Prenatal Substance Exposure and Child Maltreatment: A Systematic Review

"Instead of just taking my baby, they could've actually given me a chance": Experiences with plans of safe care among birth parents impacted by perinatal substance use

BACKGROUND

Federal legislation mandates healthcare providers to notify child protective service (CPS) agencies and offer a voluntary care plan called a "plan of safe care" (POSC) for all infants born affected by prenatal substance use. While POSCs aim to provide supportive services for families impacted by substance use, little is known about birth parents' perceptions and experiences.

OBJECTIVE

To examine birth parents' perceptions and experiences regarding POSC.

PARTICIPANTS AND SETTING

Parents offered a POSC in Philadelphia in the prior year were included.

METHODS

This is a qualitative interview study. Participants were recruited from birth hospitals and community-based programs with telephone consent and interview procedures. Transcripts were analyzed using an inductive, grounded theory approach to identify content themes.

RESULTS

Twelve birth parents were interviewed (30.7 % of eligible, contacted individuals). Fear of CPS involvement and stigma were common. Some birth parents reported that the increased scrutiny related to POSCs negatively impacted their attitudes toward healthcare providers and medications for opioid use disorder (MOUD). While parents found the consolidated resource information helpful, many did not know how to access services. Finally, parents desired more individualized plans tailored to their unique family needs.

CONCLUSIONS

Stigma, confusion, and fear of CPS involvement undermine the goal of POSCs to support substance-exposed infants and birth parents. Providers serving this population should be transparent regarding CPS notifications, provide compassionate, non-stigmatizing care, and offer coordination services to support engagement after discharge. Policymakers should consider separating POSCs from CPS to avoid exacerbating fear and mistrust.

The burden of prenatal and early life maternal substance use among children at risk of maltreatment: A systematic review

ISSUES

Although maternal substance use is a known risk factor for child maltreatment, evidence on the scale of substance use is needed to inform prevention responses. This systematic review synthesised prevalence estimates of maternal substance use during pregnancy and early life among children at risk of maltreatment. Ovid, Pubmed, CINAHL, PsychInfo and ProQuest databases were searched. We included observational studies that sampled children at risk of maltreatment in high-income countries and reported information on maternal substance use during pregnancy and/or the child's first year of life. We extracted study characteristics and data to calculate prevalence, assessed risk of bias and conducted a narrative synthesis; there were insufficient comparable populations or outcomes to quantitatively synthesise results.

KEY FINDINGS

Thirty five of 14,084 titles were included. Fifteen studies had adequately sized and representative samples to estimate prevalence. Maternal substance use prevalence ranged from 2.4% to 40.6%. Maternal substance use was highest among infants referred to child protection at birth (40.6%) and children in out-of-home care (10.4% to 37.2%). Prevalence was higher when studies defined substance use more broadly and when maternal substance use was ascertained from both child and mother records.

IMPLICATIONS

Supportive, coordinated responses to maternal substance use are needed from health and child protection services, spanning alcohol and other drug treatment, antenatal and postnatal care.

CONCLUSIONS

Prenatal and early life maternal substance use is common among child maltreatment populations, particularly among younger children and those with more serious maltreatment.

Considerations and Determinants of Discharge Decisions among Prenatal Substance Exposed Infants

Limited research has examined a comprehensive set of predictors when evaluating discharge placement decisions for infants exposed to substances prenatally. Using a previously validated medical record data extraction tool, the current study examined prenatal substance exposure, infant intervention (i.e., pharmacologic, or non-pharmacologic), and demographic factors (e.g., race and ethnicity and rurality) as predictors of associations with discharge placement in a sample from a resource-poor state (N = 136; 69.9% Non-Hispanic White). Latent class analysis (LCA) was used to examine whether different classes emerged and how classes were differentially related to discharge placement decisions. Logistic regressions were used to determine whether each predictor was uniquely associated with placement decisions. Results of the LCA yielded a two-class solution comprised of (1) a Low Withdrawal Risk class, characterized by prenatal exposure to substances with low risk for neonatal abstinence syndrome (NAS) and non-pharmacologic intervention, and (2) a High Withdrawal Risk class, characterized by a high risk of NAS and pharmacologic intervention. Classes were not related to discharge placement decisions. Logistic regressions demonstrated that meth/amphetamine use during pregnancy was associated with greater odds of out of home placement above other substance types. Future research should replicate and continue examining the clinical utility of these classes.

Cumulative risk factors for injuries and poisoning requiring hospital care in youth with prenatal substance exposure: A longitudinal controlled cohort study

Aim: To investigate whether the youth with prenatal substance exposure (PSE) (aged 15-24 years, n = 615) had been in hospital care more often due to injuries and poisoning in comparison with unexposed matched controls (n = 1787). Methods: Data from medical records (exposure) and national health and social welfare registers (outcome and confounders) were combined and youths were monitored from birth until either outpatient or inpatient hospital care for injury or poisoning, death or the end of the study period (December 2016). Cox regression models were used in the analyses accounting for associated child and maternal risk factors. Results: Half (50.4%) of the exposed group and 40.6% of controls had been in hospital care due to injury or poisoning during the follow-up (p < 0.001). The difference between groups was diminished after controlling for postnatal child and maternal risk factors (hazard ratio [HR] = 0.88, 95% confidence interval [CI] 0.72-1.07, p > 0.05). Cumulative adversity, especially out-of-home care in combination with a diagnosed attention or behavioural dysregulation problem, posed the highest risk in both groups (exposed: HR = 1.65, 95% CI 1.24-2.19, p < 0.001; controls: HR = 1.84, 95% CI 1.33-2.56, p < 0.001). Conclusion: Hospital care for injury and poisoning is more common in youth with PSE, but this is largely explained by the related postnatal child and maternal factors. Long-term support to families with maternal substance abuse problems could prevent injury and poisoning among youth with PSE.

Infant exposure to drugs of abuse investigated by hair analysis

Infant exposure to drugs of abuse represents a worldwide problem whose extent is difficult to estimate. Despite the potentially serious health consequences, few data concerning exposure in children under 1 year of age are available. Since in clinical and forensic settings, neonatal and infant hair testing represents a useful method for investigating suspected drug exposures, an observational retrospective study was performed on hair analysis of children under 1 year of age evaluated at the University Hospital of Padova between 2018 and 2022 with the aim of estimate the extent and define the characteristics of this phenomenon in the reference setting. The sample included 102 infants. Chemical-toxicological analyses were requested in 38 cases (37.3%) because of clinically suspicious symptoms of the child (e.g., neuropsychiatric symptoms and suspected neonatal abstinence syndrome) and in 64 cases (62.7%) because of other reasons (e.g., maternal drug history, at-risk environment, and suspected maltreatment). Based on the presence or absence of symptoms in the request, the sample was subdivided into two groups. Hair analysis in these two showed the presence of drug of abuse, respectively, in 44.7% and 67.2% of the cases (p = 0.026). Cocaine was the most frequently detected substance, followed by opiates, and it was detected less frequently in cases investigated for suspicious clinical symptoms (p < 0.05). The results confirm the difficulties in interpreting the clinical picture and in defining the extent of exposure to drugs of abuse. An integrated assessment is fundamental to interpret the case and achieve adequate care of the child.

Estimating the incidence of substance exposed newborns with child welfare system involvement

BACKGROUND

Prenatal substance use can have negative health consequences for both mother and child and may also increase the likelihood of child welfare involvement. The rate of newborns with substance exposure has increased dramatically. As of 2016, federal law requires notification of all infants to child welfare agencies so that a plan of safe care can be developed and referrals to services can be offered.

OBJECTIVE

Child welfare agencies have not historically collected consistent, systematic data identifying substance exposed newborns. We utilized a unique strategy to identify substance exposed newborns with child welfare involvement.

PARTICIPANTS & SETTING

We used data from the National Child Abuse & Detection System (NCANDS) which captures N = 3,189,034 unique child protective services investigations for children under the age of 1 between 2004 and 2017.

METHODS

We calculated the incidence of substance exposed newborns investigated by child welfare agencies and compared with other administrative data on prenatal substance exposure. We also analyzed this rate by infant demographic characteristics (race/ethnicity, sex, rurality).

RESULTS

Between 2004 and 2017, approximately 13 % of infants reported to child protective services were likely reported because of substance exposure at birth, and the rate of substance exposed newborns with child welfare involvement increased from 3.79 to 12.90 per 1000 births, an increase of 240 %, over this period.

CONCLUSIONS

Understanding the extent of the substance use crisis for child welfare involvement is important for policymakers to support children and families.

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.

Investigating the associations between prenatal exposure to substances and intergenerational maltreatment and symptoms of psychopathology for adolescent girls from families with low income

BACKGROUND

Adolescent girls whose families experience poverty are more vulnerable to psychopathology, and it is vital to investigate biopsychosocial factors contributing to mental health functioning.

OBJECTIVE

To test associations between prenatal exposure to substances, intergenerational maltreatment, and adolescent mental health symptoms.

PARTICIPANTS AND SETTING

Baseline data were used from a randomized controlled trial testing the efficacy of Interpersonal Psychotherapy (IPT-A) for depression among girls with and without maltreatment exposure. Adolescents (Aged 13-16; 63.5 % Black/African-American, 21.0 % White, 15.57 % other racial identity; 12.57 % Latina/x) were recruited from families experiencing financial adversity (income <200 % poverty threshold).

METHODS

Adolescent maltreatment status was determined by using multiple sources (child protective service records, parental report, and adolescent report). Mothers reported on prenatal substance exposure, experiences of maltreatment in their own childhood, and rated adolescent internalizing and externalizing symptoms. Latent Class Analysis was used to determine common patterns of prenatal substance exposure (tobacco, alcohol, marijuana, and cocaine). Structural Equation Modeling was used to evaluate associations between maltreatment in two generations, prenatal exposure to substances, and adolescent mental health symptoms.

RESULTS

Two profiles of prenatal substance exposure emerged: one typified by low substance exposure (92.8 %), and one with moderate to high substance exposure (7.2 %). Both prenatal substance exposure and maternal history of maltreatment were associated with adolescent maltreatment, which in turn, was associated with greater adolescent externalizing symptoms. Parental history of maltreatment was directly associated with greater adolescent internalizing symptoms.

CONCLUSION

Prenatal exposure to substances and intergenerational maltreatment each confer risk for mental health symptoms in adolescent girls.

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.

Reconsidering the use of urine drug testing in reproductive settings

The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.

Outcomes and experiences after child custody loss among mothers who use drugs: A mixed studies systematic review

BACKGROUND

Mothers who use drugs are more likely to experience child custody loss than mothers who do not use drugs. The negative impact of removal on children has been well characterized in current literature while less is known about the impact of custody loss on mothers. The purpose of this mixed studies systematic review is to describe the state of science on the maternal outcomes and experiences after child custody loss among mothers who use drugs.

METHODS

PubMed, PsycINFO, CINAHL, and Social Work Abstract databases were systematically searched between June 2022 to January 2023. Article eligibility criteria centered on the outcomes and experiences of mothers who use drugs after losing child custody. Studies were analyzed using results-based convergent synthesis methodology for mixed studies reviews. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT). A visual synthesis model was derived from combined results across all studies.

RESULTS

Of 2434 articles screened, 22 relevant scientific articles were selected for inclusion. Longitudinal, cohort studies (n=4) and a cross-sectional study (n=1) identified positive associations between custody loss and poorer mental health, increased drug use and overdose risk, less treatment engagement, and worsened social factors. Qualitative studies (n=17) identified themes that described re-traumatization after child custody loss and the development of coping mechanisms through identity negotiation.

CONCLUSION

Our findings indicate that child custody loss associated with drug use may exacerbate trauma and worsen maternal health. Immediate implications are provided for maternal health policy and practice in healthcare, child welfare, and legal professions.

Adverse childhood experiences, associated stressors and comorbidities in children and youth with fetal alcohol spectrum disorder across the justice and child protection settings in Western Australia

Background

Individuals with Fetal Alcohol Spectrum Disorder (FASD) are at risk of having adverse childhood experiences (ACEs), especially those with child protection and/or justice system involvement. The complex relationship between FASD and psychosocial vulnerabilities in the affected individual is an important clinical risk factor for comorbidity. This study (1) explored the ACEs and associated stressors in individuals with FASD; (2) investigated the association between ACEs and negative outcomes, i.e., justice/child protection system involvement; and (3) examined the relationship between ACEs and comorbid conditions such as mood and neurodevelopmental disorders.

Methods

Data were collected retrospectively via file review from diagnostic clinics in Western Australia. Life adversity was coded using a standardised ACEs questionnaire. A total of 211 participants (72% males) with FASD with a mean age of 11 years (range = 2–21) were included in the final sample. 70% of the total sample had been involved with the child protection system and 40% had trouble with the law.

Results

Exposure to drinking/substance misuse at home (70%) and domestic violence (52%) were the two most common ACEs across the total sample. In the entire cohort, 39% had four or more ACEs, indicating higher risks of poor health outcomes. Additional stressors recorded were disengagement from school (43%), transiency (19%), victims of bullying (12%), traumatic brain injury (9%) and homelessness (5%). ACEs such as drinking/substance misuse at home, emotional neglect and physical neglect were positively associated with child protection system involvement. Additionally, exposure to domestic violence was positively correlated with justice system involvement. Higher rates of life adversity in this clinical population were associated with an increased number of comorbidities. Specifically, those with FASD who had comorbidities such as attachment disorder, substance use disorder, and PTSD also reported higher ACEs scores.

Conclusion

ACEs were common in this clinical population. Increased ACEs in this sample were associated with increased comorbidities and involvement with the child protection and/or justice system. This highlights that prevention, intervention and early diagnosis of FASD are important for at risk children to reduce the negative effects of ACEs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03654-y.