Transcript Children and Family Futures

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
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.
CAPTA Funds 2004
 Basic State Grants

$22 million
 Discretionary Grants

$34.6 million
 Community Based Programs

$33.4 million
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
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
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));
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))
CAPTA
How many substance exposed births?
Challenges in estimating
 Prenatal drug use
 Substance exposed birth
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 substanceexposed 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.
CAPTA
How many substance exposed births in CWS?
CALIFORNIA 2003 DATA
NATIONAL 2001-2002 DATA
total births = 598,000
Total 2002 births = 4,093,000
11% = 65,780
10% = 409,300
Total substantiated reports on
children 0-1 = 12,050
Total 2002 substantiated reports on
children 0-1 = 142,026
Total in OOHC = 86,663
Total in OOHC 2001 = 542,000
Total 0-1 in OOHC = 3,913 = 4.5%
Total >1 in OOHC 2001 = 22,957 = 4%
Where did they all go?
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
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
A Graphic Overview
73 million 0-17
Children and youth
7.3 million
born
substanceexposed
4.093
million
births
annually
409,300 estimated
substance-exposed
births annually
Estimated substanceexposed births reported
to CPS: 5.6% of all
SEBs = 22,957
2.5 million CPS
reports annually
CAPTA
How do States currently respond
to prenatal drug exposure?
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)
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
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)
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
CAPTA Implementation Issues:
Four Major Areas
CAPTA focuses on four elements of SEB:
1.
2.
3.
4.
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
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?
CAPTA Implementation Issues
Identifying 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
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?
CAPTA Implementation Issues
Implementing 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
CAPTA Implementation Issues
Implementing 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 bridgebuilding 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
CAPTA Implementation Issues
Addressing 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?
CAPTA Implementation Issues
Addressing 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
CAPTA Implementation Issues
Addressing 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
CAPTA Implementation Issues
Developing 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?
CAPTA Implementation Issues
Developing 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?
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.
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
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 polydrug, alcohol and tobacco exposure
 How do States differentiate


Screening and assessment
Differential response
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.
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?
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
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
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
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?
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