susan m. stephens, md, faap medical director...susan m. stephens, md, faap medical director...
TRANSCRIPT
Susan M. Stephens, MD, FAAP Medical Director
Comprehensive Medical and Dental Program Arizona Department of Child Safety
Tracy Sloat, RN, MN Nurse Manager Office of Family Health
Maricopa County Department of Public Health
1. Science behind substance exposure
2. Care of the newborn
3. The Mom’s Story
4. The growing child
5. Navigating the health care system
6. Navigating the education system
7. Risk and Protective Factors
» Polysubstance abuse is the norm
» Fetal exposure to drugs/alcohol 20% ˃ At least 10% exposed throughout pregnancy
˃ Pregnant woman in substance abuse treatment using alcohol (+/- drug use) declined from 46.6% to 34.8%
» Alcohol use – 10.0% of pregnant women ˃ Binge drinking 4.4%
˃ Heavy alcohol use 0.8%
» Illicit drugs – 4.5% within past month • Substance abuse admissions (drugs only) rose from 51.1% to 63.8%
» Problem is under-reported
2013 SAMSHSA
» Impaired fetal growth
» Prematurity
» Neurologic deficits
» Behavioral changes
» Developmental Delays
» SIDS
» Child abuse
MacMahon JR. Perinatal Substance Abuse: The Impact of Reporting Infants to Child Protective Services. Pediatrics 1997 100(5)e1-9
Alcohol & other drugs affect whatever organ and system currently growing
The brain grows and develops every day during pregnancy
Fetal Alcohol Spectrum Disorders
» Narcotics & pain killers ˃ Prescription medications
˃ Heroin & Methadone
» Brain receptors altered ˃ Cycle of drug craving and drug withdrawal
» Methadone/Buprenorphine Therapy + Provides safer drug substitute
+ Long half-life - eliminates craving and breaks cycle
+ Goal is rehabilitation
» Do not detox during pregnancy
Craving
Withdrawal
Nicotine Alcohol Marijuana Cocaine Opioids PCP Meth Benzos
Prematurity Yes Yes No Yes Yes/No No Yes/No Yes
Low Birth Weight Yes Yes No Yes Yes/No No Yes Yes
Neuro - Behavioral SX Yes Yes Yes Yes Yes Yes Yes Yes
NAS Yes Yes No No? Yes Yes/No Yes? Yes
Congenital Malformations Yes/No Yes No? Yes/No No Yes Yes? Yes/No
SIDS Yes Yes Yes Yes Yes Yes Yes Yes
Child Abuse or Neglect Yes Yes Yes Yes Yes Yes Yes Yes
Adapted from Jansson LM, Velez ML. Peds in Review. Jan 2011
Yes/No = both have been reported, ? = controversial or unclear findings
Pediatrics Technical Report 2013; 131:e1009-e1024
» The causes of most birth defects remain unknown
» The causes of most cases of cognitive disabilities remain unknown
» The causes of most behavior disorders are unknown
» Combination of: ˃ Genetic and environmental factors ˃ Abuse of multiple substances
Substance Abuse is a Family Affair!
Contemporary
Pediatrics
» True withdrawal - opiates, sedative-hypnotics, & alcohol
» Withdrawal-like symptoms – antidepressant & antipsychotic medications & nicotine
» Onset varies + Type & amount of drugs + Time of last use + Character of labor & meds used during labor + Full term vs. premature infant + Nutritional status of mother + Presence of disease in infant
» Symptoms from birth to 72 hours of life » Duration of symptoms 6 days - 3 months
» For both the birth mother and the substance-exposed newborn, it is important to remember that it is more about support and intervention than a “cure”
» Specific diagnosis may not be possible
» Helpful guidelines: ˃ Clear understanding
˃ Realistic expectations
˃ Creative problem solving
˃ Patience
» Seen with all substances of abuse
» Tremors
» Irritability
» Difficulty being consoled
» Hypertonicity
» Increased startle response (Moro reflex)
» Respiratory, feeding, & sleeping problems
http://youtu.be/2eP5EnFSG0c
» Baby ˃ Note pitch of cry
˃ Note muscle tone
˃ Note posture
» Engage mom in treatment, if possible
» Allow infant to rest & don’t handle excessively
» Avoid overstimulation
» Establish sleep & wake routines
» Consistent & stable environment ˃ Non smoking environment!
» Coordinate all care after infant wakes
» Swaddle in blanket
» SENs at increased risk of SIDS
» “Back to Sleep” AAP Program ˃ Always have infant sleep on back, unless supervised tummy time
» Avoid overheating ˃ Dress appropriately
» Avoid second hand smoke exposure
» Safe Sleep Practices ˃ No Co-sleeping
˃ Keep infant off of soft surfaces, pillows, blankets, mattresses
» Small, frequent feeds
» May need to try different nipples
» Offer pacifier for sucking reflex
» Discuss optimal caloric needs with PCP
» May need to wake infant every 3-4 hours, if not meeting caloric needs
» May need referral for feeding evaluation
» Passive range of motion
» Infant massage
» Supportive positioning
» Tummy time (supervised)
» No walkers
» May need Occupational Therapy or Physical Therapy evaluation – ask PCP
» Don’t allow infant to become frantic
» Control and structure environmental stimuli
» Swaddle in flexed position
» Vertical rocking (vs. horizontal)
» Avoid eye contact
» Keep at arm’s length
» Give pacifier
2009 Calendar by Ann Geddes
» Refer to AzEIP (0–3 years)
» Head Start (preschool)
» Interactive reading on a daily basis
» Speech therapy referral – ask PCP
˃ If early vocalizations not present
˃ Speech delay
» Hearing evaluation
˃ All infants should be screened
˃ Ask PCP about evaluation, if concerns
»Recognize the birth mom’s story
»The gift of acceptance
»Examine our own biases
“Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces, by far, the most serious neurobehavioral effects in the fetus.”
IOM Report to Congress, 1996
No safe TIME. No safe TYPE.
No safe known AMOUNT
Nicotine Alcohol Marijuana Cocaine Opioids PCP Meth Benzos
Yes Yes Yes Yes Yes Yes Yes Yes
Adapted from Jansson LM, Velez ML. Peds in Review. Jan 2011
Yes/No = both have been reported, ? = controversial or unclear findings
Neuro - Behavioral Symptoms
Oppositional Defiance Disorder
Post-traumatic Stress Disorder
Obsessive Compulsive Disorder
Anxiety
Conduct Disorder
Emotional Disability
Attention Deficit Hyperactivity Disorder
Behavioral Disorder
Bipolar Disorder
Autism Spectrum Disorder
Asperger’s Disorder
Reactive Attachment Disorder
Fetal Alcohol Spectrum Disorder
Fetal Alcohol Syndrome
Mood Disorder
Alcohol and Other Drugs During Pregnancy Can Create a Lifelong Brain That:
....has trouble moving
information from one situation to another
...thinks in a disorganized way
...has difficulty with time and money
...forgets information
...thinks like the
brain of someone much younger
...can’t read the
emotions or body
language of other people
…uses poor judgment
…responds slowly
...can’t link
cause and effect
The Invisible Disability Brain Fatigue
Neuro-developmental Disorder
Our Environmental Demands
Slow cognitive pace (10 sec) Rapid response
Act younger than age Children are grouped by age
Difficulty transitioning Multiple, quick transitions
Need more time One timeline for everyone
Multi-sensory learners One Instructional style
Concrete learners Abstract learning - Inference
Memory deficits Memory testing
Try differently rather than
harder Trying Differently Rather Than Harder:
Fetal Alcohol Spectrum Disorders
Diane Malbin,
“If behaviors are believed to be willful, intentional, or the result of emotional problems, interventions typically focus on changing the behaviors. If behaviors are understood as reflecting brain differences, interventions focus on changing environments in order to prevent frustration and provide support” p. 25
FROM TO
Annoying Frustrated, challenged
Lazy, unmotivated Tried hard, tired of failing
Lies Confabulates, fills in blanks
Fussy Hyper-sensitive
Acting younger, babied Displays behaviors of younger children
Trying to get attention Needs contact, support
Inappropriate Displays behaviors of younger children
FROM TO
Hopelessness Hope
Fear Understanding
Chaos, confusion Organization, comprehension
Power struggles Working together
Isolation Networking, collaboration
FROM TO
Stopping behaviors Preventing problems
Behavior modification Modeling, using visual cues
Changing people Changing environments
Trying Differently Rather than Harder, Diane Malbin 2002
Arizona’s Pediatric Programs
DES
*AzEIP Early Intervention
*DDD
*Division of Child Safety (DCS)
Child Welfare
*CMDP
*ADHS OCSHCN
*ADBHS
Behavioral Health
*RBHAs; MMIC, NARBHA, CPSA,
Cenpatico
VFC
ASIIS WIC
AHCCCS
(Medicaid) Medical Health Needs
*AHCCCS Acute
Health Plans
*CRS Title XIX & V
*ALTCS
*Agencies who might
be engaged by those
children with special
healthcare needs
» Establish a PCP and Medical Home ˃ 10 EPSDTs (well child visits) in 1st 2 years of life
+ Developmental & Behavioral Health Screening ˃ Annual EPSDT after age 2
» Establish a Dental Home ˃ No referrals needed for dental care ˃ Dental care begins at age one (1)!! ˃ Routine preventative visits twice/year
» Ensure RBHA (behavioral health) services ASAP ˃ Urgent Response ˃ Assessment starts at 7 days ˃ Do NOT take “wait and see” attitude ˃ RBHAs must keep children in out of home care open for
services for a minimum of 6 months
Division for Developmental Disabilities (DDD)
DDD/ALTCS (Az Long Term Care Services)
AZ. Early Intervention Program (AzEIP)
Behavioral Health
Children’s Rehabilitative Services (CRS)
https://www.azdes.gov/appFiles/IntranetProgrammaticForms/pdf/ACY-
1235AHBPNA.pdf
»Start with your Pediatrician
»504 Plan verses IEP
»YOU are your child’s best advocate
» Prohibits discrimination on the basis of disability
» Accommodations related to the child’s disability so that he or she may participate in the general classroom setting
» Fewer procedural safeguards than the IEP
» The Individuals With Disability Education Act (IDEA)
» Qualifying diagnosis
» Measurable goals and quarterly documentation
» Processes and Procedures for Developing IEPS: http://www.azed.gov/special-education/files/2012/02/iep-aztas-07-2012.pdf
» Autism
» Blindness
» Deafness
» Emotional Disability
» Hearing Impairment
» Mental Retardation
» Intellectual Disability
» Multiple Disabilities
» Orthopedic Impairment
» Other Health Impairment
» Developmental Delay
» Specific Learning Disability
» Speech or Language Impairment
» Traumatic Brain Injury
» Visual Impairment
Drug(s)
Other Factors: Mom and Child
Postnatal Caregiving Environment
Medical Complications
» Parental Resilience
» Social Connections
» Knowledge of Parenting and Child Development
» Concrete Support in Times of Need
» Social-Emotional Competence of Children
www.cssp.org/reform/strengtheningfamilies
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www.maricopafamilysupportalliance.org/