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2009 Jordan Institute
for Families

Vol. 15, No. 1
December 2009

Parental Visits and Infants with Prenatal Substance Exposure

Child welfare professionals play a critical role in visits between parents and their children in foster care. Before visits they are often responsible for making the preparations. During visits they play multiple roles: ensuring the safety of the child, supporting parent-child closeness to facilitate reunification, and assessing parents’ progress and the parent-child relationship (Haight, et al., 2001). Afterwards, they talk with parents about what went well and explore ways to make the next visit better.

Under the best of circumstances, this is a lot to manage. When the visits involve infants and both the parent and the child are affected by substance abuse, things are even more complex.

Indeed, in their 2006 article “Facilitating Visitation for Infants with Prenatal Substance Exposure,” Caroline Long Burry and Lois Wright suggest that when it comes to visitation between parents and infants affected by substance abuse, child welfare workers are often faced with having the least-prepared parents working toward reunification with the most challenging infants.

Here’s what Burry and Wright have to say about making visitation work in this delicate situation.

Infants with Prenatal Substance Exposure
Prenatal substance exposure, or PSE, is a condition that affects children from birth to age 2 who have had prenatal exposure to drugs, alcohol, or other medications beyond what was prescribed. In the U.S., between 10% to 15% of all newborns (or up to 400,000 babies a year) test positive for drugs or alcohol at birth (Christensen, 1997; SAMHSA, 1993).

In general, infants with PSE are more difficult to care for than other infants. Specifically, they are at higher risk for developmental delays, premature birth, poor muscle tone, apnea, growth inhibition, and increased rates of Sudden Infant Death Syndrome (Bauer, 1999; Howard, et al., 1989; Tyler, et al., 1997). Due to PSE, these infants may be easily overstimulated, have piercing and insistent cries, experience difficulty feeding and being comforted, sleep lightly and irregularly, and tend to be irritable and fussy (Bauer, 1999; Zuckerman, 1993).

Impact of Caretaker Cocaine Use on the Fetus and Young Child

Although low birth weight and small head circumference are common in infants prenatally exposed to cocaine, there are other factors that can cause these things. Physicians have not been able to attribute anything seen at birth directly to maternal cocaine use.

That said, the following neonatal effects have been observed in infants born to mothers who used cocaine during pregnancy:

  • Motor abnormalities
  • Irritability
  • Seizures-tremors
  • Hearing defects
  • Increased risk of SIDS

Typically, these effects get worse in the first 9 months and then abate by the time the child is 2 years old.

Long-term effects. An extensive literature review of early childhood outcomes shows that although there are effects, there is no consistent association between prenatal cocaine exposure and physical growth, developmental test scores, receptive/expressive language, motor scores (after 7 months of age), and parent/teacher reports on child behavior.

Source: Greenbaum, 2008


Parents of Infants with PSE
If an infant with PSE is in foster care, chances are the child’s mother is involved with alcohol or other drugs. This can make parent-child visits difficult. According to Burry and Wright, challenges faced by parents struggling with substance abuse include:

  • Relapses. When parents miss scheduled visits due to substance use, their children worry about them, the parent-child connection can be undermined, and parents may come to doubt their ability to parent.
  • Denial and Guilt. These can interfere with a parent’s motivation to change and ability to learn and demonstrate enhanced parenting skills.
  • Timeframes. When parents struggle with addiction, reunification and family stability can be difficult to achieve within mandated timeframes.
  • Environmental Challenges. It can be hard to achieve and sustain reunification if parents live in neighborhoods where drugs and alcohol are readily available, substance abuse is accepted, and many people have active addictions.
  • Impaired Parenting Behaviors. Research suggests that parents with addictions may have a harder time parenting safely and effectively due to lack of knowledge, lack of support, and high stress.

Teaching Parenting Skills
To help overcome these challenges, Burry and Wright suggest sending the following messages to parents with addictions who have PSE infants:

  • Be reliable and consistent. Help parents understand that because babies with PSE often have a hard time soothing themselves and transitioning smoothly from one emotional state to another, they have a special need for routines. Without them, infants’ moods are more likely to quickly switch from a happy state to a miserable one without an intervening period of gradually increasing fussiness. Being consistent and reliable in caregiving promotes attachment and supports the development of self-regulation in babies with PSE.
  • Learn to read your child’s signals. Babies with PSE are easily overstimulated. Therefore it is important to teach parents to decipher their babies’ signals about their readiness for play or receive other stimulation. Teach parents that yawning, sneezing, hiccuping, looking away, or stiffening can all be signals that their babies are ready for stimulation. When they see those signals, parents should stimulate one sensory pathway at a time by showing a picture book (visual stimulation), singing or playing a CD (auditory stimulation), or quietly massaging the babies’ limbs (kinesthetic stimulation).
  • Respond quickly. Infants with PSE can find it difficult to delay gratification; they should be attended to promptly. Teach parents it is impossible to spoil an infant and that meeting their child’s needs nurtures them and fosters attachment that will help them develop properly and form healthy relationships later in life.
  • Tell other caregivers what works with your baby. Use visits to help parents become the experts on their babies. As they gain confidence and competence, encourage them to share their knowledge with their child’s other caregivers. For example, a mother might tell the staff of the daycare that will be caring for her child after reunification about her baby’s needs and about strategies that help calm her child.
Visits with Parents in In-Patient Treatment

If parents are in an in-patient setting, visitation should be planned in conjunction with the treatment staff at that facility. Some hospitals have the ability to supervise visits and visits are considered part of the parents’ treatment plan. Others do not and it is a case-by-case determination as to whether it is appropriate for you to bring the child to the facility. As parents exhibit a level of recovery and begin managing their symptoms, you should consider the length and frequency of the visits depending on the amount of stress a parent can successfully handle. Monitoring the parent’s progress and compliance in treatment will help you determine when to make changes to the visitation plan (FCRP, 2007).

Visitation and Permanency Plan Decisions
The conditions for reunification should always be clearly defined in terms of parenting ability and child safety. Yet because infants with PSE are so vulnerable and their needs so significant, agencies must use particular care when making decisions about the child’s permanency plan—especially if the parent has a history of substance abuse.

For this reason, Burry and Wright suggest workers use the following questions to enhance decision making about reunification of infants with PSE:

  • Has the parent realized and acknowledged the effect of substance abuse on himself or herself and the child? The parent’s ability to keep the child safe cannot be accurately assessed without asking this question.
  • Has the parent demonstrated the parenting behaviors required to meet the baby’s needs? During visitation, has the parent shown that he or she can and will provide adequate care for the baby on his or her own, without supervision?
  • How might relapses affect the quality and consistency of the parenting this infant will receive after reunification? If relapses occurred during the period of visitation, how did the parent handle them?
  • How stable is the parent’s recovery?
  • Does the parent have sufficient supports place, should a relapse occur? During the treatment period, did relatives and other support people show that they will take appropriate action to keep the child safe if the parent experiences periods of relapse or instability?

Workers can use these questions as a guide as they monitor visits. Their answers to these questions, combined with input from others involved in treatment and visitation (e.g., foster parents, addiction counselors, etc.) can help agencies reach appropriate permanency plan decisions for infants with PSE and their families.

Facilitating Visitation for Infants with Prenatal Substance Exposure, by Caroline Long Burry and Lois Wright, is available in the journal Child Welfare, 85, pp. 899-918. <>.

References for this and other articles in this issue