The Child Abuse Prevention and Treatment Act: Substance-exposed Births

1. The Child Abuse Prevention and Treatment Act: Substance-exposed Births Cathleen Otero and Sid Gardner National Center on Substance Abuse and Child Welfare www.ncsacw.samhsa.gov Melissa Lim Brodowski Office of Child Abuse and Neglect Administration on Children, Youth and Families July 14, 2004 Baltimore, MD

2. Child Abuse Prevention and Treatment Act (CAPTA) Since 1974, CAPTA has been part of the federal government’s effort to help states improve their practices in preventing and responding to child abuse and neglect. CAPTA provides grants to states to support innovations in state child protective services (CPS) and community-based preventive services, as well as research, training, data collection, and program evaluation.

3. CAPTA Funds 2004 • Basic State Grants • $22 million • Discretionary Grants • $34.6 million • Community Based Programs • $33.4 million

4. CAPTA State Grants • Provides funds for States to improve their child protective services systems • Distributed on a formula basis on the population of children under 18 years old in the State • Requires States to submit a five-year plan and an assurance that the State is operating a Statewide child abuse and neglect program that includes several programmatic requirements from the legislation

5. CAPTA State Grants The reauthorization of CAPTA in 2003 added several new eligibility requirements for States. Some of the new requirements include: • Triage procedures for referral of children not at imminent risk of harm to community or prevention services; • Notification of an individual who is the subject of an investigation about allegations made against them; • Training for CPS workers on their legal duties and parents’ rights • Provisions to refer children under age three who are involved in a substantiated case to early intervention services under IDEA Part C

6. CAPTA 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));

7. CAPTA 2003 Keeping Families Safe Act Amendments • 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))

8. CAPTA How many substance exposed births? Challenges in estimating • Prenatal drug use • Substance exposed birth

9. CAPTA How many substance exposed births? Best estimates are that a total of 10-11% of all newborns are prenatally exposed to alcohol or illicit drugs1,2 That means about 400,000-480,000 substance-exposed births nationwide last year An estimated 8 million of total of 77 million children 0-18 1. 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.

10. CAPTA How many substance exposed births in CWS? CALIFORNIA 2003 DATA total births = 598,000 11% = 65,780 Total substantiated reports on children 0-1 = 12,050 Total in OOHC = 86,663 Total 0-1 in OOHC = 3,913 = 4.5% NATIONAL 2001-2002 DATA Total 2002 births = 4,093,000 10% = 409,300 Total 2002 substantiated reports on children 0-1 = 142,026 Total in OOHC 2001 = 542,000 Total >1 in OOHC 2001 = 22,957 = 4% Where did they all go?

11. CAPTA Most go home… 90-95% are undetected and go home • Many hospitals don’t test • Law may not require report • Tests only detect very recent use

12. Why are substance-exposed births important? • 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.3,4 • SEBs require a higher level of public spending than many other target groups 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

13. A Graphic Overview 73 million 0-17 Children and youth 4.093 million births annually 409,300 estimated substance-exposed births annually 7.3 million born substance- exposed Estimated substance-exposed births reported to CPS: 5.6% of all SEBs = 22,957 2.5 million CPS reports annually

14. CAPTA How do States currently respond to prenatal drug exposure?

15. State SEB Responses 16 States have legislation that defines substance exposed births as child abuse or neglect 10 States have legislation mandating SEB reports to CPS by health care professionals and/or mandated reporters in general • 6 of which are among the 16 that define SEB as CA/N (DC, IL, IA, MI, MN, RI) • 4 States mandate reporting of SEB, but do not define SEB as CA/N (AZ, OK, UT and VA)

16. State SEB Responses • 4 States have some form of testing policy • testing mother or infant • 4 States have laws that mention SEB (CA, KY, MO, LA), but leave the judgment of CA/N to the discretion of the CPS worker (CA) or the health care provider (KY), focusing more on risk assessment and referral to services • 5 States have laws that only address AOD use/abuse during pregnancy, but do not address SEB

17. State SEB Responses 17 States have some CPS policy that specifically addresses SEB • 2 of these States (MI, MN) define SEB as CA/N • 6 of these States have an established law regarding SEB (KY, MI, MN, and MO), or an established law regarding prenatal AOD use (KA and OR)

18. State SEB Responses Of the 19 States that have a law that addresses AOD use during pregnancy, or a CPS policy that specifically addresses the response to SEB, only 2 of these States define SEB as CA/N 12 States have no official response to substance exposed births

19. CAPTA Implementation Issues: Four Major Areas CAPTA focuses on four elements of SEB: • Identifying infants affected by illegal substance abuse or withdrawal symptoms • Implementing the requirement that health care providers involved in the delivery or care of such identified infants notify the child protective services system of such conditions • Developing a plan of safe care • Addressing the needs of these infants

20. CAPTA Implementation Issues Identifying infants affected by illegal substance abuse or withdrawal symptoms EXAMINE EXISTING PRACTICE • What policies and procedures are currently in place to screen and assess for prenatal substance exposures? • What is the State’s experience regarding the adequacy of these policies and tools and methods? • Has the State established the incidence of SEB?

21. CAPTA Implementation IssuesIdentifying infants affected by illegal substance abuse or withdrawal symptoms CHALLENGES/OPPORTUNITIES • Prenatal care for at-risk early identification; “going upstream”—Ira Chasnoff’s work • Screening methods • Verbal screens by trained staff can be more effective than toxicology screens • Multiple testing methods, different costs • Identification should lead to appropriate services; a CPS report should begin the process of intervention

22. CAPTA Implementation Issues Implementing the requirement that health care providers notify the child protective service system of substance exposed births EXAMINE EXISTING PRACTICE • What maternal and child health programs have been able to provide prenatal care for high-risk women? • To what extent has that prenatal care been able to identify pregnant women in need of treatment? • To what extent have women begun/completed treatment? • How many referrals of pregnant women needing treatment and of positive tox screenings do health care providers make to CPS or other agencies?

23. CAPTA Implementation IssuesImplementing the requirement that health care providers notify the child protective service system of substance exposed births CHALLENGES • Health care providers operate independently from CWS • May have a narrow view of CPS • Health care providers may be reluctant to screen • May screen with bias toward lower-income women of color • Health care providers may be unfamiliar with the available public and private treatment resources • Wider screening can be a controversial change • Advocates have different and intense attitudes

24. CAPTA Implementation IssuesImplementing the requirement that health care providers notify the child protective service system of substance exposed births OPPORTUNITIES • Routine screenings can be adopted without disruption to the health care system with adequate training and strong referral agreements • Adapting the lessons of the wider arena of bridge-building among child welfare, treatment agencies, and the courts: • Trust takes time • A trained team is better than any screening tool • Communication among agencies is critical

25. CAPTA Implementation IssuesAddressing the needs of these infants EXAMINE EXISTING PRACTICE • How have the needed agencies been convened? • Have they developed a strategic plan for a coordinated response to the needs of these infants? • Have they agreed how to provide developmental screening for delays related to substance exposure? • Do they have any mechanisms for aftercare and follow-up with parents and children?

26. CAPTA Implementation IssuesAddressing the needs of these infants CHALLENGES • Requires a coordinated response • Maternal and Child Health, Developmental Disabilities, Children’s Mental Health, Special Education • Training for both staff and caretakers • Effects of other factors that combine with prenatal drug exposure to affect life outcomes: • Family environment, genetic predisposition, resiliency, trauma, and effects on higher executive functioning in the brain

27. CAPTA Implementation IssuesAddressing the needs of these infants OPPORTUNITIES • Following the lead of available Best Practice models • Dual track – differential response • Referral of screened infants and their parent(s) for voluntary care still requires adequate follow-up, an information system that can track cases across agencies, and client engagement that ensures parents will stay in the system

28. CAPTA Implementation IssuesDeveloping a plan of safe care EXAMININE EXISTING PRACTICE • 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?

29. CAPTA Implementation IssuesDeveloping a plan of safe care CHALLENGES/OPPORTUNITIES • How will the CPS unit monitor the safety plans? • Will drug-exposed infants be a separately identified subset of their caseloads? • Will reports of SEB infants be compared with total births and incidence reports/estimates? • What lessons can be drawn from current practice?

30. CAPTA 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.

31. CAPTA 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

32. CAPTA Issues for State Consideration Use vs. Abuse vs. Dependence • Substance Use Disorders (SUDs) include the spectrum of substance abuse and dependence • Prenatal exposure is often a combination of poly-drug, alcohol and tobacco exposure • How do States differentiate • Screening and assessment • Differential response

33. CAPTA 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-$81 depending on type of test – blood vs. urine, extent of drug panel, sensitivity, cut-off level, etc.

34. CAPTA Issues for State Consideration Verbal Screening Tools Chasnoff’s 4 P’s Plus • Has either one of your Parents had a problem with drugs or alcohol? • Does your Partner have a problem with drugs or alcohol? • Have you had a problem with drugs or alcohol in the Past? • Have you used any drugs and alcohol during this Pregnancy?

35. CAPTA 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

36. CAPTA Issues for State Consideration The Role of Dependency/Family Court • A significant number of dependency petitions are filed in response to positive toxicological screens. • 3,913 total removals of 0-1 year-olds in CA [2003] • Many states and localities lack data on removals based on SEB; court can upgrade its information systems to require this data • The court should be made aware of the roles of the other players and should be included in working with these agencies to ensure long-term interventions are provided

37. 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

38. The Policy Question • 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 • Can a pregnancy screening (like 4Ps) be the trigger for “upstream” services and referral to treatment?

39. 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 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 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 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 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