Download INTERVENTIONS WITH DRUG

Substance Abuse & Child Welfare
Rethinking Assumptions
Steven J. Ondersma, PhD
Departments of Psychiatry & Behavioral Neurosciences
and Obstetrics & Gynecology
Post-Presentation Message
from Dr. Steve Ondersma
It’s come to my attention that some attendees of my talk may have come away feeling that treatment has been proven not
to work. This was not a message I intended to give, so I’m clarifying my intended “take-away” messages here.






Treatment DOES work overall, but has, at best, a moderate positive effect. It is neither a panacea—even for those who
complete it—nor the only way to get from disordered to safe use/abstinence. It IS more than effective enough to be
recommended to persons with substance use disorders.
An overall moderate positive effect means that some persons/studies will show no effect from treatment, some will show
a small to moderate positive effect, and a few will show a very strong positive effect.
Most persons who do move from disordered use to abstinence/safe use do so without treatment. Some, however, seem to
require treatment.
Brief treatment is often as effective as extended treatment (but not in every case).
With respect to parenting interventions, single-focus treatment may be more effective than multi-focal treatment.
Rick Barth’s study suggested that substance abuse treatment was associated with a higher likelihood of future
maltreatment re-reports. These are important and baffling data, but neither he nor I take it to mean that treatment is
contraindicated. It DOES mean that we don’t yet have a complete understanding of how change happens, or what its
effects are. It may also mean that we perhaps should be appropriately humble in our emphasis on the importance of
treatment.
Overview
 Examine the issue of prenatal substance
exposure in light of scientific evidence
 Explore the conflict between the timetables
of child development and substance
dependence, in light of current science
 Explore what the above might mean in terms
of how the courts could/should respond
Oklahoma Infant
Parenting Program (IPP)
 Federally-funded
demonstration project
 Designed around needs of
drug-exposed infants and
their mothers
 Multi-component,
centralized, with emphasis
on barrier reduction
 One year in length
Overview, Part I:
Prenatal Exposure
 How should we respond to this threat?



How others are responding
The latest research on prenatal drug exposure
The risk of prenatal drug exposure compared to
that of other exposures
 Discussion and recommendations
Part I: It’s Not Easy
Threats to Children’s Welfare







Physical abuse
Sexual abuse
Neglect (all types…)
Violence exposure
Poverty
Inadequate schools
Prenatal exposures:
drugs, alcohol,
tobacco, lead,
medicine…
 Poor diet or exercise
 Parental factors often
below the legal threshold



Mental illness, drug or
alcohol abuse
Marital conflict
Excessive/inappropriate TV,
etc.
 Environmental threats
 Accidental injury
Possible Responses
to These Threats
 Education/awareness
campaigns
 School-based
prevention
 Home visitation
(universal, selective,
indicated)
 Mental health and
substance abuse
treatment
 Mentoring programs
 Community programs
 Legislative efforts (e.g.,
sin taxes, welfare,
seatbelt laws)
 Police efforts (e.g.,
alcohol-related
roadblocks)
 CWS (all levels)
 Criminal court
Issues Considered in
Matching Threats to Responses




Relative harm
 Side-effects of the
response
Moral issues
Prevalence of the threat  Cost-benefit ratio (need
to reserve strongest
Likelihood of success
response for cases where
for various options
it is most needed)
 Proportion of at-risk
children reached
A “Perfect” Match:
CPS & Physical Abuse
 Relative harm is high
 Moral outrage is nearly universal
 Affects less than 1% of all children (NIS-III)
 CPS can rapidly increase a given child’s
safety
 A relatively high proportion of affected
children are reached
 Cost and other side-effects are well justified
Another “Perfect” Match:
Smoking & Selective Prevention
 Relative harm is lower, both pre- and postnatally
 Moral concerns are present, but muted
 Prevalence is high: 29.6% of persons 12 and older
smoke cigarettes
 Most affected children and their caregivers can be
reached using public health methods
 The cost and consequences of stronger responses
may not be justified by their added benefit, if any
Is There a Perfect Match for
Prenatal Drug Exposure?
(No)
Part II: Examining Responses
in the United States
Ondersma et al., CAN, 2001
Child Welfare Intake supervisors from:
 Urban Counties:



Two of three largest
counties in each
state
Exceptions replaced
by Census region
Total N = 100
 Rural Counties:



Random selection
of two counties
with population
between 10,000 and
100,000
Exceptions: CT,
HI, MA, RI
Total N = 100
Percent of Counties
Receiving Referrals
90%
Receive referrals
Don't receive
referrals
% Cases Juvenile Charges Filed
(Among Counties Receiving Referrals)
>75% of
cases
None
25%
21%
14%
<10% of
cases
22%
41-75%
of cases
19%
11-40%
of cases
% Infants Removed--Cocaine
(Among Counties Receiving Referrals)
>75% of
cases
None
13%
29%
15%
17%
41-75%
of cases
<10% of
cases
26%
11-40%
of cases
Opinion of County Practice
Too strong
26%
Appropriate
in most
cases
69%
Inadequate to
protect child
Nationwide Survey of DA’s
 Participants: Criminal District Attorneys
randomly selected from urban, urban fringe,
and rural counties, 4 per state
 The DA most familiar with prenatal drug
exposure policy or practice identified
 Current N = 100 (goal is 200)
Opinion: How Damaging Are
Various Exposures? (1-7)
 Prenatal exposure to illicit drugs: 6.14
 Postnatal exposure to drugs: 6.02
 Prenatal exposure to alcohol: 5.89
 Prenatal exposure to tobacco: 4.48
What % Of Perinatal Drug Users
Should Be Prosecuted Criminally?
35
30
25
20
15
10
5
0
0-10% 11-40% 41-99% 100%
Response: Ideal Percent
Don't
know
Part III: Examining Harm
from an Historical Perspective
The Prehistorical Period
 Concern regarding alcohol exposure first
noted in 1973, with limited public reaction
 Prior to the mid 1980’s, drug exposure
received little attention among the scientific
and lay communities
The Early Period
 Mid 1980’s: growing concern regarding
illicit drug use in America, particularly crack
cocaine
 Research suggesting significant deleterious
effects of crack cocaine exposure emerges
Early Period:
The Media Responds
 Public fear and outrage regarding illicit drugs
galvanizes around the “crack baby” image
 This media portrayal burns lasting images
into the minds of the public
The Courts Respond in Turn…
 Criminal prosecution for cocaine use during
pregnancy is the first reaction in many states
(Ondersma & Tatum, 2001)
 1989: A hospital in South Carolina begins testing
women, without their consent, and sending results
to the police; 29 of 30 were African-American

(leads to U.S. Supreme Court decision in Ferguson v.
City of Charleston)
Middle Period: The Backlash
 1993: Growing skepticism among scientific
community culminates in a 1993 special
section in Neurotoxicology & Teratology
 Most researchers assert that the effects of
prenatal exposure to drugs have been greatly
misunderstood, and emphasize need for
appropriately controlled research
Current Period: Ostrea, Ostrea,
& Simpson, Pediatrics, 1997
 Meconium screening of 2,964 infants at Hutzel
Hospital in Detroit, MI
 Data cross-checked with death registry at age 2
 No association between drug exposure status
(of any type) and mortality
Lester et al., Science, 1998
 Meta-analysis suggests that prenatal cocaine
exposure is associated with an IQ deficit of
approximately 3.26 points
 This very small decrease, due to the
increased number of children falling below
70, is estimated to lead to approximately
$350 million annually in additional costs.
Maternal Lifestyles Study
 Large, multisite, prospective, masked study
of prenatal cocaine exposure funded by
NICHD, NIDA, ACYF, and CSAT
 Designed around the reality that cocaine is a
marker for other drugs of abuse and
compromised caregiving
Lester et al., Pediatrics, 2002
 Total of 1,388 infants (658 exposed infants and 730
comparison) evaluated at one month of age
 Cocaine exposed vs. unexposed: significant
differences on 2 of 26 areas (arousal and regulation)
 Opiate exposed vs. unexposed: significant
differences on 1 of 26 areas (hyperphonated cry)
Three Years Old:
Messinger et al., Pediatrics, 2004
 Same 572 cocaine and/or opiate-exposed infants,
compared to 655 infants not exposed to cocaine or
opiates, at age 3
 No difference on any cognitive, motor, or behavior
outcome after controlling for other factors


Even when comparing highest-exposed to non-exposed
What really mattered? Poverty, poor maternal care, and
low birthweight.
Seven Years Old (Behavior Only):
Bada et al., Pediatrics, 2007
 Controlling for all relevant factors, a few
effects were found:
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Cocaine (heavy use only): 3.6 points higher
Tobacco: 4.4 points higher
Alcohol: 4.0 points higher
 Scores on this measure have a mean of 100;
most scores fall between 60 and 140
Bada et al., 2007 (Cont.)
“Prenatal and postnatal exposures to tobacco and
alcohol are of significant public health concern.
Their combined effect on child behavior is greater
than what can be attributed to cocaine. Therefore, …
a call for increased effort toward prevention of
tobacco and alcohol use, which is a more prevalent
problem and has as great an impact on childhood
behavior problems as PCE [prenatal cocaine
exposure].”
The Case Of Attachment
 Several early studies, most with smaller sample
sizes and incomplete blinding of examiners/raters,
found high rates of disorganized attachment in
exposed infants (e.g., Rodning, Beckwith, &
Howard, 1989)
 A large-scale (N = 860), fully blinded study
conducted as part of the Maternal Lifestyle Study
found almost no association between prenatal
exposure and attachment classification (Seifer et
al., 2004)
But Wait…
Enter Methamphetamines
There are similarities between the current
climate with respect to methamphetamines,
and the mid-1980’s with respect to crack
cocaine
Prevalence is highly variable
Prevalence of prenatal exposure in one major
study focused on four high-methamphetamine
areas was 5.2%
Methamphetamine and Cocaine
Prevalence in Seattle, 1999-2002
180
160
140
ER Mentions 120
per 100,000 100
80
persons
(Source:
DAWN, U.S.
SAMHSA)
Cocaine
Meth
60
40
20
0
1999
2000
2001
2002
Methamphetamines
 Very few studies are available, most of
which involve animals
 Results with animals replicate those with
opiates, cocaine, and other drugs:
inconsistent, but some deficits are nearly
always present at sufficient doses
 Smith et al., 2003, J Dev Beh Peds: No
differences in birthweight between methexposed and not exposed human infants
Prenatal Meth Exposure and Neonatal
Neurobehavioral Outcome
(Smith et al. 2008)
 Studied 166 neonates (74 methamphetamine
exposed and 92 comparison) within first 5
days of life
 No difference in birthweight, Apgar scores;
evidence of decreased arousal and increased
stress was present (significant differences on
2 scales out of 19 measured)
 These subtle effects are consistent with those
found with cocaine
Methamphetamines--Media
A CNN report was aired repeatedly over the span
of a month, showing a picture of a baby who had
allegedly been exposed to methamphetamines
prenatally and stating: “This is what a meth baby
looks like, premature, hooked on meth and
suffering the pangs of withdrawal. They don't want
to eat or sleep and the simplest things cause great
pain.” CNN, “The Methamphetamine Epidemic in
the United States,” Randi Kaye. (Aired Feb. 3,
2005 – Mar. 10 2005).
Source: Methamphetamine open letter, Lewis et al., July 27, 2005
Methamphetamines--Media
CHICAGO TRIBUNE, Judith Graham,
“Only Future Will Tell Full Damage Speed
Wreaks on Kids” (“At birth, meth babies are
like ‘dishrags’”) (Mar. 7, 2004)
Source: Methamphetamine open letter, Lewis et al., July 27, 2005
Methamphetamines--Scientists
“Although research on the medical and
developmental effects of prenatal methamphetamine
exposure is still in its early stages, our experience
with almost 20 years of research on the chemically
related drug, cocaine, has not identified a
recognizable condition, syndrome or disorder that
should be termed “crack baby” nor found the degree
of harm reported in the media and then used to justify
numerous punitive legislative proposals.”
Source: Methamphetamine open letter, Lewis et al., July 27, 2005
Methamphetamines--Scientists
“In utero physiologic dependence on
opiates (not addiction), known as Neonatal
Narcotic Abstinence Syndrome, is readily
diagnosable and treatable, but no such
symptoms have been found to occur following
prenatal cocaine or methamphetamine
exposure.”
Source: Methamphetamine open letter, Lewis et al., July 27, 2005
Neonatal Withdrawal
 Describes a constellation of symptoms commonly
associated with withdrawal in the neonate; usually
not immediately evident
 By far, withdrawal is most clearly evident in
infants exposed to opiates
 Accumulating evidence also suggests clear
withdrawal in tobacco-exposed infants (at mean
cigarettes/day of 6.7; Law et al., 2003)
 Withdrawal from other substances is much less
clear, with no agreed-upon medical response
Summary of Drug Effects
 Negative effects are clear when all drugs of
abuse are considered together
 Negative effects of single drugs (of any type)
occur in some of the most heavily exposed
infants
 These negative effects are comparable in
magnitude to those of tobacco and perhaps
less than that of alcohol
Part IV: Harm in the Context
of Other Prenatal Risks
Prenatal Alcohol Exposure
 Alcohol presents more risk to the fetus than
any other drug of abuse
 Risks associated with prenatal alcohol
exposure include:



Intrauterine growth deficiency
Facial dysmorphology
CNS damage, including developmental delay
(severe to undetectable), hyperactivity, and
attention deficits
Alcohol: Baer et al.,
Arch Gen Psychiatry, 2003
 Study of 21-year old children of pregnant
women evaluated between 1974 and 1975,
N = 433
 Prenatal exposure to alcohol associated with
increases in alcohol problems (14.1% versus
4.5%) and heavy drinking (11.7% versus
6.9%)
Prenatal Tobacco Exposure
 Dose-dependent effects on:



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Birthweight and mortality
IQ, especially verbal ability
Behavior, especially conduct disorder in boys
Lung function, especially in children with asthma
 For example, see Ness et al., NEJM, 1999
 Cocaine use: odds increase for miscarriage = 1.4

Tobacco use: odds increase for miscarriage = 1.8
Relative Harm
 Tobacco and alcohol use during pregnancy
is far more common. Among pregnant
women:



5.5% have used any illicit drug
18.8% have used alcohol
20.4 % have smoked cigarettes
 Thus, tobacco and especially alcohol are
more likely to cause harm than illicit drugs
Lead
 Prenatal and postnatal exposure to lead is
clearly associated with cognitive and other
impairments
 Recent research (Canfield et al., NEJM,
2003) reported IQ decrements of 7.4 points
before blood lead levels reached the official
cutoff
Other Prenatal Factors
 Nutrition
 Prenatal Care
 Folic Acid
 Medications
 Violence: physical violence during pregnancy is
associated 3 times the risk of hemorrhage or
growth restriction, and 8 times the risk of death
(Janssen et al., Am J Obstet Gynecol, 2003)
Part V:
Other Issues to Consider
Side Effects
 Strong responses always have side effects;
this in itself does not preclude such responses
 Strong responses to prenatal drug exposure
have unique additional side effects:




Treatment avoidance
Hospital shopping
Reduction of honesty with medical staff
Labeling of children
Prevalence
 2.8 million children have a parent who is
dependent on drugs (7.5 million including
alcohol)
 At least 5.5% of births are drug-exposed
 We “catch” only a fraction of all cases of
prenatal drug exposure
Risk Does Not Equal Certainty
 Walsh et al., 2003: Major survey of 8,472
adults, questioned regarding parental
substance abuse and their own maltreatment
 Rates of physical abuse:


No parental substance abuse:
Parental substance abuse:
7.6%
19.8%
Screening Issues: Fairness
Chasnoff et al., NEJM, 1990
 Rates of illicit drug use similar in AfricanAmerican vs. white, public vs. private
 African-American and poor women
reported to authorities at ten times the rate
of white women
National
Pregnancy
& Health
Survey,
DHHS,
1996
Given All This:
What Is An Appropriate Response?
Why Not Simply Err on
the Conservative Side?
 We can only utilize the strongest responses
with a limited number of cases. Thus,
choosing to use the strongest response in one
case means not using it in another case.
 Responding too strongly can put our
credibility, funding, and long-term ability to
protect children at risk. (Remember the
sexual abuse backlash.)
What Fits Best?




Relative harm
 Side-effects of the
response
Moral concerns
Prevalence of the threat  Cost-benefit ratio (need
to reserve strongest
Likelihood of success
response for cases where
for various options
it is most needed)
 Proportion of at-risk
children reached
A Key Question
 Is prenatal drug exposure maltreatment, like
physical abuse, or is it a risk factor, like
depression?


If maltreatment, we must address how and why it
differs from alcohol or tobacco use.
If a risk factor, risk factors alone typically do not
merit the strongest responses.
Overview, Part II:
Substance Abuse Treatment
 Children need permanence yesterday, but
“addiction” is a chronic, relapsing condition.
Does current science offer a perspective that
may help?
 If you choose to, how might you as Court
officials modify your policies to better fit the
current science?
Assumptions Of The “Two
Clocks” Problem
 Success is impossible without treatment
 That treatment must be:



Long-term
Multi-component
Tough, and closely monitored by the court
 The presence of any substance abuse means that
unacceptable risk is present
How Well Do These Assumptions
Stack Up Against The Evidence?
(First, A Primer on Effect Sizes…)
 Research reviews often focus on statistical
significance, but magnitude of effects is much
more important
 The most common measure of effect size is
Cohen’s d statistic



Can be interpreted as the difference between the
experimental and control conditions, expressed in
standard deviation units
Small = .2, Medium = .5, Large = .8
.3 to .5 is typical for efficacious treatments
(Next, a Primer on Meta-Analyses)
 Meta-analyses combine multiple studies
(meeting certain criteria) examining the
association between two or more variables
 Meta-analyses convert outcomes in each
study to a common metric (often Cohen’s
d), and combine them to yield an overall
measure of the association between X and Y
Treatment is Crucial
Treatment Status Among Mothers With
Substance Abuse Problems And Children In
Foster Care, 1998
Completed
Other/unknown
CW Workers
recognize
substance abuse
in 18% or 30%
of cases…
(Gibbons et al.,
in press)
In
Treatment
10%
6.5%
5.5%
Never
Enrolled
(38%)
Failed
(41%)
Data from GAO, 1998
Weak Association Between
Receipt of Treatment and Sobriety
% Succeeding With/Without Treatment
 Treatment IS beneficial
 However, treatment has—
at best—a moderate
positive effect
 Recent meta-analysis:
d = .30, 57% success in
treated persons vs. 42% in
untreated
100
90
80
70
60
50
40
30
20
10
0
With
Treatment
Without
Treatment
Data from Prendergast et al., DAD 2002
Preventing Placement in
Substance-Abusing Families
(Dore & Doris, 1998)
 138 caregivers beginning specialized substance
abuse services
 Program provided in-home specialists, addiction
treatment, emergency funds, transportation, child &
respite care, etc.
 NO association between treatment and child
placement
Substance Abuse Treatment
& Recurrence
(Barth et al., 2006)
 Used data from mothers of 1,101 children who:


Were investigated by CPS
Were in need of substance abuse treatment
 Then created two groups of women who were
matched on 17 risk factors


One group received treatment (N = 219)
One group did not (N = 219)
Barth et al., 2006 (Cont.)
 Re-reporting rates 18 months later:


Untreated group:
Treated group:
 Huh?
8.6%
19.3%
Barth et al. (Cont.)
“Although this is not an argument against substance
abuse treatment, it is further evidence that we do not
have an adequate understanding of what happens
when child welfare clients receive intervention
services.”
Self-Change
 A number of studies have followed persons with
substance use disorders over time to measure
change in diagnostic status
 Up to 50% of persons with a drug or alcohol use
disorder at one point in time will NOT have that
disorder 5 years later
 Of these changers, only a minority (approximately
25%) will have obtained professional or 12-step
help
Treatment is Crucial? Summary:
 Most parents in CWS with substance use disorders
are not being recognized or treated
 Treatment has, at best, a moderate positive effect
(and just getting that is not easy)
 Most of those who do change, change on their
own
Longer is Better
Brief Vs. Extended Interventions
for Problem Alcohol Use
(Moyer et al., 2002)
Follow-up point
Effect size (d) Effect size (d)
vs. no Tx
vs. active Tx
≤ 3 months
.30***
-.03
3-6 months
.14***
.17
6-12 months
.24***
.03
> 12 months
.13***
.01
Motivational Interviewing Vs.
Extended Interventions
(Burke et al., 2003)
Problem area
Effect size (d) Effect size (d)
vs. no Tx
vs. active Tx
Alcohol (frequency)
.25
.09
Alcohol (peak BAC)
.53
---
Drug Use
.56
-.01
Diet & Exercise
.53
---
Inpatient Vs. Outpatient
Treatment
 A number of studies and reviews have compared
the efficacy of inpatient vs. outpatient treatment
for alcohol use disorders
 The first three such reviews found no advantage
for inpatient treatment (Annis, 1986; Miller &
Hester, 1986; & Saxe et al., 1983)
 A more recent review found a slight advantage for
inpatient treatment in some but not all studies (and
in none that used random assignment; Finney,
Hahn, & Moos, 1996)
Bakermans-Kranenberg et al.,
2003
 Meta-analysis of interventions designed to increase
parental sensitivity and/or infant attachment
 Shorter interventions were as or more efficacious
than longer interventions:
Sensitivity



< 5 sessions
5-16 sessions
> 16 sessions
d = .42
d = .38
d = .21
Attachment
d = .27
d = .13
d = .18
Treatment Must Address All Risks
and Needs Present (More is Better)
Chaffin et al., JCCP, 2004
 110 parents involved with CPS due to child
physical abuse
 Randomly assigned to:



Parent-Child Interaction Therapy (PCIT)
Enhanced PCIT (plus services for depression, home
visits, substance abuse services, etc.)
Standard community parent training
 Outcome: CPS re-reports at a mean follow-up of
850 days
Chaffin et al., JCCP, 2004
Meta-Analysis: Valle, Wyatt,
Filene, and Boyle, 2006
 Performed a meta-analysis on studies of
parent interventions for child maltreatment
prevention
 Included a total of 77 studies that included a
parenting intervention and a comparison
group of some kind
 Average sample size was 111
Single Focus Vs. Multi-Focal
 Overall effect size for programs focused on
parenting only = .66; the effect for
enhanced programs providing multiple
services = .33.
 This difference was statistically significant
Bakermans-Kranenberg et al.,
2003
 Treatments focusing on a specific goal did
better than multi-focal interventions,
regardless of how high-risk the sample
 Broken down by outcome:


Single focus
Multi-focal
Sensitivity Attachment
d = .45
d = .34
d = .27
d = .10
HOW COULD THIS BE?
 Brief, focused treatments may better match what
most parents are actually willing and able to
provide
 Multi-focal treatments may overwhelm and
demoralize some parents
 Success in one area may facilitate success in
another area
 We may have underestimated the capacity for selfchange (and overestimated the importance of
treatment)
Treatment Must Be Tough And
Closely Monitored By The Court
In One Way, YES
 Persons coerced into treatment do at least as
well as those who enter voluntarily
 Court awareness of attendance is justified
and probably very helpful


But what about a tough approach?
What about reports of parent effort, etc.?
Correlation Between Therapist
Empathy & Drinking Outcomes
 6-8 months
 12 months
 24 months
r = -.82
r = -.71
r = -.51
Slide courtesy William R. Miller; Miller & Baca (1983) Behavior Therapy 14: 441-448
Rogerian Skill and Client Outcomes
Valle (1981) J Studies on Alcohol 42: 783-790
40
35
30
25
Client Relapse
20
Rates
15
10
5
0
38
35
29
24
23
20
19
15
13
18
11
Low
Medium
High
5
6 Months 12 Months 18 Months 24 Months
Follow-up Points
Slide courtesy of William R. Miller, PhD
Predictors of Patient Drinking
Outcomes
 Therapist Responses

Confront
r = .65, p<.001
 Patient Responses




Interrupt
Argue
Off Task
Negative
r = .65,
r = .62,
r = .58,
r = .45,
p<.001
p<.001
p<.001
p< .01
Slide courtesy William R. Miller; Miller, Benefield & Tonigan (1993) JCCP 61: 455-461
The Association Between Problem
Recognition and Change
 Studies suggest that there is either no association
between admitting a problem exists and change
(Lemere et al., 1958; Trice, 1957) or a negative
association (Orford, 1957; Polich et al., 1980)
 The majority of persons who do change
successfully deny labels such as “alcoholic” or
“addict;” they give other reasons for changing
Therapists And Dual Roles
 Many substance abuse agencies take on both
therapeutic and evaluative responsibilities
 These roles conflict with each other



Further reduces openness
Reduces effectiveness in both roles
Contributes to mistrust on the part of parents
Mullins, Suarez, Ondersma, &
Page, 2004
 Randomly assigned mothers of drug-exposed
infants to Motivational Interviewing or
treatment as usual
 Found no positive effects
 Consistent with other evidence on
motivational approaches with coerced
persons
Any Substance Abuse =
Unacceptable Risk
Alcohol Use in 2003
 Any Use (past 30 days):
50% (119 million)
 Binge Use (≥ 5 drinks):
23% (54 million)
 Heavy Use (≥ 5, x 5):
7% (16 million)
Source: National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2004
Use of Selected
Illicit Drugs: 2003
Percent Using in Past Month
9.0
8.2
8.0
7.0
6.2
6.0
5.0
4.0
2.7
3.0
2.0
1.0
1.0
0.4
0.3
0.0
Any
Drug
Marijuana
Psycho- Cocaine
therapeutics
Hallucinogens Methamph.
Slide from www.samhsa.gov, 2004
Substance Use Disorders
 Abuse: Recurrent and significant adverse
consequences related to the repeated use of a
substance or substances.

Repeated use despite legal problems, social/
interpersonal problems, hazardous use, or
problems fulfilling role obligations.
 Dependence: The above, plus tolerance,
withdrawal, and/or compulsive seeking of the
substance.
Dependence or Abuse of
Specific Substances: 2003
Alcohol
17,951
Marijuana
4,198
Cocaine
1,515
Pain Relievers
1,424
Tranquilizers
435
Stimulants
378
Hallucinogens
321
Heroin
189
Inhalants
169
0
5,000
10,000
15,000
20,000
Numbers (in Thousands) of Users with Dependence or Abuse
Adapted from NSDUH slide at www.samhsa.gov, 2004
Average Days Using Per Year: With
and Without Disorder (Users Only)
Days using per
year
No disorder
Disordered
140
120
100
80
60
40
20
0
Marij.
Alcohol
Stim.
Heroin
Cocaine
NSDUH, 2004
Associations Between Substance
Abuse and Child Maltreatment
 The strongest studies suggest a two- to threefold increase in risk
 This still means that maltreatment is not
present in most homes in which a parent has
a substance use disorder
 This of course is more true in homes where
non-disordered substance use takes place
Substance Abuse by Parents
 In 1996, 7.5 million children (10% of all
children) had one or more parents with a
substance use disorder (Huang, Cerbone, &
Grfoerer, 1998)
 16.1% of persons with substance abuse or
dependence currently live with one or more
of their children
What Does This Suggest?
The Two Clock Problem
 Imagine a system in which long-term, intensive
treatment was emphasized less than at present. How
might that change things? Where else might you
focus resources?
 Imagine a system in which abstinence was
emphasized less than at present. How might that
change things?
 How might it change things if all parents had
counselors who only provided attendance records to
the court?
Implication 1: A Greater Emphasis
On Outcomes (Vs. Process)
 If intensive, long-term treatment is less
crucial than we have previously thought, it
may mean that parents should be primarily
responsible for sobriety rather than treatment
 If so, monitoring would need to be more
valid and thorough than at present
Implication 2: A Greater Emphasis
On Parenting (Vs. Use)
 If it is possible—and even common—that
parents can abuse alcohol or use drugs and
not maltreat their children, perhaps other
outcomes should be emphasized more
 If so, direct measures of parenting should be
emphasized
Implication 3: Harm Reduction
 Treatment or no treatment, many of the
parents who come before you will continue
to use substances.
 Can we protect children by promoting
abstinence, AND by teaching parents how to
limit harm?
Implication 4: A New Alignment
 Counselors need
“therapeutic distance”
 Consider asking for
attendance only
 Establish at least one
person on the treatment
team who is not coercive
Court
CW Prof.
Parent
Counselor
Oklahoma Infant
Parenting Program (IPP)
 Designed for drug-exposed
infants
 Multi-component & intensive,
with emphasis on barrier
reduction; 1 year in length
 Utilized a substance abuse
treatment agency in the
community (a therapeutic
community)
 Highly coordinated, with full
reporting to the court
Evaluation of the IPP
 Goal: To examine association between
service provision and outcome
 Method: within-subjects survival analysis
using follow-up CPS reports as key
outcome
 Participants: 142 mothers of drug-exposed
infants, all of whom were in out-of-home
care
Mullins, Bard, & Ondersma, Child Maltreatment, 2005
Re-Reports:
Cumulative Survival in Years
(From Mullins, Bard, & Ondersma, CM, 2005)
Association Between Program
Participation and Outcome
 No association between extent of services
received (either group minutes attended or
total services received) and subsequent rereports
 Some evidence of a dose-response
association is a necessary (but not
sufficient) condition of efficacy
Conclusions
 Consider carefully whether vigorous CWS
and Court involvement is the ideal response
to prenatal substance exposure
 Consider whether the emphasis we
traditionally place on treatment is justified
 Consider whether the way we think about
and utilize treatment should be modified