F.E.A.T Project Introduction

Project Description

Project Family Early Advocacy to Treatment (FEAT) proposes a model to address effective procedures for identification, referral, and treatment of infants who are prenatally exposed to illegal drugs and their families. The FEAT model builds on the strengths of existing community services, utilizes elements of previously funded Child Abuse Prevention Treatment Act (CAPTA) state projects, and builds on existing working groups at state and local levels, as well as the Oregon five-year CAPTA plan. In addition, new elements to help evaluate and refine the model are proposed to best serve this very vulnerable population of children and families. The FEAT model will increase the knowledge base for how best to address the needs of infants and families affected by illegal substance abuse, and will provide direction to counties for needed policies and procedures.

A logic model (Figure 1) will provide the structure to illustrate the connections between FEAT activities and outcomes, and will facilitate development of a theory of change for participants. A continuous improvement evaluation model, theory of change process, as well as collection of on-going objective data measuring child, family, and agency outcomes will be used in order to yield useful findings about effective strategies and evidence-based practices underlying the FEAT model.

(1) Objectives and Need for Assistance

The number of children in foster care in Lane County [ Oregon ] has more than doubled over the last four years from 500 to 1,000. Officials say the growing abuse of Meth in the state is one of the primary reasons that children end up in the system.."We have brought five babies exposed prenatally to Meth to foster care in the past four weeks." (Drug-Rehabs.org, retrieved 7/21/05).

The above excerpt describes a crisis - substance exposed infants - not only impacting local communities in Lane County, Oregon, but across the nation. The most recent national data for the prevalence of illicit drug use during pregnancy estimated that 222,000 infants exposed to illegal drugs were born during 1991-1992

(NIDA, 1996, 1997). A recent federal estimate of the prevalence of drug use by pregnant women is 4.3%,from self-report on the National Survey on Drug Use and Health ([NSDUH], 2005). The tremendous increase in child welfare cases since the late 1980s appears to be due to substance use (National Center on Addiction and Substance Abuse at Columbia University, 1999). The Child Welfare League of America estimated that 67% of parents with children in the child welfare system required substance abuse treatment services (National Committee to Prevent Child Abuse, 1998).

This crisis was first reported in Drug-Exposed Infants: A Generation at Risk (1990) - the current drug epidemic affecting women of childbearing age. A nationwide hospital survey indicated half of women who use illicit drugs were in the childbearing age of 15 to 44 years old. State legislatures at the National Conference (2000) affirmed the national crisis of maternal drug and alcohol use. Today, this alarming rate continues - nearly half of women of child bearing age use illicit drugs including marijuana, cocaine, Ecstasy, and other amphetamines, and heroine (marchofdimes.com, retrieved 7/21/05).

Active drug addiction is the leading cause of family involvement in the child protective system, especially for very young children. Since the late 1980s, when crack cocaine became an epidemic, the numbers of children entering the child protective system have increased exponentially. Foster care systems have not been able to keep up with the need to remove children from their families, and existing foster care models are often not appropriate for the very young infants and toddlers suffering from drug exposure (Berrick, Nedell, Barth, & Johnson-Reid, 1998) . Foster care placements rose beginning in the late 1980s and children under 5 make up the largest number of referrals for foster care (McCullough, 1991).

A large percentage of child victims (60%) are neglected by their parents or other caregivers ( Child Maltreatment , 2003), a symptom common to parents who abuse drugs. Children in the age group of birth to 3 years have the highest rate of victimization, at 16.4 per 1,000 children in the national population ( acf.hhs.gov/programs/cb/publications , retrieved 7/21/05 ). The prevalence of legal and illegal drug use by The prevalence of legal and illegal drug use by pregnant women varies considerably from area to area and hospital to hospital (Nickel & Desch, 2000). The expectant mothers' use of these drugs may alter the course of the pregnancy, affect the developing fetus, and have long-term impact on their children's development (Nickel & Desch, 2000). Expectant parents' use of alcohol and other drugs also may interfere with their ability to parent, and their infant's ability to elicit and respond to caregiving activities.

Illicit drugs can pose great risk to the fetus and pregnant mother. Illicit drug effects include low birth weight, prematurity, failure to thrive, neurological symptoms, and infectious diseases (archrespite.org, retrieved 7/21/05). Research findings reveal significant consequences of alcohol and cocaine prenatal exposure to the cognitive, speech, and language development of 4-year-old children (Cone-Wesson, 2005).

The effects of specific drugs on the fetus and newborn are difficult to pinpoint, however, for two primary reasons. First, most women who abuse drugs often use a combination of drugs and alcohol (e.g., marijuana, methamphetamines, alcohol) at varying times during their pregnancy. The Maternal Lifestyle Study (Bauer et al., 2002) has provided a statistical profile of diverse pregnant woman using opiates and cocaine from the early 1990s. Ninety-eight percent of women admitted to using more than one drug, 93% drank alcohol, and 42% used marijuana as well. These women had higher risks of medical complications due to sexually transmitted diseases, hepatitis, psychiatric and emotional disorders, abruptio placenta, and positive tests for HIV and AIDS. Second, most researchers have concluded that the environments in which these families live have a far greater effect on the outcomes of newborns than the prenatal drug abuse (Future of Children, 1993; National Abandoned Infants Assistance Resource Center, 2004b).

Initially, infants exposed prenatally to crack cocaine were reported to have smaller head circumferences, lower birth weight, and irritability (Chasnoff, 1985). Subsequent research found that cocaine did not appear to affect young children's intelligence; studies of neurobehavioral problems in newborns have been inconsistent. Current research on the prenatal effects of cocaine and opiates on children from the Maternal Lifestyle Study has identified many subtle biological and intellectual effects (Barth, 2001; Morrow et al., 2003; Weissman & Caldecott-Hazard, 1993). However, longitudinal studies of drug-affected children are suggesting significant long-term behavioral and intellectual effects of cocaine use (Jewett, 2005).

Research on methamphetamine exposure is, in comparison, meager. Methamphetamine use, like cocaine, has been shown to have an effect on infants' growth. Babies exposed to methamphetamine were significantly smaller for gestational age; smoking combined with meth use further decreased growth (Smith et al., 2003).

Recent initial research by neonatalogist, Dr. Michael Sherman, estimates that methamphetamine may be far more destructive to the fetus than crack cocaine. He estimates exposure to methamphetamine could cause 4 1/2 times more birth defects than cocaine (Jewett, 2005). Many states such as Oregon are experiencing a dramatic rise in methamphetamine use and increase in infants exposed prenatally to this toxic drug (Drug-Rehabilitation.org, retried July 30, 2005).

The complexity of services to families and infants who have been prenatally exposed to illicit drugs requires a system of care integrating a coordinated and collaborative model of programs, agencies, and departments. In a California Policy Seminar Brief (1993), such a system of care model was identified as critical to address the gaps of services to families and infants with prenatal drug exposure.

The time of a child's birth may be a particularly important time for intervention. Mothers may be more open to addressing their drug problems at this time (Reinarz & Ecord, 1999). For this reason, it is crucial that identification of drug-exposed infants be accompanied by family assessment, referral, and follow-up services (Reinarz & Ecord, 1999). A summary study from NIDA puts treatment of pregnant women as a high priority for the U.S. government (Huestis & Choo, 2002). The far-reaching social system that is affected by pregnant woman who use drugs needs increased awareness of related medical, legal, and social issues to reduce barriers to treatment (Huestis & Choo, 2002).

Caregivers' involvement, whether biological parents, relatives or foster parents, will be critical to the success of programs for infants. Because problems are so complex, states must have a variety of prevention and intervention services for both the substance exposed infant and the mother. A continuum of culturally competent, individually tailored services are necessary for the systems to be effective. Such range of services within states and communities should include the following:

•  Family planning and education - Family planning education and counseling services are vital for both female and male drug abusers ( National Abandoned Infants Assistance Resource Center ( National AIA Resource Center , 2005a).

•  Drug treatment during pregnancy - Much of the scientific research on prenatal substance abuse focuses on identifying the effectiveness of various treatments for pregnant drug abusers. Oregon has created treatment programs for pregnant mothers along with 18 other states (Guttmacher Institute, 2003).

•  Post-birth treatment interventions - Possible options for drug-exposed infants include: 1) in-home family support services, 2) out-of-home placement, 3) adoption (abandonment or voluntary relinquishment), and 4) residential treatment for mother and child (McCullough, 1991.)

For the safety and healthy well-being of all children, Shonkoff and Phillips (2002) recommend "that all children who are referred to a protective services agency for evaluation or any children suspected of abuse or neglect be automatically referred for a developmental-behavioral screening under Part C of the Individuals with Disabilities Act." Recent amendments to both Child Abuse and Prevention Treatment Act (CAPTA) as well as Individuals with Disabilities Education Act (IDEA) aim to address this growing dilemma. CAPTA requires that "provisions and procedures for referral of a child under the age of 3 who is involved in a substantiated case of child abuse or neglect to early intervention services funded under Part C of the Individuals with Disabilities Act".

In Oregon , The Status of Children in Oregon 's Child Protective Services (2004) reports child abuse and neglect data that illustrate the prevailing issue of child abuse and neglect:

•  In 2004, Oregon Department of Health and Services (DHS) child welfare received 46,524 reports of suspected child abuse and neglect - an increase of 9.6% over 2003. Since 1995, DHS has had an overwhelming increased reporting rate of 73.8%.

•  Referrals of 7,307 child abuse/neglect were "founded" in 2004, an increase of 12.2% from the 6,510 in 2003. ("Founded" means that there was reasonable cause to believe that abuse/neglect occurred.)

•  There were 10,622 child abuse/neglect victims in 2004, an increase of 12.4% from 2003.

•  Of the total victims of abuse/neglect, 49.2% of the victims were younger than 6 years old.

•  In 2004, 53.5% of neglect incidents involved children aged 0-5 (9.9% were infants). Neglect is potentially as lethal as abuse, and often requires more services over a longer period of time.

•  In 2004, the stress factor - suspected drug/alcohol abuse - in families was indicated in 44.7% of "founded" abuse reports.

•  A total of 198 drug-related deaths were reported by the State of Oregon Medical Examiner Division from heroin, cocaine, methamphetamine or a combination of the drugs, a 4% increase from the previous year (egov.oregon.gov, retrieved 7/29/05).

•  Deaths from child abuse have dramatically increased in Oregon , with 21 children killed as a result of abuse and neglect in 2004.

In response to critical state needs regarding prenatal drug exposure, the Oregon legislature recently passed a bill that makes changes to the current mandatory reporting statue. This new legislation specifically broadens the reporting statues to include: "unlawful exposure to a controlled substance resulting in a threat to the health and safety of a child." Thus, hospitals, physicians, and other agencies serving families with prenatal drug exposure will now need to develop new reporting policies and procedures. State agency representatives, including Sharon Bolen who is directing state CAPTA efforts, is eager to address these new requirements as part of the proposed Project FEAT, as outlined in Letters of Support, Appendix A.

In Lane County , the drug epidemic is reflective in community indicators. Lane County is noted second highest with drug-related deaths from the State Medical Examiner's press release. Infant Tier Program statistics on infant placement in foster care for 2005 indicate a 30% increase from 2004. Thus far in 2005, 63 infants were placed in foster care, of which 13 tested positive for illegal drugs. April 2005 was the busiest month with 14 infants placed in foster care (2005 Baby stats, 2005). These statistics reflect a small percentage of actual cases; conversations with hospital social workers, pediatricians, and child welfare workers reveal inconsistent prenatal drug testing, child welfare reporting, and hospital and social service procedures for prenatal drug exposure. Current Oregon CAPTA provisions do not as yet include procedures for prenatal drug exposure, adding to difficulty in establishing local and statewide policies.