Addressing Adverse Childhood Experiences (ACEs)
Through Family-Focused Services for Families Dealing with
Substance Use Disorders ©
By Rosemary Tisch, MA, and Rivka Greenburg, Ph.D.
"Rita"* was a homeless, struggling Mom, using drugs with her boyfriend, who had given her children to her mom and their various fathers to parent. Children & Family Services mandated that she attend a residential treatment center for women with children to help build a relationship with her children. As part of her treatment, a family-focused service was provided for all children and their caregivers. During group, Rita began to understand that the lack of connection with her children was due to her substance use. As the entire family attended group, the children’s multiple caregivers began to recognize how addiction had affected each of them and that healthy communication between them all was an important factor in mending a broken family. Through the family program, Rita was able to connect with her children in healthy ways and to become an interactive, loving parent with boundaries and structure. *Composite participant
“Juanita” was struggling with her recovery, self-described as “sober - but broken, with no hope”. Using drugs and alcohol since age 12, she was referred to a family-focused service, as part of Family Treatment Court, along with individual treatment for co-occurring disorders.As a child, she was sexually abused and as an adult she experienced domestic violence, witnessed by her young daughter. “Juanita” felt she would soon either hurt her daughter or herself and she did not want to keep living. Attending a family-focused group, as part of her required services, “Juanita” now enjoys a much better relationship with her daughter. The program “took me to real recovery with hope and courage to keep living and to help other single moms and families in recovery.”
Families with addiction are often dealing with multiple adverse childhood experiences: substance abuse, neglect, family violence and emotional, physical and sexual abuse. Commonly there is parental separation or divorce and often one or both parents are dealing with mental illness and incarceration. Their children are among those at highest risk for future physical and mental health problems, having experienced many adverse childhood experiences (ACEs). ACE authors have specifically noted this relationship:
The ACE Study provides population-based clinical evidence that unrecognized adverse childhood experiences are a major, if not the major, determinant of who turns to psychoactive materials and becomes ‘addicted’ (Felitti, 2003).
Growing up with alcohol abusing parents is strongly related to the risk of experiencing other categories of ACEs (Anda, 2010).
Family-Centered Services Are Effective As Prevention & Treatment
The most effective prevention programs target the whole family, delaying initiation of substance abuse, improving youth resistance to peer pressure to use alcohol, reducing affiliation with antisocial peers, improving problem-solving and reducing levels of problem behaviors (UNODC, 2009; Ialongo, Poduska, Werthamer, & Kellam, 2001). Family programs are found to be second only to in-home family support and nearly 15 times more effective than programs working with youth only. In addition, the effect of family skills training programs is sustained over time (Cheng, et. al, 2007; Miller-Heyl, & Fritz, 1998).
Family Treatment Courts (FTC), also referred to as Dependency Drug Courts, are another proven, successful treatment approach for child abuse, neglect, family violence and addiction, probably due to their focus on family-centered services. Reviews of FTCs show that “manualized, structured, evidence-based familytreatments...” are an essential component (Marlowe & Carey 2012).
Family-centered services are critical for healing, yet few evidence-based family-focused programs exist; fewer still focus on addiction.
Celebrating Families!™ (CF!)
“I can’t change the past, but I can make a better future.” CF! Graduate
One such program, Celebrating Families!™(CF!), was created specifically for families in Family Treatment Courts (FTC) and is listed on SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP). Celebrating Families!™ is a multi-family, strength-based, skills building program serving children ages birth through 17, their parents, and caregivers. The program consists of 16 sessions, emphasizing attachment, addiction prevention, stress/anxiety reduction, safety, and the development of a sense of hope and an expanded life view. The program gives parents needed skills to stay sober, to begin to heal, and to build healthy, non-violent relationships with their children. Long term program outcomes are to (1) Increase mental, physical, and spiritual health of youth and families, including preventing children’s future addiction; (2) Increase parental rates of recovery; and (3) Successfully reunify families, when appropriate.
Each session includes a healthy meal eaten in family groups; age-appropriate, skill building groups; and a structured, related Family Activity. The curriculum directly addresses issues of addiction in every session, helping anchor families in recovery and children better understand chemical dependency. It includes information on brain chemistry, life skills, resilience and asset development. Parents’ and age-appropriate children’s sessions include skills training on:
appropriate expression of feelings, including anger management
family/domestic violence (defining of healthy relationships)
how chemical dependency affects families
learning differences and Fetal Alcohol Spectrum Disorders (FASD)
limit and boundary setting
problem solving and decision making
Evaluation outcomes from multiple sites show significant positive results, with very large effect sizes in parenting skills and family dynamics. Sites have found the curriculum effective with diverse cultural, racial and socio-economic groups. Independent evaluators have documented that the curriculum:
Significantly increased the rate of family reunification, while decreasing the time - comparing Family Treatment Court outcomes before and after the addition of CF! (Quittan, 2004).
Significantly increased youth’s coping skills, ability to stay out of trouble, ability to work with others, knowledge and use of resources, and to learn new things (Jrapko, 2005).
Reduced parental use of marijuana and prescription drugs with 96% reporting that during the last 30 days they had not used alcohol or other illegal drugs and 74% had not used tobacco (Jrapko, 2005).
Effective with diverse populations, especially with Hispanic families “indicating that CF! may be effective among different ethnic groups and a valuable resource for working in ethnically diverse communities.” (Coleman, 2006).
For further information regarding CF! evaluation results and statistical analysis see www.celebratingfamilies.net.
Family-centered treatment offers a solution to the intergenerational cycle of substance use and related consequences by helping families
reduce substance use and improve child health and safety. (Werner, Young, Dennis, Amatetti, 2007)
A family centered program, such as Celebrating Families!™ addresses key adverse childhood experiences, thus helping:
children improve their mental and physical health (including addiction)
families heal, and
everyone to have the opportunity to live a safe, healthy and happy life.
Family-focused services need to be made available to all families and communities. Celebrating Families!™, an evidenced-based program offered by the National Association for Children of Alcoholics (NACoA), is a customized solution for settings with individuals, families, and communities at risk for adverse childhood experiences (ACEs), such as addiction, abuse and neglect.
“Celebrating Families!™ taught me a whole new way of life –simple things: having a meal together, how to breathe when feeling overwhelmed,
and how to set goals: “I had dreams but when you live a life like I had, they are just thoughts. It changed my life.
It gave me hope and self-esteem.” A CF! graduate
Anda, Robert. (2010) The Health and Social Impact of Growing Up With Alcohol Abuse
and Related Adverse Childhood Experiences: The Human and Economic Costs of the Status Quo.http://www.nacoa.org/pdfs/Anda%20NACoA%20Review_web.pdf. Accessed 5.18.15.
Cheng, S., Kondo, N., Aoki, Y., Yamagata, Z. (2007). The effectiveness of early intervention and the factors related to child behavioral problems at age 2: A randomized controlled trial. Early Human Development. 83(10):683-691.
Coleman, K. (2006) The success rate of Hispanics vs. non-Hispanics Participants in Celebrating Families. www.celebratingfamilies.net/evaluation_reports.htm. Accessed 5.19.15.
Felitti, Vincent. (2004) The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study.http://www.nijc.org/pdfs/Subject%20Matter%20Articles/Drugs%20and%20Alc/ACE%20Study%20- %20OriginsofAddiction.pdf Accessed 5.19.15
Ialongo, N., Poduska, J., Werthamer, L, and Kellam, S. (2001). The distal impact of two first-grade preventive interventions on conduct problems and disorder in early adolescence. Journal of Emotional Behavior Disorders, 9:146-160.
Jrapko, A., Ward, D., Hazelton, T. & Foster, T. (2005) Family Treatment Drug Court Head Start Program, Annual Report October 1, 2003 to September 30, 2004. Center for Applied Local Research. www.celebratingfamilies.net/evaluation_reports.htm. Accessed April 5, 2015.
LutraGroup. Final outcome evaluation report for Lucile Packard Foundation for Children’s Health. (2007)www.celebratingfamilies.net/PDF/FinalOutcomeEvalution_LutraGroup.pdf Accessed April 5, 2011.
Marlowe, Douglas B. and Carey, Shannon (2012) Research Update on Family Drug Courts May 2012 National Association for Drug Court Professionals. www.nadcp.org/sites/default/files/nadcp/Reseach%20Update%20on%20Family%20Drug%20Courts%20- %20NADCP.pdf. Accessed 5.18.15.
Miller-Heyl, J., MacPhee, D., Fritz, J.J. (1998) DARE to be you: A family-support, early prevention program. The Journal of Primary Prevention. 18(3):257-285.
Quittan, G. (2004) An evaluation of the impact of the Celebrating Families! Program and family drug treatment court on parents receiving family reunification services. www.celebratingfamilies.net/evaluation_reports.htm Accessed 5.15.15.
UNODC. United Nations Office of Drugs and Crime. (2009). Guide to implementing family skills training programmes for drug abuse prevention. United Nations Publication ISBN 978-92-1-148238-6.
Werner, D., Young, N.K., Dennis, K, & Amatetti, S. (2007) Family-Centered Treatment for Women with Substance Use Disorders – History, Key Elements and Challenges JBS International, Inc., and The Center for Children and Family Futures, Inc. Submitted to: Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf. Accessed 5.2.15
Some Questions From Readers
Since this looks like a program that is in place in likely several places --- is it regionally culturally sensitive? Celebrating Families!TM is unique as an evidence-based program as it came from the field, though it is researched based. So my belief (R Tisch) that the answer is yes. It is manualized and as an evidence-based program we are concerned about fidelity. (We only know it works when implemented as written.) In trainings we encourage leaders to adapt the program to make it appropriate for the community, such as White Bison Inc. enhancing the program with Native teachings for Native American communities. We also have the evaluation that found that CF! was “effective with diverse populations, indicating that CF! may be effective among different ethnic groups and a valuable resource forworking in ethnically diverse communities.” (Coleman, 2006).
Do these programs provide flexibility and work with others to avoid the "Silo" mentality. In my trauma- informed community building effort --- one thing I am seeing from "service agencies" is a territorial and silo ideology that I feel is detrimental to building trauma informed communities. Celebrating Families!TM is a program implemented by agencies in combination with their other programs. Written into the curriculum are assignments for parents/caregivers and children to attend community support groups and report back to their CF! group. As CF! consists of only 16 sessions, and participants are dealing with many ACEs, they need on-going support. Our goal is to anchor families in early recovery, preparing them for further services. In the Drug Courts, one of the main consumers of CF!, there is an array of services offered to parents/families including substance abuse treatment, individual counseling, groups for domestic/family violence, plus housing and employment support.
If this program were in a community, could it work with "grass-roots" efforts in a sharing and with a "we have a common goal" mindset? Absolutely. One of our goals is to have Celebrating Families! available in communities as a preventative program offered by “grass-roots” groups. (CF! ‘s program developers are “grass roots” folks themselves.) Some of CF! ‘s best leaders and co-leaders are graduates or other individuals who have dealt with addiction in their families, though a 3-day training is required.
©2017 Greenberg & Tisch