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Collaborative Interventions for Newborns and Parents Affected by Substance Abuse

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Title: Collaborative Interventions for Newborns and Parents Affected by Substance Abuse


1
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
2
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)

3
Perinatal Substance Use and Child Welfare
InvolvementParents, Infants, Social Services
4
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

5
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

6
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)

7
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

8
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
9
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
10
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

11
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

12
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

13
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

14
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

15
Collaborative Interventions Vulnerable Infants
Program of Rhode Island (VIP-RI)
16
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

17
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

18
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

19
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

20
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

21
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

22
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

23
Collaborative Interventions Rhode Island
Family Treatment Drug Court(RI-FTDC)
24
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

25
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

26
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) 

27
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
28
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

29
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

30
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

31
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

32
Permanency Outcomes
  • At 30 months
  • 90 of infants living in homes identified as
    permanent placement
  • 79 (N 48) reunified with biological mother

33
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
34
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
35
Infant Outcomes - 30 Months Cognition (Bayley)
89.0 (8.71)
91.98 (12.81)
100 (15)
100 (15)
36
Infant Outcomes - 30 Months Motor, Conceptual
Language (DIAL-R)
37
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

38
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

39
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

40
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

41
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

42
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
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