Resources to Support Families in Child Welfare Affected by Opioid and Other Substance Use Disorders

Resources to Support Families in Child Welfare Affected by Opioid and Other Substance Use Disorders


Opioid and Other Substance Use Disorders
Narrator: The National Center on Substance Abuse and Child Welfare is a resource center
jointly funded by the Substance Abuse and Mental Health Services Administration and
the Administration on Children and Families, Children’s Bureau. The National Center provides free training
and technical assistance to organizations working with families affected by substance
use disorders. Please take a moment to watch this brief motion
graphic for information about the work that we do.
[background music] Video Narrator: The National Center on Substance
Abuse and Child Welfare is a resource center that offers consultation, training, and technical
assistance to improve outcomes for families affected by substance use disorders. The Center is an initiative of the Department
of Health and Human Services, and is jointly funded by the Substance Abuse and Mental Health
Services Administration and the Administration on Children, Youth, and Families. Our focus is on families affected by substance
use disorders who are involved with child welfare services and the courts. These families have multiple complex needs
that require resources across many systems. We provide technical assistance that helps
these multiple systems come together to enhance policies, practices, and procedures that benefit
families. Our services are based on decades of work
with state, local, and community agencies nationwide. The short term technical assistance we deliver
includes phone or email consultation to provide information, resources, and publications,
as well as examples of work that we have supported across the country. Our website hosts a variety of resources,
including free online tutorials for substance use, child welfare, and court professionals. We convene national webinars and present at
conferences across the country. Our technical assistance focuses on improving
practices and policies related to a variety of topics such as family centered treatment
for opioid and other substance use disorders, infants with prenatal substance exposures,
plans of safe care, family drug treatment courts, trauma informed care, and recovery
supports. Our long term technical assistance involves
a dedicated consultant who provides relationship based coaching and support over an extended
period of time for collaborative teams, which often include child welfare, substance use
treatment, court, healthcare, and community partners. We support sites involved with the National
Center’s In Depth Technical Assistance Program, and ACYF’s regional partnership grants to
make policy and practice changes, strengthen partnerships, and achieve measurable outcomes
on behalf of children and families. Through our work, we have developed a variety
of collaborative policy and diagnostic tools that help partner organizations assess readiness
for collaboration, and identify strengths, needs, and opportunities for improvement. To request technical assistance and learn
more about the National Center’s services, visit our website. Contact us toll free at 1 866 493 2758 or
email us at [email protected] [background music ends]
Katie Ryan: My name is Katie Ryan and I’m the Technical Assistance Program Manager for
the National Center on Substance Abuse and Child Welfare. I’m going to provide an overview of national
data that demonstrates the relationship between substance use disorders and child welfare. I will also share resources that stake holders,
service providers, and policy makers can use to improve how their communities serve families
affected by opioids and other substance use disorders. We will then hear from Jill Gresham, Senior
Program Associate for the National Center about her work in the In Depth Technical Assistance
initiative. Jill will provide an overview of the initiative
and highlight tools that states developed during their participation in the initiative. The tools are available for public use and
can be tailored to meet the needs of your community. Now, we’re going to review national data regarding
child welfare and substance use disorders. Over the past 15 years, we’ve seen increases
in the number of children placed in out of home care in which their parents’ substance
use was a contributing factor for the removal. In 2016, 35 percent of children in out of
home care had parental substance use listed as a reason for removal. 35 percent translates to approximately 250,000
children. The prevalence of parental substance use as
a contributing factor for removal varies greatly from state to state, ranging from less than
5 percent in New Hampshire to nearly 70 percent in Alaska. This variation has more to do with state specific
identification and data entry protocols than actual differences in parental substance use. There’s a great deal of variability in the
protocols states use to identify parental substance use. Thresholds for that substance use affecting
removal and systems for collecting that data. The variation by state leads to what is believed
to be a substantial under count of the overall prevalence of children removed with parental
alcohol or other drug use as a contributing factor. Of all children who enter out of home care,
children under one are the largest group by far. In 2016, nearly 50,000 children who entered
out of home care were under the age of one. This under one category includes infants who
enter out of home care due to identification at birth of prenatal substance exposure. Neonatal abstinence syndrome, NAS, refers
to withdrawal symptoms resulting from exposure to a variety of substances. From 2000 to 2009, the incidents of NAS increased
three fold. This rate continued to increase from 2009
to 2012. In 2017, a study by the Office of the Assistant
Secretary for Planning and Evaluation, ASPE, found the increases in foster care entries
were related to overdose deaths at the national level. These data show that, prior to 2012, foster
care entries were generally declining while overdose deaths rose. After 2012, foster care entry rates began
increasing at the same time drug overdose deaths began climbing at a faster rate. There is variation in this relationship within
the US. Some parts of the country show a stronger
relationship between overdose death rates and foster care entries. The counties highlighted in red are counties
where rates of drug overdose deaths and foster care entries were both above the national
median. As you can see, this relationship is stronger
in New England, Appalachia, Oklahoma, parts of the southwest, and parts of the Pacific
Northwest. The ASPE study found that, nationally, the
rates of drug overdose deaths and drug related hospitalizations were associated with child
welfare caseloads, including rates of child protective services reports, substantiated
reports, and foster care placements. As the rates of overdose deaths and drug related
hospitalizations increased, so did child welfare caseloads. A 10 percent increase in overdose death rates
correlated with a 2.2 percent increase in rates of maltreatment reports, a 2.4 percent
increase in the substantiation rates, and a 4.4 percent increase in foster care entry
rates. For nearly two decades, the National Center
has worked with a variety of states, tribes, and local governments to develop comprehensive
family centered supports for families affected by substance use disorders. Since 2014, the National Center has provided
technical expertise to states to change their practice and policies to improve the outcomes
for families with prenatal substance exposure and their families. These partnerships have provided great insight
about the challenges and opportunities available to communities as well as providing excellent
site examples and tools that can support other communities as they endeavor to do similar
work. First, we will discuss the tools created to
support communities in developing a coordinated comprehensive approach to address families
affected by opioid use disorders. The National Center created a collection of
webinars on a variety of topics related to opioid use disorders. The webinars are useful for developing shared
knowledge, implementing collaborative practice, and integrating family centered services. The first webinar in this series presents
an overview and introduction to the SAMHSA publication “A Collaborative Approach to the
Treatment of Pregnant Women with Opioid Use Disorders Practice and Policy Considerations
for Child Welfare, Collaborating Medical and Service Providers.” The webinar covers the key components of the
publication and provides examples of how to use the information in your community to build
or improve collaborative practices. The second webinar in the series, “Partnering
to Treat Pregnant Women with Opioid Use Disorders Lessons from a Six Site Initiative,” provides
an overview and shares lessons from the SAMHSA funded initiative, In Depth Technical Assistance
for Infants with Prenatal Substance Exposure program. The webinar features key findings learned
in Connecticut, Kentucky, Minnesota, New Jersey, Virginia, and West Virginia. “The Opioid Use in Pregnancy A Community’s
Approach” highlights Vermont’s Children and Recovering Mothers, CHARM, collaborative. This is one community’s approach to addressing
the needs of infants with prenatal substance exposure and their families. Communities can watch these webinars to learn
about the different approaches to working with families affected by opioid use disorders
and use the information to improve their own local and/or state level policies and procedures
that are in place for helping this population. The webinar “A Framework for Intervention”
addresses practice and policy issues for infants with prenatal exposure and their families. The webinar introduces the five point framework,
which identifies points of intervention to prevent prenatal exposure and responds to
the needs of pregnant women, mothers, their families, and infants. The five points of intervention include pre
pregnancy, prenatal, identification at birth, postpartum, and infancy and beyond. The webinar “Opioid Use Dependence and Treatment
in Pregnancy” features three national experts on opioid use disorders in pregnancy as they
discuss treatment during pregnancy, its impact on infants, and innovative strategies to work
with families. The webinar “Early Identification and Treatment
of Prenatally Exposed Infants” provides information on early identification of infants with prenatal
exposure at birth, definitions of substance exposed infants across systems and pharmacological
and non pharmacological treatment of infants with NAS. The webinar “Infants with Prenatal Substance
Exposure Yale New Haven Children’s Hospital’s Approach” provides an overview of the Yale
New Haven Children’s Hospital initiative to improve the quality of care of infants with
neonatal abstinence syndrome, methods and findings of the hospital study published in
“Pediatrics” by Dr. Matthew Grossman and team from the Yale University School of Medicine
and School of Public Health in New Haven, Connecticut, and interventions focused on
non pharmacological therapies, and a simplified approach to an assessment of infants exposed
to methadone in utero. Stakeholders can use these webinars to select
what intervention points and intervention strategies they want to consider in their
localities and jurisdictions, and identify which best practices they will use in implementation
of those strategies. Partners can engage the National Center for
support in conducting a systems walkthrough to identify opportunities to better support
families affected by opioid use disorders. Medication assisted treatment is an important
component of treatment for individuals with opioid use disorders, and is recommended for
pregnant women with opioid use disorders. Unfortunately, medication assisted treatment
is often misunderstood by individuals working in different capacities to support families,
such as dependency court judges, child welfare workers, and healthcare staff. This misunderstanding can present challenges
for pregnant women and parents who are trying to attend to their treatment and recovery
needs, as well as their parenting role. This two part series on medication assisted
treatment provides an overview of MAT and various issues related to currently available
medications, as well as more detailed information about the needs of pregnant and postpartum
woman related to medication assisted treatment. These webinars can provide information and
insights to individuals who don’t understand medication assisted treatment and its positive
outcomes. In addition to webinars, the National Center
has developed a number of written materials that communities can use to enhance their
practices, improve system connections, and expand services to families affected by substance
use disorders. The publication, “A Collaborative Approach
to the Treatment of Pregnant Women with Opioid Use Disorders,” provides and overview of the
extent of opioid use by pregnant women and the effects on the infant, evidence based
recommendations for treatment approaches from leading professional organizations, and in
depth case study including ideas that can be adopted and adapted by other jurisdictions,
and a guide for collaborative planning, including needs and gaps analysis tools for priority
setting and action planning. Partners interested in developing a collaborative
approach to address the needs of women with opioid use disorders, and infants with prenatal
substance exposure can use this document to help take actionable steps grounded in research
and best practices that suit the needs and realities of their unique community. SAMHSA’s Clinical Guide for treating pregnant
and parenting women with opioid use disorders and their infants provides a research base
for decision making, as well as real world scenarios to help clinical team members identify
how best to support pregnant and parenting women with opioid use disorders and their
infants as they come in contact the healthcare and substance use treatments systems. Systems partners can use this guide to determine
what policies, protocols, and practices will support the most optimal health, recovery,
and well being outcomes for women and their infants. Plans of safe care have been required for
infants affected by substance abuse since 2003. Recent legislative changes implemented, in
part, due to the opioid epidemic, have expanded their coverage and scope. The comprehensive collaborative approach that
has been identified as a best practice by Children’s Bureau for plans of safe care aligns
closely with the collaborative family centered approach recommended by experts in their research
literature and sites around the country based on their practice based wisdom. This document, “A Planning Guide Steps to
Support a Comprehensive Approach to Plans of Safe Care,” can support jurisdictions and
communities who are working to meet the health, safety, permanency, and well being needs of
infants with prenatal substance exposure and their parents with substance use disorders. This tool is intended to lay out elements
important to a comprehensive approach to plans of safe care and development of collaborative
systems to support their implementation. National Center staff look forward to engaging
system partners from prenatal care, hospital systems, substance use treatment, child welfare,
pediatric and postpartum healthcare, early childhood services, home visiting, and others
on implementation of the elements laid out in this planning guide. In addition to webinars and publications to
support the field, the National Center provides In Depth Technical Assistance to select states. This In Depth Technical Assistance supports
communities in identifying their unique needs, developing strategic plans to address those
needs, and utilizing the tools and resources of the National Center to implement activities
to reach their goals. Through these in depth engagements with states,
the National Center develops a greater understanding of how communities are able to translate these
tools into action. We’re going to hear from Jill Gresham, a senior
program associate for the National Center on Substance Abuse and Child Welfare, and
consultant liaison for the In Depth Technical Assistance Initiative about the wealth of
practice based wisdom gained from these state engagements. Jill Gresham: The National Center historically
provided In Depth Technical Assistance, or IDTA, to states, tribes, or large jurisdictions
to support collaboration between substance use disorder providers, child welfare, and
the courts. In 2014, the National Center on Substance
Abuse and Child Welfare launched the In depth Technical Systems Program specifically to
address infants with prenatal substance exposure, and the recovery of pregnant and parenting
women and their families. A number of lessons and tools have been developed
through the work of these states involved in IDTA that can support your community’s
work with families affected by opioid use disorders and prenatal substance exposure. IDTA is an 18 to 24 month program. It’s really focused on strengthening collaboration
between child welfare, substance abuse disorder treatments, and the courts. When IDTA began focusing on infants with prenatal
substance exposure, we also started working on collaboration with maternal and infant
healthcare providers, early care and education systems, home visiting, and other key partners. After the passage of the Comprehensive Addiction
and Recovery Act of 2016, which amended sections of the Child Abuse Prevention and Treatment
Act or CAPTA, IDTA really shifted focus and began supporting states to develop policies
and protocols that worked to align their local statures and policies with the changes that
were happening at the federal level to CAPTA. You can see on the screen now which states
have received IDTA. There were 11 total states divided into three
different cohorts. The first cohort is up there in blue, and
included Connecticut, Kentucky, Minnesota, New Jersey, Virginia, and West Virginia. The second cohort included Delaware and New
York, you can see them in red, and then finally, in green, the third cohort, Florida, Maryland,
North Carolina, and West Virginia. It’s worth noting that in 2017, The National
Center hosted a policy academy to support states with CAPTA implementation. Most of the third round states attended the
policy academy and requested on going support to continue addressing implementation challenges
specific to Plan of Safe Care and CAPTA. The IDTA program has yielded valuable lessons
to resolving challenges. Key factors for success include leadership,
engagement of critical partners, cross system collaboration, and data collection, reporting,
and integration. We’re going to go and take a closer look at
each of these. All states engaged in IDTA identified a lead
agency and a liaison to support the work of the core team. At times, there were co liaisons representing
different agencies that really modeled cross system leadership. In addition to a lead agency and a liaison,
each state established a governance structure which included an oversight committee with
state level directors, commissioners, and secretaries. Then, below that oversight committee was a
core team that really implemented the work, which included critical partners from various
systems who could advance policy and practice changes. Families of infants with prenatal exposure
touch many systems across time. From OB GYNs during the prenatal period of
time, through birthing centers and hospitals, substance use disorder treatment, and then
early intervention and educational systems after birth. Because of its really broad reach, oversight
of responses requires individuals who not only understand cross system challenges but
who can also build cross system partnerships and also maintain momentum. State teams also need to think about how to
institutionalize their structure so that it will survive beyond staffing changes. Many teams chose to connect their core team
to a larger statewide body, like an opioid workgroup or governor’s council addressing
substance use disorders. This allowed them to integrate their work
with broader state initiatives addressing substance use. It also supported the institutionalization
of their workgroup beyond the IDTA period. As I discussed earlier, families of infants
with prenatal exposure touch many different systems. Ideally, responses are also going to look
upstream to that prenatal period of time to include OB GYNs and progress all the way to
the birth event and into childhood. Because of these many different partners,
it really requires teams to come together and think about all those different systems
that that family might touch to be able to engage those folks to be a part of the team
that’s making decisions about changing practice. That could include Child Welfare, substance
use disorder treatment on the courts. It’s also likely going to include primary
healthcare, OB GYNs, Public Health, pediatricians, home visiting and early intervention. Many state teams also found Medicaid to be
a really valuable partner, especially when we began discussions around universal use
of screening and toxicology during prenatal periods of time, as well as the birth event. As teams come together across disciplines,
their first step is to understand what is actually occurring in their systems. Many states we worked with admitted to being
just in the dark about what was currently going on in terms of working with pregnant
women with substance use disorders. Some questions that they had was who was being
screened during prenatal care, and who wasn’t, and what drove those decisions, as well as,
what was happening in terms of testing at the birth event, and again, what drove those
decisions by healthcare providers. There was also a lot of question about information
sharing that was happening between MAT providers or other substance use disorder treatment
providers and OB GYNs. Teams had to spend some work together to understand
what current practice currently was. Then, they needed to come together and agree
on what their mission and values were before they themselves began engaging in practice
change. Teams really needed to develop a shared understanding
and values around substance use during pregnancy, around the role of the Child Welfare and Plan
of Safe Care implementation, around the use of MAT and other very nuanced issues. These shared values will guide decision making
about practice and policy changes as the teams move toward implementation. Each jurisdiction will have different data
needs based on their proposed goals and current data access. Based on those needs, states can identify
barriers to accessing needed data and what their plans are to be able to deal with those
barriers. States need to sit down and think about what
they’re hoping to accomplish and how they can develop a data baseline. Many states are also wrestling with how to
capture the new data requirements that are specific to CAPTA. Mainly the number of infants who were born
prenatally exposed to substances, the number who received a Plan of Safe Care, and the
number of those Plans of Safe Care that included referrals for that infant or the caregiver. Part of that core team’s mission as they get
together is to negotiate a data dashboard of priority indicators. Core team members need to ask themselves,
“What is going to measure our progress?” and “What is going to measure our success?” and
“How can we capture that data?” We’re going to talk a little bit now about
the specific tools that were developed by states during IDTA to support their communities
to develop responses to infants with prenatal substance exposure. You can see the tools were categorized in
these four different buckets. First, to help states to understand what was
currently going on in their systems. As I said earlier, there were a lot of questions
about what was currently happening in systems. Questions around hospital practices, around
practices for substance use disorder treatment. Several of the states we worked with developed
tools to develop a baseline understanding of current practices with pregnant women,
as well as infants with prenatal substance exposure. As states started to delve into their systems,
one of the things they figured out was that there seemed to be a knowledge gap or a knowledge
barrier. We saw lots of states develop tools to support
education across systems. Third, we saw states start to develop tools
to address variability and inconsistency in practices, particularly around implementation
of the Plan of Safe Care and CAPTA requirements. Then finally, as we discuss the need for a
data dashboard, we’ll look at some states who had success in developing some good data
dashboards and methods for monitoring shared outcomes. Know your system. Just about every state that we worked with
in IDTA developed some level of hospital survey. Lots of questions about hospital practices
in the identification of pregnant women with substance use disorders. Then, the identification of infants who had
been born prenatally exposed to substances. You can see two good examples on the screen
right now from the Connecticut Hospital Association, then also from the state of New Jersey. Both of these states did some work to survey
hospitals and again ask about, not only what was happening in terms of identification of
pregnant women and identification of infants, but also questions about the treatment of
neonatal abstinence syndrome. Those second two surveys are out of the state
of Virginia. Virginia did not survey hospitals for a variety
of different reasons, instead, surveyed both their opioid treatment providers and their
community service boards. In Virginia, community service boards oversee
publicly funded substance use disorder treatment. They also provide quite a bit of substance
use disorder treatment as well. Virginia was really surveying these providers
to get a sense of their capacity for working with pregnant women with substance use disorders
and working with mothers of new infants who had been born prenatally exposed. Virginia asked several questions on the surveys
to get a sense of how these providers were working with OB GYNs in their community, as
well as with hospitals after the birth of the infant. While they didn’t directly survey the hospitals,
they really did get a sense of how these hospitals were working with their partners in the community
through the survey with the substance use disorder treatment providers. Again, once states had this sense of what
was going on at the system level, there did seem to be some issues around knowledge gaps,
and really specifically, knowledge gaps that were cross system in nature. You can see three examples up there of work
that states did to be able to address some of this knowledge gaps. In Connecticut, the Connecticut Certification
Board in partnership with the Connecticut Women’s Consortium developed a training for
child welfare workers. It was called the ABCs of MAT, MAT being Medication
Assisted Treatment. The training was for child welfare workers
throughout the state. They are currently being trained to better
understand both opioid use disorders and the importance of medication assisted treatment. Secondly, you see in Minnesota an online resource
guide was developed, which provided information about programs and services for American Indian
pregnant women with substance use disorders, both in the metro area, and then in each individual
tribal community. Then third, from Virginia, the department
of social services developed a brochure as a guide for hospital and healthcare providers
on the state’s legal requirements and healthcare practice implications for working specifically
with infants. Virginia has several laws on the books that
actually predated CAPTA. They require referrals of the mother to substance
use disorder treatment when an infant is born with prenatal exposure. This brochure offers further clarification
and support to healthcare providers. This brochure was developed prior to the changes
in CAPTA. After those changes in CAPTA, the brochure
was actually updated to reflect more information about the Plan of Safe Care. Through the use of surveys and ongoing state
team discussions, states began to uncover lots of variability and inconsistency in practices. In order to address this, they started to
develop some standardized protocols as part of their work toward implementation of the
Plan of Safe Care and addressing CAPTA. Both Kentucky and Virginia developed really
nice plans of safe care toolkits to support counties as they work on implementation of
a Plan of Safe Care itself. The toolkits included Plan of Safe Care templates. They also included discharge summaries and
a really nice flowchart that showed providers what happened from that birth event and the
identification of that infant, all the way through the notification process to Child
Welfare, and finally, through the implementation of Plan of Safe Care itself. Kentucky also included a discharge assessment
that did support hospitals to maybe assess some risk in terms of what they were going
to be reporting to child welfare, any concerns that might have been covered up otherwise. Both Kentucky and Virginia are working on
sending out these pilot packages to support counties as they work towards implementation. Then finally, monitoring shared outcomes. There’s lots of different examples of data
dashboards that have been developed in communities across the country. There’s three up there right now. Delaware’s data dashboard is held within their
Child Protection Accountability Commission, or CPAC. CPAC has a broad group of stakeholders Child
Welfare, of course, Public Health, education, legal, courts are there as well as law enforcement. They have been collecting data on, largely,
child welfare and also education outcomes. As they started work on their In Depth Technical
Assistance, they also started to include data that was specific to infants who were born
prenatally exposed, and then the number of Plans of Safe Care that had been implemented. Massachusetts has the Neonatal Quality Improvement
Collaborative, or NEOQIC. NEOQIC partnered with the Massachusetts Perinatal
Quality Collaborative on an initiative to support state wide quality improvement, which
was focused very much on infants who were experiencing neonatal abstinence syndrome. These hospitals, it was voluntary to sign
on to this. Most of the birthing hospitals in Massachusetts
did sign on. They all agreed through the state of use agreement
to share information about the treatment of NAS, the length of stay, the modality of treatment,
and then other quality assessment measures. Finally, North Carolina has the Plan of Safe
Care Interagency Collaborative, or the POSCIC. They came together to develop and implement
the Plan of Safe Care of North Carolina. Again, it’s a multi systemic team. It has both state and county representation
on it. They meet monthly and they review data from
each of the counties and look at the number of infants who were reported to Child Welfare,
and then, look at the number of the Plans of Safe care that had been developed. Now, ideally, those numbers should match. In the POSCIC, if they see a significant discrepancy
between those numbers, will reach out and work with that county. Offer some kind of technical assistance to
support them to develop some consistency across their reporting measures. Katie: The program summary highlights state
efforts to identify barriers and challenges in engaging families affected by prenatal
substance exposure and develop strategies to improve outcomes for pregnant and postpartum
women with opioid use disorders, and their infants and families. Through their IDTA, states identified crosscutting
lessons of successful collaboration to improve policy and practice. Narrator: Thank you for taking the time today
to learn more about the National Center tools and resources that your community can use
to support families in the Child Welfare system affected by opioids. Please continue to engage with us by regularly
checking our website, www.ncsacw.samhsa.gov, to see new information and tools as they become
available, and by contacting us by email, [email protected], or by phone at 866 493
2758, to discuss the resources, tools and support you need to foster collaborative responses
to improve the safety, permanency, well being and recovery of families in your community.

Daniel Yohans

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