Improving Treatment for Drug-Exposed Infants
Treatment Improvement Protocol (TIP) Series 5

Maternal Substance Use History

A maternal AOD use interview should be conducted at the earliest point of access into the health care system. (If possible, information about paternal substance use should also be obtained by interviewing the father or questioning the mother.) Despite concerted efforts by health care professionals to promote prenatal care, the mother may not have received such care and the delivery hospitalization may be the only opportunity to elicit information on the nature and extent of the infant's in utero exposure to drugs and alcohol. The mother's concern for her infant's health may encourage valid responses; conversely, fear of legal reprisals or loss of custody of the infant may cause the mother to deny drug use.

The AOD use interview should be conducted in as private a setting as possible and in a nonthreatening and nonjudgmental manner. Guidelines for the maternal substance use assessment, including psychosocial and mental health assessment, were developed by the consensus panel on Pregnant, Substance-Using Women and are repeated here with minor modifications.

1. The AOD use history taking should include legal and illegal drugs (prescription drugs, alcohol, and cigarettes), and should cover:
   • Duration of use, including age of first use
   • Frequency, type, and amount of drugs used and periods of abstinence
   • Route of administration
   • Social context of use (with whom the patient uses, where and when she uses)
   • AOD abuse treatment history
   • Support group involvement
   • Consequences of use (self-perceived and objective)
   • Relapse factors
   • Family history of use
   • Motivation for treatment
   • Motivation for continued use of drugs
   • Urine toxicologies as needed: A urine toxicology is indicated when an adequate drug history cannot be obtained from the mother and she is manifesting symptoms of possible addiction or withdrawal and when the child is showing signs or symptoms of withdrawal.
2. A psychosocial assessment should include:
   • Support systems (role of the patient in her family support system and the stress created by that system)
   • Patient's attitude toward the birth of this child and her perception of her ability to parent this child and any older children
   • Role of the father, both in the mother's life and his potential role with the child
   • Education and employment
   • History of physical, sexual, and emotional abuse, both as a child and as an adult
   • Current life situation, including housing, transportation, child care, monetary support, and legal considerations or problems.
3. The mental health assessment should cover:
   • Mental status examination
   • Psychiatric symptomatology
   • Psychiatric history and treatment
   • Suicide risk
   • Family psychiatric history
   • DSM-III-R diagnosis
   • Treatment recommendations.

Standardized psychiatric evaluation tools can be helpful in diagnosis and followup. Further, liaison and ongoing contact must be maintained with other members of the assessment and treatment team.

Treatment Planning

Treatment planning for mothers and involvement of representatives from all participating agencies should include referral to an appropriate AOD abuse treatment program and continued involvement with medical and psychosocial agencies. Adequate arrangements should be made to ensure that the mother can get to the treatment facility, which may, in certain instances, require the provision of transportation for the mother to the location. An indepth treatment plan should be developed for the infant through multidisciplinary efforts of doctors, nurses, social workers, and others. The mother and father should be given the opportunity and urged to take part in treatment planning. If assessment reveals that the infant may be at risk for future harm due to the mother's potential for abuse or neglect, a report should be made to the child protective services agency so that further evaluation can occur. Chapter 4 sets forth guidelines for referrals to child protective services. At a minimum, the treatment team must develop a clear followup plan for the infant upon discharge from the hospital, and must arrange for careful monitoring of compliance with the plan. Guidelines for followup are detailed in Chapter 3.