Substance Exposed Infants: Policy and Practice
25371 Commercentre Drive, Suite 140Lake Forest, CA 92630
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
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.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004566/
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/PMH0004566/
Neonatal Abstinence Syndrome (NAS)
• 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/
Neonatal Abstinence Syndrome (NAS)
• 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/PMH0004566/
Neonatal Abstinence Syndrome (NAS)
• 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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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)
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
Emotional and Behavioral Problems
• Depression• Anxiety• ADHD• Conduct disorders• Attachment deficits• Mood swings• Tantrums
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
Adapted fromDr. Erin Telford, 2012Children’s Research TriangleChicago, IL
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
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
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]
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