Variation in States' Implementation of Capta's Substance-Exposed Infants Mandates: A Policy Diffusion Analysis

Background/Purpose:  In 2016, in response to the increasingly fatal and widespread opioid epidemic, the Comprehensive Addiction and Recovery Act (CARA) amended numerous policies to expand public systems’ abilities to intervene, and treat, people with opioid use disorders.  In the child welfare system, changes were made to states’ mandates related to prenatally substance-exposed infants (Child Abuse Prevention and Treatment Act [CAPTA]).  The most substantive changes included expanding the CPS notification requirement to include infants exposed to legal drugs, and mandating universally developed plans of safe care that address the needs of both mother and baby.  Although CAPTA’s revised language is specific and intentional, a recent content analysis that analyzed each states’ CAPTA policies for consistency with the federal legislation found that only two states were in full compliance (Lloyd, Luczak, & Lew, 2019).  In order to better understand the variation in CAPTA implementation, and make recommendations for policy and future research, the current study examined thematic clusters among states’ CAPTA policies.   

Method: Content analysis methods used to analyze 51 states’ primary documents are described in detail in the above-referenced publication. The results of this previous study were presented in a table that specified each state’s assignment across twenty-three different codes reflecting domains of compliance/non-compliance with CAPTA and types of non-compliance. For the current study, a cluster analysis was conducted on the binary data contained in that coding table (n = 51). We used a symmetrical similarity measure which takes into consideration both the presence and absence of items. A complete-linkage hierarchical clustering method was utilized and the resulting dendrogram, or branch diagram, was evaluated to determine the best fit of the data.

Results: Cluster analysis identified four distinct categories of states’ CAPTA implementation: (1) “Status Quo”, (2) “Exploration and Installation”, (3) “Hybrid Implementation”, (3) “Limited Response”. Cluster one states (n = 17) relied on pre-existing mandated reporting policy and CPS responses based on child safety concerns. Cluster two states (n = 15) have started developing appropriate plan of safe care policy, but have also instituted new, incongruous, reporting mandates. Cluster three states (n = 14) have implemented congruous plan of safe care policy but have not revised existing reporting mandates. Cluster four states (n = 6) have pre-existing mandated reporting requirements, but have limited policy on CPS responses to reported infants and mothers.  The identified clusters were similar conceptually as well as geographically, suggesting that policy diffusion is influencing implementation.

Implications: Results from this analysis suggest that child protection responses substantively differ depending on where a substance-exposed baby is born.  The largest cluster of states appear to rely on policies pre-dating CARA that mandate a CPS report and require safety planning only when a child welfare case is initiated. Policy implementation is a slow and arduous process. In this case, the burdens of failed implementation befall some of the most vulnerable mothers and babies. As federal agencies and institutes expand guidance and technical assistance to states, great effort is needed to ensure that states’ policies reflect CAPTA’s language and intention.