Susan M. Stephens, MD, FAAP Medical Director

Comprehensive Medical and Dental Program Arizona Department of Child Safety

Tracy Sloat, RN, MN Nurse Manager Office of Family Health

Maricopa County Department of Public Health

1. Science behind substance exposure

2. Care of the newborn

3. The Mom’s Story

4. The growing child

5. Navigating the health care system

6. Navigating the education system

7. Risk and Protective Factors

» Polysubstance abuse is the norm

» Fetal exposure to drugs/alcohol 20% ˃ At least 10% exposed throughout pregnancy

˃ Pregnant woman in substance abuse treatment using alcohol (+/- drug use) declined from 46.6% to 34.8%

» Alcohol use – 10.0% of pregnant women ˃ Binge drinking 4.4%

˃ Heavy alcohol use 0.8%

» Illicit drugs – 4.5% within past month • Substance abuse admissions (drugs only) rose from 51.1% to 63.8%

» Problem is under-reported

2013 SAMSHSA

» Impaired fetal growth

» Prematurity

» Neurologic deficits

» Behavioral changes

» Developmental Delays

» SIDS

» Child abuse

MacMahon JR. Perinatal Substance Abuse: The Impact of Reporting Infants to Child Protective Services. Pediatrics 1997 100(5)e1-9

Alcohol & other drugs affect whatever organ and system currently growing

The brain grows and develops every day during pregnancy

Fetal Alcohol Spectrum Disorders

» Narcotics & pain killers ˃ Prescription medications

˃ Heroin & Methadone

» Brain receptors altered ˃ Cycle of drug craving and drug withdrawal

» Methadone/Buprenorphine Therapy + Provides safer drug substitute

+ Long half-life - eliminates craving and breaks cycle

+ Goal is rehabilitation

» Do not detox during pregnancy

Craving

Withdrawal

Nicotine Alcohol Marijuana Cocaine Opioids PCP Meth Benzos

Prematurity Yes Yes No Yes Yes/No No Yes/No Yes

Low Birth Weight Yes Yes No Yes Yes/No No Yes Yes

Neuro - Behavioral SX Yes Yes Yes Yes Yes Yes Yes Yes

NAS Yes Yes No No? Yes Yes/No Yes? Yes

Congenital Malformations Yes/No Yes No? Yes/No No Yes Yes? Yes/No

SIDS Yes Yes Yes Yes Yes Yes Yes Yes

Child Abuse or Neglect Yes Yes Yes Yes Yes Yes Yes Yes

Adapted from Jansson LM, Velez ML. Peds in Review. Jan 2011

Yes/No = both have been reported, ? = controversial or unclear findings

Pediatrics Technical Report 2013; 131:e1009-e1024

» The causes of most birth defects remain unknown

» The causes of most cases of cognitive disabilities remain unknown

» The causes of most behavior disorders are unknown

» Combination of: ˃ Genetic and environmental factors ˃ Abuse of multiple substances

Substance Abuse is a Family Affair!

Contemporary

Pediatrics

» True withdrawal - opiates, sedative-hypnotics, & alcohol

» Withdrawal-like symptoms – antidepressant & antipsychotic medications & nicotine

» Onset varies + Type & amount of drugs + Time of last use + Character of labor & meds used during labor + Full term vs. premature infant + Nutritional status of mother + Presence of disease in infant

» Symptoms from birth to 72 hours of life » Duration of symptoms 6 days - 3 months

» For both the birth mother and the substance-exposed newborn, it is important to remember that it is more about support and intervention than a “cure”

» Specific diagnosis may not be possible

» Helpful guidelines: ˃ Clear understanding

˃ Realistic expectations

˃ Creative problem solving

˃ Patience

» Seen with all substances of abuse

» Tremors

» Irritability

» Difficulty being consoled

» Hypertonicity

» Increased startle response (Moro reflex)

» Respiratory, feeding, & sleeping problems

http://youtu.be/2eP5EnFSG0c

» Baby ˃ Note pitch of cry

˃ Note muscle tone

˃ Note posture

» Engage mom in treatment, if possible

» Allow infant to rest & don’t handle excessively

» Avoid overstimulation

» Establish sleep & wake routines

» Consistent & stable environment ˃ Non smoking environment!

» Coordinate all care after infant wakes

» Swaddle in blanket

» SENs at increased risk of SIDS

» “Back to Sleep” AAP Program ˃ Always have infant sleep on back, unless supervised tummy time

» Avoid overheating ˃ Dress appropriately

» Avoid second hand smoke exposure

» Safe Sleep Practices ˃ No Co-sleeping

˃ Keep infant off of soft surfaces, pillows, blankets, mattresses

» Small, frequent feeds

» May need to try different nipples

» Offer pacifier for sucking reflex

» Discuss optimal caloric needs with PCP

» May need to wake infant every 3-4 hours, if not meeting caloric needs

» May need referral for feeding evaluation

» Passive range of motion

» Infant massage

» Supportive positioning

» Tummy time (supervised)

» No walkers

» May need Occupational Therapy or Physical Therapy evaluation – ask PCP

» Don’t allow infant to become frantic

» Control and structure environmental stimuli

» Swaddle in flexed position

» Vertical rocking (vs. horizontal)

» Avoid eye contact

» Keep at arm’s length

» Give pacifier

2009 Calendar by Ann Geddes

» Refer to AzEIP (0–3 years)

» Head Start (preschool)

» Interactive reading on a daily basis

» Speech therapy referral – ask PCP

˃ If early vocalizations not present

˃ Speech delay

» Hearing evaluation

˃ All infants should be screened

˃ Ask PCP about evaluation, if concerns

http://youtu.be/m7zfJCW9Yco

»Recognize the birth mom’s story

»The gift of acceptance

»Examine our own biases

“Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces, by far, the most serious neurobehavioral effects in the fetus.”

IOM Report to Congress, 1996

No safe TIME. No safe TYPE.

No safe known AMOUNT

Nicotine Alcohol Marijuana Cocaine Opioids PCP Meth Benzos

Yes Yes Yes Yes Yes Yes Yes Yes

Adapted from Jansson LM, Velez ML. Peds in Review. Jan 2011

Yes/No = both have been reported, ? = controversial or unclear findings

Neuro - Behavioral Symptoms

Oppositional Defiance Disorder

Post-traumatic Stress Disorder

Obsessive Compulsive Disorder

Anxiety

Conduct Disorder

Emotional Disability

Attention Deficit Hyperactivity Disorder

Behavioral Disorder

Bipolar Disorder

Autism Spectrum Disorder

Asperger’s Disorder

Reactive Attachment Disorder

Fetal Alcohol Spectrum Disorder

Fetal Alcohol Syndrome

Mood Disorder

Alcohol and Other Drugs During Pregnancy Can Create a Lifelong Brain That:

....has trouble moving

information from one situation to another

...thinks in a disorganized way

...has difficulty with time and money

...forgets information

...thinks like the

brain of someone much younger

...can’t read the

emotions or body

language of other people

…uses poor judgment

…responds slowly

...can’t link

cause and effect

The Invisible Disability Brain Fatigue

Neuro-developmental Disorder

Our Environmental Demands

Slow cognitive pace (10 sec) Rapid response

Act younger than age Children are grouped by age

Difficulty transitioning Multiple, quick transitions

Need more time One timeline for everyone

Multi-sensory learners One Instructional style

Concrete learners Abstract learning - Inference

Memory deficits Memory testing

Try differently rather than

harder Trying Differently Rather Than Harder:

Fetal Alcohol Spectrum Disorders

Diane Malbin,

“If behaviors are believed to be willful, intentional, or the result of emotional problems, interventions typically focus on changing the behaviors. If behaviors are understood as reflecting brain differences, interventions focus on changing environments in order to prevent frustration and provide support” p. 25

FROM TO

Annoying Frustrated, challenged

Lazy, unmotivated Tried hard, tired of failing

Lies Confabulates, fills in blanks

Fussy Hyper-sensitive

Acting younger, babied Displays behaviors of younger children

Trying to get attention Needs contact, support

Inappropriate Displays behaviors of younger children

FROM TO

Hopelessness Hope

Fear Understanding

Chaos, confusion Organization, comprehension

Power struggles Working together

Isolation Networking, collaboration

FROM TO

Stopping behaviors Preventing problems

Behavior modification Modeling, using visual cues

Changing people Changing environments

Trying Differently Rather than Harder, Diane Malbin 2002

Arizona’s Pediatric Programs

DES

*AzEIP Early Intervention

*DDD

*Division of Child Safety (DCS)

Child Welfare

*CMDP

*ADHS OCSHCN

*ADBHS

Behavioral Health

*RBHAs; MMIC, NARBHA, CPSA,

Cenpatico

VFC

ASIIS WIC

AHCCCS

(Medicaid) Medical Health Needs

*AHCCCS Acute

Health Plans

*CRS Title XIX & V

*ALTCS

*Agencies who might

be engaged by those

children with special

healthcare needs

» Establish a PCP and Medical Home ˃ 10 EPSDTs (well child visits) in 1st 2 years of life

+ Developmental & Behavioral Health Screening ˃ Annual EPSDT after age 2

» Establish a Dental Home ˃ No referrals needed for dental care ˃ Dental care begins at age one (1)!! ˃ Routine preventative visits twice/year

» Ensure RBHA (behavioral health) services ASAP ˃ Urgent Response ˃ Assessment starts at 7 days ˃ Do NOT take “wait and see” attitude ˃ RBHAs must keep children in out of home care open for

services for a minimum of 6 months

Division for Developmental Disabilities (DDD)

DDD/ALTCS (Az Long Term Care Services)

AZ. Early Intervention Program (AzEIP)

Behavioral Health

Children’s Rehabilitative Services (CRS)

https://www.azdes.gov/appFiles/IntranetProgrammaticForms/pdf/ACY-

1235AHBPNA.pdf

»Start with your Pediatrician

»504 Plan verses IEP

»YOU are your child’s best advocate

» Prohibits discrimination on the basis of disability

» Accommodations related to the child’s disability so that he or she may participate in the general classroom setting

» Fewer procedural safeguards than the IEP

» The Individuals With Disability Education Act (IDEA)

» Qualifying diagnosis

» Measurable goals and quarterly documentation

» Processes and Procedures for Developing IEPS: http://www.azed.gov/special-education/files/2012/02/iep-aztas-07-2012.pdf

» Autism

» Blindness

» Deafness

» Emotional Disability

» Hearing Impairment

» Mental Retardation

» Intellectual Disability

» Multiple Disabilities

» Orthopedic Impairment

» Other Health Impairment

» Developmental Delay

» Specific Learning Disability

» Speech or Language Impairment

» Traumatic Brain Injury

» Visual Impairment

Drug(s)

Other Factors: Mom and Child

Postnatal Caregiving Environment

Medical Complications

» Parental Resilience

» Social Connections

» Knowledge of Parenting and Child Development

» Concrete Support in Times of Need

» Social-Emotional Competence of Children

www.cssp.org/reform/strengtheningfamilies

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www.maricopafamilysupportalliance.org/