collaborative interventions for newborns and parents affected by substance abuse jean twomey, ph.d....
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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 CenterNational Center on Substance Abuse & Child Welfare
Substance Exposed Newborns: Collaborative Approaches to a Complex Issue
Old Town Alexandria, VAJune 24, 2010
OverviewPerinatal substance use & child welfare involvement
How to meet the needs of ParentsInfantsSocial service agencies
Collaborative InterventionsVulnerable Infants Program of Rhode Island (VIP-RI)
Rhode Island Family Treatment Drug Court (RI FTDC)
Perinatal Substance Use and Child Welfare Involvement
Parents, Infants, Social Services
Perinatal Substance Use & Child Welfare Involvement
Associated with growing numbers of infants in child welfare system
“Crack epidemic” in 1980sSubstance-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
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
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, O’Brien, Kleber, 2000)
Public Policies MatterApproaches 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
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 & nurturing—not just how to manage child behaviors
Home visitationResidential Motivational interviewing & contingency management
Focus on mother-infant relationship Collaboration among social service systems
Perinatal Substance Use: Parents
Associated risk factors add to concerns about parenting abilities
Lack of role models for how to be a nurturing parentParents 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 disordersDomestic violence Lack social supports
TraumaUnaddressed medical needs Limited vocational & educational experiences
Barriers to TreatmentLimited availability of programs for pregnant & parenting women
Stigma
Concerns about separation from children
Fears about losing custody
Lack of resourcesInsurance, transportation, child care
Addressing basic needs may be priorityHousing, food, transportation, heat
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
Optimizing Outcomes for Infants in Placement
Monitor case closelyFocus on child’s physical & psychological health & development
Ameliorate effects of disruptions in relationships by ensuring consistent, nurturing caregiving
Consider child’s 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
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 accountabilityMandated time frames for permanency
Budget & staff cuts
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
Collaborative Interventions
Vulnerable Infants Program of Rhode Island (VIP-RI)
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 programImproving ways social service systems deliver services and interface will positively impact families
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 priorityPermanency hearings within 12 months of foster care placementTermination of parental rights if in foster care 15 of prior 22 monthsMandates concurrent permanency planning
Overview of VIP-RICriteria for participation
Involvement in child welfare because of substance use during pregnancy
ReferralsMajority 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
VIP-RI: Care CoordinationEngages parents early
Identifies parent & infant needs
Established partnerships with agencies ensureParents/infants get appropriate services
Minimizes time on waiting lists
Are given consistent messages
Everyone is a stakeholder in infant’s permanent placement
Increase communication among social service agencies
Attend court hearings, provide input, monitor progress until permanency
VIP-RI: The First 4 Years(Twomey, Caldwell, Soave, Fontaine, & Lester, in press)
Maternal DemographicsAges ranged from 17 to 43 (N = 195)
89% single
Education61% high school graduates or equivalent
37% less than high school
Infant Demographics55% male (N = 203)
72% full-term
Placement OutcomesAt 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
Lessons Learned from VIP-RIIntervene 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
Collaborative Interventions
Rhode Island Family Treatment Drug Court
(RI-FTDC)
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 framesOptimize potential for parents to reunify
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
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%)
10
20
30
40
50
60
70
80
90
100
0 - 3 4 - 6 7 - 9 10 - 12 13 - 15 16 - 18 19 - 21 22 - 24
Months to Reunification
Per
cen
t R
eu
nif
ied
Standard Family Court
RI-FTDC
Average Time to First Reunification With Mother
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
Maternal Outcomes: Measures12 & 24 Months
Substance Abuse Subtle Screening Inventory (SASSI)
Identifies potential for substance dependenceBrief Symptom Inventory (BSI)
Identifies psychological symptom patternsAdult-Adolescent Parenting Inventory (AAPI-2)
Identifies high-risk parenting & child rearing attitudes
12 & 30 MonthsChild Abuse Potential Inventory (CAPI)
Assesses risk for child abuse Parenting Stress Index (PSI)
Measures level of parental stress that may adversely affect parenting
Infant Outcomes: Measures18 & 30 Months
Child Behavior Checklist (CBCL)-Ages 1½-5 Identifies problem behaviors
30 MonthsAttachment 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
RI FTDC Study: Maternal & Infant Demographics
Maternal DemographicsAges ranged from 19 to 45 (N = 52)
89% not married
Education40% high school graduates or equivalent
20% some post secondary education, but no college degrees
Infant Demographics56% male (N = 54)
74% full-term
Permanency Outcomes
At 30 months:
90% of infants living in homes identified as permanent placement
79% (N = 48) reunified with biological mother
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
Only 41% of study sample is comparable to the Secure Ideal Prototype of a non-clinical sample
Only 41% of study sample is comparable to the Secure Ideal Prototype of a non-clinical sample
Q-Sort attachment scores of ASFA sample is comparable to the Secure Ideal Prototype of a clinical sample
Q-Sort attachment scores of ASFA sample is comparable to the Secure Ideal Prototype of a clinical sample
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Study Sample Clinical Sample Non- ClinicalSample
r=.20 r=.21r=.32
Attachment
corr
elat
ion
s
Infant Outcomes - 18 & 30 Months:Behavior Problems (CBCL)
Higher score = greater presence and severity of symptoms50 = mean 60- 63 = borderline clinical range >63 = clinical range
Higher score = greater presence and severity of symptoms50 = mean 60- 63 = borderline clinical range >63 = clinical range
05
1015202530354045505560657075
Internalizing Externalizing Total Problem Behaviors
18 Month N = 51
30 Month N = 47
Infant Outcomes - 30 Months: Cognition (Bayley)
0
20
40
60
80
100
120
Cognitive Composite Language Composite
Mea
n (
SD
)FTDC Sample N = 45
Normative Sample
89.0 (8.71)
89.0 (8.71)
91.98(12.81)
91.98(12.81)
100(15)
100(15)
100(15)
100(15)
Infant Outcomes - 30 Months: Motor, Conceptual & Language
(DIAL-R)
0%
10%
20%
30%
40%
50%
60%
70%
Motor Concepts Language Total Score
Potential Problem
1.0 SD
1.5 SD
Summary of Developmental Findings
Most infants not exhibiting behavioral problems or cognitive delaysPossible areas of concern
Attachment may be affected by even minimal disruptions in placement22% 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
Maternal Outcomes81% of mothers graduated from RI FTDC
7% of graduates relapsedMothers 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
Maternal OutcomesAAPI-2 High-risk parenting attitudes changes between 12 and 24 months
Worsened in 2 out of 5 domainsinappropriate expectations
restricts power & independence
Improved in 1 out of 5 domainsrole reversal
CAPI Risk for child maltreatment closer to sample with abuse history
PSI Parenting stress increased between 12 & 30 months
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
Power of CollaborationCollaboration 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 functioningprevent re-entry into the child welfare systemmaintain 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
Funding SourcesVIP-RI was supported by grants from
Children’s 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 Foundation’s Substance Abuse Policy Research Program
VIP-RIBarry LesterRosemary SoaveLynne Andreozzi FontaineDonna Caldwell
RI FTDC StudyBarry LesterCynthia Miller LoncarSuzy Barcelos WinchesterMatthew Hinckley
Collaborators