Ky.gov
Effective: 2/17/2025

C3.9 Plan of Safe Care and the Impacts of Parental Substance Use in Early Childhood

Legal Authority

Introduction

​​​​​​​​Substance misuse is a pervasive issue impacting many families served by the Department for Community Based Services (DCBS). It is impossible to have meaningful and effective approaches to practice, including the areas of prevention, intake and assessment, ongoing casework, and out-of-home care (OOHC), without having solid foundational knowledge about the effects of substance misuse on families and children. Additionally, staff must be well versed in federal and state requirements for practice with substance-affected children and families, as well as being knowledgeable of available resources in local communities to assist children and families impacted. 

According to the American Academy of Pediatrics (AAP), children exposed to parental substance use are impacted in the following ways:

  • Almost a quarter of children of mothers with identified substance use disorders (SUDs) do not receive routine child health services in their first two (2) years of life. 
  • Children of parents with SUDs are also at greater risk of later mental health and behavioral problems, including SUDs. 
  • Approximately one (1) in five (5) children grow up in a home in which someone uses drugs or misuses alcohol.
  • Short-term effects of exposure to substances in utero include low birthweight, congenital anomalies, withdrawal symptoms, and neurobehavioral issues.
  • Longer-term effects of exposure to substances in utero, which may extend throughout early childhood and beyond, include continued impacts on growth, behavioral disorders, developmental delays including language and cognition, and decreased academic performance and achievement as compared to peers. 

In response to increasing rates of infants born exposed to substances in utero, new federal requirements were added in 2016 requiring that states develop a process to ensure a POSC to address the needs of infants exposed to substance abuse in utero, experiencing withdrawal symptoms or having fetal alcohol spectrum disorder (FASD). This includes a requirement for healthcare providers to report all such infants to the child protective services agency (CAPTA 106(b)(2)(B)(ii) and (iii)). An infant and family/caregiver may meet the requirements for needing a POSC without the report meeting acceptance criteria. Whether a report meets acceptance criteria impacts which professional(s) or service providers take the lead in developing and monitoring the POSC. Therefore, prompt communication and collaboration must occur among involved service providers in these situations to ensure the safety and well-being of the infant and family. 

​


Practice Guidance

​

  • ​The POSC should go beyond immediate safety threats to address the health and developmental needs of the affected infant and the caretaker’s need for treatment related to substance misuse and/or mental health. Additionally, it should identify the services and supports the caretaker needs to strengthen their capacity to nurture and care for the infant. To ensure the safety of the infant, it should also incorporate a plan of safe sleep and a plan for the care of the infant and any other children in the home in the event of a return to use. 
  • Decisions must be made and shared timely with professional reporting sources—especially with birthing hospitals in substance-affected infant cases; 
  • The frequency of contact with clients and service providers may need to increase beyond the minimum as established in SOP 3.10​ and SOP 4.24​ depending on case circumstances; 
  • It is important to recognize that in medication-assisted treatment (MAT), prescribed medication could be lifesaving and is an acceptable form of treatment, but it is only a piece of treatment and should be used in conjunction with additional services.
  • The identification of a substance-affected infant may occur during any stage of involvement, including at birth or later during the infant’s development and/or as symptoms manifest. The POSC addresses actions and services for the infant and family’s needs, and these needs must be incorporated into the safety plan, prevention plan, case plan, or aftercare plan in accordance with the best practice described in SOP 7.2 CPS Safety Planning, SOP 7.4 CPS Prevention Planning, SOP 7.6 CPS Aftercare Planning, SOP 3.4 Initial In Home Case Planning Conference, SOP 3.13 Ongoing Case Planning, SOP 4.17 Preparation for and Completion of the Ten Day Conference, SOP 4.18 Ongoing Case Planning [OOHC], and SOP 4.36 Case Closure and Aftercare Planning​.
  • When developing the POSC, the family, SSW, and other service providers should keep in mind that the postpartum period is a time of unique vulnerability and the risk of return to use increases for the mother due to:
    • Increased stress associated with motherhood, newborn care, and sleep deprivation;
    • Limited social support and resource availability;
    • Increased financial demands;
    • Pain and physical recovery from delivery; and/or
    • Physiologic transition from pregnant to non-pregnant state.
  • The child welfare agency will use existing continuous quality improvement (CQI) processes, which include collaboration with partner agencies, to monitor local development of POSC, referrals to services, and appropriate services to infants and affected families or caregivers.



Procedure

​​The SSW:

  1. Follows practice guidance and procedures in SOP G1.16 Working with Families Affected by Substance Misuse​;
  2. When warranted based on the assessment, develops a POSC in partnership with the family and treatment providers, which should include:
    1. Service referrals to meet the needs of the mother, including but not limited to:
      1. Health care including postnatal care;
      2. Identification of a consistent and appropriate primary caregiver;
      3. Medication management;
      4. Pain management;
      5. Support with breastfeeding; and
      6. Discussion of family planning;
    2. SUD treatment and mental health services which assist the mother in identifying and accessing the appropriate assessments and treatment services and which meet the following needs:
      1. Timely access;
      2. Engagement, retention, and recovery supports;
      3. Appropriate treatment (i.e. gender-specific, family-focused, accessible, MAT, trauma-responsive); and
      4. Addresses any underlying challenges such as mental health or intimate partner violence;
    3. Referrals to appropriate supportive services including, but not limited to:
      1. Kentucky Strengthening Ties and Empowering Parents (KSTEP) or Sobriety Treatment and Recovery Team (START), if available and the family meets criteria for referral1;
      2. Health Access Nurturing Development Services (HANDS);
      3. KY-Moms MATR (Maternal Assistance Towards Recovery)2; and
      4. Other community-based support services specific to assessed needs;
    4. Identification of appropriate alternate care, which may be a relative or friend who can be entrusted with the care of the child(ren) as respite or in case of return to use.
    5. Service referrals to meet the needs of the infant and other children in the home, including but not limited to:
      1. Identification of a consistent pediatrician/healthcare provider;
      2. High-risk follow-up care;
      3. Referral to specialty care, as indicated;
      4. Kentucky early intervention services (KEIS) within seven (7 )days of identification (34 CFR 303.303 (a)(2)(i)) for developmental screening and assessment; 
      5. High-quality early care and education (ECE) as described in SOP C3.3 Early Care and Education. Preference should be given to programs that offer two-generation programming and support, such as Early Head Start. 
    6. Plan for safe sleep as described in SOP C3.8 Safe Sleep​; and 
    7. Services to meet the needs of secondary caregivers and other household members, including but not limited to:
      1. SUD assessment and treatment, if indicated based on the assessment;
      2. Mental health assessment and treatment, if indicated;
      3. Medication management, if indicated;
      4. Parenting skills (i.e. bonding, nurturing, understanding of the special care needs of the infant and the ability to provide it, etc.), if indicated; 
    8. A designation of who will monitor the POSC to determine whether and how local entities are making referrals and delivering appropriate services to the infant and affected family or caregiver for cases alleging maltreatment.
  3. Contacts the family and service providers regularly following the implementation of the POSC to ensure the family is following up with post-delivery medical appointments for the infant, as well as engaging with other service providers and following recommendations. 
  4. Ensures that the designation for monitoring includes another responsible agency in the aftercare plan if the child welfare case closes.
  5. Increases the frequency of contact with treatment providers and family members based on the case-specific needs, especially if there are indicators of return to use; 
  6. Reports any concerns to the treatment provider regarding the caretaker’s functioning or ability to care for the child. (i.e., the caretaker is nodding off inappropriately, slurring words, appears to be over or under-medicated, etc.);
  7. Consults with any treatment or medication provider, to incorporate specific treatment information into the child welfare assessment and case planning, including but not limited to:
    1. Safety of child, (i.e., what are the effects of the medication on the caretaker’s ability to function daily and care for the child, safe storage of medications). Do not assume the treatment provider recognizes or considers the safety of the child while in the caretaker’s custody;
    2. Medication management, (i.e., what type of medication is prescribed, what phase of treatment);
    3. Recommendations for follow-up treatment, (i.e., in-patient, outpatient, AA/NA, length of treatment, etc.);
    4. Provider recommendation for mental health treatment. Best practice recommends that mental health treatment accompanies medication management;
    5. Verification of medication doses, (i.e., in the office or self-administered take-home);
    6. Compliance with treatment programs;
    7. Drug test results, both positive and negative, completed through the treatment program; 3 and
    8. Treatment discharge planning, including appropriate aftercare plan if the caretaker is continuing MAT after case closure.
  8. Works with service providers regarding recommendations for safe sleep and breast-feeding safety, as well as tools for caretakers of neonatal abstinence syndrome (NAS) infants;
  9. Recognizes that some individuals will return to use:
    1. If return to use occurs, SSW assesses the situation by talking to the individual, treatment provider, and any other collaterals;
    2. Assesses the risk to the child in the home; and
    3. Offers additional support to stabilize the situation if possible.
  10. Ensures appropriate designation of a case involving a substance-affected infant through the use of the correct subprogram in the central intake screens to permit reporting of the number of substance-affected infants reported, and for whom a POSC was developed, and the number of infants for whom a referral was made for appropriate services.  

The Substance Exposed Infant Reporting is a guide for the SSW to use when speaking with the delivering hospital’s medical staff regarding a substance-affected infant. The checklist can be used during any phase of interaction with the family. ​


Footnotes

  1. KSTEP and START would coordinate SUD treatment as well;
  2. KY-Moms MATR (Maternal Assistance Towards Recovery) is a behavioral health prevention and case management program focused on the risks and effects of substance use/misuse while providing education, information, resources, support, and hope to pregnant and postpartum individuals and their families. Call (800) 374-9146 or visit the Department of Behavioral Health, Developmental, and Intellectual Disabilities website.
  3. Note that some street drugs taken in conjunction with MAT can be fatal.




Documents

Revisions