Promising Practices: Center for Addiction and Pregnancy Pediatrics at Johns Hopkins Bayview Medical Center–Maryland

A Comprehensive Approach to Treatment and Support

Expectant birth parents and their families living in Baltimore City and the surrounding suburban and rural areas of Maryland access CAP for prenatal care and comprehensive interventions to support them in recovery from addictions. These parents access a wide array of professionals within CAP including counselors, psychiatrists, obstetricians and pediatricians. They have access to maternal-fetal medicine if they have specific medical problems that require specialized treatment. Mothers participate in psychoeducational groups with residential support when needed. Group discussions focus on parenting, trauma and recovery. Once babies are born (most at a hospital on the campus of the CAP program), the family has the automatic option to enroll in the pediatric practice while continuing parental treatment in the broader CAP program.

A critical component of comprehensive services within CAP Pediatrics and the broader CAP program is ongoing screening and assessment to identify the kinds of supports each family need. CAP Pediatrics staff gather information about the child and caregivers’ functioning and needs at all health supervision visits.  Ongoing communication with the CAP parenting coordinator provides a united approach to the infant’s functioning, neonatal abstinence syndrome status and any issues that arise with older siblings during CAP treatment.  Additionally, communication with other CAP staff providing SUD treatment can help pediatric providers understand the parental perspective/functioning as it may affect the care of the infant/child. When appropriate, CAP Pediatrics staff offers referrals to families that vary from mental health supports to broader social services programs. Over the years, CAP Pediatrics has had direct partnerships with social service and education organizations including child protective services, Early Head Start and Head Start, early intervention and special education, domestic violence organizations and others providing services to the families within CAP Pediatrics. These relationships have allowed CAP Pediatric providers to ensure families have the services they need to support children in growth and development starting from ante and perinatal services to the time when they transition into adult health services. This life-course perspective is essential to address the social drivers that impact the child’s development.

Providers at CAP Pediatrics respond to each family by providing what they need as they need it. Breastfeeding can be a more complex issue for mothers with substance use disorder. Therefore, CAP Pediatrics provides extensive supports for breastfeeding mothers, using an algorithm that includes analysis of relapse data to identify whether breastfeeding is appropriate for each family while also providing relapse prevention support. This ensures that both parent and infant are receiving needed care for shared outcomes. Additionally, CAP Pediatrics is careful to make referrals when the family is most ready to access the services. For example, staff may delay referrals to early intervention when the additional requirements of early intervention may impede a mother’s treatment, instead working with the mother to assure intervention for the child that is compatible with her treatment needs. Finally, CAP Pediatrics also adjusts the visit schedule to accommodate the needs of each family. Acknowledging that some families may need more support in different stages of a child’s life, families can schedule visits as often as needed. An infant experiencing neonatal abstinence syndrome symptoms after hospital discharge may require observation and intervention nearly daily, while a child with an identified behavioral or developmental problem may require more pediatric support at a later age. These simple patient and family-centered adjustments ensure an approach that accommodates both children and parents.

Organizational Systems to Support Success

The interactions between CAP Pediatrics and the broader CAP organization are critical to ensuring supports are in place for families. The automatic referral system ensures families receive ongoing medical care for children in a consistent, nurturing multi-generational approach. CAP counselors and physicians conduct ongoing screening and assessment to identify individual needs. Parents complete perinatal depression, addiction and mental health screening tools at intake and at regular intervals. In addition, the team assesses for social determinants of health such as intimate partner violence, housing, financial needs and food insecurity. CAP providers gather family histories to understand whether addiction/psychiatric problems occurred in previous generations within the family and adapt services to multi-generational mental health needs. CAP Pediatrics combines the information about adult participants enrolled in CAP with information gathered during health supervision visits to determine interventions and referrals. As needs are identified, case management meetings occur within CAP, pulling in specialists available through the Johns Hopkins Hospital System as needed. These meetings offer transparency of information while meeting confidentiality requirements through consent of the CAP enrolled parents. They also ensure costs are minimized by utilizing the resources within Johns Hopkins University Hospital System as much as possible.

To serve families appropriately, all CAP and CAP Pediatrics providers participate in ongoing training regarding judgment-free, non-stigmatizing, and culturally appropriate services. Within the larger CAP organization, providers are aware of the high prevalence of different psychiatric disorders, unresolved trauma/grief, and high level of stress in birth parents, and the impact that these factors may have on the family functioning and the physical and emotional development of the child. Additionally, the small staff at CAP pediatrics is trained in family-centered practices that eliminate jargon and use of pejorative language to create a welcoming environment. Each pediatrician and nurse receive training in creating a medical environment that adapts to the families they serve, offering guidance and support to families as they juggle the stressors of parenthood and their own mental and physical health needs. Often birth parents will bring their children to CAP Pediatrics, but the clinic also serves children living with foster families, grandparents or fathers regardless of parental treatment status. CAP Pediatrics care continues until the child’s 21st birthday, oftentimes providing the only link for the family to needed parental SUD treatment and other services once the parent leaves CAP treatment. Therefore, CAP Pediatrics providers routinely ask about parental needs in the context of the pediatric visit.

One challenge that CAP Pediatrics faces is funding their broad range of mental health and social service supports to children and families. Access to mental health supports for families through partnership with and referrals to CAP and the Johns Hopkins University Hospital System for mental and physical health alleviates some of these costs. CAP Pediatrics continues to innovate and adapt to meet families’ needs; leveraging philanthropic and other funding to provide real responses in more structured ways. One example is a family planning project that accompanied parents in their decision making regarding future pregnancies. As pregnant people enrolled in CAP prepared for or delivered a new baby, counselors would work with them to make decisions about their family structure and ways to promote family planning. These immediate resources empowered families in ways that supported perinatal mental health. Even with the support of the CAP agency and the Johns Hopkins University Hospital System, finding funding solutions continues to be an ongoing process. Further reading: AAP Coding Fact Sheets.

Lessons Learned

Ultimately, many of CAP Pediatrics greatest successes are highly replicable in any pediatric practice. Using non-judgmental, non-stigmatizing and culturally responsive comprehensive approaches, meets families where they are and offers them an individualized approach to support healthy mental and emotional development. Ongoing screening and assessment of diverse parental mental and physical health needs during pediatric care identifies treatment and referral options that work for families. Additionally, creating strong partnerships with community providers that serve children and families allows CAP Pediatrics to connect families to resources that can support them in comprehensive ways.