Building FASD State Systems Fetal Alcohol Spectrum Disorders

Building FASD State Systems Fetal Alcohol Spectrum Disorders Center for Excellence Promising Practices for FASD Prevention and Intervention May 6, 2004 Therese Grant, Ph. D. granttm@u. washington. edu University of Washington School of Medicine Director, Washington State Parent-Child Assistance Program

Parent-Child Assistance Program (PCAP) A 3 -year home visitation intervention program for high risk mothers who abuse alcohol and/or drugs during pregnancy WHEN CASE MANAGEMENT ISN’T ENOUGH

Client Picture

Parent-Child Assistance Program Primary Goal To prevent future births of alcohol and drug exposed children.

The Formula for Preventing Alcohol/Drug Exposed Births Motivate women to stop drinking or using drugs before and during pregnancy. - OR Help women who can’t stop drinking or using drugs avoid becoming pregnant.

Parent-Child Program History of. Assistance the Program 1991 -95 Federally funded demonstration: Seattle 1996 -98 Philanthropist provides interim funding 1996 -97 Governor funds replication in Tacoma 1997 -98 Follow-up study, original cohort: Seattle 1997 -05 WA State funding: Seattle and Tacoma 1999 -05 Expanded WA State funding: Spokane, Yakima, Grant County 1998 -04 Replication sites: Minnesota, N. Carolina, Alaska, Texas, Canada

PCAP Theoretical Framework Relational Theory A woman’s sense of connectedness to other is central to her growth, development, definition of self Intervention Long term, positive interpersonal relationship with advocate

PCAP Advocate Characteristics • Have experienced some of the same types of adverse life circumstances as clients, but seldom to same degree • Have subsequently achieved success in important ways • Are positive role models and offer clients hope and motivation from a realistic perspective

“I've lived through the things they've been Advocate Quote #1 through, so I'm not afraid or intimidated. I've lived with domestic violence. For someone to tell a client in a domestic violence situation to just up and go, it’s not that easy. There are lots of plans to think about. I understand when someone says, 'I can't just leave right now. ' But I can help plan a strategy, because I've lived it. ” — PCAP Advocate

PCAP Theoretical Framework Stages of Change Clients will be at different stages of readiness for change. Motivation is a process for change that occurs within the context of interpersonal relationships. Intervention Motivational Interviewing • acknowledge client’s perception of situation • encourage her to explore + and – aspects

PCAP Theoretical Framework Harm Reduction Addiction and associated risks are on a continuum. The goal is to reduce harmful consequences of the habit for mother and her child. Intervention Any steps toward decreased risk are steps in the right direction.

PCAP: A Two-Pronged Approach Paraprofessional Advocate Clients & Families Community Service Providers

The Scope of Advocacy Community Providers Bio Mom Schools Job Training Family Planning Caretakers Juvenile Justice Bio Dad Siblings Extended Family Probation Friends Neighbors Partners Alcohol/Drug Tx Children Health Care Mental Health Tx

PCAP Outcomes Over Time PCAP has demonstrated improved FASD prevention outcomes between original demonstration (1991 -1995) and current replication programs. How do we account for this?

Systems Working Together Good things happen when the State implements strong policy, and communities implement effective programs

Parent-Child Assistance Program Treatment & Abstinence Outcomes 3 -Year PCAP Outcomes Original CSAP Seattle PCAP Tacoma PCAP N=60 N=76 N=80 1991 -1995 1996 -2003 Follow up rate 92% 84% 85% Inpatient or Outpatient Tx completed or in progress 52% 76% 73% Longest abstinence ≥ 1 yr Longest abstinence ≥ 2 yrs 37% 13% 59% 22% 46% 24% Abstinent at exit for ≥ 6 mo Abstinent at exit for ≥ 1 yr 28% 17% 43% 34% 39% 33%

Systems Working Together WA State Policy • DASA increased treatment beds for women (55 in 1991; 149 in 2004) • FAS Diagnostic and Prevention Network (1995 – 2004)

Parent-Child Assistance Program Family Planning Outcomes Original CSAP Seattle PCAP Tacoma PCAP 1991 -1995 1996 -2003 N=60 N=76 N=80 Using birth control at intake Using birth control at exit More reliable method* 3% 73% 43% 13% 74% 49% 16% 71% 53% Subsequent birth, (% women) Abstinent entire pregnancy Entered Tx during pregnancy Follow up tubal, IUD 28% 18% 47% - 29% 32% 50% 25% 60% 40% 32% 3 -Year Outcomes * Tubal ligation, consistent Depo. Provera, IUD, Norplant

Systems Working Together WA State Policy • DSHS First Steps improved family planning education and access to services and supplies (1989 – 2004)

Systems Working Together PCAP CONTINUES TO IMPLEMENT AN EFFECTIVE PROGRAM • Maintains high-quality program, trained staff • Evaluates program • Demonstrates consistent positive outcomes to sustain funding • Builds acceptance, recognition in community • Participates in legislative task forces • Educates community & legislature to solve problems

"I'm going to keep having babies until they let me keep one. " Are mothers who lose custody of their children more likely to have a subsequent exposed pregnancy?

Risk for Subsequent Alcohol/Drug Exposed Pregnancy (N = 174) Factor Adjusted Model Target Child Living with Mother Always* HR (95% CI) P 0. 38 (0. 16 -0. 87) . 02 *Adjusted for age, race, education, parity, and mental health diagnosis What are the policy implications?

“Before. Client PCAP I Quote never thought about goals. They showed me the right direction. They showed me that I am responsible. That no matter who I am or what I do, I am somebody. It is never too late. ” -- PCAP Client at Graduation