# Presentation: 055549

## Substance-Exposed Infants: Policy and Practice

- Presented by Nancy K. Young, Ph.D., Director
- National Center on Substance Abuse and Child Welfare
- _[www.ncsacw.samhsa.gov](http://www.ncsacw.samhsa.gov/)_
- 714-505-3525
- June 20, 2006

## 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

- 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

**Notes:**
** I’d like to take just a moment to introduce to you the National Center on Substance Abuse and Child Welfare. We are coming up on our 2 year anniversary next month and we are quite pleased with the progress that is underway. 
Many of you may know that 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. 

## To improve outcomes for families by promoting effective practice, and organizational and system changes at the local, state, and national levels
Developing and implementing a comprehensive program of information gathering and dissemination
Providing technical assistance

- Developing and implementing a comprehensive program of information gathering and dissemination
- Providing technical assistance

- Mission

**Notes:**
You have a handout in your materials on our technical assistance program and how to reach us as well as an announcement of our first on-line curricula. 
This on-line training is directed to substance abuse counselors and explains child welfare services and the dependency court. It takes about 4 hours to complete, it is free of charge and comes with 4 hours of CEUs for those that are interested. Our second on-line curricula will be released in a few months and targets child welfare workers and explains addiction and recovery.
You can visit our website and leave us your email address if you are not currently on our distribution list to receive announcements of our products and activities and we look forward to hearing more from you.

## Overview

- The policy context
- Some numbers
- A policy and practice framework
- The 10-State study
- State policy and practice: findings, models and implementation
- Opportunities for advancing policy

**Notes:**
Disclaimer – we do not represent the views of the federal government. The information and framework we present here are our views alone, and this is our conceptualization and understanding of the issues at hand.

## Substance-Exposed Infants

- The Policy Context

## The Policy Context

- Child Abuse Prevention and Treatment Act (CAPTA) amendments of 2003
- Referrals of newborns identified as exposed illicit substances
- Referrals of children birth to age 3 to Early Intervention Services
- Increasing number of pregnant women and children affected by maternal use of methamphetamines
- Research on fetal alcohol spectrum disorders and alcohol-related neurodevelopmental disorders
- Congressional caucus addressing this issue
- Proposed State legislation aimed at both fetal alcohol exposure and maternal abuse of illegal drugs

**Notes:**
Purpose of the CAPTA amendments: “supporting and enhancing collaboration among public health agencies, the child protection system, and private community-based programs to provide child abuse and neglect prevention and treatment services (including linkages with education systems) and to address the health needs, including mental health needs, of children identified as abused or neglected, including supporting prompt, comprehensive health and developmental evaluations for children who are the subject of substantiated child maltreatment reports.’’

CAPTA amendments to State eligibility requirements – States must provide assurances that they have: 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)) 

new evidence of the long-term mental and emotional effects of prenatal exposure to alcohol, the development of new federally funded resource centers 
including punitive legislation in some States that has led to increased incarceration of mothers of infants born substance-exposed

## No One Agency 

- The SEI issue does not “belong to” any one agency, because it demands
*comprehensive* services
- provided along a *continuum* of prevention, intervention and treatment
- at different *developmental stages* in the life of the child and family
- No single agency can deliver all of these

**Notes:**
If you take those three criteria seriously-and you must if you take twenty years of child development and AOD treatment findings seriously—then you must seek all three dimensions of the response to SEIs

## The Needed Partners

- Collaboration on SEI issues requires roles for
- Hospitals
- Private physicians
- Health care management plans
- Maternal and child health
- Children’s and adult mental health
- Domestic violence agencies
- Child welfare
- Drug and alcohol prevention, treatment and aftercare
- Developmental disabilities agencies
- Schools and special education
- Family/dependency courts
- Child care and development
- Employment and family support agencies
- And more...

## Substance-Exposed Infants

- The Numbers

## The Numbers

- Use during pregnancy
- Women and pregnant women needing and receiving treatment
- Substance-exposed infants

## Use During Pregnancy

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug |  |  |  |
| Alcohol Use |  |  |  |
| Binge Alcohol Use |  |  |  |

- SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003

**Notes:**
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)

## Use During Pregnancy

| Substance Used (Past Month) | 1st Trimester | 2nd Trimester | 3rd Trimester |
| --- | --- | --- | --- |
| Any Illicit Drug | 7.7% women         315,161 infants |  |  |
| Alcohol Use | 19.6% women             802,228 infants |  |  |
| Binge Alcohol Use | 10.9% women                  446,137 infants |  |  |

- SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003

**Notes:**
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)

## Use During Pregnancy

| 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 |  |
| Alcohol Use | 19.6% women             802,228 infants | 6.1% women                249,673 infants |  |
| Binge Alcohol Use | 10.9% women                  446,137 infants | 1.4% women                 57,302 infants |  |

- SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003

**Notes:**
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)

## Use During Pregnancy

| 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, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003

**Notes:**
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)

## How are we doing at identifying and providing services to pregnant and parenting women who need treatment?

## Women and Pregnant Women in Treatment

- 565,400 women admitted to a public treatment program

- 15,277 pregnant women in publicly funded treatment

**There are four million births annually, and six and a half million women of child-bearing age who need treatment**

- 6.55 million women of child-bearing age who need treatment for alcohol or illicit drug use

- Of those who need treatment...
- 	9.7% of men
- 	7.4% of women
- ...receive treatment

**Notes:**
In this view, that 9.7% of men who need treatment and 7.43% of women who need treatment get in. The difference between the 9.7 and the 7.43 would take a 30% increase in admits for women. So if you were to raise women up to 9.7% of treatment need, an equal percentage to men, it would take 90,000 more women admissions.

## Number of Substance-Exposed Infants

Estimates are that 10-11% of all newborns are prenatally exposed to alcohol or illicit drugs; this translates to:

- Estimates are that 10-11% of all newborns are prenatally exposed to alcohol or illicit drugs; this translates to:

- An estimated 400,000-480,000 substance exposed births nationwide last year

- A cumulative 7.3 million of the 73 million children ages 0 to 17 years old

**Notes:**
Vega et al (1993).  Profile of Alcohol and Drug Use During Pregnancy in California, 1992.
2. SAMHSA, OAS. (2003). Results from the 2002 National Survey on Drug Use and Health: National findings. The SAMHSA National Survey on Drug Use and Health reported 3 percent of pregnant women aged 15 to 44 years had used an illicit drug in the past month and 9 percent reported drinking any alcohol in the past month.  The 10% figure is a conservative national number of prenatal alcohol or drug exposure because (1) this is self-report data and (2) the timeframe was only the “past month.”  The “10-11%” is based on a rounded down CA number, which is also a conservative number of total substance-exposed births because the tox screens only measure use in the last 24-72 hours.
73 million children is total child population from each state and DC as reported in Child Maltreatment 2003 report

## A Graphic View

**82.7 million children and youth age 0 to 17 years**

**25%**

**Notes:**
The data on total child population and CPS reports comes from Child Maltreatment 2004 report and California Berkeley Data (because CA was not included in Child Maltreatment 2004). 
82,710,280 Total Child population = 73,089,769 child population according to Child Maltreatment 2004 + 9,620,511 Children in California in 2005.
In 2003 there were 4,089,950 live births reported in the United States according to CDC data
983,881 Total Victims = 872,088 Child Maltreatment 2004 victims (substantiated, indicated and alternative response victims) + 111,793 substantiated victims in California based on Jan-Dec 2004 Berkeley Data
102,536 Total child victims under age 1 year = 89,970 Child victims under age 1 year in Child Maltreatment 2004 + 12,566 child victims under age 1 year in CA based on Jan-Dec 2004 Berkeley data
IF we assume that ALL 102,500 child victims under age 1 year are SEBs, then that means 25% of our estimated 409,000 SEBs are identified and reported to CPS.

## How are we doing at identifying substance-exposed infants?

- Most are not identified
- and...

## Most go home...

- 	75-90% of substance-exposed infants are undetected and go home.

- Many hospitals don’t test or don’t systematically refer to CPS
- State law may not require report or referral
- Tests only detect very recent use

- Why?

## A Policy and Practice Framework

- Five Points of Intervention

**Notes:**
You have to have a framework to understand and respond to this issue—this is ours
the birth event is one of several opportunities to make a difference, not the only one

## The Five Points of Intervention

- Pre-pregnancy and public awareness
- Prenatal screening and support
- Screening at birth
- Services to infants
- Services to parents
- So—the birth event is one of *several *opportunities to make a difference, not the only one

**Notes:**
You have to have a framework to understand and respond to this issue—this is ours
The birth event is too late, the birth event is too early

## Policy and Practice Framework: Five Points of Intervention

**Parent**

**Child**

**Identify and respond to parents’ needs**

**Initiate enhanced prenatal services**

**4. Ensure infant’s safety and respond to infant’s needs**

**2. Prenatal screening and assessment**

**1. Pre-pregnancy awareness of substance use effects**

**System Linkages**

**Respond to parents’ needs**

**System Linkages**

**Notes:**
Again, this is our conceptualization of the issues. This is not a reflection of the Federal government’s views.

## The 10-State Study

- Methods and Design

**Notes:**
You have to have a framework to understand and respond to this issue—this is ours
the birth event is one of several opportunities to make a difference, not the only one

## The 10-State Descriptive Study

- Purpose was to better understand and describe States’ policy regarding substance exposed infants
- Coordinated with AIA study
- Reviewed Federal and State legislation
- Reviewed State publications
- Reviewed other national assessments of substance exposed infant and family issues

## The 10-State Study

- Selected 10 States for in-depth interviews based on efforts in one or more of the first points of intervention

- Developed interview guide based on the policy and practice framework five points of intervention

- California, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, South Carolina, Virginia, and Washington

## What Kinds of Policy

- Federal laws
- State legislation
- State regulations and guidelines
- State budget allocations
- State interagency bodies with policy responsibilities
- The implementation of policy
- Respondents’ view of what happens in the field
- Reviewed State and national data that may indicate how policy had been implemented

## The 10-State Study

- Conducted 1- to 2-hour interviews as an open-ended guided discussion
- Contacted the Women’s Treatment Coordinator in each State
- Identified officials from several departments across agencies
- 3 to 4 respondents in each State

## The 10-State Study

- Findings, Models and Implementation

**Notes:**
You have to have a framework to understand and respond to this issue—this is ours
the birth event is one of several opportunities to make a difference, not the only one

## State Policy, Practice and Models

- Within the Five Points of Intervention
- Pre-pregnancy and public awareness
- Prenatal screening and support
- Screening at birth
- Post-natal services to infants
- Post-natal services to parents

- 10-State Study
- Findings
- Models
- Implementation

## 1. Pre-Pregnancy

**Findings**
- States have developed public education campaigns
- Warning signs at point of sale
- 3 out of 10 study States
- 37% of all States
- Warning signs at other venues
- 3 out of 10 study States
- 24% of all States

**Notes:**
“other venues” is county clerks offices, marriage license bureaus and in physician’s offices

## 1. Pre-Pregnancy

**Findings**
- States have worked with institutions of higher education in disseminating this message
- Federal "Drug Free Schools and Communities Act Amendments of 1989"
- Universities and educational institutions that accept federal funding must notify their employees and students that use of alcohol during pregnancy may have detrimental effects on their children
- Model: University of Massachusetts

**Notes:**
An example, from the University of Massachusetts student responsibilities website reads: “Mothers who drink alcohol during pregnancy may give birth to infants with fetal alcohol syndrome. These infants have irreversible physical abnormalities and mental retardation. In addition, research indicates that children of alcoholic parents are at greater risk than others of becoming alcoholics”

## 1. Pre-Pregnancy

**Implementation**
- Rates of first trimester use suggest that the message is not getting through to a critical group of pregnant women
- Use during 1st Trimester
- 7.7% women used any illicit drug (315,161 infants)
- 19.6% women used alcohol (802,228 infants)
- 10.9% women engaged in binge alcohol use (446,137 infants)

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

**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)

## 2. Prenatal Screening and Services

**Findings**
- All States had some prevention efforts and some form of prenatal screening efforts
- Model: Washington State has developed detailed guidelines for prenatal screening, and a quality improvement effort that seeks “universal screening” for substance use
- Some jurisdictions within States had screening policies
- All States gave pregnant women priority status in entering treatment, in accord with federal requirements

**Notes:**
Follow-up on repeat birth data is limited

## 2. Prenatal Screening and Services

**Implementation**
- No States *require* prenatal screening for substance abuse
- Medicaid funds 37% of births, but it is typically not used for encouraging nor requiring screening programs

**Notes:**
Private physician efforts are usually on a pilot project scale only
Medicaid could be used as a key leverage point for advancing policy – should that be revisited in the conclusions section? Also, does this point about Medicaid belong here or in the next section on screening at birth?

## 2. Prenatal Screening and Services

**Implementation**
- Referrals of pregnant women to treatment and progress in treatment are not monitored on a Statewide basis
- Wait lists persist in some States—particularly for residential care
- Admissions of pregnant women are a very small percentage of total admissions

**Notes:**
Private physician efforts are usually on a pilot project scale only
Medicaid could be used as a key leverage point for advancing policy – should that be revisited in the conclusions section? Also, does this point about Medicaid belong here or in the next section on screening at birth?

## 3. Screening and Testing at Birth

**Findings**
- Policies on screening at birth are generally not at the State level
- Local hospital policy dictates screening practices such as who is screened
- Reporting requirements
- 5 of 10 study States require reporting to CPS at birth
- 2 study States require as mandated reporters
- 37% of all States
- Recent legislation proposed or enacted in some States has expanded requirements for referrals when drug exposure is detected -- AR, CO, LA, NV, WA

**Notes:**
Requires reporting: Illinois, Massachusetts, Minnesota, Rhode Island, and Virginia. Maryland and South Carolina include substance exposure as part of definition of child abuse and neglect, so assume mandated reporters are required to report. But only the first 5 have policy specifically saying that they have to report.

## Findings
Defining substance exposure as evidence of child abuse or neglect
7 out of 10 study States
40% of all States
Policies vary for different substances 
“controlled substance,” “addictive drug,” “non-prescription, controlled substance or signs of fetal alcohol syndrome,” “cocaine, heroin or a derivative thereof”
FASD issues have received new attention in some States – HI. MD, MN, ME

- Defining substance exposure as evidence of child abuse or neglect
- 7 out of 10 study States
- 40% of all States
- Policies vary for different substances
- “controlled substance,” “addictive drug,” “non-prescription, controlled substance or signs of fetal alcohol syndrome,” “cocaine, heroin or a derivative thereof”
- FASD issues have received new attention in some States – HI. MD, MN, ME

- 3. Screening and Testing at Birth

**Notes:**
Those that consider prenatal exposure, however detected, as evidence of or the legal equivalent of child abuse or neglect (Illinois, Massachusetts, Maryland, Minnesota, Rhode Island, South Carolina, and Virginia); and
Those that do not consider prenatal exposure by itself to be evidence of abuse or neglect (California, Hawaii, and Washington State).

Up to 20 out of 50 states and DC may consider substance exposure as definition of abuse or neglect. There was significant variance between findings of our original 50 state survey, Christian, Guttmacher and Lester’s findings.  There were only 6 states where all four sources agreed: Florida, Illinois, Maryland, South Carolina, South Dakota, and Virginia.

## 3. Screening and Testing at Birth

**Implementation**
- Hospitals’ policies vary widely with few standardized protocols that are consistently implemented
- States do not monitor screening and referrals
- Hospitals do not usually provide CPS agencies with totals of screenings at birth, results of tests, or number of referrals made to CPS
- Detection of and response to FAS and FASD is inconsistent in policy and practice

## 4. Post-Natal Services to Infantsand Children

**Findings**
- Early intervention policies and process for referrals to IDEA are still emerging
- Two out of 10 Study States (MA and RI) have strong links between IDEA referrals and SEIs in child protective service agencies

**Notes:**
MA, RI, HI and IL models were pre-existing

## 4. Post-Natal Services to Infantsand Children

**Implementation**
- Too early for the 10 study States to have data on increased referrals due to CAPTA/IDEA changes
- Child welfare developmental assessments are not consistently performed for SEIs or for older children of substance abusers who may be prenatally-exposed but entered child welfare at older ages

**Notes:**
At this time it is too early for states to have data on the increase there may be in referrals due to CAPTA/IDEA changes

## 4. Post-Natal Services to Parents

**Findings**
- Some States have supplemented federal funding set-asides for treatment for pregnant and parenting women
- 5 of the 10 study States
- 37% of all States
- Strong models of family-centered services have been developed

**Notes:**
These States, as of mid-2005, were Arkansas, California, Colorado, Connecticut, Florida, Illinois, Kentucky, Louisiana, Maryland, Minnesota, Missouri, Nebraska, New York, North Carolina, Ohio, Oregon, Pennsylvania, Virginia, and Washington.

## 4. Post-Natal Services to Parents

**Implementation**
- Significant data gaps exist
- TEDS requires “pregnant at admission” but not “parenting”
- Capacity of programs is not sufficient to serve all those in need of treatment for women and infants

**Notes:**
These States, as of mid-2005, were Arkansas, California, Colorado, Connecticut, Florida, Illinois, Kentucky, Louisiana, Maryland, Minnesota, Missouri, Nebraska, New York, North Carolina, Ohio, Oregon, Pennsylvania, Virginia, and Washington.

Does the point about pregnant women admissions belong here?

## States’ Coordination Efforts

**Findings**
- All study States have perinatal councils or other coordinating bodies that address SEI issues
- IDEA interagency councils
- Women’s treatment interagency councils
- Early childhood coordinative councils
- Interagency child welfare reform bodies

## States’ Coordination Efforts

**Implementation**
- None of the study States have an interagency process to monitor data, effectiveness or outcomes across agencies

## States’ Coordination Efforts

**Implementation**
- Information gaps make tracking progress difficult
- Prevalence data gaps
- SEI referral data gaps
- Mothers treatment referral data gaps
- Treatment outcomes data gaps
- Funding comprehensive services demands skillful efforts to access multiple funding sources; few States have current inventories of available funding

## Summary

- These 10 States are responding to the SEI problem and the 2003 CAPTA changes with some strong programs
- None of the study States have developed policy at each of the five points of intervention for mothers and infants
- State policy implementation occurs across a diverse set of agencies requiring extensive coordination

## Substance-Exposed Infants: Policy and Practice

- Opportunities for advancing policy

## The barriers to collaboration on SEI issues

- Fear of flooding: “there are no treatment programs,” “we’ll get inappropriate referrals”
- Concern about punitive responses: if we report, removal of child will result
- Basic lack of information about other agencies’ services and policies
- Different missions: child safety, parents’ services needs, family stability

## How could a state self-assess its current collaboration on SEI issues?

- Review the data—what do we know, where are the gaps, how can info systems be improved?
- Review all five levels of policy: inventory current _resources_ in each of the five areas
- Review the _results_ in each area—how do we measure progress or success?
- Review who is at the table and who is missing
- Review the options for a strategic plan across agencies with shared outcomes

**Notes:**
Resources-results mix—cheap treatment is poor treatment 
A strategic plan across agencies—we could find no state that had that including all five levels of intervention

## An example: self-assessing current prenatal services

- What are current practices of physicians in screening [are 4Ps Plus or other brief tools used?]
- How many Medicaid births [37% nationally] are screened?
- How many referrals are made to treatment from prenatal screening? What %?
- What estimates do we have for current prenatal exposure—how do #s of referred women compare to the estimated need?
- What is the treatment gap and how does it compare to total of women entering treatment—is there an issue of priorities?

**Notes:**
$ Ps Plus tool used by Chasnoff in SART, Power Beyond Measure
37% of births are Medicaid—where the public policy leverage is greatest

## A second example: self-assessing screening at birth

- What are current hospital practices? How many screens, how many are positive, how many referrals?
- What happens after a CPS referral: a CPS report should *begin* the process of intervention
- What other services are available to parents? How many parents enroll?  How many complete?
- What are the “handoffs” to family support, home visitation, CWS “front-end” voluntary services, CWS reunification?
- Who case manages these services?

## The Message of the Missing Numbers

- Sherlock Holmes: the case of the dog that didn’t bark
- Sometimes it is what *doesn’t *happen that matters most—lacking the numbers to measure a problem may *be* the problem
- Caring enough to count is the heart of accountability

## Why are substance-exposed births important?

- Though a small percentage of CWS cases, these children are disproportionately 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.3,4
- SEBs require a higher level of public spending than many other target groups

**Notes:**
3.  NIAAA (2000). Tenth Special Report to Congress on Alcohol and Health. 
4. NIDA (1998). Prenatal Exposure to Drugs of Abuse May Affect Later Behavior and Learning

## An Ethical Perspective on SEBs

- Weighing the value of reducing lifetime risks to an innocent child through intervention vs. a woman's right to privacy
- The likelihood of inadequate prenatal care if screening is a deterrent
- The possibility of a punitive rather than comprehensive response
- The long-term costs to taxpayers of SEB consequences

**Notes:**
The problem of the two goods—early intervention to help a child ASAP vs privacy
We have to be willing to have this discussion too, it is not just public policy or medical judgments we are making 

## An example of the ethical tradeoffs:

- 61% of physicians fear that criminal charges would be a barrier to women receiving prenatal care, but
- More than half support legislation allowing removal of children from any woman who abused alcohol or drugs.

**Notes:**
ACOG May 2004 publication

## Parental Substance Use –

- Very little is known about the dynamics of fathering in the context of chronic drug abuse
- Men with SUDs typically begin fathering children after onset of serious drug abuse. One study showed:
- 63% of fathers, compared to 33% of mothers, were using drugs at time of birth of oldest child
- Fathers had been using drugs regularly for 14.4 years, compared to 9.5 years for mothers (McMahon et al., 2005)

- It’s Not Just About Moms

## CAPTA Implementation: Developing a plan of safe care

- How have CPS agencies responded to the current volume of positive screenings of infants?
- What safety assessments have been developed?
- How will the CPS unit monitor the safety plans?
- Will drug-exposed infants be a separately identified subset of their caseloads?
- What lessons can be drawn from current practice?

## Issues for State Consideration

**Long-Term Developmental Impact**
- The development of a plan of safe care alone does not address the long-term developmental impact of being born exposed to illegal substances, or being raised in a home with a caretaker who is affected by a substance use disorder.

## Issues for State Consideration

**The Role of Alcohol **
- The CAPTA amendment does not specifically address alcohol exposure
- States may have available data on fetal alcohol spectrum effects that can be used to assess incidence of FAS and related conditions

## Issues for State Consideration

**Toxicology Screens  **
- Blood tests only identify patients with long-term use in whom secondary symptoms have occurred
-  Timing – Urine toxicologies identify only recent use (within the past 24-72 hours)
-  Urine tests are not reliable for alcohol
-  Cost of toxicology screening
- $8-$80 depending on type of test – blood vs. urine, extent of drug panel, sensitivity, cut-off level, etc.

**Notes:**
Need more info on what cost and timing issues actually are
Is that better? No still need cost per screening—or estimates—maybe Diana is getting from SD hospitals

## Issues for State Consideration

**Verbal Screening Tools**
- Chasnoff’s 4 P’s Plus
- Has either one of your **P**arents had a problem with drugs or alcohol?
- Does your **P**artner have a problem with drugs or alcohol?
- Have you had a problem with drugs or alcohol in the **P**ast?
- Have you used any drugs and alcohol during this **P**regnancy?

## Issues for State Consideration

**Testing/Identification**
- Voluntary testing vs. universal testing vs. testing based on valid screening and assessment practice
- Given the current bias in testing, Universal testing is the only unbiased approach
- raises issues of privacy and intrusiveness
- must consider cost, false positives and confirmations of those tests
- “Upstream” prenatal screening is much preferable, and done correctly, is just as accurate or more so

## Issues for State Consideration

**The Role of Dependency/Family Court**
- A significant number of dependency petitions are filed in response to positive tox screens
- Many states and localities lack data on removals based on SEB; the court can upgrade its information systems to require this data
- The court is a key collaborative partner—but it needs to be a true partner, aware of the roles of the other players and willing to monitor its own outcomes as part of an annual accountability review

## The Policy Questions

- Can a pregnancy screening (like 4Ps) be the trigger for “upstream” services and referral to treatment?
- Can a mandated SEB report to CPS be the trigger for “downstream” follow-up services to child and parent(s)?
- Home visiting, family support, parenting skills, child development and developmental screening
- Is our interagency collaboration strong enough to guarantee that these results will happen and be monitored over time?

## Opportunities for Advancing Policy

- CFSR review II—spotlight on the child welfare system’s SEI reunification outcomes
- Federal treatment information system changes
- Monitoring of child and family service state plans

**Notes:**
Forgive the alphabet soup, but the point is that in several agencies—not just CPS—there are opportunities to frame SEI issues as collaborative potential
Yale study: preschoolers are being expelled at three times the rates of K-12—many reasons to believe these are SEI children

## Opportunities for Advancing Policy

- IDEA referrals under CAPTA
- Renewed focus on school readiness issues
- Using Medicaid funding of births to leverage screening efforts

**Notes:**
Forgive the alphabet soup, but the point is that in several agencies—not just CPS—there are opportunities to frame SEI issues as collaborative potential
Yale study: preschoolers are being expelled at three times the rates of K-12—many reasons to believe these are SEI children

## Conclusions

- Four key policy challenges:
- There are many opportunities *before and after the birth event* to intervene—a balanced policy would address all five stages of the SEI problem
- To address all five stages, States need much stronger coordination that monitors progress across multiple agencies

## Conclusions

- Four key policy challenges:
- States don’t track SEIs and treatment for mothers well enough to measure whether they are making progress on the problem or to justify additional resources
- Treatment programs do not admit enough pregnant and parenting women in comparison to those who need treatment services

## Recent Products

*Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers*
- 	(A short monograph for front-line workers)
- On-Line Training – Now Available
- Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals
- Understanding Substance Use Disorders, Treatment and Family Recovery: A Guide for Child Welfare Professionals
**Visit**
**www.ncsacw.samhsa.gov**** **

**Notes:**
Publication and on-line training.  Free of charge.

## January 30, 2007
Pre-conference symposium on substance-exposed infants with Dr. Ira Chasnoff
January 31 to February 2, 2007
 National Conference
Disneyland Hotel, Anaheim California
 Sign up for information at  
     conference@cffutures.org

- Pre-conference symposium on substance-exposed infants with Dr. Ira Chasnoff
- January 31 to February 2, 2007
-  National Conference
- Disneyland Hotel, Anaheim California
-  Sign up for information at
-      **conference@cffutures.org**

**ANNOUNCING**

**Notes:**
Use your conference graphic.

## Sources

- Office of Applied Studies. (2003). *Results from the 2002 National Survey on Drug Use and Health: National findings* (DHHS Publication No. SMA 03–3836, NHSDA Series H–22). Rockville, MD: Substance Abuse and Mental Health Services Administration at _[http://oas.samhsa.gov/2k3/pregnancy/pregnancy.htm](http://oas.samhsa.gov/2k3/pregnancy/pregnancy.htm)_
- Hamilton BE, Martin JA, Sutton PD. (2003) Births: Preliminary data for 2002. _National vital statistics reports_, 51 (11), Hyattsville, Maryland: National Center for Health Statistics at _[http://www.cdc.gov/nchs/data/nvsr/nvsr51/nvsr51_11.pdf](http://www.cdc.gov/nchs/data/nvsr/nvsr51/nvsr51_11.pdf)_
- National Institute on Alcoholism and Alcohol Abuse. (2000). *Tenth Special Report to Congress on Alcohol and Health*. Washington, DC: Department of Health and Human Services at _[http://www.niaaa.nih.gov/publications/10report/intro.pdf](http://www.niaaa.nih.gov/publications/10report/intro.pdf)_
- National Institute of Drug Abuse. (1998). Prenatal Exposure to Drugs of Abuse May Affect Later Behavior and Learning.  NIDA Notes, 13 (4) at _[http://www.drugabuse.gov/NIDA_Notes/NNVol13N4/Prenatal.html](http://www.drugabuse.gov/NIDA_Notes/NNVol13N4/Prenatal.html)_
- U.S. Department of Health and Human Services, Administration on Children, Youth and Families. *Child Maltreatment 2003 *(Washington, DC: U.S. Government Printing Office, 2005) at _[http://www.acf.hhs.gov/programs/cb/publications/cm03/cm2003.pdf](http://www.acf.hhs.gov/programs/cb/publications/cm03/cm2003.pdf)_
- U.S. Department of Health and Human Services, Administration on Children, Youth and Families. *Child Maltreatment 2002 *(Washington, DC: U.S. Government Printing Office, 2004) at _[http://www.acf.hhs.gov/programs/cb/publications/cm02/cm02.pdf](http://www.acf.hhs.gov/programs/cb/publications/cm02/cm02.pdf)_
- Christian. (2004). *Substance-Exposed Newborns: New Federal Law Raises Some Old Issues*.  Washington, DC: National Council of State Legislatures at _[http://](http://www.ncsl.org/print/cyf/newborns.pdf)__[www.ncsl.org/print/cyf/newborns.pdf](http://www.ncsl.org/print/cyf/newborns.pdf)_
- The Alan Guttmacher Institute.  (October 1, 2004)  *State Policies in Brief:  Substance Abuse During Pregnancy*.  Washington, DC: author at _[http://](http://www.guttmacher.org/statecenter/spibs/spib_SADP.pdf)__[www.guttmacher.org/statecenter/spibs/spib_SADP.pdf](http://www.guttmacher.org/statecenter/spibs/spib_SADP.pdf)_
- National Clearinghouse on Child Abuse and Neglect Information.  (2004). *State Statutes Series 2004. Parental Drug Use as Child Abuse: Full-Text Excerpts of State Laws*.  Washington, D.C.: National Clearinghouse on Child Abuse and Neglect. [Accessed 12-08-2004 at _[http://nccanch.acf.hss.gov](http://nccanch.acf.hss.gov/)_].
- Vega, W., Noble, A., Kolody, B., Porter, P., Hwang, J. and Bole, A. (1993).  Profile of Alcohol and Drug Use During Pregnancy in California, 1992: Perinatal Substance Exposure Study General Report.  Sacramento, CA: CA Dept of Alcohol and Drug Programs