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

Definitions

Citation: Child & Family Serv. Man. § C.10

The term 'assessment' refers to an in-depth look at an individual's past and current substance use and the impact of that use on the overall functioning of that individual. Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.

'Fetal alcohol spectrum disorders' (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, or learning disabilities with possible lifelong implications.

'Neonatal abstinence syndrome' (NAS) is a group of problems that occur in a newborn as a result of sudden discontinuation of addictive opioids or other legal or illegal drugs to which the newborn was exposed while in the mother's womb.

Notification/Reporting Requirements

Citation: Ann. Code § 63.2-1509(B)

A report is required when, in his or her professional or official capacity, a reporter has reason to suspect that a child is abused or neglected. For purposes of this section, 'reason to suspect that a child is abused or neglected' shall, due to the special medical needs of infants affected by substance exposure, include the following:

• A finding made by a health-care provider within 6 weeks of the birth of a child that the child was born affected by substance abuse or experiencing withdrawal symptoms resulting from in utero drug exposure
• A diagnosis made by a health-care provider within 4 years following a child's birth that the child has an illness, disease, or condition that, to a reasonable degree of medical certainty, is attributable to maternal abuse of a controlled substance during pregnancy
• A diagnosis made by a health-care provider within 4 years following a child's birth that the child has a fetal alcohol spectrum disorder attributable to in utero exposure to alcohol

When 'reason to suspect' is based upon this subsection, that fact shall be included in the report along with the facts relied upon by the person making the report. Such reports shall not constitute a per se finding of child abuse or neglect. If a health-care provider in a licensed hospital makes any finding or diagnosis as described above, the hospital shall require the development of a written discharge plan under protocols established by the hospital, pursuant to § 32.1-127(B)(6).

Assessment of the Infant and Family

Citation: Ann. Code § 63.2-1506; Child & Family Serv. Man. § C.10

A family assessment requires the collection of information necessary to determine the following:

• The immediate safety needs of the child
• The protective and rehabilitative services needs of the child and family that will deter abuse or neglect
• Risk of future harm to the child
• Whether the mother of a child who was exposed in utero to a controlled substance sought substance abuse counseling or treatment prior to the child's birth
• Alternative plans for the child's safety if protective and rehabilitative services are indicated and the family is unable or unwilling to participate in services

If a report or complaint is based upon one of the factors specified in § 63.2-1509(B), the local Department of Social Services (LDSS) shall (a) conduct a family assessment, unless an investigation is required pursuant to this subsection or other provision of law or is necessary to protect the safety of the child, and (b) develop a plan of safe care in accordance with Federal law, regardless of whether the local department makes a finding of abuse or neglect.

In policy: An essential part of the initial safety assessment is to complete a brief substance use screening to determine if a substance abuse assessment is needed and if so, what services would best meet the needs of the mother. A substance use screening should include questions concerning the following:

• Frequency and amount of alcohol consumption prior to and during pregnancy
• Frequency and amounts of over-the-counter prescriptions and legal or illegal substances prior to and during pregnancy
• Effects of substance use on life areas such as relationships, employment, legal, etc.
• Other parent or partner substance use
• Previous referrals for substance abuse evaluation or treatment
• Previous substance use treatment or efforts to seek treatment.

In addition, conditions or behaviors that may indicate risk of harm should be assessed, including, but not limited to, the following:

• Medical and/or physical problems in the infant
• Medical monitoring and/or special equipment or medications needed by the infant
• Lack of prenatal care or inconsistent prenatal care
• Previous delivery of an SEI
• Prior CPS history
• Prior removal of other children by the courts or voluntary placement with relatives
• Lack of preparations for the care of the infant
• Intellectual limitations that may impair the mother's ability to care for the child
• Psychiatric illness
• Home environment that presents safety or health hazards
• Evidence of financial instability
• Limited or no family support
• The age or immaturity of the parent(s)
• Parenting skills demonstrated in the health-care setting that suggest a lack of responsiveness to the SEI's needs (e.g., little or no response to infant's crying, poor eye contact, resistance to or difficulties in providing care)
• Domestic violence

Collateral involvement to determine risk and possible services is crucial and may include contacts with the immediate or extended family, birthing hospital, pediatrician, and substance use disorder evaluation and treatment providers. At the minimum, contact should be made with health-care providers, particularly those at the birthing hospital, in order to obtain a copy of the discharge plan and gather the following information:

• To identify how the infant was affected by in utero substance exposure, including results of laboratory tests or toxicology studies done on the infant
• To identify any needed medical treatment for the child or mother
• To assess the mother's attitude and behavior with the infant
• To determine the expected discharge dates of the mother and infant
• To determine whether there are other children in the home at risk

Responsibility for Development of the Plan of Safe Care

Citation: Ann. Code § 32.1-127; Child & Family Serv. Man. § C.10

The regulations regarding the licensure of hospitals require that each licensed hospital develop and implement a protocol requiring written discharge plans for identified, substance-abusing, postpartum women and their infants. The protocol shall require that the discharge plan be discussed with the patient and that appropriate referrals for the mother and the infant be made and documented. The discharge planning process shall involve, to the extent possible, the father of the infant and any members of the patient's extended family who may participate in the follow-up care for the mother and the infant. Immediately upon identification of any substance-abusing, postpartum woman, the hospital shall notify, subject to Federal law restrictions, the community services board (CSB) of the jurisdiction in which the woman resides to appoint a discharge plan manager. The CSB shall implement and manage the discharge plan.

In policy: The plan of safe care (POSC) should address the needs of the child as well as those of the parent, as appropriate, and ensure that appropriate services are provided to ensure the infant's safety. A POSC should begin when the mother is pregnant and be initiated by her health-care providers. Once the local department of social services (LDSS) becomes involved in a substance-exposed infant (SEI) referral, the LDSS becomes a part of this POSC. The LDSS is one of many agencies that can provide a POSC for the SEI and the mother.

A POSC should incorporate the mother's (and potentially the other primary caregivers) need for treatment for substance use and mental disorders, appropriate care for the infant who may be experiencing neurodevelopmental or physical effects or withdrawal symptoms from prenatal substance exposure, and services and supports that strengthen the parents' capacity to nurture and care for the infant and to ensure the infant's continued safety and well-being.

The LDSS must complete an initial safety assessment of the SEI and family. All reports involving a SEI will require a safety plan be developed because of the safety concerns regarding these infants. A safety plan is not the same as a POSC but is considered one critical component of the POSC. A safety plan addresses immediate safety concerns and needs, while the POSC addresses both short- and long-term needs.

Services for the Infant

Citation: Ann. Code § 32.1-127; Child & Family Serv. Man. § C.10

Appropriate referrals may include, but need not be limited to, comprehensive early intervention services for infants and toddlers with disabilities and their families.

In policy: The hospital discharge plans should include, but are not limited to, the following:

• A follow-up appointment for pediatric care for the infant within 2-4 weeks
• A referral to early intervention services for a developmental assessment and early intervention services for the infant

Regardless if a CPS on-going case is opened for services, the LDSS shall refer for early prevention services any child under the age 3 who is identified as affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.

Services for the Parents or Other Caregivers

Citation: Ann. Code § 32.1-127; Child & Family Serv. Man. § C.10

Appropriate referrals may include, but need not be limited to, treatment services and family-oriented prevention services.

In policy: Postpartum women with substance use disorders and their newborns may have multiple health care, treatment, safety, and environmental needs. Their hospital discharge plans should include, but are not limited to, the following:

• A referral of the mother to the local CSB for a substance use assessment and implementation of the discharge plan.
• Information and medical directives regarding potential postpartum complications and, as appropriate, indicators of substance use withdrawal and postpartum depression
• A follow-up appointment for the mother for postpartum gynecological care and family planning

In addition to substance abuse services, other services may include, but are not limited to, the following:

• Child care
• Relapse prevention
• Parenting education
• Job skills training/employment
• Mental health assistance
• Safe housing
• Support systems

Home visiting services match parents and caregivers with trained paraprofessionals who can provide information and support during pregnancy and throughout the child's earliest years. Home visiting programs support healthy prenatal behaviors and parenting attitudes, engage infants in meaningful learning activities, build positive parent-child relationships, and promote family self-sufficiency. Project Link is one home visiting program offered in Virginia and is specifically for pregnant and parenting substance-using women.

Monitoring Plans of Safe Care

Citation: Child & Family Serv. Man. § C.10

The plan also should ensure a process for continued monitoring of the family and accountability of responsible agencies, such as substance use disorder treatment, home visiting, public health, and health-care providers for the infant and mother.