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Mental Health; Substance Abuse; & the Child Protection System. Michael L Haney Ph.D, NCC, CISM, LMHC Forensic and Mental Health Consultant Executive Director The American Professional Society on the Abuse of Children September 8, 2011 www.apsac.org. Objectives.

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Mental Health; Substance Abuse; & the Child Protection System

Michael L Haney Ph.D, NCC, CISM, LMHC

Forensic and Mental Health Consultant

Executive Director

The American Professional Society on the Abuse of Children

September 8, 2011

www.apsac.org


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Objectives System

  • Child Protective Investigators and Law Enforcement investigators are challenged to respond to child maltreatment allegations, which are often complicated when one or more of the child's caretakers has a substance abuse issue or mental disorder, including personality disorders.

    • This presentation provides an overview of the most common types of disorders and offers strategies for responding to the needs of the families

    • Explores the assessment of risk when mental illness or substance use/abuse is present in the home.

    • Participants will be encouraged to participate through media, didactic material and group interaction and scenario discussion.


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Categories System

  • Mood Disorder

  • Psychotic Disorders

  • Personality Disorders

  • Substance Use/Dependence


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Risk Factors System

  • History of mental health problems with an impact on functioning;

  • Unmanaged mental health problems with an impact on functioning;

  • Maladaptive coping strategies:

  • Misuse of drugs, alcohol, or medication;

  • Severe eating disorders;

  • Self-harm and suicidal behavior;

  • Lack of insight into illness and impact on child;

  • Non-compliance with treatment;

  • Poor engagement with services;


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Risk Factors System

  • Previous or current compulsory admissions to mental health hospital;

  • Disorder deemed long term ‘untreatable’, or untreatable within timescales compatible with child’s best interests;

  • Mental health problems combined with domestic abuse and/or relationship difficulties;

  • Mental health problems combined with isolation and/or poor support networks;

  • Mental health problems combined with criminal offending (forensic);

  • Non-identification of the illness by professionals (e.g. untreated post-natal depression can lead to significant attachment problems);

  • Previous referrals to Social Services/Child Protection


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Risk Factors System

Some of the key findings in one review of 161 cases (47 in-depth case studies) revealed:

  • domestic violence was present in 66% of cases

  • substance misuse was present in 57% of cases

  • mental ill health was present in 55% of cases

  • All three issues were present in 34% of cases.


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Risk Factors System

  • serious neglect of the child and/or impairment to the point of not caring for the child

  • any history of domestic violence

  • A history of issues with regard to safeguarding adults

  • Any history of substance misuse by parent(s), visiting family members, friends, or other caregivers

  • Any history of significant personality disorder in a parent/caregiver.


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Risk Factors System

  • Hx or current psychotic beliefs, particularly if involving the child

  • persistent negative views expressed about a child, including rejection

  • ongoing emotional unavailability, unresponsiveness and neglect, including lack of praise and encouragement, lack of comfort and love and lack of age-appropriate stimulation

  • inability to recognize a child’s needs and to maintain appropriate parent-child boundaries


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Risk Factors System

  • ongoing use of a child to meet a parent’s own needs

  • distorted, confusing or misleading communications with a child including involvement of the child in the parent’s symptoms or abnormal thinking. (i.e., delusions targeting the child, incorporation into a parent’s obsessive cleaning/contamination rituals, or a child kept at home due to excessive parental anxiety or agoraphobia

  • ongoing hostility, irritability and criticism of the child or adolescent, inconsistent and/or inappropriate expectations of child


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Crossing Bridges SystemThe Family Model

4 Stressors & vulnerabilities

1

Adult

mental

health

2

Child dev

& mental

health

3

Parental &

fam relationships

4 Strengths, resilience & resources


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Types of disorders - Children System

  • Mood Disorders

    • Depression

    • Dysthymia

    • Bi-Polar Disorder

    • Bi-Polar Disorders – manic; depressed; mixed; NOS

    • Oppositional Defiant

      Developmental

    • Autism Spectrum Disorders

    • Developmental Delays

    • ADHD

      Substance Abuse/Dependence

    • Poly Substance Use/Dependence

    • Alcohol Abuse/Dependence

    • Marijuana Abuse/Dependence

  • Conduct Disorder (Personality Disorder < 18)

  • Post Traumatic Stress Disorder


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Types of Disorder – Adults System

  • Mood Disorders:

    • Major Depression w/or wo S/H ideation

    • Bi-Polar Disorders 1 & 2

    • Cyclothymia

    • Adjustment Disorders

      • Anxiety

      • Depressed Mood

      • Mixed

      • Emotion & Conduct

      • Unspecified


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Substance Use/Abuse/Dependence System

  • Poly Substance Use/dependence

  • Alcohol Abuse/Dependence

  • Marijuana Abuse/Dependence

  • Other drugs, etc


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Psychotic Disorders: System

  • Schizophrenia – various types

  • Paranoid

  • Disorganized

  • Catatonic

  • Undifferentiated

  • NOS


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Personality Disorders System

  • Borderline

  • Histrionic

  • Paranoid

  • Anti Social

  • Narcissistic

  • Avoidant

  • Dependent

  • Obsessive-Compulsive

  • NOS


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PTSD System

  • Frequently having upsetting thoughts or memories about a traumatic event.

  • Having recurrent nightmares.

  • Acting or feeling as though the traumatic event were happening again, sometimes called a "flashback."

  • Having strong feelings of distress when reminded of the traumatic event.

  • Being physically responsive, such as experiencing a surge in your heart rate or sweating, to reminders of the traumatic event.

  • Thoughts or actions – self-harm, cutting, burning, etc.


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Avoidance Symptoms System

  • Making an effort to avoidthoughts, feelings, or conversations about the traumatic event.

  • Making an effort to avoid places or people that remind you of the traumatic event.

  • Having a difficult time remembering important parts of the traumatic event.

  • A loss of interest in important, once positive, activities.

  • Feeling distant from others.

  • Experiencing difficultieshavingpositivefeelings, such as happiness or love.


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Personality Disorders System

  • Borderline –

    • characterized by a lack of ones own identity

    • with rapid changes in mood,

    • intense unstable interpersonal relationships, 

    • marked impulsively, 

    • instability in affect, 

    • and instability in self image.

  • ONSET:  Early adulthood and with a variety of contexts.


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Personality Disorders System

  • AntiSocial:

  • Antisocial personality disorder is characterized by a lack of regard for the moral or legal standards in the local culture. 

  • There is a marked inability to get along with others or abide by societal rules. 

  • Individuals with this disorder are sometimes called psychopaths or sociopaths.

  • Since the age of fifteen there has been a disregard for and violation of the right's of others, those right's considered normal by the local culture,  as indicated by at least three of the following:

    • Repeated acts that could lead to arrest.

    • Conning for pleasure or profit,  repeated lying,  or the use of aliases.

    • Failure to plan ahead or being impulsive.


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Personality Disorders System

  • Histrionic Personality Disorder is primarily characterized by:

    • exaggerated displays of emotional reactions, approaching theatricality, in everyday behavior. 

    • Emotions are expressed with extreme and often inappropriate exaggeration. 

    • Persons with this disorder are prone to sudden and rapidly shifting emotion expressions.

  • ONSET:  Early adulthood and with a variety of contexts.


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Depressions - System

  • Depression comes in different forms and affects many people differently. Some common signs include:

  • A sense of being "blue" or sad.

  • Wanting to be along

  • Persistent irritability

  • Difficulty and even avoiding making decisions

  • Difficultysleeping or excessive sleeping (not wanting to get out of bed)

  • Changes in appetite, either increased or decreased food intake.

  • Decreased libido

  • Anhedonia (inability to enjoy doing the things that are normally enjoyable

  • Length of course

  • Suicidal/Homicidal ideations


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So what do we do? System

  • CPS and mental health professionals must identify clients who are pregnant and those who are parents or who have regular access to children, whether they reside with children or not.

  • Professionals should consider the needs of all children as part of their assessments with CPS.

  • When adult mental health services and children’s services are both involved with a family, joint assessments should be carried out to assess the support parents need and the risk of harm to the child/ren

  • Coordination and guidance between all service providers, including multi-disciplinary staffings and follow up

  • Where appropriate, children should be given an opportunity to contribute to assessments


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So What Do We Do? System

  • CPS must include ongoing monitoring of the needs and risk factors for the children concerned.

  • Partners should be invited to contribute if they are involved with a family or where risks and needs have been identified that justify their involvement.

  • Mental health professionals must be included in strategy meetings, child protection conferences or associated meetings.

  • Mental health inpatient services should have written policies regarding the welfare of children and particularly the visiting of inpatients by children.

  • Mental health professionals can assist with obtaining necessary consents and releases of information


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What Is the Purpose of a Psychological Evaluation? System

  • Aid the trier of fact – Dependency or Criminal

  • Obtain psychological information in a standardized manner

  • Use norm referenced information

  • Determine mental capacity

  • Help determine psychopathology

  • Make treatment suggestions


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Why Are You Asking For A Psychological Evaluation? System

  • What stage are you in the investigation/evaluation?

  • What kind of information is needed?

  • What are the goals of the evaluation?

  • What are the issues and can testing help?

  • Do the attorneys, Social Services, and Judge have common questions?

  • Do the attorneys, Social Services, and Judge have different questions?

  • What is the Nexus between the event and history?


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Kinds of Evaluations in Abuse and Neglect Cases System

  • Child Medical Evaluations (CPT exams)

  • Child Evaluations

  • Child and Family Evaluations

  • Child Mental Health Assessments

  • Child Forensic Interviews

  • Sex Offender Specific Evaluations (ATSA standards)

  • Adult Mental Health Evaluations

  • Parental Competency Evaluations

  • Substance Abuse Assessments/Evaluations


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Contributing Factors in Poor Parenting System

  • Poor physical health

  • Situational and chronic stress

  • Evaluation stress

  • Ambivalence and uncertainty

  • Lack of parenting knowledge and skills

  • Mental disorder or disability

  • Family systems issues


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Three Types of Parental Competencies System1

1. Capacity to Care

Nurturing, involvement with care givers

2. Capacity to Protect

Supervision, tolerance for frustration

3. Capacity to Change

Intelligence, reactions to treatment

1Haynes, J.P. (2010). Parenting Assessment in Abuse, Neglect, and Permanent Wardship Cases. In Benedek, et al., Principles and practice of child and adolescent forensic mental health. Washington, DC: American Psychiatric Publishing, Inc.


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Psycho-legal Questions about SystemParental Competency

  • Can the parent provide adequate stimulation?

  • Can the parent respond to the child’s physical and emotional needs?

  • Can the parent set appropriate limits and relate in a non-punitive way to the child?

  • Are there specific risk factors related to the parent’s functioning including mental capacity, mental illness, substance abuse, domestic violence?


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Questions About Parenting and SystemChild Reunification

  • Is the parent aware of the emotional factors in a child’s return?

  • Can the parent support the child in negotiating the complex factors involved in reunification?

  • Including stability, bonding, attachment to foster parent, social needs, academic needs


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What Information Is Conveyed With a Mental Health Diagnosis? System

  • Severity of the problem

  • Possibility of remediation

  • Optional kinds of treatment

  • Possibility of deterioration or relapse

  • Impact on functioning both in parenting and in broader context

  • Current level of functioning


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What Information Is Not System Conveyed With a Diagnosis?

  • Rarely explains causes of a given behavior

  • May or may not be related to functioning

    in parenting

  • Functioning may vary across time, despite the diagnosis

  • May be debatable

  • Not always helpful, but sometimes useful


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What Should Be In An Evaluation Report? System

  • Court order and identifying data

  • Sources of information (interviews, tests, records, contacts)

  • Psycho-legal questions

  • Answers to the psycho-legal questions

  • Additional recommendations

  • Interview material

  • Test results

  • Collateral information


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Adult Interview System

  • Social Background

  • Parenting Interview

  • Domestic Violence

  • Substance Abuse

  • Sexual Abuse

  • Cognitive Insights

  • Social appropriateness


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Social Background Topics System

  • Social History

  • Educational History

  • Relationship History

  • Mental Health History

  • Medical History

  • Legal History

  • Child Protective Services History


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Parenting Interview System

  • Child’s development

  • Perceived needs of the child

  • Knowledge of medical needs

  • Knowledge of educational needs

  • Basic nutritional knowledge

  • Need for child’s protection

  • Ways protection might take place


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Parenting Interview System(continued)

8. Discipline techniques

9. Perceptions about reunification

10. Reactions to interventions

11. Attainment of new skills


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Special Topic Interviews System2

  • Substance Abuse Assessment

  • Domestic Violence

  • Physical Abuse

  • Sexual Abuse

  • Mental Health Assessment

    • Medication

    • Hospitalizations

    • Investment in treatment

2Sattler, J.M. (1998). Clinical and forensic interviewing of children and families: Guidelines for the mental health, education, pediatric, and child maltreatment fields. San Diego, Jerome M. Sattler, Publisher, Inc.


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Tertiary Prevention: SystemTreatment and Referral

  • Professionals need to know what they can handle through office counseling and when they need to refer families for help.

  • They must also be cognizant of the resources available in their community to address these risks.

  • This requires knowledge of the child welfare, emergency shelter and substance abuse treatment systems and how to make referrals to appropriate therapists and mental health professionals and ensure follow up.

  • CPS must be educated consumers of mental health services


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Social and Systems Change: SystemKeeping Up to Date With the Field

  • Professionals can be more effective advocates for systems change if they are knowledgeable about current prevention strategies.

  • In CPS practice, professionals can identify prevention opportunities within the population of families and children who come to their system but who are unsubstantiated or do not require that the children be taken into protective custody.

  • Professionals in clinical services and law enforcement can help prevention professionals and volunteers by recognizing the importance of their prevention work and participating in multidisciplinary training, thereby assisting in networking alliances between prevention and treatment fields.


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Intellectual capacity as measured by IQ System

Direct measure of client performance

Influenced by education

Influenced by emotional factors

Does not measure parenting abilities

Adaptive functioning

Reflects functioning in real world

Assess: responsibility, coping

Allows for comparative observations by others

No more time consuming than IQ

Used in conjunction

with IQ tests

Two Aspects of Mental Capacity


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Parent-Child Interaction System

  • Where?

  • When?

  • How?

  • Documentation?

  • Social compliance!

  • Team approach to case planning!

  • Education and transference of learning!


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The Effects of CAN - System

  • Physical Health Consequences - The immediate physical effects of abuse or neglect can be relatively minor (bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some cases the physical effects are temporary; however, the pain and suffering they cause a child should not be discounted. Meanwhile, the long-term impact of child abuse and neglect on physical health is just beginning to be explored. (ACE Study)

  • According to the National Survey of Child and Adolescent Well-Being (NSCAW), more than one-quarter of children who had been in foster care for longer than 12 months had some lasting or recurring health problem (Administration for Children and Families, Office of Planning, Research, and Evaluation [ACF/OPRE], 2004a).


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The Effects of CAN System

  • Poor physical health. Several studies have shown a relationship between various forms of household dysfunction (including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, & Carnes, 2007).


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The Effects of CAN System

  • Impaired brain development. Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (De Bellis & Thomas, 2003). These alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006)

  • NSCAW found more than three-quarters of foster children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed to less than half of children in a control sample (ACF/OPRE, 2004a).


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The Effects of CAN System

  • Behavioral Consequences

  • Not all victims of child abuse and neglect will experience behavioral consequences. However, behavioral problems appear to be more likely among this group, even at a young age. An NSCAW survey of children ages 3 to 5 in foster care found these children displayed clinical or borderline levels of behavioral problems at a rate of more than twice that of the general population (ACF, 2004b). Later in life, child abuse and neglect appear to make the following more likely:

  • Difficulties during adolescence. Studies have found abused and neglected children to be at least 25 percent more likely to experience problems such as delinquency, teen pregnancy, low academic achievement, drug use, and mental health problems (Kelley, Thornberry, & Smith, 1997). Other studies suggest that abused or neglected children are more likely to engage in sexual risk-taking as they reach adolescence, thereby increasing their chances of contracting a sexually transmitted disease (Johnson, Rew, & Sternglanz, 2006).


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The Effects of CAN System

  • Poor mental and emotional health. In one long-term study, as many as 80 percent of young adults who had been abused met the diagnostic criteria for at least one psychiatric disorder at age 21.

  • These young adults exhibited many problems, including depression, anxiety, eating disorders, and suicide attempts (Silverman, Reinherz, & Giaconia, 1996).

  • Other psychological and emotional conditions associated with abuse and neglect include panic disorder, dissociative disorders, attention-deficit/hyperactivity disorder, depression, anger, posttraumatic stress disorder, and reactive attachment disorder (Teicher, 2000; De Bellis & Thomas, 2003; Springer, Sheridan, Kuo, & Carnes, 2007).


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The Effects of CAN System

  • Juvenile delinquency and adult criminality. According to a National Institute of Justice study, abused and neglected children were 11 times more likely to be arrested for criminal behavior as a juvenile, 2.7 times more likely to be arrested for violent and criminal behavior as an adult, and 3.1 times more likely to be arrested for one of many forms of violent crime (juvenile or adult) (English, Widom, & Brandford, 2004).

  • Alcohol and other drug abuse. Research consistently reflects an increased likelihood that abused and neglected children will smoke cigarettes, abuse alcohol, or take illicit drugs during their lifetime (Dube et al., 2001). According to a report from the National Institute on Drug Abuse, as many as two-thirds of people in drug treatment programs reported being abused as children (Swan, 1998).


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The Effects of CAN System

  • Abusive behavior. Abusive parents often have experienced abuse during their own childhoods. It is estimated approximately one-third of abused and neglected children will eventually victimize their own children (Prevent Child Abuse New York, 2003).

  • Societal Consequences - While child abuse and neglect almost always occur within the family, the impact does not end there. Society as a whole pays a price for child abuse and neglect, in terms of both direct and indirect costs.


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The Effects of CAN System

  • Psychological Consequences The immediate emotional effects of abuse and neglect—isolation, fear, and an inability to trust—can translate into lifelong consequences, including low self-esteem, depression, and relationship difficulties. Researchers have identified links between child abuse and neglect and the following:

  • Difficulties during infancy. Depression and withdrawal symptoms were common among children as young as 3 who experienced emotional, physical, or environmental neglect. (Dubowitz, Papas, Black, & Starr, 2002).


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The Effects of CAN System

  • Cognitive difficulties. NSCAW found that children placed in out-of-home care due to abuse or neglect tended to score lower than the general population on measures of cognitive capacity, language development, and academic achievement (U.S. Department of Health and Human Services, 2003). A 1999 LONGSCAN study also found a relationship between substantiated child maltreatment and poor academic performance and classroom functioning for school-age children (Zolotor, Kotch, Dufort, Winsor, & Catellier, 1999).

  • Social difficulties. Children who experience rejection or neglect are more likely to develop antisocial traits as they grow up. Parental neglect is also associated with borderline personality disorders and violent behavior (Schore, 2003).


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The Effects of CAN System

  • Direct costs. Direct costs include those associated with maintaining a child welfare system to investigate and respond to allegations of child abuse and neglect, as well as expenditures by the judicial, law enforcement, health, and mental health systems. A 2006 report by Prevent Child Abuse America estimates these costs at $33 billion per year.

  • Indirect costs. Indirect costs represent the long-term economic consequences of child abuse and neglect. These include costs associated with juvenile and adult criminal activity, mental illness, substance abuse, and domestic violence. They can also include loss of productivity due to unemployment and underemployment, the cost of special education services, and increased use of the health care system. Prevent Child Abuse America estimated these costs at more than $70 billion per year (PCA, 2006)


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General Considerations System

1. Know your community and providers

2. Be culturally appropriate

3. Design strategies that you can actually implement

4. Stay informed of research and best practices

5. Adapt your approaches/programs to emerging issues, trends, and the contemporary society

6. Utilize evidence-based practices

7. Evaluate programs in an ongoing way


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Recommendations System

  • Mental Health and Substance Abuse training for CPI’s; Caseworkers; Law Enforcement

  • Required multi-disciplinary staffing when mental health or substance abuse are issues

  • Child Welfare Legal involvement

  • Training for Dependency Judges

  • A consistent Team response to the unique needs of children with parents who have substance use or mental health issues

  • Utilize evidence-based approaches with families – i.e., PCIT or search California Evidence Based Website

  • Adequate funding for specialized professionals who investigate, treat, or evaluate abused children


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The trouble with the world is not that people know too little, but that they know so many things that ain't so!

Mark Twain


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A Few Resources little, but that they know so many things that ain't so!

  • www.streetdrugs.org

  • www.aap.org

  • www.apa.org

  • www.samhsa.gov

  • www.drugabuse.gov

  • www.nida.nih.gov

  • www.nimh.nih.gov

  • ww.nationalsubstanceabuseindex.org

  • www.nami.org

  • www.cebc4cw.org/


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Questions? little, but that they know so many things that ain't so!


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