U.S. State rates of newborns reported to child protection at birth for prenatal substance exposure.

BACKGROUND: In the U.S., the opioid epidemic has revitalized national attention to newborns with prenatal substance exposure (PSE). These newborns and their caregivers have specific health and treatment needs and frequently interact with multiple systems, including child protection systems (CPS). METHODS: This study calculated rates of newborns (less than 15 days old) reported to CPS per 1,000 births due to PSE by state and year using data from the National Child Abuse and Neglect Data System (NCANDS). Given the lack of a clear definition of PSE reports in the data, we calculated rates using three different definitions. To examine the relationship between different state laws regarding the mandated reporting of PSE and PSE reports rates, we used panel data analysis. RESULTS: Rates of newborn reports more than doubled between 2011 and 2019. There was extensive state variability of rates including some states that were consistently more than 100 % greater than and others consistently more than 150 % less than the annual national mean. Reporting rates were not associated with state requirements to report PSE, but were positively associated with rates of diagnosed neonatal abstinence syndrome. CONCLUSION: State-level inconsistencies in identification, reporting, and CPS responses prevent a clear understanding of the scope of the affected population and service needs.

A Comparison of Two Statewide Datasets to Understand Population Prevalence of Substance Use in Pregnancy: Findings and Considerations for Policy & Research.

Mental health conditions including substance use disorder are the leading cause of pregnancy-related deaths in the U.S. Unfortunately, fears of child protective services' involvement interfere with maternal self-disclosure of substance use in pregnancy. Seeking to identify more mothers with substance use disorder in pregnancy or at delivery, and responsive to changes to the federal Child Abuse Prevention and Treatment Act (CAPTA), Connecticut requires hospital personnel to submit a deidentified notification to CPS for all newborns with prenatal substance exposure. However, it is unknown whether this approach aligns with maternal self-report on substance use. For the present study, we compared population parameters derived from CAPTA notifications submitted between March-December 2019 with parameters derived from self-report data on substance use in pregnancy from mothers who gave birth during the same timeframe. Results revealed that three times as many mothers self-reported any alcohol or drug use in pregnancy compared to the rate measured with CAPTA notifications. Compared to mothers who self-reported drug use in the third trimester, CAPTA notifications were made for statistically similar rates of Black mothers but half the self-reported rate of White and Hispanic mothers. This disparity reflects that CAPTA notifications were made for twice as many Black mothers as White or Hispanic. Although CAPTA notifications are not punitive in nature, this disparity reveals that the public health aims of this policy are not yet achieved.

"The Problem's Bigger than We Are": Understanding How Local Factors Influence Child Welfare Responses to Substance Use in Pregnancy, A Qualitative Study.

State eligibility for certain federal child welfare funding requires a gubernatorial assurance that infants affected by substances receive plans of safe care (POSC). We conducted 18 interviews with state and county child welfare staff to understand how POSC has been implemented and found variability in practice driven by vague policy, challenges of cross-system collaboration, and a lack of knowledge about substance use disorder. Policy improvements should align requirements with POSC practice and create shared accountability with key partners.

Family Care Plans for Infants with Prenatal Substance Exposure.

The federal Child Abuse Prevention and Treatment Act (CAPTA) requires that a plan of safe care, called a family care plan (FCP) in Connecticut, be developed for all newborns identified as being affected by substance abuse and their caregivers. In Connecticut, FCPs are developed in treatment or hospital settings, not by child protective services. Analyzing data from Connecticut from 2019-2021, we found robust yet uneven implementation of FCPs that may have resulted in inadequate support for some affected caregiver-infant dyads. Additional implementation strategies may be needed to ensure that all dyads receive comprehensive FCPs.

Novel Implementation of State Reporting Policy for Substance-Exposed Infants.

BACKGROUND: The Child Abuse Prevention and Treatment Act's provisions concerning hospitalist and child protective services response to infants with prenatal substance exposure (IPSE) were revised in 2016 to address the impact of the opioid epidemic. In 2019, Connecticut unveiled a statewide hospital reporting infrastructure to divert IPSE without safety concerns from CPS using a deidentified notification to CPS and a plan of safe care (POSC). Connecticut is the first state to implement a separate, deidentified notification system. METHODS: We used notification and birth data to determine rates per 1000 births. We employed multinomial logistic regression to understand factors associated with 3 mutually exclusive outcomes: (1) diversion with POSC, (2) report with POSC, or (3) report without POSC. RESULTS: During the first 28 months of policy implementation, hospitalists submitted over 4700 notifications (8% of total Connecticut births). Over three-quarters (79%) of notifications included marijuana exposure, and 21% included opioid exposure. Fewer than 3% included alcohol exposure. Black mothers were disproportionally overrepresented among notifications compared with the state population, and all other race groups underrepresented. Over half of identified IPSE were diverted. Type of substance exposure was the strongest predictor of outcome, controlling for maternal age and race group. CONCLUSIONS: Connecticut Child Abuse Prevention and Treatment Act diverted IPSE without provider safety concerns away from child protective services. Substance exposure type was associated with the dyad's outcome at hospital discharge. Nonuniversal screening practices may contribute to racial disproportionality in implementation.

Reasonable efforts to preserve families? An examination of service utilization and child removal.

BACKGROUND: Recent federal policy has solidified the importance of preserving families, yet over 400,000 children enter foster care each year. Although a few studies have found that certain types of services, like intensive family preservation services, may reduce child removals, more research is needed. OBJECTIVE: This study examined the relationship between family preservation, family support, and basic need service utilization and child removal among families with substantiated cases of maltreatment. METHODS: We conducted a survival analysis using data from the National Child Abuse and Neglect Data System (NCANDS). We took a cohort of families with an investigation and substantiation of maltreatment in FY 2018 and followed them through FY 2019 to identify any that experienced a child removal during the study period. This included a total of n = 558,915 children. RESULTS: Approximately 15.33% of children experienced a removal during the study period. Case management was the most frequently reported service, followed by transportation services and family preservation services. In the multivariable analysis, family preservation services (HR = 0.95, p < .01), home-based services (HR = 0.98, p < .001), and housing services (HR = 0.87, p < .001) decreased the hazards of child removal. Family support services (HR = 1.36, p < .001), transportation services (HR = 2.30, p < .001), education (HR = 1.13, p < .01), case management (HR = 1.83, p < .001), or daycare (HR = 1.26, p < .001) increased the hazards of child removal. DISCUSSION: Findings from this study suggest that utilization of various services is associated with future child removals. While preservation and home-based services decreased the likelihood of removal, several basic needs services increased the hazards of child removal. This may reflect too little too late with services that may be better applied as primary or secondary preventive efforts. Implications for policy and future rollout of the Families First Prevention Services Act are explored.