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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.)

Cover of Improving Treatment for Drug-Exposed Infants

Improving Treatment for Drug-Exposed Infants.

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Chapter 4 - Psychosocial Services for Drug-Exposed Infants and Their Families

A broad range of psychosocial services is required for an extended period of time to address the needs of the infant for a nurturing and safe environment and the mother's multiple needs as a recovering addict, parent, and perhaps, head of household.

This chapter addresses key components of psychosocial services and the assistance needed to obtain them. Strategies for keeping families intact are explored and emphasized. Despite these strategies, drug-exposed infants often must be separated, even if temporarily, from their parents. Accordingly, the panel makes specific recommendations regarding referral to child protective services, followup for infants in child protective services and foster care, and assuring the quality of services provided to them.

Public child welfare agencies (in each State, county, or city) are mandated to perform a broad array of services for infants who have been abused, abandoned, or neglected, including foster care placement and managing family unification after separation. It is often the child welfare worker who coordinates this unification.

Comprehensive Psychosocial Services

In the absence of a stable, nurturing home environment, the infant already compromised by drug exposure probably will be at increased risk of adverse outcome throughout infancy and childhood. A comprehensive range of social services can promote stability and nurturing.

Several factors should be kept in mind when developing comprehensive social services for drug-exposed infants and their families.

  • Efforts should be made to guarantee that services are sensitive to the cultural and racial backgrounds of the women using the services.

Innovative means of accomplishing this cultural competency, including extensive community involvement, should be explored.

Community involvement might include participation from: concerned families and residents in the community, community organizations, and church groups, and current or former patients in the program and their families. Community involvement can go a long way toward addressing not only issues of cultural sensitivity, but also concerns about lack of resources and funding through the contribution of volunteer services.

  • Utilization of outreach workers can provide programs with an important way to augment a wide range of services, encouraging more "one-on-one" contact with the mother and her family. Program administrators should work to ensure that sufficient funding is available to hire and maintain outreach workers as key personnel in program operations.
  • Community-based organizations (CBOs) should be utilized to support the range of social services that can be offered to the substance-using woman and her family.

Programs operating out of large institutions (such as hospitals) should strive to develop collaborative relationships with CBOs. Efforts should be made to establish ongoing mechanisms for networking between institutionally based programs and CBOs serving drug-exposed infants.

  • Whether provided at a single site or at a number of agencies throughout the community, services available to women and families caring for drug-exposed infants should be accessible, coordinated, and comprehensive. Linkages among agencies are crucial.

Many experts in the field urge that comprehensive services be provided by interdisciplinary teams at a single site. This concept is consistent with the policy recommended by the National Commission on Infant Mortality.

However, this "one-stop-shopping" approach may not be feasible in many communities. Because of the variety of services required to appropriately serve drug-exposed infants and their families, many community-based agencies often provide these services. Specific agencies in the community can offer a unique approach or focus that might be difficult to achieve in a single agency. Due to lack of effective networking mechanisms among agencies (as well as overburdened workloads), problems often arise when one agency is unaware of services provided by another. For these and other reasons, accessing services from one agency to another can be problematic. As previously mentioned, programs receiving Block Grant monies set aside to treat women and women with dependent children are required by law to provide women and their children with a comprehensive range of services, either directly or through referral.

Thus, when multiple sites are involved, the sites or agencies should carefully coordinate with one another so that needed services are provided without duplication of effort. Case management is crucial in helping to ensure access to appropriate services. Agencies may wish to consider the establishment of structured mechanisms to foster effective interagency communication regarding the provision of services to drug-exposed infants and families.

Other approaches might also be taken into consideration such as home-based nursing and counseling. Access to treatment may be enhanced if services are decentralized and close to the people being served. Easy access to public transportation is important. Decentralized services in the form of home-based nursing and counseling can also facilitate collaboration with CBOs.

Comprehensive health and psychosocial services for drug-exposed infants include substance abuse treatment for the mother, health services, mental health services, social services, and educational, vocational, and employment services. Key features of these services include:

  • Cultural competence
  • Utilization of outreach workers and community-based organizations
  • Accessible, coordinated services with interagency linkage mechanisms
  • Nontraditional approaches, such as home-based services.

Treatment For Parents

The best way to help the drug-exposed child is to help the mother (and the father when possible) recover from addiction. Treatment should occur within the context of the mother-child dyad, with particular attention paid to the mother's drug use and its impact on parenting skills. Every effort should be made to include fathers as well as mothers. Treatment should be nonthreatening, nonstigmatizing, and supportive. The treatment team should also work with other siblings and members of the extended family, especially drug-free family members. The treatment team should be culturally competent and well trained and understand how services provided with cultural awareness of the mother's and father's background can play a positive role in recovery.

Pregnant women should not be denied such treatment or have treatment postponed merely because of pregnancy. In fact, since the health and welfare of both the mother and the unborn child are at stake, efforts should be made to give pregnant women priority access to AOD abuse treatment services.

Such priority status is now a requirement for all programs receiving Substance Abuse Block Grant funds. Programs serving an injecting drug use population must give preferential treatment in the following order: (1) pregnant injecting drug users; (2) pregnant substance abusers; (3) injecting drug users; (4) all others.

If the program does not have the capacity to provide treatment services to a pregnant woman, the woman must be referred (with the use of a toll-free number or similar mechanism) to the State. The State is then required to refer the woman to a treatment program that has room to serve her not later than 48 hours after seeking treatment. Thus, the State must have a capacity tracking system to track all open AOD treatment slots available to pregnant women in the State.

Detailed treatment guidelines, including a description of an appropriate continuum of care that includes medical stabilization and detoxification guidelines, are available in the TIP, Pregnant, Substance-Using Women. Many of these guidelines are equally applicable to women in the postpartum period.

Treatment should focus on the dual goals of abstinence from drugs and successful parenting. Within the context of AOD abuse treatment programs, parenting skills should be addressed or reinforced. The program and its staff can serve as a secure base from which the mother can try new approaches to parenting, often ones that she did not experience as a child. The treatment component must acknowledge each woman's role as a mother struggling to rear young children. This parenting role must be supported by all staff, who support the mothers in their relationships with their babies and praise their ability to comfort their children, make their children smile, and know when their children are sick. These daily interactions support the mother in her parenting abilities and allow her to feel successful as a good mother to her children. Please refer to Appendix A for materials on parenting skills.

Treatment options should include residential and intensive day care treatment. Whatever the modality, the infant - as well as the woman's other children - must be accommodated.

Substance abuse treatment services should include relationship counseling and relapse prevention.

Halfway and quarterway houses should be available to women completing residential treatment so the transition to self-sufficiency is gradual and a safer home environment can be defined. 1 Ideally, such houses should accommodate infants and older children.

Maternal Health Services

Mothers of drug-exposed infants must have their basic health needs attended to if they are to function effectively in a parental role. These needs include:

  1. Postpartum care.
  2. Treatment of other health problems often attendant upon addiction. These health risks are discussed in Chapter 2 and are fully described in the TIP Pregnant, Substance-Using Women.
  3. Training in infant care (including breastfeeding, if appropriate).
  4. Reproductive health services, including family planning, contraception, and education concerning the increased risk of unintended pregnancy and HIV infection associated with the use of drugs and alcohol. These services should be delivered within the context of the mother's drug counseling to be most effective.
  5. Counseling and testing for HIV and other sexually transmitted diseases. Active efforts must be made to direct women who are HIV positive or have AIDS to appropriate services.
  6. Educational efforts concerning the effects of illegal and legal drugs, including alcohol and tobacco, on the woman's health, the health of unborn children, and the health of the infant and siblings.

Again, health care services, training, and education should also be provided to the father as much as possible.

Mental Health Services for the Parents

Substance abusers in general, and substance-abusing women in particular, often have coexisting mental health problems that must be attended to during treatment. Necessary services include:

  1. Mental health and psychiatric evaluation and treatment services, especially for depression.
  2. Assessment and counseling for physical and sexual abuse, and for the possibility of post-traumatic stress disorder.
  3. Counseling and training in self-esteem and image enhancement.
  4. Training in interpersonal skills.
  5. Training in self-sufficiency and independent living (feeding, housing, preparing meals, locating child care, etc.).
  6. Relationship training between men and women.

Parental Educational/Vocational Services And Employment Assistance

Parents of drug-exposed infants are often functioning cognitively at the age at which their own drug use first began. Their education and job history may be intermittent at best. In the absence of economic self-sufficiency, drug abuse treatment and other psychosocial services are unlikely to make a permanent improvement in the family's lot. Parents of infants and young children should be a priority for educational/vocational services. Such services should include:

  1. Job skills assessment.
  2. Graduate Equivalency Diploma (GED) classes.
  3. Vocational skills instruction geared to job opportunities in the local area.
  4. Employment-related services, such as coaching in interview techniques, preparing employment applications and resumes, mentoring by employed persons, and obtaining and reviewing lists of viable job prospects.

Other Social Services

To round out the services listed above, an assortment of ancillary services may be necessary. These include, but are not limited to:

  1. Child care and babysitting services in general, and especially during service visits.
  2. Assistance in obtaining safe living arrangements and locations.
  3. Public transportation or taxi vouchers for service visits.
  4. Family support services and training in parenting skills.
  5. Training in life management skills such as personal care, time management, and budgeting skills.
  6. Outreach services, which might include any one of the above-mentioned items.
  7. Legal services, including counsel in cases involving domestic violence, divorce, child custody, and right to treatment.

Each mother should receive an individual service and care plan responsive to the unique needs of her family. Wherever possible, services should be gender-specific, as well as culturally specific, addressing the particular circumstances of the woman and her children. Services should be designed to aid rather than punish women; to this end, focus groups consisting of addicted and recovering mothers might be convened to share information on what they consider to be particularly useful services. Service providers should also make use of recovering mothers as role models and community-based outreach workers to help with visits, transportation, and support.

Incentives should be offered for successful completion of services, including followup. Such incentives could include: donated infant supplies, infant blankets, diapers, formula, baby furniture, toys and educational toys, and coupons for specific food items.

Finally, service providers should be sensitive to the varied cultural and ethnic backgrounds of women who use alcohol and other drugs, and should therefore tailor services accordingly. Such sensitivity has a significant impact on both service utilization and compliance with the recommended treatment.

Helping Parents or Guardians Obtain Supportive Services

Mothers of drug-exposed infants display a wide variety of needs and problems that affect their lives and those of their children. These include physical and psychosocial factors contributing to their drug use as well as environmental factors harmful to adequate or healthy lifestyles.

Persons providing assistance to mothers of drug-exposed infants can recognize and work to address the barriers to services that face these women. Such barriers include, but are not limited to:

  • Lack of alcohol and drug abuse programs for pregnant and parenting women.
  • Lack of transportation to and from service providers.
  • Lack of child care or babysitting during service sessions.
  • Cost of services.
  • Insufficient funding available for substance abuse treatment programs directed to pregnant and parenting women, especially programs that are family-centered and include the mother's other children, the father, and the extended family in the treatment process.
  • Lack of sufficient programs that are adapted to the cultural, racial, and linguistic characteristics of the women using the services.
  • Lack of sufficient programs that are based in the communities or neighborhoods where the women live.
  • Nonsupportive or hostile attitudes of service providers toward drug-using women.
  • Stigma associated with drug use, especially drug use by women.
  • Lack of knowledge by drug-using women concerning the service options available to them.
  • Complex and often inconsistent eligibility requirements and application processes that vary by program.
  • Fragmentation of services - lack of a single provider or locale where all needed services can be obtained, including comprehensive health and dental services. (This can be a formidable obstacle when the woman and her children face significant chronic medical problems, such as HIV).

In addition to the above-mentioned barriers to services facing mothers of drug-exposed infants, it is important to recognize several essential components in the development of adequate services for this population of women, as outlined below.

  1. Case Management - An essential element for an effective continuum of care is the case management function. This function can be provided through the auspices of virtually any agency, and is needed by every woman and her family. Case management defines, initiates, and monitors the medical, drug treatment, psychosocial, and social services provided to the drug-exposed infant and its family. Case managers serve as advocates to help the woman and her family negotiate the bureaucracy and qualify for public programs such as Medicaid, WIC (Women, Infant and Children), AFDC (Aid to Families with Dependent Children), food stamps, and housing assistance.
    (Please see the section on referrals in Chapter 3, Followup and Aftercare, for an additional listing of public programs.)
    The multiple services coordinated by the case manager are generally provided by a variety of agencies. Some of these services are initiated during or even prior to pregnancy, and may continue long after delivery. Drug- and alcohol-abusing women and their children are also typically referred to a consortium of service providers that may change over time, depending on a patient's individual circumstances.
  2. Outreach - To help pregnant, substance-using women and mothers of drug-exposed children learn about the services available to them, service providers should develop the following:
    • Outreach efforts to culturally diverse populations. At least a portion of outreach services should be conducted through nontraditional means, such as through churches, beauty parlors, laundromats, and other social settings. Outreach workers must be sensitive to the racial, ethnic, cultural, and socioeconomic concerns of those being served.
    • Public service announcements (PSAs) advertising services available and aired on radio or TV stations that are popular with groups targeted for services.
    • A 24-hour, toll-free hotline for service information and referrals.
    • Videotapes about services that can be used by community and church groups.
    • Pamphlets advertising the services available.

      The outreach worker is crucial to a program's ability to effectively carry out these outreach efforts.
    • Affordability - Discussed below are a number of considerations from the viewpoints of both the patient and the health care facility that can help to ensure that comprehensive services are affordable to all women and families in need of such services.

Services should be provided free of charge - that is, with no out-of-pocket costs - to the woman and her family to the greatest extent possible. There is much that agencies can do to ensure that services are provided at no cost to the patient, including seeking available funding and assisting patients in accessing Medicaid, as described below.

Federal and State programs can assist agencies with funds and / or resources to facilitate the provision of accessible, affordable services to drug-exposed infants and their families. (See Appendix A for a listing of Federal and private agencies that can provide the latest information on possible funding sources).

For example, as of 1993, there is a federally mandated "set-aside" within the Substance Abuse Treatment and Prevention Block Grant stipulating that not less than 5 percent of the grant will be expended to increase the availability of treatment services for pregnant women and women with dependent children. Local programs serving AOD-using women might wish to investigate whether their State has met this obligation under the block grant set-aside provision. In sum, agencies should make sure that they are up-to-date on the availability of funds and grants from various sources and work to take advantage of them.

Agencies should also be aware of what services are Medicaid-reimbursable in their State. (Services reimbursed under Medicaid vary significantly from State to State.) If there are services currently not covered under the State's Medicaid program that agencies consider essential in the provision of care to drug-exposed infants and families, then communicating the need for this coverage to the appropriate policymakers is essential.

Agencies providing care to drug-exposed infants should also establish mechanisms to facilitate the patient's Medicaid application process so that all women who may be Medicaid-eligible apply for and receive Medicaid. Special advocacy or followup services may often be needed to guarantee that women who are Medicaid-eligible receive their Medicaid determination in a timely fashion.

Specific Medicaid advocacy mechanisms may also be needed for special populations of women for whom there may be particular obstacles in accessing Medicaid, including women who: speak little or no English; are refugees, immigrants, or illegal aliens; are deaf, blind, or mentally or physically disabled; are homeless; are HIV-infected; are incarcerated, etc.

Designated agency staff should receive initial and ongoing training in MedicaID--including covered services, eligibility and determination procedures and requirements, and the various appeals processes and procedures. (Such training often may be available through special arrangements with the State Medicaid office, upon request.) Agency competency in the Medicaid process not only assists the woman and her family, but the agency as well, enabling the agency to maximize potential reimbursement for services and patients covered under Medicaid.

When agencies do not have the funds to cover costs for women who are not Medicaid-eligible, services might be provided on a sliding fee scale, based on the woman's ability to pay. Again, agencies should familiarize themselves with the available services offered by the community, region, State, or Federal government.

Keeping Families Intact

A comprehensive and individualized assessment of the family's needs may prevent inappropriate placement of drug-exposed infants and children in foster care. To achieve the goal of keeping families intact, the drug-exposed infant and his or her family should have access to the following services:

  • Availability of case manager services on a 24-hour, on-call, basis
  • Quality day care
  • Individual / family counseling and crisis counseling
  • Housing assistance and emergency shelters
  • Procedures and arrangements for access to emergency financial assistance
  • Arrangement for provision of temporary or respite care
  • Availability of outreach workers who may be able to visit the woman and her family in her own environment.

A new program in New York City provides intensive supervision and counseling to substance-using women who have been permitted to take their babies home from the hospital. Under the program, social workers visit families at least once a week to help ensure that mothers remain in treatment and assist them in other areas, including health care for the infant and housing and other social services (Treaster, 1991).

Referral to Child Protective Services

In most jurisdictions, child welfare services are responsible for a broad array of activities including preventing unnecessary separation of children from their families, restoring children who have been removed from their natural families through provision of appropriate services, placing children in suitable adoptive homes in cases where reunification with the biological family is inappropriate, and assuring adequate care of children not living with their families.

Within the child welfare system, child protective services (CPS) is the administrative unit responsible for investigating allegations of abuse and neglect. The focus of CPS is on strengthening and empowering families who are at risk of child abuse and neglect; removing children from their homes is seen as a last resort when continued work with the family has failed. 2 Regarding the referral of a drug-exposed infant to child protective services, the following guidelines are offered:

  1. Reasons for referral - Prenatal drug use or a positive drug test should not be an adequate reason in and of itself for referring an infant to CPS. Referral should be made only when there is some question about the health and safety of the child. However, in some States, by statute, evidence of drug exposure or a positive urine toxicology is, by itself, grounds for making a child abuse report. Therefore, although a mother's presumed drug use is not an adequate reason for an infant to be referred to protective services, referrals are sometimes made on this basis.
  2. Placement decisions - The decision to remove the child from the home should be made if a child is endangered or if the parents cannot adequately provide for the child's health and welfare. Such decisions should be made only after thorough assessment of the infant's family situation. The mother's ongoing substance use, by itself, should not be a criterion for mandating removal from the home. Occasional relapse is a normal part of the recovery process and, as such, should not be the sole criterion for removing the infant from the home. By both Federal and State law, child welfare agencies must make "reasonable efforts" to prevent the removal of a child from his or her parents through the provision of services for the family, unless a child would be endangered even with the provision of such services. In some jurisdictions, the caseloads of child protective workers are so large that the goal of strengthening and empowering the family has been difficult, if not close to impossible, to achieve.
  3. Placement with relatives - If the child is to be removed from the mother, the first priority should be to place the child with responsible grandparents or other family members, rather than making an immediate placement to foster care. This recommendation should be tempered by the realization that a large proportion of substance-using mothers may themselves be children of substance-using parents. Placement of an infant with grandparents or other family members who have problems with AODs is clearly inappropriate. However, where appropriate, placement of a child with family members can result in significant benefits to the child. Such a placement may be less disruptive and stressful because the child is not separated from family.
  4. Special programs and funding for drug-exposed children - Because foster care systems are receiving increasing caseloads of drug-exposed children, there is a necessity to develop special training and other programs for meeting their needs. In addition, special funding should be procured to help meet the increased costs incurred by the adopting parents of drug-exposed infants. Most drug-exposed children qualify as "special needs" children. Both foster and adoptive parents may be able to receive special subsidies to help care for the child. In addition, children in foster care receive Medicaid, and Medicaid follows the child after adoption. Thus, children who were Medicaid-eligible before adoption can continue to be eligible to receive Medicaid after adoption, up to adulthood. However, it is a good idea to obtain verbal and written agreements regarding both the special needs subsidy and Medicaid eligibility before the adoption or foster placement is finalized.
  5. Foster placement - Given the specialized needs of the drug-exposed infant, efforts should be made to develop special foster homes with a limited number of children placed in such homes. (Child welfare agencies often provide special foster homes and / or residential facilities with additional financial reimbursement and other support.)
    1. Family reunification - If an infant is placed in foster care, the ultimate goal should be reunification with the mother at the earliest possible time, as soon as the health and safety of the infant and mother can be assured, in the best judgement of the caseworkers. This goal should be clearly communicated to foster parents. It must also be acknowledged that reunification may not be possible or practical based on the best interests of the child.
    2. Stability - Wherever possible, serial foster care placements of any infant should be avoided. Such placements weaken an infant's ability to bond with caretakers and threaten his or her emotional, physical, cognitive, and social development, with effects often lasting into the adult years.

Followup of Infants In CPS or Foster Care

The recommendations in this section are built upon those found in Chapter 2 on followup and aftercare services for infants, and are focused on the psychosocial needs of the infant.

  1. Case management - Followup services for drug-exposed infants and children in foster care should be provided using a case management model. The advocate for the infant could be a public or private case manager, a community caseworker, an outreach worker, or a recovering woman working under direction of a designated case manager. The continuing assessment and treatment needs of infants placed in foster care can be met best through case conferences, where all allied professionals provide input into the service needs of the infant and family. Telephone case conferences may be an expedient method for achieving this goal.
  2. Training - Ongoing training should be provided to all service providers working with drug-exposed infants and their foster families. Such training should include information about the effects of drug and alcohol use in general, information concerning the child protective services system, and information concerning the unique service needs of the drug-exposed infant. Initial and ongoing training should also be conducted on HIV-related issues. Foster parents themselves and other caregivers need to receive special training regarding the unique needs of drug-exposed infants and mothers. In particular, they should be trained to provide stimulation to the infant at a level appropriate for that particular infant.
  3. Reunification - Foster parents should be made aware that the ultimate goal of child protective services is to reunite the infant or child with the biological family, whenever possible.
  4. Attitudes toward substance use - Child protective service caseworkers and foster parents should evaluate their attitudes about substance-abusing women as well as their own use of substances, including alcohol and tobacco, and the example it provides to children placed in their care. Ongoing training and values orientation should be provided to caseworkers and foster parents as much as possible.

Assuring the Quality of Services For Infants in Foster Care

Quality assurance standards for child protective services, foster care agencies, and foster parents are important to ensure adequate and appropriate levels of care for drug-exposed infants in foster care. Standards of practice must be reviewed and updated on a regular basis.

Such quality assurance standards should include but not be limited to:

  1. Caseload limits - In the current era of escalating social service needs and shrinking budgets, child welfare workers are often forced to handle ever increasing and complex caseloads, prohibiting the provision of effective child protective services. Administrators and service providers working with drug-exposed infants and their families should be familiar with public and private child welfare standards, which seek to address quality assurance issues such as caseload size. Both the private and public sectors are involved in the establishment of standards or goals for practice in the field of child welfare services. For example, the Child Welfare League of America (CWLA) develops and publishes child welfare standards to be used in planning, organizing, administering, and improving services; in establishing State and local licensing requirements; and in determining the requirements for accreditation. These standards include the development of recommended caseload and workload ratios for different types of services. (For example, in the area of child protective services needed for abused or neglected children and their families, CWLA standards describe the recommended number of active and new cases per month per social worker and the recommended ratio of supervisors per social worker.) Licensing provides basic protection for the well-being and protection of children. Through the licensing of child-placing agencies, residential group care facilities, foster family homes, and child day care facilities, States exercise their power to protect children. 3
  2. Number of infants or children per foster home - Child welfare agencies establish standards regarding the maximum number of high-risk infants to be placed in a foster home or residential facility. Drug-exposed infants in need of placement should be assessed to determine the intensity of services required to adequately care for the child. Due to inadequate staffing of child welfare agencies, established standards are not always followed and placement assessments are not always accurate. Programs serving drug-exposed infants should work closely with the child welfare agency to help guarantee that an appropriate foster care placement has been made.
  3. Recruitment and training of foster parents - Agencies should be able to show evidence of ongoing recruitment of foster parents willing to accept drug-exposed infants. Prospective foster parents should receive special training concerning unique needs of drug-exposed infants. Training will also be needed regarding HIV infection and drug-exposed infants. 4
  4. Interagency agreements - Foster care agencies should develop memoranda of agreement with other service agencies to coordinate and avoid duplication of services to drug-exposed infants and children. These agencies should hold quarterly meetings to review existing standards, resolve problems, and recommend changes. Within the consortium of agencies, a single agency should be assigned responsibility for quality assurance compliance.
  5. Foster parent review - The case plan of a drug-exposed infant placed in foster care should be reviewed every 6 months, with a mandatory home visit within the first month of foster care.
  6. Cultural issues - Extensive efforts should be made to recruit foster parents from the same racial and cultural backgrounds as the infant. Effective efforts in this arena usually require extensive engagement with the community in the recruitment process. For example, ongoing or periodic foster home recruitment campaigns can be launched in coordination with local churches, sororities and fraternities, the media, civic organizations, and other grass-roots organizations familiar with the cultural nuances within the community. Many such organizations are eager to help recruit foster homes from the same racial or cultural background as the infant in need of placement. However, in addition to extensive community-based recruitment campaigns, consideration might be given to relaxing regulations that require placement of infants with parents from the same racial background. Such measures should be considered only when other efforts have failed to ensure the placement of drug-exposed infants in qualified foster homes. Such foster parents should receive initial and ongoing training around the need to understand and respect the racial and cultural background of the infant.
  7. Followup surveys of client satisfaction - Followup surveys should be conducted with the biological parent(s), the foster parents, and the coordinating agencies to determine their satisfaction with the process and any recommendations for improvement.
  8. EAPs for professional and volunteer workers - Employee assistance program components should be mandated and integrated into all agencies involved in child placement and foster care services. This will provide treatment and counseling services to caseworkers and other service providers who may themselves be substance users or abusers.
  9. Professional attitudes and behavior - All professionals working with drug-exposed infants and their mothers and families should examine their own knowledge, attitudes, and behaviors regarding use of drugs, alcohol, and tobacco and should receive ongoing training on these subjects.
  10. Stress management - Stress management training must be provided to workers involved in the care of drug-exposed infants and their families. Likewise, sensitivity training should be provided to caseworkers concerning their attitudes and behavior toward drug-using women so that a nonpunitive, supportive approach is maintained. Foster parents with drug-exposed infants also need stress management and sensitivity training. Whenever possible, such programs should be provided for these caretakers.

Footnotes

1

There is anecdotal evidence that some halfway houses turn away women maintained on methadone. Efforts should be made to reverse this trend. Women on methadone should be supported in their efforts toward self-sufficiency and should be admitted into transitional housing.

2

Unfortunately, available resources to provide some of these needed comprehensive services are frequently insufficient. For instance, although many service providers might agree that 24-hours case management services would be quite helpful, funding for such round-the-clock services is often lacking. In the long run, the provision of comprehensive and individualized assessment services to drug-exposed infants and their families is more cost-effective to society (and to the individuals involved) than the costs incurred when substance abuse remains untreated, families are broken, and children are placed in foster care. In the short run, agencies and programs serving drug-exposed infants and their families must be innovative in acquiring the needed funding and resourceful in linking up with existing community services to provide comprehensive services.

3

For a summary discussion of the background, purpose, and definition of child welfare standards, see Child Welfare League of America Recommended Caseload / Workload Standards excerpted from CWLA Standards for Child Welfare Practice. Prepared by Robert R. Aptekar, Director, Institute for the Advancement of Child Welfare Practice, Child Welfare League of America, April 1992.

4

Although beyond the scope of this TIP, it is advised that child welfare agencies develop protocols and policies regarding drug-exposed infants, HIV infection, and foster care placement. Agencies seeking additional information on this topic should contact the Child Welfare League of America at 202-638-2952.

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