This article appears in “Opportunities for Child Welfare to Respond to Prenatal Alcohol and Other Substance Exposures” (Volume 101, Numbers 2 & 3), a special double issue of Child Welfare journal, published in October 2023.


by Erin Ingoldsby and Julie Collins, Special Issue Guest Editors

With the ever-increasing numbers of families for whom substance use issues are present, the Child Welfare League of America is once again turning its focus to substance use and child welfare-related issues in a special issue of the Child Welfare journal. CWLA has partnered with James Bell Associates with the support of the Children’s Bureau of the Administration for Children and Families and the Centers for Disease Control and Prevention to develop this special issue of Child Welfare, “Opportunities for Child Welfare to Respond to Prenatal Alcohol and Other Substance Exposures.”

While a 2015 Child Welfare special issue brought attention to the needs of families involved in child welfare who have substance use disorders, this special double issue focuses attention specifically on the intersection of children who are prenatally exposed to alcohol and other drugs and their families in child welfare. The 2015 issue spoke to the advances that had taken place over the prior 15-year period, highlighting cross-system work happening to improve access to and coordination of treatment and engagement practices. Further, it integrated services that addressed the needs of both parents and children, emphasized the impact of trauma on children and families, and emphasized the importance of culturally relevant service delivery.

Over the ensuing eight years, we have seen the increasing use of synthetic opioids, specifically fentanyl, as well as increases in overdose deaths, and advances in neuroscience that further our understanding of how various drugs impact the fetus over the short and long term. We have also seen the loosening of state laws around recreational marijuana, the acceptance of medical marijuana as a treatment option for a variety of illnesses for adults and children, and the strengthening of other state laws requiring medical and treatment professionals to report any positive results of tests for prenatal substance exposure to child welfare for child abuse/neglect. With the significant numbers of individuals with addiction and overdose deaths, we experienced the federal government declaring a public health crisis in 2017 (U.S. Government Accountability Office, 2018). This enabled increased funding for the treatment of substance use disorders and addressing the prenatal impact for the infants such as neonatal abstinence syndrome, as well as the significant impact on families. Events such as the COVID-19 pandemic and the death of George Floyd, both of which highlighted significant racial inequities, brought renewed calls for attending to the issues of equity in many different systems, including child welfare. The U.S. Department of Health and Human Services Healthy People 2030 campaign, launched in 2020, further illuminated the need to focus on health equity by addressing the social determinants of health (Office of Disease Prevention and Health Promotion, 2020). In addition, the federal government is currently focusing on addressing equity for people of color and others who have been historically underserved, marginalized, and adversely affected by persistent poverty and are asking states to address issues of inequity.

The opioid crisis, much like the methamphetamine and crack cocaine epidemics before it, has led to continued increases in the numbers of families affected by substance use disorders and their newborns experiencing the impact of prenatal substance exposure. While much attention goes to the identification of and services for the fetus and young children prenatally exposed to drugs such as opioids, cocaine, and methamphetamines, we do not see the same corresponding attention given to those who are exposed to alcohol nor to older children who may be impacted by prenatal alcohol use. This is true within the medical and treatment fields, as well as in child welfare. Once a family is involved with child welfare, prenatal alcohol exposure often becomes a hidden issue.

The 2015 Child Welfare special issue pointed out the lack and fragmentation of data spread across systems, which made the prevalence of substance use issues in families involved with child welfare exceedingly difficult to assess. Despite many advances over the past eight years, estimating the prevalence of prenatal alcohol exposure has similar data limitations but with added complications. Medical testing of mothers and their newborn infants is widely ineffective in detecting alcohol exposure, and infants may not show any indicators of their exposure at birth. Still, prenatal alcohol or substance exposure can cause significant long-term effects across the lifespan. While entities such as the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are making efforts to highlight the need for increased screening and identification of this exposure, there is still no clinical diagnostic category or consistent process for identification. Fetal alcohol spectrum disorders (FASDs) has generally been adopted as an umbrella term that encompasses several diagnostic categories (not a clinical diagnosis itself  related to the adverse effects resulting from in utero exposure to alcohol, including fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD).

In the U.S. general population, prevalence of FASDs is estimated to range from 1-5% (National Institute on Alcohol Abuse and Alcoholism, 2023). There is concern that the proportion of children in child welfare with FASDs is much larger—and there is troubling evidence that many of these children do not receive an FASD diagnosis at an early age, if ever. International studies estimate that up to one quarter of children in out-of-home care in the United States may be affected. This is similar to what was reported in a study of children referred to a neurobehavioral clinic in the United States, which found that children in or previously in foster care were at higher risk of having an undiagnosed FASD than those not in foster care (Tenenbaum et al., 2020). Children who do not receive an accurate diagnosis may miss important access to interventions that can address the neurocognitive challenges that are the hallmarks of FASD. Children with prenatal alcohol exposure often need an array of supports, including medical, educational, and mental health services. In addition, evidence-based programs and practices need to adapt to meet the needs of this population. Programs and practices also should work with families, who may need services due to FASD-related behavioral and communication issues that may weaken the critical bond between child(ren) and their parent(s).

Articles in this special issue help us have a better understanding of the prevalence and needs of children who are prenatally exposed to substances, in particular those with FASDs, and what works to address these needs. The articles also reflect advances that have been made regarding how the child welfare system works with this population and what more needs to be done. A group of articles highlights state-level efforts and collaborative strategies for addressing the needs of children affected by prenatal substance exposures and their families.

The set of articles in this first of our two-part special issue focus on the prevalence, scope, and pathways of infants, children, and caregivers who are involved in child welfare and impacted by prenatal substance exposure, particularly prenatal alcohol exposure. Articles in this issue describe the complex developmental and behavioral challenges for children who are affected by FASDs, including how adverse experiences and trauma intersect to increase vulnerability and potentially cloud recognition of issues by professionals in child welfare. This issue includes a set of articles that describe efforts conducted in multiple states and jurisdictions that are designed to enhance early detection of prenatal substance exposure and development of family care plans to address needs as well as link families to services. It also highlights potential strategies and innovative coordinated responses to provide more effective care. This issue concludes with a prevention-oriented, strengths-based approach to identifying touchpoints for recognition of and services for children and families affected by prenatal substance exposure that has been implemented by a Tribal child welfare agency.

The second half of our two-part special issue focuses on the benefits of multi-pronged approaches to addressing prenatal substance exposure, reinforcing cross-systems collaborations and discussing opportunities for workforce efforts and funding avenues. A set of articles focuses on the child welfare workforce’s understanding, knowledge, and perceptions of substance use and prenatal substance exposure and impacts on infants, children, and families, highlighting needs for additional training and practice supports. Another set of five articles presents evidence-informed and evidence-based interventions as well as supportive service approaches that are often provided by systems closely allied with child welfare systems. These interventions and approaches cover a diverse array of unique and important service needs that may be of interest to child welfare administrators and managers who have the capacity or infrastructure to work with collaborative systems partners. The second of this two-part special issue will conclude with an invited paper that discusses some of the inherent challenges faced by child welfare systems in preserving and strengthening families while also working to address impacts and needs for children exposed to substances prenatally. This capstone article draws from research and findings from articles in this special double issue, as well as discourse in the field, to present overarching strategies that emphasize the critical importance of partnering with allied system providers to identify and respond to FASD and other impacts of prenatal substance exposure with the goal of family preservation front and center.

Since we began the process of collecting articles for this double issue, we have seen the unprecedented reckoning of the racial inequities for families of color. While the call for articles did not explicitly address this issue, a number of the authors did, and their findings are reflected in articles throughout both parts of this special double issue.

In the First Issue

In our lead article, Waite, a developmental pediatrician, presents a comprehensive research review of what is known about prevalence of prenatal alcohol exposures and polysubstance exposures. Waite also presents the neurocognitive and behavioral impacts and common developmental challenges faced by children with FASD, pointing out the complexity in presentation and noting intersections with trauma and adverse experiences, including child maltreatment, that exacerbate risk for negative outcomes. The author provides a discussion about the barriers that contribute to under-identification of FASD among children involved in child welfare and emphasizes how an early diagnosis of an FASD allows the education and support of families, caregivers, teachers, and individuals living with FASDs. This allows for anticipating and putting into place evidence-based strategies, supports, and accommodations to mitigate the unique challenges and enhance resilience and independence.

Bowers and colleagues, in our second article, provide a deeper data-based exploration of the associations between early traumatic and adverse experiences and prenatal substance exposure on child neurobehavioral functioning. They offer helpful insights as to what child welfare systems should consider that can provide a broader clinical picture of children’s and families’ functioning. The authors discuss the alignment of needs with tailored supports, including considerations regarding supportive caregiving situations.

The next group of articles describes different states’ recent initiatives to bring together knowledge, data, and systems partners in order to better understand and meet needs related to prenatal substance exposure among children and families involved in child welfare. These state initiatives stem from CAPTA and CARA legislation, but go beyond the federal requirements to enhance practices in their state. Gardner, in our third article, starts off this set by describing a targeted point-in-time assessment of California’s efforts to prevent and provide services in response to FASDs. The author compiles varied extant data related to FASDs and related service systems (state agency materials, literature review) and surveyed and interviewed key informants to highlight California’s performance and progress. This assessment begins to provide a map of the many components and actors across the state that could be applied in state strategic planning. The case-study and environmental scan methodologies result in insights that other states may find useful.

Chasnoff and colleagues, in our fourth article, describe an exemplary comprehensive state cross-systems collaboration in Iowa that brings together multiple public and private agencies serving children and families affected by substance misuse. The collaborative applies a systematic screening, assessment, referral, and treatment public health model to identify and develop care plans for families with children affected by prenatal substance exposure. Evaluation data suggest that progress has been achieved, but the authors also provide key challenges that have emerged during the implementation, strategies used to resolve them, and insights that will be helpful to other states building a cross-system collaborative response.

In our fifth article, Del Corral Winder and colleagues shift the focus to a multidisciplinary approach implemented by the Louisiana State University (LSU) Infant Team to improve early diagnosis of FASD and appropriate service receipt for children under the age of six who are in foster care and their caregivers. The authors provide a summary of the benefits of this type of collaboration for early identification of prenatal exposure to alcohol and/or diagnosis of FASDs. They further discuss the challenges experienced in early identification and diagnosis and issues related to children and families receiving appropriate services and supportive community resources. Description of this multidisciplinary approach and the clinical vignette used to illustrate the process may assist other states/organizations in identifying strategies to improve identification and services for children in foster care who have been prenatally exposed to alcohol.

Next, authors Wang and colleagues present their exploration of child welfare agencies’ response to the CAPTA and CARA legislation around the needs of infants with prenatal substance exposure and infants affected by withdrawal symptoms resulting from exposures. Findings from their mixed-methods descriptive study of 22 public child welfare agencies across five states provide insights into state law and child welfare policy related to prenatal substance exposures, with guidance being typically directed toward newborns or those under five years of age. Limited guidance was provided on how child welfare agencies can work with system partners to consider whether older children could be showing indications of long-term impacts of an unidentified substance exposure. Study findings indicated inconsistent assessment for prenatal substance exposures although child welfare professionals working with families on a longer-term basis (e.g., ongoing case management) were more likely to assess for exposures with most children who become involved with child welfare. Noted barriers to meeting the needs for this population of children included gaps in services, specifically access and availability of services. Study participants provided suggestions that may assist with enhanced care for children with known or suspected prenatal substance exposures, including enhanced information sharing across service providers, and modification or creation of screening tools for indicators of impacts from exposures.

In keeping with the CAPTA/CARA legislation focus, authors Lloyd Sieger and colleagues describe their examination and findings for the implementation of Connecticut’s Family Care Plan (the CAPTA’s required plan of safe care) system for all infants exposed to legal, illegal, or prescription substances at the time of birth or prenatally. The policy requires hospitals to submit a deidentified online notification to the state’s Department of Children and Families for all infants with prenatal substance exposure, noting whether a care plan was developed and its contents along with other data elements such as substance exposure type. The authors provide the study results; discuss the implementation challenges of medical and treatment entities needing to implement a child welfare-related policy; and cite the need for additional state-level implementation support, interprofessional and cross-system collaboration, additional federal technical assistance materials, and equitable supports to improve outcomes.

Loch and colleagues move beyond the single state example to explore state and county officials’ perspective on how plans of safe care (POSCs) were understood and integrated into the landscape of service provision in different county contexts. They did this using qualitative methods. Child welfare administrators described barriers and facilitators to effective POSC implementation ranging from vague interpretations of the policy itself to variations in capacity for cross-agency collaboration. Drawing on the findings, the authors maintain that to achieve the goals of the POSCs requires aligning local implementation efforts with federal guidelines through shared accountability, collaboration, and a holistic view of family needs.

Using case study methods, authors Geary and colleagues, in our final article, round out this first half of our special double issue with a case study conducted in a Tribal community that is transforming child welfare practices by holding family preservation at the center. It describes the Ombimindwaa’s (also known as Red Lake Nation) Tribal child welfare agency’s evolution from a more punitive model to one that promotes maternal wellness through the provision of culturally tailored outpatient programs, medically assisted treatment, and health care. This case study emphasizes what is working and the challenges to implementation of this strengths-based, community-oriented approach that is grounded in cultural traditions. Although the authors underscore that this place-based case study is specific to Red Lake Nation, they recommend that prenatal substance exposure prevention and intervention efforts involving Tribal Nations promote Indigenous sovereignty and align with each Nation’s unique community values.

In the Second Issue

The second half of our two-part Child Welfare special issue begins with authors Rooks-Ellis and colleagues expanding on the discussion of critical multidisciplinary needs of children and families and articulating ways in which current policies, initiatives, and workforce development can be leveraged to enhance care and outcomes. This conceptual article presents a compelling and comprehensive case for multisystem collaboration, at systems and service levels, as the essential approach to support families experiencing substance use disorders as well as infants and children with prenatal substance exposures. The authors raise a call to action for systems- and agency-level initiatives to advance in these areas.

The next two articles underscore the importance of efforts to enhance identification and care of children and families with prenatal substance exposures through workforce supports, training, and development. Authors Seay and McRell explore child welfare case managers’ perceptions of the relationship between parental substance use and child safety in a sample of case managers, conducting child welfare investigations and assessments in one urban district in a Midwestern state. The findings reflect that attitudes about specific types of substances influenced their perception of risk for the child and that specific institutional, legal, and relational challenges impact caseworkers’ capacity to provide support to parents with a substance use disorder (SUD). This study contributes some understanding of how case manager perceptions of SUDs may impact how they make decisions regarding families experiencing substance use. It also highlights the need for increased training in specific areas along with the need for policies and programs to increase access to and availability of SUD treatment and mental health counseling.

Authors Morehouse and colleagues explore the knowledge of prenatal substance exposure and prenatal alcohol exposure among professionals who work in child welfare and the caregivers (foster, kinship, and adoptive) of children in out-of-home placements. They discuss issues such as how the information was obtained, how well-prepared caregivers were to care for children with prenatal substance exposure, and the perceived needs or gaps in training and knowledge. Surveys and interviews were conducted with professionals working in 22 local or regional public child welfare agencies in five geographically diverse states. Additional focus groups and interviews were conducted in two of those states with caregivers, most of whom reported caring for at least one child with known or suspected prenatal substance exposure. Findings indicated a need for increased and updated training and resources for child welfare professionals and caregivers so that they can better care for children with prenatal substance exposure and prenatal alcohol exposure. Findings also provide insight into knowledge and educational needs, which can be used to inform the development or enhancement of trainings on prenatal substance exposure to support improving developmental outcomes, decreasing risk for child maltreatment, and reducing foster care disruption.

The next set of articles speaks to approaches to assess children with prenatal substance exposures and their families and interventions specifically to address the unique needs of children with FASDs. Authors Carmichael Olson and colleagues describe the FASD-informed Specialized Neurodevelopmental Assessment and Consultation Service (SNACS) clinic. The SNACS clinic seeks to meet three essential goals including increasing diagnostic access for children and families experiencing FASD, providing short-term consultation to families affected by FASD to address their complex needs, and improving the overall quality of FASD-informed care through tailored services and stigma-reducing consultation. Drawing from a retrospective chart review, the authors found that the SNACS clinic model is feasible and that the population served in the clinic is diverse. FASD (specifically, the ND-PAE diagnosis) could be evaluated in over 80% of the sample, although it was more difficult to assess and diagnose in children involved with child welfare. Often other co-occurring diagnoses such as anxiety disorders and learning disabilities were present. The authors note how this type of brief consultation clinic located within a medical and behavioral health community setting may be promoted by child welfare systems as they collaborate with service providers to provide a wider array and more immediate access to services for children in their FASD-related care.

In our next article, authors Bondi and colleagues focus on Mothercraft’s Breaking the Cycle (BTC) model and provide insight into its use within a child welfare framework. BTC is a community-based prevention and early intervention program for women who are pregnant, mothers, and young children with substance use exposure. It was designed to reduce maltreatment and promote health and well-being for mother-child dyads who are at risk. This program provides an array of services in one location, coupled with home visitation and street outreach. It utilizes a three-client approach that focuses on: (1) the mother, (2) the child, and (3) the mother-child relationship. The authors note that the program is well-suited for a child welfare framework, largely because it allows complex issues to be addressed comprehensively and promotes partnership between systems to better support mothers and their young children.

Next, author Sparks emphasizes the importance of caregiver support groups to help the family caregivers of children dealing with prenatal alcohol exposure and FASDs. Drawing from personal experiences in establishing and leading caregiver support groups, and the voices of caregivers themselves about the topics and experiences that are important to them, Sparks poignantly underscores the positive impacts that can be gained from providing a venue for emotional and instrumental support for parents including a sense of belonging, obtaining ideas from other parents about how to handle situations, and receiving practice information about services and supports in the community. The article outlines specific action steps for starting and maintaining a support group and provides fundamental resources that child welfare professionals can offer to family caregivers.

Because children with prenatal alcohol exposure are at increased risk for academic difficulties, authors Paley and colleagues focus attention on the 14-week SEEDS Family School Readiness Program. The authors used a deferred treatment control group design to assess the efficacy of this intensive, family-centered educational intervention aimed at enhancing young children’s (ages three to five) self-regulation, improving caregivers’ knowledge of their children’s needs, and strengthening the caregiver-child relationship. In group settings, children are engaged in facilitated situations to build their selfregulatory capacities through positive behavior management and environmental support. Caregivers reported that children showed improved self-regulation. Further, caregivers indicated a decrease in stress related to the caregiver-child relationship. The authors found that children’s different FASD diagnoses did not substantively impact results, suggesting that the intervention may benefit children with varied experiences of prenatal alcohol exposure. The dyadic approach used aligns with holistic interventions that treat caregivers as agents of change, potentially strengthening the program’s approach to enhancing children’s school readiness. The authors acknowledge that implementation necessitates a heavy logistical lift and authors are conceptualizing a modification to make program adoption more manageable and widespread.

Authors Chasnoff and colleagues focus on the Parents and Children Together (PACT) curriculum. The authors provide information on the development of the curriculum, the initial randomized control trial, and the replication study. To respond to children with FASDs needing support with self-regulation, socialization, attention, and impulse control, the evidence-based PACT curriculum was developed to provide neurocognitive habilitation for children (six to 12 years old) with an FASD diagnosis who are in foster or adoptive care. Collectively, the initial and replication studies have found that the curriculum improves executive functioning and emotional problem-solving. PACT has many benefits including a trauma-informed lens and psychoeducation on triggers for emotional dysregulation. It can be delivered by a wide range of clinical staff, including those in the child welfare system. However, as with the SEEDS Family School Readiness Program, PACT is limited by being resource- and staff -intensive and relies on substantial funding.

The volume concludes with an invited capstone article that draws from research in the field as well as the new research and innovations presented by authors in these two volumes. Richards and colleagues provide insight into the current challenges facing the child welfare system in caring for children with FASD and their families. The authors note that children with FASD are often at higher risk of child welfare involvement and out-of-home placement, which requires child welfare workers to be aware of the disorder and how it impacts the preservation of families. They illuminate some of the current discourse regarding the complexity associated with identification of prenatal substance exposure—including concerns with bias and stigma, inequities related to care, and application of information in legal contexts. The authors describe strategies that could help the child welfare system care navigate some of the complexity to enhance care for children who may be impacted by FASD while preserving their families.

Conclusion

While progress is being made by states and jurisdictions to enhance efforts to identify and care for infants, children and families affected by prenatal substance exposure, evidenced by many of the articles in this special double issue, there is still room for much more progress in educating and training of staff and caregivers and improving the implementation of plans of safe care. In particular, much more is needed to ensure that child welfare systems and their allied partners providing care for children and families have the knowledge, tools, and resources to work toward supporting and preserving families impacted by substance use—including addressing problems of bias, stigma, and inequities, or the risk for increasing inequities. Articles in this special double issue illuminate these continuing needs. For example, Connecticut’s effort to place the identification and care plan in the hands of medical professionals with the intent to mitigate concerns of family disruption may be noble, yet the completion patterns of the staff raised questions related to potential bias toward screening of Black women. Despite the potentially high prevalence of children with prenatal substance exposures, specifically those experiencing FASDs, and the research that suggests the effectiveness of a range of evidence-informed and evidence-based programs for this population, none of these are included in the Title IV-E Prevention Services Clearinghouse (Prevention Clearinghouse) as an acceptable evidence-based program. This precludes states from using their Title IV-E funds to implement these approaches and interventions to prevent children from coming into out-of-home care. More research and advocacy is necessary to get these more widely adopted in states and communities, scaled up in other relevant systems, and added to the Prevention Clearinghouse. This could lead to a significant increase in the numbers of children and their families receiving the services they need and reduce the numbers of children in out-of-home care.

Additionally, families of color are disproportionately represented in the child welfare system and among those referred to child welfare due to prenatal substance exposure. Unfortunately, these families are often failed by other systems (e.g., prenatal health care, medical care settings, education, early care/early childhood, behavioral health, and family support services) that could have provided preventive care options before they became involved with child welfare. The impact of this failure has and continues to be widely felt. As highlighted in a recent 2023 special issue of Child Welfare on the intersectionality of the social determinants of health and child welfare, authors Houshyar and colleagues presented the cascading impact of the failures of these other systems to meet the needs of children and families, often resulting in their involvement with child welfare (Houshyar et al., 2023). As a society and as child- and family-serving systems, we need to do so much better.

A number of the special issue authors touch on the impact of laws in child welfare and how this creates a trajectory for families of color that leads to their involvement with child welfare—and, in many instances, the tragic outcome of losing custody of their children. Laws such as mandated reporting that require referrals for child abuse and neglect with positive prenatal toxicology screens need changes that more accurately reflect that substance use disorders and prenatal substance exposure are/cause medical diseases and require treatment. Developmental services and supports, along with effective family-centered substance use treatments, are needed, rather than punitive interventions such as automatic child welfare involvement and the breakup of families.

We invite you to explore the thought-provoking articles and insights contained in this special double issue. They inspire us to think critically, challenge the status quo, and advocate for holistic, collaborative, and equitable approaches to address the needs of the children and families who experience impacts from prenatal substance exposure. May this special double issue serve as a catalyst for further research, discussion, and action that leads to meaningful improvement in the way we serve children who have been prenatally exposed to substances.

Erin Ingoldsby
Director
James Bell Associates

Julie Collins
VP, Practice Excellence
Child Welfare League of America

 

References

Houshyar, S., Minoff , E., Martin, M. (2023). Cascading system failures: How systems contribute to poverty, poor health, and child welfare involvement, and how to redress this. Child Welfare, 100(6), 1-21.

National Institute on Alcohol Abuse and Alcoholism. (2023). Fetal alcohol spectrum disorders. Author. https://www.niaaa.nih.gov/research/fetal-alcohol-spectrum-disorders

Office of Disease Prevention and Health Promotion. (2020). Healthy people 2030. Author. https://health.gov/healthypeople

Tenenbaum, A., Mandel, A., Dor, T., Sapir, A., Sapir-Bodnaro, O., Hertz, P., & Wexler, I. (2020). Fetal alcohol spectrum disorder among pre-adopted and foster children. BMC Pediatrics, 20(1), 275. https://pubmed.ncbi.nlm.nih.gov/32493264/

U.S. Government Accountability Office. (2018). Opioid crisis: Status of public health emergency authorities. Author. https://www.gao.gov/products/gao-18-685r