1. Welcome to MCH Scholars Richard P. Barth Dean and Professor University of Maryland School of Social Work January 7, 2012 On the Topic of Substance Exposed Newborns

2. Goals for My Remarks Recognize the Importance of the MCH Social Work Training Grant and the MCH SSW Maternal and Child Health Mini-mister Recognize the Student and Faculty Leadership Raise a major question about contribution of risks to children –PDE and/or or Adversity? Talk about Toxic Stress and a UMB-grown approach to reducing it!

3. PDE or Early Adversity? What are the effects on behavior of children? What are the effects on executive functioning of children –Direct, indirect, interactive Early Adversity (EA): 10 Risk Factors –Parental MH/SA, community violence, HOME, abuse, income,

4. Prenatal Drug Exposure to Behavioral Dysregulation or Executive Functioning Difficulties Model explains about 15% of variance in behavior and Executive functioning

5. Model with Early Adversity Added Fisher, P. A., Lester, B. M., DeGarmo, D. S., Lagasse, L. L., Lin, H., Shankaran, S.,... Higgins, R. (2011). The combined effects of prenatal drug exposure and early adversity on neurobehavioral disinhibition in childhood and adolescence. [Article]. Development and Psychopathology, 23(3), 777- 788. doi: 10.1017/s0954579411000290 Early Adversity. 35***. 15***. 18***. 00***. 39*** Model explains about 25% of variance in behavior and executive functioning

6. What Might This Mean? Childhood adversity mediates problem behavior and executive functioning of drug-exposed children Behavioral dysfunction stabilized but executive functioning got worse over time (primarily as a result of drug exposure and early adversity although both PDE and EA contribute directly) Youth who have experienced both PDE & EA are at greatest risk but each creates an independent risk

7. PDE, Tobacco, or Family Stress Prenatal exposure may have a declining impact over time Tobacco’s adverse impact doesn’t seem to decline as fast Toxic stress may be worse!

8. 2 Exposure to Cocaine or Tobacco at Birth and Later Behavioral Problemss Whitaker, Toni; Bada, Henrietta; Bann, Carla; Shankaran, Seetha; LaGasse, Linda; Lester, Barry; Bauer, Charles; Hammond, Jane; Higgins, Rosemary Serial Pediatric Symptom Checklist Screening in Children With Prenatal Drug Exposure. Journal of Developmental & Behavioral Pediatrics. 32(3):206- 215, April 2011. DOI: 10.1097/DBP.0b013e318208ee3 c Figure 1. Positive PSC screens by level of cocaine and tobacco exposure. PSC, Pediatric Symptom Checklist.

10. Shonkoff, J. et al. and the Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care. (2011). Early Childhood Adversity: Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health, Pediatrics, originally published online December 26, 2011.

11. APA Report on Toxic Stress: 1 of 5 Main Recommendations RECOMMENDATIONS 2. The growing scientific knowledge base that links childhood toxic stress with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems, and the evidence that these disruptions can lead to lifelong impairments in learning, behavior, and both physical and mental health, should be fully incorporated into the training of all current and future physicians (and all other health service providers) [material in parentheses and bright yellow text not in the original].

12. PSC is Part of “Bright Futures” Pediatric Screening… But What is Missing from It? Family (Parent) Well-Being Measures –The future isn’t bright if your parent is suffering What can we do? SEEK

13. SEEK: Easy as 1, 2, 3 1. Pediatric residents (and practitioners) who received special training, 2. Parent Screening Questionnaire (about “Family Stress), and 3. Referral to a social worker 13

14. SEEK Social Work Procedures The intervention clinics had a social worker who worked closely with the residents and families. Residents and parents chose whether to involve the social worker. Pediatric management often involved guidance and support in the clinic and referrals to community agencies. 14 Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009). Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model. [Article]. Pediatrics, 123(3), 858-864. doi: 10.1542/peds.2008-1376

15. SEEK Items 1.Do you need the phone number for Poison Control? 2.Do you need a smoke detector for your home? 3.Does anyone smoke tobacco at home? 4.In the last year, did you worry that your food would run out before you got money or Food Stamps to buy more? 5.In the last year, did the food you bought just not last and you didn’t have money to get more? 6.Do you often feel your child is difficult to take care of? 7.Do you sometimes find you need to hit or spank your child?

16. SEEK Items (continued) 8.Lately, have you often felt down, depressed, or hopeless? 9.Lately, have you felt very little interest or pleasure in things you used to enjoy? 10.Have you ever been in a relationship in which you were physically hurt or threatened by a partner? c 11.Have you ever felt you should cut down on drinking or drug use? c 12.Have you ever felt your partner should cut down on drinking or drug use? 13.Are there any other problems you’d like help with today? For more information about SEEK, ttp://www.umm.edu/pediatrics/seek_project.htmttp://www.umm.edu/pediatrics/seek_project.htm

17. SEEK: Results 17 MAJOR RESULTS After onset of the SEEK intervention, there were fewer CPS reports among intervention families (19.2% vs 13.3%; P =.03); 69% of reports were for neglect. True in Baltimore City and Baltimore County In short, SEEK reduced toxic stress for children.

18. Enjoy the Challenge of … Understanding the relationship between pre-natal drug exposure and other toxic physical and social stressors will thicken your synapses, no doubt. Learning from your interdisciplinary colleagues which will expand your interdisciplinary vocabulary Thinking along with these great speakers which will enable you to create the next generation of interventions to help children and families