Michelle Ellen Besse, LMFT, RPT-SProgram Coordinator

Alcohol and Drug Services, Sacramento County

Prenatal Substance Exposure

Learning ObjectivesStigma of Substance Use During PregnancyEffects of Prenatal Substance Exposure on Humans Long Term Impact of Prenatal Substance ExposureFetal Alcohol Syndrome and Alcohol Related Neurological DisorderAlcohol and Drug Services Programs/ ServicesPerinatal Services

According to SAMHSA about 15% of babies born in the United States have some sort of prenatal substance exposure.

Sacramento County 2017 and 2018

0 10 20 30 40 50 60

2017

2018

Perinatal Drug Use PercentagesMarijuana Opiates Methamphetamines

Drug of Choice for Pregnant Women Admitted into Residential

Addiction is not a choice

No one ever wants to be an addict, including pregnant women.

Women do not want to cause harm to their unborn child.

Most pregnant women would stop using if they had the tool they needed.

It is hard to ask for help and even harder when you are pregnant due to the stigma and the shame clients feel.

Even though as professionals we are aware that addiction is not a choice it is very common for us to have feelings about clients who are exposing their unborn babies to alcohol and other drugs.

Prenatal Substance Exposure

Shame and Stigma

How to manage our own feelings…

Providers have feelings too. It is normal to feel _______________________ about someone who

causes harm or whose behavior has negative impacts to a baby. It is ok to admit to the these feelings. Give your self permission to

acknowledge them and then work to manage these emotions. Self Care, Coping Skills, Healthy Boundaries with Clients, and

Work/Life Balance. Remember Addiction is a disease. We don’t judge diabetics for

not managing to control their blood sugar by diet. We don’t insist people with depression manage their symptoms without medication. We need to encourage clients to get the tools they need to manage their addiction and continue to be supportive.

INSERT ANY FEELING HERE

Don’t let your feelings make it harder for

women to talk about their substance use disorder or ask for

help for themselves or their children.

Remember why you are here and don’t lose yourself in the process

Substance exposure is BADfor unborn babies

Obviously we all know this… But why? • Physical Changes• Emotional Impact• Impacts as an Infant• Impacts as a Child into Adulthood

Medications vs. SubstancesEven though medications effect the baby, the mother is under a doctors care. The doctor is working with the mother to have the best and most healthy outcome for the mother and the baby.

Methadone is a medication not a substance.

Methadone is an appropriate medication prescribed by a doctor to pregnant women.

MAT services are consideredto be the BEST Practice and standard of care for pregnant women with an opioid use disorder. This is the safest option for both mother and baby.

Advantages of Methadone

Decreased Risks Associated With:• Needle Use• Drug-Seeking Behaviors• Exposure to Drugs of Unknown

Concentration and Impurities• Fluctuating Drug Highs and

Withdrawals

Increased Safety Through:• Physician Monitoring• Steady Dose• FDA Regulated Medication• Increased Prenatal Care• Specific Prenatal Groups

EVEN AFTER THE SUBSTANCE LEAVES THE FETUS OR BABIES SYSTEM THE IMPACT LASTS A LIFETIME.

Physical Impacts on Infant“Individuals whose mothers used methamphetamines during pregnancy, with or without alcohol use, had structural abnormalities in the brain that were more severe than those seen in children whose mothers abused alcohol alone.” Sowell

Impact to central nervous systemSensory sensitivityLow birth weightLow birth lengthRespiratory defectsHeart defects

Emotional Impact

• Attachment• Impulsive Behaviors• Self Perception• Self Esteem

AttachmentAttachment is an emotional bond between a caregiver and a child. There are different types of attachment. These include secure attachment, anxious attachment and avoidant attachment. Attachment style is developed through a cycle of infants expressing a need and then being soothed and responded to consistently by a caregiver. A child can love a caregiver but not be securely attached.

Difficulty with state regulation, sensory issues and a dysregulated central nervous system can impact attachment. When infants have difficulty being soothed and caregivers feel unsuccessful this increases the difficulty completing the attachment cycle.

Behavioral Difficulties

Impulsive BehaviorsDifficulty Regulating EmotionsIrritabilityNon Compliant Behaviors (Appears)

This is hard on adults as well as the kids, impacts social relationships, family relationships, school, sports and every area of life.

Impacts on Child Learning Difficulties

Behavioral Problems

Social Difficulties

Difficulty Regulating Emotions

Causes continued difficulties in school which impacts higher education and/or work and career paths.

Continued Impulsivity

Continued Social Difficulties

Difficulty Managing Feelings

Easily Overwhelmed

Outcomes as Adults

LearnHave positive

behaviorsMake friends

When we look at our society’s expectations of children from preschool through adolescents we expect them to…

Building Blocks of LifeUCLA researchers have said “These drugs are likely altering the trajectory of development, and clearly not in a good way as there are enormous developmental changes that take place during adolescence.”

FetusPrenatal Exposure

InfantPhysical and Emotional Impact

ToddlerEmotional and Behavioral Effects

School AgeSocial Impact and Learning Difficulties

Teen and Early AdulthoodSocial Impact and Learning Difficulties

Fetal Alcohol Syndromeor Alcohol Related Neurological Disorder

Fetal Alcohol Syndrome is:

Specific Diagnosis which includes:

Confirmed Alcohol Exposure

Physical Impacts

Neurological Impact

Alcohol Related Neurological Disorder is:

Specific Diagnosis which includes:

Neurological ImpactConfirmed Exposure

* Not Necessarily Physical Impacts

Physical Facial Features 19-26 day of gestation

These facial features along with the impact on brain development does not stop when babies grow into children and adults.

Physical Impactof Alcohol

Midline Teratogen Impacting

Cleft Palette Heart DefectsCurved in Pinky

Finger Separation

Between Toes

Both Brains are of 6 week old infants

A= 14 year old with normal corpus callosumB= 12 year old with Fetal Alcohol Syndrome and a thin corpus callosumC= 14 Year old with Fetal Alcohol Syndrome and Agenesis (absence) of the corpus callosum

The corpus callosum impacts the way information travels across the brain

Neonatal Abstinence Syndrome and Beyond…Withdrawal Symptoms Body Shakes

Seizures

Overactive Reflexes

Tight Muscle Tone

High Pitched Crying

Excessive Crying

Excessive Sucking/ Poor Sucking

Fever, Sweating or Blotchy Skin

Diarrhea

Throwing Up

Breathing Problems

Stuffy Nose or Sneezing

How to Reduce the Negative Effects of NAS

Allow breast feeding if the mother is on Medication Assisted Treatment

Swaddling Low Lighting Reduced Noise Allow for bonding (if

appropriate)

Prenatal Methamphetamine Exposure

• National Institute on Drug Abuse study finds that children who were exposed to methamphetamines• Infants display a reduced neonatal size and increased

lethargy• At 3-5 years old they were more emotionally reactive,

had higher rates of depression and anxiety• At 5 years old had increased externalizing behaviors

including defiance and aggression• Data suggest that methamphetamine use during

pregnancy could disrupt the normal development of the frontal cortex, says Dr. Linda LaGasse at the Warren Alpert Medical School of Brown University and Women and Infants Hospital in Providence, Rhode Island.

• The frontal cortex is responsible for ability to control impulsive behaviors, focus, and have sustained attention.

..

Alicia Lieberman-

https://www.bing.com/videos/search?q=infant+parent+psychotherapy+alicia+lieberman&&view=detail&mid=949B2F452FB24806AA39949B2F452FB24806AA39&&FORM=VRDGAR

The relationship with a child and their parent significantly impacts how the child sees themselves and relates to the world. It is important for prenatally exposed children to have parents who are understanding that these behaviors are not intentionally bad but a result of changes in brain developments that impacts their behaviors.

How are Meth and Syphilis Related?Methamphetamine increases risk taking behaviors which includes sexual risk behaviors; having multiple partners, inconsistent condom use, exchanging sex for money or drugs and poor choices in partners.

Babies in Sacramento County are being born with the disease after contracting it from their mothers.

How Big is The Problem? An estimated 600,000 people in the US are weekly

meth users. In 2015, 1.7 million people reported using meth in

the last year. California has the SECOND HIGHEST syphilis rate in

the country. In the last five years the number of syphilis cases

jumped by 38 percent.

6.26.8

7.5

11.1

13.3

4

6.1

7

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10.5

2.1

3.1 3.4

4.7

5.8

1

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15

2013 2014 2015 2016 2017

DRUG USE AND SYPHILISMethamphetamines and Syphilis Injecting and Syphilis Heroin and Syphilis

Sacramento County put out a campaign to raise awareness in the community highlighting the risks of pregnant and breast feeding women using substances.

Perinatal Clients Admitted in FY 2018-19 Source: California Outcome Measurement Service (CalOMS) Treatment System

Outpatient Treatment: 45% Withdrawal Management: 8% Residential Treatment: 22% Medication Assisted Treatment: 25%

Sacramento CountyAlcohol & Drug Services

Family Drug Court DataSource: Sacramento County FY 2016-17 Family Drug Court Annual Evaluation Report

18%

53%

11%

16%

2%

Dependency Drug CourtPrimary Drug of Choice Fiscal Year 2016-17

Alcohol MethamphetamineMarijuana OpioidsOther

17%

43%

22%

12% 6%

Early Intervention Family Drug CourtPrimary Drug of Choice Fiscal Year 2016-17

Alcohol MethamphetamineMarijuana OpioidsOther

Effective Treatment

Treatment for Mothers Outpatient Treatment

Intensive Outpatient Treatment

Residential Treatment

Detox/ Withdrawal Management

Medication Assisted Treatment (there is no medication assisted treatment for methamphetamines, opioids only.)

Treatment for Infants and Children Attachment Based Therapy

Therapy that Involves Soothing Touch

Sensory Integration

Tutoring

Stable Environment

Regional Center

Individual Education Plan School Services

Aside from the general Alcohol and Drug Services we offer to all

Sacramento County Residents we have a

Specialty Perinatal Continuum of Carefor pregnant and parenting women called Options for Recovery

Options for Recovery Residential Treatment 90 Day step down

program which filters into the intensive outpatient treatment program and includes a sober living component.

Intensive Outpatient Treatment Intensive step down

program starting with 4 days per week 6 hours per day and decreases over a 9-12 month period ending with 1 day per week for 3 hours.

Options for Recovery No waiting for services

Walk in Beginners Group Two Days Per Week

Case management

In-depth Perinatal Specialty Assessment

Education about continued prenatal exposure

Link to prenatal care

Wrap around approach addressing the needs of both women and their children.

Philosophy Treating not just the woman as a whole person but treating the child as a whole person too. Providing a step down continuum of care with a program lasting between 12-16 months of treatment. Including ability to have child in treatment with them throughout this time.

Beginners Group Services

Residential Treatment

Our residential program, in addition to standard alcohol and drug treatment it includes addressing trauma, abuse, domestic violence, parenting and co-occurring/mental health.

We provide ongoing therapy by a licensed marriage and family therapist to the women.

We have linkage to a psychiatrist with appointments reserved specifically for our residential clients.

We also have a weekly yoga for recovery and relapse prevention. This was added in 2018 as a result of the latest research looking at how yoga is successful treatment for trauma and how to use yoga for relapse prevention.

When someone abuses drugs or alcohol regularly, some of the pathways in the brain are altered, and the pathways related to feeling pleasure, regulating emotions, making sound decisions, and controlling impulses may be negatively affected. After a period of time without the influence of drugs or alcohol, brain chemistry and circuitry can heal and rebuild itself. Yoga may be able to help with this as well.

Yoga has been found to be use as an adjunct to traditional recovery services. This does not replace services but is used in addition.

Stress Relief

Pain Relief

Better Sleep

Increased Energy Levels

Emotional Healing

Reduction in Fatigue

Assists with withdrawal

Mental Health TherapyLicensed Marriage and Family Therapist who provides co-occurring disorder group along with weekly therapy appointments to the women in the program.Many of our clients have experienced extreme trauma, and abuse. These traumatic experiences have impacted their substance use disorder. We work with the clients to help them find healthy ways to process and cope with these traumas.

Sacramento County Alcohol & Drug Services

Options for Recovery Perinatal Residential Treatment Program

Admissions Data Fiscal Year 2018-19

47% successfully completed treatment17% had child(ren) residing with them during treatment63% Clients had Child Protective Services involved38% received a co-occurring mental health diagnosis17% received MAT services for Opioid Use Disorder21% were pregnant at the time of intake33% went directly into our Options Transitional Housing

Mather Sober Living EnvironmentWomen who do not have housing can be transferred directly from residential to the sober living program. Women and their children can live in the program. Currently the program houses 16 women and 30 children. In the sober living program, women and their children are transported directly to outpatient treatment. They are provided case management, employment assistance and parenting support.There is also child care and tutoring available on campus.

Options for Recovery Sober Living Environment

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5

10

15

20

25

30

35

40

17/18 18/19

Sober Living Participants

Women Children

Options for Recovery Outpatient Four Day

Four days per week six hours per dayIncludes Domestic Violence GroupsEscaping the Sex Trade GroupsParenting ClassesHealthy Relationships and BoundariesInfant Massage (First Play)Play CareLinks to Prenatal CarePsychiatry Appointments on SiteMental Health Treatment with a Licensed Marriage and Family Therapist

Three days per week 3 hours per dayIncludes Beyond Trauma GroupsParentingLife SkillsDomestic ViolenceEmployment Readiness Play Care

Mental Health Treatment with a Licensed Marriage and Family Therapist

Options for Recovery Outpatient Three Day

Options for Recovery Outpatient *One Day

Relapse Prevention paired with continued mental health

support and case management. Links to on going

services in the community.

Sacramento County Alcohol & Drug ServicesOptions for Recovery

Perinatal Outpatient Treatment Program Admissions

128

147

85

100

156

224

0

50

100

150

200

250

Fiscal Year2017-18

Fiscal Year2018-19*

Admissions Successful Completions Children Residing with Mother during Treatment

Options for Recovery Outpatient Stats

2017 156 Children Served

66% of clients who admitted into any part of outpatient completed.

96% of the clients who startedthree day treatment completedthree day treatment.

2018 224 Children Served

68% of clients who admitted into any part of outpatient completed.

97% of clients who started three day treatment completed three day treatment

Weekly Multi Disciplinary Team Meeting to Discuss Issues

Yearly All Staff Meetings

Regular Contact

Respect and Kindness

Michelle Ellen Besse, LMFT, RPT-SAlcohol and Drug ServicesSacramento County

(916) 875-2058bessem@saccounty.net

References www.addiction-intervention.com/addicition/prenatal-exposure -to-

methamphetamines https://www.sacbee.com/news/local/health-and-

medicine/article175828221.html Centers for Disease Control and Prevention http://www.towleroad.com/2019/02/rise-in-meth-use/ https://ncsacw.samhsa.gov/resources/substance-exposed-infants.aspx https://americanaddictioncenters.org/therapy-treatment/yoga https://www.cdc.gov/ncbddd/fasd/documents/cdc-activities-reducing-fasd-

fact-sheet-508.pdf https://www.cdc.gov/ncbddd/fasd/facts.html https://archives.drugabuse.gov/news-events/nida-notes/2012/12/prenatal-

methamphetamine-exposure-linked-problems