Drug addiction and pregnancy

A New Jersey court determined that a mother had not abused her child when she sought help for her painkiller addiction. She was placed on methadone. Her baby showed signs of withdrawal after birth causing child protection to intervene.  The fact that she sought treatment was seen favourably. Thus she was determined to have not been grossly negligent.

The case is worrying.  By implication had she not sought treatment then she would be negilgent placing her in the position of abusing her baby. This not only shames mothers with addiction but drives them away from help for fear of the implications.

Many women who are addicts do not get pregnant by choice. They are not seeking pregnancy. Most addicted women are victims of abuse. Many pregnancies occur within patterns of inter personal violence. I wonder what happens when we see the mother and the baby as victims together both in need of support. This case did not seem to seek to criminalize the mother as cases elsewhere have done. This is good  

Now we need to bring a harm reduction and support lens to these cases

Child protection as racist and poverty driven

It is perhaps somewhat odd that two Canadian newspapers would chose to write articles on the child protection system in the same week.  Looking at several inquiries, The National Post calls for reform of the system They start by noting that there will be an inquiry starting in Ontario in early 2015 on the death of Katelyn Sampson. She was murdered in 2008. The Toronto Star noted:

When Irving told the Children’s Aid Society on March 30, 2008, that she did not think she could provide for Katelynn and wanted her out of her home, the agency “passed the buck” to the Native Child and Family Services — Irving is part First Nations — and nothing was done, McMahon stated. (When a Native Services caseworker contacted Irving 16 days later, she lied and indicated the Toronto School Board was providing support and that she wanted the file closed, which it was.)

This inquiry will add to the long list of inquiries into the failures of child protection in Canada. In my research, we have identified about 80 inquires of various natures with at least two more on the horizon.
These will add to the legacies of Matthew Vaudreuil, Phoenix Sinclair, Christian Lee, Babby Annie, Jordan Heikamp, Kim Anne Poppen, Jeffrey Baldwin and so on. The stories are children of poverty but also of the First Nations of Canada. In other words, these are stories of the marginalized in our country.

The Toronto Star is also running a series of stories into the child protection system. They see the racism looking at how Black children are severely over represented.

Last week, the Globe and Mail told the story of Eddie Snowshoe who died through the solitary confinement system that Canada runs. But hist story starts much earlier in the institutional abuse of Canada's First Nations peoples through the residential school system. There, children were systemically abused and neglected. Today, we pay for that with the long standing impact of such broad, racist based social policies. They were designed to take the Indian out of the Indian. Now, we see the impact of fragmented Aboriginal communities and families in  the child protection systems.

It is obvious that child welfare must do a better job of the day to day management of complex cases. There are practice errors that get made and need to be corrected. That is the subject of my research. But society must also be willing to face the fact that there are several issues child protection cannot solve:

• Poverty - which is too often linked to neglect - not intentional neglect but neglect from lack of resources. These are often families where parents struggle with marginal housing and limited income, most often from low wage employment. They try to do their best with what they have but that often falls short of what is needed. Society can address these issues through economic programs.
• Aboriginal child welfare - the gross over representation of First Nations children in child protection care occurs because of the Residential Schools and the legacy they created. Child Welfare cannot fix that. 
• Underfunded mental health programs that leave families vulnerable.

The list can go on but the point here is that child welfare is being asked to "fix" problems that arise from social policies that are well beyond their control. This is a conversation we must have rather than just pointing fingers at a child protection system that cannot fix it!

Failure to criminalize a drinking pregnant mother

In a vital case in the United Kingdom, the Court of Appeal has ruled in the case of CP that a mother cannot be held criminally liable for causing FASD in her child. There are certainly many who might wish to see this happen. Indeed, it is happening in several American states. The UK decision is important as it recognizes that several key issues. In reading the decision, I am reminded of main points of debate:

• Is a foetus a child? - In Canada, this has been rejected by the Supreme Court of Canada. If the argument is accepted, then there is a wide range of behaviours that would fall under the rubric of causing harm to a child in utero - think of smoking, an unhealthy diet, obesity, taking of certain prescription medicines and so on. 
• Should a mother be criminally responsible for behaviour she could reasonably know would harm the child? This raises more than alcohol and brings back the discussion on a wide range of behaviours. But, while it stays that a mother who is drinking heavily should be expected to know that she will harm her child, it would not be hard to extend this argument against women whose various medical conditions make a pregnancy high risk. Should that mother also be held criminally responsible because she chose to take a risk that had a high probable outcome of harm?
• If the foetus is not a child within the meaning of law, then harm done in the pregnancy cannot be a criminal act. On this point, the UK Court of Appeal notes:

1. The reality is that the harm has been done to the child whilst it is in utero. The fact that if the child is born alive it will suffer the consequences of the insult to it whilst in the womb does not mean that after birth it has sustained damage by reason of the administration of the noxious substance. One only has to cast one's mind back to the Thalidomide tragedy. The injury was done to the affected children by the administration of the drug whilst they were still in the womb. Those children who were born affected were born with missing or ill-developed limbs. Whilst they suffered the consequences on a lifetime basis after birth, they did not sustain any additional damage after birth by virtue of administration of the drug.


2. Reference to the expert evidence of Dr Kathryn Ward, an experienced consultant paediatrician, whose very detailed report was before the First Tier Tribunal, (and which was not disputed), shows that the harm which is done by ingestion of excessive alcohol in pregnancy is done whilst the child is in the womb. The child would then, when born, show damage demonstrated by growth deficiency, physical anomalies and dysfunction of the central nervous system. Very often, as in this case, the full extent of retardation and damage will not become evident until the child reaches milestones in its development, at which point matters can be assessed. The fact that such deficits cannot be identified until that stage does not constitute fresh damage. It merely means that the damage was already done but has only then become apparent.


3. It seems to me that this is fatal to the appellant's contention. The time at which harm, acknowledged in this case to amount to grievous bodily harm, occurred was whilst CP was in the womb. At that stage the child did not have legal personality so as to constitute "any other person" within the meaning of s23. The basis upon which the actus reus is extended in a manslaughter case cannot apply here since nothing equivalent to death occurred to CP after her birth.

Those who argue the right to life will find this decision very disappointing. They would suggest that the foetus is a life from the moment of conception. However, to sustain this legally requires that we are, as a society, prepared to hold mothers to a very high standard of behaviour in pregnancy that must go well beyond alcohol to all behaviours that have a high probability of causing harm.

But there is another side to this. If we accept that argument then we must also hold that society has a very high obligation to protect the foetus that would include offering intensive medical help to all at risk women and pregnancies. Thus, an alcoholic or drug addicted women would be entitled to the care of the state in order to protect the foetus. 

This then takes us down the road of forcing treatment on mothers who's e behaviours may place a foetus at risk. Those who may jump on that bandwagon will most likely think of women with alcohol and drug problems. They may find the moral ground of forcing treatment on these women as a group easy due to the nature of their disease (addiction) and a belief that it is a moral versus medical issue. But what then are we to do with the poorly managed diabetic, the heavy smoker, the mother who has been advised against pregnancy due to medical risks - are we to force treatment on them?

What then are we to do with one of the higher risks for children - families who live in poverty where access to a healthy diet and good pregnancy care are very challenging? Is society willing to now say that they should have forced supports? There are many more children born to women with various forms of higher risk pregnancies arising from medical and social conditions other than alcohol.

As for drug use in pregnancy, we can fall very short in understanding the long term implications. A study by Dr. H. Hurt in Philadelphia found that the "crack baby" epidemic of 25 years ago has not materialized in the way it was predicted. Many of these children are doing well. Poverty may have been a bigger issue.

All of this is not to say that we should fail to help mothers be the best they can at being pregnant. We should - but that is not accomplished through criminalizing or jailing mothers - that is the ultimate in mother shaming. It is be education, community supports, health care and harm reduction. 

Learning from the deaths of children

Children die when involved with child protection systems. It is inevitable that some children will die as it is impossible to predict which parent is going to kill a child. However, there are several behaviours by social workers that can reduce the risks. This poster represents some of the most important themes that we have found in our research of Canadian published case reviews.

There are a few I would like to highlight:

1. Supervision really matters - when a front line worker gets good supervision we have another set of informed eyes talking about the case. The supervisor gets to ask questions about missing data, why case plans are structured the way they are and to offer ideas and suggestions about what might be done. Remember that a large number of front line workers have less than 5 years experience. Supervision matters.
2. The child is the reason the case exists - it is not hard to get distracted by the needs of the parent. This can be particularly true in cases where there is a conflict through the court system. Indeed, in a recent case I was involved in, I experienced counsel for the parents as being strongly focused on what was best for the parent but disguised in questions that made it seem about the child. Our task is to bring the case back to what serves the child.
3. Being open to the unimaginable - case workers do not like to think that the parent or caregiver that they are working with would kill the child - but if we are open to that as a possibility then we ask better questions and consider the data more thoroughly.
4. Front line social workers are generalists - they often lack specialist training in the complex issues that child protection work brings. This can range from mental health to addictions to inter personal violence to FASD and so on. BUT, the front line worker does need to know how to get at experts who can aid them in understanding the case. These experts also need to learn how to talk to front line workers in ways that make the issue clear.
5. One assessment at the beginning is not the end of assessment - assessment is an ongoing process. Things change in cases and so should the social workers understanding of the case.
6. If the child is at the centre of the case - see the child - see the child frequently.
7. History does matter - it tells us a lot - what have been the problems in the past and how successful were interventions; how are things different now that may yield strengths or ongoing deficits; is there a pattern that needs to be considered and so on.
8. The new partner is a risk - they need to be met and assessed. 

One of the big lessons for us is how important it is to talk to students about these issues - but talk with students inter professionally. Child protection requires an ability to work across professions - medical, psychology, social work, criminal justice, law - and be able to do so with a grounding in what protecting a child is all about. Inter professional communication has been a problem at the heart of many cases.

There are also cultural implications to our research which I will review in the next posting.

I do want to leave with this message as well - case reviews where things have gone wrong need to be done at the front line - but not in a way that is hanging people out to dry but rather in using the case to enhance learning and improve practice. That helps to reduce the risks of the death for children involved with child protection.