A Framework for Intervention for Infants with Prenatal Exposure and Their Families

[background music] Announcer: On behalf of the National Center on Substance Abuse and Child Welfare, welcome to our video presentation We'd like to give a special thanks to 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, who support the National Center

For more information about the National Center and other training and technical assistance, materials, and resources, please visit our website at wwwncsacwsamhsagov We hope you find this presentation helpful as you bring systems together to support family recovery, safety, and stability

Nancy Young: Hi, this is Nancy Young I'm the Director of the National Center on Substance Abuse and Child Welfare Welcome to our web presentation about infants with prenatal exposure and their families, and the way in which the National Center organizes our work to address the practice and policy issues for this set of families We're going to talk about a few topics today, but we're going to start with some data Why is this important? Many of you are familiar with these data that come from AFCARS dataset showing the increased number of children in out-of-home care in the last couple years after more than a decade of decreasing numbers, and this uptick in the last few years

Many child welfare directors tell us that the prenatal exposure and the opioid crisis in our country is associated with this increased number of children in care Certainly, when we look at the infants who are coming in to care, very disturbing to see this continuing increase of infants who are entering foster care At the same time, we know from hospital records that the incidence of neonatal abstinence syndrome, or NAS, associated with opioid withdrawal after birth has continued to increase Again, these data are a little bit older, with 2012 the most recent data available, but a disturbing trend over these last several years of increases in NAS When we look at NAS in the context of infants who are affected by prenatal exposure, you see that the left-hand side of this graphic, these are data from prevalence studies and the number of infants that were born in the country

We would encourage those that are working at a state level to know those data for your own state Or if you're a county administrator, that you have the number of births in your county, and you have this benchmark, if you will, of what are the numbers of births and infants who are potentially affected by prenatal substance exposure in your community Then that smaller number, if you will, that are actually diagnosed with a withdrawal syndrome, or FASD, or fetal alcohol spectrum disorder All three of these categories become important when we look at the Child Abuse Prevention and Treatment Act and requirements for child welfare to be monitoring and be intervening with these families Several years ago, in fact published in 2009, was a monograph, "Substance Exposed Infants and the State Responses to the Problem

" This five point framework emerged from this review that we did, almost now a decade ago, looking at the existing policy and practices in 10 states related to this population Subsequent to that, the framework was included in the Office of National Drug Control Policy's strategic plan It sets the context of some key legislative actions that have taken place over the last decade in particular that builds on this prior policy and practice about our knowledge base of how to intervene and how to put in place the structures that are needed across systems to assist families That legislative summary includes the changes that were made in the Child Abuse Prevention and Treatment Act Now, most of you will be familiar with the CAPTA that originated in 1974 that provided the first federal funding specifically under CAPTA to support prevention, assessment, investigation, and treatment activities related to child abuse and neglect

The changes that have happened in the CAPTA legislation, specific to this population of infants and their families affected by prenatal substance exposure, began in 2003 in the Keeping Children and Families Safe Act In those changes, there were new conditions for states to receive their grant There's specific language about the legislative intent of identifying infants at risk as a result of prenatal exposure so that appropriate services can be delivered We always think it's important to go back to that What was the original intent about why these changes were made in CAPTA specific to this population? Then in the reauthorization of CAPTA in 2010, some further changes were made

In particular, identifying infants who are affected by fetal alcohol spectrum disorder was added as well as reporting requirements to the annual state data reports You see the detail about the number of children referred to child welfare services with prenatal exposure, those that were involved in a substantiated case of abuse or neglect, and those that were referred to agencies providing early intervention services under Part C for the Individuals with Disabilities Education Act Subsequent to 2010, more recent changes happened as part of the Comprehensive Addiction and Recovery Act of 2016 Title V of CARA makes specific changes again in the CAPTA legislation and created a couple different changes It clarified the definition of infants who are identified as affected by substance abuse and in fact removed the term illegal

It ensures that comprehensive services are being put in place to address the treatment needs of the infant and the affected family or caregiver More information is provided about the development of a plan of safe care and specifies data to be reported by states, and increases the monitoring and oversight to ensure that plans of safe care are implemented and that families have access to appropriate services In that context, we thought it was important to go back and look at the points of intervention for a comprehensive reform to make sure that we're looking at prevention as well as the intervention and treatment needs of pregnant women, new mothers, their families, and the infants In that 2009 publication, there are some guiding principles that were important as states put intervention plans in place In particular, understanding that the birth event is only one of the opportunities that there are to effect outcomes, that interventions are needed throughout the child's developmental stages, and that early identification, early intervention makes a difference in the family's outcome

We also recognized that there was no single system that had all of the necessary resources, information, or influence to effect change among this population The cross-system linkages were necessary in coordinating the services across that spectrum of prevention, intervention, and treatment Finally, that a family-centered approach yielded the best results In fact, each family member's needs need to be assessed, need to be understood, and that improving care and supports for mothers is the most important factor in helping to ensure the health and safety of infants Let's look at those five points of intervention

You see the five, pre-pregnancy, prenatal, identification at birth, the postpartum time period, and infancy and beyond What did we find were the kinds of practice and policies that states were putting into place? In particular, promoting the public awareness of the effects of substance use during pregnancy All of us are familiar with some of these kinds of strategies Certainly, the beverage warning labels that we see on alcohol bottles are examples of broad public health approach to the prevention of prenatal substance exposure Knowing that there are educational materials at selected venues, particularly at public health clinics, that pregnant women and their families have access to the education that they may need about the implications of substance use during pregnancy

We've all probably seen the media campaigns directed at women of childbearing age, particularly in health and social service agencies, as well as the general public with, again, media campaigns about in particular smoking and alcohol use during pregnancy All of that is what we're referring to as that pre-pregnancy period in which the general education needs to happen Second is in the prenatal period and the interventions that are needed to ensure that screening takes place and that the initiation to enhance prenatal services are put in place when women are screened and need intervention that's specific to their substance use Some of those key considerations for policy and practice include the kinds of screening tools that a state or a community implements to determine how substance use during pregnancy is identified Knowing at the state or the local level, does the current practice ensure that there's specialized prenatal care? In other words, that there are OB/GYNs who are knowledgeable in addiction medicine if the woman meets criteria for a substance use disorder

Does current practice assure that there's access to medication assisted treatment, particularly for women with opioid use disorders? Then are there priority access requirements in the Substance Abuse Prevention and Treatment Block Grant implemented so that pregnant women have the priority and preferred access to enter treatment during that prenatal period? The third point of intervention is identification at birth We often find that a lot of the practice and the policy attention is given to this identification at birth But I think all of us recognize that interventions during that second time period, during that prenatal period, is the best case of being able to prevent any of the consequences that might be associated with prenatal substance exposure But that identification at birth means that there are then two ways in which we need to ensure that interventions are in place, both for the neonate and developing child as well as for the parent Again, some of the key policy considerations and practice considerations that have to be addressed during this period

Those considerations include the current practice and the procedures for testing at birth Is there are protocol for identifying and treating infants with neonatal abstinence syndrome? Important is understanding what is the current state statute regarding substantiating child abuse or neglect related to prenatal substance exposure Not all states have the same state statute regarding substantiated abuse or neglect, and the practice and the policy varies from state to state, in part due to the way in which that is defined in your state statute If you aren't familiar yet with that, that's one of the first key considerations is what does our state statute say? In fact, is there something that might need to change in that current state statute? Based on current law, what is the protocol to ensure that notification is made to child welfare services for the newborns who are identified as affected by prenatal exposure, withdrawal syndrome, or fetal alcohol spectrum disorder? Those are the three categories that are in the Child Abuse Prevention and Treatment Act Is there a notification protocol from hospitals that address each of these three populations? Is there guidance at the hotline about what happens when calls come in or notifications come in about opening cases, conducting safety assessments? What's the pathway that is intended with this population when there is a notification from the hospital as required by the Child Abuse Prevention and Treatment Act? Is there a protocol to ensure that the safe discharge plan and plan of safe care that includes the family and caregiver's needs is in place? To what extent does the current practice provide the necessary supports to maintain that infant and mother bond whenever possible? Is there also a protocol for tracking the total number of cases with prenatal exposure and their outcomes? These are all considerations that states and counties must take into account as they are developing their practice protocols and their policies related to this population

Moving on then to the postpartum period to ensure that child's safety and response to the infant's need is in place, as well as responding to the parent's needs Again, some of those key policy and practice considerations We're repeating that information about the plan of safe care because it continues after discharge Who's accountable for developing that? What is the current practice to ensure that the ongoing care is coordinated? Is this a population that's a priority for home visiting services? Who's accountable for that ongoing development of the family's plan of safe care? Then, finally, in the follow-up period in infancy and as the child develops, what are those protocols about prenatal exposure to initiate the referrals for developmental screening and early intervention services? If the child is not an open case in child welfare, is there a need to still have developmental assessments done? Who has the lead role in that ongoing monitoring of the plan of safe care? Questions again that states and communities need to grapple with as they're changing policy, as they're looking at their current practice related to this population What are some next steps? First, we hope that you will be in touch with us for learning more about, in particular, collaborative planning

A document that came out in the fall of 2015, "A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders" While it's specific to opioid use disorders, I think you'll find that it's helpful in the broader constructs of prenatal substance exposure You see the list of what's inside, current data about opioid use, guidelines for supporting collaborative practice and policy Again, we touch on the comprehensive framework for intervention You see the appendices that are some how-to with a facilitator's guide, issues related specific to medications for treating opioid-use disorders, and a case study from a community in Vermont that has implemented, over several years, a collaborative approach to this population

We encourage you to download the document and to use that as you're beginning to create your collaborative approach to address the needs of this population The monograph was the work of over 40 professionals from multiple disciplines that came together in a work group to better understand how we could provide guidance to support the efforts of states, and tribes, and communities in addressing the needs of this population It's geared to multiple professional audiences, child welfare, substance use treatment, medication assisted treatment providers, the OBGYNs, pediatricians, and neonatologists Because as we got into the real work of providing this guidance, we understand that there are multiple professionals who have different perspectives and responsibilities and are accountable for different components of practice and policy related to this population There are multiple audiences for which this monograph is intended to be useful

I mentioned already that there is a case study that looks at the implementation of a collaborative approach The Children and Recovering Mothers, or CHARM Collaborative in Burlington, Vermont is an appendix to the monograph What you find inside are the details about how they created their collaborative, where they came, how they identified the needs early in pregnancy to provide services and how they look across the spectrum of pregnancy, birth, and up to two years following birth to ensure that families are safe and that they have the services that they need Some of the principles that they operate under are making sure that they're engaging women in prenatal care as early in pregnancy as possible That they're using medication assisted treatment to manage the withdrawal syndromes and cravings of opioid use disorders

That they're engaging women in substance use disorder counseling, providing the social supports and the basic needs that families may have Coordination occurring prior to the birth and beyond The child welfare assessment is begun prior to birth so that the plan of safe care and where the child will be going home is understood prior to the birth event, which helps reduce some of the crises for child welfare when they have to do family assessments and make arrangements for kinship placements, or foster placements, or making sure that baby is safe going home with birth family That all of that can be tended to and be put in place prior to the birth event, with their overall goal is to improve the health and safety outcomes of babies who are born to women with a history of opioid disorders We certainly hope that you will take advantage of learning from their experience

Again, this is written up as an appendix in the monograph Other next steps? We'll hope you'll be in touch with us with your technical assistance questions You see our email, visit our website, let us know what your questions are and let us know if we can be of assistance to your state and local community Thank you very much for your time today [background music] Announcer: On behalf of the National Center on Substance Abuse and Child Welfare and our federal sponsors, thank you again for joining us today and listening to our presentation

For more information about the National Center, please visit our website Thank you again for all you do to strengthen partnerships and improve family outcomes

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