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Comprehensive care for at-risk children

March 19, 2015
by John de Miranda, MEd, and Anna Marquez
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Monterey County, Calif., is the site of an innovative collaboration between trauma-informed behavioral health organization Door to Hope and the county child welfare system that identifies and treats infants and children exposed to drugs in utero or to violence in early childhood. While our capacity to treat individuals with addiction is well-developed, services for infants and children of adults with a substance use disorder remain severely lacking.

Each year, more than 800 Monterey County children are born prenatally exposed to alcohol and other drugs. This exposure increases the child’s risk for developmental delays and neurological, social, emotional and behavioral problems. The window of opportunity to make a difference in these children's lives is brief, and the cost of missing that window is profound. Early identification and intervention become crucial to helping these children reach their full potential.

The Monterey County Screening Team for Assessment, Referral, and Treatment (MCSTART) provides a comprehensive model of care to identify, assess, refer and treat children who have been prenatally exposed to alcohol and other drugs, domestic violence, and trauma. The program closes a critical gap in the existing behavioral health system of care, and it both complements and supplements efforts to address the needs of families experiencing addiction or living with violence.

MCSTART is composed of three components:

  • A policy component to provide the policy framework, coordination and oversight necessary for the long-term viability and sustainability of the MCSTART mission.

  • An operational component comprising prenatal prevention and primary, secondary and tertiary intervention for children affected by the broad spectrum of developmental, social/emotional and neurobehavioral disorders caused by prenatal alcohol and drug exposure and/or perinatal exposure to domestic violence and trauma.

  • An evaluation component to provide for ongoing, systemic data collection and analysis to measure outcomes and analyze cost impacts.

History and prevalence

In 1992, the California Department of Alcohol and Drug Programs' Office of Perinatal Substance Abuse commissioned and funded a Perinatal Substance Abuse Prevalence Study to obtain accurate, population-based estimates of the number of alcohol- and drug-exposed children born in the state. That study indicated that 11.86% of all births in the mid-coast region, which included Monterey County, were exposed to alcohol and other drugs (not including tobacco).1

A more recent national report estimated that in “younger school children” the rate of all levels of fetal alcohol spectrum disorder (FASD) may be as high as 2 to 5% of the population.2 A study of prenatal screening suggests that as many as one-fifth of infants born in the United States each year are prenatally exposed to alcohol, tobacco or other drugs, and 75 to 90% of these cases go undetected.3

Many experts believe that these studies actually underestimate the number of affected children, since many mothers deny alcohol and drug use during pregnancy. Also, healthcare professionals often fail to screen women or recognize the signs of substance use, and toxicology screens provide information at only one point in time and do not identify drinking or drug use at earlier stages of pregnancy—when the neurological impact of drug exposure is most damaging.

Exposure to trauma

According to Monterey County child welfare statistics, 85% of children up to age 5 in foster care come from substance-abusing homes. While substance abuse is often associated with physical and sexual abuse, more often children are removed from the home because of neglect. Thirty-three percent of the children referred for suspected child abuse or neglect were ages 0 to 5 years, and of the total of 4,485 children referred for investigation in 2002, 1,484 were 5 or younger. Ethnicity profiles reveal an overrepresentation of Hispanics, perhaps a reflection that Hispanic families have more young children and are more likely to live near or below the poverty level.

The National Crime Victimization Survey estimated that there are 9.3 physical attacks against women by intimate partners per 1,000, and children under the age of 12 reside in slightly more than half of the affected households.4

Societal costs

The multi-system costs to the public sector associated with these traumatized children are extraordinary. For example, should a substance-exposed infant enter the child welfare system, very often his/her care costs as much as $200,000 a year to meet medical, mental health, special education and specialized placement needs.

The potential cost benefits for screening, early intervention and treatment are impressive. Total lifetime costs for caring for a substance-exposed child have been estimated at between $750,000 and $1.4 million.5 Because substance-exposed newborns often have prolonged stays in neonatal intensive care units, their treatment costs total $71 million to $113 million per year.6

Screening and early intervention offer antidotes to the costs and complications seen in these statistics. Screening during pregnancy allows for the earliest possible intervention and can dramatically reduce the harm of exposure during pregnancy. Also, our experience demonstrates that early identification and intervention before age 6 modifies the trauma exposure to such an extent that most of these children eventually fare as well as non-exposed children.

Education and screening