Plans of Safe Care Infants With Prenatal Substance Exposure and Their Families - Alabama

Definitions
Citation: Admin. Code § 660-5-34-.02; CPS Pol. & Proc., 09-DHR Protocol

For screening and accepting reports of child abuse or neglect that are received by the Department of Human Resources (DHR), the definitions of physical abuse, which is directly attributable to a physical act by the person allegedly responsible, includes fetal alcohol syndrome or drug withdrawal at birth due to the mother's substance use or misuse.

In policy: A referral meets the criteria for investigation if either of the following allegations are present:

• Positive test for alcohol at birth or fetal alcohol syndrome:
  • The child tests positive at birth for alcohol or exhibits symptoms of fetal alcohol syndrome. Fetal alcohol syndrome is associated with growth, mental, and physical problems (e.g., low birth weight, facial abnormalities, organ dysfunction, etc.) that occur in a baby when a mother consumes alcohol during pregnancy.
• Positive test for drugs at birth or drug withdrawal:
  • Infants who test positive at birth for drugs are considered abused or neglected. Infants who test positive at birth for prescription medication or over-the-counter medications due to the mother's consumption and misuse of prescription medications or over-the-counter medications are considered abused or neglected. Misuse of prescription medications or over-the-counter medications is defined as an excessive amount of medication in the infant's system as determined by a medical professional.

Note: Per DHR policy, reports on unborn children are not accepted as child abuse or neglect (CA/N) reports. Child welfare staff shall provide reporters with information about other DHR programs and community resources as appropriate.

Notification/Reporting Requirements
Citation: Admin. Code § 660-5-34-.04(2); CPS Pol. & Proc., 09-DHR Protocol

A report of alleged child abuse or neglect is not accepted on an unborn child. Other departments or community services may be provided to the family of the unborn child as deemed appropriate.

In policy: Health-care providers involved in the delivery or care of infants who are affected by substance use disorder, withdrawal symptoms resulting from prenatal substance exposure, or fetal alcohol spectrum disorder are required to report all cases to DHR for assessment. This includes those infants who test positive for prescribed medications and over-the-counter medications.

Only referral information received that meets DHR's definition of alleged abuse or neglect (i.e., risk of serious harm) is accepted as a CA/N report. Referrals that do not meet the definition of alleged abuse or neglect (i.e., no risk of serious harm) shall not be screened out and must be accepted as a child protective services (CPS) prevention referral. If, during the assessment, safety threats are identified, and a safety plan is needed, the CPS prevention assessment stops, and the case must be converted to a CA/N report.

Assessment of the Infant and Family
Citation: CPS Pol. & Proc., 09-DHR Protocol

Child welfare staff shall follow standard CA/N assessment or CPS prevention policy in all cases accepted for assessment. Upon receiving a referral involving a substance-affected or exposed child(ren), investigative staff with the county department shall respond immediately to the hospital or any other location to see the child to assess the severity of or potential for physical, mental, or emotional harm to the child.

When the report is received before the infant is discharged from the hospital, child welfare staff must do the following: 

• Make in-person contact with the mother, the infant, and hospital medical staff prior to the infant's discharge
• Verify the mother's and infant's address
• Make a home visit within 12 hours after the infant's discharge

When the report is received after the infant's discharge from the hospital, child welfare staff must collect and assess information about the following: 

• Conditions and circumstances related to the substance use or misuse (e.g., type, frequency, duration, underlying conditions)
• The presence of any other individuals (e.g., household members, friends) in the home who may also be using or misusing substances or influencing the parent's substance use or misuse
• How the parent's substance use or misuse is impacting caregiving knowledge and skills
• The parent's ability to meet the infant's unique needs
• The adequacy of living arrangements and means of financial support
• Whether the mother has other children not living with her; if so, those children's whereabouts, current living arrangements, and legal status

Child welfare staff must specifically assess whether there are safety and permanency needs (e.g., the mother left the child in an inappropriate or unsafe setting) in the current living arrangements of these other children. If there is any indication that child safety is or was a concern for these children (e.g., parental rights terminated), consideration must be given as to whether the same or similar circumstances and safety issues may occur with this infant.

During the investigative process, it is necessary to determine whether the child may safely remain in the home while treatment and services are provided to address the conditions that place the child at risk of serious harm.

Responsibility for Development of the Plan of Safe Care
Citation: CPS Pol. & Proc., 09-DHR Protocol

Development of a plan of safe care (POSC) by the county department must ensure the safety and well-being of an infant born and identified as affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder. The POSC must address the health and substance use disorder treatment needs of both the infant and the affected family or caregiver. The POSC is required for infants affected by all substance abuse, not just illegal substance abuse, and must address the immediate safety needs of the affected infant, health and substance use disorder needs of the affected family or caregiver, and referrals to appropriate services that support the affected infant and family or caregivers.

A POSC for any infant whom DHR determines is affected by substance abuse or is suffering from withdrawal symptoms resulting from prenatal drug exposure shall be developed with input from the following:

• Parents and caregivers
• Health-care providers involved in the mother's or child's medical or mental health care
• Other professionals and agencies involved in serving the affected infant and family

Services for the Infant
Citation: CPS Pol. & Proc., 09-DHR Protocol

Developed as part of the Individualized Service Plan (ISP) process, a POSC shall address the following: 

• The infant's ongoing health, development, and well-being
• Appropriate care for the infant who may be experiencing neurodevelopmental or physical effects or withdrawal symptoms from prenatal substance exposure

Child welfare staff shall refer all infants and toddlers from birth to 36 months, with indicated CA/N reports to Alabama's Early Intervention System (AEIS). AEIS, a division of the Alabama Department of Rehabilitation Services, is funded under Part C of the Individuals With Disabilities Education Act. Early Intervention Services identifies through evaluation infants and toddlers with a delay in the major areas of development (e.g., physical, social, adaptive, cognitive, or communication skills) and provides early intervention supports and services to eligible children.

Services for the Parents or Other Caregivers
Citation: Admin. Code r. 580-9-44-.29; CPS Pol. & Proc., 09-DHR Protocol

An opioid maintenance therapy program shall develop, maintain, and document implementation of written policies and procedures to address the needs of women, which include an acknowledgment in policy and practice that pregnant women are the number one treatment priority and cannot be denied treatment access solely because of pregnancy.

In policy: A POSC shall address the following: 

• The parent's or primary caregiver's need for treatment for substance use and mental disorders
• Services and supports that strengthen the parent's capacity to nurture and care for the infant and to ensure the infant's continued safety and well-being

A safety plan and POSC may often address the same processes and issues. A safety plan will address identified and documented safety threats. The POSC goes beyond immediate safety factors to address the affected caregiver's need for substance use or mental health treatment and the health and developmental needs of the affected infant.

CPS must also offer or make referrals for appropriate services. Preventive services include supportive and rehabilitative services that are provided to children and families to prevent out-of-home placements. Supportive and rehabilitative services for children and adults include, but are not limited to, case management, case planning, child care services, family planning services, and clinical services.

Monitoring Plans of Safe Care
Citation: CPS Pol. & Proc., 09-DHR Protocol

To achieve identified goals and desired case outcomes, the county department must regularly monitor and evaluate the POSC incorporated in the ISP to determine its effectiveness in producing desired outcomes. Reviewing an ISP also includes reviewing the case narrative. Supervisors review narratives to evaluate the quality of casework practice and evidence of outcomes for children and families. Narrative entries must reflect elements of the ISP process, be directly related to steps and goals, and demonstrate that actions taken are supportive of the ISP and children's permanency goals.

The State DHR Office of Data Analysis reports to the National Child Abuse and Neglect Data System the number of infants identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder; the number of such infants for whom a POSC was developed; and the number of such infants for whom a referral was made for appropriate services, including services for the affected family or primary caregiver.

In addition, the State DHR Office of Child Welfare Quality Assurance, as a normal part of onsite reviews, will randomly select and review POSCs to ensure county staff are implementing steps outlined in the POSC.