On the first day of my neonatology elective I met Aaron*, a one-day-old born to a mother with a history of intravenous drug abuse. The mother was reportedly attending a methadone clinic during her pregnancy to address her opioid addiction, but her urine drug screen was positive for fentanyl. Since we could not obtain a consistent story from the mother, Aaron was admitted to the neonatal intensive care unit (NICU) for probable neonatal abstinence syndrome (NAS) as a result of opioid withdrawal. Aaron was monitored closely for symptoms of opioid withdrawal — sure enough, within a few hours in the NICU, he scored very highly on the NAS scoring system.
The NICU team was a well-oiled machine that handled the situation efficiently. They were experts with the NAS protocol, since they often encounter patients born to mothers of drug abuse. What the doctors did not partake in, however, was formulating a plan to address the broader social implications for the patient and his family. I realized that on the wards it is easy to become immersed in the scientific, protocol-laden details of different disorders. Following through on that muscle memory, however, often obscures the larger context of a patient.
As I began to follow Aaron’s hospital course, I had several questions. Would his mother be able to visit him in the unit? Would he ultimately be discharged home with her? And if not, what would this mean for his long-term custody? Working alongside Aaron’s social worker helped delineate the process. The social worker is tasked with involving the Georgia Division of Family and Children Services (DFCS) in three main situations: a positive maternal drug test, homeless parents or history of mental illness in the mother. DFCS then assigns a case manager who assesses obvious and subtle family dynamics by observing and interviewing the mother as well as close family members and friends who may have a role in the care of the infant.
After observing a few interactions between the mother and infant and processing the background history of each case, the social worker makes a recommendation as to whether they think the mother can visit. From that point on, visits are scrutinized and the social worker and DFCS case manager work together to determine if the mother is suited to care for the newborn. How comfortable is the mother holding the baby? Is she able to comfort her child during a crying spell? Is she able to appropriately feed the baby, whether by breast or bottle, and able to clean up afterwards?
Custody of the infant is the next big decision. DFCS does try to grant custody to the family because once a parent relinquishes rights to their child, whether by choice or circumstance, it becomes more difficult over time to regain custody. Many parents sign away rights at the hospital since they do not want DFCS to become intertwined in their habits of drug abuse. If the biological parents do not pass the evaluation, extended family members and, if necessary, even close friends of the family are investigated. If none of those connections are appropriate options, the foster care system is the last resort.
Upon discharge of the infant, DFCS formulates a safety plan, which dictates the terms under which the parents may interact with their child. In Aaron’s case, his uncle was responsible for taking care of him, and his mother was only allowed to visit with the uncle present. Although safety plans are implemented to keep children safe, they are often difficult to enforce and monitor. For example, in the case of another infant born to a mother with a history of drug abuse, DFCS granted custody to the mother and the safety plan dictated that the mother was not to partake in recreational drug abuse while in the direct presence of the infant. As I sat listening in the social worker’s office, I was stunned at how impractical that plan sounded out loud.
I also found that although the short-term inpatient algorithm for addressing these scenarios was relatively straightforward, the long-term implications were not. What would happen to Aaron if, 10 years down the road, his uncle decided he did not wish to be his primary guardian? Primary custody would automatically transfer back to the mother, and DFCS would then have to re-evaluate if she is appropriately equipped to take care of him.
I began to question the integrity and sustainability of the model. It was clear that the parents were not always in a position to fully understand the situation and how their choices would affect them later on in life. For example, if Aaron’s mother ever wanted to regain custody of her baby, she would have to undertake the arduous process of appealing to the probate and juvenile courts to wage a custody battle against her own family. I also remained unconvinced as to whether the safety plans devised by the DFCS were placing each newborn in the best possible social care or were just rote protocol based on precedent.
I propose improvements in two areas. First and foremost, I believe that the safety plans put forth by the DFCS should be more vigorous and attainable. From the prior anecdote, it may not reasonable to think that a mother who has a history of regular drug use will abruptly be able to refrain from using just when she is around her child. Habits often permeate into multiple sectors and it can be difficult for parents to curtail their practices through arbitrary barriers. Instead, safety plans should have concrete and measurable goals. Using the same example, perhaps the newborn’s custody should be contingent on routine maternal drug screens. My second proposition is that every effort is taken to ensure that parents are making well-informed decisions at the hospital regarding custody and long-term care of their baby. Though it is not always their decision whether they get to keep their baby, I believe it is their right to know what would happen down the road if they were to surrender their rights now. Regular family meetings should become an integral part of the decision process with the parents, immediate family members, with social workers and DFCS case manager closely involved.
Watching Aaron’s story unfurl, I learned that just because a protocol is in place does not mean every resulting plan will be sound. If a proposed social situation does not seem safe and secure, it may be necessary to dig deeper, below a veneer of plausibility. By taking the time to observe organic relationships unfold, you can relay a more cohesive social picture to the social worker, act as a resource for our patients and advocate for a secure and realistic safety plan. Ultimately as students, we are the patient’s advocates and by immersing ourselves in diverse aspects of healthcare, we can positively impact their lives beyond the walls of the hospital.
*Patient’s name and other identifying information have been altered to protect the patient’s identity.