Substance Exposed Pregnant Women and their Babies

1. Substance Exposed Pregnant Women and their Babies Dixie L. Morgese, BA, CAP, ICADC

2. Premises • Every woman wants a healthy baby. • Every woman deserves a healthy baby. • Pregnancy is a finite period that can be the determinant for a child’s future. • Pre-pregnancy is the BEST time to address alcohol and drug use!

3. Learning Objectives • Identify three screening techniques for use with pregnant women who may be using alcohol or other drugs. • Gain an increased understanding of various classes of drugs and their effects on pregnant women, the developing fetus, and the newborn baby. • Identify five systems of care and their roles and responsibilities related to substance exposed pregnant women and their babies. • Learn a five point approach to effective multidisciplinary staffing and coordination.

4. Terms • SEN – Substance Exposed Newborn • CDN – Chemically Dependent Newborn • NAS – Neonatal Abstinence Syndrome • NAS* - Neonatal Abstinence Scoring • FASD – Fetal Alcohol Spectrum Disorder • FAS – Fetal Alcohol Syndrome • WIS – Women’s Intervention Specialist • FIS – Family Intervention Specialist • ATOD – Alcohol, Tobacco and Other Drugs • CNS – Central Nervous System

5. Terms • Hyperreflexia – Overactive reflexes – response to stimuli • Overstimulated – “overwhelmed” by stimulus • Philtrum – vertical groove on the median line of the upper lip. • Feeding intolerance – inability to suck, swallow or retain feedings.

6. Terms • Drug Endangered Infant/Child – a wide range of risk associated with exposure to alcohol and other drugs. • Marchman Act – petition that supports legal remedy regarding evaluation and intervention. • State Regulation – ability to adapt to external stimulation.

7. CNS Substances • Children of mothers who used drugs: • Stimulants – risk of preterm labor and abruption • Depressants – alcohol most damaging • Opiates – increasing numbers of cases • Marijuana • Hallucinogens • Tobacco* - low birth weight, SIDS Varying responses, particularly during infancy. Prognosis for other drugs is better than with FAS depending on term of pregnancy and environment.

8. Screening is IMPORTANT! • Find an approach that works for you. • Be non judgmental • Make it a routine part of care and conversation. • Know how to respond • Be positive • Follow up with other systems of care

9. The 5 A’s Framework

10. “5 A’s” • Ask about alcohol, tobacco or other drug use • Advise to quit – unless opiates are involved. If the woman is opiate dependent, gain consent and coordinate with health care providers. • Assess willingness to quit • Assist with support and referral • Arrange follow-up

11. Instruments Used for Screening • 5 P’s and 4 P’s Plus • CAGE AID • T-ACE

12. When Should You Screen? • Screening should be a routine part of care. • Look for physical and environmental indicators. (fingers, arms, eyes, paraphernalia, clothing, etc.) • Review life management issues. (personal hygiene, behavioral incidences, avoidance, etc.) • Use your senses. • Follow your instincts. • Intervene and Support

13. 5 P’s • Parents - Did any of your parents have a problem with alcohol or other drug use? • Peers - Do any of your friends have a problem with alcohol or other drug use? • Partner - Does your partner have a problem with alcohol or other drug use? • Past – Have you used alcohol or drugs in the past? • Present - In the past month, have you drunk any alcohol or used other drugs?

14. CAGE-AID • Have you ever felt you ought to cut down on your drinking or drug use? • Have people annoyed you by criticizing your drinking or drug use? • Have you felt bad or guilty about your drinking or drug use? • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? CAGE Source: Ewing 1984. CAGE-AID Source. Reprinted with permission from the Wisconsin Medial Journal Brown, R.L. and Rounds, LA Conjoint screening questionnaires for alcohol and drug abuse. Wisconsin Medical Journal 94: 135-140, 1995.

15. The T-ACE Questionnaire • TTolerance: How many drinks does it take to make you feel high? • A   Have people annoyed you by criticizing your drinking? • C   Have you ever felt you ought to cut down on your drinking? • EEye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? The T-ACE is considered to be positive with a score of 2 or more. Affirmative answers to the A, C, and E questions are each scored 1 point. A reply of more than two drinks to the T question is scored 2 points (Sokol et al. 1989).

16. How Do You Start the Conversation? • Be non-judgmental and build rapport. • Keep it Simple. • Use observable strengths. • When the door opens – be straight-forward. • Know your limitations. • Know your resources.

17. What Next? • Know your limitations and disclose them • Negotiate Consent for Release. • Develop a “short term contract.” • Be aware of timing and environment. (conflict at home, day of the week, other children, etc.) • Seek supervision and coordination. • Consider resources and barriers.

18. Barriers • Dependence • Language/Culture – paradigm to a strength • Fear of system/outcomes • Partner – control or violence issues • Treatment access/residential availability • Family system/relationships and other children • Stressors • Depression • Economic Limitations

19. Systems of Care • Medical – CHD’s, CMS, hospitals, physicians, midwives • Treatment Centers – SMA, Haven House, DMTC – WIS, TOPWA other • Early Steps – screening of children • Child Welfare (DCF and Community Based Care) – legal, investigative, case management, wrap around services – use PNA • Healthy Start – care coordination and linkage to additional resources.

20. Other Possible Systems • Legal – drug court, probation, child support enforcement. • Workforce Development – economic self sufficiency for mother and partner. • Child Care/ELC – respite, structure, stability. • Others – Homeless Services, Domestic Violence support, HIV/TOPWA, Mental Health, Healthy Families, Insurance.

21. Five Point Approach • Identify key players – including and centering on the patient. • Unify referral processes - identify the point person/entity. • Coordinate consent – Healthy Start screening form can support collaboration until further consent is obtained. • Align policies and procedures – ensure systems have interagency agreements which delineate roles and responsibilities.. • Utilize unified staffing forms.

22. Follow Up • Identify additional staffing activities – establish dates, times. • Key coordinator – typically case management or care coordination. • Ensure client completed referrals and verify subsequent appointments. • Prior to delivery, coordinate with hospital/birthing center. • Provide documentation for pediatric follow up. • Identify who will provide ongoing education to the family. • Establish family planning and interconceptional care plan.

23. Points to Remember • SEN babies are at elevated risk for SUIDS – ensure family has safe sleeping environment. • Mothers at elevated risk for PPD or relapse – identify support system. • Caregivers need to know how to handle SEN babies – ensure special instruction is provided and ongoing.

24. Questions?

25. Let’s work together to keep them ALL safe, healthy, and happy!

26. Thank You! To learn more about the Infant Mental Health Chapter of Volusia and Flagler Counties, visit us on our website at: www.healthystartfv.org