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

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Child Abuse Prevention and Treatment Act (CAPTA)

• Since 1974, CAPTA has been part of the federal
  governments 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

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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

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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

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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))

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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))

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CAPTA

• How many substance exposed births?

• Challenges in estimating
• Prenatal drug use
• Substance exposed birth

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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.
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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 gt1 in OOHC 2001 22,957 4
Where did they all go?
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CAPTA
Most go home 90-95 are undetected and go home

• Many hospitals dont test
• Law may not require report
• Tests only detect very recent use

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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
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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
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CAPTA

• How do States currently respond
• to prenatal drug exposure?

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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)

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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

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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)

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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
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CAPTA Implementation Issues Four Major Areas
CAPTA focuses on four elements of SEB

1. Identifying infants affected by illegal substance
   abuse or withdrawal symptoms
2. 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
3. Developing a plan of safe care
4. Addressing the needs of these infants

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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 States experience regarding the
  adequacy of these policies and tools and methods?
  
• Has the State established the incidence of SEB?

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CAPTA Implementation IssuesIdentifying infants
affected by illegal substance abuse or
withdrawal symptoms
CHALLENGES/OPPORTUNITIES

• Prenatal care for at-risk early identification
  going upstreamIra Chasnoffs 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

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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?

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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

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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

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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?

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CAPTA Implementation IssuesAddressing the needs
of these infants
CHALLENGES

• Requires a coordinated response
• Maternal and Child Health, Developmental
  Disabilities, Childrens 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

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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

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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?

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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?

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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.

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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

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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

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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.

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CAPTA Issues for State Consideration

• Verbal Screening Tools
• Chasnoffs 4 Ps 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?

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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

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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

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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

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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?

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Sources

• Office of Applied Studies. (2003). Results from
  the 2002 National Survey on Drug Use and Health
  National findings (DHHS Publication No. SMA
  033836, NHSDA Series H22). Rockville, MD
  Substance Abuse and Mental Health Services
  Administration at http//oas.samhsa.gov/2k3/pregna
  ncy/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/int
  ro.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/P
  renatal.html