The Leadership Institute

The Leadership Institute is a community-based learning and planning experience that focuses on developing a system of care for pregnant and parenting women at risk for alcohol, tobacco and illicit drug use and, for those children who are born affected by prenatal exposure, ameliorating the effects through early intervention and the use of research-proven treatment strategies.

The Leadership Institute has two dimensions:

  1. Preventing prenatal substance exposure.
  2. Helping young children who have been substance-exposed (and other high-risk children) early in life when there is time to make a difference in their lives. 

In combination, these two dimensions help a community avoid the human and financial costs of prenatal substance exposure and serious emotional and behavioral problems of early childhood.

The case of Jose makes a strong argument in favor of early intervention.

The Case of José 
Jose is a child in a rural California County.  At first glance his story is one of an unstable home, disordered parents and, ultimately, his own self-destructiveness.  But, on closer inspection, it also is a story of fragmented services, another child lost in a morass of good intentions but poor follow-up.  A review of what happened along the way was created when Jose was thirteen years old. 

Jose’s difficulties were known as early as kindergarten when he was referred to the school’s high risk program.  Before José was in second grade, seven referrals had been made to the Department of Children and Family Services (DCFS) on his behalf.  In first grade it was noted in his Individual Education Plan (IEP) that he was testing very low academically and had severe behavior problems.  In second grade his records included references to “enuresis, conduct disorder, anxiety, a possible learning disability” and a request for a mental health consultation that was dropped due to lack of follow up.  The family was in crisis, and three more referrals were made to DCFS citing a lack of supervision, alleged physical abuse and possible drug use.  By the sixth grade, José was viewed as out of control and dangerous.  He experienced frequent suspensions from school and was placed on probation after he stole his father’s car.  He was expelled after he assaulted a student.  Jose finally received a full mental health assessment at the end of sixth grade, several years after it was first requested. At age 13 Jose has a first grade reading level and has been expelled from school for fighting.  He is gang involved, uses drugs and is noncompliant with court orders.  Jose’s mental health records indicate he is “sad, depressed, paranoid; has nightmares; wets his bed; and experiences insomnia”. 

The review of Jose’s case showed that 23 different agencies had come into contact with the family over a seven-year period.  Several of the agencies were delivering similar services to multiple members of the family, and in many instances the services for each family member were being duplicated by several agencies at the same time.  We can assume that none of the agencies set out to fail Jose, and no professional with whom he came in contact was indifferent to his problems. But the community must ask, “How could so much effort and money yield so little real help for this young boy?”  And, perhaps more importantly, “How can we do better for the Jose’s in our system today and tomorrow?” 

When we visit other communities and share Jose’s story, community leaders inevitably acknowledge that they have their share of Jose’s – too many.  

The human cost of lost potential and the suffering which could have been avoided is clearly represented in the case of Jose.  But, we must also consider the financial costs.  One iconic statistic makes the case - children like Jose often find themselves in foster care, and because there is no suitable and willing family for them, they live in group homes.  The costs for these group homes vary from place to place but the $3000 per child per month paid in Southern California by San Bernardino County means the county spends $6M each month for group homes - $72M/year. 

There are many other costs - special education, medical and dental, foster care and all too often courts and corrections.

There are many other costs - special education, medical and dental, foster care and all too often courts and corrections.

Does The Leadership Institute Work?
“I have been in the maternal child health field for many years, and for the last 20 years, we have been trying to address the problem of prenatal substance abuse in our county.  It was not until our team attended the Leadership Institute's Leadership Institute, that we actually were able to implement a perinatal substance use assessment program with our Obstetricians and begin screening all pregnant women in our county for the use of tobacco, alcohol and illicit drugs.  We have accomplished more in the last three years than we had been able to do in 20 years.  The institute helped us focus on our vision, set goals and objectives, and develop a scope of work that was easy to implement and support within our community.” - Jan Campbell, RN, PHN, Maternal Child and Adolescent Health Director, San Luis Obispo, Ca.

Where is The Leadership Institute Being Implemented?
The red dots indicate the states in which The Leadership Institute is being implemented.  In some cases single counties/regions have begun the process, for example Tulsa, Oklahoma, is the only location in Oklahoma implementing the process.

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In other cases, most notably California, Kentucky and New Jersey, The Leadership Institute has been adopted in multiple communities, as the map of California illustrates.  Some communities are in the early stages of the process while others are implementing one or both aspects – perinatal and children.

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How Does The Leadership Institute Work and What Is SART?
The Leadership Institute works by establishing two SART processes. SART is an acronym for screening, assessment, referral, and treatment.  There two SART processes – one for preventing perinatal substance exposure (Perinatal SART) and one for providing early intervention services to high-risk children (Children’s SART) share the acronym but are quite different

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How is a Perinatal SART©  Established?
Establishing a Perinatal SART© process involves several stages that unfold over a period of approximately 18 months, though, obviously, there is considerable variability among the communities with regard to how quickly they implement the process.  Every effort begins with a vision.  Here is a typical vision for the implementation of a Perinatal SART© process:

In Butte County, every baby will be born free of the effects of alcohol, tobacco, and drug exposure.  We will educate and unify the community to establish a comprehensive, effective program of screening, assessment, referral and treatment for at-risk women and children.

That is a vision of the end state – a SART process fully implemented.  How to get there? The development and implementation of a Perinatal SART© process occurs in six stages.

I.              Building Awareness and Resolve

II.             Leadership Team Formation and Preparation

III.            Leadership Institute – Initial Planning 

IV.            Building Community Support

V.             Formal Plan Development

VI.            Full Implementation

How is a Children’s SART Established?                                                        

The road leading to a SART process for high-risk children proceeds through four stages:

I.  Design
II.  Implementation Planning
III. Start-Up of the Children’s Center
IV. Technical Assistance  - Clinical and Organizational

Here is how two communities expressed their aspirations for their Children’s SART© process:

San Bernardino County is committed to providing all high-risk children the services and support they need to reach their full potential.  We agree to do this in a collaborative spirit, respecting the county’s diversity and the challenges inherent in the geography of our community. 

The community of San Luis Obispo County is dedicated to ensuring that all children will:

  • receive any interventions, treatment and support they may need to reach their highest level of growth and development;
  • live safely in their homes, succeed in school, and have meaningful friendships: and,
  • Grow up to be healthy, strong, and resilient citizens of our community.

If that is what a community hopes to accomplish here, briefly, is how.

Design
The design phase begins with a 3 ½ day planning session – The Leadership Institute very much in the style of the Leadership Institute which helps begin the process for developing a Perinatal SART© process. The design process of discussion, analysis and writing ultimately produces a document which describes a model of care for young children most often children between the ages of zero and five.

Implementation Planning: The Children’s Center
The design phase provides all the basic concepts and leads to implementation planning which addresses the specifics of how screening, assessment, referral and treatment will be provided.  Each of these aspects of the Children’s SART process requires careful planning but the assessment function is of particular importance.

The development of a Children’s Center to house a transdisciplinary team is no small undertaking both organizationally and financially.  Some communities because of their geographic size of required the development of more than one Children’s Center.  Some communities have a wealth of clinical talent and staffing the Children’s Center is a matter of choosing the best and other communities may struggle to find competent professionals interested in joining the effort.  The Children’s Center must be financially sustainable in this part of the planning receives particularly close attention.

Start-Up of the Children’s Center
The clinical staff of the Children’s Center participates in a Clinical Institute offered in partnership with the Children’s Research Triangle in Chicago.  The Clinical Institute is a four-day hands-on experience beginning in Chicago where the staff of the Children’s Center work side-by-side with experienced professionals at the Children’s Research Triangle. Shortly thereafter members of the Children’s Research Triangle visit the newly developed Children’s Center to coach the staff as they work with their first patients.

We strongly recommend a controlled startup phase during which time the number of children seen by the staff of the Children’s Center is intentionally kept low to ensure that the clinical and administrative processes function properly. 

Technical Assistance - Clinical and Organizational
During the first few months clinical and organizational technical assistance is made available on an as needed basis.  Experience has taught that more rather than less technical assistance is needed. The Children’s Center represents a significant investment for the community and going the extra mile to insurer its proper functioning as proved to be a wise choice.

The Leadership Institute Agenda
A glance through The Leadership Institute agenda reveals the interplay between information sharing and time for planning.  The program content and schedule follows a core concept but may vary to accommodate the needs of a particular team.

Here is the basic agenda for a Perinatal SART Leadership Institute. The Children’s SART Leadership Institute shares the balance of input and planning but the content is geared to the problems of high-risk children.

DAY ONE:
8:30 AM Continental breakfast
9:00 AM Welcome and introduction of team and faculty  
9:15 AM Overview of The Leadership Institute  
9:30 Am Integrating Screening and Assessment Strategies Across Systems of Care 
In this session Dr. Chasnoff reviews the relevant literature on drug use patterns among pregnant women and a variety of approaches to screening.  The research background on the 4Ps Plus screening instrument is described.
12:00 Noon Lunch
1:30 PM SART Flow Chart and Community SART Audit
In this session Dr. McGourty initiates the planning process with a systematic review of the county’s strengths and weaknesses with regard to screening/assessment, referral to treatment and treatment programs. Subsequent sessions labeled "action planning" are an extension of the process begun in this session. 
3:30 PM Action Planning - Identifying Leverage Issues 
“Identifying Leverage Issues” is the process whereby the team determines the issues which will constitute the key elements of their plan.   
5:00 PM Adjourn
6:30 PM Team and Faculty Dinner 

DAY TWO:
8:30 AM Continental breakfast
9:00 AM A Model for Gender Specific Treatment of Mothers and Their Children
In this session Dr. Chasnoff clarifies what is meant by "gender specific treatment" and provides the research and theoretical background supporting the use of gender specific treatment.  With this information as background the team will identify opportunities to support substance abuse treatment programs for pregnant and parenting women. 

10:45 AM Action Planning – Formulating a Vision
A shared vision is critical if the plan will be acceptable to the community and will foster commitment by key groups and individuals. A review of vision statements generated by other teams helps start this process. Dr. McGourty will lead this process.   
12:00 Noon Lunch
1:30 PM The Biological Basis of Behavior: Implications for Children Exposed to Substances
This session highlights a "brain-based" approach to understanding children who have been exposed to substances. The implications of this understanding for a prevention oriented approach of the community are spelled out.
3:00 PM Action Planning – Goal Setting
Goal-setting is begun in this session. The goals which constitute the plan are typically set within six categories

  • Organizational Preparation (those things which have to be done to prepare the community for implementing the SART process);
  • Screening and Assessment;
  • Referral;
  • Treatment;
  • Professional Education; and,
  • Community Education 

5:00 PM Adjourn

DAY THREE:
8:30 AM Continental breakfast
9:00 AM Action Planning
Drs. McGourty and Chasnoff work with the team to formulate the action plan. 
10:45 AM Systems Integration: CRT’s Child Study Center Model
"Systems integration" is contrasted with "service integration" in order to highlight the advantages for a county that takes a systems oriented approach.  The commonly referred to problem of organizational silos which impedes the provision of services is examined. 
12:00 Noon Lunch
1:30 PM  Action Planning - Goal Setting
Drs. McGourty and Chasnoff work with the team to formulate the action plan. 
5:00 PM Adjourn

DAY FOUR:
8:30 AM Continental breakfast
9:00 AM Final Review of the Action Plan   
11:00 AM Team Functioning
This brief session focuses on those aspects of team functioning which have been shown over time to be associated with success. Suggestions are made for how the team can coordinate its efforts.
11:00 AM Next Steps
Team members decide who in their community will receive a courtesy briefing about the results of the Leadership Institute.  The practical matter of establishing a place and time for the team’s first meeting is addressed.      
12:00 Noon Adjourn

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