Connect: Plans of Safe Care for Substance-Exposed Infants

Background/Purpose: Substance-exposed infants (SEI) face increased risk of child maltreatment due to multiple factors, including their and their caregivers’ complex health and substance use treatment needs. Aiming to prevent maltreatment, the federal Child Abuse Prevention and Treatment Act (CAPTA) was revised in 2016, specifying that Plans of Safe Care (POSC) be developed for infants exposed to both legal and illegal drugs and clarifying that POSC address the health and substance use treatment needs of parent-infant dyads. CAPTA faces another reauthorization in 2022, which retitles POSC to multi-disciplinary family care plans and explains that plans be developed before delivery when possible. Despite POSC being a CAPTA requirement since 2003, there has been almost no research examining implementation of the legislation. The purpose of this study is to examine factors associated with the timing and contents of POSC in Connecticut.

Method: This study analyzed CAPTA notifications made in Connecticut between March 15, 2019, and July 21, 2021. During this period, 4,763 births (6% of total births) received CAPTA notifications. We examined descriptive characteristics including POSC status (no POSC, POSC developed prenatally, POSC developed postnatally) and POSC contents (up to 27 specific service needs categorized into five service need domains) across six mutually exclusive substance exposure types (five single substance or polysubstance exposure). We used multiple linear regression to examine the association between substance exposure type and POSC contents, controlling for mother race, age, and presence of safety concern. We used multinomial logistic regression with predicted probabilities to measure association between substance exposure type and POSC status, controlling for the same covariates. Both regressions employed cluster robust standard errors.

Results: The records of two thirds of the parent-infant dyads indicated there was a POSC at the time of the CAPTA notification, with 40% of these infants having a prenatal POSC. On average, POSC included more than three specific service needs. The most common service need domains were parenting (56% of plans), followed by parent mental health (43%), concrete services (41%), substance use services (22%), and children’s services (13%). Our multiple regression revealed that POSC identified significantly fewer service needs if developed prenatally compared to postnatally, controlling for covariates. POSC had significantly more service needs identified for infants with single substance medication for opioid use disorder (MOUD) exposure or polysubstance exposure compared to marijuana exposure. In our multinomial logistic regression, alcohol-, illegal drug-, and polysubstance-exposed infants were most likely to have no POSC, prescription-exposed most likely to have a postnatal POSC, and MOUD-exposed most likely to have a prenatal POSC.

Implications: Despite the universal POSC mandate, our results suggest that hospital workers were less inclined to develop POSC for infants with certain substance exposures. This may reflect a phenomenon documented in previous studies in which hospital and CPS workers maintain differing perceptions of risk for alcohol compared to marijuana compared to illegal drugs. Additionally, prenatal POSC may fail to include sufficient service referrals. If the reauthorization is passed, implementation support may be needed to ensure that all dyads receive comprehensive POSC