Trust and Safety: How to Manage a Kinship Caregiver Relationship with Parents with Substance Use Disorders

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

3

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

The FDC TTA Program is supported by:

The Office of Juvenile Justice and Delinquency Prevention Office of Justice Programs (2013-DC-BX-K002)

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

• 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 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

Child Abuse and Neglect Intakes and Accepted Reports by Year

Vermont

21% 27% 31% _30% 32% _{30% 29% 30%} 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000 2007 2008 2009 2010 2011 2012 2013 2014

Vermont

8

Vermont

—

Children in Care by Quarter

2013-2015 saw a 36% increase

15% 0% 10% 20% 30% 40% 50% 60% 70% AL (N= 7,4 43 ) AK (N= 2,8 42 ) AZ (N= 23 ,85 4) AR (N =7 ,41 1) C A (N =8 5,1 14 ) C O (N =1 0 ,54 2) C T (N =5 ,80 3) D E (N =1 ,16 0) D C (N= 1,9 31 ) FL (N =3 3,2 70 ) GA (N= 13 ,54 2 ) H I (N =2 ,0 54 ) ID (N= 2,4 38 ) IL (N =2 1,9 57 ) IN (N= 18 ,69 5) IA (N =1 0,5 70 ) KS (N= 9 ,8 45 ) KY (N= 12 ,17 3) LA (N= 7,3 84 ) M E (N =2 ,44 1) M D (N= 7 ,0 61 ) M A (N =1 3,6 39 ) M I (N =22 ,26 1) M N (N= 1 1, 11 4 ) M S (N = 6 ,0 7 2 ) M O (N =16 ,18 6) M T (N =3 ,39 7) N E (N =7 ,74 2) N V (N =8 ,02 8) N H (N= 1,2 82 ) N J (N =1 2 ,08 2) N M (N= 3 ,7 46 ) N Y (N =3 0,9 81 ) N C (N= 13 ,40 1) N D ( N =1 ,92 3) OH (N =2 1 ,43 5) OK (N =1 5,0 96 ) OR (N =1 2 ,22 6) PA (N =2 2 ,93 8) RI (N =2 ,9 02 ) SC (N =5 ,98 9) SD (N =2 ,29 6 ) TN (N =1 4,3 91 ) TX (N= 46 ,28 6) UT (N= 4,8 77 ) V T (N =1 ,60 5 ) V A (N =7 ,1 83 ) WA (N= 15 ,22 2) WV (N= 7,9 06 ) WI (N =1 0,8 52 ) WY (N= 1,8 90 ) PR (N =4 ,83 6)

Source: AFCARS Data, 2013

National Average: 31%

Parental Substance Use as Reason for Removal

Across States, 2013

Age of Children in Care

In 2015, young children (ages 0-5) surpassed all other groups

Percent of Children Removed from Parents’ Custody with

Parental Alcohol and/or Drug Use

as a Reason for Removal by Age, 2013

27.1

13.3

0 10 20 30 40 50 60 70 80 AK (N= 2,8 42 ) AL (N= 7,4 43 ) AR (N =7 ,41 1) AZ (N= 23 ,85 4) C A (N =8 5,1 14 ) C O (N =1 0,54 2) C T (N =5 ,80 3) D C (N= 1,9 31 ) D E (N =1 ,16 0) FL (N =3 3,2 70 ) GA (N= 13 ,54 2 H I (N =2 ,0 54 ) ID (N= 2,4 38 ) IA (N =1 0,5 70 ) IL (N = N /A) IN (N= 18 ,69 5) KS (N= 9,8 45 ) KY (N =1 2 ,1 7 3 ) LA (N= 7,3 84 ) M A (N =1 3,6 39 ) M D (N= 7 ,0 61 ) M E (N = 2 ,4 4 1 ) M I (N =22 ,26 1) M N (N= 11, 11 4) M O (N =16 ,18 6) M S (N =6 ,07 2) M T (N =3 ,39 7) N C (N= 13 ,40 1) N D ( N =1 ,92 3) N E (N =7 ,74 2) N H (N= 1,2 82 ) N J (N =1 2 ,08 2) N M (N= 3 ,7 46 ) N V (N =8 ,02 8) N Y(N =3 0 ,9 8 1 ) OH (N= 2 1, 43 5 ) OK (N =1 5,0 96 ) OR (N =1 2 ,22 6) P A (N = 2 2 ,9 3 8 ) RI (N =2 ,9 02 ) SC (N = 5 ,9 8 9 ) SD (N =2 ,2 9 6 ) TN (N =1 4,3 91 ) TX (N= 46 ,28 6) UT (N= 4,8 77 ) V T (N = 1 ,6 0 5 ) V A (N =7 ,1 83 ) WA (N= 15 ,22 2) WI ( N =1 0,8 52 ) WV (N= 7,9 06 ) WY (N= 1,8 90 ) PR (N =4 ,83 6)

Under Age 1 Age 1 and Older

VERMONT

Under Age 1: 27%

Age 1 and Older: 13%

N= Total number of children removed by State Source= AFCARS 2013 Foster Care File

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

The number of individuals using heroin at treatment admission

is increasing faster than for other opioids/synthetics

Understanding

Substance Use

Disorders, Treatment and

• 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

Substance use Disorders are Complex

and Generally Begin Early in Life!

TEXT PAGE

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

Nucleus accumbens

Ventral tegmental _{Area (VTA)}

Dopamine

release

Cortex

Mesolimbic

System

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.

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.

Natural Rewards Elevate Dopamine Levels

0 50 100 150 200 0 60 120 180 Time (min) % o f B asa l D A Ou tp u t NAc shell Empty Box Feeding

Source: Di Chiara et al.

FOOD

100 150 200 D A C o n cen tr atio n (% B ase li n e) Mounts Intromissions Ejaculations 15 0 5 10 Co pula tion Fre quenc y Sample Number 1 2 3 4 5 6 7 8 9 1011121314151617 ScrScr

BasFemale 1 Present

Scr

Female 2 Present

Scr

Source: Fiorino and Phillips

Effects of Drugs on Dopamine Levels

0 100 200 300 400 500 600 700 800 900 1000 1100 0 1 2 3 4 5 hr Time After Amphetamine

% of Bas a l Rel e a s e DA DOPAC HVA Accumbens

AMPHETAMINE

0 100 200 300 400 0 1 2 3 4 5 hr Time After Cocaine

% of Bas a l Rel e a s e DA DOPAC HVA Accumbens

COCAINE

0 100 150 200 250 0 1 2 3 4 5hr

Time After Morphine

% of Bas a l Rel e a s e _Accumbens 0.5 1.0 2.5 10 Dose (mg/kg)

MORPHINE

0 100 150 200 250 0 1 2 3 hr Time After Nicotine

% of Bas a l Rel e a s e Accumbens Caudate

NICOTINE

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;}

• 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

TEXT PAGE

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

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, methamphetam-ine.

TEXT PAGE

Diagnosing Substance Use Disorders:

DSM 5 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

Mild

2-3 Criteria

Moderate

4-5 Criteria

Severe

6+ Criteria

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

34

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-treatment-research-based-guide-third-edition/acknowledgments on September 18, 2014

TEXT PAGE

•

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

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 sustained-release (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

MEDICATIONS USED TO TREAT ALCOHOL USE DISORDERS

MEDICATION PRIMARY USE FORMULATION TREATMENTSETTING 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

TEXT PAGE

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

MEDICATIONS USED TO TREAT OPIOID USE DISORDERS

MEDICATION PRIMARY USE FORMULATION TREATMENT

SETTING MAXIMUM CLIENT CAPACITY ADMINISTRATION Methadone (Dolophine®, Methadose®) •Agonist— Suppresses cravings and withdrawals •Detoxification •Maintenance •Liquid •Tablet/Diskette •Powder •SAMHSA Certified Opioid Treatment Program (OTP) ---- •Daily at OTP

•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

TEXT PAGE

ADDITIONAL MEDICATIONS USED TO TREAT OPIOID USE DISORDERS

MEDICATION PRIMARY USE FORMULATION TREATMENT

SETTING MAXIMUM CLIENT CAPACITY ADMINISTRATION Naloxone (Narcan®) •Antagonist— Displaces opiates from brain receptors and reverses

respiratory depression

•Reverse overdose

•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

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

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.

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

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.

*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

Estimated Number of Infants* Affected by Prenatal Exposure,

by Type of Substance and Infant Disorder

640,000 15.9% 340,000 8.5% 240,000 5.9% 108,000 2.7% 12,000 0.3% 30,000

(0.5-7 per 1,000 births) _{(3.3 per 1,000} 13,000 births) 0 100,000 200,000 300,000 400,000 500,000 600,000 700,000

Tobacco Alcohol Illicit Drugs Binge Drinking Heavy Drinking FAS/ARND/ARBD NAS

Includes nine categories of illicit drugs, including

heroinand the

nonmedical use of

prescription medications.

TEXT PAGE

Prenatal Exposure and Postnatal Environment

in Vermont

Prenatal Exposure

Postnatal Environment

~6,500 births 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 ~2,200 (33.4%) prenatally exposed birth

~1,000 [16%] tobacco prenatal exposure per year

~750 [12%] alcohol prenatal exposure per year

~400 [6%] illicit drugs, including heroin and nonmedical use of prescription medications, prenatal exposure

Impact of Prenatal Exposure

47

Tobacco Exposure

• Low birth weight

• Brainstem (respiratory and autonomic functions) abnormalities • 2nd _{hand exposure and asthma}

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):

TEXT PAGE

• 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

Neonatal Abstinence Syndrome (NAS)

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.htmon 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

NAS occurs with

notable variability,

with 55-94% of

exposed infants

exhibiting

symptoms

Medication is

required in

approximately

50% of cases

Neonatal Abstinence Syndrome—Treatment

•

Non-Pharmacological Treatment

• Swaddling

• Breastfeeding

• Calm, low-stimulus environment

• Rooming with mother

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

The overarching goal of treatment is

to soothe the newborn’s discomfort

and promote mother-infant bonding

and attachment.

•

Pharmacological Treatment

• Individualized based on the severity of withdrawal symptoms

• 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

Different Populations of Women Can Give Birth to

Infants with NAS Symptoms

Chronic pain or other medical conditions maintained on medication Actively abusing or dependent on heroin Misuse of own prescribed medication Misuse of non-prescribed medication In recovery from opioid addiction & maintained on methadone or buprenorphine (e.g. medication assisted treatment)

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

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.

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

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

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

No intervention

In-Home Services

Removal

No Use

Mild

Moderate

Severe

Low Risk

Low Need

High Risk

Low Need

Low Risk

High Need

High Risk

High Need

Alternative Response

DSM 5 Dia gn osis

TEXT PAGE

Children Go Home, Stay Home…

or Find Home

1 Children’s Bureau. Child Welfare Outcomes 2008-2011, Report to Congress. U.S. Department of Health and Human Services, Administration for Children and Families, Administration of Child Youth and Families.

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.

Impact on Kinship Care

:

Family Dynamics,

Children’s Needs,

Caregiver’s Needs and

Child’s Desire for Visitation

Promotes healthy attachment and reduces the negative effects

of separation for the child Establishes and strengthens

the parent-child relationship

Eases the pain of separation, loss and abandonment for the child

Improves child well-being

Keeps hope alive for the parents and enhances parents’

motivation to change

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

Parent’s Right to Visitation

Eases the pain of separation, loss and abandonment for the parent Promotes healthy attachment and reduces the

negative effects of separation for the parent

Allows kinship and foster caregivers to support birth parents

Opportunity for kinship and foster caregivers to model positive parenting skills

Caregiver’s Opportunity

for Engagement

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 Provides a setting for the caseworker

to observe and suggest how to improve parent-child interactions

Provides information to the court and caseworker on the family’s progress

Social Worker’s Opportunity for

Observation and Engagement

Family Time

Shorter stays in out of home care Increased reunification

Honoring a Child’s Desire to Know Their Parents

• 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

It’s easy when the parent is compliant.

Contracting Considerations

Describe the target behavior change in

the parent’s own words. Incentives can be included to reinforce positive behaviors The signature is a meaningful ritual!

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

Considerations for Visitation:

Developmental Tasks, Ages 0-5

•

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.

Consistent, Routine & Predictable Safe location Transitional objects

Considerations for Visitation:

Developmental Tasks, Ages 6-11

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.

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

Considerations for Visitation:

Developmental Tasks, Ages 12-18

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.

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

" 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.“

Strengthening the parent-child bond through visitation may be a

more

effective motivator

for a parent to address their substance use.

“Continued contact between the child and his family is essential to maintaining and

strengthening family bonds

. Changes in visitation arrangements shall be directly

What Children

Need

•

Listening

and helping to identify

feelings

• 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!

“You

are not the reason your parent has

a disorder

.”

“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

.”

“Who

can you trust who you might talk with

about your concerns

–

a teacher, close friend,

an adult in your family

?”

“There

are a lot of kids like you. You are

not alone

– and there’s no reason to feel

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…

Clear

expectations,

transparency,

openness to

change,

& healthy

boundaries

are the keys to

rebuilding trust.

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

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

TEXT PAGE

Types of Kinship Care: Resources

Informal

Kinship Care

Permanent

Guardianship

Adoption

Guardianship

Assistance

Foster Care

Payments

Subsidized

Guardianship

Temporary

Assistance for Needy

Families (TANF):

Income Based

Eligibility

TANF-Child Only

Benefit

Federal Title IV-E

Adoption Assistance

State Adoption

Assistance

Additional

Resources

Supplemental

Nutrition Assistance

Program

Child’s Health

Insurance: Medicaid

or Children’s Health

Insurance Program

Respite Care

Foster Care

Custody; Guardianship

Educational Supports

• Remain in home school if appropriate

• Eligible for educational surrogate parent to help navigate educational issues

• Reimbursement for transportation to school

• Remain in home school until disposition: otherwise only if relative lives in the same town or school agrees

• Not eligible • None

Other Benefits for Child

• Eligible for Medicaid • Free hot lunch

• Child care in licensed facility (100% covered

• 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%

Other Supports for child, parent and family

• 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

• 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

Other

• 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

• 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