Beyond the Hospital: Nurturing the Drug Exposed Baby

1. Beyond the Hospital:Nurturing the Drug Exposed Baby Margaret McLaren, MD Connecticut Children’s Medical Center University of Connecticut School of Medicine

2. Outcome of Prenatal Drug Exposure - Trends Late 1990sMuch ado about nothing 1980sLost generation 2000s Biological vulnerability ?

3. Infants of Substance Using MothersDouble Jeopardy Biological vulnerability + environmental risk factors • Effects of PDE on infant/child • Effects of SU on parental behavior • Antecedents of maternal substance use • Co-risk factors

4. Increased risk of Developmental/ behavioral problems Child maltreatment Caregiver disruption & foster care Concerns

5. Response • Remove child from potential harm • Disruption • Increase in foster/ kinship placement • Delayed reunification until mother “proves herself” • Strengthen care-giving environment while keeping child visible

6. Hope The postnatal care-giving environment is a powerful toolthatcan positively affect outcome through prevention of new/ further insults and promotion of a secure attachment relationship

7. Infant Brain Research

8. The Limbic System

9. Advances in Neurobiology • PLASTICITY of the brain • Sensitive periods for development • Context - relationships • First 2 yrs - emotional development • 1st year - EMPATHY • 1st 1.5 years - ATTACHMENT

10. A T T A C H M E N T

11. Attachment • The development of attachment relationships between children and their caregivers constitutes one of the most important aspects of human social and emotional development View of self, significant others, social world

12. Healthy (Secure) Attachment • Major developmental task • Protective factor for RESILIENCE • Promoter: A care giver - able and willing to engage in the intimate dance which occurs between a mother and her infant.

13. Pattern Secure - B Insecure /ambivalent - C Insecure/ avoidant - A Care-giving Environment Sensitive, responsive, positive regard Inconsistently sensitive/ responsive Insensitive. hostile, avoidant of contact Attachment Patterns(Mary Ainsworth)

14. Disorganized Attachment (D)(Mary Main) Risk factors: • Unresolved trauma, loss/ rejection, • Child maltreatment, • Substance use Strongest predictor of psychopathology

17. Effects of Separation on Substance Using Mothers • Mothering = most important aspect of getting life back together for many women with chemical dependency - the glue that holds everything else in place • Loss/ separation leads to grieving, depression, & intensified use

18. Secure (B) Bio mother 20% Abstinent 50% Kinship10% Foster38% Control64% Insecure (A) (C) 80% 30% 50% 50% 90% 54% 36% 72% 43% 29% 36% 16% 20% Attachment Patterns in Infants With Prenatal Substance Exposure (Rodning, Beckwith, Howard, 1991)

19. Disorganized Attachment in Infants With Prenatal Substance Exposure • Bio mother 75% • Kinship 64% • Foster 71% • Control12% (Rodning, Beckwith, Howard, 1991)

20. Foster Labeling Defenses Fewer bio visits More placements More resources More adaptive Attachment issues Grandparents Fear “sick” baby Projection More frequent bio visits More stability Fewer resources Conflict as gatekeepers Characteristics of Alternative Care-givers of DE Infants

21. Crack baby !!!! • Drug addicted baby !!!!

22. Effect of Labeling • Yale Study (Mayes et al) • College students observed children at play • Told some were “CE” and some “NCE” Significantly rated “CE children” as having more problem behaviors

23. PROkids Plus Promoting Resilience & Optimal development Through enhancing the mother-child relationship & the well-being of both

24. PROkids Plus • 0 to 3 months of age at entry • A system’s model based on attachment and relational theory • Works with biological and/ or alternative care-givers • Stays with the child irrespective of placement

25. Under One Umbrella

26. Components • Expanded well child visits • Developmental follow-up & parenting support Plus (since 12/2000) • Home visitation, case management & family development • Motivational enhancement • Collaboration and advocacy

27. PROkids Clinic • Primary Care as a portal of entry • Non stigmatizing, normal parental activity • Essential ingredient = TRUST • Visits expanded in frequency and duration • Addresses medical, social, & developmental needs • Parallel tracks with bio and foster parents

28. Family Development / Home Visitation Component • 2 social workers and 3.5 paraprofessional family development workers • Group support – Family Life Education • Therapeutic relationships • Addiction / recovery needs • EMPATHIC CARE

29. EMPATHIC CARE* MODEL Enhancement of the parent-infant relationship within the real life context of the caregiver’s multiple intense needs PROkids Plus 2004

30. Essential Ingredient • EMPATHY – The ability to feel for another and SHOW compassion while maintaining healthy psychological boundaries

31. Parallel processing Do unto others what you would them do to others. Staff to staff Staff to caregiver Caregiver to child Pivoting Holding in mind & focusing on the needs of the child & parent-child relationship while addressing multiple needs of family/ crises. Essential strategies of EMPATHIC CARE*

32. Empathy Maintain contact Presence Affect attunement Tuning into the baby’s cues Holding in mind/ Pivot Internal working models Communication Consistency Affirm strengths Respect/ reflection Efficacy *PROkids Plus Intervention PrinciplesEMPATHIC CARE *

34. “The more parents experience positive supportive relationships, the more opportunities they have to enhance their internal working models of themselves, their infants and their relationships with their infants.” Gowen, Nebrig, 1997

35. Every encounter is therapeutic and an opportunity for a dyadic intervention. • Affirm strengths in the dyad– in every mother there is a “good” mother and in every baby, there is a good baby.

36. 0 to 3 months: 3 to 6 months: 7 to 18 months: 19 to 36 months: Window of opportunity The dance - Building blocks of attachment Securing base from which to explore Reciprocal attachment Phases of EMPATHIC CARE

37. Openness to transformation Shift to the baby Preoccupied with love and fear for infant’s safety 0 to 3 Months: “Window of Opportunity”

38. “My baby is my butterfly – he saved my life.” -A PROkids mom

39. Caregiver Mothering constellation (Stern) Addiction – less priority Relapse risk Intrusion - DCF Infant Gaze, Cues / state Sensory capacities Response to cry, soothing Carrying Window of Opportunity

40. Infant Carrying Project

41. Mother Cocaine Less flexible, Less engaged Opiate Increased arousal Infant No effects Prolonged sucking bursts, fewer pauses, more feeding problems, more arousal LaGasse LL et al, Arch Dis Child Fetal Neonatal Ed 2003;88:F391-F399 Feeding Behavior at 1 Month

42. 4 to 6 Months: “Dancing Together” - Building blocks of attachment Goals: • Develop reciprocal positive interactions • Help mothers maintain the child as their primary relationship • Prevent substances resuming the primary position

43. Caregiver Availability Contingent responses Mother’s identity begins to shift to “addict” Staff parallels interaction with caregiver Infant Enhancing positive affect Soothing negative affect Readiness to interact Avoiding over-stimulation Face en face Following lead Routines & quiet time Dancing Together

44. Caregiver Ambivalence Effects of trauma Cultural attitudes Relapse risk in toddlerdom ! Secure base for recovery / safety Building supports Videotaped interactions Infant Providing a secure base Positive exploration Dependency/autonomy Sharing positive affect/ joy Playing together Reunions / repair 7 to 18 Months: Securing a Base From Which to Explore

45. 19 to 36 months: Reciprocal attachment • Pattern organized, • Emerging autonomy • Alter trajectory if insecure/ disorganized. • Self efficacy

46. Reducing Risks of Separation: • Facilitate regular contact with care-giver – including medical visits ( triadic approach) • Nurture stable alternative family (experience does not equal competence) • Educate child welfare & the court on importance of attachment in guiding placement decisions, visitation frequency, and permanency time lines • Understand relapse and recovery

47. Understanding Relapse “Relapse is part of recovery. Don’t take my baby !” - A PROkids Mom to DCF and the police as they come to take her baby:

48. A Useful Analogy……. • For toddler, learning to walk – frequent falls before mastery • For mother, learning to stay in recovery – relapses may occur on the way, but it is possible to get up again and again, each time a little stronger until eventually mastery is achieved.

49. Facilitating Reunification • The infant should not be a stranger to her biological mother. • The mother should feel that she has remained important in her child’s life and has participated in her rearing. • The foster mother’s role is valued as a “comadre” and guide to the biological mother and her child.

50. How Does this Approach Differ from Others? • Relational focus, on all levels • Emotional development focus • Fostering adaptive internal models • Strength-based / efficacy-promoting • “Facilitating” non- hierarchical model