Better Than Punishment

From an editorial by Dr Ruchi Fitzgerald in LINK>The Hill – It is unimaginable to think that seeking medical care could lead to losing custody of their children, yet this devastating predicament is all too real for pregnant women with addiction in the United States.

In our nation, the systems that aim to protect children from the negative effects of parental substance use often prioritize punitive approaches over proven public health strategies. Fear of being imprisoned, stigmatized, or having their children removed makes many pregnant women with substance use disorder (SUD) afraid to seek medical care, contributing to poor maternal health outcomes. Some state laws, including the law in Illinois where I practice medicine, even mandate that health care professionals report cases of detected controlled substances in a newborn infant as evidence of child neglect. While the federal Child Abuse Prevention and Treatment Act (CAPTA) has no such requirement, CAPTA’s overall approach has led to significant variation in how states, counties, and health care institutions implement its reporting requirements when substance use is involved during pregnancy.

Threatening child removal from a birthing parent with SUD without a risk assessment or evidence of danger to the child is not ultimately improving outcomes for children. Research has long shown that children affected by the trauma of family separation tend to experience worse long-term outcomes on a wide variety of indicators, including education, health, housing, employment, substance use, and involvement with the criminal legal system. With over 400,000 children in foster care across the US, the trauma of separation is widespread.

Forced separation also brings unimaginable pain to new families – triggering in some parents such despair that it deters them from seeking or continuing medical care, including treatment for their SUD. Study after study shows child removal is associated with parental overdose, mental illness, post-traumatic stress disorder, and return to substance use. Public health-oriented policies that can result in better outcomes for families are part of the solution.

As an addiction specialist physician, I am involved with the medical care of pregnant people with SUD, and I have seen counterproductive child welfare and criminal investigations launched after a newborn infant tests positive for a controlled substance. Too often, parents become hopeless about recovery once their children are gone.

Current policies and practices related to substance use during pregnancy also result in serious health inequities. Pregnant and parenting people of color are much more likely to be impacted by forced separation than their white counterparts. Black parents are more likely than white parents to be reported for substance use to the child protection system at their child’s delivery despite similar rates of drug use, while Black and Native American children are overrepresented in foster care relative to white children in the setting of parental substance use.

Meanwhile, health outcomes are unnecessarily worse for mothers of color. Since 80% of maternal deaths are due to overdose or suicide, we can save lives with policies and practices that encourage treatment, not punish pregnant women with SUD for seeking it. Policymakers need to remove controlled substance reporting requirements that overreach and contribute to the current punitive approach.

The American Society of Addiction Medicine (ASAM) encourages child protective services agencies not to use evidence of substance use, alone, to sanction parents—especially with child removal; supports eliminating in-utero substance exposure language in child abuse and neglect statutes, and supports policies that extend social services benefits and financial support to families in need.

The US Senate will contemplate reauthorizing and reforming CAPTA this year. Health care professionals who treat pregnant people with medications for addiction, like methadone or buprenorphine for opioid use disorder, do not need to involve child protective services for that reason.

Recovery is possible with the right medical care and support. A pregnant person with addiction seeking medical care deserves a chance to heal and recover with her children. If we want pregnant and parenting people with addiction to access the evidence-based treatment they need, our decision-makers must embrace public health over punitive policies.

The Impact of the Opioid Crisis on Adoption

“I always like to tell everybody we raised yours, mine, ours, my brother’s, now others.” ~ Suzanne Valle

The opioid crisis has strained child welfare systems in recent years, as kids who often face neglect and abuse are taken from their families and put into foster care. Jesus and Suzanne Valle thought they would become empty nesters indulging in their love of travel but they became adoptive parents instead. From 2007 to 2018, they took in six children, all from Ohio families struggling with addiction, including their own. Four are the kids of Suzanne’s brother, and two kids came through the foster care system. They had already raised nine of their own biological children.

The above is courtesy of StoryCorps and NPR. I also found this first person account – What Happened After I Tried to Adopt an Opioid-Dependent Baby from Washingtonian written by Susan Baer for Carrie Brady, a longtime employee at Google.

She was 40 and single when she decided to adopt a baby. Because of America’s opioid crisis, her chances of finding a match were better if she agreed to accept the child of someone addicted to drugs. She had received a call from the adoption agent for the baby she expected to adopt. The mother had hemorrhaged and given birth in an emergency C-section, actually five days earlier. The baby had aspirated blood and been without oxygen, then helicoptered to a hospital in the mother’s home state, down south, and might not survive.

Her whole rationale for adoption was to be the best mom for whatever baby she was matched with. But now she found herself confiding to her sister, “I worry that if this baby survives with major brain damage, it was going to be too much for me.” She prayed about it and hoped the baby would somehow lead her to the answer. She asked her adoption agent, “Do you ever have families looking for special-needs babies?” She said, “Yeah, I do.”

She knew adopting a baby on her own would throw her tidy life into disarray. Her mother asked repeatedly, “Why do you want to uproot your life like this?” She simply felt she could give a different sort of life to a child born into tough circumstances. Reminds me of my own father, when my husband and I decided to have children (thanks to assisted reproduction) at an advanced age, “I question your sanity.” That has come back to me a few times.

The baby was taken off life support and was going to die. She wanted the baby girl to be baptized and so a chaplain was called. The nurses brought her a dress and booties. Carrie was able to hold the baby girl the only time she would ever be held. Carrie says, “I told her why she was here and how sad I felt. I promised to remember her.” For the first time, there were no sounds. The room was still.

The first thing she learned was that if she wanted to be an adoptive mother anytime soon, meaning within two years or so, she’d have to consider a baby who might have some drug dependency. Over the last several years, because of the opioid epidemic, a growing number of infants placed with adoption agents in the US (as many as 60 or 70 percent at some agencies) have had exposure to drugs or alcohol in utero, mostly opioids or treatment drugs such as methadone. Methadone is a very powerful drug given to help keep addicts off of heroin and other related opioids. The opioid crisis has had such a profound impact on the adoption landscape that placement agencies provide classes on prenatal drug exposure so that prospective parents can decide whether it’s something they can handle.

Adoption is a control freak’s worst nightmare and with an addicted birth mother, it can be nerve wracking. It is excruciating to have such a tenuous grasp on something as important as adopting a newborn and hard not to read too much into every unanswered text or canceled date. Her adoption consultant told her, “It’s not a bad thing to be all in.”

Two months after the baby girl died, her adoption agent called with the news: Another birth mother, also from the South, had chosen her profile and was having a baby boy at the end of the year. She was also in a methadone treatment program for a drug addiction (same as the first birth mother). The adoption agent cautioned her, the birth mother had been expected to place her last child for adoption but had backed out after the birth and chose to keep the baby.

This birth mother had been on methadone for three years, it was likely her baby would be dependent. The detox period could last weeks to months. Carrie was there for the baby’s delivery. He weighed 6.9 pounds and was 20 inches long. She was allowed to cut the cord and was the first to hold him. That night had been stormy with the birth mother. However, the next day when she arrived at the hospital, the birth mother was holding her infant son. They looked so peaceful. Carrie told her, I just want the best for him and would love her, even if she wanted to change her mind. She didn’t.

In NICU, the baby’s blood had a higher concentration of red blood cells than was normal, a condition that can result from maternal smoking. He was getting fluids through an IV but might need a blood transfusion. Thankfully, the fluids resolved the issue and the baby avoided a transfusion. But his withdrawal symptoms were escalating. His crying wasn’t like any baby’s cry she’d ever heard. Imagine the screams of someone being tortured. That’s what it sounded like—pure anguish—and nothing would stop it. With his symptoms worsening, doctors decided morphine would allow him a little relief.

When they weaned him from the morphine, the withdrawal came back with a vengeance. She finally got him into his crib with the sand weights, pulled down one side of the crib to lay her head down next to his. She started singing to him the country song she’d listened to on her morning walks to the hospital: “Everything’s gonna be alright. Nobody’s gotta worry ’bout nothing. Don’t go hitting that panic button. It ain’t near as bad as you think. Everything’s gonna be alright. Alright. Alright.”

He finally improved enough to be discharged. The nurses assured her that best thing for him was to be home. “It’s the nurture part that gets these babies through,” they said. For two more months, the baby struggled through withdrawals. Crying sometimes for hours on end, clenching up his face and body, and appearing mad at the world for many of his waking hours. He rarely slept more than two hours at a time, and once he started crying, it was hard to get him to stop.

At three months old, he got better and would take a pacifier to soothe himself. He started sleeping three and four hours at a time and then through the night. She never heard that awful cry of pain again. Besides normal pediatrician visits, he was seen monthly by a developmental therapist, who dismissed them after about a year. He had hit all of his milestones and showed no signs of any delay.

The Rights of a Non-Surrendering Father

This is such a complicated case. It really took reading through the lengthy legal opinions regarding this case (Kruithoff v. Catholic Charities of W. Mich. – In re Doe) to try and make some sense out of the situation. I leave it to my readers if they have that much interest to wade through the complexities. Below I will include a couple of reasonable arguments made in descent.

What is involved is the Michigan Safe Delivery of Newborns Law (SDNL) which is intended to prevent the abandonment of unwanted infants. The mother gave birth under her maiden name. There is also an indication that she was taking Methadone during pregnancy, so that the infant was born addicted to that substance. She also made allegations of domestic violence against the father, while acknowledging that she was still legally married at the time of the infants birth. She did not provide the father’s name.

Known or unknown to her was that the father had filed a petition for divorce and request for the custody of his unborn child the day before the mother gave birth. That is a part of the complication in the determination of this case.

It was never determined whether the paternal custody of the child was in the best interests of the child or whether the accusations of domestic violence were warranted.

Upon voluntary surrender by the mother at the hospital where she gave birth, custody of the infant was given to Catholic Charities. It appears they did not knock themselves out to identity, locate or notify the father. The father is trying to regain custody of his now 3 yr old son. The story has been published by a Grand Rapids Michigan newspaper with the title – Biological father sues Catholic Charities over newborn’s adoption.

Even as difficult as it has been for the courts to sort this one out, it is difficult to know what the best interests of the child are at this point. Both the surrendering and the non-surrendering parents had their rights terminated prior to the finalization of adoption proceedings.

At the end of the legal record were these statements of dissent.

To presume that it would somehow be in Doe’s best interest-the standard under the SDNL-to rip him from the arms of the only family he has known and place him with a stranger, as if Doe was somehow a mere piece of property instead of a living person.

The Legislature therefore enacted a policy that prefers to err on the side of protecting the safety of the child and of the surrendering parent, even at the possible detriment to the nonsurrendering parent.