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


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

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
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.

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
Parent-Child Assistance Program (PCAP)
An intensive, 3-year home visitation intervention
for high-risk alcohol and/or drug abusing mother
Primary Goal To Prevent Future Births of Alcoh
ol and Drug Exposed Children

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
  • WA State Dept. Social and Health Services
  • (Division of Alcohol and Substance Abuse)
  • March of Dimes
  • Nesholm Family Foundation
  • Private Philanthropy

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

-or- Have delivered a child with a diagnosis of
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
PCAP A Two-Pronged Approach
Clients Families
Community Service Providers
Core Components of the Intervention
  • PCAP is a 3-year home visitation model
    implemented by well trained, supervised
  • Caseload recommendation 15-16 active client
  • 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
  • Link clients with appropriate community
    services assure clients receive services.
  • Provide advocacy for all family members as

The Scope of Advocacy
Community Providers
Juvenile Justice
Bio Dad
Job Training
Extended Family
Alc/Drug Tx
Family Planning
Room- mates
Mental Health Tx
Health Care
The Formula for Preventing Alcohol/Drug Exposed
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
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
Results Treatment Abstinence
Results Family Planning
Results Income Custody
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

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.
  • Mothers in PCAP were themselves
  • the abused, neglected children
  • in our communities just 10-15 years ago.

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

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

Systems Working Together for Substance Abuse
Division of Alcohol Substance Abuse (DASA) t
reatment expansion Increased treatment beds for
women 55 to 153
(1991 - 2007)
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
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).
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.
  • Implementing a
  • Home-Visitation Model
  • Lessons Learned

Lessons Learned Develop a Theoretically-Based
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.
Theoretical Framework
  • Relational Theory
  • Intervention
  • Long term, positive interpersonal
    relationship with case manager and PCAP team.

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
(No Transcript)
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
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.
The Difference Game
Lessons Learned Help Client Identify Goals
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.

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

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

Strategies for Preventing Alcohol/Drug Exposed
  • Alcohol/Drug Treatment
  • Family Planning

Alcohol Drug Treatment
  • 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.

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

Alcohol Drug Treatment
  • 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.

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

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

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?
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.
Preventing Future Alcohol-Exposed Births
  • Without PCAP about 30 (or 23) of 78 drinking
    mothers would have had another highly exposed
  • 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.

Preventing Future Alcohol-Exposed Births Cost
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.  
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.
(No Transcript)
Working With Women Who Have Fetal Alcohol
Spectrum DisordersPilot project funded by the
March of Dimes Birth Defects Foundation
  • 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.

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

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
  • Obtaining a diagnosis in adulthood was
  • Even for experienced PCAP advocates, working
    with an FASD client was more difficult than
    working with a typical PCAP client.

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
Advocates Experience She just doesnt get it!
  • The impact of neuropsychological deficits was
  • Advocates had to modify their usual approaches.
  • Clients were often unable to learn new skills or
    learned them very slowly.

Strategies to Use with Clients Who Have FASD
  • Use short sentences, concrete examples, and avoid
  • 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

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

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.
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.

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,
Ongoing Challenge Maternal Alcohol Use During
PregnancyIts not just alcohol
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.
If Im pregnant, can I fly a plane? Yes
if you could before, says Dr. Donald Gibb of
Londons Portland Hospital. In commercial jets,
he says, short rides are fine up to 36 weeks.
have a beer? The Centers for Disease Control s
ays no level of alcoholhas been determined
safe, but some doctors feel limited drinking
no more than a pint a day, suggests Dr. Gibb
after the first trimester is okay.
bleach or dye my hair? Many doctors give a th
umbs up after the first 12 weeks, so long as
chemicals are kept away from the scalp.
- People Magazine, April 17, 2006, pp 102-107