Nature of the Problem and State of the Field

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Nature of the Problem

and State of the Field

Linda Carpenter, Project Director June 23, 2010, A Program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment and the Administration on Children, Youth and Families Child ’ B Children’s Bureau Office on Child Abuse and Neglect 2

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What is the

Nature of the

Problem?

An Overview of the Challenge

• Prevalence numbers will show that many more

children are affected than the attention we give to this issue

• The cost over time to treat these children is far greater than the cost of prevention and early identification

• Our efforts are now fragmented and focused more on pilot projects than systems change

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http://www.cffutures.org/publications/substance‐exposed‐infants

An Overview of the Challenge

• Of the 74,602,590 children under the age of

18 11% 8 3 illi li ith

18, 11% or 8.3 million live with one or more parent who is dependent on alcohol or illegal drugs

• Of children entering the child welfare system,

40-80%* are affected by their parents’ or caretakers’ substance abuse

caretakers substance abuse

• Prenatal screening studies document 15-20% of newborns prenatally exposed to alcohol, tobacco, or illegal drugs

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Children Living with One or More

Substance

Substance--Abusing Parent

Abusing Parent

Numbers indicate millions c1

Use During Pregnancy

SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2007-2008 Annual Average

Total U.S. Births 2007: 4,317,000

Substance Used (Past Month)

1st Trimester 2nd Trimester 3rd Trimester

Any Illicit Drug 7.2% 5.0% 2.8%

Alcohol Use 20.7% 7.8% 3.5%

Binge Alcohol Use 10.3% 1.9% 1.3%

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Slide 7

c1 New Slide here and copied Previous Slide after since the 9% bullet point is explained in this graph

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Legal Drugs Affect

Far More Children

• PRAMS Colorado data says 2007 rate of

alcohol use in LAST 3 months of pregnancy was 11.4% (= 8,072 newborns)

• PRAMS Colorado data says 2007 rate of tobacco use in last three months was 10.8% (= 7,647 newborns)

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• National estimates of illicit drug use 2.3 % last trimester (= 2,761 newborns)

Number of Children Prenatally

Exposed to Substances

State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth

Total births = 4,317,000 2007

11% of total births = 474,870

Total child victims

under age 1 year = 91 652 2008

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What is the

Impact on the

Child?

Impact on the Child

• Complex interchange of biological, psychological and sociological events • Other issues in parental behavior,

competence, and disorders interact which may lead to multiple co-occurring problems for children

• Children of parents with a substance use disorders are at an increased risk for developmental delays as well as

involvement with child welfare services.

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Impact on the Child

• Effects of prenatal exposure and postnatal

environment may include:

– Physical Health Consequences – Language Delay / Disorders

– Behavioral/Emotional Dysregulation/Poor Social Skills – Cognition/Learning Disabilities/Delayed School Readiness – Executive Dysfunction

– Motor DelaysMotor Delays – Attentional Problems

– Below Average Intellectual Abilities – Memory Difficulties

– Attachment disorders

Impact on the Child

• Research has focused primarily on the impact of illi it d ( i & th h t i

illicit drugs (cocaine & methamphetamine more recently), and usually only one drug—not poly-drug use as is most often the case.

• The adverse effects of prenatal exposure to alcohol have been clearly established:y

Prenatal exposure to alcohol is the most common form of preventable brain damage.

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Impact on the Child

• FAS (Fetal Alcohol Syndrome) rates range from 0.2-1.5 1 000 li bi th

cases per 1,000 live births.

• Other prenatal alcohol conditions, such as ARND (alcohol-related neuro-developmental disorders) and ARBD (alcohol-related birth defects) are estimated to occur about three times as often. (Fetal Alcohol Surveillance Network (FASSNet), Centers for Disease Control and Prevention)

Centers for Disease Control and Prevention)

• It is estimated that approximately 1 out of every 100 people in the

US may have FASD. (May and Gossage,Estimating the Prevalence of FAS, 2001)

Impact on the Child

State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth

Total births = 4,317,000 2007

11% of total births = 474,870

Total child victims

under age 1 year = 91 652 2008

under age 1 year = 91,652 2008

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Most Go Home…

75-90% of substance-exposed infants are

d t t d d h

• Many hospitals don’t test or don’t

systematically refer to CPS undetected and go home.

Why?

systematically refer to CPS

• State law may not require report or referral • Tests only detect very recent use

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Where Are They?

• They are the children who arrive at kindergarten

unready for school

• They are in special education caseloads • They are disproportionately in foster care • They are in juvenile justice caseloadsy j j • They are in residential treatment programs

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What Are We

Doing to Address

this Issue?

Substance Exposed Infants

The Spotlight on this

Issue is Getting Brighter

• States assurances of CAPTA compliance

• New federal attention to home visiting models for high-risk

births

• Expanded Early Head Start funding

• States have developed and are monitoring their

Performance Improvement Plans in response to the Child and Family Services Reviews (CFSRs)

• Perinatal treatment programs have accomplished a great d l f ll ti f th bl

deal—for a small portion of the problem

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The Framework:

Five Points of Intervention

• Pre-pregnancy and public awareness • Prenatal screening and support

• Screening at birth • Services to infants • Services to parents

So—the birth event is one of several

opportunities to make a difference, not the only one

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States have implemented several pieces of the puzzle: • Pre-pregnancy: Ad campaigns

• Prenatal screening : 4PsPlus screening, other g g, tools (WA)

• At birth: Model prevalence studies*

• Infants 0-2: Early screening projects combining Medicaid with mental health and developmental disabilities funding; CAPTA assessments (MA) disabilities funding; CAPTA assessments (MA) • Preschool 3-5: Head Start models, family

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Compiled Tools, Resources

and Effective Models

• SEI Paper- Substance-Exposed Infants: State Responses to the Problem

Responses to the Problem • Models

• Washington State

• Research Triangle Institute • RPG Children's Cluster

Mi i Z t T C t • Miami Zero to Two Court • Strengthening Families • Celebrating Families

Policy and Practice Framework: Five Points of Intervention

Initiate enhanced 2. Prenatal screening and

1. Pre‐pregnancy awareness of substance use effects Parent Child Initiate enhanced prenatal services 3. Identification at Birth 4. Ensure infant’s safety and d t i f t’ d 2. Prenatal screening and assessment Respond to parents’ needs System k 24 Identify and respond to parents’ needs respond to infant’s needs 5. Identify and respond to the needs of ●_Infant ●_Preschooler ●_Child ●_Adolescent System Linkages Linkages

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Where Do We Go

From Here?

Substance Exposed Infants

No One Agency: a Classic Services

Integration Issue

The issue of prenatal exposure does not “belong

to” any one agency, because it demands

– comprehensive services

– provided along a continuum of prevention, intervention and treatment

– at different developmental stages in the life of the child and family

child and family

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What Would a Statewide Interagency

Response Look Like?

• It would compile baseline measures of the current problem across key agencies—for the first time— problem across key agencies—for the first time— including CAPTA reports

• It would set targets and monitor them in an annual report card format—for the first time

• It would inventory current efforts and spending across agencies (as Oregon has)—for the first time across agencies (as Oregon has)—for the first time • It would spotlight and disseminate information on

model programs at the local level

• It would work at all five levels of intervention

What Would a Statewide Interagency

Response Look Like?

• It would be coordinated from the Governor's

Office or an overhead agencyg y

• It would include at least the state agencies with these functions:

– Drug and alcohol treatment – Child welfare

– Maternal and child health Medicaid

– Medicaid – Mental health

– Education and special education – Developmental disabilities

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A Discussion of Underlying Values

is Essential

• A Collaborative Values Inventory can be used to

surface some of the important disagreements and different perceptions of the SEI issue, as noted in the attached examples of responses to past CVIs

• The wide differences in attitudes about practices

d li h th d f i t i

and policy show the need for intensive interagency and inter-professional dialogue about these differences

In our community, alcohol use during pregnancy is seen as problematic as drug use.

34% 39% 35% 40% 45% 9% 13% 1% 3% 5% 10% 15% 20% 25% 30% 35% 1% 0%

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16 Our community has good methods of identifying

substance exposure in prenatal screening.

38% 35% 40% 8% 26% 22% 3% 4% 5% 10% 15% 20% 25% 30% N = 158 0% Strongly Agree

Agree Neutral Disagree Strongly Disagree

N/A

n = 12 n = 60 n = 41 n = 34 n = 5 n = 6

Our community has good methods of identifying prenatal exposure at birth.

46% 40% 45% 50% 10% 22% 16% 3% 4% 10% 15% 20% 25% 30% 35% 40% N = 156 3% 4% 0% 5% Strongly Agree

N/A

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Hospitals in my community do a good job of screening newborns affected by prenatal exposure to alcohol.

33% 29% 30% 35% 7% 23% 3% 6% 5% 10% 15% 20% 25% N = 153 0% Strongly Agree

N/A

n = 11 n = 50 n = 44 n = 35 n = 4 n = 9

Prenatal screening should be mandated as a part of all prenatal care.

48% 50% 60% 32% 8% 8% 1% 3% 10% 20% 30% 40% 1% 0%

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18 Screening for alcohol and drugs at birth should

be required by law. 39% 35% 40% 45% 27% 14% _13% 4% _3% 5% 10% 15% 20% 25% 30% N = 153 0% Strongly Agree

N/A

n = 59 n = 42 n = 21 n = 20 n = 6 n = 5

Our community has good methods for further assessing and providing appropriate services to newborns who are prenatally exposed.

45% 40% 45% 50% 8% 23% 17% 5% _3% 5% 10% 15% 20% 25% 30% 35% N = 155 0% 5% Strongly Agree

N/A

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Seek Opportunities for Advancing

Policy and Leveraging Change

• Health Care Reform—using Medicaid funding of

births (41% and rising) to leverage screening

• CFSR review II—spotlight on the child welfare

system’s SEI reunification outcomes

• Federal treatment information system changes

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Seek Opportunities for Advancing

Policy and Leveraging Change

• Monitoring of child and family service state

plans, IDEA Part C and CAPTA

• CAPTA reauthorization to include alcohol

• Ensure SENs are high priority for Home Visiting

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It is time to call the question

• Will there be a “going to scale” discussion? • The Ethical Argument: How can we not respond

when we know the impact on a child?

• The Fiscal Argument: How can we not respondThe Fiscal Argument: How can we not respond when we know the costs of a lifetime of care?

National Center on

Substance Abuse and Child Welfare

• How do I access technical assistance?

– Visit the NCSACW website for resources and

products at http://ncsacw.samhsa.gov

– Complete the contact form on the website

@ ff

– Email us at [email protected]