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The Child Abuse Prevention and Treatment Act: Substance-exposed Births

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Title: 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

2
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

4
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

5
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

6
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))

7
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))

8
CAPTA
  • How many substance exposed births?
  • Challenges in estimating
  • Prenatal drug use
  • Substance exposed birth

9
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.
10
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?
11
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

12
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
13
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
14
CAPTA
  • How do States currently respond
  • to prenatal drug exposure?

15
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)

16
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

17
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)

18
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
19
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

20
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?

21
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

22
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?

23
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

24
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

25
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?

26
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

27
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

28
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?

29
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?

30
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.

31
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

32
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

33
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.

34
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?

35
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

36
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

37
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

38
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?

39
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
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