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1
Substance Abuse, Child Welfare and
the Courts: What’sthe Courts: What s the Connection?
Pamela Petersen-Baston, MPA, CAP, CPP
Presented at the:
Children’s Law Conference
November 5, 2010
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7 1 47 1 4 -- 5 0 55 0 5 -- 3 5 2 53 5 2 5n c s a c w @ c f f u t u r e s . o r g n c s a c w @ c f f u t u r e s . o r g
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A Program of the
Substance Abuse and Mental Health
Services AdministrationCenter for Substance Abuse
Treatmentand the
Administration on Children, Youth and Families
Children’s Bureau
TEXT PAGE
Children s BureauOffice on Child Abuse and Neglect
2
Overview
• What is the connection?
• Strategies for collaboration
TEXT PAGE
What’s theWhat s the Connection?
3
The Hard Questions
How widespread is substance abuse in the child welfare caseload?
Why should substance abusing parents in the child welfare system be given priority in access to treatment?
Why must substance abuse be combined with mental health, family violence, poverty and other influences on child abuse and neglect?
Is treatment effective for parents who are at risk or involved with the child welfare system? What are the issues about the quality of treatment for parents in the child welfare system?
Do positive treatment outcomes assure positive reunification outcomes?
How widespread is
substancesubstance abuse in the child welfare
caseload?
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• Practitioners often cite estimates of 40% to 80% of child welfare-involved families have substanceinvolved families have substance abuse problems.
• Report to Congress estimated between one third and two thirds of children in child welfare were affected by parental substance abuse.
(Semidei, Radel, & Nolan, 2001; Young, Gardner, & Dennis, 1998; USDHHS, 1999)
Children Living with One or Children Living with One or More More
SubstanceSubstance--Abusing ParentAbusing Parent
10.6
127,000 children in South Carolina
6.2
7.5
8.3
8.4
11%
TEXT PAGE
4.5
2.8
0 5 10 15
Numbers indicate millions
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Children Living with One or Children Living with One or More More
SubstanceSubstance--Abusing ParentAbusing Parent
Lived with a parent who was dependent
on or abusedParent Gender
TEXT PAGENational Survey on Drug Use and Health (2009)
Alcohol Illicit Drug
Father Mother
Treatment Admissions and Child Maltreatment Data
Summary, 2008
United States
South CarolinaStates Carolina
Number
Percent
Number
Percent
Total Treatment Admissions
2,016,077
100%
27,193
100%
Alcohol834,4
6241.4%
14,621
53.8%
All Other 1 181 58 6 12 57 46 2
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All Other Drugs
1,181,615
58.6%
12,572
46.2%
Child Maltreatment Victims*
758,289
20.9%
12,549
30.3%
Child Victimization Rate
9.5 11.4
1) U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2008 (Washington, DC: U.S. Government Printing Office, 20010). Tables 3.1, 3.32) Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS) Highlights - - 2008 National Admissions to Substance Abuse Treatment Services. Tables 2a, 6a. OAS Series #S-40, DHHS Publication No. (SMA) 08-4313, Rockville, MD, 2008.
*Includes those with disposition of substantiated, indicated or alternative response victim. Percentage is number of maltreatment cases out of total number of children who received a CPS investigation.
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Parents Entering Publicly-Funded
Substance Abuse Treatment
59%• Had a
child under age 18
22%• Had a
child removed by CPS
10%• If a child
was removed, lost parental rights
Based on CSAT TOPPS-II Project
Risks to Children:Different Situations for
Children
• Parent uses or abuses a substance
• Parent is dependent on a psubstance
• Special considerations when Methamphetamine production is involved
– Parent involved in a home lab or super lab
• Parent involved in trafficking
• Mother uses a substance while pregnant
Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005
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Past Year Substance Use by Youth Age 12 to 17
50%
Compared to African-American Youth, Caucasian Youth were more likely to use alcohol (41.4% versus 29.8%)
and illicit drugs (36.2% versus 26.7%)
Compared to African-American Youth, Caucasian Youth were more likely to use alcohol (41.4% versus 29.8%)
and illicit drugs (36.2% versus 26.7%)
37.8%34.4%33.6%
21.7%
10%
20%
30%
40%
50%
TEXT PAGE
0%
10%
Alcohol Illicit Drug
Ever in Foster Care
Source: Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care
Percent of Youth Ages 12 to 17 Needing Substance Abuse Treatment by Foster
Care Status
TEXT PAGE
Source: Office of Applied Studies, SAMHSA (2005) Substance Use and Need For Treatment among Youths Who Have Been in Foster Care
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Use During Pregnancy
SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2004-2005
Annual Average, Applied to 2008 South Carolina birth data: 63,001
Substance Used (Past Month)
1st Trimester
2nd Trimester
3rd Trimester
Any Illicit Drug
2.3% women1,449 infants
6.7% women4,221 infants
7.0% women 4,410 infants
20.6% women
3.2% women2,016 infants
10.2% women6,426 infants
Alcohol Use
Binge Alcohol UseState prevalence studies report 10-12% of infants or
mothers test positive for alcohol or illicit drugs at birth
1.6% women1,008 infants
12,978 infants
7.5% women4,725 infants
2.6% women1,638 infants
Number of Children Prenatally Exposed to Substances
South Carolina total live births = 63 001 (2008)63,001 (2008)
12% of total live births = 7,560
Total child victims under age 1 year = 1,544
(2008)
Where did they all go?
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80-95% are undetected and go home without assessment and needed services.
Most Go Home
• Many doctors and hospitals do not test, or may have inconsistent implementation of state policies– Tests detect only very recent use
• Inconsistent follow-up for woman identified as AOD using or at-risk, but with no positive test at birth
TEXT PAGE
but with no positive test at birth
• CAPTA legislation raises issues of testing and reporting to CPS
How Many Children in South Carolina?
• 127,000 children living with alcohol or drug-dependent parents
• 9,400 children in the child welfare system affected by parental substance abuse
• 2,500 children taken into out of home care each year affected by parental substance abuse
• 7,560 prenatally exposed infants each year
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Why should substance
abusing parents in the child welfare system be given
priority in access to treatment?
Intergenerational Effects
Substance use disorders are What we knowdisorders are
family diseases
Affected children• Children we
remove• Children we
send back home• Children we
What we know
California sample
Family • Children we leave at home
ycentered treatment
works
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Developmental Effects
Five levels of
impact on younger children
CAPTA
What we know
80-95% of prenatally
Prenatal exposure CAPTA
amended in 2003
prenatally exposed
children are not identified at birth and
just go home
peffects can be reduced
through early identification
and early intervention
Models of Priority Access
• A few states and jurisdictions have made child welfare parents a priority in accessing treatmentpriority in accessing treatment.
– Arizona Executive Order
– Sacramento
– Santa Clara
• Federal 48-hr requirement, but not reported or monitored annuallyp y
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Why must substance b b bi dabuse be combined with mental health,
family violence, poverty or other
influences on child abuse and neglect?
Health and Hospitals
Mental Health
Schools and Special Education
Developmental Disabilities
Domestic Violence
Child Development
Juvenile Justice
Family Income Support
Courts
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Comprehensive Approaches
• Integrated treatment coordinates substance abuse and mental health interventions to treat the whole person pmore effectively
• Recognizes the importance of ensuring that entry into any one system can provide access to all needed systems
• Colorado and California have developed models of links between family income support programs and child welfare
Is treatment effective for
parents who are at risk or involved
ith th hildwith the child welfare system?
What are the issues about the
quality of treatment for
parents in theparents in the child welfare
system?
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Key Questions
• Are family treatment services provided?
• Is treatment the right dose and duration?
• Does comprehensive treatment include treatment for co-occurring disorders?
• Are recovery support services available for the family?
Compliance with Medical Treatment
• > 50% of “re-occurrence” was due to lack of compliance
• > 50% of medical patients lie about compliance
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Source: McLellan, A., Metzger, D. A., Alterman, A. I., Woody, G. E., Durell, J., & O’Brien, C. P. (1995). Is addiction treatment “worth it”? Public health expectations, policy-based comparisons. Philadelphia, PA: The Penn-VA Center for Studies on Addiction and the Treatment Research Institute.
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Reasons for Disease Re-Occurrence
#1 - Lack of Compliance
#2 - Socioeconomic Factors
#3 - Family Support
#4 - Psychiatric Co-morbidity
AOD Treatment - Predictors of OutcomeOutcome
EmploymentFamily Support
Psychiatric Status
Source: McLellan, A., Metzger, D. A., Alterman, A. I., Woody, G. E., Durell, J., & O’Brien, C. P. (1995). Is addiction treatment “worth it”? Public health expectations, policy-based comparisons. Philadelphia, PA: The Penn-VA Center for Studies on Addiction and the Treatment Research Institute.
Do positive treatmenttreatment outcomes
assure positive reunification
outcomes?
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Understanding the Outcomes
Monitored by CFSR process
Need to prove that
treatment works for
What we know
Reunifications linked to
substance b
Baselines for reunification vs.
baselines for substance-
child welfare cases
abuse substanceaffected children
Research Findings
• Mothers with more employment and psychiatric problems were less likely to be reunified with their children
• Completion of 90 or more days in treatment approximately doubled their likelihood of reunification
• Mothers who were treated in programs providing a “high” level of family-related or education/employment services were approximately twice as likely to reunify
TEXT PAGE
pp y y ywith their children as those who were treated in programs with “low” levels of these services
Source: Journal of Substance Abuse Treatment, Volume 36, Issue 3, Pages 278-293 C. Grella, B. Needell, Y. Shi, Y. Hser
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Sacramento Family Dependency Drug Court
• Immediate identification of alcohol and drug problems by early intervention specialist workers
Critical components of DDC:
• Prompt assessment and placement in treatment services, usually within 2-5 working days;
• A full continuum of alcohol and drug treatment services; Intensive recovery management provided by the STARS program;
• Drug Court hearings at 30,60,and 90 day intervals to monitor compliance and ensure accountability for all parents with alcohol and drug problems (Phase I - mandatory); p ( y);
• More frequent drug court hearings for parents who are in need of additional support and monitoring in order to succeed (Phase II and III -voluntary); and,
• Timely use of incentives and progressive sanctions.
Child Placement Outcomes at 36 Months
**p<.01; ***p< 001
Comp n=173; DDC n=2086
Source: CWS/CMS
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Child Reunification Rates by DDC
Graduation Status – Over Time
TEXT PAGE
Source: STARS; CWS/CMS
The Reunification Gap: A State-level Example
Case Study:
• 63% of reunifications occur within 12 th12 months
(3,255 of 5,166 children in care)
• Per the National target of 75.2%, this state’s 12 month reunification goal should be 3,885.
• Therefore, the gap between the current and target reunification rate gis 630 children.
• 630 children 454 parents– Child-parent ratio conversion = .72
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• 454 parents need to complete treatment to meet the National Target reunification rate.
The Reunification Gap: A State-level Example
g
• To have 454 parents complete treatment, an additional 1,261 treatment spaces are necessary.– Assume 36% of parents who enter
treatment successfully complete the treatment episode
• 1,261 new treatment spaces , prepresents 4.7% of the state’s total treatment admissions (assuming no overlap).– State has 27,000 annual treatment
admissions
Tools for Collaboration:
10 Element Framework
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The Five Clocks
Temporary Assistance for Needy Families (TANF)• 24 months work participation• 60 month lifetime
Adoption and Safe Families Act (ASFA)
• 12 months permanency plan
• 15 of 22 months in out-of-home care must petition for Termination of Parental Rights (TPR)
RecoveryO d t ti f th t f
TEXT PAGE
• One day at a time for the rest of your life
Child Development• Clock doesn’t stop
• Moves at the fastest rate from prenatal to age 5
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The Most Important Clock
• The 5th Clock: The one that’s ticking on us
H l d h t t if• How long do we have to act if
our families have
• 24 months to work and
• 12 months to reunify?
• Taking this clock seriously meansthat we take aggressive action t il th l k hild
TEXT PAGE
to reconcile the clocks on children and families
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Why Collaborate?
• Avoid duplication of effort
• Problem solving opportunities
• Exchange knowledge
• Build relationships
• Increase communication
• Improve outcomes
ChangingThe System
Getting Better at Getting Along:
Four Stages of Collaboration
ChangingThe Rules
Existing Funding
External Funding
InformationExchange
JointProjects
Sid Gardner, 1996Beyond Collaboration to Re
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Navigating the PathwaysPublished by CSAT
• A framework for defining elements of collaboration
To define linkage points across systems: where are the most important bridges we need to build?
• Methods to assess effectiveness of collaborative work
To assess differing values
To assist sites in measuring their implementation
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Mission
1. Underlying Values and Priorities
Elements of System LinkagesElements of System LinkagesThe Ten Key BridgesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
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Collaborative Practice and PolicyTools
Ten Element Framework – A method to organize collaborative activities in specific practice and policy areas
Collaborative Values Inventory – An anonymous way to explore values and beliefs to facilitate the development of common principles using web‐based data collection
Collaborative Capacity Instrument – An anonymous way to assess the strengths and challenges in each of the areas of system linkages using web‐based data collection
i f i S i k i b dMatrix of Progress in System Linkages – A practice‐based approach that specifies characteristics of advance collaboration practice in the elements of system linkages
Screening and Assessment for Family Engagement, Retention and Recovery — SAFERR ‐‐ A guidebook to develop effective communication across systems while engaging families in services
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Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
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Underlying Values and Principles of Collaboration
Tools and Resources
• Collaborative Values Inventory
• Synthesis of Cross System Values and Principles: A National Perspective
Models
• IDTA Memoranda of Understanding and statements of shared valuesand statements of shared values and principles
Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Missing Boxes
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
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DropoffDropoff PointsPoints
50,000 Children with Substantiated Abuse/Neglect 33,000 Parents
60% of Parents Need Assessment 60% of Parents Need Assessment 19,800
50% Go for Assessment 9,900
80% Need Treatment 7,920
50% Go to First Session 3,960
30% Complete 90 Days – 1,188
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50% Reunify or Stay with Parents 594
Screening and Assessment
Tools and Resources
• SAFERR-Screening and Assessment for Family Engagement, Retention and Recovery
Models • Arizona – Families
F.I.R.S.T. Model• Washington –
GAIN-SS and CDPs statewide
• Maine-
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Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Call Me Tuesday
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
Engagement and Retention
Tools and Resources• SAFERR- Screening and
Assessment for FamilyAssessment for Family Engagement, Retention and Recovery
• SAS- Substance Abuse Specialist Paper
Models • Arizona – Families F I R S T Model• Arizona – Families F.I.R.S.T. Model• Sacramento- STARS• Cuyahoga County- START
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Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
10 Element FrameworkServices to Children
• Complex interchange of biological, psychological and sociological eventsevents
• Screening is complicated by:– 1. There is no absolute profile of
developmental outcomes
– 2. Other issues in parental behavior, competence, and disorders
interact which may lead to multiple co-poccurring problems for children
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Daily Practice – Services to Children
Multiple Opportunities for Intervention
• Commonly noted consequences for children– Fetal Alcohol Syndrome (FAS)Fetal Alcohol Syndrome (FAS)– Alcohol-related neuro-developmental
disorders (ARND)• Physical health consequences• Lack of secure attachment• Psychopathology• Behavioral problems• Poor social relations/skills• Deficits in motor skills• Cognition and learning disabilities• Cognition and learning disabilities
Services to Children
Tools and Resources
• Substance-Exposed Infants: State Responses to the Problem
Models • Washington State• Research Triangle
I tit tInstitute• RPG Children's
Cluster• Miami Zero to Two
Court• Strengthening
FamiliesCelebrating
In Process, review of children’sIn the SAPTBG
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Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
What is the role of the RecoveryCommunity in Child Welfare Prac
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
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Joint Accountability, Shared Outcomes and Information
Systems
Tools and Resources• RPG Data codebook• Webinars on linkagesWebinars on linkages• Analysis of “what it takes to move the
CFSR needle”
Models • Michigan revised SACWIS to prioritize
families with substance use disorders• CFSR and NOMS processes
C lif i C lOMS t k 7500• California CalOMS now tracks 7500 CW parents in treatment and knows which had positive outcomes [36%]
Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
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Training and Staff Development
Tools and Resources
• NCSACW online tutorials
• Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers
• Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals
• Understanding Substance Use Disorders, Treatment and Family Recovery: A Guide for Legal Professionals
Online Training
Available at no charge at http://ncsacw.samhsa.gov
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Implementing Online Tutorials
Available at no charge at http://ncsacw.samhsa.gov
Training and Related Products
• On-Line Training
– Available at no cost
– Upon completion of the tutorial:Upon completion of the tutorial:
• Certificate awarded
• CEUs and CLEs are available
• Child Welfare Training Toolkit: Helping Child Welfare Workers Support Families with Substance Use, Mental, and Co-Occurring Disorders http://www.ncsacw.samhsa.gov/training/toolkit/olkit/
• State Legislator information resources web-pages (in development)
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Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
Budget and Sustainability
Tools and Resources
• White Paper on Funding Comprehensive Services for Families with Substance Use Disorders in Child Welfare and Dependency Courts
• Funding Family-Centered Treatment for Women With Substance Use Disorders– Detailed tables of Federal funding sources for
comprehensive services
• Sustainability discussion guide for Regional Partnership Grants and webinars
• IDTA State strategic plans for continued efforts
Models
• Milwaukee Courts Integrated Funding System
• Cost Studies in Sacramento and Sonoma
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Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
Working with Other Agencies
Partnership most frequently cited as necessary:
• Mental health services for adults• Mental health services for adults.
• Mental health services for children.
• Domestic Violence
• Housing
• Income Support (TANF, Vocational Training, Employment)
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Working with Other Agencies
Tools and Resources• Family Centered Treatment for
WomenWomen• A Review of Alcohol and Drug
Issues in the States’ Child and Family Service Reviews and Program Improvement Plans regarding Service Array
ModelsModels • Shields for Families,
PROTOTYPES, Meta House • Other multiservice agencies
Mission
1. Underlying Values and Priorities
Elements of System LinkagesThe Ten Key Bridges
System Elements
Children, Family, Tribal, and Community Services
2. Screening and Assessment
3. Engagement and Retention
4. Services for Children
5. Community and Family Support
Outcomes
10. Shared Outcomes and Systems Reforms
6. Information Systems
7. Training and System Tools
8. Budget and Sustainability
9. Working with Other Agencies
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Shared Outcomes System Reforms
Tools and Resources
• SAFERR communication protocols
• IDTA State communication protocols and
examples of data system improvements
• RPG Logic Model
• A Review of Alcohol and Drug Issues in the
States' Child and Family Service Reviews and
Program Improvement Plans
Models
• Guide to Cross-System Data Sources for State
and Tribal Child Welfare, Substance Abuse
Treatment and Court Systems (In Development)Treatment, and Court Systems (In Development)
• May 16, 2008: Connecting the Dots: How States
and Counties Have Used Existing Data Systems
to Create Cross System Data Linkages
– http://www.cffutures.com/webinars.shtml#May
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Levels of Technical Assistance
Level One:
Information and Sharing of Models
Level Two:
Expert Consultation and Research
Level Three:
Development of Issue‐Specific Products
Level Four:
Strategic Planning, Training Resources
and Facilitation
16 States3 Tribes1 County
53 Grantees
10 Pre‐IDTA
247 requests
366 requests
1077 requests
September 2001 through June 2009 72
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Types of TA Products
• Collaborative practice and policy tools
• Information and sharing of models
• Expert consultation and research
• Development of issue-specific products
Monographs, white papers, fact sheets
• Training resources and collaborative
facilitation
On-line courses, training materials, g
• Longer-term strategic planning and development of protocols and practice models
73
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
– Email us at [email protected]
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Discussion