Addiction Professional – Comprehensive care for at-risk children
March 19, 2015 by John de Miranda, MEd, and Anna Marquez
Monterey County, Calif., is the site of an innovative collaboration between trauma-informed behavioral health organization Door to Hope and the county child welfare system that identifies and treats infants and children exposed to drugs in utero or to violence in early childhood. While our capacity to treat individuals with addiction is well-developed, services for infants and children of adults with a substance use disorder remain severely lacking.
Each year, more than 800 Monterey County children are born prenatally exposed to alcohol and other drugs. This exposure increases the child’s risk for developmental delays and neurological, social, emotional and behavioral problems. The window of opportunity to make a difference in these children’s lives is brief, and the cost of missing that window is profound. Early identification and intervention become crucial to helping these children reach their full potential.
The Monterey County Screening Team for Assessment, Referral, and Treatment (MCSTART) provides a comprehensive model of care to identify, assess, refer and treat children who have been prenatally exposed to alcohol and other drugs, domestic violence, and trauma. The program closes a critical gap in the existing behavioral health system of care, and it both complements and supplements efforts to address the needs of families experiencing addiction or living with violence.
MCSTART is composed of three components:
- A policy component to provide the policy framework, coordination and oversight necessary for the long-term viability and sustainability of the MCSTART mission.
- An operational component comprising prenatal prevention and primary, secondary and tertiary intervention for children affected by the broad spectrum of developmental, social/emotional and neurobehavioral disorders caused by prenatal alcohol and drug exposure and/or perinatal exposure to domestic violence and trauma.
- An evaluation component to provide for ongoing, systemic data collection and analysis to measure outcomes and analyze cost impacts.
History and prevalence
In 1992, the California Department of Alcohol and Drug Programs’ Office of Perinatal Substance Abuse commissioned and funded a Perinatal Substance Abuse Prevalence Study to obtain accurate, population-based estimates of the number of alcohol- and drug-exposed children born in the state. That study indicated that 11.86% of all births in the mid-coast region, which included Monterey County, were exposed to alcohol and other drugs (not including tobacco).1
A more recent national report estimated that in “younger school children” the rate of all levels of fetal alcohol spectrum disorder (FASD) may be as high as 2 to 5% of the population.2 A study of prenatal screening suggests that as many as one-fifth of infants born in the United States each year are prenatally exposed to alcohol, tobacco or other drugs, and 75 to 90% of these cases go undetected.3
Many experts believe that these studies actually underestimate the number of affected children, since many mothers deny alcohol and drug use during pregnancy. Also, healthcare professionals often fail to screen women or recognize the signs of substance use, and toxicology screens provide information at only one point in time and do not identify drinking or drug use at earlier stages of pregnancy—when the neurological impact of drug exposure is most damaging.
Exposure to trauma
According to Monterey County child welfare statistics, 85% of children up to age 5 in foster care come from substance-abusing homes. While substance abuse is often associated with physical and sexual abuse, more often children are removed from the home because of neglect. Thirty-three percent of the children referred for suspected child abuse or neglect were ages 0 to 5 years, and of the total of 4,485 children referred for investigation in 2002, 1,484 were 5 or younger. Ethnicity profiles reveal an overrepresentation of Hispanics, perhaps a reflection that Hispanic families have more young children and are more likely to live near or below the poverty level.
The National Crime Victimization Survey estimated that there are 9.3 physical attacks against women by intimate partners per 1,000, and children under the age of 12 reside in slightly more than half of the affected households.4
The multi-system costs to the public sector associated with these traumatized children are extraordinary. For example, should a substance-exposed infant enter the child welfare system, very often his/her care costs as much as $200,000 a year to meet medical, mental health, special education and specialized placement needs.
The potential cost benefits for screening, early intervention and treatment are impressive. Total lifetime costs for caring for a substance-exposed child have been estimated at between $750,000 and $1.4 million.5 Because substance-exposed newborns often have prolonged stays in neonatal intensive care units, their treatment costs total $71 million to $113 million per year.6
Screening and early intervention offer antidotes to the costs and complications seen in these statistics. Screening during pregnancy allows for the earliest possible intervention and can dramatically reduce the harm of exposure during pregnancy. Also, our experience demonstrates that early identification and intervention before age 6 modifies the trauma exposure to such an extent that most of these children eventually fare as well as non-exposed children.
Education and screening
Once research showed a significant level of drug-exposed births at the local public hospital, several key leaders in the community developed a strong interest in establishing services. Several visits to the community from Ira Chasnoff, MD, a national leader in fetal alcohol syndrome treatment, served as a catalyst for the MCSTART initiative.
All referred pregnant women receive education on the impact of prenatal use of alcohol, tobacco and other drugs, and substance use prevention information. Specific interventions are discussed within the context of each woman’s prenatal care. Community health staff are available to consult with healthcare professionals and/or the pregnant woman/birth mother to provide for a wide array of services and support.
The goal of screening is to encompass all at-risk children, not merely those births with positive toxicology screens of the newborn and/or mother at delivery. (The quantifiable results from blood tests at birth are often what will trigger involvement of the child welfare system.) The screening protocol includes but is not limited to:
- Late or lack of prenatal care;
- Positive toxicology screen at birth or delivery;
- Low-weight newborns;
- Neonatal intensive care admissions;
- Children ages 0 to 11 who enter the child welfare system;
- Children ages 0 to 5 whose mothers are in substance use disorder treatment or are involved with the criminal justice system; and
- Children ages 0 to 5 identified with developmental delays and/or troubling behaviors at home or in day care centers, Early Head Start, and Head Start programs.
Children referred to MCSTART undergo a comprehensive cognitive, medical, behavioral, social, educational and developmental assessment. Parental stability and functioning are also evaluated. Door to Hope operates the MCSTART clinic as one of its 10 overall programs.
The multidisciplinary team of professionals involved in this initiative includes a physician, physician assistant, clinical psychologist, psychiatric social worker, infant mental health specialist, substance use disorder professional, occupational therapist, case managers, and support staff. Most of the team members are part of the Door to Hope staff, but the Monterey County Behavioral Health Department also houses staff at the clinic site.
MCSTART utilizes a transdisciplinary approach that puts the family at the center of the team process and requires all professionals to integrate services across disciplines and institutional boundaries.
The comprehensive assessment is conducted over a four- to eight-hour period at the MCSTART clinic site. The assessment utilizes standardized assessment tools as indicated and includes:
- Parent/caregiver reports of the child’s behaviors and development;
- A comprehensive physical assessment, including hearing, language, vision and sensory;
- Cognitive, emotional, social, dyadic and developmental assessments;
- Direct observation;
- Play observation; and
- Evaluation of the family/caregiver.
The family, whether biological, adoptive or foster, serves as the central force in goal-setting and decision-making. Preliminary recommendations are discussed and a comprehensive written report is prepared. Once completed, the evaluating professionals, all involved agencies and practitioners, and the family meet as a team to finalize a treatment plan to guide short- and long-term interventions. A case manager ensures that the family understands all information being presented, and serves as an advocate to secure the needed services.
All services are trauma-informed and include healthcare, dyadic (child-parent/caregiver) therapy, sensory integration, physical therapy, speech and language, education, substance use disorder and/or mental health treatment for family members, and case management. Case management and ongoing support for actualizing the treatment plan is an essential focus. (See case study below for an example of how services might unfold.)
MCSTART has developed systematic follow-up and monitoring procedures, which means that each child’s referral is followed by a phone call to determine if the child has received the recommended treatment service. A case manager working at the MCSTART clinic handles referral and follow-up activities.
Treatment and referral are culturally and linguistically competent. All services build on the strengths of each family as expressed through history, tradition, language, ethnicity and culture.
The trademarked Theraplay, Circle of Security, Parent Child Interactive Therapy and Parents as Teachers are utilized in treatment. Attachment therapy or dyadic therapy serves as the centerpiece to develop positive, nurturing and appropriate relationships to modify risk and maximize resiliency in the high-risk infant or child. Developmental needs are met through the provision of sensory integration therapy, physical therapy, and speech and language therapy.
Parent education, utilizing both the Parents as Teachers model and psychoeducational groups, are a major intervention strategy for the high-risk child and his/her family. All of these interventions promote attachment, the most significant factor to promote social and emotional growth in the trauma-exposed child.
The initiative is supported by a blended funding stream derived mainly from the social-services sector. Initial funding came from the local First 5 Commission, charged to set spending priorities for revenue from a statewide initiative taxing individuals with high wealth.
As a result of MCSTART, community capacity has been increased in three ways:
- Development of new services, including comprehensive assessment of the substance- and trauma-exposed child age 0 to 11, early intervention services, dyadic therapy utilizing the Theraplay evidence-based model, Circle of Security, sensory integration occupational therapy, consultation with child care centers and schools, and specialized case coordination and management.
- Expansion of existing services to include infant/children’s behavioral therapy; family therapy; the Parents as Teachers evidence-based parent education model; Mentor Moms mentorship programs for adoptive/foster parents, relative caregivers and biological parents; and a focused parent/caregiver education program to foster resiliency in substance-exposed children.
- Improving services already available in the community, but now better tailored to meet the needs of the substance- and trauma-exposed child and his/her family. Integration with other agencies working with high-risk children, including the child protective teams, maternal and child health programs, developmental disability service providers, and school readiness programs, are emphasized. MCSTART also works closely with other providers and agencies to increase awareness of the needs of substance- and trauma-exposed children, including day care centers, Head Start and Early Head Start providers, Monterey County’s Child Abuse Prevention Council, addiction treatment centers treating pregnant and parenting women, domestic violence programs, and mental health treatment centers.
Caring proactively for the infants and children born to parents with substance use disorders may pose the next great challenge in evolving our nation’s addiction treatment infrastructure. While the MCSTART program at Door to Hope may be unique to Monterey County, infants and children exposed in utero to drugs and requiring trauma-informed prevention and intervention services exist in all communities.
1. Vega W, Noble A, Kolody B, et al. Profile of Alcohol and Drug Use During Pregnancy in California, 1992. Sacramento, Calif.: State of California Health and Welfare Agency; 1993.
2. May PA, et al. Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies. Dev Disabil Res Rev 2009;15:176-92.
3. Carpenter L. Nature of the Problem and State of the Field. Presentation at the National AIA Resource Center Substance Exposed Newborns Conference, Alexandria, Va.; June 2010.
4. National Crime Victimization Survey. Retrieved from http://futureofchildren.org/futureofchildren/publications/docs/09_03_1.pdf, Feb. 9, 2015.
5. Kalotra CJ. Estimated Costs Related to the Birth of a Drug and/or Alcohol Exposed Baby. Washington, D.C.: Office of Justice Programs Drug Court Clearinghouse and Technical Assistance Project, American University; 2002.
6. National Abandoned Infants Assistance Resource Center. Prenatal Substance Exposure: Fact Sheet; 2012.
Case study demonstrates impact
“T.J.” is a 6-year-old boy who was referred to MCSTART at age 4 by Monterey County’s child welfare department for a medical, psychological and developmental evaluation. He had been removed from his biological parents and placed in a foster home. While in utero T.J. was exposed to alcohol, methamphetamine, prescription medication and cocaine. As a young child he experienced physical and sexual abuse, as well as poverty. T.J. witnessed domestic violence against his mother by several of her boyfriends, and often was deprived of food and clean clothes because his mother was unable to provide for him and his six siblings.
When T.J. first came to MCSTART, he showed signs of significant emotional and behavioral dysregulation (for example, he would laugh or make loud noises for no apparent reason and he was quick to anger), impulsivity (he frequently ran away from caregivers) and inattention (he jumped from one activity to another). Also, T.J. had difficulty with social cognition and basic communication (he often struggled to recognize cues from others and to communicate his needs effectively). Compounding this, he often misread people and was overly friendly with strangers and had inadequate social boundaries.
Upon entering MCSTART, T.J. met with a case manager who conducted several evaluations to determine his language development, cognitive abilities, adaptability, sensory processing and behavioral development. The case manager then referred T.J. for a medical evaluation conducted by our physician. The medical evaluation determined that the boy would be a good candidate for occupational therapy, which ultimately assisted T.J. in promoting the organization of his early sensory and emotional experiences through sensory play. This assisted his brain in continuing to move from danger-based functioning to more flexible and less anxious processing ability.
T.J. also received a complete psychological evaluation conducted by our psychologist, further exploring areas in which he needed assistance. As a team, T.J.’s entire group of caregivers, including the medical provider, psychologist and his case manager, decided which therapeutic referrals would be best. He also was referred for attachment-based therapy to build rapport and trust.
As a result of T.J.’s cognitive evaluation, he was able to qualify for California’s developmental disability regional center services under the eligibility criterion “intellectual disability,” and to obtain an Individualized Education Plan (IEP) and placement in a specialized kindergarten class with a low student-to-teacher ratio and an individual aide to help him in school. Since his engagement with MCSTART services, T.J. has developed a healthy attachment with his caregivers, has decreased his angry outbursts, and has begun to develop appropriate self-regulation and self-soothing skills.
MCSTART will continue to provide T.J. with regular case management and medical evaluations as well as attachment-based family therapy for the purpose of maximizing his developmental potential. MCSTART will follow him until the age of 11. His eligibility for developmental regional center services is lifelong, and he likely will continue with an IEP through high school.