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