Substance Exposed Infants: Policy and Practice

1. Substance Exposed Infants: Policy and Practice Oklahoma Specialty Court Conference October 11, 2013 Linda Carpenter, M.Ed. 25371 Commercentre Drive, Suite 140 Lake Forest, CA 92630 714-505-3525 ncsacw@cffutures.org www.ncsacw.samhsa.gov

2. A Program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment and the Administration on Children, Youth and Families Children’s Bureau Office on Child Abuse and Neglect

3. 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.

4. Statement of the Problem

5. 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

6. 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

7. 2009 Child Welfare Data Children Entering Foster Care 10/08-9/09 Source: Data (USDHHS, 2010)

8. 2009 Child Welfare DataTypes of Abuse Source: Data extracted from Table 3-12 (USDHHS, 2010)

9. Impact on the Child • Prenatal exposure • Postnatal environment: • Living with a parent with a substance use disorder • Trauma • Separation and attachment

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

11. National vs. LocalRates of Positive Screens (C) NTI Upstream, 2010

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

13. Impact of Prenatal Substance Exposure • 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/

14. Methamphetamines 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

15. Cocaine • 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

16. Neonatal Abstinence Syndrome (NAS) 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/

17. 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/

18. 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 decade • http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004566/

19. 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/

20. Alcohol • The most severe consequence of exposure to alcohol during pregnancy is Fetal Alcohol Syndrome (FAS), the largest preventablecause of birth defects and mental retardation • Fetal Alcohol Spectrum Disorder (FASD) – full range of effects

21. Fetal Alcohol Spectrum Disorder (FASD) • 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)

22. 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

23. Prenatal Exposure to Alcohol • 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, 2012 Children’s Research Triangle Chicago, IL

24. Fetal Alcohol Syndrome (FAS) • 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:

25. Impact on the Child • 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/

26. Prenatal Exposure: Complicated Issue • 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

27. Impact on the Child • 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.

28. Impact on the Child 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 • Disruption of parent/child relationship, child’s sense of trust and belonging

29. Childhood Trauma • 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 difficulties Lieberman et al., 2003

30. What Happens to Children Whose Own Needs are Not Addressed? • 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

31. Secondary Disabilities Adapted from Dr. Erin Telford, 2012 Children’s Research Triangle Chicago, IL

32. Shift Emotional Control Inhibit Initiate Monitor Working Memory Plan/Organize Executive Functioning Problems Adapted from Dr. Erin Telford, 2012 Children’s Research Triangle Chicago, IL

33. 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 from Dr. Erin Telford, 2012 Children’s Research Triangle Chicago, IL

34. 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 from Dr. Erin Telford, 2012 Children’s Research Triangle Chicago, IL

35. 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 from Dr. Erin Telford, 2012 Children’s Research Triangle Chicago, IL

36. Emotional and Behavioral Problems Adapted from Dr. Erin Telford, 2012 Children’s Research Triangle Chicago, IL Depression Anxiety ADHD Conduct disorders Attachment deficits Mood swings Tantrums

37. Social Deficits Adapted from Dr. Erin Telford, 2012 Children’s Research Triangle Chicago, IL 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

38. What is the Relationship Between Children’s Issues and Parent’s Recovery? Treatment Should Be About Families

39. 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

40. Challenges for Parents • 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?

41. Making the Case for Family-Centered Services

42. How Family-Based Are You? Who Receives Services? Parent and child receive services and each have case plans Services offered to include other family members Parent is the focus but have children with them Entire family unit receive services Individual is the focus Family-Based Treatment Family Involvement

43. How Family-Based Are You? Outcomes Measures retention, child and parent well-being, parenting, family functioning Measures parent, child, & family outcomes; ensures early intervention; increased reunification Assesses outcomes compared to programs without family context Measures Family Transform-ationand stability Measures visitation, parenting motivation Family-Based Treatment Family Involvement

44. Collaborative Courts and Responsibility • 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

45. Don’t Do It Alone • Maternal and child health, • Mental health • Child development, • Youth services • Special education • Delinquency prevention • Collaborative Courts don’t have to serve children alone…but should be connected to those who are serving children.

46. All Courts Are Family Courts - - when their clients include parents and children • 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.

47. What Can All Adult Drug Courts Do? #1 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.

48. Ask Important Questions #2 • Ensure that questions about child and family status are asked at intake.

49. 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?

50. 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?