Trends in Infants Entering Foster Care 2005 to 2015: Estimating the Effects of Neonatal Abstinence Syndrome and Drug Removals

Background/Purpose:  Anecdotal accounts and early evidence suggest that the opioid epidemic is impacting the child welfare system.  Particular concern is paid to infants, because prenatal opioid exposure can result in a number of post-natal health complications including neonatal abstinence syndrome (NAS).  A recent study observed that infants reported to child protective services (CPS) due to NAS nearly doubled between 2004 and 2014, with the most pronounced increases occurring between 2010 and 2014 (Lynch, Sherman, Snyder, & Mattson, 2018).  Unknown is whether the opioid epidemic is having a similar impact on infants coming into foster care.  This study aimed to determine rates of infants entering foster care and proportions of drug removals across every state and territory between 2005-2015 and evaluate the impact of NAS incidence rates on these removals.

Method: National state-level data (n = 52) from three sources was linked in Stata.  Ten years of Adoption and Foster Care Analysis and Reporting System (AFCARS) identified infants (age < 1 at removal date) entering foster care between 2005-2014.  KIDS Count data provided state-level estimates on annual birthrates between 2005-2014.  NAS incidence data from 2005-2013 for 28 states was retrieved from a CDC report. All data were analyzed in increments of infant birth year.  Due to large variability across states, both state-level and national data were analyzed.  Descriptive analyses examined rates per 1,000 births of infants entering foster care and proportion removed due to parental or child drug use for 52 states and territories.  A Generalized Estimating Equations (GEE) model estimated the interaction effect of NAS incidence and proportion of drug removals over time on national annual rates of infants entering foster care for 28 states from 2005-2013.

Results: Between 2005-2014, rates of infants entering foster care increased in 22 states, with percent increases ranging from 1.1 to 91.4.  Twelve states’ saw increases of over 30%.  Between 2005-2014, 41 states saw increase in proportions of infants removed due to drugs, with percent increases ranging from .5 to 263.7.  Nationally, the rate increased 33.3%.  Of states with NAS incidence data, between 2005-2013, 18 saw increases in rates of NAS, ranging from 79.3% to 777.8%, with an average increase of 248.2%.  Results of the GEE revealed a significant main effect for year (p<.001) and drug removals (p<.001), and a significant interaction of NAS incidence and drug removals (p<.001), indicating that rates if infants entering foster care increased over time qualified by a significant NAS incidence x drug removal interaction.   

Implications: The results of this study contribute to the burgeoning knowledge regarding the effect of the opioid epidemic on vulnerable children and families, and confirm reports of child welfare system-impact stemming from this public health crisis.  Because of the special medical needs of these infants, sufficient allocation of funding and resources is needed to ensure healthy development of these infants both in and out of foster care.