DES MOINES, Wash. — Kateri Whiteside looked at the pictures of her six kids on the wall: boys and girls, from toddlers to adults.
She hasn't seen some of them for years.
But she says she doesn't plan to give up on her 4-year-old daughter — the one who, on a recent day at Whiteside's duplex in this Seattle suburb, was bouncing up and down on the sofa, on and off her mom's lap, stopping only to watch YouTube videos and swing around her Poppy the Troll doll.
"I'm tired. I don't want to do dope," Whiteside said. "I want to have a chance at life, to be a mom again."
Seated on the other side of the couch was Dorothy Fowler, a social worker who has ridden the recovery roller coaster by Whiteside's side.
It's a story with so many plot twists it's hard to keep track. But it started when Whiteside was 10, when she first sold crack.
"I got addicted to the life," the now 39-year-old said.
Her parents were addicted to drugs and not around. There was no food in the house; the lights weren't on. Instead, she and her siblings found community in the streets of Tacoma, Washington.
She got pregnant at 14. She graduated to selling PCP. She got hooked on meth.
"I was literally high when I gave birth to my fourth child," Whiteside said. She cried, and gave a long stare. "She's never lived with me."
She sees one of the other five kids on the weekends, but that's it. She's holding tight to her youngest daughter, Nai'Yana — literally at times — like she's afraid to let her go.
"I can obviously say right now life is great. It's wonderful," Whiteside said, like she's still trying to convince herself.
She got connected with Fowler, the social worker, in 2014 at a treatment center for pregnant women. Nai'Yana was in her belly. Mom and daughter were later in rehab together. Whiteside said she's been clean for four years.
Fowler acted as a navigator, an advocate. She was there for Whiteside when no one else wasn't; she once picked her up from jail at 6 in the morning.
Fowler works for the King County, Washington, branch of the Parent-Child Assistance Program, an evidence-based program that tries to get pregnant women off drugs. The social workers do it any way they can — by finding open treatment beds, providing transportation to appointments — but mostly they bring structure to the lives of people who are severely lacking it.
The program, known as PCAP, was founded in the early 1990s when America's hard-drug-of-choice was cocaine. Researchers at the University of Washington had been studying its effects on fetuses. As they were enrolling women, the researchers observed the chaos in their subjects' lives, the childhood trauma that was playing itself out in reverse.
"It became really apparent to me that almost all of these women were raised in the same way they were raising their kids," said Therese Grant, PCAP's director and a professor of psychiatry and behavioral sciences at the University of Washington. "They just didn't have any kind of a template for what normal parenting would look like."
So the academics' turned their attention to the mothers — it was obvious that using drugs during pregnancy wasn't healthy for a fetus — to figure out how they could ensure the women would not give birth to another drug-exposed baby.
The researchers designed a Seattle-based program where social workers would visit pregnant women and new moms at least twice a month, over three years, to help them find and steer their way through treatment.
Twenty-eight years later, the state of Indiana, which has higher-than-average rates not only of child abuse and neglect but also of babies born exposed to opioids, plans to implement PCAP. The Indiana Department of Child Services is seeking proposals to start a PCAP pilot site. The state's interest came after a recent evaluation of DCS explicitly recommended PCAP. The report identified mental health and substance abuse treatment as being among the state's biggest needs.
Indiana puts children into foster care at twice the national average, and the parents used drugs in more than half of those cases, the DCS evaluation found.
PCAP has expanded to 18 other counties — buoyed by more than $8 million a year in state and federal funding, or about $5,800 a client — and to Canada and several other states. University of Washington researchers continue to evaluate it. They found that during the most recent five-year period, more than 90% of the program graduates had completed or were in the process of completing treatment, about three-fourths had been sober for six months or more, and 80 percent lived with their kids. Most of the women were using birth control and pursuing an education or job training. Only about 1 in 10 went on to do drugs during a subsequent pregnancy.
It doesn't work for everybody. Some women drop out along the way; some have overdosed and died (the King County branch lost one woman and three babies in the last 22 months alone). But for the ones it worked for, it provided a vital lifeline at a precarious time for them and their babies.
Andrea Turner pursued Jelicia Givens for nearly three years.
Turner, a PCAP social worker, was doing what she and her colleagues call "tracking and chasing": calling relatives, driving to favorite haunts, Googling to see if obituaries pop up.
That persistence finally paid off, though Givens' daughter had already died during childbirth.
Givens, 29, was addicted to heroin and meth four years ago when she found out she was pregnant. At first, she thought she had the flu; the random cravings for carrots and ranch dressing gave it away.
She went to treatment, where she was referred to PCAP. She stayed clean for a couple of months, but people around her were still using. She was lonely, and bored. She succumbed to the temptation.
Upon arriving at the hospital, in labor, the staff indicated something was wrong. They rushed her into surgery, for an emergency C-section.
"I was down for, I think, four hours," she recalled. "I woke up, and they told me my daughter didn't make it. After that, I fell into a huge depression. I think at one point I was having suicidal thoughts. I didn't feel like I had a purpose anymore."
The girl had died after ingesting meconium, or a baby's first stool, which, if expelled in the uterus and aspirated during labor or delivery, can block the child’s airway.
"I walked around with guilt every single day because I used during my pregnancy," Givens said. "I felt nobody loved me. They all hated me because of what happened."
She tried opioid-replacement drugs: methadone, buprenorphine. But she eventually returned to the real stuff. She wound up in jail; that's where Turner found her, years after they first met.
"I bribed her with my dog," recalled Turner, who exudes the patience and empathy of a preschool teacher (which she used to be). They met at a park. Turner drove Givens to detox.
Givens went on to a Salvation Army rehab. She graduated from that program in January. She now works at a day care and resides at a sober-living home in Seattle.
"If it wasn't for Andrea constantly checking on me and letting me know she's there, I wouldn't have had an urge to want to get clean," said Givens, who is strikingly composed yet couldn't help but cry when the two reunited in early March at the PCAP office in north Seattle. "She didn't push me, but she pushed me when I needed it. She's a true blessing."
The next day at the office, Turner was chatting with her boss, Charlene "Lena" Takeuchi, about gardening. Turner talked about "my butterfly bush that I raised from a little twig."
They switched to discussing the women they serve.
"The clients who don't succeed right away, they're not a lost cause. Because we planted the seed," Takeuchi said.
Turner had to leave, to go to the graduation of one of her clients.
"Is she with baby?" Takeuchi asked.
Turner said yes.
"Yay!" Takeuchi exclaimed.
Social worker Betsy Ward set out in one of the Hyundai Tucsons in the King County PCAP's fleet. There was a child safety seat in the back, along with books with titles like "Five Little Pumpkins" and "Mrs. Wow Never Wanted a Cow." The weather was stereotypical Seattle: overcast, drizzling.
She was headed to meet a client to drive to the methadone clinic. The woman's Hopelink Medicaid transportation hadn't showed up.
"Sometimes you have a plan for the day and things change and things fall through and you kind of just roll with it," said Ward, who has the unflappably positive vibe of someone skilled in compartmentalization.
She arrived at an apartment complex in Lynwood, Washington, a northern suburb, with a YWCA sign out front.
A woman opened the passenger door, already talking. It wasn't long before she mentioned the bank robbery. "I did it with a note," said NaVēy Skinner, the PCAP client. She had been caught and sentenced to 3 1/2 years in prison.
She said drugs — meth and heroin, specifically — "stole my soul." "When I put a substance in my body, I can't stop," she said, talking at the same constant pace as the rain. "Right now my disease is in remission. It is a disease. It's not a party thing. It's f---ing scary." She said she's been sober nearly two years.
She got linked with PCAP in rehab. She was six months pregnant. Her almost 2-year-old daughter, who has Down syndrome, is now in foster care.
PCAP doesn't give up on its mothers, even if they lose their kids. The goal is to prevent them from ever using during a pregnancy again.
The Hyundai pulled up to the methadone clinic, which was located in the back corner of a corporate office building nestled in a residential neighborhood of Everett, Washington.
"That's my homegirl right there — she's pregnant," Skinner said. She pointed to a woman, also a client of the clinic, who was pushing a stroller, smoking, her belly distended.
Skinner, 41, walked up to the clinic and came back a few minutes later, a cloud of vape juice in her wake.
The next stop was a high-end apartment community. Skinner hoped to rent there.
She didn't waste any time in telling the leasing agent about the bank robbery. The news didn't seem to faze the woman, who bonded with Skinner over their shared religiosity.
The woman showed Skinner a two-bedroom, second-story apartment that looked out into the woods. Skinner kept asking if she'd pass the background check. The woman said she couldn't say for sure.
Ward and Skinner got back into the SUV to head to the Everett YWCA. Skinner talked about the other social worker programs that serve her, an alphabet soup of acronyms that were difficult to keep up with.
She pointed out landmarks from her adolescence.
"This is the street, they call it Little Chicago," she said, of a block dotted with fast-food joints and weed dispensaries. She said there's gang activity here, drugs. She calls her hometown "Ever-rot."
Over there is the cemetery where the movie "Assassins" was filmed, she said. A pyramid-shaped mausoleum towered over the gravestones. "Every kid in Everett has climbed it on acid," she said.
She said she wanted to be a journalist but didn't go to high school. When she has worked, it was mostly as a cake decorator.
She said her mom and stepdad were "functional alcoholics," and her biological father was addicted to heroin. (Nearly 90 percent of PCAP clients had parents who abused drugs; two-thirds were physically or sexually abused as children). "I remember the first time I ever smoked pot, with two boys, Darren and Joe," she said. One of them was later shot in the head, she said, robbed for the meth he was dealing.
Older men seduced her with crack. She went to treatment for the first time at 14.
She and Ward arrived at the YWCA. Skinner came out about 15 minutes later with free clothes, cosmetics and toothpaste from the clothing bank there.
On the way home, Skinner talked about her future goals: She wants to get her criminal record erased, her driver's license, a bunion on her toe removed.
"I think I'm going to be a drug and alcohol counselor," she said. "Because I've got a lot to say."
In north Seattle, Fowler, the social worker, pulled up to a multistory apartment complex, whose buildings alternated white and clay-colored, with orange roofs and trim. The place looked new (there's construction everywhere in Seattle). On the side of the road was a public-art project: snails, squirrels, rats and pigeons, made out of street signs.
Fowler is a gentle woman who gives the impression that you wouldn't want to cross her. She often gets frustrated with clients. She is in recovery herself and knows the work it takes.
"We can connect the dots, they have to be willing to have the dots connected," she said of the women in PCAP. "People just bow down and are overwhelmed with life and just want to escape. People just want to be taken care of." She sees a lot of "program-hopping," as she called it.
Still, she added, "I have to extend the same grace to them that was extended to me."
She walked up to the complex. A young woman in a shawl cardigan, her hair in a bun, was outside with a stroller, smoking a cigarette. This was Mattie Snook.
Fowler met her when she was living in a homeless shelter with her partner and newborn baby, Homer. (To qualify for PCAP, women must have used during their pregnancies; they don't have to be pregnant at the time).
Snook heard about PCAP from a friend who was a client. She knocked on its door, asking for help.
She had been addicted to heroin for about a decade. She thought she was infertile, she said, so she hadn't been using protection.
"In a perfect world, I thought getting pregnant would make me stop using," she said.
Homer was born last May, two months early. He was dependent on opioids because Snook had been taking methadone (legally). He had to be put on morphine for 17 days to treat his withdrawal.
"He was ready to come when he came," Snook said. "I had to learn I was going to be on his schedule for the rest of my life."
The 33-year-old said she's been clean for a year now. She goes to meetings with a friend who also has an infant. A nonprofit called Muslim Housing Services helped her get the apartment. She hopes to become a death doula, providing comfort and holistic care to people at the end of their lives.
Fowler ate one of the gluten-free, ancient-grains-mix cookies Snook had just baked. Fowler doted over Homer.
"He's adorable," she said. "Hmm, hmm."
"He's my lifesaver," Snook said. "If it wasn't for him I know I wouldn't have gotten sober, for sure."
Homer rolled around the floor, matching every smile he saw with one of his own. He was learning to crawl, his mom said.
This series was produced as a project for the USC Center for Health Journalism's Data Fellowship.