Substance-exposed newborn infants and public health law: Differences in addressing the legal mandate to report

Trends from 2005 to 2018 in child maltreatment outcomes with caregivers' substance use

BACKGROUND

Caregivers' substance use is associated with child maltreatment.

OBJECTIVE

Examine trends from 2005 to 2018 in percentages of three outcomes with caregivers' drug or alcohol use: child protective services (CPS) referrals, substantiated maltreatment reports, and foster care placements.

PARTICIPANTS AND SETTING

22 U.S. states that contributed child-level maltreatment outcomes and caregivers' substance use data to the National Child Abuse and Neglect Data System from 2005 to 2018.

METHODS

Joinpoint regression was used to examine the average annual percent change (AAPC) in outcomes with caregivers' drug or alcohol use and to identify temporal changes.

RESULTS

From 2005 to 2018, CPS referrals with caregivers' drug use increased (AAPC 2.33, p < .001), while referrals with alcohol use remained unchanged (AAPC -0.11, p = .92) (trend difference p = .04). Substantiated reports with caregivers' drug and alcohol use increased (AAPC drug use 3.63, p < .001, AAPC alcohol use 1.28, p = .03), with a greater increase observed with drug use (difference p = .03). Foster care placements with caregivers' drug use increased (AAPC 2.54, p < .001), while placements with alcohol use did not change (AAPC -1.22, p = .29), (difference p = .005). Within the study period, changes in trends with caregivers' drug use included increased substantiated reports from 2010 to 2018 (p < .001) and increased foster care placements from 2009 to 2018 (p < .001). With caregivers' alcohol use, CPS referrals and foster care placements decreased from 2007 to 2018 (all p < .001).

CONCLUSIONS

Trends differed for outcomes with caregivers' drug versus alcohol use. Findings can inform policies to improve care for families affected by substance use.

Health care provider decision-making around prenatal substance use reporting

BACKGROUND

Recent research has found that harms related to alcohol and/or drug (AOD) use during pregnancy are not limited to those associated with use itself; harms also result from policies and health care practices adopted in response, including reporting to Child Protective Services (CPS). This study sought to understand factors that influence health care providers' reporting practices.

METHODS

We conducted 37 semi-structured interviews with hospital-based obstetricians/gynecologists, family medicine physicians, and emergency department physicians, focused on experiences with reporting pregnant/birthing people with AOD to government authorities. We deductively applied an implementation science framework, the Theoretical Domains Framework (TDF) to identify the relevant domains and then inductively coded within domains to identify sub-themes.

RESULTS

Most participants saw reporting as someone else's job, primarily social workers. While a few participants associated reporting with increased connection to services, many participants expressed awareness of negative consequences associated with reporting. Nonetheless, participants were much more concerned about potential harms to the baby associated with not reporting and expressed considerable anxiety about these harms occurring if a report was not made. While a few participants described making reporting decisions themselves, most described interpersonal, hospital-level, and state policy-level factors that constrained their decision-making.

CONCLUSIONS

Many of the factors that influence physician decision-making in reporting pregnant/birthing people who use AOD to CPS are outside the control of individual physicians and require social, structural, and policy changes. Those that are individual-focused involve intense emotions and thus are unlikely to be influenced by solely didactic cognitive-focused trainings.

Factors contributing to level and type of child welfare involvement following prenatal substance exposure: A scoping review

BACKGROUND

An understanding of factors contributing to variation in child welfare outcomes in cases of prenatal substance exposure (PSE) can help identify gaps in research and practice and guide state and agency policy.

OBJECTIVE

To summarize the evidence base and identify critical gaps in the literature, we conducted a scoping review regarding individual- and institutional-level factors associated with child welfare decision-marking across the service continuum and caregivers' perceptions of child welfare involvement in cases of PSE.

PARTICIPANTS AND SETTING

The sample included peer-reviewed studies based in the United States.

METHODS

We conducted a comprehensive search of four databases for studies investigating 1) sociodemographic, behavioral, policy, or other factors contributing to variation in child welfare outcomes and 2) maternal, family, or provider perceptions of the child welfare process in cases of PSE. We followed an established methodological framework for conducting scoping reviews.

RESULTS

Of the 23 articles included in the review, 20 explored variation in decision-making across the child welfare services continuum and three examined caregivers' perceptions of child welfare involvement. At the institutional level, provider characteristics, such as agency capacity, were linked to specific child welfare outcomes including reports and removals. At the individual level, factors such as socioeconomic status, race, and substance type were also associated with outcomes across the service continuum.

CONCLUSIONS

Child welfare agencies use an unsystematic approach in addressing PSE, contributing to a variation in child welfare outcomes and potentially allowing for bias. This review highlights a need for increased resources and guidance for caseworkers.

Dismantling the legacy of failed policy approaches to pregnant people's use of alcohol and drugs

Most U.S. states have one or more pregnancy-specific alcohol or drug policies. However, research evidence indicates that some of these policies lead to increases in adverse birth outcomes, including low-birthweight and preterm birth. We offer explanations for why these ineffective policies related to pregnant people's use of alcohol and drugs in the U.S. exist, including: abortion politics; racism and the 'War on Drugs'; the design and application of scientific evidence; and lack of a pro-active vision. We propose alternative processes and concepts to guide strategies for developing new policy approaches that will support the health and well-being of pregnant people who use alcohol and drugs and their children. Processes include: involving people most affected by pregnancy-specific alcohol and drug policies in developing alternative policy and practice approaches as well as future research initiatives. Additionally, we propose that research funding support the development of policies and practices that bolster health and well-being rather than primarily documenting the harms of different substances. Concepts include accepting that policies adopted in response to pregnant people's use of alcohol and drugs cause harms and working to do better, as well as connecting to efforts that re-envision the child welfare system in the U.S.