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

Date: November 2024

Definitions
Citation: Ann. Code §§ 15-11-2(56); 31-12-2; DCFS Child Welf. Pol. Man., Pol. # 19.27

The term 'prenatal abuse' means exposure to chronic or severe use of alcohol or the unlawful use of any controlled substance, as such term is defined in § 16-13-21, that results in either of the following: 

  • Symptoms of withdrawal in a newborn or the presence of a controlled substance or a metabolite thereof in a newborn's body, blood, urine, or meconium that is not the result of medical treatment
  • Medically diagnosed and harmful effects on a newborn's physical appearance or functioning 

The term 'neonatal abstinence syndrome' means a group of physical problems that occur in a newborn infant who was exposed to addictive illegal or prescription drugs while in utero.

In policy: An infant 'affected by prenatal exposure to substance use' means the following: 

  • The infant is experiencing symptoms of withdrawal or exhibiting harmful effects in their physical appearance or functioning due to exposure to substances (legal or illegal).
  • The infant has tested positive for the presence of a substance or a metabolite thereof in their body, blood, urine, or meconium.
  • The infant has symptoms of a fetal alcohol spectrum disorder (FASD).
  • The mother tested positive for illegal substances at the birth of the infant.
  • The mother tested positive for prescription drugs due to misuse at the birth of the infant. 
    •    The mother self-disclosed at the birth of the infant a substance or alcohol use problem and use during pregnancy.

FASD is a set of conditions that can affect infants born to mothers who drank alcohol during pregnancy. Children with FASD may experience mild to severe physical, mental, behavioral, or learning disabilities, some of which may have lifelong implications (e.g., brain damage, physical defects, attention deficits). Symptoms of FASD can include facial abnormalities, growth deficiencies, skeletal deformities, organ deformities, central nervous system handicaps, and behavioral problems. FASD diagnostic conditions include the following:

  • Type I: Fetal alcohol syndrome (FAS) with confirmed maternal exposure
  • Type II: FAS without confirmed maternal exposure
  • Type III: Alcohol-related birth defects
  • Type IV: Alcohol-related neurodevelopmental disorder 

'Neonatal abstinence syndrome,' formerly known as 'withdrawal symptoms,' may occur when a pregnant woman takes drugs such as heroin, codeine, oxycodone, methadone, or buprenorphine. Because the baby is no longer getting the drug after birth, the withdrawal may occur as the drug is slowly cleared from the baby's system. Symptoms may appear within a few hours of birth to 14 days after birth and depend on the type of substance used, length of time used, etc. Symptoms generally include blotchy skin coloring (mottling), diarrhea, excessive crying or high-pitched crying, excessive sucking, fever, hyperactive reflexes, increased muscle tone, irritability, poor feeding, rapid breathing, seizures, sleep problems, slow weight gain, stuffy nose, sneezing, sweating, trembling (tremors), and vomiting.

Notification/Reporting Requirements
Citation: Ann. Code § 31-12-2; DCFS Child Welf. Pol. Man., Pol. # 3.4; 19.27

The Department of Public Health (DPH) requires notice and reporting of incidents of neonatal abstinence syndrome. A health-care provider, coroner, medical examiner, or any other person or entity DPH determines has knowledge of diagnosis or health outcomes related, directly or indirectly, to neonatal abstinence syndrome shall report incidents of neonatal abstinence syndrome to DPH.

In policy: The Division of Family and Children Services (DFCS) shall receive intake reports involving substance use or abuse when following when any of the following criteria are met: 

  • Child maltreatment involving the caregiver's substance or alcohol use or abuse and their ability to meet the needs of their children
  • Prenatal abuse occurring when infants are exposed to chronic or severe use of alcohol or the unlawful use of any controlled substance that results in any of the following
    • Symptoms of withdrawal in a newborn
    • The presence of a controlled substance or a metabolite thereof in a newborn's body, blood, urine, or meconium that is not the result of medical treatment
    • Medically diagnosed and harmful effects on a newborn's physical appearance or functioning, including FASD

Note: All intakes involving prenatal exposure require the development of a plan of safe care (POSC).

While prenatal exposure may include cases with child maltreatment (prenatal abuse), not all cases requiring a POSC involve maltreatment. Some examples of cases involving prenatal exposure with no allegations of maltreatment are as follows: 

  • The infant is prenatally exposed resulting from the mother's use of prescribed medication for an illness. The mother is following her medication and treatment plan, as verified by her health-care provider.
  • The infant is prenatally exposed resulting from the mother being given prescribed medication during the delivery process.
  • The infant is prenatally exposed due to the mother's participation in a medication-assisted treatment (MAT) program for a substance use disorder. The mother is complying with her medication and treatment plan, as verified by the substance treatment provider and her health-care provider. 

Assessment of the Infant and Family
Citation: DCFS Child Welf. Pol. Man., Pol. # 19.27

DFCS shall do the following:

  • Assess the health and substance use needs of the infant, caregiver, and other family members  
  • Review and analyze all information gathered from the assessment to determine the health and substance use needs of the infant, caregiver, and other family members, including, but not limited to, the following:
    • Substance use disorder assessment from the substance use disorder treatment provider, other assessments conducted, etc.
    • Children's first screening results
    • Health information collected for the infant, other children, and the mother's medical provider, hospital discharge records, etc.
    • Interviews with the mother, other caregivers, and other family members
    • Observation of the infant, other children, and caregivers
    • Observation of the home
    • Other information as appropriate
  • Initiate a staffing with the social services supervisor to discuss, at a minimum, the following:
    • The impact of the substance or alcohol use by the mother and any other caregivers in the home on the care and protection of the infant and other children in the home
    • The mother's compliance with medically assisted treatment, if applicable
    • The mother and other caregiver's functioning, including physical health, mental health, life management, relationships, parenting, etc.
    • The health care, developmental, or other needs of the infant and any other children in the home
    • Current formal or informal supports

Responsibility for Development of the Plan of Safe Care
Citation: DCFS Child Welf. Pol. Man., Pol. # 19.27

DFCS, in partnership with other agencies providing services to the family, shall develop and implement a POSC for families with infants identified as being affected by substance abuse (illegal or legal) or withdrawal symptoms resulting from prenatal drug exposure, or FASD.

The POSC incorporates into one document the plans from various agencies providing services to the family, such as the child welfare assessment, hospital discharge plan, substance use treatment case plan, and prenatal care plan to address the medical, behavioral, developmental, social, and emotional well-being of the family. Coordinated services to the family ensure timely access to a continuum of care, minimize barriers to accessing care, improve infant and maternal outcomes, and facilitate identification of the family's overall needs and engagement in the appropriate services.

The POSC is required when a health-care provider has identified that an infant has been affected by substance abuse, withdrawal symptoms resulting from prenatal drug exposure, or FASD. This identification may occur during any stage of DFCS involvement, including at birth or later during the infant's development or as symptoms manifest. DFCS may develop the POSC prior to the birth of an infant if child welfare is providing services due to other children in the home and the family agrees.

Services for the Infant
Citation: DCFS Child Welf. Pol. Man., Pol. # 19.27

A POSC should address the following:

  • The following needs of the infant:
    • Health care, as follows:
      • Identification of a consistent pediatrician or health-care provider
      • Referral to specialty care, as indicated
      • High-risk follow-up care
    • Safety with the caregivers
    • Developmental screening and assessment
    • Linkage to early intervention services
    • Early care and education program
  • The following needs of other children in the home:
    • Identification of a consistent pediatrician or health-care provider
    • Safety with the caregivers
    • Developmental screening and assessment
    • Linkage to early intervention services
    • Early care and education program

Services for the Parents or Other Caregivers
Citation: Admin. Code § 65D-30.0142; DCFS Child Welf. Pol. Man., Pol. # 19.27

Methadone medication-assisted treatment providers shall develop policies and procedures for the treatment of pregnant women, as follows:

  • Prior to the initial dose, each female shall be fully informed of the risks of taking and not taking methadone during pregnancy, including possible adverse effects on the mother or fetus.
  • Pregnant individuals shall be informed of the opportunity and need for prenatal care by referral to publicly or privately funded health-care providers. The provider shall establish a documented system for referring individuals to prenatal care.
  • In the event there are no publicly funded prenatal referral resources to serve those who are indigent, or if the individual refuses the services, the provider shall offer her basic prenatal instruction on maternal, physical, and dietary care as part of its counseling service. The nature of prenatal support shall be documented in the clinical record.
  • When the individual is referred for prenatal services, the practitioner to whom she is referred shall be notified that she is undergoing methadone medication-assisted treatment and provided treatment plans addressing pregnancy and postpartum care.

Pregnant individuals, regardless of age, who have had a documented addiction to opioid drugs in the past and who may be in direct jeopardy of returning to opioid drugs, may be placed in methadone medication-assisted treatment. For such individuals, evidence of current physiological addiction to opioid drugs is not needed if a physician or their qualified designee certifies the pregnancy and, in utilizing reasonable clinical judgment, finds treatment to be medically justified.

In policy: A POSC should address the following:

  • The following needs of the mother:
    • Health care, as follows:
      • Identification by the mother of a consistent and stable primary caregiver
      • Medication management
      • Pain management
      • Breastfeeding, if recommended by the physician
    • Substance use and mental health care, including the following:
      • Timely access
      • Engagement, retention, and recovery supports
      • Appropriate treatment that is gender-specific, family-focused, accessible, and trauma-responsive and may include medication-assisted treatment
      • Treatment for depression, anxiety, or domestic violence, as needed
      • Appropriate assessments and treatment services
    • Parenting or family support
    • Coordinated case management or home visits to assess infant care, parent and infant bonding, nurturing, mother's understanding of the special care needs of the infant(s) and ability to provide such care, parenting guidance and skill development, safe sleep practices, and maternal support
    • Child care
    • Benefits or eligibility determination for employment support, housing, and transportation
    • Supportive network (having relationships and social networks that provide support, friendship, love, and hope)
  • The following needs of other family members:
    • Substance use disorder assessment and treatment
    • Mental health assessment and treatment
    • Pain management
    • Medication management
    • Parenting skills (e.g., bonding, nurturing, understanding of the special care needs of the infant and the ability to provide it, safe sleep practices, etc.)
    • Their ability to meet the care and protection needs of the infant and any other children living in the home 

Monitoring Plans of Safe Care
Citation: Ann. Code § 31-12-2; DCFS Child Welf. Pol. Man., Pol. # 19.27

DPH shall provide an annual report to the President of the Senate, the Speaker of the House of Representatives, the chairperson of the House Committee on Health and Human Services, and the chairperson of the Senate Health and Human Services Committee. The annual report shall include any department findings and recommendations on how to reduce the number of infants born with neonatal abstinence syndrome.

In policy: DCFS will do the following:

  • Follow up with other parties responsible for making referrals to determine if the referrals have been made or initiated, including, but not limited to, the following:
    • Substance use disorder treatment or any other recommendations from the substance use disorder assessment
    • Medical services for the infant, mother, and other household members
    • Referrals for developmental screening and any subsequent services for the infant and other children in the home
  • Engage the parents or caregivers to determine if services have been initiated and are being provided in accordance with the plan 

Ensuring the services identified in the POSC are implemented is critical to assuring the ongoing health and substance abuse needs of the infant and family. The POSC will address actions and services for the infant and family's needs that support the family in achieving long-term recovery. Therefore, the needs must be incorporated into the case plan if the case is transferred to family preservation services or foster care to ensure ongoing monitoring. If the family does not continue child welfare services with DFCS, another individual or agency must be identified to monitor the POSC. This could be the medical provider or other providers already involved with the family and who can obtain information to monitor the plan.

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