Using a notification system that is quickly becoming a national model, the state of Connecticut is diverting more than half of substance-exposed infants identified at birth from the child welfare system, putting families instead contact with community supports and services, according to a UConn study published by the journal Hospital Pediatrics.
But there is room for improvement in the system, especially when it comes to reducing racial and ethnic disparities in testing and reporting.
“We are doing a great job and we can do better,” says Margaret Lloyd Sieger, lead author of the study and assistant professor at the UConn School of Social Work.
A prolific researcher in the field of substance use disorders and child welfare, Lloyd Sieger has extensively studied the implementation and impact of federal child abuse prevention and treatment law. also known as CAPTA – the U.S. Basic Child Abuse Prevention Legislation – which requires states to collect notifications when infants are born and exposed to certain medications in utero.
“In 2003, federal legislation mandated for the first time the notification of infants identified as being affected by prenatal exposure to illegal drugs,” says Lloyd Sieger. “In 2010 Congress added Fetal Alcohol Spectrum Disorder and in 2016 removed the word illegal so infants exposed to legal drugs, namely prescription opioids, would need notification. . But it wasn’t until real funding accompanied these mandates — that funding rolled out in 2017 and 2018, in response to the opioid epidemic — that states really got support to start implementing. this federal policy.
A public health tool
Connecticut, through its Department of Children and Families, opted to treat federally mandated notifications as public health data and instituted an anonymized surveillance system. The notification system requires that when a hospital or provider identifies an infant as born exposed to substances, they notify through the system.
The reporting system also includes a mini-risk assessment, in which the reporting provider is asked a short series of questions designed to determine if there is a concern for the well-being of the infant in addition to exposure to the substance. Situations where the supplier expresses a concern may result in a report to the DCF.
No identifying information is collected in the notification – notifications indicate that a birth exposed to the substance has occurred, identify the type of substance or substances identified in the exposure, and include demographic information, including the age, race and ethnic origin of the biological parent.
“Connecticut realized that this federal policy was trying to straddle the line of public health and child welfare in a way that could go in one direction and result in many babies being reported to protective services. childhood and eventually their placement in foster care,” says Lloyd Sieger. “Connecticut smartly recognized that potential, and so Connecticut said, ‘Let’s do this as a public health surveillance tool. Surveillance is an integral part of public health efforts to understand how many people have a problem and what kind of system-level support is needed.
For this study, Lloyd Sieger partnered with DCF to analyze notification data to determine system performance. The analysis looked at 4,763 notifications submitted through the system between March 2019 and July 2021. During the same period, 59,273 births were recorded in Connecticut.
“One input from this analysis is the proportion of the total number of births – approximately 8% of babies born in Connecticut during this time period received notification, meaning that exposure to a substance was identified in the baby. “, explains Lloyd Sieger. “According to national estimates, approximately 15% of babies are exposed to substances in utero. So that means Connecticut detects not all infants exposed to a substance, but more than half, and those notifications are submitted to the DCF.
More than half of all notifications resulted in no security issues reported to the DCF.
Pioneer of an “anonymized” approach
The analysis also found that as federal policy escalated due to the onset of the opioid epidemic, the overwhelming majority of notifications in Connecticut involved exposure to marijuana as the sole substance of abuse. exposure. Twenty-one percent of reports included exposure to opioids.
“It’s not like they all have opioids and then also marijuana,” says Lloyd Sieger. “Seventy-nine percent of them are marijuana. Only about one in five involved an opioid, and that includes both medications for opioid use disorder – which would be methadone or buprenorphine – as well as illicit and illegal opioids.
While more than half of all reports resulted in no indicated safety concerns and no additional DCF referrals, infants reported as prenatally exposed to illegal drugs – including cocaine, non-prescription opioids and PCP- and infants reported as prenatally exposed to more than one substance were significantly more likely to be referred to DCF.
“In many states, hospitals are required to refer every identified infant to child protective services,” says Lloyd Sieger. “Connecticut is the first state to take this anonymized approach.”
This anonymized approach also involves the development and implementation of safe care plans, which are mandated by CAPTA for substance-exposed infants and include strategies and services to support newborn health and safety as well as the ongoing treatment of drug dependent caregivers. troubles. Connecticut is the first state where safe care plans are not developed by child protection workers, but rather by the hospital or a substance abuse treatment provider.
“The ideal situation would be for a parent to receive the Safe Care Plan when they are pregnant, give birth, complete treatment, and never interact with the child protection system,” says Lloyd Sieger. “This safe care plan is a planning tool, a system navigation tool and an assessment, all rolled into one. They get what they need in the community and never come into contact with child protective services. That’s the goal, and that’s really what makes Connecticut politics very unique in the national landscape.
Identify disparities, work towards ambitious goals
The study, however, found a significant racial disproportion among infants who received notifications. Relative to the state’s birth population, Connecticut’s black mothers were disproportionately overrepresented, while white and Hispanic mothers were underrepresented.
“There are several points where racial disparities can appear, including the identification of infants,” explains Lloyd Sieger. “However, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists both recommend universal screening as a starting point, in terms of reducing disparities. With universal screening, everyone is going to be asked the same questions, or we’re going to give everyone the same toxicology test. That way we’re going to catch everyone who uses any type of substance. Since we’re seeing pretty consistent rates of substance use across all racial and ethnic categories, we would then assume that we would detect equivalent rates across racial and ethnic groups.
The study also found that the Connecticut system under-identified alcohol as an exposure substance, a finding that Lloyd Sieger did not find surprising because it is not a commonly tested substance and because the symptoms associated with Fetal Alcohol Spectrum Disorder are usually not present at birth.
“It only becomes clear when certain development milestones are missed,” she says. “Hospital birth substance testing almost never tests for alcohol. The provider has to go the extra mile to request a BAC test, and that’s just rare. Unless a parent does not present intoxicated for childbirth or has a long history of alcohol abuse on her medical record, the test is unlikely to include alcohol.
Despite these shortcomings, the study showed that Connecticut’s new policy strives to achieve its goals by diverting significant numbers of substance-exposed infants and their caregivers from the child welfare system to services and community supports.
“Hopefully, with continued research into this policy, we can dig deeper to better understand where the disparities exist and what other factors may be shaping these results,” says Lloyd Sieger, “so that we can provide even more personalized recommendations to the State. ”
In addition to Lloyd Sieger, graduate student Cynthia Nichols, of the UConn School of Social Work; graduate student Shiyi Chen, from the economics department of the UConn College of Liberal Arts and Sciences; research associate Melissa Sienna, with UConn Health and the UConn School of Medicine; and Dr. Marilyn Sanders, Department of Pediatrics, UConn School of Medicine and Connecticut Children’s Medical Center, contributed to this study.
This study was supported by the Connecticut Department of Children and Families, with flow-through funding from the U.S. Department of Health and Human Services Administration for CAPTA Grants for Children, Youth, and Families.