Chapter 2 : Section 11.1

Investigations Involving Substance Exposed Newborns

Procedures

In addition to policy and procedures specified in Initial Contact and Conducting Interviews, and the Family Functioning Assessment (FFA) - Investigation complete the following:

• Gather information concerning the medical condition of the newborn, including any complications from the substance exposure, the discharge status and instructions (where applicable), and any recommendations for follow-up medical care.

• If available, obtain documentation by the health care professional(s) about the newborn infant’s prenatal substance exposure including:

  • clinical indicators in the prenatal period including maternal and newborn infant presentation;

  • information regarding history of substance abuse or use by the mother;

  • birth and medical records; and

  • toxicology results and/or other laboratory test results on the mother and the newborn infant.

• Obtain information from the health care professional(s) regarding their observations of the parental responsiveness to the newborn, visitation, feeding, understanding of the newborn’s special needs, or any other information to assist in the safety assessment and development of the Infant Care Plan (ICP).

• Obtain the hospital discharge plan and recommendations from the health care professional about post-discharge infant care and medical follow-up.

• If the newborn is hospitalized at the time of the report:

  • visit the newborn’s home environment prior to the newborn’s discharge, or if it is not possible to visit the home prior to discharge, visit the home on the day of the newborn’s discharge; and

  • advise the health care professional that an assessment of the newborn’s safety in the home environment is being completed and request that DCS be notified prior to the newborn’s discharge from the hospital.

• Obtain the name(s) and contact information of the health care professional(s) who will provide routine health care for the newborn, and any recommended special medical care.

• Gather information to assess the six domains of family functioning, as described in FFA - Investigation. In addition, gather the following information to assess threats of danger and parent/caregiver protective capacities in a family with a Substance Exposed Newborn (SEN):

  • parent/caregiver’s history of depression, anxiety, or other mental health concerns that would place the parent/caregiver at risk for post-partum depression;

  • parent/caregiver’s history of substance use, including types, frequency, and amount of drugs used;

  • parent/caregiver’s history of SEN births;

  • parent/caregiver’s history of participation in substance abuse treatment services and other prevention or intervention services;

  • parent/caregiver’s perception of his/her caretaking role and responsibilities;

  • parent/caregiver’s plan to meet the newborn’s basic needs for shelter clothing, medical care, etc.;

  • parent/caregiver’s proposed feeding plan for the newborn;

  • parent/caregiver’s ability to purchase baby formula or obtain formula through the Arizona WIC Program in order to meet the newborn’s nutritional needs;

  • whether tobacco is smoked in the home and plans to discontinue use;

  • identification of the proposed caregivers of the newborn on a daily basis and when the parent(s) is/are unavailable, and the parent/caregiver’s knowledge of each caregiver’s ability to provide safe care to the newborn;

  • sleeping arrangements, including assessment of whether the infant has a safe sleep environment and if multiple births, arrangements for a separate safe sleep environments for each infant;

  • parent/caregiver’s history of parenting, including parenting of siblings in the past or currently; and

  • parent/caregiver’s knowledge of child development, infant/toddler mental health, and behavior management, to include information surrounding relationships between parent/newborn and newborn/siblings.

• If needed, consult with a community and/or contracted substance abuse treatment professional to gain clinical expertise and advice regarding severity of drug usage, signs and symptoms, behavioral indicators, and motivation for treatment.

• For parents who are qualified patients under the Arizona Medical Marijuana Act, ask the parent/caregiver to sign an Authorization to Disclose Health Information or release of information with their provider, and gather the following:

  • a copy (front and back) of the parent’s Medical Marijuana Registry Identification Card;

  • a copy of the physician completed Medical Marijuana Certification Form;

  • the debilitating medical condition and medical records documenting the debilitating medical condition; and

  • the mother’s obstetrics medical records documenting the recommended marijuana dosing and usage during pregnancy.

• For parents engaged in Medically Assisted Treatment (MAT) to control an opioid addiction, ensure that the MAT program includes counseling and behavioral therapies, in addition to the use of medications (such as Methadone or Buprenorphine), to provide a whole-patient approach to the treatment of the parent/caregiver’s substance abuse disorder. To determine if a parent/caregiver is appropriately engaged in MAT, ask the parent/caregiver to sign an Authorization to Disclose Health Information or Release of Information with their provider. Talk to the provider to learn the parent/caretaker’s:

  • length of time engaged in MAT;

  • treatment plan, including whether it includes counseling and behavioral therapies to address the substance use disorder;

  • compliance with the treatment plan and consistency of participating in the program;

  • engagement in random urinalysis testing; and

  • medication dosage and management.

• Check in regularly with the MAT provider to confirm the parent remains compliant and no additional safety threats or diminished protective capacities have been identified.

• For infants suspected of having FASD, obtain as soon as possible or within one year:

  • documentation of the diagnosis by a health professional indicating clinical findings consistent with FASD;

  • the child’s medical records; and

  • the health professional’s recommendations for services for the child.

• Contact the child’s health care professional(s) to verify that newborn follow-up appointments have been scheduled and/or attended; and ask the newborn’s health care professional about potential impacts of breast feeding on the newborn’s health if the mother is using prescribed or non-prescribed drugs.

Provide the Safe Sleep flyer and AZ DCS Safe Sleep Campaign video to the parent/caregiver and review it with them. Visit the home to observe the sleeping conditions of the child and discuss any observed risks. If needed, make referrals to community resources.

Developing the Infant Care Plan (ICP)

Develop an ICP for the newborn infant who was prenatally exposed to alcohol or substance use by the mother, or child up to one year old diagnosed with FASD. When developing the ICP, actively involve the following:

• parents/caregivers;

• the infant’s health care professionals;

• the parent’s/caregiver’s substance abuse treatment service providers, to include MAT provider if applicable;

• out-of-home caregivers; and

• supportive adults identified by the parents/caregivers (if applicable) to develop the ICP.

The ICP describes the services and supports that will be provided to ensure the health and well-being of the infant and addresses the substance abuse treatment needs of the parents/caregivers. Each plan shall address the following areas:

• substance abuse treatment needs of the parents/caregivers;

• medical care for the infant;

• safe sleep practices;

• knowledge of parenting and infant development;

• living arrangements in the infant’s home;

• child care; and

• social connections.

Utilize the Identifying Safe Children for In-Home Oversight Standard Work when deciding if a case involving a SEN who has been assessed as safe should be opened for services.

If a case involving a SEN is opened for services, oversee the implementation of the ICP by observing, discussing, and assessing the child’s status indicators and participation with health care providers during monthly in-person contacts with the child and the child’s parent/caregiver.

If a parent/caregiver has been referred to substance abuse treatment or other services, oversee the sufficiency of the services by observing, discussing, and assessing the parent/caregiver’s progress and participation in services during monthly in-person contacts with the parent/caregiver and through communication with the parent/caregiver’s service provider(s).

Review and reassess the ICP during case plan staffings, Child and Family Team meetings, and whenever there is indication that the child’s health or health care needs resulting from prenatal substance exposure have changed. Update the ICP when applicable and distribute to the parent/caregiver and other team members.

In ongoing cases, development and oversight of the ICP may end when:

• the infant is at least three months old and will remain in an out-of-home placement that is consistently meeting all of the infant’s medical, developmental, social and emotional needs;

• the infant has turned one year of age (ensure any on-going medical, developmental or other needs of the child are met through the DCS Case Planning process); or

• DCS is closing the ongoing case prior to the infant turning one year of age, and has:

  • met with the protective parent, the child’s health care provider, and other service providers (e.g. home visitors) to update the plan;

  • ensured that anticipated future needs of the infant are addressed in the plan; and

  • developed the Aftercare Plan including additional referrals for the family not addressed in the ICP.

If an Assessment involving a SEN will close at investigation, review the ICP with:

• the protective parent, guardian, or custodian;

• the child’s health care provider;

• the parent/caregiver’s substance abuse assessment or treatment provider (if applicable);

• other services providers (e.g. home visitors); and

• any other adults who have a role in the plan to determine that each person is able and willing to consistently and reliably implement the actions described in the ICP.

Provide a copy of the ICP for review during the Aftercare Planning discussion with the parents/caregivers.

Determining the Need for Ongoing Services

Complete a FFA to determine whether the infant is unsafe due to impending danger, following the policies and procedures in FFA - Investigation.

A newborn infant who has been prenatally exposed to alcohol or a controlled legal or illegal substance, or is demonstrating withdrawal symptoms resulting from controlled substances, is considered vulnerable to abuse or neglect. The overall substance use by the parent (including prenatal drug use, whether prescribed or not) and the parents’ ability to perform essential parental responsibilities must be considered in the assessment of the newborn’s safety. For more information regarding substance exposure to a newborn infant, see Pre-Commencement Activities to Prepare for Initial Response.

If the child is assessed as unsafe due to impending danger, immediately implement a Safety Plan following the policies and procedures in Safety Planning. A case cannot be closed when a child is assessed as unsafe.

Determining the Need for In-Home Services

If the child is assessed as safe and this is the first SEN report, consider the following to determine whether the case should be opened for ongoing services:

• The parent or caregiver’s recognition of the problem and motivation to make necessary behavioral changes.

• The family may benefit from services to strengthen protective factors, in order to reduce the risk of future abuse or neglect (assess the family’s protective factors following the policies and procedures in Aftercare Planning and Services).

• The likelihood that the parent or caregiver will consistently and reliably follow the ICP without Department and/or court oversight, including plans for routine and specialized infant health care, use of safe caregivers, participation in parental substance abuse treatment (if applicable), and other actions listed in the ICP. Consider parent/caregiver history and behavior such as:

  • history of SEN reports;

  • follow through with the newborn screening medical appointment;

  • follow through with current substance abuse assessment recommendations (if applicable);

  • history of participation in treatment services offered in the past (if applicable), stability of his/her current living arrangement;

  • demonstrated ability to consistently and reliably meet his/her own needs for housing, medical care, mental health care, nutrition, etc.; and

  • demonstrated understanding of the ICP.

• The parent or caregiver has diminished protective capacities that impacts his/her ability to consistently and reliably follow the ICP.

If the child is assessed as safe and there is prior SEN history, the Program Manager shall review the case history to determine whether In-Home services are appropriate. Identify the family’s needs for agency and/or court oversight. See Determining the Level of Department Intervention, Services and Court Oversight.

S.E.N.S.E. Program

The S.E.N.S.E. (Substance Exposed Newborn Safe Environment) Program can be considered for SEN newborns deemed safe or unsafe, with or without court oversight. An unsafe infant will also have a Safety Plan. See Safety Planning.

If the infant is assessed as safe, engage with the family to determine how S.E.N.S.E. program services can strengthen the family’s protective factors and/or enhance the parents’ protective capacities.

The DCS Investigator will transfer the case for In-Home services to further engage with the family to develop the service and case plans.

The DCS In-Home/Ongoing Specialist who manages the S.E.N.S.E. case will:

• submit a completed S.E.N.S.E. tracking evaluation;

• schedule a home visit within two business days;

• submit a complete S.E.N.S.E. referral to the Resource Unit

• confirm all S.E.N.S.E. team members have received a request for services and are in agreement;

• share the ICP and Safety Plan with all team members (to include updates as they occur);

• arrange drug testing or confirm it is in place;

• conduct weekly home visits early on and as needed;

• oversee weekly S.E.N.S.E. team emails;

• review and update the ICP, Safety Plan, and S.E.N.S.E. Service Plan at 10, 45, and 90-day staffings; and

• report any new allegations of abuse or neglect to the DCS Program Supervisor and the Intake Hotline.

Referring for Substance Abuse Assessment and Treatment Services

Follow policies and procedures in Adult Behavioral Health & Substance Abuse Services. Refer the parent, guardian, or custodian(s) to Arizona Families F.I.R.S.T. (AFF). Provide the parent with a copy of the AFF flyer and encourage the parent’s participation in Substance Abuse Awareness services and, if recommended substance abuse treatment, in order to achieve behavioral changes and improve family functioning.

For more information on coordination of substance abuse treatment services, see Roles and Responsibilities in the Coordination of SEN Cases.

If the AFF provider or other substance abuse service provider informs the DCS Program Supervisor that the family has refused or discontinued treatment, reassess the family member’s substance abuse treatment needs as well as the level of Department and court oversight.

Determining when to Close an Ongoing Services Case Involving a SEN

To determine when it is appropriate to close an ongoing case involving a SEN, determine whether the parent:

• understands the care necessary to help the newborn overcome the effects of the substance use and reliably acts to provide necessary care;

• has taken steps to change or control the behavior or conditions that placed the child in impending danger and whether these steps are sufficient to determine the child is safe from impending danger;

• is involved with extended family members, community support networks, or service providers who will help the family maintain these changes over time; and

• understands the ICP and knows how and where to access help if additional needs for health care or substance abuse treatment arise in the future.

Prior to closing the case, complete an Aftercare Plan as described in Aftercare Planning and Services.

Documentation

Document the outcome of the FFA in Guardian.

Document the status of the Assessment, including participation in the S.E.N.S.E. and Safe Sleep programs in Guardian.

Document the ICP. Obtain signatures from the parents and out-of-home caregivers, upload as an artifact in Guardian, and file the hard copy in the hard copy record.

Document the Aftercare Plan. Obtain signatures from the parents, upload as an artifact in Guardian, and file a copy in the hard copy record

Effective Date: May 4, 2022

Revision History: November 30, 2012, June 30, 2017, February 1, 2021