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A Closer Look: Q&A with Laura Denton

Laura DentonLaura Denton is a program evaluator for AIA grantee, Great Starts, a program of Child & Family Tennessee (CFT) that provides comprehensive mental health and addiction treatment for pregnant and postpartum women who reside in eastern Tennessee.  She talked with us about treatment and child welfare efforts to support families impacted by prenatal opioid use in East Tennessee and an intensive outpatient program beginning soon at the local hospital.

What are the current problems related to prenatal opioid use in your region?

Prenatal opioid use is an overwhelming problem necessitating an immediate and thorough response from all involved parties, including child welfare, medical providers and treatment providers. In Tennessee, an estimated 65% of substantiated child abuse and neglect cases involve alcohol and other drug use by caregivers, and 31% of these parents are poly-substance abusers. Tennessee’s rate of  prescription drug abuse has drastically increased, with opioids being the most abused prescription drug. In 2011, 1,062 deaths were due to prescription overdoses; an increase from 422 in 2001.

The increase in prescription drug use has made Neonatal Abstinence Syndrome (NAS) increasingly prevalent. Tennessee data shows NAS increased by 98% statewide from 2008 to 2011, an alarming 63% (319) were East Tennessee babies. Almost one-third of these (128) were born in Knox County. According to our partner, Tennessee’s Department of Children’s Services (DCS), 1 in every 5 NAS babies end up in child welfare’s custody. DCS officials state NAS is the major reason Tennessee has increased child welfare placements by 33% over the last 5 years. Maternal opioid use has increased 4.7 fold.

What is the treatment and services trajectory at East Tennessee Children’s Hospital (ETCH) for a delivering mother who used opioids while pregnant?

Mothers and babies with prenatal opioid exposure face long-term involvement with both the medical and child welfare systems. Shortly after birth, babies are assessed using the standard Finnegan Neonatal Abstinence Scale. Babies who present with NAS are referred to East Tennessee Children’s Hospital (ETCH) and subsequently placed within the specialized Neonatal Intensive Care Unit (NICU), where they will receive round-the-clock care as they withdraw from the drugs in their system.  Locally, when an infant is admitted for NAS, the hospital social worker is notified. The social worker refers 100% of the families to Department of Children’s Services (DCS). DCS has a special drug exposed infant team who looks at the information and places the family into a referral system. Families are generally seen by DCS within 72 hours. The social worker also simultaneously refers the family to the treatment services with Child & Family Tennessee (CFT). The goal is to get the family in for an assessment as soon as possible, but always within a week.

Once the family is referred to both treatment and child welfare, these systems communicate and collaborate at least weekly until child welfare closes the case and until the family finishes treatment. The infant spends anywhere from a few weeks to a few months in the NICU and can accompany the mother to treatment if the infant is released before the mother finishes her treatment.

What are the goals of the Intensive Outpatient Program at East Tennessee Children’s Hospital (ETCH), and what are the lessons you are learning in this initial implementation phase of the program?

As with any Intensive Outpatient Program (IOP), the primary goal is the treatment of substance abuse and/or co-occurring issues. This treatment will optimally lead to decreased substance abuse, decreased risk of child abuse and neglect and increased family functioning. For the IOP co-located at ETCH, the goals include: 1) preparing mothers to bond with and parent their children who have been diagnosed with NAS; and 2) children with NAS exit the hospital in the care of their parents and do not enter foster care. It is the goal of CFT that the entire family would be treated while children recover in the NAS NICU.

Currently CFT  is awaiting final approval to begin services; however, much has been learned through the start-up phase. A primary lesson is that education around NAS and parents struggling with addiction is needed in all disciplines. Additional lessons include:

• the need for streamlined communication across disciplines to provide wrap-around services for the families;
• the ongoing need for a shared goal and collaboration across disciplines;
• the important role of secondary trauma within the social service and medical workforce and how that impacts services and collaboration;
• the need for education to help medical staff understand the substance abuse and mental health treatment needs of the mothers;
• an understanding that social service staff and child welfare staff may not understand the medical needs of children with NAS; and
• data sharing is and will continue to be key in developing data sets sufficient for analysis of impact and for improving practice. Data sharing agreements are currently in the works between CFT and ETCH.

What are the reasons for a new program specific for mothers with children diagnosed with NAS?

In 1990, CFT saw an issue with parents having to choose between substance abuse treatment and their children. In response, CFT applied for and was awarded AIA funding for Great Starts, an Intensive Outpatient Program coupled with supported housing and on-site daycare for mothers and their children. The Intensive Outpatient Program at ETCH came about in 2013 to meet an overwhelming need for substance abuse treatment that also facilitates parental bonding with their children who are in ETCH’s NICU for babies with NAS. CFT and ETCH developed the idea for this new program through multiple conversations regarding community need for our shared clients. We believe in meeting clients where they are. In this case, that means ensuring parents do not have to leave their children for an extended amount of time while they travel to and from treatment. The partnership between CFT and ETCH looks to integrate necessary on-site substance abuse treatment with weekly parenting classes specific to parenting babies, and subsequently children, with NAS.

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