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Development, Implementation, and Evaluation of a Pilot Parenting Educational Intervention in a Pregnancy Buprenorphine Clinic
DEVELOPMENT, IMPLEMENTATION, AND EVALUATION OF A
Pilot Parenting educational Intervention IN A Pregnancy buprenorphine Clinic averie c. giles • diaNXu reN • saNdra fouNds
Substance misuse during pregnancy, a considerable health care concern, predisposes a newborn to the possibility of physiologic and neurobehavioral problems (Jansson & Velez, 2012). Antepartum maternal opiate use has increased significantly from 1.19 per 1,000 hospital births per year in 2000 to 5.63 per 1,000 hospital births in 2009 (Patrick et al., 2012). In 2010, use of any illicit drug during pregnancy was 16.2% among young women ages 15 to 17 years, 7.4% among women ages 18 to 25 years, and 1.9% among women ages 26 to 44 years (Substance Abuse and Mental Health Services Administration, 2011). In an updated report, the Substance Abuse and Mental Health Services Administration reported an increase in substance misuse during pregnancy across all of these age groups in 2012, with 18.3% in young women ages 15 to 17 years, 9.0% in women ages 18 to 25 years, and 3.4% in women ages 26 to 44 years (Substance Abuse and Mental Health Services Administration, 2013). Abstract: We developed a pilot evidence-based prenatal educational intervention to increase knowledge of neonatal abstinence syndrome (NAS) and early parenting skills for women with opiate dependency who enrolled in a pregnancy buprenorphine clinic. We developed, implemented, and tested modules regarding expectations during newborn hospitalization for observation or treatment of NAS and regarding evidence-based parenting skills in response to NAS behaviors. Testing evaluated baseline knowledge of early parenting skills with newborns at risk for NAS and change from baseline after the educational intervention. No statistically significant difference in composite knowledge scores was observed. A brief survey completed by the participants postpartum affirmed the perception of women that the educational intervention effectively prepared them for the early postpartum period while their newborns were hospitalized. http://dx.doi.org/10.1016/j.nwh.2016.04.024 Keywords: buprenorphine | neonatal abstinence syndrome | opioids | parenting skills | prenatal education
Neonatal Abstinence Syndrome
Our Pilot Evidence-Based Protocol The purpose of this pilot evidence-based clinical protocol was to develop, implement, and evaluate an educational intervention to increase knowledge of early parenting skills regarding newborns at risk for NAS in pregnant women with opiate or opioid dependency who enrolled in a pregnancy buprenorphine clinic within a metropolitan women’s hospital.
Background Substance misuse during pregnancy can create a collection of potential adverse consequences for newborns. Prenatal exposure to opiates, opioids, and opioid agonists such as buprenorphine often leads to NAS after birth because of the sudden termination of the drugs that the neonate was exposed to as a fetus (ACOG, 2012). Medical effects of NAS include signs of withdrawal such as excessive high-pitched crying, sleep-wake disturbances, feeding difficulties, alterations in tone and movement, autonomic dysfunction, and gastrointestinal disturbances such as vomiting and loose stools, but these effects are widely variable (Jansson & Velez, 2012). Psychosocial effects include child welfare concerns due to inadequate parenting skills that place the offspring at risk for maltreatment and neglect (Marsh & Smith, 2011; Suchman & Luthar, 2000; Suchman, Pajulo, Decoste, & Mayes, 2006). Women with substance misuse often have received poor parenting themselves, including sexual, physical, and emotional Averie C. Giles, DNP, FNP-C, is a graduate of the DNP program at the University of Pittsburgh School of Nursing in Pittsburgh, PA. Dianxu Ren, PhD, is an associate professor and associate director for statistical support services at the University of Pittsburgh School of Nursing in Pittsburgh, PA. Sandra Founds, PhD, CNM, FNP-BC, is an associate professor of health promotion and development at the University of Pittsburgh School of Nursing in Pittsburgh, PA. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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Substance misuse during pregnancy can create a collection of potential adverse consequences for newborns maltreatment, creating a deficit in their own parenting skills (Jansson & Velez, 1999). Furthermore, pregnant women with substance use disorder often have insufficient parenting knowledge, especially regarding basic parenting, newborn care, and child development (Rizzo et al., 2014; Velez et al., 2004). This lack of parenting knowledge paired with difficult neonatal behaviors in opioid-exposed newborns creates an impediment to parenting well for the opioid-dependent mother. Nurses with specialized training find caring for newborns experiencing NAS to be challenging and time consuming (Fraser, Barnes, Biggs, & Kain, 2007); new mothers with opioid dependency who may have limited parenting skills often care for their newborns with little to no preparation. For example, women with opioid dependency may have difficulty identifying and reacting to their newborns’ cues (Jansson, Velez, & Harrow, 2009; Velez & Jansson, 2008). Evidenced-based parenting education is predominantly for the general population (Ateah, 2013; El-Mohandes et al., 2003). There is a paucity of literature identifying evidence-based parenting education programs in the prenatal period, especially for high-risk pregnant women with substance misuse. An exhaustive librarian-assisted literature search of PubMed, Ovid, CINAHL, and UpToDate yielded no results for prenatal parenting education for this patient population. Parenting guides from major health systems in the United States, Australia, and Europe were found in the lay literature, although these materials did not include citations from peer-reviewed journals. In the United States, 43% of addiction treatment programs offer some sort of parenting classes for parents with substance use disorders, but very few use any sort of structured curriculum (Arria et al., 2013). Most parenting education occurs in the immediate postpartum period, and for those in addiction treatment, this may be too late (Barlow et al., 2013; Berlin, Shanahan, & Appleyard Carmody, 2014; El-Mohandes et al., 2003). This is especially notable for NAS education, because the neonate may already be experiencing NAS. Maternal education to prepare for the neonate’s possible neurobehavioral dysregulation related to withdrawal is essential to aid in optimal parenting during the immediate postpartum period (Jansson & Velez, 2012). ACOG (2012) notes that pharmacologic treatment focuses on the relief of signs and symptoms of withdrawal for the newborn and on
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Using discharge data, Patrick, Davis, Lehmann, and Cooper (2015) documented a rate of 5.8% per 1,000 hospital births per year of newborns diagnosed with neonatal abstinence syndrome (NAS) in 2012 and identified a fivefold increase in incidence since 2000. For pregnant women with opioid or opiate dependence, comprehensive medication-assisted treatment reduces the risk of complications to the fetus and the woman (American College of Obstetricians and Gynecologists [ACOG], 2012). Women receiving buprenorphine treatment during pregnancy express concern regarding neonatal withdrawal from the medication (Rizzo et al., 2014). Providing education concerning the hospital course generally and NAS specifically may optimize women’s interactions with their newborns and their early parenting skills.
for pregnant women in an opiate-to-buprenorphine conversion and maintenance program to increase knowledge of early parenting skills with newborns at risk for NAS, integrating the specific needs of women in opiate addiction recovery; (b) determine if educational sessions increase knowledge of early parenting skills with newborns at risk for NAS by measuring change in pre- versus posteducation assessment scores; and (c) evaluate the effects of the educational intervention in the first 1 to 2 weeks postpartum.
Methods
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Setting
preventing complications of withdrawal. New mothers have a limited role in this aspect of care. Providing parenting education during the prenatal period about nonpharmacologic care of opioid-exposed infants can improve maternal interactions and facilitate parenting behaviors that decrease those interactions that may exacerbate withdrawal symptoms (Maguire, Cline, Parnell, & Tai, 2014). Nonpharmacologic care focuses on minimizing external stimuli, promoting rest, and providing adequate nutrition (Hudak, Tan, Committee on Drugs, Committee on Fetus and Newborn, & American Academy of Pediatrics, 2012). In addition, educational interventions may raise awareness for the challenges of parenting in the early prenatal period (Rizzo et al., 2014). Unfortunately, there is a critical gap in the availability of tailored prenatal education to help women with opioid dependency acquire the necessary parenting skills to care for their newborns at risk for or diagnosed with NAS.
Goals of Our Intervention The goals of this new evidence-based clinical program were to (a) develop an evidence-based educational intervention
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In response to an invitation by the hospital’s outreach coordinator, who recognized a need for prenatal education for this vulnerable population, this project was implemented at the new Pregnancy Recovery Center (PRC), an opiate or opioid-to-buprenorphine conversion and maintenance program providing a Medical Home Model within a large health system’s outpatient clinic in Pittsburgh, Pennsylvania. The PRC integrates a medication-assisted treatment program with comprehensive prenatal care, social services, and birthing care. This teaching hospital provides care for approximately 11,000 newborns born each year, with well newborn and neonatal intensive care services available. This quality improvement project was approved by the tertiary hospital–based clinical projects review committee and was also determined to not need university institutional review board approval because it was not research.
Project Design The project was developed in two phases. The first phase involved development, implementation, and evaluation of an educational program for substance-abusing pregnant women who were in recovery. The second phase evaluated the perceptions of the new mothers regarding the effectiveness of the education related to their early parenting efforts in the immediate postpartum period.
Phase I We developed a pilot evidence-based prenatal educational intervention for pregnant women in an opiate or opioidto-buprenorphine conversion and maintenance program to increase knowledge of early parenting skills with newborns at risk for NAS, integrating the specific needs of women in substance misuse recovery. Initially, we informally surveyed the pregnant women of the PRC to determine their perceived educational needs and to begin to develop trust. In response to the pregnant women’s most common needs, two educational
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The testing also informed the quality of the education and identified strengths and weaknesses in the educational materials and process nence scoring tool used to quantify NAS symptoms (Finnegan, Connaughton, Kron, & Emich, 1975). The second module included elements of nonpharmacologic interventions important to the care of the substance-exposed newborn. The information integrated evidenced-based written materials using the principles of addiction recovery outlined in the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment (2012) for the women in the PRC. Specifically, the principle that states that providing substance-abusing women in addiction recovery an opportunity to actively participate in their recovery, in this case by education, increases the likelihood of good outcomes (National Institute on Drug Abuse, 2012). The educational materials were reviewed by experts in obstetrics, women’s health, and addiction. A checklist of the three educational modules was developed to identify areas of education addressed and completed for each participant. The education was presented to the PRC participants in small segments during the course of their weekly visits to the PRC up through birth. The first author was present in the PRC 3 days per week over an 8-week period to deliver the education to each participant initially. The education used verbal communication and an infant simulator to provide demonstration of NAS scoring activities and parenting responses to NAS signs in a neonate. The simulator was particularly useful in supporting visual learners, especially for more complicated actions such as containment (a facilitated tucking technique) used to soothe and comfort a neonate. After the completion of this initial phase, the PRC’s addiction-certified patient care manager, who is a registered nurse, was trained to deliver the education. To determine if the educational sessions increased knowledge of early parenting skills with newborns at risk for NAS, we measured change in pre- versus posteducation assessment scores. The testing also informed the quality of the education
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and identified strengths and weaknesses in the educational materials and process. We developed a 14-question pretest to assess knowledge of NAS and early parenting skills. Each item was a true/false question or a multiple choice question (see Table 1). The same test questions were administered at the completion of all of the educational modules. A trifold brochure summarizing the provided parenting educational information to address NAS behaviors was developed and offered to participants at the completion of all of the educational modules and the posttest. The brochure was intended to provide a quick reference for parents while their newborns were hospitalized.
Phase II To explore the practical effects of the educational intervention, at 1 to 2 weeks after birth when the women followed up with the PRC, participants were asked to complete a brief survey, which consisted of two questions using Likert scale responses (range, 1–5), with responses ranging from strongly agree to strongly disagree. This survey identified the women’s perceptions regarding the effectiveness of the educational program in preparing them for the early postpartum period. The survey items were: My participation in the parenting education project in the PRC helped me to prepare for the immediate postpartum
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modules were developed and implemented: (a) what to expect while the newborn is hospitalized for observation or treatment of NAS and (b) how to interact with newborns at risk for or with NAS. The first module included two components: education regarding the hospital stay and information about the hospital’s Neonatal Abstinence Scoring Sheet, which is based on the Finnegan Scoring System, a widely used neonatal absti-
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table 1
Questions Pre- and Postintervention Q1 M y baby will be required to stay in the hospital for a minimum of _______not counting the day my baby is born. A. 3 days B. 5 days C. 7 days D. 14 days Q2 B ecause all of my family and friends want to bond with my baby, it is important that I let each of them hold him/her. A. True B. False Q3 T he Neonatal Abstinence Scoring System will be used to determine if my baby is having symptoms of withdrawal and the scores will be recorded on the Neonatal Abstinence Scoring Sheet. A. True B. False Q4 I f my baby shows signs of withdrawal and needs medication, they will give him/her Subutex. A. True B. False Q5 S igns of withdrawal include A. Excessive sucking B. High-pitched cry C. Tremors D. Snoring E. Vomiting or spitting up F. Stuffy nose G. Difficulty feeding H. Sneezing Choose one best answer A. A, B, C, H B. A, B, C, E, F, G, H C. All of the above Q6 I f it is daytime, I should keep bright lights on and if it is night-time I should keep them turned off. That way my baby will not get his/her days and nights mixed up. A. True B. False
Q7 Swaddling my baby will help him/her feel calmer. A. True B. False Q8 If my baby scores ________ or greater for _____consecutive scores, or averages greater than _____, the nurse will call the doctor or nurse practitioner. A. 6, 3, 6 B. 8, 3, 8 C. 8, 5, 8 Q9 If my baby stops eating during a feeding, he/ she is not hungry anymore and I should stop feeding him/her. A. True B. False Q10 If my baby is crying, especially if it is high pitched, I can help him/her calm down by holding him/her close to me or skin-to-skin, swaddling him/her in a blanket, or by slow, gentle vertically rocking. A. True B. False Q11 My love and care are essential to the care of my baby and I am a very important part of the care team while my baby is in the hospital. A. True B. False Q12 If I am breastfeeding, I can still use a pacifier for my baby because he/she needs comfort sucking between feedings. A. True B. False Q13 If my baby is sleeping when I arrive, it is OK to wake him/her because she will be happy to see me. A. True B. False Q14 I have allergies and I sneeze a lot so if my baby sneezes a lot, he/she probably has allergies also. A. True B. False
Note. Boldface indicates correct answers. Q = question.
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period while my newborn was hospitalized and My participation in the parenting education project in the PRC helped me to understand how best to interact with my newborn at risk for neonatal abstinence syndrome during the early postpartum period.
Analysis The results of the pre- and posttests were collected by the first author and compiled in a spreadsheet on a password-protected computer. De-identified clinical and demographic data were collected and entered into a database. All data were then imported into SPSS for Windows version 22. Pre- and posttests were evaluated with descriptive and comparison statistics to determine baseline knowledge and change from baseline after the education.
Results Phase I During the implementation period, 19 pregnant women were enrolled in the PRC. Two women declined participation in the educational intervention, two gave birth before the education was completed, and 15 finished the educational intervention, for a final sample of 15 women (N = 15). De-identified demographic data were examined for means, frequencies, standard deviations, and distributions. The mean age of project participants was 28.3 years. One hundred percent of the participants were White, 80% were smokers, and 100% had a minimum of a high school diploma or high school equivalent. Pre- and posttest questions were examined for frequencies. Final scores comparing baseline knowledge on the pretest with knowledge after the educational intervention were analyzed using the Wilcoxon rank-sum test because of the small sample size. The overall change in knowledge score did not reach statistical significance.
Phase II Only four of the women (n = 4) who participated in the educational intervention birthed their newborns during the 8-week implementation phase of the project. These women all responded that they agreed or strongly agreed with both of the postpartum questions (Phase II): that their participation in the parenting education project helped them to (a) prepare for the immediate postpartum period while their newborns were hospitalized and (b) understand how best to interact with their newborns at risk for NAS during the immediate postpartum period. Since the end of the implementation period, seven more women have given birth and completed the survey. All but one agreed or strongly agreed with both questions on the survey. One participant was neutral on the second question.
Discussion Substance misuse during pregnancy is a significant health concern because it predisposes newborns to the possibility of physiologic and neurobehavioral problems (Jansson & Velez, 2012).
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Poor parental role modeling and lack of parenting knowledge paired with difficult neonatal behaviors create a barrier to parenting well for women with opioid dependency (Jansson & Velez, 1999; Rizzo et al., 2014; Velez et al., 2004). With regard to participant demographics, 100% of participants were White. This finding is consistent with Centers for Disease Control and Prevention’s 2015 data indicating a heroin use rate of 3.0 per 1,000 among non-Hispanic Whites versus 1.7 per 1,000 for other races in 2011 through 2013 (C. M. Jones, Logan, Gladden, & Bohm, 2015). These data are also consistent with the landmark Maternal Opioid Treatment: Human Experimental Research (MOTHER) study that showed a 95% White sample in the buprenorphine group and an 85% White sample in the methadone group versus other races (H. E. Jones et al., 2010). We also identified an 80% cigarette smoking rate at the time of our demographic data collection. This was fairly consistent with or somewhat lower than a number of studies that identified an 88% to 95% cigarette smoking rate at the onset of treatment (Akerman et al., 2015; Chisolm et al., 2013; H. E. Jones et al., 2009). We identified no statistically significant change in knowledge from pretest to posttest. Question 5, with five correct responses on the pretest and eight correct responses on the posttest, might benefit from rewording, because the wording may have been confusing. In Question 9, the number of correct responses decreased, which may indicate that the question was unclear. No changes in Questions 4, 11, 12, 13, and 14 may indicate a lack of a knowledge deficit. The test questions were written with participant self-esteem in mind and may reflect a reluctance to include more difficult questions and a desire to add questions that may enhance self-esteem. This was particularly true of Question 11. As a result, the scores may not reflect true knowledge at pretest or posttest. Future projects may benefit from a more comprehensive knowledge test that includes more difficult and less brief questions to identify whether or not there was a true change in knowledge. The final survey was brief but adequate to represent participants’ responses to the intervention. We did not include a qualitative component for the survey but recognize that this may prove beneficial. Implementation of the new evidence-based educational intervention in the PRC received positive feedback from the PRC staff, social workers who followed up with the participants, and the participants themselves. Although statistical significance was not achieved when identifying a change from baseline knowledge to postintervention knowledge, the women and stakeholders affirmed a clear benefit for the participants. The pregnant women in recovery were all very interested in learning about what to expect, and many included family and significant others in the educational process.
Limitations This was a pilot project with a limited number of participants. Because this is a new clinic, the patient population and,
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therefore, the potential number of project participants, was low. Because the education was designed for use in only one clinical setting, some of the educational materials are not applicable to other settings and clinics for pregnant women on buprenorphine maintenance. Specifically, the materials regarding what to expect while the newborn is hospitalized may vary across settings and locations depending on institutional policies and procedures. Additionally, the project was available to all women enrolled in the PRC, including many who were very early in their pregnancies. As a result, only four women gave birth during project implementation and were surveyed regarding their impressions of the effectiveness of the education. Extension of Phase II to include evaluation by all women who participated in the educational intervention is an opportunity for further development and future directions. Had more women responded to the survey, the results may have been different.
Implications for Clinicians To our knowledge, this was a novel initiative. Pregnant women in recovery from opiate dependency have special challenges when facing childbirth, the hospitalization of their newborn, and parenting. Providing parenting education in the prenatal period may improve postpartum and early parenting interactions for women and their newborns.
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Pregnant women in recovery from opiate dependency have special challenges when facing childbirth, the hospitalization of their newborn, and parenting Future Directions A future direction for this program is to revise the pretest/ posttest to include a more comprehensive approach based on the National Institute on Drug Abuse principles (2012) while continuing to remain cognizant of the women’s self-esteem. Because the PRC is a small but growing unit, including a longer implementation period to achieve a larger group of participants is desirable. Implementing the project in other similar facilities may be a long-range goal if the program is successful when implemented on a larger scale. The project is expected to lead to additional tailored evidence-based educational modules and parenting program development for this high-risk childbearing population, such
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as anticipatory guidance for growth and development and parenting during the first month of life. Extension of the evaluation period to include all women who participated in the program is planned. The patient care manager has agreed to continue to administer and send the final surveys as they become available after the women give birth. Finally, the addition of a qualitative component may prove beneficial and may steer future educational projects for this patient population. H. E. Jones et al. (2010) reported a shorter withdrawal phase for newborns born to women who were converted to buprenorphine compared with methadone during pregnancy. Furthermore, ACOG (2012) concluded that, based on the results of existing evidence, buprenorphine may be a potential first-line medication for opioid-dependent pregnant women. For this reason, buprenorphine conversion and treatment programs for pregnant woman may become more commonplace, creating opportunities for evidence-based parenting education for these women.
Conclusion A formalized, evidence-based educational intervention in the PRC was implemented for the pregnant women enrolled in the clinic. The program was very well received by the women, the clinic staff, social workers who are involved with the clinic, and the administrators who support it. Although our findings do not suggest a statistically significant change in knowledge from baseline to posteducation, the women expressed eagerness to learn and enhance their parenting ability in the early postpartum period. This new educational program is expected to continue under the direction of the clinic’s patient care manager, who was especially pleased with the project.
Acknowledgment Thanks to Bawn Maguire, MSN, RN, for identifying the educational need for the women in the pregnancy buprenorphine conversion and maintenance clinic and for facilitating entrance into the clinic, and to the clinic’s patient care manager, Stephanie Bobby, BSN, RN, CARN, for her advice and expertise with the patient population. NWH
Arria, A. M., Mericle, A. A., Rallo, D., Moe, J., White, W. L., Winters, K. C., & O’Connor, G. (2013). Integration of parenting skills education and interventions in addiction treatment. Journal of Addiction Medicine, 7(1), 1–7. doi:10.1097/ ADM.0b013e318270f7b0 Ateah, C. A. (2013). Prenatal parent education for first-time expectant parents: “Making it through labor is just the beginning . . .”. Journal of Pediatric Health Care, 27(2), 91–97. doi:10.1016/j. pedhc.2011.06.019 Barlow, J., Sembi, S., Gardner, F., Macdonald, G., Petrou, S., Parsons, H., . . . Dawe, S. (2013). An evaluation of the parents under pressure programme: A study protocol for an RCT into its clinical and cost effectiveness. Trials, 14, 210. doi:10.1186/1745-6215-14-210 Berlin, L. J., Shanahan, M., & Appleyard Carmody, K. (2014). Promoting supportive parenting in new mothers with substance-use problems: A pilot randomized trial of residential treatment plus an attachment-based parenting program. Infant Mental Health Journal, 35(1), 81–85. doi:10.1002/imhj.21427 Chisolm, M. S., Fitzsimons, H., Leoutsakos, J. M., Acquavita, S. P., Heil, S. H., Wilson-Murphy, M., . . . Jones, H. E. (2013). A comparison of cigarette smoking profiles in opioid-dependent pregnant patients receiving methadone or buprenorphine. Nicotine & Tobacco Research, 15(7), 1297–1304. doi:10.1093/ntr/nts274 El-Mohandes, A. A., Katz, K. S., El-Khorazaty, M. N., McNeelyJohnson, D., Sharps, P. W., Jarrett, M. H., . . . Herman, A. A. (2003). The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: A randomized, controlled study. Pediatrics, 111(6 Pt. 1), 1324–1332. Finnegan, L. P., Connaughton, J. F., Jr., Kron, R. E., & Emich, J. P. (1975). Neonatal abstinence syndrome: Assessment and management. Addictive Diseases, 2(1–2), 141–158. Fraser, J. A., Barnes, M., Biggs, H. C., & Kain, V. J. (2007). Caring, chaos and the vulnerable family: Experiences in caring for newborns of drug-dependent parents. International Journal of Nursing Studies, 44(8), 1363–1370. doi:10.1016/j.ijnurstu.2006.06.004 Hudak, M. L., Tan, R. C., Committee on Drugs, Committee on Fetus and Newborn, & American Academy of Pediatrics. (2012). Neonatal drug withdrawal. Pediatrics, 129(2), e540–560. doi:10.1542/peds.2011-3212 Jansson, L. M., & Velez, M. (1999). Understanding and treating substance abusers and their infants. Infants & Young Children, 11(4), 79–89. Jansson, L. M., & Velez, M. (2012). Neonatal abstinence syndrome. Current Opinion in Pediatrics, 24(2), 252–258. doi:10.1097/ MOP.0b013e32834fdc3a
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The American Journal of Drug & Alcohol Abuse, 35(5), 375–380. doi:10.1080/00952990903125235 Jones, H. E., Kaltenbach, K., Heil, S. H., Stine, S. M., Coyle, M. G., Arria, A. M., . . . Fischer, G. (2010). Neonatal abstinence syndrome after methadone or buprenorphine exposure. New England Journal of Medicine, 363(24), 2320–2331. doi:10.1056/ NEJMoa1005359 Maguire, D., Cline, G. J., Parnell, L., & Tai, C. Y. (2014). Validation of the Finnegan Neonatal Abstinence Syndrome tool–short form. Advances in Neonatal Care, 13(6), 430–437. doi:10.1097/ anc.0000000000000033 Marsh, J. C., & Smith, B. D. (2011). Integrated substance abuse and child welfare services for women: A progress review. Child and Youth Services Review, 33(3), 466–472. doi:10.1016/j. childyouth.2010.06.017 National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide (3rd ed.). Bethesda, MD: Author. Retrieved from http://www.drugabuse.gov/publications /principles-drug-addiction-treatment-research-based-guide -third-edition/principles-effective-treatment Patrick, S. W., Davis, M. M., Lehmann, C. U., & Cooper, W. O. (2015). Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. Journal of Perinatology, 35(8), 650–655. doi:10.1038/jp.2015.36 Patrick, S. W., Schumacher, R. E., Benneyworth, B. D., Krans, E. E., McAllister, J. M., & Davis, M. M. (2012). Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. Journal of the American Medical Association, 307(18), 1934–1940. doi:10.1001/jama.2012.3951
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Pilot Parenting educational Intervention IN A Pregnancy buprenorphine Clinic averie c. giles • diaNXu reN • saNdra fouNds
Substance misuse during pregnancy, a considerable health care concern, predisposes a newborn to the possibility of physiologic and neurobehavioral problems (Jansson & Velez, 2012). Antepartum maternal opiate use has increased significantly from 1.19 per 1,000 hospital births per year in 2000 to 5.63 per 1,000 hospital births in 2009 (Patrick et al., 2012). In 2010, use of any illicit drug during pregnancy was 16.2% among young women ages 15 to 17 years, 7.4% among women ages 18 to 25 years, and 1.9% among women ages 26 to 44 years (Substance Abuse and Mental Health Services Administration, 2011). In an updated report, the Substance Abuse and Mental Health Services Administration reported an increase in substance misuse during pregnancy across all of these age groups in 2012, with 18.3% in young women ages 15 to 17 years, 9.0% in women ages 18 to 25 years, and 3.4% in women ages 26 to 44 years (Substance Abuse and Mental Health Services Administration, 2013). Abstract: We developed a pilot evidence-based prenatal educational intervention to increase knowledge of neonatal abstinence syndrome (NAS) and early parenting skills for women with opiate dependency who enrolled in a pregnancy buprenorphine clinic. We developed, implemented, and tested modules regarding expectations during newborn hospitalization for observation or treatment of NAS and regarding evidence-based parenting skills in response to NAS behaviors. Testing evaluated baseline knowledge of early parenting skills with newborns at risk for NAS and change from baseline after the educational intervention. No statistically significant difference in composite knowledge scores was observed. A brief survey completed by the participants postpartum affirmed the perception of women that the educational intervention effectively prepared them for the early postpartum period while their newborns were hospitalized. http://dx.doi.org/10.1016/j.nwh.2016.04.024 Keywords: buprenorphine | neonatal abstinence syndrome | opioids | parenting skills | prenatal education
Neonatal Abstinence Syndrome
Our Pilot Evidence-Based Protocol The purpose of this pilot evidence-based clinical protocol was to develop, implement, and evaluate an educational intervention to increase knowledge of early parenting skills regarding newborns at risk for NAS in pregnant women with opiate or opioid dependency who enrolled in a pregnancy buprenorphine clinic within a metropolitan women’s hospital.
Background Substance misuse during pregnancy can create a collection of potential adverse consequences for newborns. Prenatal exposure to opiates, opioids, and opioid agonists such as buprenorphine often leads to NAS after birth because of the sudden termination of the drugs that the neonate was exposed to as a fetus (ACOG, 2012). Medical effects of NAS include signs of withdrawal such as excessive high-pitched crying, sleep-wake disturbances, feeding difficulties, alterations in tone and movement, autonomic dysfunction, and gastrointestinal disturbances such as vomiting and loose stools, but these effects are widely variable (Jansson & Velez, 2012). Psychosocial effects include child welfare concerns due to inadequate parenting skills that place the offspring at risk for maltreatment and neglect (Marsh & Smith, 2011; Suchman & Luthar, 2000; Suchman, Pajulo, Decoste, & Mayes, 2006). Women with substance misuse often have received poor parenting themselves, including sexual, physical, and emotional Averie C. Giles, DNP, FNP-C, is a graduate of the DNP program at the University of Pittsburgh School of Nursing in Pittsburgh, PA. Dianxu Ren, PhD, is an associate professor and associate director for statistical support services at the University of Pittsburgh School of Nursing in Pittsburgh, PA. Sandra Founds, PhD, CNM, FNP-BC, is an associate professor of health promotion and development at the University of Pittsburgh School of Nursing in Pittsburgh, PA. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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Substance misuse during pregnancy can create a collection of potential adverse consequences for newborns maltreatment, creating a deficit in their own parenting skills (Jansson & Velez, 1999). Furthermore, pregnant women with substance use disorder often have insufficient parenting knowledge, especially regarding basic parenting, newborn care, and child development (Rizzo et al., 2014; Velez et al., 2004). This lack of parenting knowledge paired with difficult neonatal behaviors in opioid-exposed newborns creates an impediment to parenting well for the opioid-dependent mother. Nurses with specialized training find caring for newborns experiencing NAS to be challenging and time consuming (Fraser, Barnes, Biggs, & Kain, 2007); new mothers with opioid dependency who may have limited parenting skills often care for their newborns with little to no preparation. For example, women with opioid dependency may have difficulty identifying and reacting to their newborns’ cues (Jansson, Velez, & Harrow, 2009; Velez & Jansson, 2008). Evidenced-based parenting education is predominantly for the general population (Ateah, 2013; El-Mohandes et al., 2003). There is a paucity of literature identifying evidence-based parenting education programs in the prenatal period, especially for high-risk pregnant women with substance misuse. An exhaustive librarian-assisted literature search of PubMed, Ovid, CINAHL, and UpToDate yielded no results for prenatal parenting education for this patient population. Parenting guides from major health systems in the United States, Australia, and Europe were found in the lay literature, although these materials did not include citations from peer-reviewed journals. In the United States, 43% of addiction treatment programs offer some sort of parenting classes for parents with substance use disorders, but very few use any sort of structured curriculum (Arria et al., 2013). Most parenting education occurs in the immediate postpartum period, and for those in addiction treatment, this may be too late (Barlow et al., 2013; Berlin, Shanahan, & Appleyard Carmody, 2014; El-Mohandes et al., 2003). This is especially notable for NAS education, because the neonate may already be experiencing NAS. Maternal education to prepare for the neonate’s possible neurobehavioral dysregulation related to withdrawal is essential to aid in optimal parenting during the immediate postpartum period (Jansson & Velez, 2012). ACOG (2012) notes that pharmacologic treatment focuses on the relief of signs and symptoms of withdrawal for the newborn and on
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Using discharge data, Patrick, Davis, Lehmann, and Cooper (2015) documented a rate of 5.8% per 1,000 hospital births per year of newborns diagnosed with neonatal abstinence syndrome (NAS) in 2012 and identified a fivefold increase in incidence since 2000. For pregnant women with opioid or opiate dependence, comprehensive medication-assisted treatment reduces the risk of complications to the fetus and the woman (American College of Obstetricians and Gynecologists [ACOG], 2012). Women receiving buprenorphine treatment during pregnancy express concern regarding neonatal withdrawal from the medication (Rizzo et al., 2014). Providing education concerning the hospital course generally and NAS specifically may optimize women’s interactions with their newborns and their early parenting skills.
for pregnant women in an opiate-to-buprenorphine conversion and maintenance program to increase knowledge of early parenting skills with newborns at risk for NAS, integrating the specific needs of women in opiate addiction recovery; (b) determine if educational sessions increase knowledge of early parenting skills with newborns at risk for NAS by measuring change in pre- versus posteducation assessment scores; and (c) evaluate the effects of the educational intervention in the first 1 to 2 weeks postpartum.
Methods
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Setting
preventing complications of withdrawal. New mothers have a limited role in this aspect of care. Providing parenting education during the prenatal period about nonpharmacologic care of opioid-exposed infants can improve maternal interactions and facilitate parenting behaviors that decrease those interactions that may exacerbate withdrawal symptoms (Maguire, Cline, Parnell, & Tai, 2014). Nonpharmacologic care focuses on minimizing external stimuli, promoting rest, and providing adequate nutrition (Hudak, Tan, Committee on Drugs, Committee on Fetus and Newborn, & American Academy of Pediatrics, 2012). In addition, educational interventions may raise awareness for the challenges of parenting in the early prenatal period (Rizzo et al., 2014). Unfortunately, there is a critical gap in the availability of tailored prenatal education to help women with opioid dependency acquire the necessary parenting skills to care for their newborns at risk for or diagnosed with NAS.
Goals of Our Intervention The goals of this new evidence-based clinical program were to (a) develop an evidence-based educational intervention
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In response to an invitation by the hospital’s outreach coordinator, who recognized a need for prenatal education for this vulnerable population, this project was implemented at the new Pregnancy Recovery Center (PRC), an opiate or opioid-to-buprenorphine conversion and maintenance program providing a Medical Home Model within a large health system’s outpatient clinic in Pittsburgh, Pennsylvania. The PRC integrates a medication-assisted treatment program with comprehensive prenatal care, social services, and birthing care. This teaching hospital provides care for approximately 11,000 newborns born each year, with well newborn and neonatal intensive care services available. This quality improvement project was approved by the tertiary hospital–based clinical projects review committee and was also determined to not need university institutional review board approval because it was not research.
Project Design The project was developed in two phases. The first phase involved development, implementation, and evaluation of an educational program for substance-abusing pregnant women who were in recovery. The second phase evaluated the perceptions of the new mothers regarding the effectiveness of the education related to their early parenting efforts in the immediate postpartum period.
Phase I We developed a pilot evidence-based prenatal educational intervention for pregnant women in an opiate or opioidto-buprenorphine conversion and maintenance program to increase knowledge of early parenting skills with newborns at risk for NAS, integrating the specific needs of women in substance misuse recovery. Initially, we informally surveyed the pregnant women of the PRC to determine their perceived educational needs and to begin to develop trust. In response to the pregnant women’s most common needs, two educational
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The testing also informed the quality of the education and identified strengths and weaknesses in the educational materials and process nence scoring tool used to quantify NAS symptoms (Finnegan, Connaughton, Kron, & Emich, 1975). The second module included elements of nonpharmacologic interventions important to the care of the substance-exposed newborn. The information integrated evidenced-based written materials using the principles of addiction recovery outlined in the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment (2012) for the women in the PRC. Specifically, the principle that states that providing substance-abusing women in addiction recovery an opportunity to actively participate in their recovery, in this case by education, increases the likelihood of good outcomes (National Institute on Drug Abuse, 2012). The educational materials were reviewed by experts in obstetrics, women’s health, and addiction. A checklist of the three educational modules was developed to identify areas of education addressed and completed for each participant. The education was presented to the PRC participants in small segments during the course of their weekly visits to the PRC up through birth. The first author was present in the PRC 3 days per week over an 8-week period to deliver the education to each participant initially. The education used verbal communication and an infant simulator to provide demonstration of NAS scoring activities and parenting responses to NAS signs in a neonate. The simulator was particularly useful in supporting visual learners, especially for more complicated actions such as containment (a facilitated tucking technique) used to soothe and comfort a neonate. After the completion of this initial phase, the PRC’s addiction-certified patient care manager, who is a registered nurse, was trained to deliver the education. To determine if the educational sessions increased knowledge of early parenting skills with newborns at risk for NAS, we measured change in pre- versus posteducation assessment scores. The testing also informed the quality of the education
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and identified strengths and weaknesses in the educational materials and process. We developed a 14-question pretest to assess knowledge of NAS and early parenting skills. Each item was a true/false question or a multiple choice question (see Table 1). The same test questions were administered at the completion of all of the educational modules. A trifold brochure summarizing the provided parenting educational information to address NAS behaviors was developed and offered to participants at the completion of all of the educational modules and the posttest. The brochure was intended to provide a quick reference for parents while their newborns were hospitalized.
Phase II To explore the practical effects of the educational intervention, at 1 to 2 weeks after birth when the women followed up with the PRC, participants were asked to complete a brief survey, which consisted of two questions using Likert scale responses (range, 1–5), with responses ranging from strongly agree to strongly disagree. This survey identified the women’s perceptions regarding the effectiveness of the educational program in preparing them for the early postpartum period. The survey items were: My participation in the parenting education project in the PRC helped me to prepare for the immediate postpartum
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modules were developed and implemented: (a) what to expect while the newborn is hospitalized for observation or treatment of NAS and (b) how to interact with newborns at risk for or with NAS. The first module included two components: education regarding the hospital stay and information about the hospital’s Neonatal Abstinence Scoring Sheet, which is based on the Finnegan Scoring System, a widely used neonatal absti-
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table 1
Questions Pre- and Postintervention Q1 M y baby will be required to stay in the hospital for a minimum of _______not counting the day my baby is born. A. 3 days B. 5 days C. 7 days D. 14 days Q2 B ecause all of my family and friends want to bond with my baby, it is important that I let each of them hold him/her. A. True B. False Q3 T he Neonatal Abstinence Scoring System will be used to determine if my baby is having symptoms of withdrawal and the scores will be recorded on the Neonatal Abstinence Scoring Sheet. A. True B. False Q4 I f my baby shows signs of withdrawal and needs medication, they will give him/her Subutex. A. True B. False Q5 S igns of withdrawal include A. Excessive sucking B. High-pitched cry C. Tremors D. Snoring E. Vomiting or spitting up F. Stuffy nose G. Difficulty feeding H. Sneezing Choose one best answer A. A, B, C, H B. A, B, C, E, F, G, H C. All of the above Q6 I f it is daytime, I should keep bright lights on and if it is night-time I should keep them turned off. That way my baby will not get his/her days and nights mixed up. A. True B. False
Q7 Swaddling my baby will help him/her feel calmer. A. True B. False Q8 If my baby scores ________ or greater for _____consecutive scores, or averages greater than _____, the nurse will call the doctor or nurse practitioner. A. 6, 3, 6 B. 8, 3, 8 C. 8, 5, 8 Q9 If my baby stops eating during a feeding, he/ she is not hungry anymore and I should stop feeding him/her. A. True B. False Q10 If my baby is crying, especially if it is high pitched, I can help him/her calm down by holding him/her close to me or skin-to-skin, swaddling him/her in a blanket, or by slow, gentle vertically rocking. A. True B. False Q11 My love and care are essential to the care of my baby and I am a very important part of the care team while my baby is in the hospital. A. True B. False Q12 If I am breastfeeding, I can still use a pacifier for my baby because he/she needs comfort sucking between feedings. A. True B. False Q13 If my baby is sleeping when I arrive, it is OK to wake him/her because she will be happy to see me. A. True B. False Q14 I have allergies and I sneeze a lot so if my baby sneezes a lot, he/she probably has allergies also. A. True B. False
Note. Boldface indicates correct answers. Q = question.
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period while my newborn was hospitalized and My participation in the parenting education project in the PRC helped me to understand how best to interact with my newborn at risk for neonatal abstinence syndrome during the early postpartum period.
Analysis The results of the pre- and posttests were collected by the first author and compiled in a spreadsheet on a password-protected computer. De-identified clinical and demographic data were collected and entered into a database. All data were then imported into SPSS for Windows version 22. Pre- and posttests were evaluated with descriptive and comparison statistics to determine baseline knowledge and change from baseline after the education.
Results Phase I During the implementation period, 19 pregnant women were enrolled in the PRC. Two women declined participation in the educational intervention, two gave birth before the education was completed, and 15 finished the educational intervention, for a final sample of 15 women (N = 15). De-identified demographic data were examined for means, frequencies, standard deviations, and distributions. The mean age of project participants was 28.3 years. One hundred percent of the participants were White, 80% were smokers, and 100% had a minimum of a high school diploma or high school equivalent. Pre- and posttest questions were examined for frequencies. Final scores comparing baseline knowledge on the pretest with knowledge after the educational intervention were analyzed using the Wilcoxon rank-sum test because of the small sample size. The overall change in knowledge score did not reach statistical significance.
Phase II Only four of the women (n = 4) who participated in the educational intervention birthed their newborns during the 8-week implementation phase of the project. These women all responded that they agreed or strongly agreed with both of the postpartum questions (Phase II): that their participation in the parenting education project helped them to (a) prepare for the immediate postpartum period while their newborns were hospitalized and (b) understand how best to interact with their newborns at risk for NAS during the immediate postpartum period. Since the end of the implementation period, seven more women have given birth and completed the survey. All but one agreed or strongly agreed with both questions on the survey. One participant was neutral on the second question.
Discussion Substance misuse during pregnancy is a significant health concern because it predisposes newborns to the possibility of physiologic and neurobehavioral problems (Jansson & Velez, 2012).
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Poor parental role modeling and lack of parenting knowledge paired with difficult neonatal behaviors create a barrier to parenting well for women with opioid dependency (Jansson & Velez, 1999; Rizzo et al., 2014; Velez et al., 2004). With regard to participant demographics, 100% of participants were White. This finding is consistent with Centers for Disease Control and Prevention’s 2015 data indicating a heroin use rate of 3.0 per 1,000 among non-Hispanic Whites versus 1.7 per 1,000 for other races in 2011 through 2013 (C. M. Jones, Logan, Gladden, & Bohm, 2015). These data are also consistent with the landmark Maternal Opioid Treatment: Human Experimental Research (MOTHER) study that showed a 95% White sample in the buprenorphine group and an 85% White sample in the methadone group versus other races (H. E. Jones et al., 2010). We also identified an 80% cigarette smoking rate at the time of our demographic data collection. This was fairly consistent with or somewhat lower than a number of studies that identified an 88% to 95% cigarette smoking rate at the onset of treatment (Akerman et al., 2015; Chisolm et al., 2013; H. E. Jones et al., 2009). We identified no statistically significant change in knowledge from pretest to posttest. Question 5, with five correct responses on the pretest and eight correct responses on the posttest, might benefit from rewording, because the wording may have been confusing. In Question 9, the number of correct responses decreased, which may indicate that the question was unclear. No changes in Questions 4, 11, 12, 13, and 14 may indicate a lack of a knowledge deficit. The test questions were written with participant self-esteem in mind and may reflect a reluctance to include more difficult questions and a desire to add questions that may enhance self-esteem. This was particularly true of Question 11. As a result, the scores may not reflect true knowledge at pretest or posttest. Future projects may benefit from a more comprehensive knowledge test that includes more difficult and less brief questions to identify whether or not there was a true change in knowledge. The final survey was brief but adequate to represent participants’ responses to the intervention. We did not include a qualitative component for the survey but recognize that this may prove beneficial. Implementation of the new evidence-based educational intervention in the PRC received positive feedback from the PRC staff, social workers who followed up with the participants, and the participants themselves. Although statistical significance was not achieved when identifying a change from baseline knowledge to postintervention knowledge, the women and stakeholders affirmed a clear benefit for the participants. The pregnant women in recovery were all very interested in learning about what to expect, and many included family and significant others in the educational process.
Limitations This was a pilot project with a limited number of participants. Because this is a new clinic, the patient population and,
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therefore, the potential number of project participants, was low. Because the education was designed for use in only one clinical setting, some of the educational materials are not applicable to other settings and clinics for pregnant women on buprenorphine maintenance. Specifically, the materials regarding what to expect while the newborn is hospitalized may vary across settings and locations depending on institutional policies and procedures. Additionally, the project was available to all women enrolled in the PRC, including many who were very early in their pregnancies. As a result, only four women gave birth during project implementation and were surveyed regarding their impressions of the effectiveness of the education. Extension of Phase II to include evaluation by all women who participated in the educational intervention is an opportunity for further development and future directions. Had more women responded to the survey, the results may have been different.
Implications for Clinicians To our knowledge, this was a novel initiative. Pregnant women in recovery from opiate dependency have special challenges when facing childbirth, the hospitalization of their newborn, and parenting. Providing parenting education in the prenatal period may improve postpartum and early parenting interactions for women and their newborns.
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Pregnant women in recovery from opiate dependency have special challenges when facing childbirth, the hospitalization of their newborn, and parenting Future Directions A future direction for this program is to revise the pretest/ posttest to include a more comprehensive approach based on the National Institute on Drug Abuse principles (2012) while continuing to remain cognizant of the women’s self-esteem. Because the PRC is a small but growing unit, including a longer implementation period to achieve a larger group of participants is desirable. Implementing the project in other similar facilities may be a long-range goal if the program is successful when implemented on a larger scale. The project is expected to lead to additional tailored evidence-based educational modules and parenting program development for this high-risk childbearing population, such
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as anticipatory guidance for growth and development and parenting during the first month of life. Extension of the evaluation period to include all women who participated in the program is planned. The patient care manager has agreed to continue to administer and send the final surveys as they become available after the women give birth. Finally, the addition of a qualitative component may prove beneficial and may steer future educational projects for this patient population. H. E. Jones et al. (2010) reported a shorter withdrawal phase for newborns born to women who were converted to buprenorphine compared with methadone during pregnancy. Furthermore, ACOG (2012) concluded that, based on the results of existing evidence, buprenorphine may be a potential first-line medication for opioid-dependent pregnant women. For this reason, buprenorphine conversion and treatment programs for pregnant woman may become more commonplace, creating opportunities for evidence-based parenting education for these women.
Conclusion A formalized, evidence-based educational intervention in the PRC was implemented for the pregnant women enrolled in the clinic. The program was very well received by the women, the clinic staff, social workers who are involved with the clinic, and the administrators who support it. Although our findings do not suggest a statistically significant change in knowledge from baseline to posteducation, the women expressed eagerness to learn and enhance their parenting ability in the early postpartum period. This new educational program is expected to continue under the direction of the clinic’s patient care manager, who was especially pleased with the project.
Acknowledgment Thanks to Bawn Maguire, MSN, RN, for identifying the educational need for the women in the pregnancy buprenorphine conversion and maintenance clinic and for facilitating entrance into the clinic, and to the clinic’s patient care manager, Stephanie Bobby, BSN, RN, CARN, for her advice and expertise with the patient population. NWH
Arria, A. M., Mericle, A. A., Rallo, D., Moe, J., White, W. L., Winters, K. C., & O’Connor, G. (2013). Integration of parenting skills education and interventions in addiction treatment. Journal of Addiction Medicine, 7(1), 1–7. doi:10.1097/ ADM.0b013e318270f7b0 Ateah, C. A. (2013). Prenatal parent education for first-time expectant parents: “Making it through labor is just the beginning . . .”. Journal of Pediatric Health Care, 27(2), 91–97. doi:10.1016/j. pedhc.2011.06.019 Barlow, J., Sembi, S., Gardner, F., Macdonald, G., Petrou, S., Parsons, H., . . . Dawe, S. (2013). An evaluation of the parents under pressure programme: A study protocol for an RCT into its clinical and cost effectiveness. Trials, 14, 210. doi:10.1186/1745-6215-14-210 Berlin, L. J., Shanahan, M., & Appleyard Carmody, K. (2014). Promoting supportive parenting in new mothers with substance-use problems: A pilot randomized trial of residential treatment plus an attachment-based parenting program. Infant Mental Health Journal, 35(1), 81–85. doi:10.1002/imhj.21427 Chisolm, M. S., Fitzsimons, H., Leoutsakos, J. M., Acquavita, S. P., Heil, S. H., Wilson-Murphy, M., . . . Jones, H. E. (2013). A comparison of cigarette smoking profiles in opioid-dependent pregnant patients receiving methadone or buprenorphine. Nicotine & Tobacco Research, 15(7), 1297–1304. doi:10.1093/ntr/nts274 El-Mohandes, A. A., Katz, K. S., El-Khorazaty, M. N., McNeelyJohnson, D., Sharps, P. W., Jarrett, M. H., . . . Herman, A. A. (2003). The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: A randomized, controlled study. Pediatrics, 111(6 Pt. 1), 1324–1332. Finnegan, L. P., Connaughton, J. F., Jr., Kron, R. E., & Emich, J. P. (1975). Neonatal abstinence syndrome: Assessment and management. Addictive Diseases, 2(1–2), 141–158. Fraser, J. A., Barnes, M., Biggs, H. C., & Kain, V. J. (2007). Caring, chaos and the vulnerable family: Experiences in caring for newborns of drug-dependent parents. International Journal of Nursing Studies, 44(8), 1363–1370. doi:10.1016/j.ijnurstu.2006.06.004 Hudak, M. L., Tan, R. C., Committee on Drugs, Committee on Fetus and Newborn, & American Academy of Pediatrics. (2012). Neonatal drug withdrawal. Pediatrics, 129(2), e540–560. doi:10.1542/peds.2011-3212 Jansson, L. M., & Velez, M. (1999). Understanding and treating substance abusers and their infants. Infants & Young Children, 11(4), 79–89. Jansson, L. M., & Velez, M. (2012). Neonatal abstinence syndrome. Current Opinion in Pediatrics, 24(2), 252–258. doi:10.1097/ MOP.0b013e32834fdc3a
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The American Journal of Drug & Alcohol Abuse, 35(5), 375–380. doi:10.1080/00952990903125235 Jones, H. E., Kaltenbach, K., Heil, S. H., Stine, S. M., Coyle, M. G., Arria, A. M., . . . Fischer, G. (2010). Neonatal abstinence syndrome after methadone or buprenorphine exposure. New England Journal of Medicine, 363(24), 2320–2331. doi:10.1056/ NEJMoa1005359 Maguire, D., Cline, G. J., Parnell, L., & Tai, C. Y. (2014). Validation of the Finnegan Neonatal Abstinence Syndrome tool–short form. Advances in Neonatal Care, 13(6), 430–437. doi:10.1097/ anc.0000000000000033 Marsh, J. C., & Smith, B. D. (2011). Integrated substance abuse and child welfare services for women: A progress review. Child and Youth Services Review, 33(3), 466–472. doi:10.1016/j. childyouth.2010.06.017 National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide (3rd ed.). Bethesda, MD: Author. Retrieved from http://www.drugabuse.gov/publications /principles-drug-addiction-treatment-research-based-guide -third-edition/principles-effective-treatment Patrick, S. W., Davis, M. M., Lehmann, C. U., & Cooper, W. O. (2015). Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. Journal of Perinatology, 35(8), 650–655. doi:10.1038/jp.2015.36 Patrick, S. W., Schumacher, R. E., Benneyworth, B. D., Krans, E. E., McAllister, J. M., & Davis, M. M. (2012). Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. Journal of the American Medical Association, 307(18), 1934–1940. doi:10.1001/jama.2012.3951
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