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

Definitions

Citation: CPS Assessments Policy, Protocol, and Guidance

A 'substance-affected infant' is an infant that meets one of the following definitions:

• Affected by substance abuse: The 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 behavioral health assessment indicative of an active substance use disorder, during the pregnancy or at time of birth.
• Affected by withdrawal symptoms: The infant manifests clinically relevant drug or alcohol withdrawal.
• Affected by fetal alcohol spectrum disorder (FASD): The infant is diagnosed with one of the following:
  • Fetal alcohol syndrome (FAS)
  • Partial FAS (PFAS)
  • Neurobehavioral disorder associated with prenatal alcohol exposure (NDPAE)
  • Alcohol-related birth defects (ARBD)
  • Alcohol-related neurodevelopmental disorder (ARND)
• The infant has known prenatal alcohol exposure when there are clinical concerns for the infant per current evaluation and management standards.

Notification/Reporting Requirements

Citation: CPS Assessments Policy, Protocol, and Guidance

The Child Abuse Prevention and Treatment Act (CAPTA) and the Comprehensive Addiction and Recovery Act of 2016 (CARA) require States to have policies and procedures in place to do the following:

• Require health-care providers involved in the delivery and care of infants born with and identified as being affected by substance abuse (not just abuse of illegal substances as was the requirement prior to this change), withdrawal symptoms resulting from prenatal substance exposure, or to notify child protective services (CPS) of the occurrence
• Ensure the safety and well-being of such infants following their release from the care of health-care providers by developing a plan of safe care (POSC) that addresses the health and substance use disorder treatment needs of both the infant and affected family or caregiver

As specified in CAPTA, the notification is to ensure that services are provided to the infant and caregiver, but it does not establish a definition under Federal law of what constitutes child abuse or neglect. Furthermore, the requirement for notification should not be construed to mean that prenatal substance use is intrinsically considered child maltreatment. Therefore, while the notification is required, not every report about a substance-affected infant will result in a CPS assessment.

Assessment of the Infant and Family

Citation: CPS Assessments Policy, Protocol, and Guidance

During the screening process, a child welfare agency may share confidential information with public and private agencies that are providing or facilitating protective services. In order to comply with confidentiality laws and to ensure that a POSC can be created for every infant, it is important that a referral be made to the Care Coordination for Children (CC4C) agency during the screening of the report and prior to making a determination to screen in or screen out the report. The timing of the referral is critical because confidentiality laws will prohibit a child welfare agency from making the referral to CC4C if the report has already been screened out and child protective services are no longer being provided.

A report that only alleges that an infant was exposed to substances prior to birth does not intrinsically meet the statutory definition of child abuse, neglect, or dependency. To determine whether a report about a substance-affected infant should be accepted, the child welfare agency must examine the effect that the substance exposure has had on the infant and the infant's health and safety. Only reports that meet the statutory definition of child abuse, neglect, or dependency can be accepted.

The county welfare child agency must refer to the Substance-Affected Infant Screening Tool to screen for allegations of child maltreatment. Reports of child maltreatment of substance-affected infants must be accepted and a CPS assessment initiated when the information gathered is consistent with any of the following:

• The infant has received one of the following diagnoses: FAS, PFAS, NDPAE, ARBD, or ARND.
• The infant had a positive drug toxicology or is experiencing withdrawal symptoms. However, if it is known that the drug is a medication prescribed to the mother and is being used appropriately, then the report should not be accepted on that basis alone. This includes medications prescribed for the treatment of opioid use disorders.
• The mother had a positive drug toxicology at the time of infant's birth and she is demonstrating behaviors that impact her ability to provide care to the infant.
• The mother had a medical evaluation or behavioral health assessment that is indicative of an active substance use disorder at the time of the infant's birth and she is demonstrating behaviors that impact her ability to provide care to the infant.
• The mother had a positive drug toxicology at the time of the infant's birth and a review of county child welfare agency history revealed a pattern of substantiations or findings of services needed or a particularly egregious finding that correlates with the allegations.
• The mother had a medical evaluation or behavioral health assessment that is indicative of an active substance use disorder at the time of the infant's birth, and a review of county child welfare agency history revealed a pattern of substantiations or findings of services needed or a particularly egregious finding that correlates with the allegations.

A mother's prescribed and appropriate use of medications should not be coupled with county child welfare agency history to justify the acceptance of a report.

Responsibility for Development of the Plan of Safe Care

Citation: CPS Assessments Policy, Protocol, and Guidance

CAPTA requires that every infant 'born with and identified as being affected by substance abuse, withdrawal symptoms resulting from prenatal drug exposure, or FASD has a plan ensuring his/her safety following the release from the care of health-care providers. A POSC is required for all substance-affected infants regardless of whether the circumstances constitute child maltreatment. Therefore, a county child welfare agency must develop a POSC for each infant that is the subject of a substance-affected infant report. To develop the POSC, the county child welfare agency must complete a CC4C referral form that includes a POSC. It must submit the referral to the local CC4C program.

The components of the POSC should reflect and address the needs of both the infant and the affected family or caregiver through the services available with CC4C. CC4C will work with the family on a voluntary basis to implement the POSC.

Services for the Infant

Citation: CPS Assessments Policy, Protocol, and Guidance

Due to the increased risk associated with sleep-related infant death for substance-affected infants, the child welfare worker must encourage the family to arrange for safe and separate sleeping arrangements for the infant. This must be documented in the case record.

Part C of the Individuals with Disabilities Education Act (IDEA) requires that a child under age 3 who is identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure be referred for early intervention services. In North Carolina, children who are identified as substance-affected infants must be screened for referral to the North Carolina Infant Toddler Program through the local Children's Developmental Services Agency for early intervention services.

Services for the Parents or Other Caregivers

Citation: CPS Assessments Policy, Protocol, and Guidance

While the safety agreement and POSC are not intended to be duplicative interventions, they will likely address many of the same processes and issues. The major difference, however, is that the POSC should go beyond immediate safety factors to address the affected caregiver's need for substance use and/or mental health treatment and the health and developmental needs of the affected infant. Additionally, it should identify the services and supports the caregiver needs to strengthen his or her capacity to nurture and care for the infant. CC4C will implement the Plan of Safe Care with the family on a voluntary basis. However, that does not negate the role the child welfare worker has in supporting the family, while also assessing risk and safety.

All components of the POSC may not have been met at the time of case decision; however, the child welfare worker should have assisted the family in addressing the identified needs, with emphasis on those connected to the infant's safety and well-being. Should the case require CPS in-home services or child placement services, family service agreements must reflect components of the POSC if they remain relevant to child safety and well-being.

Monitoring Plans of Safe Care

Citation: CPS Assessments Policy, Protocol, and Guidance

The amended provisions of CAPTA also require that States report additional information through 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.