These recommendations were collectively elaborated by the major part of the members of the International Parenthood-Drug Abuse Network, on basis of the results of the research « Treatment and care of drug-using young and future parents and their children in Europe » and on basis of analysis discussed during the Paris Seminar of March 97.
 

MULTIDISCIPLINARITY
 

a. Out-patients departments for pregnant women, drug-using parents and their children should be established around a multidisciplinary team: they must offer psycho-social care, accompany parenthood and network organisation projects.

Such a network must create and strengthen care practices for these patients with sound medical and social support.

b. Specialised services must be integrated into more general services in order to avoid unnecessary stigmatisation of the customers.

This integration will be made as soon as possible while ensuring that it does not lead to a reduction in the quality or quantity of the services offered to drug users and their children.

c. One of the explicit functions of the specialised services is to transmit the methodology they have acquired through experience to other general services.

TRAINING
 
 

The multidisciplinary team requires specific training in the problems of drug dependency and in associated problems, problems in which professionals are generally poorly trained.

RESPECT for THE PATIENT AND CONFIDENTIALITY
 

The services for drug addicted pregnant women must respect their needs and personal choices. The fact that these women may be unwilling to accept medical or social advice and recommendations must never be a reason for refusing a service. Confidentiality must be guaranteed as a sine qua non condition.

HARM REDUCTION, ACCESSIBILITY
 

a. These services must not be over-ambitious and should be based on harm reduction rather than the single option of abstinence.

b. The services must be free or covered by the health insurance applicable in the country.

c. Initiatives for the creation of structures of non-medical sheltering for drug-taking pregnant women, mothers and their young children or families, should be supported by the public authorities and should be accessible to these customers.

PREVENTION OF PARENT-CHILDREN SEPARATION
 

a. Drug addiction does not in itself constitute sufficient reason for separating parents from their child because a separation often leads to problems that are just as serious for the children. The best option is therefore not to separate them.

b. If the parents do not want to care for their child, or if the child is in immediate danger, only then is separation an acceptable solution.

If separation should occur, then it should be temporary and as brief as possible.

c. In all cases of social and medical care, the development of the child and the continuity of the links between mother and child(ren) must take priority.
 

COMBINATION OF PSYCHIATRIC DISORDERS
 

The frequency of a combination of psychiatric and/or somatic disorders means that each team should make provision for detection and propose a suitable protocol of care, either in situ or as part of the local medico-psychiatric network.

GUARANTEE OF THE RIGHT TO TREATMENT DURING INCARCERATION
 

While we do not want to interfere in the legal practices of countries, we notice that the prison environment is the most dangerous for drug-using pregnant women or for mothers with young children.

These imprisoned women and their babies must be able to benefit from specific attention and the appropriate psycho-social and medical care.

If such care can not be offered, the imprisonment constitutes a serious breach of Human Rights as guaranteed in the Universal Declaration of Human Rights, which in no circumstances can be justified.

PRENATAL CARE
 

a. The main intention of the care offered to drug-using future parents and to their children about to be born is to keep them as healthy as possible.

b. Like all other pregnant women, those who are drug

users must receive prenatal care and have access to check-ups for the detection of infectious diseases (chlamydia, gonorrhoea, syphilis, tuber-culosis, toxoplasmosis, HIV, hepatitis B / C ).

LOCAL WORK
 

It is important to come into contact with drug-using pregnant women.

INVESTIGATION OF DRUG CONSUMPTION
 

Medical and paramedical teams who are in contact with pregnant women must investigate their drug consumption in a systematic way but without making presumptions.

COMPETENCE
 

In cases of drug abuse, women must have access either to a competent service or a qualified professional, for the appropriate monitoring and treatment.

SUBSTITUTION TREATMENT
 

a. The doctor must be able to begin a substitution treatment without arbitrary limitation (neither political nor ideological).

b. Methadone is a specific and effective substi-tution treatment for heroin-addicted pregnant women.Other substitution treatments such as buprenorphine may be considered.

c. Other treatments may be envisaged. Acupuncture is an effective means of helping with abstinence in general, including therefore abstinence from cocaine.

d. If the pregnant woman is in a stable condition and if she agrees to it, then a progressive reduction in the dosage of methadone may be envisaged with caution by an experienced doctor.

MONITORING AFTER ABSTINENCE
 

If the woman abstains from drug-taking then she should be able to continue being monitored.

PSYCHO-SOCIAL SUPPORT FOR PARENTS AND CHILDREN
 

a. Pregnancy is a good time to introduce - if necessary - psychological and/or social support for both drug-using future parents (mother and father), as well as for their older children.

b. The drug-using future parents and their new family should be able to obtain accommodation and minimum financial assistance in order to be able to support their family properly.

COLLABORATION BETWEEN TEAMS
 

a. The medical and psycho-social teams must work together closely, whether they belong to the same multidisciplinary institution or are part of a mobile unit.

b. Contact between the drug-using future parents and teams (doctors and nurses) from the gynaecology-obstetrics and neonatal services must be encouraged throughout the pregnancy.

CONTINUOUS CONTACT BETWEEN PARENTS AND CHILDREN
 

If the newborn child needs to be transferred to the neonatal service, both drug-using parents must be able to have continuous contact with their baby.

BREAST-FEEDING
 

a. Like all mothers, drug users should be encouraged to breast-feed their child.

b. The indications and contraindications of breast-feeding must be evaluated on a case by case basis, while bearing in mind that breast-feeding strengthens the bond between mother and child.

c. The mother's methadone treatment does not constitute a contraindication to breast-feeding.

d. If the mother is HCV positive (PCR+ or PCR), breast-feeding is not necessarily contraindicated.

e. Being HIV positive is a contraindication to breast-feeding.

ACCOMPANYING MONITORING
 

a. The (future) parents and their children should be able to enjoy a friendly and non-judgemental environment.

b. The criminalisation of drug-using young and future parents must be avoided.

GENERAL
 

a. Contrary to popular wisdom, drug users can possess good parental skills.

b. Drug-using parents and pregnant women must receive:

- the necessary support in their desire to have a child

- a professional approach to care that is non-stigmatising, non-moralising

- special programmes involving access to a gynaecologist, midwives, an anaesthetist, social workers, a paediatrician, child psychologist and child psychiatrist.

c. It is desirable that specialists in parenthood and family care intervene in a co-ordinated way from pregnancy onwards.

d. It is necessary to ensure that the presence of such professionals does not lead to a pathologisation or psychiatrisation of the normal evolution of the pregnancy, the delivery, the establishment of the relationship between parent and child and the development of the child.

SUBSTITUTION TREATMENT DURING THE PREGNANCY OF HEROIN DEPENDENT WOMEN
 

a. Substitution is recommended for drug-using pregnant women.

b. Substitution programmes that include pregnant patients must encourage these women to have their pregnancy monitored in hospitals that have experience of drug-using pregnant women.

c. A substitution treatment involving decreasing doses must be envisaged with caution and undertaken by an experienced team for those women who request it.

Sudden abstinence is not recommended.

d. Mothers should be allowed to stay with their child for as long as the baby remains in hospital.

e. Access of parents to their child in hospital must be encouraged.

STAYING IN A MATERNITY SERVICE

The length of time drug-using mothers spend in a maternity service should not differ from that of other mothers.

DELIVERY
 

It is possible that during labour (or the delivery), drug-using women require extra analgesic or methadone.

BREAST-FEEDING
 

Any mother who wishes to breast-feed her child should be encouraged to do so, taking account of the following medical contraindications:

- if the substitution treatment has not been stabilised

- in cases of drug consumption outside the treatment

- in cases where infection may be transmitted through the milk (HIV, HBV).

The transmissibility of HCV is still uncertain.

In such cases caution should be exercised.

NEONATALOGY: NEONATAL ABSTINENCE SYNDROME AND ITS TREATMENT
 
 

a. A guide of medical practice needs to be drawn up to improve and harmonise practices involving drug-using mothers and their newborn babies.

b. Controls are recommended using a scale of abstinence scores for:

- symptoms of neonatal abstinence

- pharmacological therapy

c. Support measures are very important in order to calm the children, for example by providing:

- a quiet room or corner of the ward

- subdued lighting

- a dummy for the baby

- swaddling-clothes / a cot / a hammock

- frequent feeding, but in small quantities and upon request

- protection of the skin against abrasions caused by hypermobility, scratching and diarrhoea

- a baby-carrier in case of prolonged crying

- extra baths

The need to spend time in a neonatal service should be evaluated on a case by case basis.

d. Pharmacological therapy is defined according to the total abstinence score, and prescribed according to the type of drug used by the mother.

The abstinence syndrome results in suffering for the child; this must be taken into consideration and treated with morphine-based drugs in decreasing doses.

FURTHER SUPPORT
 

Particular attention must be given to the development of the child in terms of their physical, psycho-emotional and cognitive well-being, wherever they live and whatever type of drugs the mother has used during the pregnancy.

MAINTENANCE OF THE BOND BETWEEN PARENT AND CHILD
 

a. The maintenance of parent-child relationships must be one of the main objectives of any health programme targeted at young drug-using parents and their children.

b. The desire of the parents to live with their child must be supported. The social and medical means that may allow the reasonable achievement of this must be available.

c. If the parents do not wish to live with their child, or if a welfare authority forbids it, then specific support must be provided to the parents as well as to the children.

NON-DISCRIMINATION
 

General practice institutions (kindergartens, prisons, crèches, paediatric services, nurseries, schools) must accept these parents and these children in the same way they would any others.

Such establishments should therefore be sent information to guide them.

REGULAR MONITORING
 

Regular medico-psycho-social monitoring of drug-using parents benefits the development of their children. If a child displays psychological or developmental problems then, at the initiative of the parents, the monitoring will aim to reinforce the bond between parent and child.

Beyond such scientific objectives, there is no need to carry out a mandatory and structured monitoring of these children.

THE FATHER'S PLACE
 

Treatment of the father helps in stabilising the child within his generation.

This must be encouraged.
 

TREATMENT OF THE CHILDREN
 

Centres specialised in the care of drug-using parents must also treat their children, possess material suitable for such age groups, as well as have staff trained in child psychiatry.

MAINTENANCE OF THE BOND BETWEEN PARENT AND CHILD IN CASES OF IMPRISONMENT
 
 

a. If their drug-using parents are imprisoned, the children must be allowed to visit them in good material and psychological conditions.

b. They must be allowed to reside at the detention centre.

c. A specialised service must be set up by the prison, either within its own establishment or in collaboration with an external service.

RESPECT OF THE RIGHT TO TREATMENT AND OF THE BOND BETWEEN PARENT AND CHILD
 

No pressure should be brought to bear concerning the medical treatment of the parents and their right to personal contacts with their children.

CONFIDENTIALITY
 

Along with their parents, the children have the right to confidentiality of any information concerning their parents' drug use.

STANDARDISED STUDY
 

Prospective studies dealing with the development of children of drug-using parents in Europe cover only small sample groups and contain significant experimental distortions.

The placing of a high percentage of these children outside the original family is an example of this.

A standardised study involving several European centres will enable solid evaluation of the development of these children and propose measures to be implemented in order to enhance it.

TRAINING CONCERNING THE CHILDREN OF DRUG-USING PARENTS
 

Training in the area of the treatment and care of children of drug-using parents must be integrated into the school and university curriculum for the training of health professionals and magistrates.
 

PURSUIT OF EUROPEAN STUDIES
 

Non-European studies have shown that the children of drug-using parents evolve in a particular way.

These studies have been carried out on cases situated in a different socio-econo-mic context from those encountered in Europe.

The European studies under way in this field must be pursued and completed.

The psycho-medico-social monitoring of families including parents who are or who have been drug users must therefore be prolonged beyond the perinatal period, either by specialised centres or by general practice establishments for treatment and care.

STUDIES AND RESEARCH
 

a. The advent of parenthood brings with it many new problems for the drug user. It is necessary to conduct research studies in order to better target policies in the areas of health, the family and education.

b. The target groups are the drug-using parents, drug-using future parents and their children.

These groups are different from those focused on by the research into drug addiction in general.

It is therefore necessary to draw up research protocols (with standardised tools) that are specific to the problems and populations being targeted.

RESEARCH
 

These different research areas should cover the following:

a. Quantitative epidemiology (with a view to guaranteeing epidemiological monitoring) involving the identification and collection of prevalence and incidence indicators from various institutions and associations.

b. Clinical epidemiology allowing the collection - with the help of a data processing tool - of minimal information common to the centres, in terms of institutions, patients, and their evolution.

c. Descriptive research into existing structures of care, channels of treatment and types of intervention (case studies), as well as associations.

d. Assessment of the evolution of the patients and the effectiveness of the services.
 

The following need to be established:

a. A training seminar to define priorities in terms of the issues and to establish a research protocol.

b. The possibilities for studies and research into the appropriate and available resources in terms of personnel (experts and clinicians).

Preparations should be made to submit these projects to those authorities likely to provide funding.
 

MODALITIES
 

Preparations should also be made for a network of correspondents to undertake the monitoring of indicators, the bibliographical research, inventories of fixtures, comparison of tools (questionnaires and software), training, the conducting of interviews and the administration of the tools employed (questionnaires, etc).