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Family-Based Recovery: Home-based Treatment for Families Affected by Parental Substance Abuse. Managing Risk in the Best Interest of the Child. Presentation Collaborators. Yale Child Study Center Jean Adnopoz , M.P.H. Karen E. Hanson, L.C.S.W. Dale Saul, Ph.D.

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family based recovery home based treatment for families affected by parental substance abuse

Family-Based Recovery:Home-based Treatment for Families Affected by Parental Substance Abuse

Managing Risk in the Best Interest of the Child

presentation collaborators
Presentation Collaborators

Yale Child Study Center

Jean Adnopoz, M.P.H.

Karen E. Hanson, L.C.S.W.

Dale Saul, Ph.D.

Jeffrey J. Vanderploeg, Ph.D.

The State of Connecticut

Department of Children

And Families

Peter Panzarella, M.A.

connecticut
Connecticut
  • Population - 3,409,549
    • Approximately 750,000 under age 18
  • No County Government (169 Town Governments)
  • CT Department of Children and Families is a consolidated Children’s Agency with mandates:
    • Child Welfare
    • Children’s Behavioral Health
    • Juvenile Justice
    • Prevention
connecticut department of children and families
Connecticut Department of Children and Families
  • DCF serves at any point in time 36,000 children and 16,000 families across mandates
  • DCF with Department of Social Services (Medicaid) carved out Behavioral Health and manage the Connecticut Behavioral Health Partnership
  • DCF Behavioral Health develops and implements policy, programs and services in the community
  • DCF has developed a broad array of intensive in-home behavioral health services
drug use in connecticut
Drug Use in Connecticut
  • In Connecticut during 2005-2006 (average), 9.2% of men and women ages 12 and older reported using illicit drugs in the past month, compared to 8.2% overall in the U.S. 
  • In Connecticut in 2008, a study of women of childbearing age (18-44 years) revealed that:
    • 18.7% of women of reported smoking, compared to 20.0% of women overall in the U.S.
    • 16.0% of women reported binge drinking in the past month, compared to 14.8% overall in the U.S.

Source: Peristats March of Dimes

family based recovery history
Family-Based Recovery: History
  • Stages of Community Readiness
    • No Awareness
    • Denial
    • Vague Awareness
    • Preplanning
    • Preparation
    • Initiation
    • Stabilization

(From: National Implementation Research Network) http://www.fpg.unc.edu/~nirn/resources/publications/Monograph/index.cfm

family based recovery community readiness
Family-Based Recovery:Community Readiness
  • 2005 Conference and Report (Funded by AIA/DCF)
  • Disseminated the latest research on substance-exposed infants and their families in a report Attachment & Recovery: Caring for Substance Affected Families

http://aia.berkeley.edu/media/pdf/attachment_recovery.pdf

  • Explore systems collaboration strategies and participate in the development of regional collaborative networks to best serve the needs of Connecticut families
family based recovery recommendations 2005
Family-Based Recovery Recommendations 2005
  • Comprehensive community based care for child and family
  • Importance of attachment theory in service design
  • Co-occurring problems and housing needs
  • Implement best practices
family based recovery 2006
Family-Based Recovery 2006
  • Re-design of DCF funded Substance Abusing Parents/ Children at RISK programs combined funding with In-Home Behavioral Health
  • DCF, Yale Child Study Center and Johns Hopkins University collaborated on model development
  • Infrastructure developed for the needed Quality Assurance and Consultation (Family-Based Recovery Services)
  • Request for Proposal was released in 2006 for five service providers
family based recovery
Family-Based Recovery
  • DCF contracted with 6 providers
  • Yale Child Study Center – provides QA
  • DCF developed a MOA with the University CT Health Center on independent evaluation
    • Qualitative Analysis of FBR Implementation
    • Quantitative Analysis of (Matched Group Design)
fbr opportunity
FBR: Opportunity

Family-Based Recovery (FBR) integrates two treatment modalities to focus on attachment, parenting, substance abuse recovery and psychotherapy.

Coordinated Intervention for Women and Infants (CIWI), an attachment-based parent-child therapeutic approach (Yale Child Study Center)

Reinforcement-Based Treatment (RBT), a contingency management substance abuse treatment model (John Hopkins University)

fbr mission
FBR Mission

The mission of FBR is

1) to ensure that children develop optimally in drug-free, safe and stable homes with their parent/s

2) to develop a replicable, evidence-based practice model

fbr key constructs
FBR Key Constructs
  • Attachment critical for healthy development
  • Substance abuse treatment works
  • Risk management for stability and permanence
fbr key constructs1
FBR Key Constructs

FBR draws on the wish of most adults to be recognized as competent to engage them in substance abuse recovery and promote adequate parenting behaviors

the fbr way
The FBR Way

FBR is more than a treatment for parents who are using substances: it is a way of engaging, treating and being with a client and his/her children. The FBR approach incorporates good clinical skills, motivational interviewing techniques with lessons learned about home-based work.

the fbr way1
The FBR Way

Once the risk for relapse and child neglect/abuse decreases, the work expands to address other client-identified goals. The FBR team supports and encourages the client’s efforts towards change in all aspects of their life: education, relationships, parenting. There are no limits to success for FBR clients.

the abc s of fbr
The ABC’s of FBR
  • Acceptance
  • Building Trust
  • Commitment to Engagement
acceptance
Acceptance
  • Staff need to accept clients where they are in order to promote change and allow clients to determine their own goals
  • Staff will be exposed to family systems and environments that might differ from their own experiences and values
    • Differences can cause discomfort
    • Individuals vary in their ability to conduct in-home work
building trust
Building Trust

Trust is an essential element of effective intervention: building trust requires a commitment to the process of engagement and a willingness to endure testing, rejection, frustration and hostility

commitment to engagement
Commitment to Engagement

Key values are:

  • Respect
  • Patience
  • Persistence
  • Willingness to allow families to lead the intervention
  • Early success offering concrete service can enhance initial engagement
putting it together

Putting it together

CIWI

RBT

FBR

DCF

the fbr team
The FBR Team

FBR Teams is composed of:

  • 2 Full-Time Master’s level clinicians
    • 1 Clinician provides parent-child related interventions to six families
    • 1 Clinician provides sobriety-related interventions to six families
  • 1 Full-Time Bachelor’s level Family Support Specialist
  • A Half-Time Supervisor
  • A Part-Time Psychiatrist
fbr clients
FBR Clients
  • A parent who is actively abusing substances and/or has a recent history of substance abuse (w/in 30 days)
  • A child who is:
      • under the age of 24 months
      • resides with the index parent at the time of referral, or
      • in foster care with a plan for imminent reunification
complex families
Complex Families
  • FBR families:
    • Often come to parenting with legacy of childhood emotional neglect and abuse, loss, abandonment
    • Problematic relationships in adulthood
    • Emotion regulation more challenging with neglect/abuse hx, and for those modulating emotion with substance use
emotion regulation
Emotion Regulation
  • Parenting that requires emotion regulation can easily overwhelm/be a source of disconnection
  • Goal: “Overriding” first response of anger or hopelessness, and reflecting on what is going on with this child at this moment
  • FBR listens, observes, reflects with parents, contains the moment
infant mental health and attachment
Infant Mental Health and Attachment
  • Infant Mental Health: the developing capacity of the very young child to experience, regulate and express emotion; form close, secure interpersonal relationships; explore and learn—all in the context of family, community and cultural expectations
attachment
Attachment
  • Attachment theorist Bowlby stated that for infants to survive,
    • They must behave in ways that help keep parents close and communicate in ways that get parents to respond
    • Their parents must be able to understand them
attachment1
Attachment
  • A young child’s relationship with the primary caregiver is key to healthy development in socio-emotional, cognitive and health domains
  • Parents’ perceptions of being parented affects how they parent and how they see their child
attachment based work
Attachment-based Work
  • Fosters change in maladaptive attachment relationships
  • Targets Internal Working Model of the relationship for both parent and child
infant mental health approach
Infant Mental Health Approach
  • FBR uses an Infant Mental Health approach:
    • Encourages parent to identify and explore feelings re parenting
    • Focuses on the infant’s feelings: “speaking for the baby”
    • Focuses parent on the needs of the child
    • Links past with current caregiving experiences
infant mental health approach1
Infant Mental Health Approach

Not parent education:

FBR uses everyday moments—feeding, bathing, reciprocal play, singing, talking, touch-- to help parents make connections between feelings, action, and consequences of acting on feelings in the parent-child relationship.

What behaviors frighten the parent or child, what brings them close?

competent parents competent babies
Competent Parents, Competent Babies
  • We use the opportunity of a baby to help parents resolve issues with early caregivers (“Ghosts in the Nursery”) that are interfering with the capacity to parent and establish secure attachments
  • Our task: to help parents feel competent and be a “secure base” from which their children can explore the world; for babies to feel understood and safe in their parents’ care
reflective functioning
Reflective Functioning
  • RF: seeing from the child’s perspective, or being able to make sense of the child’s behavior, emotion, feelings
  • FBR uses natural parent-child interaction as opportunity for intervention: moment of anticipating/understanding a need; moment of shared delight or when parent can soothe child; staying present with child despite stress
reflective functioning1
Reflective Functioning
  • Techniques to enhance RF:
    • Helping parent identify what emotions are baby’s and what are parent’s
    • Helping parent see baby as separate being, developing with age-appropriate behaviors and needs
    • Helping parent feel her/his unique importance to this child
parent child measures
Parent-Child Measures
  • Measures that inform and guide the parent-child work are:
    • Parent Stress Inventory –Short Form
    • Edinburgh Postnatal Depression Scale
    • Postpartum Bonding Questionnaire
    • Genogram
    • Ages and Stages (ASQ and ASQ-Social Emotional) Questionnaires
slide39

Reinforcement-based Treatment

  • Reinforcement-based Treatment (RBT) is an evidence-based behavioral approach to substance abuse treatment.
  • RBT incorporates:
    • Community Reinforcement Approach(Budney & Higgins, 1998)
    • Motivational Interviewing(Miller & Rollnick, 1992).
slide40

FBR: Basic Principles

  • Positive reinforcement is the most effective means of producing behavior change.
    • The best way to eliminate an individual’s drug use is to offer competing reinforcersthat can take the place of drug use
    • Competing reinforcers: People, Places and Things that can take the place of drug use
    • FBR believes that the infant/child is the primary positive reinforcer
fbr tools for treating substance abuse
FBR Tools for Treating Substance Abuse
  • Functional Assessments
  • Contracts
  • Graphs
  • Feedback Report
  • Drug Testing/Vouchers
functional assessment
Functional Assessment

The Functional Assessment (FA) is a clinical instrument that structures the gathering of information on a client’s drug use at intake and after each relapse. Information is organized into categories:

  • Internal and external triggers
  • Behavior (route of use, amount)
  • Short-term positive consequences
  • Consequences
slide43

Contracts

Contracts are used throughout treatment

  • Whenever there is a need to emphasize a behavioral goal: “critical time points”
  • Early on in treatment as an agreement to “sample” abstinence
    • Sobriety Sampling Contract signed as initial contract at intake
  • Clients might “break the contract” and use, but hope contract will make the individual stop and ponder this choice
graphs
Graphs

A clinical tool that:

  • Makes abstinence and abstinence-related goals salient to the client
  • Helps clients understand the ongoing relationship between substitution behaviors and abstinence
  • Provides a concrete way for the clinician to reinforce (both socially and tangibly) progress towards goals
  • Helps clinician predict relapses
days clean graph
Days Clean Graph

Isabel’s

PCP

PCP

Isabel

Congratulations to me!

Refused testing

August

feedback report
Feedback Report

Feedback is a technique that has been shown effective in getting clients to think about change.

  • Similar to how patients in the medical setting view results of cholesterol testing, blood pressure
  • Feedback is tailored to the individual and provides specific scientific results that carry weight
social club
Social Club

A weekly group for clients and their children during which the clients:

  • Receive peer and staff acknowledgement (reinforcement) and support for parenting and abstinence
  • Practice interacting with other non-drug using parents in a non-drug environment
  • Provide some continuity after graduation from FBR
social club1
Social Club
  • Whatever the topic or activity, a goal of Social Club is for the conversation to ultimately link to issues of parenting and/or recovery.
  • It is the role of FBR staff to link the group topic/activity to parenting and/or substance use.
  • As the group process evolves and membership stabilizes this time will generally be client-led.
drug testing
Drug Testing
  • The team conducts substance abuse screening (urine and/or breathalyzer) at each home visit
  • An 8-panel urine dip stick yields results in 5 minutes
  • Clients receive a $10 gift card for each clean screen during the first part of treatment
  • Clients can earn up to $720
fbr services
FBR Services
  • FBR Services provides:
    • Weekly 1 hour consultation with each site
    • Weekly ½ hour consultation for each supervisor
    • Quarterly network trainings
    • Quarterly QA reports to sites and DCF
    • Annual credentialing
    • Manual
quality assurance approach and goals
Quality Assurance Approach and Goals

Goals of Quality Assurance:

  • Data collection that is accurate and timely
  • Monitor adherence to clinical services inherent to FBR model (e.g., FBR Tools and Measures)
  • Provide quarterly reports to DCF that describe FBR client population and programmatic adherence measures
    • One network (aggregated) report
    • One report for each site on adherence data
duration of services
Duration of Services
  • Kaplan-Meier survival curve plots estimated LOS based on all available data (open and closed cases)
  • Using this method, the median length of time in the program is 6.2 months
  • Among discharged cases (236), only 7% have been discharged in less than one month after referral
fbr tox screen data
FBR Tox Screen Data
  • Total of 17,298 screens program to date
  • Among the 17,298 screens to date, 77% have been clean, 23% have been positive for one or more substances
    • 71% of positive screens were for marijuana
    • 9% cocaine
    • 9% prescription drugs
    • 9% PCP
    • 6% opiates
    • 3% other
acknowledgements
Acknowledgements

Yale University

Jean Adnopoz

Karen E. Hanson

Christian M. Connell

Dale Saul

Jeffrey J. Vanderploeg

Jeanette Radawich

Amy Myers

Johns Hopkins/U. of Maryland

Michelle Tuten

Cindy Schaeffer

Jennifer Ertel

Dept. of Children & Families

Robert Plant

Peter Panzarella

Francis Gregory

Tere Foley

University of Connecticut

Jo Hawke

Karen Steinberg

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