Trust and Safety: How to Manage a Kinship Caregiver Relationship with Parents with Substance Use Disorders Nancy K. Young, Ph.D. Director, Children and Family Futures National Center on Substance Abuse and Child Welfare 11 th Annual Kinship Conference Burlington, VT September 2015
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A Program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment and the Administration on Children, Youth and Families Children s Bureau Office on Child Abuse and Neglect 3
Family Drug Court Training and Technical Assistance Program The Mission - to improve outcomes for children and families by providing TTA that supports planning and implementation of comprehensive FDCs. FDC TTA Needs Assessment FDC Guidelines FDC Learning Academy Webinar Series FDC Peer Learning Program FDC Orientation Materials FDC@cffutures.org The FDC TTA Program is supported by: The Office of Juvenile Justice and Delinquency Prevention Office of Justice Programs (2013-DC-BX-K002)
Agenda Setting the Stage with some Data Understanding Substance Use Disorders, Treatment and Recovery Understanding Risks to Children Impact on Kinship Care: Family Dynamics, Children s Needs, Caregiver s Needs and Parent s Needs Safety and Achieving Balance: A Team Effort
Vermont Child Abuse and Neglect Intakes and Accepted Reports by Year 20000 18000 16000 14000 12000 10000 8000 6000 4000 21% 27% 31% 30% 32% 30% 29% 30% 2000 0 2007 2008 2009 2010 2011 2012 2013 2014 Intakes Accepted Reports Percent Vermont Department for Children and Families, Family Services Division, 2014 Report on Child Protection in Vermont http://dcf.vermont.gov/sites/dcf/files/pdf/fsd/2014-cp-report.pdf
Source: Wolcott, Cindy. S.9/Act 60 Implementation (PowerPoint). State of Vermont, Cross Leadership Meeting. September 17, 2015. Vermont
Vermont Children in Care by Quarter 2013-2015 saw a 36% increase Source: Wolcott, Cindy. S.9/Act 60 Implementation (PowerPoint). State of Vermont, Cross Leadership Meeting. September 17, 2015. 8
AL (N=7,443) AK (N=2,842) AZ (N=23,854) AR (N=7,411) CA (N=85,114) CO (N=10,542) CT (N=5,803) DE (N=1,160) DC (N=1,931) FL (N=33,270) GA (N=13,542) HI (N=2,054) ID (N=2,438) IL (N=21,957) IN (N=18,695) IA (N=10,570) KS (N=9,845) KY (N=12,173) LA (N=7,384) ME (N=2,441) MD (N=7,061) MA (N=13,639) MI (N=22,261) MN (N=11,114) MS (N=6,072) MO (N=16,186) MT (N=3,397) NE (N=7,742) NV (N=8,028) NH (N=1,282) NJ (N=12,082) NM (N=3,746) NY (N=30,981) NC (N=13,401) ND (N=1,923) OH (N=21,435) OK (N=15,096) OR (N=12,226) PA (N=22,938) RI (N=2,902) SC (N=5,989) SD (N=2,296) TN (N=14,391) TX (N=46,286) UT (N=4,877) VT (N=1,605) VA (N=7,183) WA (N=15,222) WV (N=7,906) WI (N=10,852) WY (N=1,890) PR (N=4,836) Parental Substance Use as Reason for Removal Across States, 2013 70% 60% National Average: 31% Vermont: 15% 50% 40% 30% 20% 15% 10% 0% Source: AFCARS Data, 2013
Age of Children in Care In 2015, young children (ages 0-5) surpassed all other groups Source: Wolcott, Cindy. S.9/Act 60 Implementation (PowerPoint). State of Vermont, Cross Leadership Meeting. September 17, 2015.
AK (N=2,842) AL (N=7,443) AR (N=7,411) AZ (N=23,854) CA (N=85,114) CO (N=10,542) CT (N=5,803) DC (N=1,931) DE (N=1,160) FL (N=33,270) GA (N=13,542 HI (N=2,054) ID (N=2,438) IA (N=10,570) IL (N =N/A) IN (N=18,695) KS (N=9,845) KY (N=12,173) LA (N=7,384) MA (N=13,639) MD (N=7,061) ME (N=2,441) MI (N=22,261) MN (N=11,114) MO (N=16,186) MS (N=6,072) MT (N=3,397) NC (N=13,401) ND (N=1,923) NE (N=7,742) NH (N=1,282) NJ (N=12,082) NM (N=3,746) NV (N=8,028) NY(N=30,981) OH(N=21,435) OK (N=15,096) OR (N=12,226) PA (N=22,938) RI (N=2,902) SC (N=5,989) SD (N=2,296) TN (N=14,391) TX (N=46,286) UT (N=4,877) VT (N=1,605) VA (N=7,183) WA (N=15,222) WI (N=10,852) WV (N=7,906) WY (N=1,890) PR (N=4,836) Percent of Children Removed from Parents Custody with Parental Alcohol and/or Drug Use as a Reason for Removal by Age, 2013 80 70 60 VERMONT Under Age 1: 27% Age 1 and Older: 13% 50 40 30 20 10 27.1 13.3 0 N= Total number of children removed by State Source= AFCARS 2013 Foster Care File Under Age 1 Age 1 and Older
People treated for opioid addiction in the Vermont treatment system has dramatically shifted Alcohol: 72% in 2000; 40% in 2014 Opioids: 5% in 2000; 42% in 2014 Source: Substance Abuse Treatment Information System (SATIS) Source: Foldand, Tony. PowerPoint. State of Vermont, Cross Leadership Meeting. September 17, 2015.
The number of individuals using heroin at treatment admission is increasing faster than for other opioids/synthetics Source: Substance Abuse Treatment Information System (SATIS) Source: Foldand, Tony. PowerPoint. State of Vermont, Cross Leadership Meeting. September 17, 2015.
Understanding Substance Use Disorders, Treatment and Recovery
Substance use Disorders are Complex and Generally Begin Early in Life! No child writes their essay on what they want to be is an alcoholic or drug addict No one wakes up one day and says today s a great day to develop a brain disorder that risks my health, family, job, future, freedom and possibly life Yet in the time we are together today, 180 people will die of addiction
It is also a Developmental Disorder The vast majority of addiction begins in adolescence as teens experiment, and for a critical few, begin a progression of changed neurochemistry with life-long consequences The changing circuitry of teenagers' brains appears to leave them especially vulnerable to the effects of drugs and alcohol TEXT PAGE
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Cortex Nucleus accumbens Mesolimbic System Ventral tegmental Area (VTA) Dopamine release http://www.vivitrol.com/opioidrecovery/howvivitrolworks
When the receptors are unlocked, they release neurotransmitters including dopamine in the brain. Dopamine gives you a good feeling to reward you for doing something you enjoy. This reward is what makes you want to repeat these behaviors. http://www.vivitrol.com/opioidrecovery/howvivitrolworks
When that activity is something you enjoy, your brain releases chemicals called endorphins that make you feel good. Endorphins attach to receptors much like a key fitting into a lock and unlock the receptors. http://www.vivitrol.com/opioidrecovery/howvivitrolworks http://www.vivitrol.com/opioidrecovery/howvivitrolworks
WWW.NIDA.NIH.GOV
% of Basal DA Output DA Concentration (% Baseline) Natural Rewards Elevate Dopamine Levels 200 FOOD NAc shell 200 SEX 150 150 100 50 0 Empty Box Feeding 0 60 120 180 Time (min) Source: Di Chiara et al. 100 ScrScr BasFemale 1 Present Scr Scr Sample1 2 3 4 5 6 7 8 9 1011121314151617 Number Mounts Intromissions Ejaculations 15 10 5 0 Female 2 Present Source: Fiorino and Phillips Copulation Frequency
% of Basal Release % of Basal Release % of Basal Release % of Basal Release Effects of Drugs on Dopamine Levels 250 200 150 NICOTINE Accumbens Caudate 250 200 150 Accumbens MORPHINE Dose (mg/kg) 0.5 1.0 2.5 10 100 100 0 0 1 2 3 hr Time After Nicotine 0 0 1 2 3 4 5hr Time After Morphine 400 300 200 100 0 Accumbens COCAINE DA DOPAC HVA 0 1 2 3 4 5 hr Time After Cocaine 1100 1000 900 800 700 600 500 400 300 200 100 0 Accumbens AMPHETAMINE DA DOPAC HVA 0 1 2 3 4 5 hr Time After Amphetamine Source: Di Chiara and Imperato
When you take opioids such as heroin or opioid pain medications (e.g. VICODIN, Percocet and OxyContin ), they attach to a particular type of receptor. This results in the release of greater amounts of dopamine, which creates a pleasure response or reward. VICODIN is a registered trademark of Abbott Laboratories; Percocet is a registered trademark of Endo Pharmaceuticals; http://www.vivitrol.com/opioidrecovery/howvivitrolworks
A chronic, relapsing brain disease Brain imaging studies show physical changes in areas of the brain that are critical to Judgment Decision making Learning and memory Behavior control These changes alter the way the brain works, and help explain the compulsion and continued use despite negative consequences
Substance Use Disorders are similar to other diseases, such as heart disease. Both diseases disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, are preventable, treatable, and if left untreated, can result in premature death
A treatable disease Substance use disorders are preventable and is a treatable disease Discoveries in the science of addiction have led to advances in drug abuse treatment that help people stop abusing drugs and resume their productive lives Similar to other chronic diseases, addiction can be managed successfully Treatment enables people to counteract addiction's powerful disruptive effects on brain and behavior and regain areas of life function TEXT PAGE
These images of the dopamine transporter show the brain s remarkable potential to recover, at least partially, after a long abstinence from drugs - in this case, methamphetamine.
Diagnosing Substance Use Disorders: DSM 5 Criteria Severe 6+ Criteria Moderate 4-5 Criteria Mild 2-3 Criteria 1. Impaired Control Larger amounts or over a longer time than originally intended Persistent desire to cut down A great deal of time spent obtaining the substance Intense craving 2. Social Impairment Failure to fulfill work or school obligations Recurrent social or interpersonal problems Withdraw from social or recreational activities 3. Risky Use Recurrent use in situations physically hazardous Continued use despite persistent physical or psychological problem that is likely to have been caused or exacerbated by use 4. Pharmacological Criteria Tolerance: Need for markedly increased dose to achieve the desired affect Withdrawal: Syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use TEXT PAGE
Principles of Effective Drug Addiction Treatment: A Research Based Guide 1. Addiction is a complex but treatable disease that affects brain function and behavior 2. No single treatment is appropriate for everyone 3. Treatment needs to be readily available 4. Effective treatment attends to multiple needs of the individual 5. Remaining in treatment for an adequate period of time is critical 6. Behavioral therapies are the most commonly used forms of drug abuse treatment 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies 8. An individual s treatment and services plan must be continually assessed and modified 9. Many drug-addicted individuals also have other mental disorders 10. Medically assisted detoxification is only the first stage of addiction treatment 11. Treatment does not need to be voluntary to be effective 12. Drug use during treatment must be monitored continuously as lapses do occur 13. Treatment programs should test patients for infectious diseases http://www.drugabuse.gov/publications/principles-drug-addiction-treatment National Institute on Drug Abuse (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Retrieved from http://www.drugabuse.gov/publications/principles-drug-addiction-treatmentresearch-based-guide-third-edition/acknowledgments on September 18, 2014 34
http://www.vivitrol.com/opioidrecovery/howvivitrolworks
Medication-Assisted Treatment (MAT) Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies National Institute on Drug Abuse, Principles of Drug Addiction Treatment Recent review by American Society of Addiction Medicine and National Institute on Drug Abuse Advancing Access to Addiction Medications: Implications for Opioid Addiction Treatment http://www.asam.org/docs/advocacy/implications-for-opioid-addiction-treatment TEXT PAGE
MEDICATIONS USED TO TREAT TOBACCO DEPENDENCE MEDICATION PRIMARY USE FORMULATION TREATMENT SETTING ADMINISTRATION Nicotine replacement therapies (Nicotine) Replace nicotine from smoking and reduce withdrawal symptoms Gum Lozenge Inhaler Nasal Spray Patch Gum: Over the counter (OTC) Lozenge: OTC Inhaler: prescription Nasal Spray: prescription Patch: OTC and prescription Gum: 1-2 pieces/hour; no more than 20 pieces/day Lozenge: n/a Inhaler: As directed by physician Nasal Spray: As directed by physician Patch: Single patch worn daily Bupropion sustainedrelease (Zyban ) Blocks brain receptors and interferes with the dopamine reward pathway Tablet Prescribed Twice a day Varenicline tartrate (Chantix ) Partial agonist and antagonist Blocks nicotine receptor sites Tablet Prescribed Once or twice daily Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4465757/pdf/nihms59469.pdf
MEDICATIONS USED TO TREAT ALCOHOL USE DISORDERS MEDICATION PRIMARY USE FORMULATION TREATMENT SETTING ADMINISTRATION Disulfiram (Antabuse ) Inhibits production of an enzyme (acetaldehyde) that allows the body to absorb alcohol Acetaldehyde builds up and causes unpleasant effects flushing, nausea and palpitations Tablet Physician prescribed Supervised ingestion is preferred as a key component of treatment plan Daily Oral Naltrexone (Revia ) Antagonist Blocks effects of opioids Tablet Prescribed Daily Extended-Release Injectable Naltrexone (Vivitrol ) Antagonist Blocks effects of opioids Injection Administered by medical professional Monthly
ADDITIONAL MEDICATIONS USED TO TREAT ALCOHOL USE DISORDERS MEDICATION PRIMARY USE FORMULATION TREATMENT SETTING ADMINISTRATION Acamprosate (Campral ) Reduces symptoms related to abstaining from alcohol insomnia, anxiety, restlessness, and unpleasant changes in mood Tablet Prescribed Three times daily Center for Substance Abuse Treatment. Incorporating Alcohol Pharmacotherapies into Medical Practice: A Review of the Literature. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 09-4380. Rockville, MD: Substance Abuse and Mental Health Services TEXT PAGE Administration, 2009.
MEDICATIONS USED TO TREAT OPIOID USE DISORDERS MEDICATION PRIMARY USE FORMULATION Methadone (Dolophine, Methadose ) Agonist Suppresses cravings and withdrawals Detoxification Maintenance Liquid Tablet/Diskette Powder TREATMENT SETTING SAMHSA Certified Opioid Treatment Program (OTP) MAXIMUM CLIENT CAPACITY ---- Daily at OTP ADMINISTRATION Some individuals may qualify for take-home prescriptions lasting up to 30 days Buprenorphine (Subutex ) Partial Agonist Suppresses cravings and withdrawals; partial stimulation of brain receptors Detoxification Tablet Physicians or psychiatrists granted a DATA waiver Some SAMHSA Certified OTPs 100 Daily Individuals can be prescribed a supply to be taken outside of the treatment setting Buprenorphine- Naloxone Combination (Suboxone ; Zubsolv) Maintenance Sublingual Tablets Prescription ---- Daily
ADDITIONAL MEDICATIONS USED TO TREAT OPIOID USE DISORDERS MEDICATION PRIMARY USE FORMULATION Naloxone (Narcan ) Antagonist Displaces opiates from brain receptors and reverses respiratory depression Reverse overdose TREATMENT SETTING MAXIMUM CLIENT CAPACITY ADMINISTRATION Injection First Responders ---- When overdose is suspected or signs of overdose are observed Naltrexone Extended- Release (Vivitrol ) Antagonist Blocks effects of opioids Maintenance Injection (primarily) Any healthcare provider licensed to prescribe medications ---- Monthly, following medically supervised detoxification Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004. Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 13-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Retrieved from https://store.samhsa.gov/shin/content/sma13-4742/overdose_toolkit_2014_jan.pdf Substance Abuse and Mental Health Services Administration. Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide.. HHS Publication No. (SMA) 14-4892R. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Retrieved from http://store.samhsa.gov/shin/content/sma14-4892/sma14-4892.pdf TEXT PAGE
Summary Points Each medication varies in its ability to: Prevent or reduce withdrawal symptoms Prevent or reduce drug craving Medical doctors determine the appropriate type of medication, dosage and duration based on each person s: Biological makeup Addiction history and severity Life circumstances and needs
OTP Certification Guidelines Medical Director licensed to practice medicine and has experience in addiction medicine. Responsible for monitoring and supervising all medical services. Provision of adequate medical, counseling, vocational, educational, and other assessment and treatment services. Special services for pregnant patients, including priority access and provision of or referral for prenatal care and other gender specific services.
Risks to Children
Estimated Number of Infants* Affected by Prenatal Exposure, by Type of Substance and Infant Disorder 700,000 640,000 15.9% 600,000 Past Month Substance Use by Pregnant Women Incidence of Infant Disorder 500,000 400,000 300,000 340,000 8.5% 240,000 5.9% Includes nine categories of illicit drugs, including heroin and the nonmedical use of prescription medications. 200,000 100,000 0 *Approximately 4 million (3,952,841) live births in 2012 Estimates based on: National Survey on Drug Use and Health, 2012; Martin, Hamilton, Osterman, Curtin & Mathews. Births: Final Data for 2012. National Vital Statistics Report, Volume 62, Number 9; Patrick, Schumacher, Benneyworth, et al. NAS and Associated Health Care Expenditures. Journal of the American Medical Association (JAMA) 2012; 307(18):1934-1940. doi: 10.1001/jama.2012.3951; May, P.A., and Gossage, J.P.(2001).Estimating the prevalence of fetal alcohol syndrome: A summary.alcohol Research & Health 25(3):159-167. Retrieved October 21, 2012 from http://pubs.niaaa.nih.gov/publications/arh25-3/159-167.htm 108,000 2.7% 12,000 0.3% 30,000 (0.5-7 per 1,000 births) 13,000 (3.3 per 1,000 births) Tobacco Alcohol Illicit Drugs Binge Drinking Heavy Drinking FAS/ARND/ARBD NAS
Prenatal Exposure and Postnatal Environment in Vermont Prenatal Exposure Postnatal Environment ~6,500 births per year ~2,200 (33.4%) prenatally exposed birth ~1,000 [16%] tobacco prenatal exposure per year ~750 [12%] alcohol prenatal exposure per year 8.3 million children in the nation have a parent who needs treatment 11% of children in the country ~13,500 children of parent who needs treatment ~400 [6%] illicit drugs, including heroin and nonmedical use of prescription medications, prenatal exposure per year in Vermont TEXT PAGE
Tobacco Exposure Low birth weight Brainstem (respiratory and autonomic functions) abnormalities 2 nd hand exposure and asthma Impact of Prenatal Exposure Fetal Alcohol Spectrum Disorders: Range of disorders related to growth deficiencies, physical anomalies, and central nervous system (CNS) dysfunctions Fetal Alcohol Syndrome (FAS): Growth deficiency Unique cluster of minor facial anomalies (small eyes, smooth philtrum, thin upper lip) Severe CNS dysfunctions Partial FAS: Some growth deficiency and facial anomalies Severe CNS dysfunctions Alcohol Related Neurodevelopmental Disorder (ARND): Range of disabilities in behavior, adaptive skills, executive functioning, and self-regulation 47
Neonatal Abstinence Syndrome (NAS) An expected and treatable condition that follows prenatal exposure to opioids Symptoms begin within 1-3 days after birth, or may take 5-10 days to appear Symptoms include blotchy skin; difficulty with sleeping and eating; trembling, irritability and difficult to soothe; diarrhea; slow weight gain; sweating; hyperactive reflexes; increased muscle tone Timing of onset is related to characteristics of drug used by mother and time of last dose Most opioid exposed babies are exposed to multiple substances NAS occurs with notable variability, with 55-94% of exposed infants exhibiting symptoms Medication is required in approximately 50% of cases The American College of Obstetricians and Gynecologists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076. U.S. National Library of Medicine, National Institutes of Health. Neonatal Abstinence Syndrome. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007313.htm on July 24, 2014 Hudak, M.L., Tan, R.C. The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012, 129(2): e540 Jansson, L.M., Velez, M., Harrow, C. The Opioid Exposed Newborn: Assessment and Pharmacological Management. Journal of Opioid Management. 2009; 5(1):47-55 TEXT PAGE
Non-Pharmacological Treatment Swaddling Breastfeeding Calm, low-stimulus environment Rooming with mother Pharmacological Treatment Neonatal Abstinence Syndrome Treatment Individualized based on the severity of withdrawal symptoms The overarching goal of treatment is to soothe the newborn s discomfort and promote mother-infant bonding and attachment. Scoring tool to measure severity of withdrawal symptoms should be adopted Based on an assessment of the risks and benefits of pharmacologic therapy Type of medication should match the type of agent causing withdrawal 80% of children can be successfully weaned from methadone completely within 5-10 days Mean length of hospital stay for newborns: Methadone = 9.9 days; Buprenorphine = 4.1 days American Academy of Pediatrics, Committee on Drugs (1998). Neonatal Drug Withdrawal. Pediatrics, 101(6), 1079-1088. Hudak, M.L., Tan, R.C. The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012, 129(2): e540 Jansson, L.M., Velez, M., Harrow, C. The Opioid Exposed Newborn: Assessment and Pharmacological Management. Journal of Opioid Management. 2009; 5(1):47-55 Jones, H., Kaltenbach, K., Heil, S., Stine, S., Coyle, M., Arria, A., O Grady, K., Selby, P., Martin, P., Fischer, G. (2010). Neonatal Abstinence Syndrome After Methadone or Buprenorphine Exposure. New England Journal of Medicine, 363(24):2320-2331
Different Populations of Women Can Give Birth to Infants with NAS Symptoms Chronic pain or other medical conditions maintained on medication Misuse of own prescribed medication In recovery from opioid addiction & maintained on methadone or buprenorphine (e.g. medication assisted treatment) Actively abusing or dependent on heroin Misuse of nonprescribed medication Adapted from Dr. Cece Spitznas, White House Office of National Drug Control Policy 9;307(18):1934-40.
Opioids during Pregnancy
The American Congress of Obstetricians and Gynecologists: Withdrawal from Opioids During Pregnancy Withdrawal or the abrupt discontinuation of opioids in an opioid-dependent pregnant woman is not recommended as it can result in preterm labor, fetal distress, or fetal demise Medically supervised withdrawal can be accomplished in some instances and should be undertaken by a physician experienced in perinatal addiction treatment The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076.
The American Congress of Obstetricians and Gynecologists: Treatment of Opioid Dependence During Pregnancy The current standard of care for pregnant women with opioid dependence is opioid assisted therapy with methadone Buprenorphine is an effective option for pregnant women who are new to treatment or maintained on buprenorphine pre-pregnancy. Maternal outcomes, pain management considerations and breastfeeding recommendations are similar between the medications used in the treatment of opioid dependence Opioid relapse rate in pregnant women with opioid use disorder is between 41-96% The American Congress of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076. Hendree Jones, Presented at the NADCP Annual meeting, May 28, 2014, Anaheim, CA. Jones, H., O Grady, K., Malfi, D., & Tuten, M. (2008). Methadone maintenance vs. methadone taper during pregnancy: Maternal and neonatal outcomes. American Journal on Addictions, 17(5), 372-386
As part of a comprehensive treatment program, MAT has been shown to: Increase retention in treatment Decrease illicit opiate use Decrease criminal activities Decrease drug-related HIV risk behaviors Decrease obstetrical complications Fullerton, C.A., et al. November 18, 2013. Medication-Assisted Treatment with Methadone: Assessing the Evidence. Psychiatric Services in Advance; doi: 10.1176/appi.ps.201300235 The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076.
Long-Term Impact Studies demonstrate cognitive development to be within the normal range up to age 5 Advances in the field call for additional studies on the long-term impact of opioid prenatal exposure Family characteristics, improved prenatal care, exposure to multiple substances, and other medical and psychosocial factors have a significant impact on long-term outcomes The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076. Emmalee, S. B. et al. (2010) Prenatal Drug Exposure: Infant and Toddler Outcomes. Journal of Addictive Diseases, 29(2), 245-258. Baldacchino, A., et al. (2014). Neurobehavioral consequences of chronic intrauterine opioid exposure in infants and preschool children: a systematic review and meta-analysis. BMC Psychiatry, 14(104).
Parenting and Family Factors that Increase Risk Single family households larger family size as well as single-family households at greater risk Family history of interpersonal violence correlated with increase risk of physical child abuse but weaker for sexual abuse and neglect Issues affecting parenting ability - Severe/abusive tactics - Dysphoria - Stress - Poor coping mechanisms - High reactivity (impulsivity, affect)
Child Factors that Increase Risk Age younger children (under age 6) Special needs vs. non-special need children Gender mixed results, but girls may be at higher risk of sexual abuse than boys Younger children in family younger children are at higher risk than older children; infants under age 1 are the highest risk group Child health and behavior Positive toxicology report children born with positive toxicology
Parent Factors that Increase Risk Substance abuse/mental health issues most frequent risk factor for maltreatment Age younger parent, the higher risk of maltreating History of foster care themselves Lower educational levels Paternal experience of abuse in childhood Social isolation and lack of social support Maternal employment Paternal factors more research needed
DSM 5 Diagnosis Severe Moderate Low Risk High Need High Risk High Need Mild Low Risk Low Need High Risk Low Need No Use No intervention Alternative Response In-Home Services Removal Child Welfare Intervention
Children Go Home, Stay Home or Find Home Annually, there are approximately 740,000 instances of child maltreatment in the United States. 1 Approximately 65% of these children will remain at home. Another 20% to 25% will be returned home following a removal. Total of 80% to 85% of children remaining at or returning home. I wish you helped my mom. 1 Children s Bureau. Child Welfare Outcomes 2008-2011, Report to Congress. U.S. Department of Health and Human Services, Administration for TEXT Children PAGE and Families, Administration of Child Youth and Families.
Impact on Kinship Care: Family Dynamics, Children s Needs, Caregiver s Needs and Parent s Needs
American Bar Association, Visitation with Infants and Toddlers in Foster Care: What Judges and Attorneys Need to Know; http://www.americanbar.org/content/dam/aba/administrative/child_law/visitation_brief.authcheckdam.pdf NRC for Family Centered Practice and Permanency, Information Packet: Parent-Child Visiting; http://www.hunter.cuny.edu/socwork/nrcfcpp/downloads/information_packets/parent-child_visiting.pdf Establishes and strengthens the parent-child relationship Eases the pain of separation, loss and abandonment for the child Improves child well-being Child s Desire for Visitation Keeps hope alive for the parents and enhances parents motivation to change Eases the pain of separation, loss and abandonment for the parent Promotes healthy attachment and reduces the negative effects of separation for the parent Parent s Right to Visitation Promotes healthy attachment and reduces the negative effects of separation for the child Provides a setting for the caseworker to observe and suggest how to improve parent-child interactions Family Time Shorter stays in out of home care Increased reunification Successful reunification Involves parents in their child s everyday activities and development Helps parents gain confidence in their ability to care for their child and allows parents to learn and practice new skills Allows kinship and foster caregivers to support birth parents Social Worker s Opportunity for Observation and Engagement Provides information to the court and caseworker on the family s progress Caregiver s Opportunity for Engagement Opportunity for kinship and foster caregivers to model positive parenting skills
Honoring a Child s Desire to Know Their Parents It s easy when the parent is compliant. What will you do in the difficult situations? Start with a contract contingency contracting Be open to parents growth and change Plan for and anticipate difficult visitation situations Parent is under the influence Parent has a lapse or relapse Child is maltreated Parent is not engaged or doesn t show to visitation Developmentally appropriate Bonding and attachment is critical for newborns and infants
Contracting Considerations 1. Contracting on goals supportive of recovery lead to better outcomes than those more directly related to substance use 2. The severity of the consequences for breaking a contract positively affects the adherence to the contracts terms Describe the target behavior change in the parent s own words. The signature is a meaningful ritual! Incentives can be included to reinforce positive behaviors
Considerations for Visitation: Developmental Tasks, Ages 0-5 Consistent, Routine & Predictable Safe location Transitional objects Newborn and Infants: Establish a sense of trust Make needs known and have them met Develop attachment to at least one primary caregiver Breastfeeding and Neonatal Abstinence Syndrome: Promote bonding and soothes infant Toddlers Increased self-awareness and self-regulation Continue attachment bonding with caregiver(s) Visitations should be frequent and long enough to enhance the parent-child relationship. Adapted from: http://www.courts.mo.gov/hosted/circuit11/documents/parental%20guide%20to%20visitation.pdf
Considerations for Visitation: Developmental Tasks, Ages 6-11 Teach the 7 C s I didn t Cause It I can t Cure it I can t Control it I can Care for myself by Communicating my feelings, Making healthy Choices And By Celebrating myself NACOA National Association for Children of Alcoholics School Age: Development of self-esteem, self-worth, moral development and personal security Development of relationships with peers and adults Aware of parents as individuals Aware of parents substance use and recovery May feel anger towards parent May blame self Help the child understand the parents substance use and that the child is not the cause.
Considerations for Visitation: Developmental Tasks, Ages 12-18 Provide an opportunity for youth to share experiences with each other Partner with a treatment agency Provide space at CW office Celebrating Families! Curricula NACOA National Association for Children of Alcoholics Pre-Adolescents, Teens and Transitional Age Youth: Establish identity Establish sense of independence Establish peer group Separation from family Mourn childhood Help the adolescent normalize the experience of having a parent with a substance use disorder through peer connections.
" Assure frequency or length of visits will not be used as punishment or reward, but is a right of all family members unless child safety is jeopardized. Continued contact between the child and his family is essential to maintaining and strengthening family bonds. Changes in visitation arrangements shall be directly related to the ongoing risk and family assessment. Strengthening the parent-child bond through visitation may be a more effective motivator for a parent to address their substance use.
Listening and helping to identify feelings What Children Need Providing information about substance use and mental disorders Providing ongoing support to keep them safe and help them recover! Following through on screenings to ensure they receive the counseling and support they need! Helping them to understand they are not to blame! Who can you trust who you might talk with about your concerns a teacher, close friend, an adult in your family? You are not the reason your parent has a disorder. There are a lot of kids like you. You are not alone and there s no reason to feel embarrassed. Your parents addiction is a disease that may cause them to lose control or do things that do not keep you safe or cared for.
What Caregivers Need Self Care is the heart of the Kinship Balancing Act Where do you find support? What do you do to refuel?
Setting the Boundary: Maintaining Hope Tolerance Safety Hope But be prepared for children to seek out their birth parents, regardless of the limits you set..
Continuum of Trust Levels in Kinship Care A Shared History No Trust Rigid boundaries with parent, won t be flexible to meet parents needs Codependent Overly trusting of parent, allows inappropriate access to child Balanced Understands needs of child and parent, balances child safety with bonding needs Clear expectations, transparency, openness to change, & healthy boundaries are the keys to rebuilding trust.
Safety and Achieving Balance: A Team Effort Child Caregiver Parent Social Worker Trust & Transparency Shared Information
Key Information Treatment progress Child well-being Changes in visitation Changes in case plan goals Decisions on child s health, education, etc.
Types of Kinship Care: Resources Informal Kinship Care Permanent Guardianship Adoption Additional Resources Temporary Assistance for Needy Families (TANF): Income Based Eligibility TANF-Child Only Benefit Guardianship Assistance Foster Care Payments Subsidized Guardianship Federal Title IV-E Adoption Assistance State Adoption Assistance Supplemental Nutrition Assistance Program Child s Health Insurance: Medicaid or Children s Health Insurance Program Respite Care TEXT PAGE
Supports for Foster Care or Kinship Caregivers VERMONT SPECIFIC Foster Care Custody; Guardianship Educational Supports Other Benefits for Child Other Supports for child, parent and family Other Remain in home school if appropriate Eligible for educational surrogate parent to help navigate educational issues Reimbursement for transportation to school Eligible for Medicaid Free hot lunch Child care in licensed facility (100% covered Social worker or contracted agency assistance for support, negotiating family issues, parent visitation, etc. Help for parents to reunite with the child and/or to experience safe contact Access to Family Services (FS) contracted services Legal support for court proceedings, including TPR Permanency planning for the child: Reunification, TPR/adoption, permanent guardianship Reimbursement of mileage to doctor s, counseling, other appointments of child Respite services so the family has a break and can come back together renewed Trainings available for foster parents to be better parents and to better understand child s trauma and needs Remain in home school until disposition: otherwise only if relative lives in the same town or school agrees Not eligible None Eligible for Medicaid or Dr. Dynasaur if eligible for Child Only Research up grant Free hot lunch if eligible for Child Only Reach Grant Childcare if a proven need; covered up to maximum allowed, not typically 100% None unless ordered by court None unless ordered by court or DCF open case Only at Commissioner's discretion and dependent on available funding None once DCF is no longer involved (except OCS) Permanency planning when reunification is the goal: legal custody or guardianship unless the child s attorney or relative petitions for TPR; cost of legal representation is usually the relative s None (some exceptions with Medicaid eligibility) From VKAP or Agencies on Aging if caregiver is 55+ Some trainings
Contact Information Nancy K. Young, PhD, MSW Director, Children and Family Futures Director, National Center on Substance Abuse and Child Welfare 1-866-493-2758 nkyoung@cffutures.org www.cffutures.org www.ncsacw.samhsa.gov/default.aspx