Prenatal Opioid Exposure and the Child Welfare System: Community Context Implications for Placement Decision-Making

Background & Purpose:

Substance use during pregnancy is an ongoing problem in the U.S. which carries significant consequences for children, families, and the systems that serve them, including child protective services (CPS). Nationally, the rate of opioid disorder at delivery more than quadrupled from 1999 to 2014 (Haight et al., 2018). Research suggests that prenatal opioid exposure is linked to adverse maternal and child outcomes, with complications leading to increased risk for child maltreatment and subsequent CPS involvement. Yet, in light of the opioid epidemic, few studies have examined child welfare trajectories for infants diagnosed with prenatal opioid exposure. The purpose of this study was to examine how a county’s opioid overdose rate is associated with varying levels of CPS involvement (e.g., no involvement, out-of-home placement, or hospitalization and/or death) for infants diagnosed with prenatal opioid exposure at birth. Clarifying this link can inform decisions about how to target child welfare resources while building an evidence-base around effective strategies for reducing the impact of the opioid crisis on children and families.

Methods:

The dataset consisted of linked administrative data of birth, hospitalization, death, and CPS records for all children born in one U.S. state in the West from 1999 to 2013 (N=1,271,416). Children with prenatal opioid exposure were identified through maternal and infant diagnostic codes from the birth record. The primary exposure indicator was county-level rates of opioid overdose-related hospitalizations or deaths. Analyses included chi-square tests and multistate survival modeling to identify three placement transitions from the birth hospital: 1) home of parents, 2) out-of-home placement, and 3) hospitalization or death. Covariates included community poverty, any CPS report, child’s sex, birth payment type, maternal race/ethnicity, maternal age at birth, and parity. This is an established set of control variables available in child welfare studies involving integrated birth records (e.g. Putnam-Hornstein, 2011).

Results:

We identified 5,927 infants diagnosed with prenatal opioid exposure, of whom 69.2% had any CPS involvement before age 5. Opioid exposed infants born in counties with higher rates of opioid overdoses were less likely to go home from the hospital (coefficient: -6.10, p < .001). Similarly, opioid exposed infants born in counties with higher rates of opioid overdoses were more likely to be placed in out-of-home care from the hospital (coefficient: 1.46, p = 0.02). Infants who went home from the hospital were less likely to make the transition from home to hospitalization or death in counties with higher rates of opioid overdoses (coefficient: -1.18, p = 0.002). There was no association between county-level opioid overdose rate and transition from out-of-home care to hospitalization/death for infants placed out-of-home.

Conclusions:

Counties that were hardest hit by the opioid epidemic, as measured by overdoses, were more likely to place opioid-exposed infants in out-of-home care after birth compared to counties with lower overdose rates. These differences highlight how community contexts are associated with CPS decisions and may be under consideration by social workers. Policy and practice implications will be discussed.