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

Definitions
Citation: CW Pol. Man. Res., Substance-Affected Infant

In policy: The term 'substance-affected infant' (SAI) applies to any of the following conditions:

• An infant has a positive urine, meconium, or cord segment drug screen with confirmatory testing in the context of other clinical concerns as identified by current evaluation and management standards.
• The infant's mother has had a medical evaluation, including history and physical, or a behavioral health assessment indicative of an active substance use disorder during the pregnancy or at the time of birth.
• An infant manifests clinically relevant drug or alcohol withdrawal.
• An infant is affected by fetal alcohol spectrum disorder (FASD) with a diagnosis of fetal alcohol syndrome (FAS), partial FAS, a neurobehavioral disorder associated with prenatal alcohol exposure (NDPAE), alcohol-related birth defects, or alcohol-related neurodevelopmental disorder.
• An infant has known prenatal alcohol exposure when there are clinical concerns for the infant per current evaluation and management standards.

'Nighttime parenting' is a more appropriate term for what was once referred to as Safe Sleep. It acknowledges that there are differences in parenting at night and requires intentional actions by a parent to ensure safety during that time.

Notification/Reporting Requirements
Citation: CW Pol. Man. Res., Substance-Affected Infant

The Child Abuse Prevention and Treatment Act (CAPTA) and the Comprehensive Addiction and Recovery Act of 2016 require health-care providers to notify child protective services (CPS) of all SAIs. The notification itself is not an allegation of maltreatment and requires the assigned intake worker to complete a thorough screening to determine whether the notice meets the definition of abuse, neglect, and/or dependency.

Assessment of the Infant and Family
Citation: CW Pol. Man. Res., Substance-Affected Infant; DSS-1402

During CPS intake activities, the DSS-1402 is completed for all notifications and includes questions that are specific to an SAI. The intake worker may need to support the healthcare provider in making the decision about the information that the healthcare provider can share. However, if this is a notification of an SAI, the intake worker is still required to obtain as much information as possible in the completion of the intake form (DSS-1402). Basic demographic information is captured about the alleged victim child or infant. In instances where an infant is identified as an SAI, additional information should be gathered to assist the assessment worker in addressing safety for the SAI, the parents, and other caregivers. Asking a question about the discharge date of the infant from the health-care facility directly impacts the assessment of safety because remaining in the hospital is a safety measure.

From the DSS-1402 instructions: When assessing an SAI, the intake worker must ask the following questions:

• Has the infant been identified as substance-affected by the health-care provider involved in their delivery or care?
• Did the infant have a positive drug toxicology? If yes, for what substances?
• Is the infant experiencing drug or alcohol withdrawal symptoms? What is the present physical condition of the infant?
• Is the infant's exposure to substances related to the mother's prescribed and appropriate use of medications? If yes, what is the medication and what condition is it treating? Have you verified with the prescribing provider?
• Has the infant been diagnosed with FAS, Partial FAS, NDPAE, or an alcohol-related birth defect?
• Did the mother have a positive drug or alcohol toxicology screen during the pregnancy or at the time of the birth? Was there a medical evaluation or behavioral health assessment that indicated she had an active substance use disorder during the pregnancy or at the time of birth?
• Is the substance use having an impact on the mother's ability to care for the infant? If so, what behaviors have you seen that demonstrate this?
• What is the attitude of the mother or other caregivers toward the infant?
• Are you aware of the family having any history that indicates there is an unresolved substance use disorder related to a prior case of child abuse and neglect?
• If the infant is in the hospital, when are they scheduled to be released?
• Based on what you know about the infant and family, would they benefit from any of the following services: evidence-based parenting programs, mental health treatment, home visiting programs, housing resources, food resources, transportation assistance, referral to child care resources, or other? 

A CPS report in which the only allegation is prenatal substance use does not in itself meet the statutory criteria for child abuse, neglect, or dependency. It is the effect that the substance use has had on the infant and the infant's safety that guides decision-making rather than purely the prenatal use of the substance. Agency intervention without such justification is inappropriate.

Responsibility for Development of the Plan of Safe Care
Citation: CW Pol. Man. Res., Substance-Affected Infant; DSS-1402

When a report is accepted and the infant (0–6 months) is diagnosed by a medical provider as being an SAI, a plan of safe care (POSC) must be developed prior to the infant being discharged from the hospital. Safety planning must include a needs assessment of the SAI, the parents or caregiver, and other members of the family, including any siblings in the home, and how all identified needs will be addressed.

Open and transparent discussions must be held about any substance use disorder or mental health diagnoses, both past and present. Asking for this information is not to be punitive but to help create a plan that will keep the child safe. Talking with the family about any history of mental health or parental or family substance use disorder can help connect the family and child welfare with providers familiar to the family. These discussions with the parents and caregivers of the child/children must include the following:

• Discussions about how parents access illegal substances, how often and under what circumstances they use substances, and known triggers
• Discussions about stressors, including having a new baby in the home, lack of sleep, financial challenges, stress on relationships, etc., and how these are impacted by substance use
• Plans for keeping the child or children safe knowing that the mother has recently used illegal substances
• Discussions about the significant risk of death for these children due to rollover deaths must be addressed in the POSC, which is discussed below
• Discussions about safe sleep 

The POSC must be developed with the parent(s) and family and include any needs for all members of the household. Ensuring that the parent(s) understand that the plan as written should also include the parent's signature on the plan that indicates their understanding and agreement. The POSC is separate from the completion of the safety assessment but can assist in the development of the family's safety plan.

From the DSS-1402 instructions: The child welfare agency must develop a POSC using only the information learned at intake and refer the infant to the county Care Coordination for Children (CC4C) program prior to making a screening decision. The county child welfare agency must not share any information protected by Federal regulations.

Services for the Infant
Citation: CW Pol. Man. Res., Substance-Affected Infant

The infant safety plan or POSC should clearly identify and document the parent/caregiver(s) response regarding the following: 

• Nighttime parenting (also known as safe sleep):
  • Have the parent explain the efforts they will take to ensure safe nighttime parenting
  • Ensure that resources for nighttime parenting are provided and parent(s) understanding of nighttime parenting
• Follow-up medical care in partnership with the healthcare provider:
  • Discuss with the parent(s) the current and future medical needs of the infant
  • Document upcoming appointments, the plans for referrals, and parental understanding of the information presented
• Basic needs:
  • Assess the basic needs of the infant within the home, such as housing, food, crib, and diapers
  • Identify basic needs that are lacking and document plans for meeting those needs
• Address any additional needs that are specific to the infant

Services for the Parents or Other Caregivers
Citation: CW Pol. Man. Res., Substance-Affected Infant

Infant safety is tied to parental behavior. Substance use causes impairments in judgment and behavioral changes that can create increased risk to the infant. Talking with the parent(s) about their safety plan and the risks to their child should they return to using substances posthospitalization is meant to be preventive, not punitive. Elements of a parental safety plan must include the following: 

• A plan that addresses infant safety in the event of a parent returning to active substance abuse, including the following elements:
  • Names, phone numbers, and addresses of safe people who will keep the child safe if the parent engages in substances
  • The location of the bag of supplies that is ready for the child if someone needs to come and get the child that includes food or formula, diapers, extra clothing, medications, and the pediatrician's number
• A parent-recovery support plan that may include the following:
  • An identified support person who agrees to check on the parent regularly and agrees to protect the child(ren) if necessary
  • Attendance at recovery support groups
  • A list of community resources to support having basic needs met
  • An identified list of people who are not allowed in the home when the child(ren) are present
  • A list of reasons to remain abstinent and in recovery
  • A list of mental health, substance use disorder, and physical health resources available in the community
• Completion of a mental health and substance use disorder assessment and engagement in recommended services
• Information on how to access harm reduction programs and naloxone in their community
• Engagement with mental health and substance use disorder providers for an assessment or treatment recommendations that include safety for the child(ren)
• Parent medical care: Referral to a medical home or postnatal care plan that the parent(s) will use
• Any other needs that are specific to the parent's ability to ensure the safety of the child(ren)

Monitoring Plans of Safe Care
Citation: CW Pol. Man. Res., Substance-Affected Infant

When there are continued safety concerns, and a case decision is made to send a family to in-home services or foster care, the POSC becomes a central part of the foundation for the initial family services agreement (FSA). The plan should consist of behaviorally specific objectives and goals for the parent or caregivers to address to keep their child or children safe. The plan moves past the incident and into future safety for the child or children. The child welfare worker should include those components of the POSC that allow a parent to demonstrate improvements in the safety of the child(ren). Documentation of work with the parents may be included in the FSA or any other documentation tool the county child welfare agency has developed if all the elements in the safety plan are included.

The amended provisions of CAPTA also require that States report additional information through the National Child Abuse and Neglect Data System (NCANDS) and that States develop monitoring systems to ensure that appropriate referrals and services are being provided through the implementation of POSCs.

The following must be reported to NCANDS: 

• The number of infants identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or FASD
• The number of such infants for whom a POSC was developed
• The number of such infants for whom a referral was made for appropriate services, including services for the affected family or caregiver 

County child welfare agencies must collect the following data: 

• The number of substance-affected infants for which the agency received notification from a health-care provider
• The number of infants and families for whom the agency developed a POSC
• The number of infants the agency referred to the CC4C for appropriate services
• The number of those infants who were accepted for CPS assessment
• The number of those infants who were not accepted for CPS assessment 

The North Carolina Division of Social Services will collect this data monthly. An interagency collaborative will meet quarterly to review the data collected by DSS and CC4C, determine gaps and needs, develop a plan of intervention, and provide technical assistance at the local level.