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Center for Substance Abuse Treatment. Improving Treatment for Drug-Exposed Infants. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1993. (Treatment Improvement Protocol (TIP) Series, No. 5.)

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Improving Treatment for Drug-Exposed Infants.

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Chapter 3 - Followup and Aftercare of Drug-Exposed Infants

Drug-exposed infants should not be viewed as a homogeneous group but as individual at-risk infants presenting with a broad spectrum of possible effects, ranging from healthy term newborns with no apparent effects to high-risk births with significant effects. Living in a drug-abusing family is, in itself, a significant risk factor, regardless of prenatal exposure. Maternal drug use (and paternal drug use as well) represents a health, biological, and psychosocial risk to the developing fetus and a social risk to the young child. The primary focus of the addicted woman is characteristically on her drug of choice, not on her child. A child whose mother abuses drugs often lives in a chaotic environment. Prenatal drug exposure and suboptimal home environments are highly correlated. In combination, they have a synergistic and devastating effect on the child's health and development (Kaltenbach and Finnegan, 1984, 1987, 1988).

Because the infant exists as part of a mother-child dyad, effective treatment must occur within the context of that relationship, as the mother often serves as the gatekeeper for the child's access to services. Knowledge of other siblings, extended family, the father, friends, neighbors, and other caregivers is also crucial to treatment. Followup and aftercare services should also be based on a multicultural and multilinguistic model that takes into account the cultural backgrounds of the mother, the father, and the extended family, as well as the service providers. Staff should reflect the different cultural and racial backgrounds of the communities being served. When appropriate, bilingual staff should be hired or other provisions made so that the inability to speak English is not a barrier to care. In sum, to be effective, treatment must occur within the cultural context of the mother and father, the extended family, and the community.

Knowledge of specific drug exposure is necessary for the appropriate medical management and treatment during the newborn period; the type of pharmacotherapy used in treating neonatal abstinence varies according to the specific drugs or combinations of drugs used by the mother. But followup and aftercare should not be based on a deficit model that assumes and screens for specific abnormalities caused by specific drugs. Rather, followup and aftercare should be based on a multirisk model that takes into account not only the prenatal drug exposure but also the medical status of the mother and the caregiving environment of the infant.

All health care and other service providers should consider the possibility that a number of environmental factors may contribute to specific deficits that have been attributed to drug exposure, as outlined below.

Experience with drug-using mothers and their children has demonstrated that drug exposure is only one of a number of risk factors that may affect the lives of the mothers and children. Other risk factors include:

  • Chronic poverty
  • Poor nutrition
  • Inadequate or no prenatal health care
  • Sexually transmitted diseases, including HIV exposure
  • Domestic violence
  • Child abuse or neglect
  • AOD abuse within the family (including the father and the extended family)
  • Homelessness, transient or inadequate living arrangements, or substandard housing
  • Unemployment
  • History of incarceration
  • Low educational achievement
  • Poor parenting skills
  • Discrimination based on race, gender, or culture.

The lack of sufficient training among providers also affects the quality of the followup care given to drug-exposed infants and families.

To counter the drug-exposed child's early disadvantages, service providers must be prepared to intervene early, often, and from many perspectives. Above all, health care and other service providers should not adopt the attitude that all drug-exposed infants are doomed to an unhappy, unhealthy life. Many, if not most, can eventually lead productive lives, given adequate intervention, education, and treatment services.

The following recommendations address interventions for infants and toddlers, the transition to the preschool period, and training for child-oriented professionals. In general, many services require pediatric supervision by a specially trained physician.

Early Interventions For Infants

  1. Components - Because of their distinctive needs, drug-exposed infants should receive more than the standard medical followup. Such followup should preferably be carried out under the supervision of a specially trained pediatrician. Followup interventions include but are not limited to:
    • Nutrition (especially if inadequate sucking reflex is evident)
    • Psychomotor assessment and monitoring of development
    • Vision and hearing screening
    • Speech and language assessments and therapy
    • emotional development assessments and therapy
    • Play therapy
    • Early educational needs assessments
    • Physical therapy
    • Immunization (see Exhibits 6 and 7).
  2. Referrals - All health care and other service providers, including physicians, should stay abreast of available community services for drug-exposed infants and their families. Administrators should develop clear procedures to ensure that referrals are made to the appropriate resources. (For example, procedures might clarify whose responsibility it is to make referrals, such as case managers or social workers.)

Examples of routine health care referrals for drug-exposed infants and their families should include referrals to Federal programs such as:

  • Early Periodic Screening, Diagnosis and Testing Program
  • Maternal and child health services
  • Community health centers
  • Healthy Start Program.

Although federally supported, these programs vary from State to State and city to city. In addition, regulations and resources associated with these programs may be subject to change each fiscal year. It is important for programs and individual providers serving this population to be aware of these Federal and State resources and to utilize them. Developing and maintaining contact with a public agency (such as the local maternal and child health office, usually housed under the jurisdiction's public health department) can facilitate the process of keeping abreast of programs and resources appropriate for AOD-using mothers and infants.

In addition, in order to provide appropriate referral and followup services to drug-exposed infants and their families, providers and administrators should develop personal contacts among: physicians, social workers, alcohol and other drug counselors, speech and language specialists, early childhood educators, child development specialists, community volunteers, child protective services staff, and others. The new Substance Abuse Block Grant regulations require programs receiving block grant funds set aside for pregnant women and women with dependent children to provide a comprehensive range of services to women and their children, either directly or through linkages with community-based organizations. Thus, contacts with appropriate personnel in these AOD treatment programs should help other agencies with the provision of appropriate referrals.

The appropriateness of certain referrals will vary with the income of the mother, among other factors. For instance, referrals for mothers below the poverty level will usually differ from referrals for mothers who are in a middle-income bracket.

3.

Outcomes - Intervention strategies for drug-exposed infants should promote the following outcomes:

  • Self-regulation: the ability to regulate activity, attention, and affect.
  • Secure relationships with mother and other significant caregivers.
  • Developmentally appropriate progress in motor, cognitive, and speech and language skills.

4.

Delivery System - The Federal early intervention system, mandated under the Individuals with Disabilities Education Act (IDEA), should be used whenever possible to deliver these family-focused services to both infant and mother. Please refer to Appendix D for a more detailed description of IDEA. 1

IDEA, which focuses on disabled and "at-risk" children aged 6 and younger and their families, establishes two new Federal programs. One (Part H) addresses disabled and at-risk infants and toddlers from birth to 3 years of age; the other program (Part B) addresses disabled children aged 3 to 5. The law provides States with Federal funds to plan and implement early intervention services for children, aimed primarily at coordination. Each State must designate a single lead agency, assisted by a 25-member interagency council. Close coordination among health, social services, and educational agencies is required. The State must establish a public awareness program, a system to locate eligible children, procedural safeguards, data collection, and a State definition of developmental delay. Because designated Federal dollars are for coordination, States must develop strategies for funding direct services. The local school system can be contacted for help in identifying the lead agency responsible for coordination of Part H (infants to toddlers) as well as Part B (children aged 3 to 5) of IDEA.

Eligible children must include those who experience developmental delays as well as children with diagnosed physical or mental conditions, such as Down's syndrome or spina bifida, which are likely to cause delays. States also have the option of including children who are medically or environmentally at risk of substantial delay. Thus, States can, but are not required to, include all children born to mothers who have used drugs in utero. However, if an infant is developmentally delayed as a result of this drug exposure, the infant must be included in the program.

The Act also requires an Individualized Family Service Plan (IFSP), which must be developed by a multidisciplinary team and reviewed at least once every 6 months. The following section on the service plan describes what the IFSP must include.

Despite the significance of IDEA, there is a concern that many early intervention programs are designed for infants with more obvious impairments and do not address the more subtle and shared needs of drug-exposed infants and their parents. New models of service delivery and curriculum development must be created to meet the needs of these multirisk infants within the mainstream of early childhood education.

Intervention strategies can also be delivered through:

  • Home visits (by early intervention programs or home health services)
  • Parent-child services delivered within an integrated treatment program of drug treatment and pediatric care
  • Parent-child groups that are center- or community-based.
5.

Service Plan - The intensity and format of interventions should be based on the needs of the individual child and family, using a format such as the Individual Family Service Plan (IFSP), developed through early intervention programs. (See Appendix E for a sample IFSP form.) The ISFP must include statements regarding

  • The child's present developmental status and
  • The family's strengths and needs.

    Major outcomes expected to be achieved for both the child and the family are:
  • Timelines for measuring progress
  • Specific early intervention services (including health care services) necessary to meet the distinctive needs of the child and the family
  • Projected startup dates and the expected duration of service provision
  • Name of the case manager
  • Steps for transition from early intervention into the preschool program.

    However, there is a concern among some in the field that the utility of the required IFSP is questionable and problematic (Dunst et al., 1988).
  • Additional Casefinding - When an infant receives early intervention services, providers should explore the possibility that siblings may also have been exposed to drugs in utero, have been living in a home affected by drug use, and have unidentified or unaddressed service needs.
  • Supportive Services - Quality child care should be provided for the infant and siblings when the mother or the mother-infant dyad are in treatment. Likewise, transportation services for mothers and their children should be provided to facilitate treatment and other community services.
  • Schedule - Followup and aftercare services should be regularly scheduled. (See Exhibits 6 and 7 , previous pages.)

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Exhibit 6: Followup and Aftercare Time Line Chart.

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Exhibit 7: Recommendations for Universal Hepatitis B Immunization.

Interventions for Toddlers

  1. Early childhood programs - For toddlers who have been receiving early intervention services and whose behavior and development are within normal limits, interventions would include quality, developmentally based early childhood programs like Head Start (modified for younger children with appropriate staffing and curriculum), preschool programs, and parent-child groups.
    Quality early childhood programs offer children and their parents the opportunity to be exposed to other adults who have different approaches to childrearing, to try out new activities and learning experiences within a supportive environment, to participate as part of a group, to interact with peers, to receive feedback from others about their behavior, and to experience success and a sense of accomplishment. Children at risk for school failure because of their drug exposure or drug-using home environment can master these critical tasks within an integrated early childhood program.
  2. Individual Therapy - Some children may not have received early intervention, or may still need individual therapy. Interventions, including speech and language services and physical and play therapy should be based on individual profiles of abilities and weaknesses. Low child: teacher ratios (1:1 being optimal) are recommended to allow for quality programming and an individualized focus.
  3. Self-Regulation - Early childhood marks the beginning of self-regulation. Specific strategies to support self-regulation include (Appendix A, Section V):
    • An orderly, consistent, child-appropriate environment.
    • Predictable routines and consistent schedules.
    • Clear expectations and rules.
    • Clear patterns for transitions (such as a daily routine, warning signals, and signals to move to next activity).
    • Offering choices to children.
    • Praising a child's efforts, not just successes, each day.
    • Using anticipatory guidance to avoid difficult situations.
    • Explaining how a child's actions affect others.
  4. Relationships - Strategies to support secure relationships with ongoing caregivers include:
    • Individual attention, encouragement of mutual respect, and celebration of each person to build healthy self-esteem.
    • Activities that foster self-esteem in both mother and child.
    • Labeling of feelings, so the child can learn to identify and express a range of emotions.
    • Clear boundaries within adult-child relationships.

Transition to the Preschool Period

Transition from the toddler to preschool period should involve careful planning and preparation with the mother and child to ensure compliance with the new program. Early intervention and developmentally based parent-child and early childhood programs should continue to provide services within a family-centered model, and should feature low child to teacher ratios of 4:1 for multirisk children. In addition, class size should remain small, with no more than eight children and two teachers per classroom. Lower ratios and small class size ensure that the children receive the individualized attention critical to their educational development.

To deal adequately with the complex problems of multirisk children in a school setting:

  1. Needed therapeutic services should be provided:
    • Speech and language services
    • Physical therapy
    • Occupational therapy
    • Play therapy.
  2. Teachers should be provided with training to:
    • Understand addiction issues in general.
    • Understand women's addiction issues and family systems.
    • Understand cultural and racial factors in the family's background.
    • Recognize behavioral cues in individual children to promote the child's self-regulation.
    • Provide a consistent, predictable, well-structured environment to promote the child's self-regulation.
    • Plan for transitions to promote the child's self-regulation.
    • Address issues relating to addiction, abuse, and violence.

Quality Assurance Checklist

To ensure the quality of followup and aftercare services to the drug-exposed child, the hospital AOD abuse treatment program should provide the following services:

  • Qualified staff and inservice education programs.
  • Interdisciplinary staff that includes AOD treatment providers.
  • Appropriate AOD treatment services for the mother as well as the father.
  • Significant involvement of mother and child dyad; if the father is present, he should be involved.
  • Child to staff ratio not exceeding 3:1 up to 3 years of age in the early intervention program.
  • Transportation.
  • Regular medical exams according to schedule.
  • Up-to-date immunizations.
  • Weekly monitoring visits during first 3 months, and monthly visits up to 18 months; visits should be conducted by the organization responsible for case management.
  • Availability of visiting nurses.
  • Regular reports to and from social services.
  • Ongoing relationship with child protective services.
  • Long-term retention of mothers in the program.
  • Mechanism for peer review.

Refer to Appendix B for sample comprehensive programs for substance-using women and their infants.

Training for Child-Oriented Professionals

Health professionals often lack training and experience working with substance-abusing women, addicted families, prenatal drug exposure, and effective intervention strategies. Educators and health care providers must understand addiction, family functioning, and be able to communicate effectively with families.

Child-oriented professionals need specific training and supervision in: taking AOD histories; addiction models and issues for women; family systems - especially regarding the addicted family; prenatal drug exposure (medical, developmental, and behavioral outcomes); child development; family-focused interventions; parent-child interactions; intervention strategies for mothers and children (and fathers); HIV and its relationship to AOD abuse; treatment and referral strategies; and the impact of culture and ethnicity on service delivery.

All professionals working with addicted people and their children must have access to regular clinical supervision. Clinical supervision provides information, support, and stress management.

Footnotes

1

IDEA was formerly known as P.L. 99-457. The Education of the Handicapped Act Amendments of 1986. In 1990, the title of the Act was changed, and some changes were made as well in the content of the law. (For instance, greater emphasis is now placed on the transition component from toddlers to children aged 3 to 5.) The numbers of the law were also dropped when referring to the Act, since the numbers change each time the law is reauthorized. In 1992, the Act is authorized under P.L. 101-476.

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