how to manage a kinship caregiver relationship with parents...

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

11th Annual Kinship Conference

Burlington, VT

September 2015

TEXT PAGE

3

A Program of the

Substance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment

and the

Administration on Children, Youth and FamiliesChildren’s Bureau

Office on Child Abuse and Neglect

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

[email protected]

• 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

Agenda

Vermont Department for Children and Families, Family Services Division, 2014 Report on Child Protection in Vermonthttp://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

Intakes Accepted Reports Percent

Vermont

Source: Wolcott, Cindy. S.9/Act 60 Implementation (PowerPoint). State of Vermont, Cross Leadership Meeting. September 17, 2015.

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

,44

3)

AK

(N

=2,8

42

)

AZ

(N=2

3,8

54

)

AR

(N

=7,4

11

)

CA

(N

=85

,11

4)

CO

(N

=10,

54

2)

CT

(N=5

,80

3)

DE

(N=1

,16

0)

DC

(N

=1,9

31

)

FL (

N=3

3,2

70

)

GA

(N

=13

,54

2)

HI (

N=2

,05

4)

ID (

N=2

,43

8)

IL (

N=2

1,9

57

)

IN (

N=1

8,6

95

)

IA (

N=1

0,5

70

)

KS

(N=9

,84

5)

KY

(N=1

2,1

73

)

LA (

N=7

,38

4)

ME

(N=2

,44

1)

MD

(N

=7,0

61

)

MA

(N

=13

,63

9)

MI (

N=2

2,2

61

)

MN

(N

=11

,11

4)

MS

(N=

6,0

72

)

MO

(N

=16

,18

6)

MT

(N=3

,39

7)

NE

(N=7

,74

2)

NV

(N

=8,0

28

)

NH

(N

=1,2

82

)

NJ

(N=1

2,0

82

)

NM

(N

=3,7

46

)

NY

(N=3

0,9

81

)

NC

(N

=13

,40

1)

ND

(N

=1,9

23

)

OH

(N

=21,

43

5)

OK

(N

=15

,09

6)

OR

(N

=12,

22

6)

PA

(N

=22,

93

8)

RI (

N=2

,90

2)

SC (

N=5

,98

9)

SD (

N=2

,29

6)

TN (

N=1

4,3

91

)

TX (

N=4

6,2

86

)

UT

(N=4

,87

7)

VT

(N=1

,60

5)

VA

(N

=7,1

83

)

WA

(N

=15

,22

2)

WV

(N

=7,9

06

)

WI (

N=1

0,8

52

)

WY

(N=1

,89

0)

PR

(N

=4,8

36

)

Source: AFCARS Data, 2013

National Average: 31%

Parental Substance Use as Reason for Removal

Across States, 2013

Vermont: 15%

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

,44

3)

AR

(N

=7,4

11

)

AZ

(N=2

3,8

54

)

CA

(N

=85

,11

4)

CO

(N

=10,

54

2)

CT

(N=5

,80

3)

DC

(N

=1,9

31

)

DE

(N=1

,16

0)

FL (

N=3

3,2

70

)

GA

(N

=13

,54

2

HI (

N=2

,05

4)

ID (

N=2

,43

8)

IA (

N=1

0,5

70

)

IL (

N =

N/A

)

IN (

N=1

8,6

95

)

KS

(N=

9,84

5)

KY

(N=1

2,1

73

)

LA (

N=7

,38

4)

MA

(N

=13

,63

9)

MD

(N

=7,0

61

)

ME

(N=

2,4

41

)

MI (

N=2

2,2

61

)

MN

(N

=11

,11

4)

MO

(N

=16

,18

6)

MS

(N=6

,07

2)

MT

(N=3

,39

7)

NC

(N

=13

,40

1)

ND

(N

=1,9

23

)

NE

(N=7

,74

2)

NH

(N

=1,2

82

)

NJ

(N=1

2,0

82

)

NM

(N

=3,7

46

)

NV

(N

=8,0

28

)

NY(

N=3

0,9

81

)

OH

(N=2

1,4

35)

OK

(N

=15

,09

6)

OR

(N

=12,

22

6)

PA

(N

=2

2,9

38

)

RI (

N=2

,90

2)

SC (

N=

5,9

89

)

SD (

N=2

,29

6)

TN (

N=1

4,3

91

)

TX (

N=4

6,2

86

)

UT

(N=4

,87

7)

VT

(N=

1,6

05

)

VA

(N

=7,1

83

)

WA

(N

=15

,22

2)

WI (

N=1

0,8

52

)

WV

(N

=7,9

06

)

WY

(N=1

,89

0)

PR

(N

=4,8

36

)

Under Age 1 Age 1 and Older

VERMONT

Under Age 1: 27%

Age 1 and Older: 13%

N= Total number of children removed by StateSource= 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

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

• 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

WWW.NIDA.NIH.GOV

Nucleus accumbensVentral tegmental Area (VTA)

Dopamine release

Cortex

MesolimbicSystem

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

Natural Rewards Elevate Dopamine Levels

0

50

100

150

200

0 60 120 180

Time (min)

% o

f B

asal D

A O

utp

ut

NAc shell

Empty

Box Feeding

Source: Di Chiara et al.

FOOD

100

150

200

DA

Co

ncen

trati

on

(%

Baseli

ne)

MountsIntromissionsEjaculations

15

0

5

10

Co

pu

latio

n F

req

uen

cy

Sample

Number

1 2 3 4 5 6 7 8 9 1011121314151617

ScrScrBasFemale 1 Present

ScrFemale 2 Present

Scr

Source: Fiorino and Phillips

SEX

Effects of Drugs on Dopamine Levels

0100200300400500600700800900

10001100

0 1 2 3 4 5 hr

Time After Amphetamine%

of

Bas

al R

ele

as

e

DADOPACHVA

Accumbens AMPHETAMINE

0

100

200

300

400

0 1 2 3 4 5 hrTime After Cocaine

% o

f B

as

al R

ele

as

e

DADOPACHVA

AccumbensCOCAINE

0

100

150

200

250

0 1 2 3 4 5hrTime After Morphine

% o

f B

as

al R

ele

as

e Accumbens

0.51.02.510

Dose (mg/kg)

MORPHINE

0

100

150

200

250

0 1 2 3 hrTime After Nicotine

% o

f B

as

al R

ele

as

e

AccumbensCaudate

NICOTINE

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;


• 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

A chronic, relapsing brain disease

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, methamphetamine.

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 therapies8. 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

34National 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

http://www.drugabuse.gov/publications/principles-drug-addiction-treatment

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

Medication-Assisted Treatment (MAT)

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 replacementtherapies(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 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465757/pdf/nihms59469.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465757/pdf/nihms59469.pdf

MEDICATIONS USED TO TREAT ALCOHOL USE DISORDERS


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

TEXT PAGE

ADDITIONAL MEDICATIONS USED TO TREAT ALCOHOL USE DISORDERS


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 Administration, 2009.

MEDICATIONS USED TO TREAT OPIOID USE DISORDERS

MEDICATION PRIMARY USE FORMULATIONTREATMENT

SETTING

MAXIMUM

CLIENT

CAPACITY

ADMINISTRATION

Methadone(Dolophine®, Methadose®)

•Agonist—Suppresses cravings and withdrawals

•Detoxification

•Maintenance

•Liquid

•Tablet/Diskette

•Powder

•SAMHSACertified Opioid Treatment Program (OTP)

---- •Daily at OTP

•Some individuals may qualify for take-home prescriptionslasting 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 FORMULATIONTREATMENT

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.

https://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.pdf

http://store.samhsa.gov/shin/content/SMA14-4892/SMA14-4892.pdf

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

*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

640,00015.9%

340,0008.5%

240,0005.9%

108,0002.7%

12,0000.3%

30,000(0.5-7 per 1,000 births)

13,000(3.3 per 1,000

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 heroin and the nonmedical use of prescription medications.

Past Month Substance Use by Pregnant Women Incidence of Infant Disorder

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

per year in Vermont

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):

• Range of disabilities in behavior, adaptive skills, executive functioning, and self-regulation

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.htm on July 24, 2014Hudak, M.L., Tan, R.C. The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012, 129(2): e540Jansson, 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

http://www.nlm.nih.gov/medlineplus/ency/article/007313.htm

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): e540Jansson, L.M., Velez, M., Harrow, C. The Opioid Exposed Newborn: Assessment and Pharmacological Management. Journal of Opioid Management. 2009; 5(1):47-55Jones, 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)

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

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

Opioid relapse rate in pregnant women with opioid use disorder is between 41-96%

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.201300235The 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

No intervention In-Home Services Removal

No Use

Mild

Moderate

Severe

Low Risk

Low NeedHigh Risk

Low Need

Low Risk

High Need

High Risk

High Need

Alternative Response

DS

M 5

Dia

gn

osis

Child Welfare Intervention

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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.

“I wish you helped my mom.”

Impact on Kinship Care:

Family Dynamics,

Children’s Needs,

Caregiver’s Needs and

Parent’s Needs

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.pdfNRC 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 TimeShorter stays in out of home care

Increased reunification

Successful 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.

What will you do in the difficult situations?

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

Adapted from: http://www.courts.mo.gov/hosted/circuit11/Documents/Parental%20guide%20to%20visitation.pdf



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

Teach the 7 C’s



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 related to the ongoing risk and family assessment.”

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 embarrassed.”

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 boundariesare 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

• Decisions on child’s health, education, etc.

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

Supports for Foster Care or Kinship Caregivers—VERMONT SPECIFIC

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

[email protected]

www.cffutures.org

www.ncsacw.samhsa.gov/default.aspx

mailto:[email protected]

http://www.cffutures.org/