CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Families Affected by Parental Substance Use Vincent C. Smith, MD, MPH, FAAP, Celeste R. Wilson, MD, FAAP, COMMITTEE ON SUBSTANCE USE AND PREVENTION

Children whose parents or caregivers use drugs or alcohol are at increased abstract risk of short- and long-term sequelae ranging from medical problems to psychosocial and behavioral challenges. In the course of providing health care services to children, pediatricians are likely to encounter families affected by parental substance use and are in a unique position to intervene. Therefore, pediatricians need to know how to assess a child’s risk in the context of a parent’s substance use. The purposes of this clinical report This document is copyrighted and is property of the American are to review some of the short-term effects of maternal substance use Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy during pregnancy and long-term implications of fetal exposure; describe of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of typical medical, psychiatric, and behavioral symptoms of children and Pediatrics has neither solicited nor accepted any commercial adolescents in families affected by substance use; and suggest profi ciencies involvement in the development of the content of this publication. for pediatricians involved in the care of children and adolescents of families Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external affected by substance use, including screening families, mandated reporting reviewers. However, clinical reports from the American Academy of requirements, and directing families to community, regional, and state Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent. resources that can address needs and problems. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics INTRODUCTION automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.

In the course of providing health care services to children, pediatricians DOI: 10.1542/peds.2016-1575 often encounter families affected by substance use, distribution, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). manufacturing, or cultivation that ultimately places parents and their Copyright © 2016 by the American Academy of Pediatrics children at risk. Substance use can include illicit substances such as marijuana, heroin, cocaine, and methamphetamine (eg, crystal meth), FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to as well as misuse of alcohol and prescription medications. As defined by disclose. the National Alliance for Drug Endangered Children, drug-endangered FUNDING: No external funding. children are those who are at risk for suffering physical or emotional harm as a result of their caregiver’s substance use, possession, POTENTIAL CONFLICT OF INTEREST: The authors have manufacturing, cultivation, or distribution. 1, 2 Children also may be indicated they have no potential confl icts of interest to disclose. endangered when parents’ substance use interferes with their ability to raise their children and provide a safe, nurturing environment. 1 Parents’ substance use may affect their ability to consistently prioritize To cite: Smith VC, Wilson CR, AAP COMMITTEE ON SUBSTANCE the child’s basic physical and emotional needs over their own need for USE AND PREVENTION. Families Affected by Parental Sub- stance Use. Pediatrics. 2016;138(2):e20161575 substances. Cigarette smoking often accompanies substance use and can

PEDIATRICS Volume 138 , number Downloaded2 , August 2016 from :e 20161575 http://pediatrics.aappublications.org/ by guest FROMon December THE AMERICAN6, 2017 ACADEMY OF PEDIATRICS pose additional hazards to children developmental evaluation. For the discussion could apply to any (www2. aap. org/ richmondcenter). example, children may have their primary adult who cares for a child, Furthermore, the home environment ears examined for chronic otitis including guardians, grandparents, may be unsanitary or unsafe, media because of greater exposure and foster parents. particularly if illegal or legal drugs, to smoke or large breathable chemicals, or paraphernalia are particulates in their homes or for accessible or if drugs are being more frequent developmental EPIDEMIOLOGY OF SUBSTANCE USE IN cultivated or manufactured in the assessments, given risks of emotional THE UNITED STATES home. Such conditions can lead to and behavioral disorders, delays A 2013 national government survey poor child health and developmental in expressive language, and mental on drug use and health reported that outcomes or child maltreatment and illness. more than 9.4% of the US population even child death. Pediatricians who help identify 12 years and older uses psychoactive Children exposed to a parent’s substance use problems in a child’s substances. 8 In 2013, an estimated substance use commonly experience family members are not expected 24.6 million Americans 12 years or educational delays and inadequate to solve, manage, or treat these older had used an illicit substance medical and dental care. 3 Almost problems; rather, they can assist in the 30 days before the survey. 8 a quarter of children of mothers families by working in partnership The total annual societal cost of with identified substance use with other professionals to provide substance use in terms of lost goods, disorders (SUDs) do not receive access to state, regional, and local lost productivity, treatment, and routine child health maintenance resources available to families. medical services in the United States services in their first 2 years of life. 3 Being familiar with effective harm is estimated to be $510.8 billion. 9 Children of parents with SUDs are reduction strategies and being This estimate includes costs related also at greater risk of later mental prepared to inform public debate to alcohol and drug treatment and health and behavioral problems, on how to use evidence-based prevention services; substance including SUDs. 4, 5 Pediatricians strategies to protect and advocate use–related medical condition have an opportunity to help break for children whose parents have management and sequelae; lost multigenerational cycles of child SUDs are important roles that earnings attributable to premature abuse and neglect and substance use the pediatrician can assume. In death, substance use–related illness, by being informed about the effects addition, medical professionals are and loss of employment; goods and of parental substance use on children, mandatory reporters of suspected services associated with substance intervening when necessary, and child maltreatment and may be the use–related crime, criminal justice, collaborating with the family, only professionals who have the motor vehicle crashes, property other health care providers, and opportunity to recognize that a child, damage, and fires; and police, fire appropriate government agencies to especially one of preschool age, has department, adjudication, and address the issues involved. been abused or neglected. sanctioning expenses. 9 Pediatricians are in a unique position The purposes of this clinical report Exposure to substances begins to identify and assess a child’s are to review some of the short- prenatally for many infants. risk in the context of a parent’s term effects of maternal substance Specifically, a study by Patrick et al 10 SUD and intervene to protect the use during pregnancy and long- of a nationally representative sample child. Research has shown that a term implications of fetal exposure; of infants demonstrated that in 2012, majority of parents are accepting describe typical medical, psychiatric, approximately 22 000 infants were of their child’s pediatrician asking and behavioral symptoms of children diagnosed with neonatal abstinence them about their own substance and adolescents in families affected syndrome. Neonatal abstinence use. 6 Pediatricians can include by substance use; and suggest syndrome includes a combination questions about the extent of family proficiencies for pediatricians of physiologic and neurobehavioral substance use as part of the routine involved in the care of children and signs that include such things as family assessment during health adolescents of families affected by sweating, irritability, increased supervision visits or when clinically substance use, including screening muscle tone and activity, feeding indicated. 7 Given the risks to health families, mandated reporting problems, diarrhea, and seizures and and development, children in families requirements, and directing families is the result of prenatal exposure with known or suspected parental to community, regional, or state to opioids followed by withdrawal SUDs may warrant more frequent resources that can address needs at birth. 11 This problem persists, appointments with their pediatrician and problems. Throughout this as evidenced by a recent study that for close medical follow-up or report, the term parent is used, but showed among 112 029 pregnant

e2 Downloaded from http://pediatrics.aappublications.org/ by guest on DecemberFROM 6, 2017 THE AMERICAN ACADEMY OF PEDIATRICS women, 31 354 (28.0%) were TABLE 1 Short- and Long-term Effects of Fetal Substance Exposure prescribed at least 1 opioid pain Effect Alcohol Marijuana Opiates Cocaine Methamphetamine 12 reliever during pregnancy. Short-term effects or birth outcome It is estimated that 1 in 5 children Fetal growth +++ +/− ++ + +++ grows up in a home in which Anomalies −−−− Withdrawal −−+++ - Unknown someone uses drugs or misuses Neurobehavior ++ ++ − alcohol. 7 The exact number of Long-term effects children living with adults with SUDs Growth +++ −−+/− Unknown is unknown 13; however, an estimated Behavior +++ + + + Unknown +++ + +/− + 8.3 million children younger than Cognition Unknown Language +-Unknown + Unknown 18 years (12%) were residing with Achievement +++ + Unknown +/− Unknown at least 1 substance-dependent or Adapted with permission from Behnke et al (2013). 11 +++, strong effect; +, effect; +/−, no consensus about effect; −, no substance-using parent between known effect. 2002 and 2007.14 constituents are fat soluble and can and autonomic regulation, and bind to cannabinoid receptors in poor alertness and orientation. 11 IMPLICATIONS OF FETAL EXPOSURE the fetal brain. 19 Newborn infants Prenatal cocaine exposure also may SECONDARY TO MATERNAL SUBSTANCE can have small-for-gestational- hinder fetal growth. 11 Similarly, USE age head circumference after prenatal methamphetamine Detailed discussions of short- and prenatal exposure to cannabis. 19 exposure can inhibit fetal growth long-term effects of prenatal Fetal exposure to cannabis has and alter neurobehavior (ie, poor substance use on the exposed fetus been associated with subtle movement quality, decreased are available elsewhere. 11, 15 – 17 A neurobehavioral disturbances (ie, arousal, and increased stress).11 brief description follows (Table 1). exaggerated and prolonged startle Prenatal buprenorphine exposure reflexes and increased hand–mouth causes fewer withdrawal symptoms Short-term Medical Effects of Fetal behavior), high-pitched cries, and and, similar to methadone, has a Exposure sleep cycle disturbances with longer duration of action than other The detrimental effects of fetal electroencephalographic changes in opioids.20 exposure to alcohol are well the newborn period.11, 19 Repeated documented. 11, 15, 17 Fetal alcohol fetal exposure to cannabis disrupts Long-term Medical Effects of Fetal spectrum disorders, fetal alcohol endocannabinoid signaling, Exposure effects, prenatal complications (eg, particularly the temporal dynamics Children with prenatal drug prematurity, low birth weight), and of the CB1 cannabinoid receptor, exposure are more likely to develop prolonged postnatal hospitalization and alters fetal cortical circuitry disruptive behavioral disorders all are associated with alcohol use development. 16 Interference with the such as oppositional defiant during the prenatal period, but a full endocannabinoid system disrupts disorder; impaired intellectual and review is beyond the scope of this normal neurobiological development, academic achievement; and cognitive report. particularly of neurotransmitter problems, such as delayed language maturation and neuronal survival. 19 Because there is passive diffusion development, poor memory, and the 2, 6 across the placenta of substances Effects of fetal cocaine and opioid inability to learn from mistakes. smaller than 500 dalton (d), exposure may appear during the Children who were exposed to drugs most illicit and some other newborn period as any of the prenatally also have a higher risk of 2, 6 substances used by a pregnant following symptoms of withdrawal: developing an SUD. Prenatal drug woman will directly affect the irritability, poor and irregular exposure is associated with increased fetus (eg, methamphetamine = feeding patterns, frequent crying, rates of anxiety and mood disorders, 149 d, buprenorphine = 467 d, tremulousness, increased respiratory lower self-esteem, and perceived lack 6 tetrahydrocannabinol [THC] = 314 d).18 and heart rates, hypertonia, an of control over their environment. Exposure to substances during the exaggerated startle response, Fetal alcohol exposure continues to first trimester can affect the structure vomiting, frantic sucking, and affect growth, cognition, behavior, of the developing fetal brain, and difficulty being consoled. 6, 11 language, and achievement exposure during the second and Prenatal cocaine exposure can have throughout life. 11, 17 Children exposed third trimesters may affect brain effects on neurobehavior, which in utero to cannabis may have a function. 18 Marijuana crosses the may manifest clinically as lability small-for-age head circumference placenta, and its psychoactive of state, decreased behavioral well into their teenage years and

PEDIATRICS Volume 138 , number 2 , AugustDownloaded 2016 from http://pediatrics.aappublications.org/ by guest on December 6, 2017 e3 permanent neurobehavioral, TABLE 2 General Warning Signs for Child Abuse cognitive, and intellectual deficits Frequent injuries, bruising, welts, or burns that cannot be suffi ciently explained (eg, cigarette burns, that vary depending on the timing bruises on the face, lips, and mouth or on several surface planes at the same time). and degree of in utero exposure. 16, 19 Withdrawn, fearful, or extreme behavior. Specifically, heavy use (defined as Clusters of bruises, welts, or burns, indicating repeated contact with a hand or instrument. Injuries appear to have a pattern (eg, straight lines or circles) such as marks from a hand, belt, or more than 1 joint, or approximately electric cord. 10 mg of THC, per day) during the Any bruise without a plausible explanation in an infant who is not yet cruising is suspicious for abuse. first trimester has been associated Unusual injuries on children where children do not usually get injured (eg, the torso, back, neck, with lower verbal reasoning skills in buttocks, or thighs). the child, whereas second trimester Is always watchful and “on alert, ” as if waiting for something bad to happen. Shies away from touch, fl inches at sudden movements, or seems afraid to go home. use was associated with impairments of the child’s composite short- Adapted from www.mass. gov/ eohhs/ gov/ departments/ dcf/ child- abuse- neglect/ warning- signs. html. The list presents some general warning signs but is not comprehensive. The criteria for abuse and neglect may vary by region or state. 19 term memory. Children exposed Pediatricians should check their state and local laws for more detailed information. prenatally to heavy amounts of cannabis often struggle with tasks prenatally.20 There is also some emotionally, or sexually abused and requiring visual memory, analysis, evidence of decreased myelination 4 times as likely to be emotionally and integration; acquire language and disrupted striatal cholinergic or physically neglected. 21, 32 Higher skills slowly; show increased levels activity in children of women who rates of neglect have been noted in of aggression; and display poor received buprenorphine during rural populations. 33 The neonatal attention span. 19 pregnancy. 20 Prenatal exposure period, when infants are the most to cocaine may result in behavior, vulnerable, is the period of highest Mothers who have heroin addiction cognition, and language deficits risk of harm. 32 Parenting impairment or are receiving medication- in children. 11 Children who were varies to different degrees depending assisted treatment with methadone exposed to crystal methamphetamine on which substances parents use. 34 may have infants who exhibit prenatally may have developmental Mandatory involvement of child increased activity as well as poorer delays in communication, personal protective services helps ensure a coordination during childhood than and social skills, fine and gross motor child’s safety but may result in the children of similar age without skills, and problem-solving skills child being placed in an alternate prenatal opioid exposure. 4 Children as well as aggressive or withdrawn living situation with a relative with prenatal heroin exposure behaviors. 21 (ie, kinship care) or unrelated have more behavioral problems caregiver.35 Nonetheless, transition (including hyperactivity, brief into foster care may be necessary to attention span, sleep disturbance, PSYCHOSOCIAL IMPACT OF LIVING protect a child’s physical safety. and temper outbursts) at 12 to 24 IN A FAMILY AFFECTED BY PARENTAL months of age; language delay at 24 SUBSTANCE USE The home environment may lack to 32 months of age; and, overall, appropriate childproofing safety more difficulties learning when Parental substance use is associated measures because of transience of compared with their age-matched with myriad family and social housing and parents being distracted peers.4 Similarly, children of mothers problems. 22 – 27 Whether secondary by substance use or alcohol misuse. treated prenatally with methadone to inconsistency in parenting, The use of open flames or lighters maintenance are more impulsive, disruption or lack of healthy family for the consumption or production immature, and irresponsible than routines and rituals, or parental of drugs may increase the dangers of their unexposed peers and also conflict and stress, children of accidental burns, fires, and explosions perform poorly on intelligence tests substance-using parents where children live. Children are at at 3 to 7 years of age. 4 Information typically are denied the security increased risk of acquiring infectious about the long-term developmental that is associated with structure and diseases because of exposure to outcomes of prenatal buprenorphine stability provided by appropriate needles and drug paraphernalia. 21 exposure is limited, and many of the parenting. The parent’s SUD and the Because of the significant cost of reports have conflicting findings. 20 violent and erratic behavior that illicit substance use, household funds Several studies have found that may be associated place the child may be more limited, and parents children with fetal exposure to at higher risk of being abused or with an SUD may struggle to meet prescribed buprenorphine score neglected ( Tables 2 and 3). 21, 28 – 31 their household financial demands.3 lower on Bayley cognitive and Children whose parents use Homes used to produce crystal language scales compared with substances and misuse alcohol are methamphetamine may be unsafe and children who were not exposed 3 times as likely to be physically, uninhabitable because of the presence

e4 Downloaded from http://pediatrics.aappublications.org/ by guest on DecemberFROM 6, 2017 THE AMERICAN ACADEMY OF PEDIATRICS of toxic ingredients and byproducts, TABLE 3 General Warning Signs for Child Neglect including mercury, lead, and other Lack of medical or dental care large breathable particulates that settle Lack of personal care or hygiene (eg, unbathed, matted and unwashed hair, lice or scabies, or noticeable close to the floor.21 Home production body odor) of butane-extracted cannabis may Clothes are ill-fi tting, fi lthy, or inappropriate for the weather Missing key pieces of clothing (eg, underwear, socks, shoes) lead to explosions or house fires. Poor school attendance or frequent tardiness Children living in these chaotic home Lack of supervision (eg, young children left unattended or with other children too young to protect or environments may be at risk for having care for them or being left alone or allowed to play in unsafe situations and environments) contact with people in their house Lack of proper nutrition using or buying drugs; witnessing Lack of adequate shelter Lack of primary medical care, dental care, or immunizations as well as untreated illnesses or injuries criminal behavior and interacting Self-destructive feelings or behavior with criminals; ingesting or inhaling Adapted from www.mass. gov/ eohhs/ gov/ departments/ dcf/ child- abuse- neglect/ warning- signs. html. The list presents drugs or chemicals; being exposed to some general warning signs but is not comprehensive. The criteria for abuse and neglect may vary by region or state. deplorable living conditions, including Pediatricians should check their state and local laws for more detailed information. human waste, vermin, insects, clutter, garbage, and filth; and being subjected documented, it is not necessarily a risk of having problems ranging to sexual abuse and trafficking. direct causal relationship, because from serious medical conditions a significant portion of adults to psychobehavioral difficulties. Because of potential for abuse, with SUDs also have concurrent Compared with their peers whose neglect, and a hazardous home mental illness, including anxiety, parents do not have SUDs, they environment, children whose parents depression, and posttraumatic stress are twice as likely to sustain have SUDs tend to come to the disorder.32 Parents with SUDs often serious injuries, increasing the attention of child welfare agencies experience financial instability, food risks of missed time from school, at a younger age than other children and housing insecurity, a chaotic hospitalization, or surgical and are more likely than other living environment, inconsistent treatment. 43 –47 A recent study found children to be placed and remain in employment, domestic violence, social that 23% of children whose mothers foster care. 36 Many families receiving stigma or isolation, incarceration, were substance users were not child welfare services are affected by and stress.3, 32 Parental substance engaged with routine child health parental substance use. 37 – 39 The US use has been linked with negative services at any point during the first Department of Health and Human parental behaviors that include 2 years of life. 3 Mothers of drug- Services concluded that parental lower levels of parental involvement, exposed newborn infants may be ill substance abuse is a contributing limited or absent parental monitoring, equipped to cope with their infants’ factor for one-third to two-thirds of ineffective control of children’s health care needs. 6 Youth whose children being involved with the child behaviors, and poor discipline skills parents have SUDs are more likely welfare system.37 This estimate is including use of coercive control, to be neglected, and chronic neglect based on very old data, and as noted harsh discipline, and failure to follow has more long-term implications by a recent review, parental SUD through.42 Collectively, these factors for a child’s mental health and prevalence rates based on these older all contribute to substance use development than do abuse and data may no longer be representative and child mistreatment. Any single other forms of maltreatment. 48 of current trends, but more current factor, such as prenatal substance data are lacking. 38 exposure, may be less salient to the Mental health problems experienced overall developmental outcome of by children of parents with SUDs Despite early maternal intentions these children than the cumulative can include anxiety disorders, and supportive interventions, 27% of effects of exposure in the context of attention-deficit/hyperactivity children born to women with significant multiple home environmental and disorder, depression, oppositional SUDs needed the involvement of circumstance risks. defiant disorder, conduct disorder, child protective services during the truancy, and trauma and stress- preschool years.40 An estimated 20% related disorders.49, 50 It has been of substantiated cases of child abuse MEDICAL, PSYCHIATRIC, AND noted recently that among children or neglect were associated with an BEHAVIORAL SYMPTOMS OF CHILDREN whose parents have SUDs, children SUD in the caregiver, and nearly 10% AND ADOLESCENTS IN FAMILIES in rural populations have a greater involved a caregiver with an alcohol use AFFECTED BY PARENTAL SUBSTANCE risk of mental health problems. 33 disorder.41 USE Adverse childhood experiences Although the link between child abuse Children and adolescents of include abuse (eg, emotional, and neglect and substance use is well parents with SUDs are at greater physical, or sexual), neglect

PEDIATRICS Volume 138 , number 2 , AugustDownloaded 2016 from http://pediatrics.aappublications.org/ by guest on December 6, 2017 e5 (eg, emotional or physical), and interact with a health care provider of contact, pediatricians generally household dysfunction (eg, substance who demonstrates empathy and ask about feeding methods. abuse, mental illness, intimate knowledge regarding the effects of Providing information to a mother partner violence, incarceration, or prenatal substance use, the process of with a history of substance use separation or divorce), and these engagement has a better start. Many about possible transmission of events may exceed the child’s coping times, the likelihood of engagement substances, including ethanol, into mechanisms, resulting in permanent depends on the confidence the family human milk may open the door to changes in the developing brain. 51, 52 has that the health care providers a deeper discussion of the mother’s These brain changes can manifest meeting them at the intense period substance use. Medically prescribed as behavior problems, violence, and of birth will continue comprehensive buprenorphine or methadone is not substance use health risk behaviors care and that their issues will be a contraindication to breastfeeding. by the child through the life span. 52 incorporated into a care plan. Recommendations regarding the support of breastfeeding and Educational problems are especially As an approach to engaging families, potential effects on the newborn common in children exposed to pediatricians may want to first ask brain from passage of these substance use. 53 These educational about subjects remote from the substances warrant additional problems may be secondary to substance use issue. Inquiring about investigation and consensus. 59 baseline cognitive limitations as other topics such as, “Do you have a result of perinatal substance any medical problems? Are there In a perfect health care system, exposure or external distraction from any mental health problems such the mother’s health history would a chaotic and unstructured home as depression or anxiety disorders include sequential screening for environment. Children affected by in the family?” before moving to alcohol, tobacco, and substance parental substance use may have a questions like, “Do you or anyone in use throughout the pregnancy, high absenteeism rate and impaired your home smoke? Do you or anyone and obstetric providers would attention, compromising their in your home drink alcohol? Do you communicate concerns to the academic productivity. Behavior or anyone in your home use drugs?” pediatric team caring for the problems place children at greater may be better received by parents, infant. With potentially concerning risk of suspension or expulsion from because it allows the provider to information, the discharging school. establish an initial rapport with medical team might offer the mother Children are often distressed by their parents around portions of their resources to support her intentions parents’ substance use.54 Children health that may be perceived as less of becoming a good parent for the may blame themselves for the parents’ threatening. infant with substance exposure. behavior and may feel responsible Those services might include home for its cure. Children’s prolonged In the nursery setting, a new mother visiting, direction to home- and exposure to inappropriate modeling typically has a great interest in community-based services such as of substance use increases their discussing all health issues that might those that exist in Indian Health vulnerability to future substance affect her infant. Taking a history that Service units, insurance company use.55 Children of alcoholics are nearly includes questions such as, “Before case managers, specialized clinics, 4 times more likely to have an alcohol you knew you were pregnant, how developmental follow-up, and use disorder, with rates of hazardous would you describe your use of primary care settings that embrace use starting in the adolescent years alcohol?” and then asking, “After you the care of mothers with SUDs and and continuing into adulthood.56 –58 knew of your pregnancy, how would infants with prenatal exposure. you describe your use of alcohol?” Incorporating a short screening allows the mother to discuss the tool and directing parents who METHODS TO ASSESS AND ENGAGE changes she attempted and provides screen positive back to either their THE FAMILY AFFECTED BY PARENTAL information to the pediatrician about own primary care physician or a SUBSTANCE USE either assisted or self-initiated harm specialist is a practical approach. Pediatricians have a unique reduction. Similarly, inquiring about Bright Futures: Guidelines for Health opportunity to identify and engage tobacco, prescription medications Supervision of Infants, Children, families affected by substance use. with attention to opioids and and Adolescents60 recommends The opportunities for pediatricians sedative hypnotics, marijuana, developmental screening by a to engage with a family begin with cocaine, methamphetamine, and standardized instrument, such as the transition of the mother from heroin could be included. the Ages & Stages Questionnaires, prenatal care to delivery of an In the office setting, during the Third Edition (ASQ-3), matched infant. If the mother and family newborn period and first months with the clinical examination,

e6 Downloaded from http://pediatrics.aappublications.org/ by guest on DecemberFROM 6, 2017 THE AMERICAN ACADEMY OF PEDIATRICS to assess developmental delays screened by a more comprehensive the opportunity for disagreement. possibly related to prenatal substance use instrument, probably Parents can be directed back substance exposure or neglect by his or her primary care physician. to their primary care physician of the child’s nutrition and Once a parent has screened positive, for management and services. 61 socioemotional needs. For example, a provider may use the time as a Pediatricians may find it efficient to reports by parents of advanced teaching moment to engage the have a prepared list of community, communicative development parent, explain the results, express regional, state, and national may not be substantiated by concern, provide a more structured resources from which to choose and verbal communication or capacity brief intervention incorporating to offer to parents. Likewise, options noted during the examination. nonjudgmental, motivational for adult primary care physicians In addition, attention to growth interviewing-informed interactions, can be helpful for parents without an trends, particularly weight patterns, and suggest a more complete established medical home. provides important information evaluation by the parent’s primary Parent screening for medical, in early infancy about adequacy of care physician. If the results of a psychiatric, psychosocial, and feeding, particularly if the mother screen are positive and the parent substance use disorders can help has initiated breastfeeding. Between would like more information about identify problems. If present, possible 9 and 24 months of age, deceleration treatment locations, the Substance signs and symptoms associated with of weight gain can indicate family Abuse and Mental Health Services acute substance intoxication (eg, system stresses and inattention to Administration has a searchable pinpoint pupils, frequent yawning, the child’s feeding in the home. database of treatment locations slurred speech, excessive attention throughout the United States (http:// to external stimuli, ataxic gait, or Some pediatricians can feel findtreatment. samhsa. gov). incoherent thought patterns) can overwhelmed by what they perceive be objectively documented in the as their inability to screen parents As a reference, several short tools child’s medical record. Office staff and react to a positive screen are available to screen for substance could be encouraged to report any successfully during a 15-minute use by family members. The Alcohol of these signs or symptoms to the appointment. To help, some Use Disorders Identification Test pediatrician. 67 Additional guidance brief screening questions could Consumption questions for alcohol on dealing with the judgment- be incorporated into a routine and the Drug Abuse Screening Test impaired parent in the pediatric health surveillance office visit. The for drugs are 2 tools that are short 64–66 office can be found in another National Institute on Alcohol Abuse but garner vital information. clinical report from the American and Alcoholism recommends the NIDA also provides a resource Academy of Pediatrics. 13 Indications use of a single screening question guide for substance use screening of abuse or neglect would require to accurately identify unhealthy in the general medical setting that 63 a mandatory report to the child alcohol use. The question, “How includes sample scripts. As with protective services agency. many times in the past year have the single-question screening tools, you had X or more drinks in a day?” pediatricians using the short tools Research has shown that parents (in which X is 5 for men and 4 for to screen need to be prepared to who screened positive for substance women, and a response of >1 is direct parents who screen positive use were open to the pediatrician considered positive) has shown to their primary care physician or discussing their use with them good sensitivity and specificity for another specialty provider for a more and presenting the parents with detection of unhealthy alcohol use standardized brief intervention. follow-up options. 67 With supportive in a primary care population. 62 The It is difficult to anticipate a parent’s care, parents often are willing to National Institute on Drug Abuse reaction to a discussion about enter drug treatment or engage in (NIDA) has a single-question drug their substance use. Therefore, harm reduction on behalf of their screen: “How many times in the past providers are encouraged to secure children. Even when parents do not year have you used an illegal drug a supportive and safe environment go to treatment, they may reduce or used a prescription medication for the conversation to occur. When use of the substances that they for nonmedical reasons?” 63 If the engaging in the conversation, a view as more threatening, such as answer is “Never” for all drugs, NIDA nonjudgmental, nonaccusatory methamphetamine, but increase recommends that the physician tone will help to convey to parents marijuana or tobacco use. Parents reinforce abstinence. However, if the pediatrician’s concern for them may also decrease their substance the answer is for any use of illegal or and their child. Objectively sharing use even if they do not completely prescription drugs for nonmedical the facts of the screen results and abstain. Therefore, pediatricians reasons, the parent needs to be other observations will decrease can feel empowered to address

PEDIATRICS Volume 138 , number 2 , AugustDownloaded 2016 from http://pediatrics.aappublications.org/ by guest on December 6, 2017 e7 these topics when speaking with the commissure. The combined presence of proficiency for a primary care parent. of patterned cutaneous or skeletal provider who is not primarily injury appearing over unusual managing substance use. Additional In addition to screening of parents, locations (eg, posterior surfaces, proficiencies are suggested (Table 4) a careful physical examination of soft tissues, genitalia) may indicate for health care providers who the child should be performed in all additional inquiry or investigation accept responsibility for prevention, situations in which abuse or neglect to establish or allay suspicions of assessment, intervention, and is suspected, because important possible physical abuse and/or an coordination of care and those cutaneous findings can be concealed underlying medical condition. 71, 72 who accept responsibility for long- easily by clothing ( Tables 2 and Similarly, any abnormality noted on term treatment of children and 3). Although skin findings alone physical examination of the genitals adolescents in families affected by are not specific for maltreatment, or anal area that is consistent with substance use. their presence and the particular trauma may indicate additional Level 1 is a basic understanding of characteristics of findings, such inquiry to allay suspicion for the biology of addiction, including as bruises, lacerations, abrasions, possible sexual abuse. 73 However, recognition that drug and alcohol burns or thermal injuries, and bite in all states, suspected child abuse addiction are chronic and relapsing marks, could raise suspicion for or neglect requires the filing of a neurologic disorders that result abuse. Any bruise without a plausible mandated report with the state child from various drug effects on the explanation or a skeletal injury in protective services agency. All health brain’s reward circuitries and an infant who is not yet cruising can care professionals need to become neurotransmitter systems. 76 Chronic raise suspicion for abuse. 68 Bruises familiar with the specific reporting drug exposure may ultimately are common on young ambulatory laws governing their state and know impair the function of brain regions children, with the most common what exactly to report. involved with motivation and self- sites being the anterior tibia or When a mandatory report to child control. 76 Awareness of the medical, knee, forehead, scalp, and upper protective services is necessary, psychiatric, and behavioral signs leg (ie, anterior surfaces and bony health care professionals can engage and symptoms of substance use prominences). It is far less common the families in this process with may assist health care providers in for children to have bruising over a transparent and caring direct identifying affected families. 74 posterior surfaces, the chest, the face approach. To set the stage for a (except for forehead), the buttocks, transparent interaction up front, a Substance use screening that is age, 68, 69 or hands. Bruising in these areas health care professional can discuss sex, and culturally appropriate can as well as protected areas, such as all of the following: the risks to and be included in routine pediatric 75 the abdomen, genitalia, and ears, in effects on children related to parental health maintenance care. By using infants and toddlers, although still substance abuse, the requirements motivational interviewing techniques nonspecific, is suspicious for inflicted for mandated reporting to child (asking screening questions, 68–70 trauma. Patterned bruises might protective services, the resources and developing discrepancy, expressing suggest a device or implement was services available to the family, and empathy, avoiding argumentation, used to cause the injury. Children how child welfare can be a support to rolling with resistance, and struck with linear objects (eg, rods, the family. supporting patient self-efficacy), rulers, belts) may present with linear a provider can assist families in configured scars. Likewise, flexible identifying problems substance use implements that are doubled over SUGGESTED PROFICIENCIES FOR can cause and reasons a person may (eg, ropes, cords, chains) can leave PEDIATRICIANS INVOLVED IN THE CARE want to quit or cut back. 75 Substance a loop-configured bruise, abrasion, OF CHILDREN AND ADOLESCENTS OF use screening could include review or scar at the site of contact. Slap FAMILIES AFFECTED BY SUBSTANCE of the mother’s prenatal medical USE marks may appear as a negative information and screening by image such that an outline of the In 1999, Adger et al 74 defined history and, when indicated, urine handprint is created on the skin potential levels of proficiencies for toxicologic testing in the newborn as a result of blood extravasation pediatricians that varied depending period before hospital discharge. from vessels into the surrounding on their experience with substance It is helpful for the pediatrician to interstitial space. Binding devices (eg, use treatment. For the purpose of understand the interpretation of wires, ropes, cords) may manifest as this report, those recommendations positive urine drug screens in the circumferentially configured bruises, are updated and supplemented on mother and infant. In addition, it is lacerations, or abrasions involving the basis of more recent literature helpful for pediatricians to provide the neck, wrists, ankles, or oral focusing on a reasonable level brief interventions to adolescent

e8 Downloaded from http://pediatrics.aappublications.org/ by guest on DecemberFROM 6, 2017 THE AMERICAN ACADEMY OF PEDIATRICS patients with positive screens for TABLE 4 Suggested Profi ciencies for Pediatricians 75,77, 78 substance use. Be able to direct Level 1: For all health professionals with clinical responsibility for the care of children and adolescents: families to community, regional, or Be aware of the medical, psychiatric, and behavioral syndromes and symptoms with which children state resources available for children and adolescents in families with substance use present and of the potential benefi t to both the and adolescents in families with child and the family of timely and early intervention. Be familiar with and able to direct families to community, regional, and state resources available for substance use. Discussing identified children and adolescents in families with substance use. concerns with the family and As part of the general health assessment of children and adolescents, health professionals include offering information, support, and appropriate screening for family history and current use of alcohol and other drugs by parents. follow-up are components of quality Use motivational interviewing techniques (asking screening questions, developing discrepancy, pediatric care. 74 It is important for expressing empathy, avoiding argumentation, rolling with resistance, and supporting patient self- effi cacy), assist families in identifying problems substance use can cause and reasons a person pediatricians to develop respectful, may want to quit or cut back.75 compassionate approaches Assist parents who screen positive and identify treatment options. regardless of condition, ethnicity, age, Offer information, support, and follow-up for parents who screen positive. or sexual orientation. 75 Understand state mandatory child abuse reporting laws and know how to make a report to the responsible investigating agency. Because health care providers are Level II: In addition to Level I profi ciencies, health care providers accepting responsibility for prevention, mandated reporters, they should assessment, intervention, and coordination of care of children and adolescents in families with understand obligatory child abuse substance use may: Apprise the family of the nature of SUDs and their effects on all family members and strategies for reporting laws in their states achieving optimal health and recovery. and should know how to make a Recognize and treat, or refer, all associated health problems in the child. report to the responsible agency Evaluate resources (physical health, economic, interpersonal, and social) to the degree necessary to that investigates cases of alleged formulate an initial management plan. Determine the need to involve extended family and other support people in the initial management child abuse or neglect in their plan. 73 jurisdiction. Develop a long-term management plan in consideration of the above standards and with the child’s or adolescent’s participation. Level III: In addition to Level I and II profi ciencies, the health care provider with additional training, who COLLABORATING WITH OTHER accepts responsibility for long-term treatment of children and adolescents in families with substance PROVIDERS use, may: Acquire knowledge, by training or experience, in the medical and behavioral treatment of children in Using a multidisciplinary approach, families affected by substance use. providers can do much to protect Throughout the course of health care treatment, continually monitor and treat, or refer for care, any drug-endangered children when they health needs or psychiatric or behavioral disturbances of the child or adolescent. Acquire knowledge, by training or experience, of the recovery process and gain an understanding of work together across specialties and how to establish and evaluate screening, brief intervention, and referral to treatment systems in disciplines. It is important for the practice.75 various professionals who have the Request consultation as needed. opportunity to recognize a child at risk Be available to the child or adolescent and the family, as needed, for ongoing care and support. to understand their role in protecting Adapted with permission from Adger et al (1999).74 and providing services to that child and the role of other professionals and for parents who screen positive, Substance Abuse and Mental Health who may be involved with the same discuss options for access to treatment Services Administration: www. family. Reaching outside the silos of from their primary care physician or an samhsa. gov one’s profession in a collaborative appropriate specialist; be alert for signs Massachusetts Department of Health fashion greatly increases the chance of child abuse or neglect in children and Human Services: www. mass. for more informed decision-making and families affected by substance use; gov/ eohhs/ gov/ departments/ dcf/ regarding families affected by parental monitor children for developmental child- abuse- neglect substance use. delays and other academic difficulties; and be familiar with mandatory Child Welfare Information Gateway: reporting requirements for suspected www. childwelfare. gov SUMMARY child abuse and neglect. Drug Endangered Children: www. Substance use is a major public health whitehouse. gov/ ondcp/ dec- info Government Web Sites concern in the United States, and National Web Sites substance use disorders are common. National Institute on Drug Abuse: Pediatricians are likely to encounter www. drugabuse. gov Monitoring the Future: www. families affected by parental substance monitoringthefutu re. org use. Pediatricians are encouraged National Institute on Alcohol Abuse Youth Risk Behavior Surveillance: to screen parents for substance use, and Alcoholism: www. niaaa. nih. gov www. cdc. gov/ HealthyYouth/ yrbs

PEDIATRICS Volume 138 , number 2 , AugustDownloaded 2016 from http://pediatrics.aappublications.org/ by guest on December 6, 2017 e9 National Survey on Drug Use and LIAISONS From the 2013 National Survey on Health: www. samhsa. gov/ data/ Vivian B. Faden, PhD – National Institute of Alcohol Drug Use and Health: Summary of population- data- nsduh Abuse and Alcoholism National Findings. NSDUH Series H-48. Gregory Tau, MD, PhD – American Academy of HHS Publication No. (SMA) 14-4863. National Resource Center for Child and Adolescent Psychiatry Rockville, MD: Substance Abuse and In-Home Services, In-Home Mental Health Services Administration; Programs for Drug Affected STAFF 2014 Families: https://nrcihs- stage. Renee Jarrett, MPH 9. Miller TR, Hendrie D. Substance Abuse icfwebservices.com/ sites/ Prevention Dollars and Cents: A default/files/ drugaffectedmemo. ABBREVIATIONS Cost–Benefi t Analysis. Rockville, MD: pdf US Department of Health and Human NIDA: National Institute on Drug Children and Family Futures: www. Services, Substance Abuse and Mental Abuse Health Services Administration, Center cffutures. org SUD: substance use disorder for Substance Abuse Prevention; 2009 National Alliance for Drug 10. Patrick SW, Davis MM, Lehmann CU, Endangered Children: www. Cooper WO. Increasing incidence and nationaldec. org geographic distribution of neonatal National Association for Children of REFERENCES abstinence syndrome: United States Alcoholics: www. nacoa. org 2009 to 2012 [published correction 1. National Alliance for Drug Endangered appears in J Perinatol. 2015;35(8):667]. Bright Futures: brightfutures.aap.org Children. The problem. Available at: J Perinatol. 2015;35(8):650–655 www.nationaldec. org/ theproblem. html. Street Drug Name Web Sites Accessed November 3, 2015 11. Behnke M, Smith VC; Committee on Substance Abuse; Committee on Fetus www. drug- slang. com 2. Jessepe L. Abuse and neglect: the toxic and Newborn. Prenatal substance lives of drug endangered children. www. streetlightpublic ations. net/ abuse: short- and long-term effects Indian Country Today Media Network. on the exposed fetus. Pediatrics. misc/ ondcp. htm July 21, 2014. Available at: http:// 2013;131(3). Available at: www. www. urban75. com/ Drugs/ drugterm. indiancountrytoda ymedianetwork. com. pediatrics. org/ cgi/ content/ full/ 131/ 3/ Accessed November 3, 2015 html e1009 3. Callaghan T, Crimmins J, Schweitzer 12. Patrick SW, Dudley J, Martin PR, et al. Offi ce Safety Web Sites RD. Children of substance-using Prescription opioid epidemic mothers: child health engagement and Occupational Safety and Health and infant outcomes. Pediatrics. child protection outcomes. J Paediatr 2015;135(5):842–850 Administration (OSHA): www. osha. Child Health. 2011;47(4):223–227 gov 13. Fraser JJ Jr, McAbee GN; American 4. Johnson JL, Leff M. Children of Academy of Pediatrics Committee Treatment Locations substance abusers: overview of on Medical Liability. Dealing with the research fi ndings. Pediatrics. A searchable directory of 12 000 parent whose judgment is impaired 1999;103(5 pt 2):1085–1099 by alcohol or drugs: legal and facilities with treatment programs 5. Bailey JA, Hill KG, Oesterle S, Hawkins ethical considerations. Pediatrics. for drug and alcohol abuse JD. Linking substance use and 2004;114(3):869–873 throughout the United States: http:// problem behavior across three findtreatment. samhsa. gov 14. Substance Abuse and Mental Health generations. J Abnorm Child Psychol. Services Administration, Offi ce of 2006;34(3):263–292 Applied Studies. The NSDUH Report: LEAD AUTHORS 6. Dore MM, Doris JM, Wright P. Children Living With Substance- Vincent C. Smith, MD, MPH, FAAP Identifying substance abuse in Depending or Substance-Abusing Celeste R. Wilson, MD, FAAP maltreating families: a child Parents: 2002–2007. Rockville, MD: welfare challenge. Child Abuse Negl. Substance Abuse and Mental Health COMMITTEE ON SUBSTANCE USE AND 1995;19(5):531–543 Services Administration; 2009 PREVENTION, 2015–2016 7. Kulig JW; American Academy of 15. Hoyme HE, May PA, Kalberg WO, et al. Sheryl A. Ryan, MD, FAAP, Chairperson Pediatrics Committee on Substance A practical clinical approach to Pamela K. Gonzalez, MD, MS, FAAP Abuse. Tobacco, alcohol, and other diagnosis of fetal alcohol spectrum Stephen W. Patrick, MD, MPH, MS, FAAP Joanna Quigley, MD, FAAP drugs: the role of the pediatrician disorders: clarifi cation of the Lorena Siqueira, MD, MSPH, FAAP in prevention, identifi cation, and 1996 Institute of Medicine criteria. Leslie R. Walker, MD, FAAP management of substance abuse. Pediatrics. 2005;115(1):39–47 Pediatrics. 2005;115(3):816–821 16. Tortoriello G, Morris CV, Alpar FORMER COMMITTEE MEMBER 8. Substance Abuse and Mental Health A, et al. Miswiring the brain: Vincent C. Smith, MD, MPH, FAAP Services Administration. Results Δ9-tetrahydrocannabinol disrupts

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2016/07/14/peds.2 016-1575 References This article cites 65 articles, 18 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2016/07/14/peds.2 016-1575.full#ref-list-1 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Substance Use http://classic.pediatrics.aappublications.org/cgi/collection/substance_ abuse_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: https://shop.aap.org/licensing-permissions/ Reprints Information about ordering reprints can be found online: http://classic.pediatrics.aappublications.org/content/reprints

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since . Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .

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