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Beyond the Hospital: Nurturing the Drug Exposed Baby. Margaret McLaren, MD Connecticut Children’s Medical Center University of Connecticut School of Medicine. Outcome of Prenatal Drug Exposure - Trends. Late 1990s Much ado about nothing. 1980s Lost generation.

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Beyond the hospital nurturing the drug exposed baby

Beyond the Hospital:Nurturing the Drug Exposed Baby

Margaret McLaren, MD

Connecticut Children’s Medical Center

University of Connecticut School of Medicine

Outcome of prenatal drug exposure trends
Outcome of Prenatal Drug Exposure - Trends

Late 1990sMuch ado about nothing

1980sLost generation

2000s Biological vulnerability ?

Infants of substance using mothers double jeopardy
Infants of Substance Using MothersDouble Jeopardy

Biological vulnerability + environmental risk factors

  • Effects of PDE on infant/child

  • Effects of SU on parental behavior

  • Antecedents of maternal substance use

  • Co-risk factors


Increased risk of

Developmental/ behavioral problems

Child maltreatment

Caregiver disruption & foster care



  • Remove child from potential harm

    • Disruption

    • Increase in foster/ kinship placement

    • Delayed reunification until mother “proves herself”

  • Strengthen care-giving environment while keeping child visible

Beyond the hospital nurturing the drug exposed baby

The postnatal care-giving environment is a powerful toolthatcan positively affect outcome through prevention of new/ further insults and promotion of a secure attachment relationship

Advances in neurobiology
Advances in Neurobiology

  • PLASTICITY of the brain

  • Sensitive periods for development

  • Context - relationships

  • First 2 yrs - emotional development

  • 1st year - EMPATHY

  • 1st 1.5 years - ATTACHMENT

Beyond the hospital nurturing the drug exposed baby












  • The development of attachment relationships between children and their caregivers constitutes one of the most important aspects of human social and emotional development

    View of self, significant others, social world

Healthy secure attachment
Healthy (Secure) Attachment

  • Major developmental task

  • Protective factor for RESILIENCE

  • Promoter: A care giver - able and willing to engage in the intimate dance which occurs between a mother and her infant.

Attachment patterns mary ainsworth


Secure - B

Insecure /ambivalent - C

Insecure/ avoidant - A

Care-giving Environment

Sensitive, responsive, positive regard

Inconsistently sensitive/ responsive

Insensitive. hostile, avoidant of contact

Attachment Patterns(Mary Ainsworth)

Disorganized attachment d mary main
Disorganized Attachment (D)(Mary Main)

Risk factors:

  • Unresolved trauma, loss/ rejection,

  • Child maltreatment,

  • Substance use

    Strongest predictor of psychopathology

Effects of separation on substance using mothers
Effects of Separation on Substance Using Mothers

  • Mothering = most important aspect of getting life back together for many women with chemical dependency - the glue that holds everything else in place

  • Loss/ separation leads to grieving, depression, & intensified use

Attachment patterns in infants with prenatal substance exposure rodning beckwith howard 1991



Bio mother 20%

Abstinent 50%





(A) (C)

80% 30% 50%


90% 54% 36%

72% 43% 29%

36% 16% 20%

Attachment Patterns in Infants With Prenatal Substance Exposure (Rodning, Beckwith, Howard, 1991)

Disorganized attachment in infants with prenatal substance exposure
Disorganized Attachment in Infants With Prenatal Substance Exposure

  • Bio mother 75%

  • Kinship 64%

  • Foster 71%

  • Control12%

    (Rodning, Beckwith, Howard, 1991)

Characteristics of alternative care givers of de infants




Fewer bio visits

More placements

More resources

More adaptive

Attachment issues


Fear “sick” baby


More frequent bio visits

More stability

Fewer resources

Conflict as gatekeepers

Characteristics of Alternative Care-givers of DE Infants

Beyond the hospital nurturing the drug exposed baby

Effect of labeling
Effect of Labeling

  • Yale Study (Mayes et al)

  • College students observed children at play

  • Told some were “CE” and some “NCE”

    Significantly rated “CE children” as having more problem behaviors

Prokids plus
PROkids Plus


Resilience &

Optimal development

Through enhancing the mother-child relationship & the well-being of both

Prokids plus1
PROkids Plus

  • 0 to 3 months of age at entry

  • A system’s model based on attachment and relational theory

  • Works with biological and/ or alternative care-givers

  • Stays with the child irrespective of placement


  • Expanded well child visits

  • Developmental follow-up & parenting support

    Plus (since 12/2000)

  • Home visitation, case management & family development

  • Motivational enhancement

  • Collaboration and advocacy

Prokids clinic
PROkids Clinic

  • Primary Care as a portal of entry

  • Non stigmatizing, normal parental activity

  • Essential ingredient = TRUST

  • Visits expanded in frequency and duration

  • Addresses medical, social, & developmental needs

  • Parallel tracks with bio and foster parents

Family development home visitation component
Family Development / Home Visitation Component

  • 2 social workers and 3.5 paraprofessional family development workers

  • Group support – Family Life Education

  • Therapeutic relationships

  • Addiction / recovery needs


Empathic care model


Enhancement of the parent-infant relationship within the real life context of the caregiver’s multiple intense needs

PROkids Plus 2004

Essential ingredient
Essential Ingredient

  • EMPATHY – The ability to feel for another and SHOW compassion while maintaining healthy psychological boundaries

Essential strategies of empathic care

Parallel processing

Do unto others what you would them do to others.

Staff to staff

Staff to caregiver

Caregiver to child


Holding in mind & focusing on the needs of the child & parent-child relationship while addressing multiple needs of family/ crises.

Essential strategies of EMPATHIC CARE*

Intervention principles empathic care


Maintain contact


Affect attunement

Tuning into the baby’s cues

Holding in mind/ Pivot

Internal working models



Affirm strengths

Respect/ reflection


*PROkids Plus

Intervention PrinciplesEMPATHIC CARE *

Beyond the hospital nurturing the drug exposed baby

“The more parents experience positive supportive relationships, the more opportunities they have to enhance their internal working models of themselves, their infants and their relationships with their infants.”

Gowen, Nebrig, 1997

Beyond the hospital nurturing the drug exposed baby

Phases of empathic care

0 to 3 months: dyadic intervention.

3 to 6 months:

7 to 18 months:

19 to 36 months:

Window of opportunity

The dance - Building blocks of


Securing base from which to


Reciprocal attachment


0 to 3 months window of opportunity

Openness to transformation dyadic intervention.

Shift to the baby

Preoccupied with love and fear for infant’s safety

0 to 3 Months: “Window of Opportunity”

Beyond the hospital nurturing the drug exposed baby

“My baby is my butterfly – he saved my life.” dyadic intervention.

-A PROkids mom

Window of opportunity

Caregiver dyadic intervention.

Mothering constellation (Stern)

Addiction – less priority

Relapse risk

Intrusion - DCF



Cues / state

Sensory capacities

Response to cry, soothing


Window of Opportunity

Infant carrying project
Infant Carrying Project dyadic intervention.

Feeding behavior at 1 month

Mother dyadic intervention.

Cocaine Less flexible,

Less engaged

Opiate Increased



No effects

Prolonged sucking bursts, fewer pauses, more feeding problems, more arousal

LaGasse LL et al, Arch Dis Child Fetal Neonatal Ed 2003;88:F391-F399

Feeding Behavior at 1 Month

4 to 6 months dancing together
4 to 6 Months: dyadic intervention.“Dancing Together” -

Building blocks of attachment


  • Develop reciprocal positive interactions

  • Help mothers maintain the child as their primary relationship

  • Prevent substances resuming the primary position

Dancing together

Caregiver dyadic intervention.


Contingent responses

Mother’s identity begins to shift to “addict”

Staff parallels interaction with caregiver


Enhancing positive affect

Soothing negative affect

Readiness to interact

Avoiding over-stimulation

Face en face

Following lead

Routines & quiet time

Dancing Together

7 to 18 months securing a base from which to explore

Caregiver dyadic intervention.


Effects of trauma

Cultural attitudes

Relapse risk in toddlerdom !

Secure base for recovery / safety

Building supports

Videotaped interactions


Providing a secure base

Positive exploration


Sharing positive affect/ joy

Playing together

Reunions / repair

7 to 18 Months: Securing a Base From Which to Explore

19 to 36 months reciprocal attachment
19 to 36 months: dyadic intervention.Reciprocal attachment

  • Pattern organized,

  • Emerging autonomy

  • Alter trajectory if insecure/ disorganized.

  • Self efficacy

Reducing risks of separation
Reducing Risks of Separation: dyadic intervention.

  • Facilitate regular contact with care-giver – including medical visits ( triadic approach)

  • Nurture stable alternative family (experience does not equal competence)

  • Educate child welfare & the court on importance of attachment in guiding placement decisions, visitation frequency, and permanency time lines

  • Understand relapse and recovery

Understanding relapse
Understanding Relapse dyadic intervention.

“Relapse is part of recovery. Don’t take my baby !”

- A PROkids Mom to DCF and the police as they come to take her baby:

A useful analogy
A Useful Analogy……. dyadic intervention.

  • For toddler, learning to walk – frequent falls before mastery

  • For mother, learning to stay in recovery – relapses may occur on the way, but it is possible to get up again and again, each time a little stronger until eventually mastery is achieved.

Facilitating reunification
Facilitating Reunification dyadic intervention.

  • The infant should not be a stranger to her biological mother.

  • The mother should feel that she has remained important in her child’s life and has participated in her rearing.

  • The foster mother’s role is valued as a “comadre” and guide to the biological mother and her child.

How does this approach differ from others
How Does this Approach Differ from Others? dyadic intervention.

  • Relational focus, on all levels

  • Emotional development focus

  • Fostering adaptive internal models

  • Strength-based / efficacy-promoting

  • “Facilitating” non- hierarchical model

The power of the relationship approach
The Power of the Relationship Approach dyadic intervention.

  • Motivation for treatment and recovery

  • Healing potential for trauma/ loss

  • Enhances the emotional development of both mother & child

  • Protective factor for resilience

  • Interruption of intergenerational cycles

Training supervision
Training & Supervision dyadic intervention.

  • Hiring – Empathy cannot be taught

  • Empathic Care - A blueprint for supervision

  • Training – trauma, MET, attachment

  • Requires a shift in traditional paradigms – relationship as the focus

Beyond the hospital nurturing the drug exposed baby

OUTCOMES dyadic intervention.

  • A medical home

  • Achieved Healthy People 2000 primary health care goals

  • Reduced risk of maltreatment incidents

  • Decrease use of ER

Placement outcomes
Placement Outcomes dyadic intervention.

  • 78% of infants discharged to their biological mothers are still in their care at 18 months

  • 22% of infants discharged to alternative care are reunified by 18 months.

Co workers

Chrystal Balicki – Program coordinator dyadic intervention.

Dorien Barnett APRN

Lise Banach RN - Clinic nurse

Michael Coyle - Psychologist

Juanita DeJesus – Administrative assistant

Ann Heaney RN – Developmental coordinator

Ann Kiwanuka APRN

Lucretia Klieback – Social worker

Sally Leed RN– Developmental nurse

Sweets Wilson – Social worker

Family development workers – Marilyn Claudio, Marilyn Cosme, Sakina Maldonado, Angie Portillo,

Co- workers

Colleagues dyadic intervention.

  • Karen Steinberg PhD– UConn

  • Julian Ford PhD - UConn

  • Jennifer Haley – UConn evaluation team

  • Jocelyn – Hispanic Health Council

  • Tere Foley & Peter Panzarella – DCF

  • Lisa Candells – Family Life Education