Drug Addiction Intervention
Preventing alcohol and drug exposed births in Washington State: intervention findings from three Parent-Child Assistance Program sitesTherese M. Grant INTRODUCTION
Maternal alcohol and drug abuse during pregnancy remains a serious public health concern (1-7). Prenatal exposure incurs physical and neurodevelopmental risk for the child (8-10) and a birth mother with an untreated substance abuse problem is likely to provide a compromised home environment and continue to have repeat exposed pregnancies (11-13). Home visitation has emerged as a promising intervention for helping at-risk mothers improve parenting skills and become healthier and more self-sufficient, yet few programs have been developed and evaluated specifically for women who abuse alcohol and drugs during pregnancy (14-20).
The Parent-Child Assistance Program (PCAP, originally known as the Birth to 3 Project) is a three-year home visitation intervention that began in Seattle in 1991 as a federally-funded research demonstration with a primary aim of preventing subsequent alcohol and drug exposed births among mothers who abused alcohol and/or drugs during an index pregnancy. Research findings demonstrated the model's efficacy compared to controls, and in 1996 researchers obtained funding from the state of Washington and private philanthropy to replicate the intervention arm of the project at two sites, in Seattle (King County) and Tacoma (Pierce County), the two largest cities in Washington. The resources were targeted for direct intervention services in response to community need and for program evaluation; funding for comparison groups was not available. This article describes three-year intervention findings from the initial three PCAP sites: the original demonstration (1991-1995), the Seattle replication (1996-2003), and the Tacoma replication (1996-2003).
In 1999, two additional PCAP sites were funded through Washington State legislative appropriation. Sufficient data were not available from these sites to include in the present analysis. A dozen maternal intervention programs in the U.S. and Canada have been modeled on PCAP concepts (21).
METHODS
Participants
The original demonstration (OD) sample was recruited from July 1991 through December 1992 and exited the program between July 1994 and December 1995. The Seattle replication (SR) and Tacoma replication (TR) samples were recruited from January 1996 through October 2000 and exited between January 1999 and October 2003. Eligibility criteria included: 1) pregnant or postpartum; 2) self-report of heavy alcohol or illicit drug use during pregnancy (defined as drinking [greater than or equal to] 5 alcoholic drinks/occasion [greater than or equal to] once/month and/or use of any illicit substance [greater than or equal to] once/week during pregnancy); and 3) ineffective or nonengagement with community social services. OD participants were enrolled within one month postpartum; SR and TR participants were enrolled during pregnancy (38%) or through six months postpartum (53% within three months postpartum).
OD subjects were identified and recruited through two sources: hospital postpartum screening by study researchers at two urban hospitals using a one-page, confidential self-report instrument (22); and referral from community providers (e.g., social workers, public health nurses). Eligible, consenting hospital-screened women were systematically assigned to either the intervention or control condition (every third woman as a control). SR and TR subjects were recruited solely through community referral to PCAP. All participants received an intake interview. Subjects were followed through the three-year intervention and completed an exit interview.
Human Subjects approvals were obtained from participating hospitals and the University of Washington, and informed consent was obtained from all subjects.
Intervention
Theoretical background and details of the PCAP model have been described in detail elsewhere (17, 23-26). In brief, the primary aim of the intervention is to prevent future alcohol and drug exposed births among high-risk mothers who have already delivered at least one exposed child. To achieve this aim, PCAP case managers assist women in obtaining alcohol and drug treatment and staying in recovery, and link them with comprehensive community resources that will help them build healthy, independent lives. They work individually with approximately 15 families, help mothers identify personal goals and steps necessary to achieve them, and monitor progress. They facilitate integrated service delivery among providers, offer regular home visitation, transport clients and children to important appointments, and work actively within the context of the extended family. PCAP case managers are paraprofessionals not formally trained or credentialed in the helping professions (27). They share some life experiences with their clients but have overcome obstacles and achieved significant successes, enabling them to be credible role models with clients who have formerly had little reason to trust anyone. They receive initial and ongoing training and weekly individual supervision by a master's level professional (25).
Objectives
In this study comparing three-year findings from the OD, SR, and TR, three questions are addressed:
* Did baseline characteristics differ between subjects enrolled in the OD versus those enrolled at the later SR and TR sites?
* Were OD outcomes maintained or improved at the SR and TR sites?
* What factors explain differential outcomes at the replication sites?
Intake Measure
OD subjects and the first 100 enrolled in the SR and TR (50 at each) were interviewed by a trained researcher using a 50-minute structured instrument used by the authors in previous studies (17, 28, 29). Subjects enrolled after 1996 (n= 84) were interviewed using the 5th edition Addiction Severity Index (ASI) with supplemental questions. The semistructured ASI assesses problems in six domains: medical, employment, legal, family/social, psychiatric/emotional, alcohol/drug use (30-32). PCAP supplemental questions included items on pregnancy substance use, contraception, and service utilization.
Exit Measure
At three-year exit, a researcher interviewed OD subjects using a structured instrument assessing areas measured in the intake interview. SR and TR subjects were interviewed at exit using the ASI 5th edition, with the PCAP supplemental questions including items on status of the index child and subsequent births.
PCAP data collection methods enhanced accuracy of self-report. Detailed instruction manuals and intensive training to establish inter-rater reliability insured standardized interview procedures. Exit interviews were conducted by independent research staff at a University of Washington facility. Interviewers took time, asked subjects to think carefully and thanked them for their openness and honesty. They used calendar prompts to improve subject recall, and reminded subjects of previous responses to assist with present responses. The study obtained a Certificate of Confidentiality from the U.S. Department of Health and Human Services to safeguard client data.
Statistical Methods
This cohort study is a pretest-posttest comparison across three sites. Enrollment and exit characteristics between two groups (subjects retained versus those lost to follow-up) were compared by t-test or chi-square. Overall program efficacy was measured in the OD by creating a baseline (intake) summary variable (18 items) and an endpoint (three-year) summary variable (23 items) (17). Items reflected five domains expected to be most affected by the intervention (see Table 2) and were scored on a five-point scale from most negative (-2) to most positive (+2). Item scores were summed to compute individual domain scores and the total summary score. Cronbach's alpha computed from the five component domain scores was .91 for the baseline score and .82 for the endpoint score, suggesting good item-to-scale reliability (33). In this analysis, we constructed SR and TR baseline and endpoint summary variables in the same manner. We compared the endpoint summary variables across the three sites, using three-group analysis of covariance adjusting for the baseline variable to test for differences. Also, to reflect our primary interest in alterations in actual behavior, we present descriptive statistics comparing clinically relevant outcomes across the three sites. Data were analyzed using S-Plus and SPSS.
RESULTS
Full findings from the OD are reported in Ernst et al. (17). In brief, of 2,244 postpartum women who completed the screening questionnaire, 131 met eligibility criteria: 28 were not asked to participate because of living out of area, twin birth, or neonatal death, 65 were enrolled as clients in the intervention, 31 were enrolled as controls, and 7 refused enrollment. Among the 65 clients, 5 (8%) were lost to follow-up. Sixty completed the three-year exit interview and are included in the main analysis for this report.
At the combined replication sites (SR and TR), a total of 683 women were referred to PCAP during the study period. Three hundred twenty (47%) were ineligible and referred to more appropriate programs; 13 (2%) had fetal alcohol spectrum disorders (FASD) and were enrolled in a separate pilot study; 349 (51%) met eligibility criteria. Among the eligible, 105 (30%) avoided contact after being referred or refused the intervention, 14 (4%) enrolled but declined services within a few months and did not receive the intended intervention, and 1 woman died during the program of assault injuries. Among the 229 who enrolled and participated in the intervention, 45 (13%) are excluded from this analysis because of lack of a valid interview or exit interview conducted more than 6 months after program completion. Among the remaining 184, 28 (15%) were lost to follow-up at 3 years (14 at each site); the 156 retained are included in the main analysis (n=76 at SR; n=80 at TR).
We compared baseline characteristics of subjects lost to follow-up with those retained. In the OD, the 5 lost to follow-up (8%) were approximately 3 years younger, with a year less education (17). At the combined SR and TR sites, subjects lost to follow-up were younger (27.1 vs. 28.6 years), with 3 or more children (75% vs. 60%), and at least one child removed from their custody (75% vs. 62%). Fewer were binge alcohol drinkers during the index pregnancy (25% vs. 50%, p < .01), and a higher proportion were methamphetamine users (43% vs. 24%, p < .05).
Baseline Characteristics
Among subjects enrolled at all three sites, most had been physically or sexually abused as children, had parents who abused alcohol/drugs, had been incarcerated as adults, and were currently receiving welfare; approximately half were not living in stable housing; on average, there were 2 prior children, most not in the mother's care (Table 1). More subjects in the replication samples were married compared to the OD (SR/TR=15% vs. OD=3%, p < .002) and had been victims of domestic violence (SR/TR=41% vs. OD=18%, p < .001). In Tacoma, a higher proportion were White, reflecting population demographics. Approximately half the subjects at the SR and TR had a diagnosed mental health disorder (not assessed in the OD).
All OD participants, and 81% of those in the combined replications, were polysubstance abusers (binge alcohol and cocaine was the most common combination). Substances used during the index pregnancy were strikingly different in Tacoma compared to the OD and SR (both conducted in Seattle). The TR had 11-fold greater use of methamphetamine, and more alcohol and binge alcohol use, but only half the rate of heroin use during the index pregnancy.
Summary Scores
Compared to the OD, baseline summary scores at the SR and TR were higher (means: OD=-20.7; SR=-10.5; TR=-11.5), as were scores on all five baselines (Table 2). Higher scores in two domains ("alcohol/drug treatment" and "connection with services" prior to program intake) accounted for 70% of the difference between OD and replication site baseline summary scores, reflecting increased availability of community services during more recent years.
In the OD, hospital-recruited clients scored significantly higher than controls on the endpoint summary score, adjusting for baseline summary score (p < .02). Three-group analysis of covariance (hospital-recruited clients, community referred clients, and controls) was also significant (p < .05) (17). Comparing data across the OD, SR, and TR, slopes for the regression of endpoint summary score on baseline score were similar across the groups. Each of the replication samples performed significantly better than the OD (p < .02), adjusting for baseline.
Three-Year Outcomes
Treatment and Abstinence
Compared to the OD, at exit from the intervention, a higher proportion of subjects in both replication samples completed inpatient (OD=45%; SR=54%; TR=61%), outpatient (OD=35%; SR=59%; TR=43%), and other forms of treatment (OD=45%; SR--72%; TR=49%) (Table 3). SR and TR subjects also accrued longer duration of abstinence from alcohol and drugs: for [greater than or equal to] 6 months at exit (OD=28%; SR=43%;TR=39%); for [greater than or equal to] 1 year at exit (OD=17%; SR=34%; TR=33%); for any period of abstinence [greater than or equal to] 1 year while in the program (OD=37%; SR=59%; TR=46%).
Family Planning and Subsequent Birth
Outcomes were sustained or improved at the SR and TR for regular use of a contraceptive at program exit (OD = 73 %; SR = 74%; TR = 71%), and use of a more reliable method (tubal ligation, IUD, Norplant, or consistent Depo Provera injections) (OD=43%; SR=49%; TR=53%). The rate of subsequent pregnancy during the three-year intervention was notably lower at the TR (OD=52%; SR=50%; TR=38%), although the subsequent birth rate was similar (OD=28%; SR=29%; TR=25%), suggesting a higher rate of spontaneous or therapeutic abortions among Seattle subjects (OD and SR). Among those who had a subsequent birth during the intervention, the proportion unexposed to alcohol or drugs throughout the pregnancy doubled at the SR and TR compared to the OD (OD= 18%; SR=32%; TR=40%). At all three sites, on program exit most subjects were no longer at present risk of having another alcohol or drug exposed pregnancy, either because they were using a reliable contraceptive method or had been abstinent from alcohol/ drugs for at least six months, or both (OD=60%; SR=67%; TR=74%).
Primary Income Source
In the OD, public assistance as the primary source of income dropped by 40% from program enrollment to exit (83% to 50%) compared to a 63% reduction at the combined replication sites (71% at enrollment to 26% at exit). In both replication sites, employment as primary source of income at program exit was nearly 2.5 times greater than in the OD (OD=12%; SR=29%; TR=29%). Employment replaced public assistance as primary income source among 35 women (32%) at the replication sites.
Index Child
The percentage of index children in custody of their mothers or other family members at program exit was similar across sites (OD=71%; SR=70%; TR=77%). Among those in custody of their families, over 90% at all three sites were receiving well-child care. Overall, fewer of those at the replication sites were in the state foster care system (OR=26%; SR= 17%; TR=9%). Over three times as many SR and TR children were adopted compared to the OD (SR=13%; TR=14%; OD=4%).
DISCUSSION
Future alcohol and drug exposed births can be prevented in one of two ways: by helping women avoid alcohol and drug use during pregnancy, or by helping them avoid becoming pregnant if they are using alcohol or drugs. This study demonstrates that PCAP community-based intervention has been effective in achieving these ends over time and across venues. Compared to the original demonstration, outcomes at the replication sites were either improved (alcohol/drug treatment completed; abstinence from alcohol/drugs; subsequent delivery unexposed to alcohol or drugs) or maintained (regular use of contraception and use of a reliable method; number of subsequent deliveries during the program). Other findings included increased maternal employment, more permanent child custody placements, and increased connection with services. These are clinically relevant outcomes that help mothers build healthy and productive lives, improve the quality of the home environment for the children, and reduce the burden on community social and economic systems.
A number of factors account for our findings. PCAP maintained strong administrative and quality control protocols. Community recognition grew as PCAP staff participated in service delivery networks and assured that clients followed through with recommendations. Some study posttest change could be attributed to the process of maturation as case managers continued to receive training and became more experienced.
Over the study period (1991-2003) a number of public policies and programs aimed at the population served by PCAP were initiated in Washington State. Study outcomes were subject to multiple influences because of increased services made available. For example, Washington's "WorkFirst" welfare-to-work program was initiated in 1997. Between 1997 and June 2004 the number of families receiving any welfare income in Washington dropped by 41% (personal communication: Debra Came, Washington State Office of Financial Management, July 16, 2004, Debra.Came@OFM.wa.gov). We observed a similar 42% reduction among PCAP participants between 1996 and 2003 (76% received any welfare income at enrollment vs. 44% at program exit, data not shown on table), although PCAP women were at higher risk for unemployment than the general welfare population because all were substance abusers and fewer were white (47% vs. 63%).
The Washington State Division of Alcohol and Substance Abuse (DASA) nearly tripled the number of gender-specific inpatient residential treatment beds for pregnant and postpartum women from 55 to 149 between 1991 and 2003. The availability of these specialized treatment facilities undoubtedly had a positive impact on PCAP's treatment and abstinence outcomes.
Washington State DSHS initiated First Steps in 1989 to help low-income pregnant women obtain health and social services including family planning. In 1993 coverage was extended statewide and to one year postpartum; in 2001 no-cost family planning services became available to individuals with incomes up to 200% of the federal poverty level. State data indicate that from 1994 to 2000 the birth rate among welfare recipients dropped by 29% (34). Further, from 1991 to 2000, the percent of women identified as substance abusers who gave birth and had a subsequent birth within two years, dropped from 18.7% to 16.5% (personal communication: Laurie Cawthon, M.D., May 11, 2004, cawthml@dshs.wa.gov). The PCAP two-year subsequent birth rate has remained consistently lower than the state rate: 13% at the OD (1991-1996); and 13% at the combined SR and TR (1996-2003) (data not shown on table).
The Washington Permanency Framework was a five-year plan begun in 1998 to improve the lives of children in the foster care system by increasing rates of permanent placements in a timely manner; parental substance abuse is cited as a common reason for children entering the system. State data indicate nearly twice as many children were adopted in 2003 as in 1995 (35). PCAP child placement outcomes improved during the period corresponding with implementation of the Framework: children not with family were three times more likely to be adopted at program exit, and only half as likely to be in the state foster care system.
Improved findings observed at the replication sites do not appear to be attributable to enrollment of less afflicted women, as the groups did not systematically differ from the OD on background characteristics.
At the replication sites, 78 women drank alcohol in a binge pattern ([greater than or equal to] 5 drinks per occasion) during the index pregnancy. Alcohol is a known teratogen (36, 37) whose neurobehavioral effects have been found to be more injurious than cocaine and other drugs abused prenatally (38-41). Prenatal alcohol exposure puts fetuses at risk for fetal alcohol syndrome (FAS), a permanent birth defect and a leading preventable cause of mental retardation and neurodevelopmental disorders in the United States (42, 43). The estimated average lifetime cost for an individual with FAS is $1.5 million (44, 45).
We found that 51 of the 78 PCAP heavy drinkers (65%) were no longer at present risk of having an alcohol exposed pregnancy at PCAP program exit: 24 (31%) were using a reliable contraceptive method (tubal ligation, IUD, or consistent Depo Provera injections); 18 (23%) had been abstinent from alcohol (and drugs) for at least six months; and 9 (12%) were both using a reliable contraceptive and were abstinent. Without PCAP intervention, we assume about 30% (or 23) of these 78 drinking mothers would have delivered another highly exposed child. Instead, the number was reduced by 65%, preventing approximately 15 exposed births. The incidence of FAS is estimated at 4.7% to 21% among heavy drinkers (46-48), therefore, we estimate that PCAP prevented at least one and up to three new cases of FAS. The cost of the PCAP program is approximately $14,760 per client for the three-year program including intervention, administration and evaluation. If PCAP prevented the occurrence of just one new case of FAS, the estimated lifetime cost savings is equivalent to the cost of the PCAP intervention for 102 women.
Of related note, a 2004 independent economic analysis by the Washington State Institute for Public Policy found an average net benefit of $6197 per client among selected well researched home visiting programs, including PCAP, for at-risk families in the U.S. (49).
Our study was subject to several limitations. Because data were obtained from personal interviews, they were subject to self-report biases (50). Positive study outcomes may reflect some spurious improvement due to the fact that we selected subjects with extremely poor social behavior history (statistical regression toward the mean) (51). The PCAP model might not affect the same degree of change among mothers whose baseline profile is not as severe.
Public health researchers have argued that when evaluation resources are limited, sound decisions may be made on the basis of adequacy or plausibility evaluations conducted under routine conditions (as opposed to randomized controlled trials) (52). Our quasi-experimental study does not allow us to draw confident causal conclusions because it is not a randomized design and we cannot rule out the possibility that historical events operated to improve PCAP outcomes. We have, however, demonstrated: 1) compared to control subjects, clients in the original sample had significantly better endpoint summary scores, and both replication sites scored significantly better than the original sample; 2) improved outcomes are not attributable to enrollment of less impaired women; 3) there was sustained or improved impact over time and across settings; and 4) for most outcomes that may have been associated with state programs implemented, PCAP has improved women's status over and above what state data bases demonstrate.
The social and economic costs of prenatal substance abuse are high, and the toll on each new generation of exposed and affected children is profound. What is heartening is that the problem is preventable. The PCAP intervention strategy offers hope to high-risk families and has proven to be a cost-effective investment for the state.
ACKNOWLEDGMENTS
This research was supported in part by the U.S. Department of Health and Human Services Center for Substance Abuse Prevention under grant H865SPO2897-01-06, and by the State of Washington Department of Social and Health Services Division of Alcohol and Substance Abuse, under contracts #7141-1 and #6376-0.
An earlier version of this article was presented at the 27th Annual Meeting of the Research Society on Alcoholism, June 2004. We thank Dr. Paul Sampson (Department of Statistics, University of Washington) and Dr. Fred Bookstein (Institute of Gerontology, University of Michigan, and Institute of Anthropology, University of Vienna, Austria) for their constructive comments and suggestions and technical assistance.
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Therese M. Grant, Ph.D., (1) Cara C. Ernst, M.A., (2) Ann Streissguth, Ph.D., (2) and Kenneth Stark, M.Ed., M.B.A. (3)
(1) Department of Psychiatry and Behavioral Sciences and Department of Epidemiology, University of Washington, Seattle, Washington, USA
(2) Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
(3) Division of Alcohol and Substance Abuse, Washington State Department of Social and Health Services, Seattle, Washington, USA
Address correspondence to Therese M. Grant, Ph.D., Department of Psychiatry and Behavioral Sciences and Department of Epidemiology, University of Washington, 180 Nickerson, Suite 309, Seattle, WA 98109, USA; Fax: (206) 685-2903; E-mail: granttm@u.washington.edu
Table 1. Baseline demographics and characteristics of
participants in the original demonstration (1991-1995)
and the Seattle and Tacoma PCAP replications (1996-2003)
Original demonstration
(n=60) mean or n (%)
Age (mean yrs) 27.6
Education (mean yrs) 11.5
High school diploma/GED 31/60(52)
Race
White 18/60(30)
African American 27/60(45)
Native American 10/60(17)
Other (Hispanic, Asian) 5/60(8)
Married 2/60(3)
Number prior children 2.1
None 10/60(17)
Living with mother (mean) 0.8
Primary income source
Public assistance 50/60 (83)
Employment 0/60(0)
Stable housing 28/60(47)
Childhood risk indicators
Parent(s) abused alcohol/drugs 40/53 (75)
Physical/sexual abuse 40/62 (65)
Adult risk indicators
Domestic violence, current 10/57 (18)
partner (a)
Mental health disorder (b) --
Ever incarcerated 47/59(80)
Substance use during
index pregnancy
Alcohol 47/60(78)
Binge alcohol 23/60 (38)
Heroin 13/60(22)
Cocaine 53/60 (88)
Marijuana 28/60(47)
Methamphetamine 0/60(0)
Cigarettes 56/60(93)
Seattle replication
(n=76) mean or n (%)
Age (mean yrs) 28.7
Education (mean yrs) 10.7
High school diploma/GED 32/75 (43)
Race
White 29/76 (38)
African American 32n6(42)
Native American 7n6(9)
Other (Hispanic, Asian) 8n6(11)
Married 12/76(16)
Number prior children 2.1
None 15n6(20)
Living with mother (mean) 0.5
Primary income source
Public assistance 60/76(79)
Employment 2/76(3)
Stable housing 34/76 (45)
Childhood risk indicators
Parent(s) abused alcohol/drugs 56/67 (84)
Physical/sexual abuse 61/76(80)
Adult risk indicators
Domestic violence, current 29/54(54)
partner (a)
Mental health disorder (b) 37/68 (54)
Ever incarcerated 62/75 (83)
Substance use during
index pregnancy
Alcohol 48/76 (63)
Binge alcohol 33/76 (43)
Heroin 18/76(24)
Cocaine 62/76 (82)
Marijuana 38/76 (50)
Methamphetamine 3/76 (4)
Cigarettes 68/76 (89)
Tacoma replication
(n=80) mean or n (%)
Age (mean yrs) 28.4
Education (mean yrs) 10.8
High school diploma/GED 38/80(48)
Race
White 45/80(56)
African American 25/80 (31)
Native American 7/80(9)
Other (Hispanic, Asian) 3/80(4)
Married 11/80(14)
Number prior children 2.3
None 13/80(16)
Living with mother (mean) 0.8
Primary income source
Public assistance 50/80(63)
Employment 4/80(5)
Stable housing 42/80(53)
Childhood risk indicators
Parent(s) abused alcohol/drugs 61/71 (86)
Physical/sexual abuse 59/79 (75)
Adult risk indicators
Domestic violence, current 22/70 (31)
partner (a)
Mental health disorder (b) 38/75 (51)
Ever incarcerated 66/79 (84)
Substance use during
index pregnancy
Alcohol 62/80(78)
Binge alcohol 45/80(56)
Heroin 10/80(13)
Cocaine 46/80(58)
Marijuana 49/80(61)
Methamphetamine 35/80(44)
Cigarettes 70/80 (88)
Replications combined
(n=156) mean or n (%)
Age (mean yrs) 28.6
Education (mean yrs) 10.8
High school diploma/GED 70/155 (45)
Race
White 74/156(47)
African American 57/156 (37)
Native American 14/156(9)
Other (Hispanic, Asian) 11/156 (7)
Married 23/156 (15)
Number prior children 2.2
None 28/156 (18)
Living with mother (mean) 0.7
Primary income source
Public assistance 110/156 (71)
Employment 6/156(4)
Stable housing 76/156(49)
Childhood risk indicators
Parent(s) abused alcohol/drugs 117/138 (85)
Physical/sexual abuse 120/155 (77)
Adult risk indicators
Domestic violence, current 51/124(41)
partner (a)
Mental health disorder (b) 75/143 (52)
Ever incarcerated 128/154 (83)
Substance use during
index pregnancy
Alcohol 110/156 (71)
Binge alcohol 78/156(50)
Heroin 28/156 (18)
Cocaine 108/156 (69)
Marijuana 87/156 (56)
Methamphetamine 38/156(24)
Cigarettes 138/156 (88)
(a) Ascertained from the Difficult Life Circumstances Scale
from Ref. (53).
(b) Information on mental health diagnosis was not collected for the
original demonstration. Diagnoses for the replication samples
include: mood disorders 38%; anxiety disorders 20%; personality
disorders 3%; others [less than or equal to] 1% each.
Table 2. Baseline and endpoint summary scores and baseline
summary domain scores of the original demonstration (1991-1995)
and Seattle and Tacoma replication (1996-2003) samples
Original demonstration
(n=60) mean (SD)
Baseline score -20.7 (6.1)
Baseline domain scores:
Alcohol/drug treatment -2.5 (3.7)
Abstinence -5.7 (1.0)
Family planning -5.0 (1.9)
Index child -2.2 (2.5)
Connection with services -5.4 (3.3)
Endpoint Score 17.0 (13.2)
Seattle replication
(n=76) mean (SD)
Baseline score -10.5 (7.5)
Baseline domain scores:
Alcohol/drug treatment 1.7 (3.9)
Abstinence -5.4 (1.4)
Family planning -3.7 (2.6)
Index child -0.8 (2.6)
Connection with services -2.3 (3.2)
Endpoint Score 27.2 (11.3)
Tacoma replication
(n=80) mean (SD)
Baseline score -11.5 (7.8)
Baseline domain scores:
Alcohol/drug treatment 0.7 (4.0)
Abstinence -5.5 (1.4)
Family planning -3.6 (2.7)
Index child -0.6 (2.5)
Connection with services -2.5 (3.3)
Endpoint Score 24.9 (13.9)
Replications combined
(n=156) mean (SD)
Baseline score -11.0 (7.6)
Baseline domain scores:
Alcohol/drug treatment 1.2 (4.0)
Abstinence -5.4 (1.4)
Family planning -3.7 (2.6)
Index child -0.7 (2.5)
Connection with services -2.4 (3.3)
Endpoint Score 26.0 (12.8)
Table 3. Exit outcomes at three sites: Original demonstration
(1991-1995) and the Seattle and Tacoma replication sites (1996-2003)
Original demonstration
(n=60) n (%)
Alcohol/drug treatment
Inpatient or outpatient 31/60 (52)
Inpatient 28/60 (47)
Outpatient 21/60 (35)
Other (e.g., AA, counseling) 27/60 (45)
Abstinence from alcohol/drugs
[greater than or equal to]
6 mo at program exit 17/60 (28)
[greater than or equal to]
1 year at program exit 10/60 (17)
Abstinence [greater than or equal to]
1 yr during program 22/60 (37)
Family planning and subsequent birth
Regular contraceptive use 44/60 (73)
Reliable method' 26/60 (43)
Subsequent pregnancy 31/60 (52)
Subsequent birth during program 17/60 (28)
Unexposed to alcohol/drugs 3/17 (18)
Primary income source
Public assistance 30/60 (50)
Employment 7/60 (12)
Index child
Custody at 3 years
Biological mother 28/54 (52)
Other family 10/54 (19)
Adopted 2/54 (4)
State foster care 14/54 (26)
Regular well-child care (b) 35/38 (92)
Connection with services
Regular family healthcare 37/60 (62)
Mental health (c) 7/10 (70)
Completed education/training 13/60 (22)
program
Completed parenting class 22/60 (37)
Permanent, stable housing 36/60 (60)
Seattle replication
(n=76) n (%)
Alcohol/drug treatment
Inpatient or outpatient 58/76 (76)
Inpatient 41/76 (54)
Outpatient 45/76 (59)
Other (e.g., AA, counseling) 55/76 (72)
Abstinence from alcohol/drugs
[greater than or equal to]
6 mo at program exit 33/76 (43)
[greater than or equal to]
1 year at program exit 26/76 (34)
Abstinence [greater than or equal to]
1 yr during program 45/76 (59)
Family planning and subsequent birth
Regular contraceptive use 56/76 (74)
Reliable method' 37/76 (49)
Subsequent pregnancy 38/76 (50)
Subsequent birth during program 22/76 (29)
Unexposed to alcohol/drugs 7/22 (32)
Primary income source
Public assistance 20/76 (26)
Employment 22/76 (29)
Index child
Custody at 3 years
Biological mother 43/76 (57)
Other family 10/76 (13)
Adopted 10/76 (13)
State foster care 13/76 (17)
Regular well-child care (b) 51/53 (96)
Connection with services
Regular family healthcare 67/76 (88)
Mental health (c) 29/37 (78)
Completed education/training 28/76 (37)
program
Completed parenting class 54/76 (71)
Permanent, stable housing 61/76 (80)
Tacoma replication
(n=80) n (%)
Alcohol/drug treatment
Inpatient or outpatient 58/80 (73)
Inpatient 49/80 (61)
Outpatient 34/80 (43)
Other (e.g., AA, counseling) 39/80 (49)
Abstinence from alcohol/drugs
[greater than or equal to]
6 mo at program exit 31/80 (39)
[greater than or equal to]
1 year at program exit 26/80 (33)
Abstinence [greater than or equal to]
1 yr during program 37/80 (46)
Family planning and subsequent birth
Regular contraceptive use 57/80 (71)
Reliable method' 42/80 (53)
Subsequent pregnancy 30/80 (38)
Subsequent birth during program 20/80 (25)
Unexposed to alcohol/drugs 8/20 (40)
Primary income source
Public assistance 21/80 (26)
Employment 23/80 (29)
Index child
Custody at 3 years
Biological mother 45/79 (57)
Other family 16/79 (20)
Adopted 11/79 (14)
State foster care 7/79 (9)
Regular well-child care (b) 58/61 (95)
Connection with services
Regular family healthcare 59/80 (74)
Mental health (c) 34/43 (79)
Completed education/training 27/80 (34)
program
Completed parenting class 50/80 (63)
Permanent, stable housing 53/80 (66)
Replications combined
(n=156) n (%)
Alcohol/drug treatment
Inpatient or outpatient 116/156 (74)
Inpatient 90/156 (58)
Outpatient 79/156 (51)
Other (e.g., AA, counseling) 94/156 (60)
Abstinence from alcohol/drugs
[greater than or equal to]
6 mo at program exit 64/156 (41)
[greater than or equal to]
1 year at program exit 52/156 (33)
Abstinence [greater than or equal to]
1 yr during program 82/156 (53)
Family planning and subsequent birth
Regular contraceptive use 113/156 (72)
Reliable method' 79/156 (51)
Subsequent pregnancy 68/156 (44)
Subsequent birth during program 42/156 (27)
Unexposed to alcohol/drugs 15/42 (36)
Primary income source
Public assistance 41/156 (26)
Employment 45/156 (29)
Index child
Custody at 3 years
Biological mother 88/155 (57)
Other family 26/155 (17)
Adopted 21/155 (14)
State foster care 20/155 (13)
Regular well-child care (b) 109/114 (96)
Connection with services
Regular family healthcare 126/156 (81)
Mental health (c) 63/80 (79)
Completed education/training 55/156 (35)
program
Completed parenting class 104/156 (67)
Permanent, stable housing 114/156 (73)
(a) Includes tubal ligation, consistent Depo Provera injections,
IUD, and Norplant implant.
(b) Among those in custody of biological mother or a family
member at exit.
(c) Among clients who expressed a need for the service.
COPYRIGHT 2005 Taylor & Francis Ltd.
COPYRIGHT 2005 Gale Group
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