substance exposed infants: policy and practice

Substance Exposed Infants: Policy and Practice

25371 Commercentre Drive, Suite 140Lake Forest, CA 92630

[email protected]

www.ncsacw.samhsa.gov

Oklahoma Specialty Court Conference October 11, 2013

Linda Carpenter, M.Ed.

A Program of the

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

and the

Administration on Children, Youth and FamiliesChildren’s Bureau Office on Child Abuse and Neglect

The National Family Drug Court Technical Assistance and Training Program is supported by Award No. 2009-DC-BX-K0609 awarded by the

Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs.

Statement of the Problem

Substance Use and Child Maltreatment

Substance use and child maltreatment are often multi-generational problems that can only be addressed through a coordinated approach across multiple systems to address needs of both parents and children

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Child Welfare and Parental Substance Abuse

• Almost one-third of all children entering foster care are under age 3.

• Children under age 3 constitute the largest cohort of victims of substantiated cases of abuse and neglect.

• Children under age 1 are involved in over one-third of substantiated neglect reports and over half of all substantiated cases of medical neglect.

Promoting the Healthy Development of Young Children in Foster Care ; Sheryl Dicker, JD, Executive Director, and Elysa Gordon, MSW, JD, Senior Policy Analyst, Permanent Judicial Commission on Justice for Children; 2005

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2009 Child Welfare Data Children Entering Foster Care 10/08-9/09

Age Group of Victims Number Rate per 1,000 Rate per

1,000 in 2003

Age <1 40,931 16% 14%Age 1 19,230 8% 6%Age 2 16,701 7% 6%Age 3 14,021 6% 5%Age 4 12,717 5% 5%Age 5 11,372 4% 4%

Total 114,972

ofTotal 255,418

46% 40%

Source: Data (USDHHS, 2010)

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2009 Child Welfare DataTypes of Abuse

Of the approximately 3.3 million referrals for child maltreatment in 2009, the number of nationally estimated duplicate victims was 763,000; the number of nationally estimated unique victims was 702,000.

Neglect 78.3%Physical Abuse 17.8%Sexual Abuse 9.5%

Psychological/Emotional Abuse 7.6%

Medical Neglect 2.4%Total >100 as children may

have suffered more than one type of abuse

Source: Data extracted from Table 3-12 (USDHHS, 2010)

• Prenatal exposure• Postnatal environment:

- Living with a parent with a substance use disorder

- Trauma- Separation and

attachment

Impact on the Child

Prenatal screening studies document 11-15% of infants were prenatally exposed to alcohol, tobacco, or drugs

Prenatal Exposure

National vs. LocalRates of Positive Screens

0%5%

10%15%20%25%30%35%40%45%50%

Alcohol Tobacco IllicitDrugs

CALANJILHINVSo Oregon

(C) NTI Upstream, 2010

What is the Impact of Prenatal Substance Use on the Child?

• The type of drug the mother used• How the mother's body breaks down the drug• How much of the drug she was taking• How long she used the drug• Whether the baby was born full-term or early

(premature)http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004566/

Impact of Prenatal Substance Exposure

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004566/

Methamphetamine

• Long-term outcomes still unknown• Some research indicates deficits with visual recognition,

place navigation, and verbal memory• Early research suggests some deficits with overall

cognitive abilities and academic deficits

Methamphetamines

• Over the years, studies have shown differing results• Generally, minimal to no difference in cognitive abilities• Expressive language deficits, but no notable deficits in

receptive language skills• Dysregulation in infancy/early childhood with increased

rates of ADHD

Cocaine

Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive illegal or prescription drugs while in the mother’s womb. Babies of mothers who drink during pregnancy may have a similar condition.


Neonatal Abstinence Syndrome (NAS)


Neonatal abstinence syndrome occurs because a pregnant woman takes addictive illicit or prescription drugs such as:• Amphetamines• Barbiturates• Benzodiazepines (diazepam, clonazepam) • Cocaine• Marijuana• Opiates/Narcotics (heroin, methadone, codeine)



http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0000558






• Symptoms depend on the drug involved. They can begin within 1 - 3 days after birth, or they may take 5 - 10 days to appear

• May stay in hospital longer• Sharp increase in the rates of NAS over the past

decadehttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004566/



• Blotchy skin coloring (mottling)• Excessive sucking• Fever• Increased muscle tone• Poor feeding• Seizures• Slow weight gain• Tremors• Diarrhea

• Excessive crying or high-pitched crying

• Hyperactive reflexes• Irritability• Rapid breathing • Sleep problems• Vomiting



http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003023/


• The most severe consequence of exposure to alcohol during pregnancy is Fetal Alcohol Syndrome (FAS), the largest preventable cause of birth defects and mental retardation

• Fetal Alcohol Spectrum Disorder (FASD) – full range of effects

Alcohol

• Refers to the range of physical, neurological and developmental/growth impairments that can affect a child who has been prenatally exposed to alcohol

• Factors can influence the severity of impairments and what functions they most affect. (i.e. frequency, quantity and at what point during the pregnancy)

Fetal Alcohol Spectrum Disorder (FASD)

Symptoms include: • Delayed growth, small head size, heart defects• Delayed development and problems in three or more

major areas: thinking, speech, movement, or social skills• Characteristic facial dysmorphology

Fetal Alcohol Spectrum Disorder (FASD)

Impacts multiple areas of the brain:• Frontal lobes

- Decision making• Limbic system

- Emotional controls• Parietal lobes

- Sensory integration and language

• Basal ganglia- Movement and impulse

• Corpus of brain is impacted- Communication across

the two sides of brain

Size of the brain is impacted.Adapted from

Dr. Erin Telford, 2012Children’s Research Triangle

Chicago, IL

Prenatal Exposure to Alcohol

• Fetal Alcohol Syndrome (FAS) is one of a spectrum of neurological impairments that can affect a child who has been exposed to alcohol in the womb

• Children with FAS have distinctive facial features:

Fetal Alcohol Syndrome (FAS)

• Larger amounts of alcohol appear to increase the problems. Binge drinking is more harmful than drinking small amounts of alcohol

• Timing of alcohol use during pregnancy is also important

• Alcohol use appears to be the most harmful during the first 3 months of pregnancy; however, drinking alcohol any time during pregnancy can be harmful

No “safe” level of alcohol use during pregnancy has been

established.

http://www.ncbi.nlm.nih.gov/pubmedhealth/P H0004566/

Impact on the Child


• Poly-drug use is common—difficult to differentiate the effects of specific drugs

• Poor prenatal care, nutrition, trauma, stress also impact prenatal development

• Critical to document history or prenatal substance exposure

Prenatal Exposure: Complicated Issue

• Executive functioning problems, inability to self-regulate and to generalize across situations

• Gross and fine motor delays

• Attention problems• Memory difficulties • Attachment disorders

Children of parents with substance use disorders are

at an increased risk for developing their own

substance use and mental health problems.

Impact on the Child

Disruption of parent/child relationship, child’s sense of

trust and belonging

Impact of living in a household with parental substance use disorders:• Severe, inconsistent or

inappropriate discipline• Neglect of basic needs: food,

shelter, clothing, medical care, education, supervision

• Situations that jeopardize the child’s safety and health (e.g. drug manufacturing and trafficking)

• Chronic trauma

Impact on the Child

Trauma disrupts all aspects of normal development, especially during infancy and early childhood, including:• Brain development• Cognitive growth and learning• Emotional self-regulation• Attachment to caregivers and

social-emotional development• Trauma predisposes children to

subsequent psychiatric difficultiesLieberman et al., 2003

Childhood Trauma

• They are children who arrive at kindergarten not ready for school• They are in special education caseloads• They are disproportionately in foster care and are less likely to

return home• They are in juvenile justice caseloads• They are in residential treatment programs

What Happens to Children Whose Own Needs are Not Addressed?

Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL

Secondary Disabilities

Executive Functioning Problems

Shift

Emotional Control

Initiate

Working MemoryPlan/Organize

Monitor

Inhibit


Academic Deficits

Some children qualify as learning disabled, but many “fall between the cracks”:

- Mathematics deficits- Reading comprehension

difficulties- Difficulties with written

expression- Speech and language

delays- Fine motor delays


Academic Deficits

• “She seems to remember things one day, but not the next…”

• Wide range of memory deficits:- Visual memory- Verbal memory- Attention/concentration- Information processing

deficits


Sensory Dysfunction

• May be a source of agitation and discomfort

• May lead to distractibility• May lead to irritability/behavioral

outbursts• May interfere with overall

functioning• Can mimic other disorders (e.g.,

ADHD)


Emotional and Behavioral Problems

• Depression• Anxiety• ADHD• Conduct disorders• Attachment deficits• Mood swings• Tantrums


Social Deficits

• Typically desire friendships• Emotional dysregulation contributes to social

difficulties• Inability to anticipate consequences leads to

interaction problems• Often respond to peers in an impulsive manner


What is the Relationship Between Children’s Issues and

Parent’s Recovery?

Treatment Should Be About Families

Focusing Only on Parent’s Recovery Without Addressing the Needs of

Children and Families Can threaten parent’s ability to achieve and sustain recovery, and establish a healthy relationship with their children, thus risking:• Recurrence of maltreatment• Re-entry into out of home care• Relapse and sustained sobriety• Additional substance-exposed infants• Additional exposure to trauma for

child/family• Prolonged and recurring impact on child

well-being

• The parent or caregiver may lack understanding of and ability to cope with the child’s medical, developmental, behavioral and emotional needs?

• The child’s physical, developmental needs were not assessed, or the child did not receive appropriate interventions/treatment services for the identified needs?

• The parent and child did not receive services that addressed trauma (for both of them) and relationship issues?

• They no longer have access to supportive services following reunification?

Challenges for Parents

Making the Case for Family-Centered Services

How Family-Based Are You?

Family Involvement Family-Based Treatment

Individual is the focus

Parent is the focus but have children with them

Parent and child receive services and each have case plans

Services offered to include other family members

Entire family unit receive services

Who Receives Services?

Family InvolvementFamily-Based

Treatment

Assessesoutcomes compared to programs without family context

Measures visitation, parenting motivation

Measures retention, child and parent well-being,parenting, family functioning

Measures Family Transform-ation and stability

OutcomesMeasures parent, child, & family outcomes; ensures early intervention; increased reunification

How Family-Based Are You?

• Collaborative courts hold parents responsible for their recovery and their parenting

• But to function effectively, courts must also hold the system accountable for responding to the needs of children

Collaborative Courts and Responsibility

Collaborative Courts don’t have to serve children alone…but should be connected to those who are serving children.

• Maternal and child health,• Mental health• Child development,• Youth services• Special education• Delinquency prevention

Don’t Do It Alone

The challenge is not to divert resources from treating parents to help their children

But to mobilize and link to new resources from other agencies that already serve children

That’s what collaborative means.

- when their clients include parents and children

All Courts Are Family Courts -

Understand that the court’s decisions have an impact on the child as well as the parent, even if you never see the child in your court.

What Can All Adult Drug Courts Do?

#1

Ensure that questions about child and family status are asked at intake.

#2

Ask Important Questions

Family Relationships:Key Questions to Ask

• Do you have children? • Do you have any information about non-residential

parent? (identity, location, prenatal history)• How involved are you (and the other parent) in the

child’s life? How frequent are visits? What is the quality of the relationship?

Services:Key Questions to Ask

• Has your child received appropriate screenings, assessments, intervention and treatment services?

• Do you understand the results of such assessments?• Are you getting the help you need to effectively

parent your child?

Court Involvement: Key Questions to Ask

• Are you involved in any other court system? Can this court obtain information about your other case(es)?

• Are there other court orders that may impact/impede your progress in this program?

Advocate Family-Centered Approach

• Family-based treatment services

• Parenting classes are evidence-based for parents with substance abuse and co-occurring mental health issues

• Ensure parent has opportunity to express concerns about parenting a child with delays or problems—without repercussions

#3

Monitor Implementation

• Ensure that court information systems track clients who are parents and progress of children

• Ensure annual accountability review of outcomes of agencies funded to serve children and families

#4

Raising the Bar

If treatment has a family dimension—and it clearly does—then collaborative courts must raise the bar on their capacity to serve families.

• Do you ask if the client has children?• Do you screen children for service needs?• Do you refer and follow-up to outside agencies with

children’s services?• Are child-serving agencies on your collaborative

team?

Key Questions for Collaborative Courts

Effective Strategies

Importance of Integrative Treatment Approach

• Multiple levels of treatment across different systems is critical

• Regular communication and collaboration between treatment providers

• Team approach is necessary

Intervention Strategies:External Brain

• Change the environment, NOT the child

• Consistency across contexts

• Plan, structure, organize, and predict

• Respect the child and his/her abilities

• Help develop self-regulation• Distinguish between willful

behavior and neurological deficits

• Multi-sensory learning


Intervention Strategies: Prevention

• Identify triggers and causes of over-stimulation• Look for cues that the child is feeling overwhelmed• Model calm, organized behavior• Use intervention only when the child is calm and in

control• Defer discussions of misbehavior until the child is calm


Intervention Strategies:Attention

• Ensure child is listening prior to direction

• Use multi-sensory teaching• Break instructions into small

segments• Do not assume prior

knowledge• Have child repeat

instructions in his/her own words

• Discuss what to listen for/look for

• Encourage child to pay attention to details

• Ask questions that cue memory

• Picture cues/schedules• Audio tape important

information


Intervention Strategies: Communication

• Avoid timed activities• Closely monitor

independent work• Avoid “why” questions• Use “how,” “who,” “what,”

and “where” questions• Give 1 instruction at a

time


Where Do We Go From Here

Looking to the Future

• No amount of alcohol or drugs is safe during pregnancy

• For women already using substances, recommendation is to stop as soon as possible

• Provide substance abuse treatment for families impacted by substances

• Children prenatally and environmentally exposed should be closely monitored- Cognitive- Academic- Social- Behavioral

• Early intervention and treatment is key

Policy and Practice Framework: Five Points of Intervention

1. Pre-pregnancy awareness of substance use effects

2. Prenatal screening and assessment

Initiate enhanced prenatal services

3. Identification at BirthChild Parent

4. Ensure infant’s safety and respond to infant’s needs

Respond to parents’ needs

5. Identify and respond to the needs of

-Infant -Preschooler -Child -Adolescent

Identify and respond to parents’ needs

System Linkages

System Linkages

Child Abuse Prevention and Treatment Act (CAPTA)

CAPTA language as amended in 2010• State Plans shall contain assurances that there is a state law or

statewide program that includes:– “(b)(2)(A)(ii) policies and procedures (including appropriate

referrals to child protection service systems and for other appropriate services) to address the needs of infants born with and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder, including a requirement that health care providers involved in the delivery or care of such infants notify the child protective services system of the occurrence of such condition in such infants, except that such notification shall not be construed to—

CAPTA language as amended in 2010• State Plans shall contain assurances that there is a state law or

statewide program that includes:– “ that such notification shall not be construed to—

• (I) establish a definition under Federal law of what constitutes child abuse or neglect; or

• (II) require prosecution for any illegal action.– iii) the development of a plan of safe care for the infant born

and identified as being affected by illegal substance abuse or withdrawal symptoms, or a Fetal Alcohol Spectrum Disorder”

Child Abuse Prevention and Treatment Act (CAPTA)

The Core Messages

Prevention for Children occurs in the context of Family

Treatment Should

Be about Families

Don’t Forget the Children

Q&A and Discussion

Child-Centered Court:Resources

To download a copy: http://www.americanbar.org/groups/child_law/pages/healthybeginnings.html

Questions Every Judge and Lawyer Should Ask About Infants and Toddlers in the Child Welfare System

To download a copy: http://www.ncjfcj.org/images/stories/dept/ppcd/pdf/spr%2004_4%20osofsky%20et%20al.pdf

A Judge’s Guide - addresses the wide array of health needs of very young children in the child welfare system

http://www.americanbar.org/groups/child_law/pages/healthybeginnings.html

To Obtain a Copy:

http://www.ncsacw.samhsa.gov/improving/daily-practice-client.aspx

Child-Centered Practices for the Courtroom & Community

by Lynn F. Katz, Cindy S. Lederman, and Joy D. Osofsky (2011)

Available at: www.Amazon.com

To request a copy of this DVD, visit: www.zerotothree.org

Helping Babies from the Bench: Using the Science of Early Childhood Development in Court -DVD

Child-Centered Court:Resources

http://main.zerotothree.org/site/DocServer/DVD_Order_Form_2009.pdf?docID=9301

Ashford, J. (2004). Treating substance abusing parents: A study of the Pima County Family Drug Court approach. Juvenile & Family Court Journal, 55, 27-37.

Boles, S., & Young, N. K. (2010, July). Sacramento County Dependency Drug Court year seven outcome and process evaluation findings. Irvine, CA: Children and Family Futures.

Boles, S., & Carpenter, L. (December 16, 2011). “Regional Partnership Grant Program: Improving Outcomes for Families Affected by Substance Abuse. 2011 Beyond the Bench Conference. California Administrative Office of the Courts.

Burrus, S. W. M., Mackin, J. R., & Finigan, M. W. (Summer 2011). Show Me the Money: Child Welfare Cost Savings of a Family Drug Court. Juvenile and Family Court Journal, 62 (3), 1-14.

Burrus, S. W. M., Mackin, J. R., & Aborn, J. A. (Aug. 2008). Baltimore City Family Recovery Program (FRC) independent evaluation: Outcome and cost report. Portland, OR: NPC Research.

References

Carey, S. M., Sanders, M. B., Waller, M. S., Burrus, S. W. M., & Aborn, J. A. (March 2010). Jackson County Community Family Court – Outcome and Cost Evaluation: Final Report. Submitted to the Oregon Criminal Justice Commission. Portland, OR: NPC Research

Carey, S. M., Sanders, M. B., Waller, M. S., Burrus, S. W. M., & Aborn, J. A. (March 2010). Marion County Fostering Attachment Treatment Court – Process, Outcome and Cost Evaluation: Final Report. Submitted to the Oregon Criminal Justice Commission. Portland, OR: NPC Research

Harwin, J., Ryan, M., Tunnard, J., Pokhrel, S., Alrouh, B., Matias, C., & Momenian-Shneider, S. (2011, May). The Family Drug and Alcohol Court (FDAC) evaluation project final report. London: Brunel University.

Worcel, S. D., Green, B. L., Furrer, C. J., Burrus, S. W. M., Finigan, M. W. (March 2007). Family Treatment Drug Court Evaluation: Final Report. NPC Research: Portland, OR.

Zeller, D., Hornby, H., & Ferguson, A. (2007, Jan.). Evaluation of Maine’s Family Treatment Drug Courts: A preliminary analysis of short and long-term outcomes. Portland, ME: Hornby Zeller Associates.

References

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Contact Information

Linda Carpenter, M.Ed.Program Director

In-Depth Technical Assistance

National Center on Substance Abuse and Child Welfare

Children and Family Futures

Phone: (866) 493-2758

E-mail: [email protected]

substance exposed infants: policy and practice

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