  parents to relinquish parental rights

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VIP-RI Care Coordination

• Engages parents early
• Identifies parent infant needs
• Established partnerships with agencies ensure
• Parents/infants get appropriate services
• Minimizes time on waiting lists
• Are given consistent messages
• Everyone is a stakeholder in infants permanent
  placement
• Increase communication among social service
  agencies
• Attend court hearings, provide input, monitor
  progress until permanency

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VIP-RI The First 4 Years(Twomey, Caldwell,
Soave, Fontaine, Lester, in press)

• Maternal Demographics
• Ages ranged from 17 to 43 (N 195)
• 89 single
• Education
• 61 high school graduates or equivalent
• 37 less than high school
• Infant Demographics
• 55 male (N 203)
• 72 full-term

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Placement Outcomes

• At discharge from VIP-RI significantly greater
  percentage of infants placed with biological
  parent
• 56 at discharge vs. 32 at enrollment
• No change in placement for 43 of infants
  following hospital discharge
• 44 remained with a biological parent
• 22 remained with family member
• By 12 months, identified permanent placements for
  84 of infants

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Lessons Learned from VIP-RI

• Intervene early
• Maximize parents opportunities to engage in
  services
• Instill hope
• Connect families to services matched to their
  identified needs
• Provide ongoing support
• Coordinate with all social service providers to
  increase collaboration

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Collaborative Interventions Rhode Island
Family Treatment Drug Court(RI-FTDC)
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Rhode Island Family Treatment Drug Court (RI FTDC)

• Grew out of partnership with VIP-RI
• Established in September 2002
• Specifically for perinatal substance users
• Primary purposes
• Permanency within ASFA time frames
• Optimize potential for parents to reunify

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Family Treatment Drug Court

• Interactive, therapeutic approach
• More informed judicial decisions regarding child
  placement and permanency
• Coordinates provision of services
• Intensive case monitoring
• Frequent court reviews
• Hearings less frequent as participant progresses
• Incentives sanctions

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Comparison of RI FTDC Standard Court Outcomes

• VIP-RI participants enrolled in RI-FTDC (N
  79) standard family court (N 58)
• Cohorts were comparable
• Time to initial reunification significantly
  quicker for RI-FTDC participants
• Within 1st 3 months, reunification for RI-FTDC
  participants was (73) compared to standard
  family court (39) 

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Average Time to First Reunification With Mother
100
90
RI-FTDC
80
Standard Family Court
70
60
50
Percent Reunified
40
30
20
10
0 - 3
4 - 6
7 - 9
10 - 12
13 - 15
16 - 18
19 - 21
22 - 24
Months to Reunification
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Longitudinal Outcomes of RI FTDC
Participants(Twomey, Miller Loncar, Hinckley
Lester, under review)

• 54 substance-exposed infants whose mothers
  participated in RI FTDC
• Assessments done at 6 month intervals between 12
  to 30 months of age
• Permanent placements for substance-exposed
  infants
• Infant developmental outcomes
• Functioning of mothers after RI FTDC involvement

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Maternal Outcomes Measures

• 12 24 Months
• Substance Abuse Subtle Screening Inventory
  (SASSI)
• Identifies potential for substance dependence
• Brief Symptom Inventory (BSI)
• Identifies psychological symptom patterns
• Adult-Adolescent Parenting Inventory (AAPI-2)
• Identifies high-risk parenting child rearing
  attitudes
• 12 30 Months
• Child Abuse Potential Inventory (CAPI)
• Assesses risk for child abuse
• Parenting Stress Index (PSI)
• Measures level of parental stress that may
  adversely affect parenting

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Infant Outcomes Measures

• 18 30 Months
• Child Behavior Checklist (CBCL)-Ages 1½-5
• Identifies problem behaviors
• 30 Months
• Attachment Q-sort
• Assesses attachment
• Child Bayley Scales of Infant Development - 3rd
  ed
• Measures cognitive abilities
• Developmental Indicators for the Assessment of
  Learning Revised (DIAL-R)
• Measures motor, conceptual language skills

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RI FTDC Study Maternal Infant Demographics

• Maternal Demographics
• Ages ranged from 19 to 45 (N 52)
• 89 not married
• Education
• 40 high school graduates or equivalent
• 20 some post secondary education, but no college
  degrees
• Infant Demographics
• 56 male (N 54)
• 74 full-term

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Permanency Outcomes

• At 30 months
• 90 of infants living in homes identified as
  permanent placement
• 79 (N 48) reunified with biological mother

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Infant Attachment
Q-Sort compares attachment behaviors of sample
to Secure Ideal Prototype Q-Sort attachment
score is derived for each child Attachment
score per child is correlated with Secure Ideal
Prototype Correlation range of -1.00 to 1.00
Higher correlations indicative that child is
similar to Secure Ideal Prototype
Attachment
Q-Sort attachment scores of ASFA sample is
comparable to the Secure Ideal Prototype of a
clinical sample
correlations
Only 41 of study sample is comparable to the
Secure Ideal Prototype of a non-clinical sample
r.32
r.20
r.21
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Infant Outcomes - 18 30 Months Behavior
Problems (CBCL)
Higher score greater presence and severity of
symptoms 50 mean 60- 63 borderline
clinical range gt63 clinical range
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Infant Outcomes - 30 Months Cognition (Bayley)
89.0 (8.71)
91.98 (12.81)
100 (15)
100 (15)
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Infant Outcomes - 30 Months Motor, Conceptual
Language (DIAL-R)
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Summary of Developmental Findings

• Most infants not exhibiting behavioral problems
  or cognitive delays
• Possible areas of concern
• Attachment may be affected by even minimal
  disruptions in placement
• 22 of Bayley language composite scores fall
  below the clinical cutoff
• DIAL-R results provide a comparison of how child
  outcomes can be interpreted when different
  standards are applied to assess potential problem
  areas
• Whether or not these findings are indicators of
  incipient difficulties in learning or
  infant-caregiver relationships depends on many
  factor
• appropriate developmental stimulation, adequate
  resources, nurturing homes that remain constant,
  maternal functioning

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Maternal Outcomes

• 81 of mothers graduated from RI FTDC
• 7 of graduates relapsed
• Mothers who did not graduate significantly more
  likely to relapse
• SASSI Probability of substance dependence
  disorder increased at 24 months
• BSI Psychiatric symptoms increased at 24 months

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Maternal Outcomes

• AAPI-2 High-risk parenting attitudes changes
  between 12 and 24 months
• Worsened in 2 out of 5 domains
• inappropriate expectations
• restricts power independence
• Improved in 1 out of 5 domains
• role reversal
• CAPI Risk for child maltreatment closer to sample
  with abuse history
• PSI Parenting stress increased between 12 30
  months

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Importance of Ongoing Collaboration

• Even with positive permanency outcomes chronic
  issues are not easily resolved
• Conceptualize permanency as an ongoing state
• normalize interventions for families who would
  benefit from periodic or more intensive attention
  support
• Recognize changing family circumstances
• when mothers move away from supportive services
• as infant needs evolve into the needs of toddlers
  and preschoolers

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Power of Collaboration

• Collaboration benefits families and the social
  service systems that work with them by increasing
  efficacy and more positive outcomes
• Ongoing access to treatment needed to
• promote adaptive parental functioning
• prevent re-entry into the child welfare system
• maintain placement stability
• optimize infant developmental outcomes
• Benefits of cross-fertilization broaden
  perspectives in ways that better meet needs of
  families affected by perinatal substance use

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Funding Sources

• VIP-RI was supported by grants from
• Childrens Bureau Abandoned Infants Assistance
• Robert Wood Johnson Foundation, Center for
  Substance Abuse Treatment
• After ASFA Outcome of the RI-FTDC was supported
  by
• Robert Wood Johnson Foundations Substance Abuse
  Policy Research Program

Collaborators
RI FTDC Study Barry Lester Cynthia Miller
Loncar Suzy Barcelos Winchester Matthew Hinckley
VIP-RI Barry Lester Rosemary Soave Lynne
Andreozzi Fontaine Donna Caldwell