Intervention as Prevention: Working Effectively with HighRisk Mothers who Abuse Alcohol and Drugs

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Intervention as Prevention Working Effectively
with High-Risk Mothers who Abuse Alcohol and Drugs
2007 Washington State Institute on Addictions
Treatment Partnerships for Recovery Meeting the
Challenge June 27-29, 2007 Sheraton Tacoma Hot
el, Tacoma, Washington
Therese M. Grant, Ph.D. Associate Professor, UW
School of Medicine LaShaunda Harris Clinical S
upervisor, Yakima Parent Child Assistance Program
(PCAP)
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Children, Youth, and Family Track
Focus Continuum of family services

• Workshop Objectives
• Describe prevention strategies that have been
  demonstrated among substance abusing women to
  prevent future alcohol and drug exposed births.
  
• Describe effective methods for collaborating with
  community service providers to better understand
  and serve high-risk clients.
  
• Discuss how strong state policies can work
  together with community prevention programs to
  enhance outcomes.
  

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The Problem
Maternal alcohol and drug use puts children
at risk because of

• Possible effects of prenatal exposure on the
  childs health
  
• Likelihood of a compromised home environment
• Likelihood that these mothers will have more
  exposed, affected children

These problems are costly to society and are
completely preventable
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Parent-Child Assistance Program (PCAP)
An intensive, 3-year home visitation intervention
for high-risk alcohol and/or drug abusing mother
s
WHEN CASE MANAGEMENT ISNT ENOUGH
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Primary Goal To Prevent Future Births of Alcoh
ol and Drug Exposed Children

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PCAP Background

• 1991-present
• WA State locations King, Pierce, Yakima,
  Grant, Spokane, Cowlitz, Skagit Counties
  
• Replication sites MN, NC, AK, TX, NV, LA, PA
  
  
• multiple sites in Canada
• We thank our funders
• SAMHSA (CSAP)
• WA State Dept. Social and Health Services
• (Division of Alcohol and Substance Abuse)
• March of Dimes
• Nesholm Family Foundation
• Private Philanthropy

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PCAP Enrollment Criteria

• Used alcohol/drugs heavily during pregnancy
• Not effectively engaged with community
  resources
  
• Are currently pregnant, up to six months
  postpartum

-or- Have delivered a child with a diagnosis of
FAS/E
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Advocate Characteristics
Have experienced some of the same types of
adverse life circumstances as clients, but
seldom to same degree Have subsequently achieve
d success in important ways Are positive role
models and offer clients hope and motivation
from a realistic perspective
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PCAP A Two-Pronged Approach
Advocate
Clients Families
Community Service Providers
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Core Components of the Intervention

• PCAP is a 3-year home visitation model
  implemented by well trained, supervised
  advocates.
  
• Caseload recommendation 15-16 active client
  families
  
• Advocates

• Assess clients strengths, needs.
• Help clients identify goals and baby steps to
  meet goals (every 4 months).
  
• Develop a network among clients service
  providers to facilitate effective treatment
  planning.
  
• Link clients with appropriate community
  services assure clients receive services.
  
• Provide advocacy for all family members as
  needed.

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The Scope of Advocacy
Community Providers
Juvenile Justice
Schools
Children
Partners
Bio Dad
Job Training
Friends
Probation
Siblings
Extended Family
Alc/Drug Tx
Family Planning
Caretakers
Neighbors
Room- mates
Mental Health Tx
Health Care
CPS
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The Formula for Preventing Alcohol/Drug Exposed
Births
Motivate women to stop drinking or using
drugs before and during pregnancy
OR Help women who cant stop drinking
or using drugs to avoid becoming pregnant
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Preventing Alcohol and Drug Exposed Births in
Washington State Intervention Findings from
Three Parent-Child Assistance Program Sites
American Journal of Drug and Alcohol Abuse, 2005
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Results Treatment Abstinence
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Results Family Planning
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Results Income Custody
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An Ongoing Challenge

• Pregnant and parenting women who abuse
  substances are unfailingly characterized as
  bad mothers.
  
• They have been labeled unmotivated and difficult
  if not impossible to reach.
  
• These mothers become distrustful of helping
  agencies.

The result is that the women at highest risk for
delivering children with serious medical,
developmental, and behavioral problems are the
least likely to seek and receive assistance.
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• Mothers in PCAP were themselves
• the abused, neglected children
• in our communities just 10-15 years ago.

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Enrollment Characteristics
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• Our challenge is to engage these mothers and
  their children together to break this
  
• intergenerational pattern.

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Good things happen when communities implement
effective programs and states implement strong
policy.
Systems Working Together

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Systems Working Together for Substance Abuse
Treatment
Division of Alcohol Substance Abuse (DASA) t
reatment expansion Increased treatment beds for
women 55 to 153
(1991 - 2007)
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Systems Working Together for Family Planning
DSHS Take Charge program (1989-present)
Developed to help low income pregnant women obta
in services Recent development Free family p
lanning supplies for women and men at 200 below
FPL
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Systems Working Together
Work First Welfare to Work program (1997)
State 41 reduction in families on welfare (199
7-04) PCAP 42 reduction (1995-03) PCAP sub
jects were higher risk compared to general
welfare population (fewer white, fewer married,
all substance abusers).
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Systems Working Together forSafe, Stable Custody
WA Permanency Framework developed to increase
rates of permanent placement for children in
foster care (1998) State reunification rate co
nsistent decrease (1997-02) PCAP with bio mom
at exit 52 (1991-95) and 57 (1996-03)
1996-03 cohort half as likely to be in foster ca
re and 3x more likely to be adopted compared to
1991-95 cohort.
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• Implementing a
• Home-Visitation Model
• Lessons Learned

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Lessons Learned Develop a Theoretically-Based
Model
Relational Theory A womans sense of connectednes
s to others is central to her growth,
development, definition of self.
Positive relationships within the intervention,
treatment, and recovery setting are critical.
The quality of interpersonal relationships
may determine whether or not a woman remains
in an intervention may be more important than
the concrete services received.
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Theoretical Framework

• Relational Theory
• Intervention
• Long term, positive interpersonal
  relationship with case manager and PCAP team.

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Theoretical Framework
Stages of Change Clients will be at different st
ages of readiness for change.
Intervention Motivational Interviewing
acknowledge clients perception of situation
encourage her to explore and aspects
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Theoretical Framework
Self-Efficacy An individuals belief in her ab
ility to accomplish the behaviors required to
produce desired outcomes. Your expectatio
ns about self-efficacy are influenced most
powerfully by your own history of
accomplishment.
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Theoretical Framework
Harm Reduction Addiction and associated risks ar
e on a continuum. The goal is to reduce
harmful consequences of the habit for mother
and her child. Intervention Any steps toward
decreased risk are steps in the right direction.
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The Difference Game
Lessons Learned Help Client Identify Goals
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Client Goals

• The Difference Game
• Identify the baby steps it will take to reach
  each goal.
  
• Make sure at least some of these baby steps are
  attainable in the 4-month period.
  
• The client must observe herself succeeding in
  order for her to build self efficacy and move
  toward change.

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Lessons Learned Quality Control Through Outcome
and Process Evaluation
Measure Monitor

• Identify program outcomes
• Evaluate progress
• Identify areas for improvement
• Develop protocols (e.g., boundaries)
• Individualized feedback helps staff see their
  outcomes relative to others, encourages them to
  learn improvement strategies from others
  
• Weekly, monthly, biannual feedback

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Lessons Learned Supervision, Group Staffing,
Team Support

• Supervisor meets individually with advocates
• every other week
• Review each case
• Make recommendations
• Discuss how the focus can be re-directed to the
  Big Picture and client goals, and away from
  small crises the client can handle
  
• Listen for common issues/problems that should be
  addressed with the group in weekly staffing
  
• Group staffing once a week
• Brain-storming, problemsolving sessions that
  leave participants in a positive frame of mind
  for the challenges they face
  
• Close-knit state team interaction
• Meetings every 3 months
• Annual retreat

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Strategies for Preventing Alcohol/Drug Exposed
Births

• Alcohol/Drug Treatment
• Family Planning

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Alcohol Drug Treatment
BEFORE

• Mandated treatment may be necessary.
• Seek women-only treatment setting.
• Seek treatment where children can stay.
• Gain cooperation of client support system.
• Prepare the client for what to expect.

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Alcohol Drug Treatment
DURING

• Get Releases of Information signed.
• Maintain boundaries with treatment agency.
• Arrange for child visitation.
• Stay in close touch.
• Arrange for post-treatment, transitional
  housing.

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Alcohol Drug Treatment
AFTER

• Relapse is part of the disease be explicit and
  honest about consequences.
  
• Help client identify triggers and make a plan,
  e.g. call advocate immediately.
  
• Introduce client to relevant support groups.
• Consider relocation to new neighborhood.

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Family PlanningRates of Unintended Pregnancy
U.S. Unintended Pregnancy. 50 Of these
Unintended live births 23 Abortions 27
Using contraception before pregnancy
48 WA State Unintended Pregnancy.. 50 Us
ing contraception at time of pregnancy 43.4

Henshaw, 1998 WA State DSHS RDA, April 2004
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Family Planning

• Does NOT mean never having another baby
• DOES mean having more control over whether, and
  when, to have another child

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Family Planning Strategies
Education

• Basic anatomy, how pregnancy occurs
• How various family planning methods work
• Possible contraindications
• Consider lifestyle and health status
• Consider cognitive and functional status

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Family Planning Strategies
Encourage clients to discuss, acknowledge
previous experiences. Motivational Interviewin
g help client identify pros and cons of having
another child revisit this topic. Reestabli
sh client goals every 4 months. How will having
another child affect achieving goals?
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Preventing Future Alcohol-Exposed Births
At PCAP replication sites, 78 women were binge
drinkers (5 drinks/occasion) during the index
pregnancy. At PCAP exit, 51 (66) were no longe
r at present risk of having another alcohol
exposed pregnancy 24 (31) using reliable
contraception 18 (23) abstinent from alco
hol/drugs 6 months 9 (12) both relia
ble contraceptive and abstinent.
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Preventing Future Alcohol-Exposed Births

• Without PCAP about 30 (or 23) of 78 drinking
  mothers would have had another highly exposed
  birth.
  
• We reduced that by 66, preventing about 15
  alcohol- exposed births.
  
• The incidence of FAS is estimated at 4.7 to 21
  among heavy drinkers.
  
• Therefore, we estimate PCAP prevented at least
  one and up to three new cases of FAS.
  

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Preventing Future Alcohol-Exposed Births Cost
Savings
The average lifetime cost for an individual with
FAS is 1.5 million. PCAP costs about 15,000
/ client for 3 years (intervention,
administration, evaluation).
If we prevented just one new case of FAS, the e
stimated lifetime cost savings cost of PCAP
for 102 women.  
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Benefits and Costs of Prevention and Early
Intervention Programs
Home Visiting Programs for At-Risk Mothers an
d Children
Washington State Institute for Public Policy, Ju
ly 2004 found an average net lifetime benefit of
6197 per client among selected well-researched
home visiting programs, including PCAP.
www.wsipp.wa.gov
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Working With Women Who Have Fetal Alcohol
Spectrum DisordersPilot project funded by the
March of Dimes Birth Defects Foundation
(2001-2002)

• A pilot community intervention for young women
  with fetal alcohol spectrum disorders. Community
  Mental Health Journal 2004, 40(6) 499511.
  
• Quality of life and psychosocial profile among
  young women with fetal alcohol spectrum
  disorders. Mental Health Aspects of
  Developmental Disabilities 2005, 8(2) 3339.

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Profile PCAP FASD Clients (N19)

• Average age 22 Years
• Mostly white (60), unmarried(85), and poorly
  educated (45)
  
• Troubled life history profiles
• High levels of psychiatric distress and
  behavioral problems
  
• Poor quality of life relative to other at-risk
  populations

• Family history drug/alcohol abuse (100)
• Sexual abuse (79)
• Physical abuse (84)
• Unstable and disrupted care giving (100)

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Community Service Providers What We Found

• Providers knew very little about FASD.
• Providers had limited direct experience with
  this population.
  
• Few services were suited for individuals with
  FASD.
  
• Obtaining a diagnosis in adulthood was
  difficult.
  
• Even for experienced PCAP advocates, working
  with an FASD client was more difficult than
  working with a typical PCAP client.
  

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Educating Providers

• We identified key providers interested in the
  problem, and willing to work with a PCAP client
  who has FASD.
  
• We provided FASD education, a PCAP case
  manager, and follow-up consultation.
  
• Providers learned to deliver services
  appropriately tailored to specific needs of
  FASD patients.

Education hands-on experience FASD demystified
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Advocates Experience She just doesnt get it!

• The impact of neuropsychological deficits was
  obvious.
  
• Advocates had to modify their usual approaches.
• Clients were often unable to learn new skills or
  learned them very slowly.
  

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Strategies to Use with Clients Who Have FASD

• Use short sentences, concrete examples, and avoid
  analogies
  
• Present information using multiple modes
• Simple step-by-step instructions (written and/or
  with pictures)
  
• Role-playing
• Ask patient to demonstrate skills (dont rely
  solely on verbal responses)
  
• Revisit important points during each session

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Strategies to Use with Clients Who Have FASD

• Teach generalization Dont assume a lesson
  learned in one context will transfer to another
  
• Help client identify physical releases when
  escalating emotions become overwhelming
  
• Be alert for changes/transitionsmonitor more
  carefully, do advance problem-solving
  

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An experienced and clinically supported case
manager, working in collaboration with her client
and a network of educated providers, might
reasonably expect to accomplish a number of
intervention steps over a 12-month period.
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FASD clients may need life long advocacy, but
intervention steps can be taken in the short term

• Secure stable housing, and safe placements for
  the children.
  
• Secure some financial stability for the future
  (SSI, DDD).
  
• Assist clients in choosing a reliable
  contraceptive method.
  
• Establish an educated network of service
  providers and committed mentors who will continue
  to work with clients.

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Think Younger Adjust expectations to be more co
ngruent with the individuals developmental level
of functioning.
Diane Malbin FASCETS (Fetal Alcohol Syndrome
Consultation Education and Training Services,
Inc.) www.fascets.org dmalbin_at_fascets.org
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Ongoing Challenge Maternal Alcohol Use During
PregnancyIts not just alcohol
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February 21, 2005U.S. Surgeon General Releases
Advisory on Alcohol Use in Pregnancy

• Women who are pregnant or who may become pregnant
  should abstain from alcohol consumption in order
  to eliminate the chance of giving birth to a baby
  with any of the harmful effects of the Fetal
  Alcohol Spectrum Disorders (FASD).

This updates a 1981 Surgeon General's Advisory.
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