Child Abuse Prevention and Treatment Act, family care plans and infants with prenatal substance exposure: Theoretical framework and directions for future research

Prenatal Substance Exposure and Multilevel Predictors of Child Protection System Reporting

OBJECTIVE

To describe child protection system (CPS) reports after delivery and examine associations between individual- and hospital-level predictors and CPS reporting in a cohort of infants with prenatal substance exposure.

STUDY DESIGN

This state-level, retrospective cohort study used administrative data to analyze births to Black, White, and US-born Hispanic mothers with documented prenatal substance exposure. We used a random intercept mixed-model with individual- and hospital-level predictors to capture any association between birth hospital and CPS reporting. Interaction terms allowed for different effects dependent on characteristics of the delivering parent and the dominant demographics of the hospital setting.

RESULTS

Among 260 525 births during 2018 in California, 2.6% had documented substance exposure, with observed racial differences in substance use and type. Nearly 4% of births to Black mothers had documented cannabis exposure compared with roughly 1% among White and Hispanic mothers. The delivery hospital explained 24% of variance in CPS reporting. Hierarchical models revealed race and insurance-type differences in the likelihood a CPS report followed a substance exposed birth. Namely, publicly-insured births in hospitals where majority births were covered by private insurance had nearly twice the probability of being reported compared with those with private insurance.

CONCLUSIONS

We found variation in CPS reporting of births with diagnosed substance exposure at the hospital level, and interactions between hospital- and individual-level characteristics in their association with the likelihood of CPS reporting. Associations offer insight into potential areas of bias and inconsistency in policy implementation that might be diminished through improved decision-making tools and provider training.

Reimagining Supportive Approaches at the Intersection of Mandatory Reporting Policies for the Mother-Infant Dyad Affected by Substance Use

BACKGROUND

As rates of substance use during pregnancy persist, the health and optimal development of infants with prenatal substance exposure remain a key priority. Nurses are tasked with identifying and reporting suspected cases of child maltreatment, including abuse and neglect, which is often assumed to be synonymous with substance use during pregnancy. While policies aimed at protecting infants from child abuse and neglect are well intentioned, literature regarding the short- and long-term social and legal implications of mandatory reporting policies is emerging.

PURPOSE

In this article, we explore the intersections between the condition of substance use in pregnancy and policies related to mandatory reporting.

METHODS

We provide an overview of historical and current trends in mandatory reporting policies for nurses related to substance use in pregnancy and related ethical and social implications for mother-infant dyads.

RESULTS

Nurses often function at the intersection of healthcare and social services, underscoring the important role they play in advocating for ethical and equitable care for both members of the mother-infant dyad affected by substance use.

IMPLICATIONS FOR PRACTICE AND RESEARCH

We offer recommendations for practice including the integration of respectful care and family-centered support for the mother-infant dyad affected by substance use. Cross-sectoral collaborations, inclusive of the family, are important to the advancement of evidence-based and equity-focused research, advocacy, and policy initiatives to support familial preservation and reduce mother-infant separation.

The Hypocritical Oath? Unintended Consequences of Prenatal Substance Use Policies and Considerations for Health Care Providers

Prenatal substance use (PSU) is a serious perinatal health issue in the United States with consequential health effects. To address this issue and protect children from the detrimental effects of substance exposure during pregnancy, the US government amended the Child Abuse Prevention and Treatment Act to provide funding to states with protocol to notify child protective services of PSU cases and develop treatment plans for affected families. Although well-intentioned, this statute resulted in diverse inter- and intrastate interpretations and implementation of PSU regulations nationwide, ultimately leading to mass confusion about who the policy applies to and when it should be applied. PSU policies are largely punitive in nature, which has led to null or adverse effects on perinatal outcomes. Treatment-prioritizing policies present hope for supporting birthing parents who use substances; however, their potential benefits are obstructed by fear and confusion instilled by coexisting punitive policies, stigma of disclosing substance use during pregnancy, variable or lack of screening methods, and insufficient knowledge about PSU health risks and counseling methods. Precis: Punitive prenatal substance use policies may result in adverse perinatal outcomes. Treatment-oriented protocols and legislation should be prioritized.

Improving health and well-being for infants with prenatal substance exposure

Substance use disorders (SUD) among caregiving adults has inexorable linkage to the health and well-being of millions of children in the U.S. This piece provides an overview of such linkages, examples of relevant policies and regulations, and the role of pediatric healthcare within the health trajectories of children and families at this intersection. A commonality throughout this work is need for non-stigmatizing engagement and support to facilitate connections to care and reduce barriers.

Three-Year Custody Outcomes Among Infants Investigated by Child Protection Systems for Prenatal Substance Exposure in California

OBJECTIVE

Infants affected by prenatal alcohol and drug use are more likely to be removed from parental custody than those in the general population, although it is unclear whether their custody outcomes differ from infants investigated by child protection systems (CPS) for other reasons. This analysis seeks to compare trajectories of involvement and custody outcomes among infants investigated by CPS with and without documentation of prenatal substance exposure (PSE).

METHOD

We used vital birth records linked to administrative CPS records to examine the timing of system involvement and 3-year custodial outcomes among investigated infants with and without identified PSE. We defined PSE according to documentation on the state's standardized hotline screening form, which CPS completes upon referral for alleged maltreatment. We estimated the likelihood a child was in nonparental custody at age 3 by specifying multivariable generalized linear models, adjusted for covariates available in the birth record.

RESULTS

In our sample of 22,855 infants investigated by CPS in 2017 in California, more than 26% had documentation of PSE. These infants experienced an accelerated timeline of system penetration and were 2.2 times as likely to be in nonparental placement at age 3.

DISCUSSION

PSE confers an independent risk of custody interruption among infants investigated by CPS. The younger age of these infants, complexity of parental substance use, and potential misalignment of administrative permanency timelines with parental recovery all suggest the need for increased research, policy, and programmatic interventions to serve this vulnerable population.

"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.