# Presentation: 438033

## Nancy K. Young, Ph.D.

Cathleen Otero, M.S.W., M.P.A.

Presented at the 15th National Conference on Child Abuse and Neglect – April 2005

- Cathleen Otero, M.S.W., M.P.A.
- Presented at the 15th National Conference on Child Abuse and Neglect – April 2005

- Current Substance Abuse Issues Impacting Child Abuse and Neglect

## Current Substance Abuse Issues Impacting Child Abuse and Neglect

- Overview of NCSACW
- The Five Clocks
- Potential Consequences for Children affected by parental Substance Use Disorders
- Issues regarding infants prenatally exposed to substances
- Issues regarding parental methamphetamine use
- Identifying parental Substance Use Disorders
- A Framework and Policy Tools for Practice and Policy Changes

## A Program of the 
Substance Abuse and Mental Health 
Services Administration

Center for Substance Abuse Treatment

and the

Administration for Children and Families

Administration on Children, Youth and Families
Children’s Bureau

Office on Child Abuse and Neglect

- Substance Abuse and Mental Health
- Services Administration
- Center for Substance Abuse Treatment
- and the
- Administration for Children and Families
- Administration on Children, Youth and Families
- Children’s Bureau
- Office on Child Abuse and Neglect

**Notes:**
I’d like to take just a moment to introduce to you the National Center on Substance Abuse and Child Welfare. We are co-funded by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment and the Administration for Children, Youth and Families’ Children’s Bureau, Office on Child Abuse and Neglect. We’re just beginning our third year. 

## Key Barriers Between Substance    Abuse, Child Welfare, and the Courts

- Beliefs and values
- Competing priorities
- Treatment gap
- Information systems
- Staff knowledge and skills
- Lack of communication
- Different mandates

**Notes:**
In Summarizing those reports, we found they typically mention several key barriers between the systems

Beliefs and values that workers come with
Competing priorities for innovations 
A very real treatment gap that means clients compete with each other for treatment space as do workers compete with each other to get their clients into too scarce slots
Information systems that can’t talk to each other and few formal systems in how workers should or could be communicating 
Staff knowledge and skills to work with these families
A very real communication gap about families who need services and how they are doing in care
Different mandates of what each system is funded to do

## The Five Clocks

-  Temporary Assistance for Needy Families (TANF)
- 24 months work participation
- 60 month lifetime

** **Adoption and Safe Families Act (ASFA)
- 12 months permanent plan
- 15 months out of 22 in out-of-home care must petition for TPR

** **Recovery
- One day at a time for the rest of your life

** **Child Development
- Clock doesn’t stop
- Moves at fastest rate from prenatal to age 5

## Biggest challenge:

- CLOCKS STILL RUNNING

**The Four Clocks**

## Clocks Still Running

- ASFA Timetable

- Timeliness of intervention
- versus “Call me Tuesday.”

## ASFA Timetable

- 	CFSR’s have documented
- Case reviews found parental substance use disorders were a factor in 16% to 48% of cases
- Need for child welfare training in addictions
- Gaps in services
- Inadequate assessment and follow up on the underlying needs of families, including substance abuse
- Substance use disorders in families with repeat cases

- Clocks Still Running

## TANF Timetable

- Clocks Still Running

- 	Neglect is often associated with both substance abuse and poverty.

## Clocks Still Running

- Recovery Timetable

- 	“A day at a time for the rest of your life.”
- 	Recovery is a lifelong process requiring a disease management approach rather than emergency care.

## Interventions for children of substance abusers must  recognize potential pre-natal and post-natal effects.

Require multi-dimensional assessments and interventions responding to developmental status and special needs created by substance use disorders in the family.

Alcohol-related neuro-developmental disorders
Attachment, separation, loss, grief

- Interventions for children of substance abusers must  recognize potential pre-natal and post-natal effects.
- Require multi-dimensional assessments and interventions responding to developmental status and special needs created by substance use disorders in the family.
- Alcohol-related neuro-developmental disorders
- Attachment, separation, loss, grief

- Child Development Timetable

- Clocks Still Running

## Prenatal substance exposure
Fetal alcohol syndrome, fetal alcohol spectrum disorder, neuro-developmental disorders

Postnatal environment factors 
Violence or traumatic events
Drug and/or alcohol seeking behaviors
Illicit drug sales or manufacturing
Lack of adult interpersonal support systems
Community effects such as living in poverty
Lack of proper health care
Inconsistent caregivers

- Fetal alcohol syndrome, fetal alcohol spectrum disorder, neuro-developmental disorders
- Postnatal environment factors** **
- Violence or traumatic events
- Drug and/or alcohol seeking behaviors
- Illicit drug sales or manufacturing
- Lack of adult interpersonal support systems
- Community effects such as living in poverty
- Lack of proper health care
- Inconsistent caregivers

- Potential Consequences for Children

## Areas of Child Development Affected by Parental Substance Use Disorders

- Physical health consequences
- Lack of secure attachment
- Psychopathology
- Behavioral problems
- Poor social relations and skills
- Deficits in motor skills
- Cognition and learning disabilities

- Research has shown that these effects can manifest themselves in multiple areas, including:

**Notes:**
Could be an effect of postnatal environment, but could be compounded by prenatal exposure
While it is crucial that the parents are screened, assessed and engaged in treatment, it is also critical that the child’s social, emotional, developmental and psychological needs are addressed. Without intervention, the child’s unaddressed needs may impede a parent’s recovery or interfere with the timely resolution of the child’s permanent plan. Coping with the issues of recovery and the challenges of a child with unmet or undetected special needs can pose barriers for parents trying to maintain a safe and stable home for their child. Identifying and addressing the needs of these children will support parents in this effort. In addition to the time limits on reunification under ASFA, the Federal legislation’s "fast track" provision gives States the option of bypassing efforts to reunify families in certain egregious situations. Depending on how a State views parental SUDs, there is a potential to fast track the termination of parental rights for these families, particularly those in which an infant has been prenatally exposed to illicit drugs.

## Children Living with One or More Substance Abusing Parent

- In millions

**Notes:**
I always start with this slide – it points out one of the fundamental problems for child welfare
This is from the Report to Congress – Blending Perspectives and Building Common Ground. It shows the variety of ways that “Children of Substance Abusers” can be defined – parent used in past  year, etc.
The one I think is important is this 8.3 million children that live with a parent who is dependent on alcohol or needs treatment for drugs. This translates to 11% of the kids in our country or 1 million kids in CA.  If 11% of kids, 3 out of every elementary school classroom, are going home to a parent who is alcoholic or needs treatment for drug abuse, how does child welfare handle this issue when that same family comes to their attention due to abuse or neglect?
What’s the right standard for when a child should be removed in the context of parental addiction? What’s the right standard for when a child can be returned home in the context of 11% of the children?
We might have different opinions about what those standards should be, but these are certainly issues that we need to take that into account when we are devising policies and practices that work for these families.
CA in July 2003 has 9,485,676 children 0-17, 11% of them is 1,043,424

## State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth5,6

- State prevalence studies report 10-12% of infants or mothers test positive for alcohol or illicit drugs at birth5,6

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug | 7.7% women         315,161 infants | 3.2% women           130,976 infants | 2.3% women          94,139 infants |
| Alcohol Use | 19.6% women             802,228 infants | 6.1% women                249,673 infants | 4.7% women               192,371 infants |
| Binge Alcohol Use | 10.9% women                  446,137 infants | 1.4% women                 57,302 infants | 0.7% women                28,651 infants |

- SAMHSA, OAS, National Survey on Drug Use and Health, 2002 and 2003 reported:

**Notes:**
SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003
Applied to survey percentages to 4,093,000 births in 2002
State Prevalence Studies
California		11.35% tested positive for drugs or alcohol	     	Statewide random screening 1992
Hawaii		12.7% testing positive for drugs			1996 random screening
South Carolina	12.1% used alcohol and drugs (urine) 		Sample in 1991
			22.4% (meconium) 25.8% (both methods)	

## Number of Children Prenatally Exposed to Substances

- Total births = 4,093,000			   2002
- 10% of total births = **409,300****	****	****	**
- Total substantiated reports
-                 for children 0-1 = **142,026****	****   **2002
- Total age 0-1 in OOHC = **22,957****	**	    2001

***Where did they all go?***

- Number of Children Prenatally Exposed to Substances

## MOST GO HOME.

- 	80-95% are undetected and go home without assessment and needed services.

- Many doctors and hospitals do not test, or may have inconsistent implementation of state policies
- Tests detect only very recent use
- Inconsistent follow-up for woman identified as AOD using or at-risk, but with no positive test at birth
- CAPTA legislation raises issues of testing and reporting to CPS

**Notes:**
The answer is of course that...
These issues are now being raised with changes to the Child Abuse Prevention and Treatment Act (CAPTA) within the Keeping Families Safe Act of 2003.  These changes include a requirement that states have policies and procedures requiring health care providers to notify CPS of “infants born and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.”  States must also develop a “plan of safe care” for such infants.  The law does not require reporting of children prenatally exposed to legal substances such as alcohol and tobacco.  Nothing in the law, however, prevents states from requiring such reporting.
Whatever side of the debate you sit on regarding testing and reporting of substance exposed births, I would expect that we can agree on the need for a comprehensive response – whether the lead be taken by child welfare, public health or AOD services – because, even though these kids may go home and miss becoming part of the system at birth, we continue to find that these kids come back into one of several systems later.

## A Graphic Overview

## There is no absolute profile of developmental outcomes based on a child’s exposure to his or her parents’ substance use, abuse, or dependence.2  

Other problems arising in parental behavior, competence, and disorders interact with substance use, abuse, and dependence to cause multiple co-occurring problems in the lives of these children. 

- Other problems arising in parental behavior, competence, and disorders interact with substance use, abuse, and dependence to cause multiple co-occurring problems in the lives of these children.

- The complexity of screening and assessment for these children is compounded by at least two realities:

- Screening and Assessment of Consequences for Children

**Notes:**
To understand the forces influencing the futures of children exposed to alcohol and drugs, it is necessary to assess many different factors that affect their lives. The consequences of alcohol and drug use are the products of a complex interchange of biological, psychological, and sociological events. 

## The importance of identifying infants prenatally exposed to substances

- Though a small percentage of CWS cases, these children are disporportionately affected by many lifetime conditions
- Prenatal exposure to alcohol is the leading cause of mental retardation
- Special education classrooms contain a disproportionate number of children who were prenatally exposed to drugs.7,8
- SEBs require a higher level of public spending than many other target groups

## Child Abuse Prevention and Treatment Act (CAPTA) 2003 Amendments

- 2003 Keeping Families Safe Act Amendments
- Policies and procedures (including appropriate referrals to child protection service systems and for other appropriate services) to address the needs of **infants born and identified as affected by illegal substance abuse** or **withdrawal symptoms resulting from prenatal drug exposure**, 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 (I) establish a definition under Federal law of what constitutes child abuse; or (II) require prosecution for any illegal action (section 106(b)(2)(A)(ii));
- The development of **a plan of safe care** for the infant born and identified as being affected by illegal substance abuse or withdrawal symptoms (section 106(b)(2)(A)(iii))

**Notes:**
CAPTA amendments put a spotlight on the identification and referral of SEIs

##  Children and Parents - Intervention Points

-  Children and Parents - Intervention Points

- Prenatal screening and assessment

- Pre-pregnancy awareness and substance use

**Family literacy and economic**
** ****support**

**Bonding supports**

**Parents’ role in **
**child care**

**Notes:**
But the identification and referral of SEIs must be considered in the larger context, which requires partnerships between several agencies

## Trends in State Policies

- Legislation that defines substance-exposed births as child abuse or neglect
- Legislation mandating substance exposed birth reports to CPS by health care professionals and/or mandated reporters in general
- Policies for testing mother and/or infant

## Trends in State Policies

- Leaving the judgment of child abuse or neglect to the discretion of the CPS worker or the health care provider
- Addressing alcohol and drug use/abuse during pregnancy, but not necessarily addressing the substance exposed birth
- CPS policies on how to respond to a substance exposed birth
- No official response

## Special Issue: Methamphetamine

## Concern Regarding Children

- Need to consider prenatal as well as environmental exposure
- Prenatal exposure
- Need for developmental interventions
- Environmental exposure includes increased risk for children of cookers
- Need to know child’s status
- Super labs
- Cookers
- Traffickers
- Users

## Worker Safety Issues

- Dangers associated with being in proximity to methamphetamine users and “chemists.”
- Identify potential signs of methamphetamine use in child welfare clients
- Identify signs that methamphetamine is being “cooked” in or around the client’s home
- Ensuring the safety of the child welfare worker in settings where methamphetamine is being used or “cooked.”

## Issues Specific to Methamphetamine 

- Meth users begin younger than other drugs
- Meth lasts longer acting than other stimulants (cocaine/crack)
- Differ from other users in their drug use pattern—they use more days
- Differ in their cognition—particularly in early abstinence
- Need alternative methods of imparting information

## Women’s Issues

- Females MA users are more likely to:
- Live alone with their children
- Use MA more days
- Smoke MA rather than snort or inject the drug
- Have worse psychiatric profiles
- Have worse medical, employment and psychiatric composites than male MA users

- Reiber, 2000

## Slide 30

## Treatment Outcomes

- Outcomes have not differed from other drugs of abuse treatment studies

## Treatment Outcomes

- Of 10 MA-abusing women
- entering treatment,

**3 still MA-abstinent**
** ****48 mo. after treatment **

**After treatment:               1mo.          12mo.               24mo.                                  48mo.   **

**Still MA-abstinent:            6                  4                       3                                         3  **

## Treatment Outcomes

- Positive treatment outcomes were achieved using:
- Intensive outpatient setting
- Three to five visits per week of comprehensive counseling for at least the first three months
- Cognitive behavioral approach
- Contingency management
- Reducing consequences associated with drug use
- Motivational interviewing & brief intervention models
- Intervening earlier and reducing cumulative harm
- Attending to co-occurring mental disorders

## Screening for Prenatal Substance Exposure and Parental Substance Use Disorders (SUDs)

## Identifying Infants withPrenatal Substance Exposure

- Verbal screen with mother
- Review of mother’s history and medical records
- Observation of mother and/or newborn
- Drug testing (urine, blood, hair or meconium)

- Prenatal substance exposure can be screened for in  several ways. The most common methods, used alone or in combination, are:

## Verbal Screening Tools4Ps Plus

- Did either of your parents ever have a problem with drinking or using drugs?
- Does your partner have any problem with alcohol or drugs?
- Have you ever had any beer or wine or liquor?
- In the month before you knew you were pregnant, how much beer/wine/liquor did you drink?
- In the month before you knew you were pregnant, how many cigarettes did you smoke?

## Identifying Parental Substance Use Disorders

- Studies conducted on brief screens of six or less items suggest that there are a limited number of common constructs
- An effective screen for substance use disorders includes questions about:
- Unintended use
- Desire to restrict use
- Consequences of use
- Concern about consequences of use

**Notes:**
Important that an effective screen must be institutionalized and consistent.  That is, you have to decide that you will do a screen, you have to decide when you will administer the screen, and then you have to be sure to be consistent about administering the screen at the designated time.  May not be appropriate to use a screening tool during an ER, but it would certainly be useful during an investigation.

## Screening for ParentalSubstance Use Disorders: UNCOPE

- In the past year, have you ever drank or **used** drugs more than you meant to?
- Have you ever **neglected** some of your usual responsibilities because of using alcohol or drugs?
- Have you felt you wanted or needed to **cut down** on your drinking or drug use in the last year?
- Has anyone **objected** to your drinking or drug use?
- Have you ever found yourself **preoccupied** with wanting to use alcohol or drugs?
- Have you ever used alcohol or drugs to relieve **emotional** discomfort, such as sadness, anger, or boredom?

##   Check list for Identifying SUDs:4
A report of substance use is included in the child protective services call or report.
Paraphernalia is found in the home (syringe kit, pipes, charred spoon, foils, large number of liquor or beer bottles, etc).
The home or the parent may smell of alcohol, marijuana, or drugs.
A child reports alcohol and or other drug use by parent(s) or other adults in the home.
A parent appears to be actively under the influence of alcohol or drugs (slurred speech, inability to mentally focus, physical balance is affected, extremely lethargic or hyperactive, etc).
A parent shows signs of addiction (needle tracks, skin abscesses, burns on inside of lips, etc).
A parent admits to substance use.
A parent shows or reports experiencing physical effects of addiction or being under the influence, including withdrawal (nausea, euphoria, slowed thinking, hallucinations, or other symptoms).

- A report of substance use is included in the child protective services call or report.
- Paraphernalia is found in the home (syringe kit, pipes, charred spoon, foils, large number of liquor or beer bottles, etc).
- The home or the parent may smell of alcohol, marijuana, or drugs.
- A child reports alcohol and or other drug use by parent(s) or other adults in the home.
- A parent appears to be actively under the influence of alcohol or drugs (slurred speech, inability to mentally focus, physical balance is affected, extremely lethargic or hyperactive, etc).
- A parent shows signs of addiction (needle tracks, skin abscesses, burns on inside of lips, etc).
- A parent admits to substance use.
- A parent shows or reports experiencing physical effects of addiction or being under the influence, including withdrawal (nausea, euphoria, slowed thinking, hallucinations, or other symptoms).

- Identifying Parental Substance Use Disorders

**Notes:**
A system of setting up the investigation and identification of substance abuse issues

## Introduction to a Framework and Policy Tools for Practice and Policy Changes

- Getting the Clocks in Sync

## Navigating the Pathways 
published by CSAT1

Established:

	A framework for defining elements of 	collaboration 

	Methods to assess effectiveness of 	collaborative work

- published by CSAT1
- Established:
- 	A framework for defining elements of 	collaboration
- 	Methods to assess effectiveness of 	collaborative work

## To define linkage points across systems

To describe the components of the initiative

To assess the progress in implementation

To assist sites in measuring their implementation 

- To describe the components of the initiative
- To assess the progress in implementation
- To assist sites in measuring their implementation

- Framework and Policy Tools for Systems Change

## Underlying values

- Joint accountability   and shared outcome
- Information systems
- Training and staff development
- Budgeting and program sustainability

- Elements of System Linkages

- Daily practice  screening and assessment
- Daily practice  client engagement and retention in care
- Daily practice  AOD services to children

- Working with related agencies
- Building community supports

## Policy Tools

- 	Policy tools to facilitate collaborative work across systems:
- Collaborative Values Inventory
- Collaborative Capacity Instrument
- Matrix of Progress in Linking Substance Abuse and Child Welfare Services
- Screening and Assessment for Family Engagement, Retention and Recovery (SAFERR)

**Available at **_[http://](http://www.ncsacw.samhsa.gov/)__[www.ncsacw.samhsa.gov](http://www.ncsacw.samhsa.gov/)_** **

## Models of Improved Services

- Family Treatment Courts

- Training and Curricula Development

- Persons in Recovery act as Advocates for Parents

- Multidisciplinary Teams for Joint Case Planning

- Counselor Out-stationed at Child Welfare Office

- Paired Counselor and Child Welfare Worker

**Notes:**
** This work and efforts in other sites began to draw on the expertise of people in recovery to act as advocates for parents in the child welfare system. 
I have to tell you that in 1996, Laura Feig Radel who many of you know from the Office of the Assistant Secretary for Planning and Evaluation, and I sat in a meeting passing back and forth a piece of paper with a list of program models that we could name that were putting initiatives together to better address the child welfare and substance abuse issues. Probably not a very scientific method of classification but at that time, we named about 7 models and about 20 locations with programs up and running. 
For example, Delaware paired a substance abuse counselor with a child welfare worker; many communities, including the state of New Jersey established a system of outstationed substance abuse counselors in child welfare offices who acted as technical advisors to child welfare workers; 
Many communities also established multidisciplinary case planning efforts; sites began to draw on the recovery community for its expertise; 

there was much emphasis on developing training and curricula to train front-line practitioners and finally, family treatment courts emerged.
These innovators and leaders provided the lessons with two common themes in their programs: experimenting with staffing patterns and drawing on persons in recovery who provided some type of increased case management and recovery management for parents.

## Integrated 
Both dependency matters and recovery management conducted in the same court with the same judicial officer
Dual Track 
Both dependency matters and recovery management conducted in same court with same judicial officer during initial phase 
If parent is noncompliant with court orders, parent may be offered DDC participation and case may be transferred to a specialized judicial officer who increases monitoring of compliance and manages only the recovery aspects of the case
Parallel
Dependency matters heard on regular family court docket 
Specialized court services offered before noncompliance occurs
Compliance reviews and recovery management heard by a specialized court officer

- Both dependency matters and recovery management conducted in the same court with the same judicial officer
**Dual Track**
- Both dependency matters and recovery management conducted in same court with same judicial officer during initial phase
- If parent is noncompliant with court orders, parent may be offered DDC participation and case may be transferred to a specialized judicial officer who increases monitoring of compliance and manages only the recovery aspects of the case
**Parallel**
- Dependency matters heard on regular family court docket
- Specialized court services offered before noncompliance occurs
- Compliance reviews and recovery management heard by a specialized court officer

- Models of Family Drug Treatment Courts

## Every 70 seconds a baby is born who was prenatally exposed to alcohol or illicit drugs. 
Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention.
	A baby and a family you already know are highly at risk.

- Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention.
- 	A baby and a family you already know are highly at risk.

- The Fifth Clock

**URGENCY**

**Notes:**
Two statistics, one which I have already cited, make that point concrete:
Every 70 seconds a baby is born in this country who was prenatally exposed to alcohol or illicit drugs 
Every minute and a half, one of those babies goes home without screening or any effort to begin early intervention—for a baby and a family we already know are highly at risk 

## The Voice of a Child

**Nothing But Silence**
**By Ashley G.**
**Age 12**
**January 2005**

## 
People all around me
Calling out my name
But no I cannot hear them
For my heart is filled with shame
Nothing but silence

But only till the break of dawn
Will I be feeling sad
For wandering out on the streets
Are my birth mom and dad

Why’d she do this to her and me
With this we’ll have to cope
But while she’s clean you never know
There still could be hope

But in the perfect world I know
There’s no harmful stuff
But now I’ve come to realize
It’s just a bunch of bluff

Nothing but silence

- People all around me
- Calling out my name
- But no I cannot hear them
- For my heart is filled with shame
- Nothing but silence
- But only till the break of dawn
- Will I be feeling sad
- For wandering out on the streets
- Are my birth mom and dad
- Why’d she do this to her and me
- With this we’ll have to cope
- But while she’s clean you never know
- There still could be hope
- But in the perfect world I know
- There’s no harmful stuff
- But now I’ve come to realize
- It’s just a bunch of bluff
- Nothing but silence

- Sitting by the widow sill
- A tear rolls down my cheek
- Although it hurts I can’t express
- My heart is just too weak
- Nothing but ache
- It’s funny what one pill can do
- To a mother or a kid
- And now I know that for a fact
- I won’t do what she did
- Nothing but ache
- Now I live a better life
- And drugs...I wouldn’t dare
- Away from all the harmful things
- With a family who cares
- Nothing but love
- I know it hurts, it sure hurt me
- And that’s why I’ll remain drug free
- Nothing... but hope

## The fifth clock is the one that is ticking on us. 
It measures how fast we get it, how rapidly we respond to human needs that grow larger by the day. 
We have to measure what we do against what needs doing, not against what we did last year.

- It measures how fast we get it, how rapidly we respond to human needs that grow larger by the day.
- We have to measure what we do against what ***needs doing*****,** not against what we did last year.

- The Fifth Clock

**Notes:**
**The fifth clock is urgency, the one that measures how fast we get it—how rapidly we respond to human needs that grow larger by the day. We have to measure what we do against what needs doing, not against what we did last year.

## Notes

- Young, N.K. and Gardner, S.L. (2002). *Navigating the Pathways: Lessons and Promising Practices in Linking Alcohol and Drug Services With Child Welfare*. SAMHSA Publication No. SMA-02-3639. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
- Chasnoff, I.J. (1997). Prenatal Exposure to Cocaine and Other Drugs: Is there a Profile? In: Accardo, P.J., Shapiro, B.K., & Capute, A.J. (Eds.), *Behavior Belongs in the Brain*. Baltimore, MD: York Press, 147-163.
- Lester, B.M., Andreozzi, L., & Appiah, L. (2004). Substance Use During Pregnancy: Time For Policy to Catch Up With Research. *Harm Reduction Journal*, 1(5).
- Young and Gardner, *Navigating the Pathways*,  p. 132.
- Vega et al (1993).  Profile of Alcohol and Drug Use During Pregnancy in California, 1992.
- 6.       SAMHSA, OAS. (2003). Results from the 2002 National Survey on Drug Use and Health: National findings.
- 7.       NIAAA (2000). *Tenth Special Report to Congress on Alcohol and Health*.
- 8.       NIDA (1998). Prenatal Exposure to Drugs of Abuse May Affect Later Behavior and Learning

- NCSACW				 714-505-3525** **
- 4940 Irvine Blvd, Suite 202		 714-505-3626 fax** **
- Irvine, CA  92620		       	 _[www.ncsacw.samhsa.gov](http://www.ncsacw.samhsa.gov/)_