family-based recovery: home-based treatment for families affected by parental substance abuse...

Family-Based Recovery:Home-based Treatment for

Families Affected by Parental Substance Abuse

Managing Risk in the Best Interest of the Child

Presentation Collaborators

Yale Child Study Center

Jean Adnopoz, M.P.H.

Karen E. Hanson, L.C.S.W.

Dale Saul, Ph.D.

Jeffrey J. Vanderploeg, Ph.D.

The State of Connecticut

Department of Children And Families

Peter Panzarella, M.A.

Connecticut

• Population - 3,409,549– Approximately 750,000 under age 18

• No County Government (169 Town Governments)

• CT Department of Children and Families is a consolidated Children’s Agency with mandates:– Child Welfare– Children’s Behavioral Health– Juvenile Justice– Prevention

Connecticut Department of Children and Families

• DCF serves at any point in time 36,000 children and 16,000 families across mandates

• DCF with Department of Social Services (Medicaid) carved out Behavioral Health and manage the Connecticut Behavioral Health Partnership

• DCF Behavioral Health develops and implements policy, programs and services in the community

• DCF has developed a broad array of intensive in-home behavioral health services

Drug Use in Connecticut • In Connecticut during 2005-2006 (average),

9.2% of men and women ages 12 and older reported using illicit drugs in the past month, compared to 8.2% overall in the U.S. 

• In Connecticut in 2008, a study of women of childbearing age (18-44 years) revealed that:– 18.7% of women of reported smoking, compared to

20.0% of women overall in the U.S.– 16.0% of women reported binge drinking in the past

month, compared to 14.8% overall in the U.S.

Source: Peristats March of Dimes

Connecticut Substance Abuse Screening GAIN Short Screen Data for Protective

Services

Family-Based Recovery: History

• Stages of Community Readiness– No Awareness– Denial– Vague Awareness– Preplanning– Preparation– Initiation– Stabilization

(From: National Implementation Research Network) http://www.fpg.unc.edu/~nirn/resources/publications/Monograph/index.cfm

Family-Based Recovery:Community Readiness

• 2005 Conference and Report (Funded by AIA/DCF)

• Disseminated the latest research on substance-exposed infants and their families in a report Attachment & Recovery: Caring for Substance Affected Families

http://aia.berkeley.edu/media/pdf/attachment_recovery.pdf• Explore systems collaboration strategies and

participate in the development of regional collaborative networks to best serve the needs of Connecticut families

Family-Based Recovery Recommendations 2005

• Comprehensive community based care for child and family

• Importance of attachment theory in service design

• Co-occurring problems and housing needs

• Implement best practices

Family-Based Recovery 2006 • Re-design of DCF funded Substance

Abusing Parents/ Children at RISK programs combined funding with In-Home Behavioral Health

• DCF, Yale Child Study Center and Johns Hopkins University collaborated on model development

• Infrastructure developed for the needed Quality Assurance and Consultation (Family-Based Recovery Services)

• Request for Proposal was released in 2006 for five service providers

Family-Based Recovery

• DCF contracted with 6 providers• Yale Child Study Center – provides

QA• DCF developed a MOA with the

University CT Health Center on independent evaluation – Qualitative Analysis of FBR

Implementation– Quantitative Analysis of (Matched

Group Design)

FBR: Opportunity

• Family-Based Recovery (FBR) integrates two treatment modalities to focus on attachment, parenting, substance abuse recovery and psychotherapy.– Coordinated Intervention for Women and

Infants (CIWI), an attachment-based parent-child therapeutic approach (Yale Child Study Center)

– Reinforcement-Based Treatment (RBT), a contingency management substance abuse treatment model (John Hopkins University)

FBR Mission

The mission of FBR is

1) to ensure that children develop optimally in drug-free, safe and stable homes with their parent/s

2) to develop a replicable, evidence-based practice model

FBR Key Constructs

• Attachment critical for healthy development

• Substance abuse treatment works

• Risk management for stability and permanence

FBR Key Constructs

FBR draws on the wish of most adults to be recognized as competent to engage them in substance abuse recovery and promote adequate parenting behaviors

The FBR Way

FBR is more than a treatment for parents who are using substances: it is a way of engaging, treating and being with a client and his/her children. The FBR approach incorporates good clinical skills, motivational interviewing techniques with lessons learned about home-based work.

The FBR Way

Once the risk for relapse and child neglect/abuse decreases, the work expands to address other client-identified goals. The FBR team supports and encourages the client’s efforts towards change in all aspects of their life: education, relationships, parenting. There are no limits to success for FBR clients.

The ABC’s of FBR

• Acceptance

• Building Trust

• Commitment to Engagement

Acceptance

• Staff need to accept clients where they are in order to promote change and allow clients to determine their own goals

• Staff will be exposed to family systems and environments that might differ from their own experiences and values– Differences can cause discomfort

– Individuals vary in their ability to conduct in-home work

Building Trust

Trust is an essential element of effective intervention: building trust requires a commitment to the process of engagement and a willingness to endure testing, rejection, frustration and hostility

Commitment to Engagement

Key values are:– Respect– Patience – Persistence– Willingness to allow families to lead

the intervention– Early success offering concrete

service can enhance initial engagement

Putting it together

CIWI RBT

DCFFBR

The FBR Team

FBR Teams is composed of:• 2 Full-Time Master’s level clinicians

– 1 Clinician provides parent-child related interventions to six families

– 1 Clinician provides sobriety-related interventions to six families

• 1 Full-Time Bachelor’s level Family Support Specialist

• A Half-Time Supervisor• A Part-Time Psychiatrist

FBR Clients

• A parent who is actively abusing substances and/or has a recent history of substance abuse (w/in 30 days)

• A child who is:–under the age of 24 months– resides with the index parent at the

time of referral, or– in foster care with a plan for

imminent reunification

Parent-Infant Intervention

Complex Families

• FBR families: – Often come to parenting with legacy

of childhood emotional neglect and abuse, loss, abandonment

– Problematic relationships in adulthood– Emotion regulation more challenging

with neglect/abuse hx, and for those modulating emotion with substance use

Emotion Regulation• Parenting that requires emotion

regulation can easily overwhelm/be a source of disconnection

• Goal: “Overriding” first response of anger or hopelessness, and reflecting on what is going on with this child at this moment

• FBR listens, observes, reflects with parents, contains the moment

Infant Mental Health and Attachment

• Infant Mental Health: the developing capacity of the very young child to experience, regulate and express emotion; form close, secure interpersonal relationships; explore and learn—all in the context of family, community and cultural expectations

Attachment

• Attachment theorist Bowlby stated that for infants to survive, – They must behave in ways that help

keep parents close and communicate in ways that get parents to respond

– Their parents must be able to understand them

Attachment

• A young child’s relationship with the primary caregiver is key to healthy development in socio-emotional, cognitive and health domains

• Parents’ perceptions of being parented affects how they parent and how they see their child

Attachment-based Work

• Fosters change in maladaptive attachment relationships

• Targets Internal Working Model of the relationship for both parent and child

Infant Mental Health Approach

• FBR uses an Infant Mental Health approach:– Encourages parent to identify and

explore feelings re parenting– Focuses on the infant’s feelings:

“speaking for the baby”– Focuses parent on the needs of the

child– Links past with current caregiving

experiences

Infant Mental Health Approach

Not parent education:FBR uses everyday moments—

feeding, bathing, reciprocal play, singing, talking, touch-- to help parents make connections between feelings, action, and consequences of acting on feelings in the parent-child relationship.

What behaviors frighten the parent or child, what brings them close?

Competent Parents, Competent Babies

• We use the opportunity of a baby to help parents resolve issues with early caregivers (“Ghosts in the Nursery”) that are interfering with the capacity to parent and establish secure attachments

• Our task: to help parents feel competent and be a “secure base” from which their children can explore the world; for babies to feel understood and safe in their parents’ care

Reflective Functioning

• RF: seeing from the child’s perspective, or being able to make sense of the child’s behavior, emotion, feelings

• FBR uses natural parent-child interaction as opportunity for intervention: moment of anticipating/understanding a need; moment of shared delight or when parent can soothe child; staying present with child despite stress

Reflective Functioning

• Techniques to enhance RF:– Helping parent identify what emotions

are baby’s and what are parent’s – Helping parent see baby as separate

being, developing with age-appropriate behaviors and needs

– Helping parent feel her/his unique importance to this child

Parent-Child Measures

• Measures that inform and guide the parent-child work are:– Parent Stress Inventory –Short Form– Edinburgh Postnatal Depression Scale– Postpartum Bonding Questionnaire– Genogram– Ages and Stages (ASQ and ASQ-Social

Emotional) Questionnaires

Substance AbuseTreatment

Reinforcement-based Treatment

• Reinforcement-based Treatment (RBT) is an evidence-based behavioral approach to substance abuse treatment.

• RBT incorporates:– Community Reinforcement Approach

(Budney & Higgins, 1998)

– Motivational Interviewing (Miller & Rollnick, 1992).

FBR: Basic Principles

Positive reinforcement is the most effective means of producing behavior change.

– The best way to eliminate an individual’s drug use is to offer competing reinforcers that can take the place of drug use

– Competing reinforcers: People, Places and Things that can take the place of drug use

– FBR believes that the infant/child is the primary positive reinforcer

FBR Tools for Treating Substance Abuse

• Functional Assessments

• Contracts

• Graphs

• Feedback Report

• Drug Testing/Vouchers

Functional Assessment

The Functional Assessment (FA) is a clinical instrument that structures the gathering of information on a client’s drug use at intake and after each relapse. Information is organized into categories:– Internal and external triggers– Behavior (route of use, amount)– Short-term positive consequences– Consequences

Contracts

Contracts are used throughout treatment• Whenever there is a need to emphasize a

behavioral goal: “critical time points”

• Early on in treatment as an agreement to “sample” abstinence

– Sobriety Sampling Contract signed as initial contract at intake

• Clients might “break the contract” and use, but hope contract will make the individual stop and ponder this choice

A clinical tool that: • Makes abstinence and abstinence-

related goals salient to the client• Helps clients understand the ongoing

relationship between substitution behaviors and abstinence

• Provides a concrete way for the clinician to reinforce (both socially and tangibly) progress towards goals

• Helps clinician predict relapses

Graphs

Days Clean Graph_______'s Days Clean from _____________

0123456789

10111213141516171819202122232425262728293031

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Day of Month _____________

To

tal

days c

lean

Isabel PCP

Congratulations to me!

Refused testing

August

Isabel’s PCP

Mood Graph

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

__Isabel_'s Daily Mood

Day of Month _____________

Kids removed due to PCP use

Visit with kids

Feedback ReportFeedback is a technique that has been shown effective in getting clients to think about change.– Similar to how patients in the medical

setting view results of cholesterol testing, blood pressure

– Feedback is tailored to the individual and provides specific scientific results that carry weight

Social Club

A weekly group for clients and their children during which the clients:

• Receive peer and staff acknowledgement (reinforcement) and support for parenting and abstinence

• Practice interacting with other non-drug using parents in a non-drug environment

• Provide some continuity after graduation from FBR

Social Club

• Whatever the topic or activity, a goal of Social Club is for the conversation to ultimately link to issues of parenting and/or recovery.

• It is the role of FBR staff to link the group topic/activity to parenting and/or substance use.

• As the group process evolves and membership stabilizes this time will generally be client-led.

Drug Testing

• The team conducts substance abuse screening (urine and/or breathalyzer) at each home visit

• An 8-panel urine dip stick yields results in 5 minutes

• Clients receive a $10 gift card for each clean screen during the first part of treatment

• Clients can earn up to $720

Family-Based Recovery Services

FBR Services

• FBR Services provides:– Weekly 1 hour consultation with each

site– Weekly ½ hour consultation for each

supervisor– Quarterly network trainings– Quarterly QA reports to sites and DCF– Annual credentialing – Manual

Quality Assurance Approach and Goals

Goals of Quality Assurance:• Data collection that is accurate and timely

• Monitor adherence to clinical services inherent to FBR model (e.g., FBR Tools and Measures)

• Provide quarterly reports to DCF that describe FBR client population and programmatic adherence measures

– One network (aggregated) report– One report for each site on adherence data

FBR Network Case, Caregiver and

Index Child Characteristics

FBR Network Cases/Clients Served

Site Active Cases Active Clients

New Intakes

New Discharges

Site 1 14 28 5 4

Site 2 13 27 2 4

Site 3 17 35 7 6

Site 4 18 41 7 9

Site 5 16 36 7 4

Site 6 14 28 3 3

Quarter Total 92 195 31 30

Program to Date

316 680 316 254

FBR Network: Referral Source

91%

1%

7%

DCFOtherMissing

FBR Network: Family Makeup

15%

82%

3%

CouplesMother onlyFather only

FBR Network: Mother’s Age

13%

38%

29%

10%10%

17-2021-2526-3031-3536+

FBR Network: Maternal Marital Status

74%

8%12%

1%

0% 6%Single, never marriedDivorced/separatedMarriedWidowedOtherMissing/unknown

FBR Services: Maternal Education

35%

33%3%

15%

2%

11%Some High SchoolHS Grad/GEDTrade/VocationalSome CollegeCollege Grad. or GreaterMissing

FBR Network: Father’s Age

7%

30%

23%14%

25%

17-2021-2526-3031-3536+

FBR Network: Paternal Marital Status

57%

9%

23%

11%

Single, never marriedDivorced/separatedMarriedWidowedOtherMissing/unknown

FBR Services: Paternal Education

34%

36%2%

29%

Some High SchoolHS Grad/GEDSome CollegeMissing

FBR Network: Child Demographics

1%

62%11%

12%

14% 1%

Child’s Age

In Utero

0-6 months

7-12 months

13-18 months

19+ months

Missing

52%48%

Child’s Gender

BoysGirls

FBR Network: Child Race/Ethnicity

31%

0%

14%38%

14%2%

African-AmericanAsianBiracialCaucasianHispanicMissing

FBR Services: Child Placement at Intake

4%

87%

8% 1% 0%

Child’s Living Situation

Foster CareHome with Bio. ParentsWith RelativesOtherMissing

Parental Substance Use and Clinical

Characteristics

Maternal Risk Factors

Psych

iatri

c Illness

Physical A

buse

Sexual

Abuse

Domes

tic V

iole

nce

Sold D

rugs

Prostit

ution

Crimin

al Convi

ction

Probat

ion/P

arole

0

20

40

60

80

100

46

23 25

43

10 6

35

15

1017 17 13 17 16 12 9

Yes Unknown/Missing

Paternal Risk Factors

Psych

iatri

c Ill

ness

Physic

al A

buse

Sexual

Abuse

Domes

tic V

iole

nce

Sold D

rugs

Prost

itutio

n

Crimin

al C

onvict

ion

Probat

ion/P

arole

0

20

40

60

80

100

23 2011 16

29

0

48

2520 21 27 23 27

18 23 21

Yes Unknown/Missing

Index Child Clinical and Risk Characteristics

Child Risk Characteristics

N Mean Range

Gestational Age

212 37.9 weeks (s.d. = 3.1 weeks)

27 - 42 wks.

Birth Weight 198 6.3 lbs (s.d. = 1.3 lbs.) 2.2 – 9.4 lbs.

Case Outcomes

Duration of Services

• Kaplan-Meier survival curve plots estimated LOS based on all available data (open and closed cases)

• Using this method, the median length of time in the program is 6.2 months

• Among discharged cases (236), only 7% have been discharged in less than one month after referral

FBR Tox Screen Data

• Total of 17,298 screens program to date• Among the 17,298 screens to date, 77% have been

clean, 23% have been positive for one or more substances– 71% of positive screens were for marijuana– 9% cocaine – 9% prescription drugs– 9% PCP– 6% opiates– 3% other

Clean Tox Screens

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 1

0

Week 1

1

Week 1

2

Week 1

3

Week 1

4

Week 1

50%

10%20%30%40%50%60%70%80%90%

100%

43%

58%65%

69% 71% 73% 73% 74%

70%

75% 75%79% 78% 79% 79%

Percent of Clients with Clean Urine Screen, by Weeks in Program (N=228)

Clean Screen

Child Placement at Discharge

72%

12%

10%2% 4%

Home with Bio. Parents

Relative's Care

Foster Care

Other

Missing

Clinical MeasuresMeasures

NPre-Test Score

Post-Test Score

Change Score and

Significance

Edinburgh Depression Scale 255

Total Score 5.95 5.05 -0.90 **

Parenting Stress Index-Short Form

112

Total Score 67.62 60.89 -6.73 **

Parenting Distress 26.05 22.30 -3.75 **

Parent-Child Dysfunctional Interaction 18.89 16.86 -1.93 **

Difficult Child 22.44 21.18 -1.26 NS (p=.06)

Parental Bonding Questionnaire 100

Total Score 5.89 4.04 -1.85 **

Impaired Bonding 3.53 2.49 -1.04 **

Rejection-Anger 0.77 0.53 -0.24 NS

Anxiety-Care 1.57 1.02 -0.55 **

Risk of Abuse 0.04 0.00 -0.04 NS

AcknowledgementsYale UniversityJean AdnopozKaren E. HansonChristian M. ConnellDale SaulJeffrey J. Vanderploeg Jeanette RadawichAmy Myers

Johns Hopkins/U. of Maryland

Michelle TutenCindy SchaefferJennifer Ertel

Dept. of Children & FamiliesRobert PlantPeter PanzarellaFrancis GregoryTere Foley

University of ConnecticutJo HawkeKaren Steinberg