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

Chapter 3 - Followup and Aftercare of Drug-Exposed Infants

Drug-exposed infants should not be viewed as a homogeneous group but as individual at-risk infants presenting with a broad spectrum of possible effects, ranging from healthy term newborns with no apparent effects to high-risk births with significant effects. Living in a drug-abusing family is, in itself, a significant risk factor, regardless of prenatal exposure. Maternal drug use (and paternal drug use as well) represents a health, biological, and psychosocial risk to the developing fetus and a social risk to the young child. The primary focus of the addicted woman is characteristically on her drug of choice, not on her child. A child whose mother abuses drugs often lives in a chaotic environment. Prenatal drug exposure and suboptimal home environments are highly correlated. In combination, they have a synergistic and devastating effect on the child's health and development (Kaltenbach and Finnegan, 1984, 1987, 1988).

Because the infant exists as part of a mother-child dyad, effective treatment must occur within the context of that relationship, as the mother often serves as the gatekeeper for the child's access to services. Knowledge of other siblings, extended family, the father, friends, neighbors, and other caregivers is also crucial to treatment. Followup and aftercare services should also be based on a multicultural and multilinguistic model that takes into account the cultural backgrounds of the mother, the father, and the extended family, as well as the service providers. Staff should reflect the different cultural and racial backgrounds of the communities being served. When appropriate, bilingual staff should be hired or other provisions made so that the inability to speak English is not a barrier to care. In sum, to be effective, treatment must occur within the cultural context of the mother and father, the extended family, and the community.

Knowledge of specific drug exposure is necessary for the appropriate medical management and treatment during the newborn period; the type of pharmacotherapy used in treating neonatal abstinence varies according to the specific drugs or combinations of drugs used by the mother. But followup and aftercare should not be based on a deficit model that assumes and screens for specific abnormalities caused by specific drugs. Rather, followup and aftercare should be based on a multirisk model that takes into account not only the prenatal drug exposure but also the medical status of the mother and the caregiving environment of the infant.

All health care and other service providers should consider the possibility that a number of environmental factors may contribute to specific deficits that have been attributed to drug exposure, as outlined below.

Experience with drug-using mothers and their children has demonstrated that drug exposure is only one of a number of risk factors that may affect the lives of the mothers and children. Other risk factors include:

• Chronic poverty
• Poor nutrition
• Inadequate or no prenatal health care
• Sexually transmitted diseases, including HIV exposure
• Domestic violence
• Child abuse or neglect
• AOD abuse within the family (including the father and the extended family)
• Homelessness, transient or inadequate living arrangements, or substandard housing
• Unemployment
• History of incarceration
• Low educational achievement
• Poor parenting skills
• Discrimination based on race, gender, or culture.

The lack of sufficient training among providers also affects the quality of the followup care given to drug-exposed infants and families.

To counter the drug-exposed child's early disadvantages, service providers must be prepared to intervene early, often, and from many perspectives. Above all, health care and other service providers should not adopt the attitude that all drug-exposed infants are doomed to an unhappy, unhealthy life. Many, if not most, can eventually lead productive lives, given adequate intervention, education, and treatment services.

The following recommendations address interventions for infants and toddlers, the transition to the preschool period, and training for child-oriented professionals. In general, many services require pediatric supervision by a specially trained physician.