Introduction. Background

Transcription

1 Introduction The Orange County Substance Exposed Babies Report, , on substance use by pregnant women in Orange County found that 15% of all babies were exposed to alcohol, tobacco, and/or other drugs before birth. Alcohol was the most common substance used during pregnancy (12.9%), followed by tobacco (4.9%), and illicit drugs (3.5%). These rates are higher than the Healthy People 2010 objectives to reduce alcohol use to 6%, reduce pregnant women's use of cigarettes to 2%, and eliminate all illicit drug use (0%). These new results correspond to approximately 6,800 substance exposed babies born each year in Orange County, the majority of whom are not detected by current screening and treatment efforts needlessly placing them at risk for potential physical, developmental, cognitive, and behavioral disabilities. For more details please see This special section describes how substance exposure of the fetus affects development of a child, the economic costs of substance exposed babies, the risk factors associated with prenatal substance use in Orange County, and the profile of women with the highest prevalence rates of alcohol, tobacco, and illicit drug use. In addition, the status of the child welfare system in the county with respect to substance abuse and current prevention and screening strategies is presented. Finally, a discussion of promising practices and recommendations to better address the issues for substance exposed babies in Orange County is offered. Background Maternal use of alcohol, tobacco, and/or other drugs (ATOD) during pregnancy increases a baby s risk for developmental, physical, behavioral, and social disabilities due to their deleterious effects on the developing fetus. The impacts of substance exposure on a child are both short-term and long-term. The table on the right describes the potential impacts of substance exposure from birth to 18 years of age across the domains of birth/health outcomes; language/cognition/education; safety/criminal justice; and social/economic impact. In addition to the developmental impact of substance exposed babies, there are substantial economic costs incurred by public and private entities. Economic Costs of Substance Exposed Babies Potential outcomes for the newborns exposed to substances include a lifetime of challenges requiring public support. Starting at birth, babies born to substance using women cost more due to longer hospital stays and greater utilization of intensive care units, compared to babies not exposed. 2 The most recent research available on the cost estimates of substance exposed babies dates back to 1992, estimating that the cost of treating fetal alcohol syndrome-affected babies, children, and adults was over $1.9 billion annually. 3 The lifetime cost of treating a child affected with fetal alcohol syndrome is estimated to be $1.4 million. 4 The U.S. General Accounting Office reported that in 1987, the estimated long-term service costs for medical care, special education, and other related social services over the first 18 years of an exposed baby s life was as high as $750, An American College of Obstetricians and Gynecologists committee opinion notes that treatment is both more effective and less expensive than restrictive policies and it results in savings for medical expenses per mother/infant pair. 22 Report on the Conditions of Children in Orange County, 2008

2 Potential Impacts of Substance Exposure on a Child Domain 0-5 Years of Age 6-12 Years of Age Years of Age Birth Outcome/Health Intrauterine growth retardation, low birth weight and prematurity Placental abruptions, fetal death, stillbirth, Sudden Infant Death Syndrome Addiction withdrawal symptoms Increased muscle tremor, rigidity and excitability Increased risk for major birth defects Decreased head circumference Increased impulsivity Increased hyperactivity Asthma, wheezing, and other respiratory problems Decreased head circumference and brain volume Reduced cortical grey matter Increased impulsivity Increased hyperactivity Asthma, wheezing, and other respiratory problems Decreased head circumference and brain volume Reduced cortical grey matter Language/Cognition/Education Delayed babbling Impaired language development Mental retardation Neurobehavioral disorders Significant deficits in reading, spelling, and arithmetic Reduced intelligence scores Impaired reading comprehension Speech and language problems requiring special education Psychological disorders Increased impulsivity Visio-spatial skill deficits Underachievement Working memory deficits Decreased general intelligence Psychological disorders Lower reading scores Decreased attentiveness Externalizing problems Difficulties with independent living Safety/Criminal Justice Increased risk of abuse/neglect due to parental substance use Increased delinquency Increased risk of future alcohol, tobacco, and other drug dependence Increased delinquency Increased risk of future alcohol, tobacco, and other drug dependence Social/Economic Impact Difficulty forming secure attachments to their caregivers Parents impaired functioning due to substance use problems Healthcare costs Lifetime costs ($1.4 million per child with Fetal Alcohol Syndrome) Poor self-esteem Difficulty developing positive peer relationships Increased risk of substance use Costs associated with foster care Mental health issues such as suicide attempts and Post Traumatic Stress Disorder Occupational difficulties Alcohol and drug use are the largest burdens of disease in terms of productive life lost (premature death & disease; see pages ) Additional impacts on babies exposed to substances include stillbirths, premature babies, low-birth weight, birth defects, and disabilities. Details are discussed in the following paragraphs. Stillbirths When fetal death occurs after 20 weeks of pregnancy and before delivery, it is called stillbirth. These tragic deaths occur in about 1 in 200 pregnancies. Recently, a large study of more than 650,000 pregnancies found that women who drank alcohol increased risk of a stillbirth during their pregnancy. Overall, the risk of stillbirth was 40% higher among drinking women compared to nondrinkers. Moreover, the risk of early fetal death was even higher (80%) among women who drank alcohol compared to women who did not drink. 6 Premature Babies A premature baby is born before the 37th week of pregnancy. Premature birth occurs in 8% to 10% of all pregnancies in the United States. 7 Previous research, as well as a study completed last year in Orange County, has shown that women who use substances are more likely to have premature babies. Pregnant women in Orange County who used substances were almost five times more likely to have babies born prematurely and four times more likely to have a baby born with low birth weight. Pre-term babies are twice as likely as full-term babies to exhibit birth defects. This relationship is even stronger for earlier preterm infants. 8 Report on the Conditions of Children in Orange County,

3 Birth Defects and Disabilities Alcohol consumption during pregnancy can lead to birth defects and childhood disabilities; however, addressing alcohol consumption during pregnancy makes this a completely preventable issue. 9 The adverse effects associated with fetal alcohol syndrome include growth deficiency, brain structure and functional anomalies, and abnormalities of the head and face. 10 Research has also shown that the physical effects of substance use on developing brain structure can last well into adolescence, if not beyond. These results are even more severe when the child was exposed to more than one substance in utero. 11 Clearly, prenatal exposure to substances due to maternal use of alcohol, tobacco, and/or other drugs can have a long-term impact on a child s health and wellbeing. Alcohol, tobacco, and/or other drug use during pregnancy may adversely affect fetal development with impacts that can challenge a child throughout their lifespan. The parents of infants exposed in utero to drugs or alcohol also may be functioning at an impaired level due to ongoing drug or alcohol addiction and related psychosocial problems. This can lead to instability in the areas of employment, housing, money management, and family relationships. All of these factors compound the challenge of meeting the special care needs of drug and/or alcohol exposed children and place the child at greater risk for potential abuse or neglect. Risk Factors Associated with Substance Use During Pregnancy In the 2007 Orange County Substance Exposed Babies Report, risk factor profiles of Orange County women who used substances while pregnant were compared to profiles of non-using women. 12 Compared with non-users, women who used alcohol, tobacco, and/or other drugs while pregnant were more likely to have initiated prenatal care later or did not receive prenatal care. Moreover, substance users were: 3 times more likely to have a close family member with a substance problem; Almost 8 times more likely to be exposed to secondhand smoke; 2 times more like to experience high stress during pregnancy; Almost 5 times more likely to have a baby born prematurely; and, 4 times more likely to have a baby born with lower birth weight. This information can be used by prenatal care providers to help identify those women most at risk during their pregnancy and improve prevention and screening efforts. 24 Report on the Conditions of Children in Orange County, 2008 Prevalence of Alcohol, Tobacco, and/or Other Drug Use During Pregnancy in Orange County The results of a 1992 statewide study by Vega and colleagues found that 7.5% of Orange County women tested positive for alcohol or drugs at the time of labor and delivery. 13 As a result, a variety of interventions to support the reduction of substance use by pregnant women were initiated. In April to July 2007, the Orange County Health Care Agency, in collaboration with medical, health, and social service agencies throughout the county, conducted a twophased, multi-method assessment of prenatal substance use. The goal of this study was to provide an up-to-date estimate of the prevalence of substance exposed babies in the county. Nearly 2,600 pregnant women participated in the anonymous assessment, which included urinalysis of women giving birth at participating hospitals and self-report surveys completed by women during a prenatal visit with their obstetrician. The participants were representative of all women giving birth and totaled about 15% of all births that occurred countywide during the study period. All Substances The prevalence of substance use before and during different prenatal periods was based on self-reported use. As shown in the chart below, the countywide prevalence rate of women who reportedly used at least one substance (alcohol, tobacco, and/or other drug) the month before pregnancy was 31.5%. When asked about substance use at any time during pregnancy, the number of women who reported using at least one substance decreased, by half, to 15.1%. Almost 1 in 10 (or 8.9%) indicated that they used a substance in their most recent month of pregnancy. % of Women Self-Reported Prevalence of Alcohol, Tobacco, and Other Drug Use (ATOD) Before Pregnancy 15.1 Anytime During Pregnancy 8.9 Past Month of Pregnancy

4 Self-reported alcohol, tobacco, and/or other drug use at any time during pregnancy within each racial/ethnic group is presented in the figure below. Non-Hispanic White women were found to have the highest substance use prevalence rate; at 22.5%, they were significantly higher than all other groups. This rate was followed by 12.9% of Asian/Pacific Islanders and women in the Other category (13%) using at some time during their pregnancy. Hispanic women had the lowest reported prevalence rate, with 10.3% using substances at some time during pregnancy. Thus, results of the urinalysis portion of the study were used to assess the prevalence of recent illicit drug use among pregnant women in Orange County. Use of illicit drugs during the month before pregnancy was reported by 4.7% of women (see figure below). In contrast, 3.5% of women used illicit drugs at some time during pregnancy (based on 2.4% who had a positive urinalysis at delivery, plus 1.1% who tested negative at delivery but reported using at some time during pregnancy). 25 Self-Reported ATOD Use Prevalence Anytime During Pregnancy by Race/Ethnicity 22.5 Prevalence of Illicit Drug Use based on Self-Report and Urinalysis at Different Times During Pregnancy % of Women % of Women Asian/ Pacific Islander Hispanic Non-Hispanic White Other 0 Self-Report Before Pregnancy Urinalysis & Charted Use Anytime During Pregnancy Urinalysis At Time of Delivery While the self-reported prevalence of alcohol, tobacco, and/or other drug use decreased upon becoming pregnant, a significant percentage of women continued to use alcohol, tobacco, and/or illicit drugs during their pregnancy. Among women who reported using tobacco during the past month of their pregnancy, they averaged 3.24 cigarettes per day. Women who reported drinking alcohol during the past month of their pregnancy averaged 2.52 drinks per month. Illicit Drugs The use of illicit drugs during pregnancy is a well-known contributor to developmental, physical, behavioral, and social disabilities. 14,15,16 There have been numerous studies showing that individuals have a tendency to underreport their use of illicit substances. 17 This reluctance to disclose drug use may be due to perceived negative consequences. 18 Further, research has found that underreporting is most problematic for recent/current drug use. 19 Such under-reporting would result in an artificial drop in the prevalence of illicit drug use when comparing recent (e.g., past month of pregnancy) to distant past use (e.g., early in pregnancy). While only about 1.1% of pregnant women self-reported using illicit drugs during the past month of pregnancy, urinalysis results showed that 2.4% tested positive for illicit drugs at the time of delivery. Therefore, the higher rate of 2.4% was used to estimate past month illicit drug use. It is important to recognize that these results likely underestimate the actual number of babies who have been exposed to substances, especially illicit drugs, during pregnancy. In one study, researchers found that upwards of 75% of individuals who denied using drugs tested positive. 20 Similar results were found in the current urinalysis study, where 83% of women who tested positive for illicit drugs denied using. Type of Drug Used Based on urinalysis, the types of drugs used by mothers included (in order from most commonly to least commonly used): opiates, amphetamines, marijuana, benzodiazapines, barbiturates, methadone, and propoxyphene. No samples were found to be positive for cocaine, PCP, or MDMA (Ectasy). However, detection of specific drugs is influenced by the fact that different substances remain detectable in the urine for different periods of time. Note: Please see page 186 for footnote references. Report on the Conditions of Children in Orange County,

5 Poly-Substance Users Drug Choice Combination Nearly 1 in 5 substance-using mothers (18%) used two or three different substances. Nicotine was the most common substance used by poly-users, and most poly-users had used nicotine and an illicit drug. A small percentage had used two illicit substances. Orange County Regional Use Rates All Substances: The map below identifies the regional distribution of self-reported alcohol, tobacco, and/or other drug use at any time during pregnancy, based on the woman s ZIP code of residence. The western and southern regions of Orange County had the highest rates, 16.9% and 16.6% respectively. The central region had a rate of 14.5% for all substances. The northern region reported the lowest rate of any substance use during pregnancy at 12.1%. The central and northern regions were both lower than the county-wide rate of 15.1%. SUBSTANCE EXPOSED BABIES The table below compares the use of alcohol, tobacco, and/or other drugs by regions. The region with the highest rate of alcohol consumption among pregnant women was the southern region (14.5%). Tobacco use was highest in the western region, at 6.0%, which was higher than the county average of 4.9%. Both the western (4.4%) and southern (3.7%) regions had higher rates of illicit drug use at any time during pregnancy than the overall county rate of 3.5%. Percentage of Women Using Any Substance (Alcohol, Tobacco, and/or Other Drugs) During Pregnancy by Region of Orange County Substance Type Region All Substances Alcohol Tobacco Illicit Drugs North 12.1% 9.9% 5.0% 2.4% West 16.9% 13.8% 6.0% 4.4% Central 14.5% 12.5% 4.3% 3.1% South 16.6% 14.5% 4.6% 3.7% County-Wide 15.1% 12.9% 4.9% 3.5% *All prevalence rates are based on self-reported use except for illicit drug use prevalence, which was based on results from hospital urinalysis/charted use. 26 Report on the Conditions of Children in Orange County, 2008 Note: Please see page 186 for footnote references.

6 Estimated Number of Substance Exposed Babies per Year in Orange County Use at Any Time During Pregnancy Substance Type Prevalence Rate* Minimal # of Estimated Babies All 15.1% 6,800 Alcohol 12.9% 5,800 Tobacco 4.9% 2,200 Illicit Drugs 3.5% 1,600 *All prevalence rates are based on self-reported use except for illicit drug use prevalence, which was based on results from hospital urinalysis/charted use. Estimated Number of Substance Exposed Babies per Year in Orange County In the present study, 15.1% of pregnant women in Orange County reportedly used alcohol, tobacco, and/or other drugs while pregnant. Based on the prevalence rate of 15.1% for substance use at any time during pregnancy, it is estimated that about 6,800 babies annually are exposed to the deleterious effects of alcohol, tobacco, and/or illicit drugs (see table above). Alcohol is the most commonly used substance (12.9%), affecting an estimated 5,800 babies, followed by 2,200 babies whose mothers smoke while pregnant (based on a 4.9% prevalence rate). Approximately 1,600 babies in Orange County are exposed in utero each year to illicit drugs based on the prevalence rate of 3.5%. Comparison to Previous Statewide Study In the chart below, the current rates of specific illicit drugs detected in urinalysis at labor and delivery in Orange County are compared to the results from a California-wide study that was conducted 15 years ago by Vega and colleagues. 22 Consistently, Orange County rates are lower than the statewide rate of illicit drug use. Moreover, use of certain substances changed markedly over the past 15 years. For example, a notable increase in the prevalence of amphetamine use in Orange County has occurred since the 1992 study. Marijuana and opiates were less prevalent in the present study compared to county rates in Cocaine use was not detected in the 2007 urinalysis study, but was self-reported in the survey of Orange County women in These figures are likely to be under-estimates given that nearly 10% of pregnant women who used substances did not seek prenatal care, and therefore would not have been captured by the self-report survey, along with the fact that pregnant women may underreport their substance use These prevalence rates are very similar to results from a multicommunity study that included two California counties. It found, via a structured clinical interview during a prenatal visit, that 15% of pregnant women had used substances. In addition, the study found that 11% continued to use alcohol after knowledge of their pregnancy and 4% continued to use drugs. 21 Notes: Please see page 186 for footnote references. % of Women Given the current level of substance use and the potential number of Orange County babies at risk, it is important to assess the current screening service and treatment capacity in the county. Comparison of SEB Sample Illicit Drug Use Prevalence to 1992 Statewide Study Marijuana Amphetamines Opiates Cocaine 0.7 Report on the Conditions of Children in Orange County, CA 1992 OC 1992 OC 2007

7 Orange County Child Welfare and Substance Abuse The County of Orange Social Services Agency and its partners work to investigate and prevent child abuse and neglect. A recent assessment of the reasons why children less than 2 years of age were removed from an unsafe situation determined that parental substance abuse was a common underlying cause. Researchers analyzed the investigative narrative from a cohort of about 300 children (< 2 years) who entered foster care in In the majority of physical abuse cases, the primary care-giving parent had a history of substance abuse. Additionally, this study found that 71% of neglect cases indicated exposure to drugs. Referrals from Dependency Drug Court for Substance Exposed Babies The Dependency Drug Court program serves families with alcohol, and/or other drug issues. Eligible participants are promptly identified and placed in a drug court program. Collaboratively operated by Social Services Agency, Health Care Agency, and Orange County Superior Court, this program provides clients with access to a continuum of alcohol, drug, and other needed treatment and rehabilitation services, and thereby increases the likelihood of reunification and reduces the reoccurrence of child abuse and neglect. From 2005 to 2007 there were 120 Dependency Drug Court enrollments from referrals for substance exposed babies (29 of these were in 2007). Other county service data related to substance exposed children includes information on cases with Social Service Agency s Children and Family Services Division, pregnant women entering drug or alcohol treatment, referrals to Dependency Drug Court, and referrals to the Perinatal Substance Abuse Services Initiative/Assessment and Coordination Team. Referred, substantiated, and removed 0-1 year olds In 2005/06, the Social Service Agency s Children and Family Services Division provided emergency response services that resulted in juvenile court intervention to 164 substance-exposed infants and their families. In the past ten-year period, there has been a 46% decrease in the number of infants taken into protective custody after testing positive for alcohol or drugs from 302 in 1996/97 to 164 in 2005/06. From 2000 to 2006, an average of 144 infants per year have been taken into protective custody as a result of testing positive for alcohol or drugs at birth. 24 Pregnant women entering Alcohol and Drug Abuse Services treatment In 2006/07, 151 pregnant women began treatment with the Health Care Agency s Alcohol and Drug Abuse Services treatment. Interestingly, the majority of women (50.3%) were not ordered by a court and entered treatment voluntarily (e.g., self-referred or referred by a health care provider). Less than half (44.4%) were ordered into treatment by a criminal court and 5.3% were referred by the Dependency Court (Source: CalOMS, HCA/ADAS). Over the past 6 years an average of 170 pregnant women entered treatment per year, representing 4.6% of all women in treatment. ACT Program The Health Care Agency offers a number of early substance abuse intervention programs, specifically the Perinatal Substance Abuse Services Initiative (PSASI)/Assessment and Coordination Team (ACT) Program. ACT is a voluntary home visiting case management program for women (and their families) affected by substance abuse and/or HIV infection during pregnancy and through the first six to twelve months of the child s life. Public health nurses ensure that pregnant women have access to and maintain prenatal care, drug and alcohol treatment, methods of family planning, and assistance with basic needs. In 2007, a total of 438 pregnant women were referred to the ACT program. Of those, 68% (n = 299) were assessed and received services. Combined with existing cases, there was a total of 518 open cases with the following results: 99% of the babies were illicit drug free at birth; The average gestational age was 39 weeks; The average birth weight was 7lb. 1 oz. (3,301 grams); and, 80% of the infants went home with their mothers. Combined, the numbers of parents and infants receiving services through the ACT program and the Dependency Drug Court program are substantially less than the estimated prevalence rate from the recent Orange County Substance Exposed Babies Study. 28 Report on the Conditions of Children in Orange County, 2008

8 Prevention and Screening Strategies In addition to the existing screening and treatment options described earlier, there are two successful screening programs currently operating in Orange County, MOMS Orange County and the Bridges for Newborns program. For a detailed list of other programs and services, please see page 193. MOMS Orange County MOMS Orange County is a non-profit, community-based, health care organization. MOMS Orange County, working closely with the Health Care Agency, has developed an effective screening and early intervention program for lowincome pregnant women. Pregnant women are referred to MOMS Orange County once they have a positive pregnancy test or are in their first trimester; have no health insurance; or have a high deductible they cannot afford to pay. MOMS Orange County provides prenatal support services through monthly home visits, regular health screenings, and prenatal health education to increase the likelihood of positive birth outcomes. Mothers enroll into MOMS Orange County voluntarily and are considered to be low risk for substance abuse by their medical provider. In 2007, MOMS screened 4,283 pregnant mothers, and 150 mothers (3.5%) were referred to ACT for substance abuse treatment. Bridges for Newborns Program The Children and Families Commission of Orange County's Bridges for Newborns Program began in 2000 as a way to greet every mother of a newborn bedside at the hospital. Program staff screen for risk conditions so that families who could benefit from additional support are linked to a network of early intervention services. The program is implemented at high-birth hospitals and a network of community service providers. Mothers who are identified as being at risk through the hospital-based screening are referred to either a short-term home visitation program that is linked to a community Family Resource Center (FRC) or referred to a longer-term home visitation program. In 2007, Bridges hospitals screened 87% of birth families (over 28,000 families) and referred 6% to a long-term Bridges home visitation provider and 10% to a FRC Health Access Program. Five Levels of Effective Intervention The birth event is only one of several points at which prenatal exposure can be addressed. Both upstream and downstream interventions are needed to address the unidentified substance exposed babies. The use of the Five Level framework, developed by Children and Family Futures, Inc., enables a state or locality to organize practice and policy responses for these children by identifying 5 major time frames when interventions could reduce the potential long-term harm of prenatal substance exposure. 25 Five Levels of Effective Intervention Level 1: Education and awareness are the key elements for an effective prevention strategy. 1. Promote awareness of effects of prenatal substance use Level 2: Systematic screening and assessment of all women during prenatal care visits with treatment referrals to those identified at risk. 2. Screen pregnant women for substance use and assessment 2. Initiate enhanced prenatal services Level 3: Screening of newborns suspected of being substance exposed depends on the ability of the birthing hospitals to identify those women who are presently flying under the radar. 3. Screen newborns for substance exposure Level 4 & 5: Developmental screening to identify any ongoing issues related to substance exposed babies. 4. Ensure newborn s safety and respond to newborn s needs 4. Respond to immediate needs of family members 5. Identify and respond to needs of Infant/Preschooler Child Adolescent 5. Identify and respond to ongoing needs of family members Report on the Conditions of Children in Orange County,

9 Kaiser Permanente - Northern California A recent study by Kaiser Permanente in Northern California reported that pregnant women with substance abuse problems can have successful pregnancies if they receive treatment early in their pregnancies. 27 An important factor for success in this program is that screening for alcohol, tobacco and/or other drug use, as well as treatment, was available to pregnant women in one place. About 50,000 pregnant women were screened during prenatal care visits. Those with substance abuse problems received counseling with on-site social workers and licensed therapists directly following their regular prenatal care appointments. A total of 2,100 (or 4.2%) women received treatment for substance abuse. Promising Practices In addition to implementing a five-level plan for intervention there are existing models of promising practices for review, including but not limited to Chasnoff s 4P s Plus Model and Kaiser Permanente s one-stop services program in Northern California. Chasnoff s 4P s Plus Model The 4P s Plus model is a five-question screen specifically designed to quickly identify obstetrical patients in need of in-depth assessment or follow-up monitoring. It can easily be integrated into the initial prenatal visit and used for follow-up screening through the pregnancy. Chasnoff and his colleagues analysis suggested that primary care physicians can ask the five questions in the context of a prenatal health evaluation to target women for referral to a full clinical assessment for drug and alcohol use. A recent implementation of the 4P s Plus model in 17 California counties has demonstrated the program s effectiveness in reducing substance use during pregnancy and subsequently the rate of low birth weight babies born. 26 The investigators recommended that prevention efforts target highly educated, mid/upper socioeconomic status, Non-Hispanic White women. Importantly, this is a compilation of risk factors consistent with the findings of the 2007 Substance Exposed Babies study in Orange County. Combining substance abuse counseling and prenatal care would be an ideal method of care for pregnant women. Presumably the "one-stop shopping" approach at Kaiser Permanente helped prevent women from cancelling appointments and reduced their need to leave work or find child care. The challenge in large metropolitan counties like Orange County, with about 45,000 births per year would be to duplicate the study's success most private prenatal care providers do not have access to therapists and social workers to treat patients with substance abuse problems. National Center for Substance Abuse and Child Welfare To promote coordination of services for this population, the County of Orange is currently involved in a collaborative effort with the National Center for Substance Abuse and Child Welfare (NCSACW) and a team consisting of representatives from the Orange County Social Services Agency, the Orange County Juvenile Court, and Health Care Agency. The goal of the project is to improve outcomes for clients involved with the three Orange County agencies across the systems to ensure clients receive necessary services, appropriate resources are provided, and all staff working with this population are trained on successful engagement strategies. There are four subcommittee work-groups; focusing on Training, Data, Services, and Resources. Orange County was one of the first counties chosen to participate in this project to receive 15 months of In-Depth Technical Assistance from the NCSACW. This work will not only develop effective practices in California, but also will provide leadership at a broader level for other jurisdictions who may want to replicate this program. 30 Report on the Conditions of Children in Orange County, 2008

10 SUBSTANCE EXPOSED INFANTS Conclusions The Orange County Substance Exposed Babies study completed in 2007 has compiled better data on the prevalence of prenatal exposure than Orange County has had in fifteen years. The data and the important ongoing efforts provide a strong foundation for action to respond to the needs of the thousands of children affected by prenatal substance exposure. The research findings estimate that: 15% of all births were prenatally exposed; 6,800 babies were prenatally exposed to substances; 500 to 600 mothers and their children are currently being served; and Over 90% of substance exposed babies are not detected by current screening efforts. It must be recognized that 6,800 prenatally exposed births annually translates into a total of more than 120,000 children under 18 in Orange County who have been prenatally exposed, along with thousands more who are affected by continued substance abuse in their families and its post-natal effects. Recommendations With powerful new data documenting the extent of the problem, as well as evidence of which approaches are proving most effective in the County and around the nation, a comprehensive response to the problem is possible and critical. The Perinatal Substance Abuse Steering Committee, along with the Children s Services Coordination Committee, has been considering options for responding to these findings as a multi-disciplinary body that could develop a comprehensive interagency effort. The committee would involve agencies and groups such as the medical community, hospitals, law enforcement, and religious organizations that address maternal and child health; drug and alcohol treatment; child welfare; mental health; developmental disabilities; general and special education; and, child care and development. 2. Efforts to work with private practitioners including training their personnel to screen mothers as part of regular prenatal visits. 3. Efforts to work with hospitals to clarify current screening protocols under the AB 2669 state legislation and to compile better data from hospitals on an annual basis. 4. Continued efforts to work with home visiting and family resource programs to give greater emphasis to prenatal care, referrals to substance abuse treatment, and aftercare in their services, with annual reports to their funders on levels of service in each of these areas. 5. Enhancing efforts within the Social Services Agency and Health Care Agency to improve data collection and client monitoring as well as training and technical assistance. Clients need to be tracked from initial identification to intervention programs, treatment, and aftercare. Those who are referred from maternal and child health to child welfare and on to treatment programs should be followed across agencies using unique identifiers and adequate protection of client privacy. 6. Efforts to create policy statements from county agencies and policy leaders making it clear that women who screen positive for alcohol or drug use and enrolling in treatment should receive the highest priority for publicly funded treatment services and will be supported in their efforts to parent their child while complying with their treatment program. In addition, women identified as pregnant and needing treatment services should receive the highest priority for publicly funded treatment services. These findings and recommendations will be key to improving birth outcomes and the lives of children in Orange County. Approaches being considered include models such as the Five Levels of Intervention and the following activities: 1. Efforts to work with local high schools and colleges to expand pre-pregnancy education about the effects of prenatal exposure, given the high frequency of first trimester use among women of child-bearing age. Report on the Conditions of Children in Orange County,