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Too many babies were boarding in hospital beyond medical necessity because of ... care (in 1995, RI had the 2nd highest rate of out of home placement in the US) ... – PowerPoint PPT presentation

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Title: General


1
Illegal Substance Expose During Pregnancy
Impacts and Implications
Barry M. Lester, PhD Brown Center for the Study
of Children at Risk
Forum on Enhancing Services for Substance Exposed
Newborns and Their Families Springfield,
September 2008
2
11 of children (8.3 million) live with at least
one parent who is either alcoholic or in need of
treatment for the abuse of illicit drugs
Substance Abuse
3
Substance abuse is a contributing factor in 40
of the 1.2 million cases per year of child abuse
and in 40-80 cases of families involved with
child welfare system
Substance Abuse
4
Substance Abuse
Presence of substance use disorders in parents
results in a threefold increase in risk of child
maltreatment These children are 3 times more at
risk for early onset drug use
5
Part of a cycle that includes
Domestic Violence
Community Violence
Can lead to psychopathology, delinquency and
substance use in adolescents
Violent Friends
6
Maternal Drug Use and Child Outcome
GENETIC AND PRENATAL ENVIRONMENT
PRENATAL
POSTNATAL
TERATOGENIC
CAREGIVING ENVIRONMENT
IMMEDIATE
LATENT
SPECIFIC
GENERAL
TRANSIENT
LONG LASTING
COA
RISK
PROTECTIVE
D E V E L O P M E N T
7
Maternal Lifestyles Study
Wayne State S. Shankaran
U. Tenn at Memphis H. Bada
U. Miami C. Bauer
MLS B. Lester (PI)
Brown U. B. Lester
Brown Data Center
Research Triangle Institute A. Das
8
History of MLS
COCAINE HURTS BABIES
When drug babies reach school age
Mothers Turned Into Monsters
Pregnant cocaine user guilty of abuse
Crack A Disaster of Historic Dimension, Still
Growing
Studies Future bleak for crack babies
Cocaine a vicious assault on a child
Cracks Toll Among Babies A Joyless View, Even
of Toys
In the 1980s, the war on drugs, the
crack/cocaine epidemic focused national attention
on the relationship between drug use, and social
and economic problems in society
9
History of MLS
COCAINE HURTS BABIES
When drug babies reach school age
Mothers Turned Into Monsters
Pregnant cocaine user guilty of abuse
Crack A Disaster of Historic Dimension, Still
Growing
Studies Future bleak for crack babies
Cocaine a vicious assault on a child
Cracks Toll Among Babies A Joyless View, Even
of Toys
Early reports on prenatal cocaine effects created
a public frenzy and the myth about unfit to
parent women and their damaged crack babies."
This impacted legal activities by states on
policy decisions affecting women who use illegal
drugs during pregnancy
10
History of MLS
Prenatal cocaine exposure has subtle effects on
childrens ability to focus their attention
Major Trial Finds Only Subtle Fetal Injury From
Cocaine
A mothers cocaine use may not doom her child
after all
Crack Kids Not Broken
A Rush to Judgment
Hope for Snow Babies
Researchers debunk myth of the crack baby
But, later studies (including MLS) failed to
support significant associations between prenatal
cocaine exposure and increased prevalence of
serious newborn congenital malformations, and
medical complications
11
History of MLS
The focus has now turned to the long term
developmental outcome of children with prenatal
cocaine exposure, especially as they reach
adolescence
12
Pregnancy and Newborn (N8,000)
  • Previously reported medical problems in the
    mothers (e.g. placenta previa, abruptio
    placenta) were rare (cocaine
  • (Bauer et al., 2002)

13
Pregnancy and Newborn (N8,000)
  • Previously reported physical damage to the
    infant (e.g. congenital anomalies,
    intraventricular hemorrhage) was rare (not related to cocaine
  • (Bauer et al., 2005)

14
Pregnancy and Newborn
  • Cocaine effects were found on infant gestational
    age (8.4 days), birthweight (536 grams) head
    circumference (1.5 cm), small for gestational age
    (29 vs 13)
  • Cocaine exposed infants showed more soft signs
    (e.g. irritability)

  • (Bauer et al., 2005)

15
Neonatal Neurobehavioral Scale
Developed for the NIH Selected for National
Childrens Study
(Lester and Tronick 2002)
16
Early Behavioral Findings
  • During first 3 years cocaine exposed infants
    showed dysregulated neurobehavior
  • The mother - infant relationship is altered
  • Maternal factors are also involved

(Lester et al., 2002 2003 LaGasse et al., 2003
Sheinkopf et al., 2006 Tronick et al., 2006
Loncar et al., 2005 Seifer et al., 2004)
17
Special Education Referrals
IEP at Age 7
referred
not referred
11
89
COMP n436
84
16
EXP n547
(5 increase)
Odds Ratio 1.56 CI 1.054 2.199
(Levine et al., 2008)
18
Cocaine Effects On IQ Increase With Age
Mental Functioning Over Time
110
COMP
EXP
100
90
80
IQ
7.8 at 15
70
4.4 IQ Pts
Mean effect 1.45 IQ with covariates site,
gender, birthweight, SES, maternal IQ, prenatal
opiate, alcohol, marijuana, tobacco
60
50
1
2
3
4
5
6
7
Age (Years)
(Lester et al 2004)
19
Externalizing Behavior
P(Bada et al., 2007)
20
Antisocial Behavior
P 21
Blunted Cortisol Stress Reactivity
60
P.009
50
40
30
20
10
0
Exposed Comparison
22
Psychopathology
23
Environmental Factors
  • Child Abuse
  • Domestic Violence
  • Community Violence
  • Postnatal Alcohol Use
  • Maternal Psychological Problems

24
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25
NNNS Profiles
(n1248)
26
Profiles and 9-11 Year Outcome
LPP
27
MRI and fMRI
Functional MRI (fMRI) studies brain function
MRI studies brain anatomy
28
Neuroimaging MRI
(Neyzi, 2007)
29
Neuroimaging fMRI
(Sheinkopf et al., in press)
30
Summary of MLS Findings
  • Prenatal cocaine exposure has a different face
    than originally thought
  • Effects that may be precursors of later substance
    abuse (academic and behavior problems,
    psychopathology, and antisociality)
  • Some deficits appear to be mediated by altered
    HPA reactivity
  • Opportunities for intervention/prevention

31
(No Transcript)
32
METH
33
Here we ago again….
meth babies could make the crack baby look
like a walk in the nursery
Meth Infants Called the New Crack Babies
Crack Then, Meth Now What the press didnt learn
from the last drug panic
New drug wave delivers 'crank babies'
One Hit of Meth Enough to Cause News
Defects Commentary, Join Together Online
ONE SHOT OF CRYSTAL METH CAUSES BIRTH DEFECTS U
OF T STUDY Oops mice MA injected into
peritoneum
34
Infant Development Environment And Lifestyle
Study
Infant Cohort Auckland, NZ
35
Small for Gestational Age (SGA)
10
MA Exposed
Incidence of SGA ()
3.5X more likely to be SGA
5
Not MA Exposed
P.001
0
(Smith et al., 2007)
36
Neurobehavioral (NNNS) Effects
  • Lower arousal
  • More stress signs
  • Similar to cocaine

(Smith et al., 2007)
37
Bayley MDI
38
The Brain is the Ultimate Use-It or Lose-It
Machine
  • Synapses
  • At birth 50 trillion
  • At 1 year 1000 trillion
  • At age 20 500 trillion

39
The Role of Experience in Brain Development
  • The human brain has the ability to be shaped by
    experience
  • Experience, in turn, leads to neural changes in
    the brain
  • The remolded brain facilitates the embrace of new
    experiences and so the process goes on

40
Policy is dependent on Social Context
We find the defendant guilty as charged by the
media
41
Policy Responses 2 parallel policy responses
towards drug use by
women Punitive Treatment
42
Problems With Punitive Approach
  • Fear of being reported drives women away from
    health care system (e.g. prenatal care)
  • Denies the opportunity to parent for those who
    can/want to parent

43
Problems With Punitive Approach
  • Overburdens foster care system
  • Childs ability to form attachments is
    jeopardized by multiple foster placements

44
  • Treatment
  • Drug use by pregnant women viewed as a mental
    health (medical) issue
  • Harm reduction
  • Reproductive health care, substance abuse and
    mental health treatment,
  • relationship with child

45
Number Of States By Type Of Substance Abuse
Statue
18
16
14
12
10
8
6
4
2
0
Term. Of
Test/
Child
Treatment
Alcohol
Rights
Rep./ID
Abuse
Lester, Andriozzi Appiah, J. Harm Reduction,
2004
46
State Laws Some Examples
It is presumed that a newborn child is abused or
neglected and that the child cannot be protected
from further harm without being removed from the
custody of the mother upon proof that a blood or
urine test of the child at the time of birth or
the mother at birth shows the presence of any
amount of a controlled substance or the
metabolite of a controlled substance not
administered by medical treatment… (South
Carolina)
47
  • A person mandated to report substance exposure
    in an infant shall immediately report to the
    local welfare agency if the person knows or has
    reason to believe that a woman is pregnant and
    has used a controlled substance for a nonmedical
    purpose during pregnancy. The local welfare
    agency shall immediately conduct an appropriate
    assessment and offer services, including but not
    limited to, chemical dependency services, a
    referral for chemical dependency treatment, and a
    referral for prenatal care.(Minnesota)

48
Does Treatment Work?
Ill have an ounce of prevention
49
Recovery of Brain Dopamine Transporters in Meth
Abuser After Abstinence
3
0
ml/gm
METH Abuser (1 month detox)
Normal Control
METH Abuser (24 months detox)
( Volkow, ND et al., Journal of Neuroscience 21,
9414-9418, 2001)
50
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
Addiction Treatment Does Work
100
90
80
70
60
Percent of Patients Who Relapse
50
40
30
20
10
0
Drug Dependence
Type I Diabetes
Hypertension
Asthma
(McLellan, A.T. et al., JAMA, Vol 284(13),
October 4, 2000)
51
Effective Treatment
  • Start treatment during pregnancy
  • Length of treatment residential or outpatient
  • Comprehensive treatment
  • Home-based treatment
  • Motivational interviewing and contingency
    management
  • Emphasis on the mother-infant relationship
  • Family treatment drug court

(Lester and Twomey 2008)
52
  • Model Programs
  • Family centered
  • Comprehensive
  • Interdisciplinary staff
  • Nonjudgmental, nonpunitive, nurturing,
    culturally appropriate
  • Parenting programs
  • Mental health and womens issues
  • Child care
  • Transportation

(Lester, Andriozzi, Appiah 2004)
53
Vulnerable Infants Program (VIP)
VIP (Women and Infants Hospital)
VIP is a statewide hospital based program for
women who have used illegal drugs and/or alcohol
during pregnancy, their infants and families
Family Treatment Drug Court
CPS
54
Purpose of VIP
Facilitate the ability of the Rhode Island Family
Court to comply with the Adoption and Safe
Families Act (ASFA) regarding the placement of
drug exposed newborn infants in R.I.
The Providence Journal March 11, 2000
55
  • VIP was developed because in RI
  • Too many babies were boarding in hospital beyond
    medical necessity because of issues surrounding
    placement
  • Concerns about how placement decisions were being
    made
  • Too many infants were placed in foster care (in
    1995, RI had the 2nd highest rate of out of home
    placement in the US)
  • RI Court was having trouble complying with the
    1997 Adoption and Safe Families Act (ASFA)

56
Family Treatment Drug Court
  • FTDC established in 2003
  • Specifically designed for perinatal
    substance users and their families
  • Facilitate permanency placements for substance
    exposed infants
  • Ensure parents receive substance use treatment
    and ancillary services to increase opportunities
    for reunification

57
  • VIP Provides
  • Evaluation of mother for substance use disorder,
    mental health, parenting, life skills, family
    resources, support, and evaluation of infant
    using standardized assessments.
  • Recommendation to CPS and Court for placement
  • Development of treatment plan for mother to keep
    or be reunified with baby
  • Case management to implement treatment plan,
    liaison with Court to follow ASFA guidelines

58
Components of VIP
  • Administrative
  • Education/Training
  • Service/Linkage

59
Administrative
  • Develop an infrastructure to work with Court and
    Child Protective Services (DCYF) to facilitate
    compliance with ASFA , provide linkages with
    other state and community agencies
  • DCYF-VIP partnership with standardized hospital
    protocol
  • Partner with Family Court to develop Family
    Treatment Drug Court

60
Education/Training
  • Provide an education program for the Court, state
    and community agencies in relevant substance
    abuse issues to help more informed decisions
    regarding placement of drug exposed infants

61
Service/Linkage
  • Standardized testing determines treatment needs
  • Treatment referrals ancillary services
    facilitated
  • Collaboration with CPS
  • Attend FDTC hearings, provide input, monitor
    progress, until permanent placement

62
  • In-Hospital Component
  • Birth MD Records Drug Exposure
  • VIP-RI enrolls patient, completes intake and
    administers assessments
  • VIP-RI shares assessments results, make
    referrals to treatment and services
  • VIP-RI meets with CPS to share assessments,
    currents services and placement for infant
  • Enroll in Family Treatment Drug Court

63
Family Treatment Drug Court
  • Employs a therapeutic not adversarial approach
  • Collaboration among multiple social service
    agencies to achieve timely permanent placement
    for infants
  • VIP-RI provides care coordination for FTDC
    participants

64
Philosophy of FTDC
  • Early identification
  • Intervention with intensive case monitoring
  • Frequent court reviews
  • Facilitates more informed judicial decisions
    regarding child placement and timely permanent
    placement decisions

65
Participants
  • Cocaine primary drug of choice
  • 60 mothers had substance use disorder
  • 75 mothers previous treatment for substance
    abuse
  • 53 mothers previous mental health treatment

66
Hospital Length of Stay For Drug Exposed Infants
Days
67
Placement
68
Improved Maternal Psychological Symptoms
69
Mothers with one or more high risk scores on the
Adult Adolescent Parenting Inventory
 Expectations, Empathy Discipline, Family Roles,
Power/Control
70
More Infants Are Being Placed With Their Families
With Family Treatment Drug Court
Treatment Court (n64)
Family Court (n81)
(60 reduction foster care placement)
71
Average Time to Reunification
100
Family Court (Standard) Total
90
FTDC (Specialty) Total"
80
73
70
60
Percentage of Clients Reunified
50
39
40
33
30
20
20
11
7
6
6
6
10
0
0
0
0
0 - 3 months
4 - 6 months
7 - 9 months
10 - 12 months
13 - 15 months
16 - 18 months
Number of Months to Reunification
72
Participant Satisfaction Quotes
Everyone listened to what I had to say and
respected me.
(They) believed in me and I was always given the
benefit of the doubt.
It helped me rethink me direction (in) life.
(they are) very easy to talk to and always make
me feel good about succeeding.
(They) stood by me and believed in me when I
didnt believe in myself.
73
Participant Satisfaction Data
74
Summary of VIP Findings
  • Preliminary findings from the VIP/FTDC program
    are encouraging
  • Utility of standardized assessment battery
  • Decreased length of hospital stay
  • Reduced number of children in out of home
    placement

75
Summary of VIP Findings
  • Increased number of children placed with
    biological mothers (with and without CPS
    involvement)
  • Reduced psychological symptoms in mother
  • Reduced high risk parenting scores
  • Earlier reunification with birth mother in FTDC
  • Positive client satisfaction

76
After ASFA
  • Functioning of parents after court involvement
  • Stability of permanent placements for
    substance-exposed infants
  • Infant developmental outcomes

77
Preliminary Infant Results
  • Majority of infants (82) reunited with
    biological parent at by 12 months
  • Absence of behavioral problems at 18 30 months
    on CBCL (M53, SD9)
  • Majority of infants have no cognitive delays (10
    Bayley
  • Majority of infants (55) in unclassified
    attachment category

78
Preliminary Maternal Results
  • Substance Dependence Disorder (SASSI) decreased
    65-53
  • Psychiatric symptoms (BSI) increased
  • 50-70
  • Child Abuse Potential (CAPI) decreased (150-130)
  • Home environment (HOME) similar to normative
    sample

79
What Have We Learned?
Our understanding of addiction has also changed
in two decades. We know more about addiction as a
disease a medical condition that can be
treated Addiction is a complex disease with
multiple mental health co-morbidities Women who
use drugs also tend to be depressed and anxious
and may have even more severe mental health
problems. So the bad news Addiction is
complex The good news Addiction is treatable. We
can reduce the problem of drug addiction
80
What Have We Learned?
  • It is extremely difficult to take a swing at bad
    mothers without the blow landing on their
    children.
  • While there are drug users who are inadequate
    mothers, there are also drug users who are
    competent mothers who, with treatment, can care
    for their children. Families can be preserved.

81
Some Policy Recommendations
A national consensus on how to deal with maternal
substance use based on research and tested
treatment strategies and that demonstrates a fair
and unbiased attitude towards substance using
women and their children
82
Some Policy Recommendations
Improve access to treatment and develop
coordinated treatment programs with
interconnected services based on the needs of
women, mothers and children (It does no good to
tell a poor mother with four kids to keep 3
different appointments in 3 different locations
without providing transportation or baby-sitting)
83
Avoid Labeling Top Medical Doctors, Scientists
Specialists Urge Major Media Outlets Not to
Create Meth Baby Myth   Signatories from
Leading Hospitals and Research Institutes In US
and Abroad Agree That Term Lacks Scientific Basis
as Does the Claim That Treatment Does Not
Work   Letter Sent to CBS National News,
Minneapolis Star Tribune, New York Times, Los
Angeles Times. Chicago Tribune, Sunday Oklahoman
and Other Media Perpetuating Such Myths   On July
25, 2005 more than 90 leading medical doctors,
scientists, psychological researchers and
treatment specialists released a public letter
calling on the media to stop the use of such
terms as ice babies and meth babies. This
prestigious group agrees that these terms lack
scientific validity and should not be used.
84
Some Policy Recommendations
 Educate the public including the media, law
makers, policy makers and health care
professionals about the validity of scientific
findings on maternal drug use and child outcome,
treatment effectiveness and the dangers of
stigmatizing children
85
Some Policy Recommendations
  • Legislation prohibiting health facilities that
    receive federal funds from denying treatment to
    patients with addiction and dependency disorders
    because they have relapsed and manifested the
    disease they are fighting
  • Legislation protecting mothers who voluntarily
    seek drug treatment from having their children
    taken away
  • (Many mothers who want treatment are afraid to
    come forward out of fear they will lose their
    children)

86
Some Policy Recommendations
  • Develop evidence based guidelines for
    comprehensive risk assessment of mother, infant,
    family and home
  • Determine who are the families that are able to
    care for the child and benefit from treatment
  • Develop training programs for the risk assessment
  •  

87
Final Thought…
  • Tremendous strides in past 20 years
    understanding drug addiction/treatment.
  • Have the opportunity to keep families together
    today in ways that were not possible only a few
    years ago.
  • Optimistic about our ability to reduce addiction
    and save future generations of children through
    treatment.
  • Failure to take advantage of what we have learned
    is not only a missed opportunity but a giant
    step backward

88
Prevention is Cost Effective
  • 120,000 drug exposed infants/year
  • X 5
  • (extra 6000 drug exposed children per year
    needing special education services)
  • X 9204
  • (cost special education services per child)
  • 55,224,000
  • per year additional funds

Levine et al 2008
89
Never, ever, think outside the box
90
(No Transcript)
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