Challenges and Considerations to Enhance Identification of Children with Prenatal Substance Exposures in Child Welfare Populations: Findings from a Multisite Mixed Methods Study

Background and Purpose: An estimated 400,000 infants affected by prenatal substance exposure (PSE) are born in the United States each year. Children with PSE are at higher risk for poor developmental outcomes as well as child maltreatment. Elevated estimates of substance abuse and PSE among families receiving child welfare services underscore the importance of identifying these children and families. Clinical opinions agree that identification, referral for appropriate and ongoing care for children with PSEs and their families in the child welfare system is essential for optimum developmental and family outcomes.

This presentation describes a multisite, mixed-methods, descriptive study that explored how child welfare agency staff report assessing and identifying children with PSE. A discussion of identified gaps in child welfare agency policy, practices, and training on this issue is included.

Methods: Surveys (n=272) were conducted among staff at 23 county or regional child welfare agencies across 5 states. In addition, key informant interviews were conducted with a subset of 171 staff, including state and county directors. Instruments included questions related to knowledge, current practices, training, and policies concerning identification, documentation, and referrals to services for children with PSE as well as communication with providers and caregivers.

A multilevel coding process was used to examine qualitative data, relying on principles of content analysis and thematic coding. Survey data were analyzed using descriptive statistics. Additional subgroup analyses were performed to compare groups of states or respondents.

Results: Across data methods, this study found shortfalls in the extent to which child welfare agency staff assess for PSE and the methods used to gather information related to PSE. Overall, child welfare agency staff indicated low levels of assessment for PSE as survey respondents indicated they assessed for PSE with “some” (41%) or “most” (48%) children in their agency, while 11% of staff did not routinely assess PSE. In both surveys and interviews agency staff reported that the top methods used to gather relevant PSE information were hospital staff reports at birth (93%), behavioral indicator(s) (77%), and ancillary case records (e.g., medical or birth records) (77%). Qualitative data revealed that staff largely rely on toxicology reports at intake to identify exposure and neonatal impacts (e.g., neonatal abstinence syndrome). However, less attention is paid to identifying possible previous prenatal alcohol exposures (PAE), particularly among older children.

Conclusions and Implications: Despite clinical consensus that screening for PSE is important, this study found a lack of formalized structured assessments of PSE for children in the child welfare system, especially for PAE, a known teratogen with lifelong effects. Child welfare agencies may consider enhancing training, practices, and policies to emphasize the importance of assessing for PSE, in particular PAE, for younger and older children across all phases of case management to enable appropriate treatment and interventions.