Perinatal Substance Abuse: The Impact of Reporting Infants to Child Protective Services

James R. MacMahon, MD

ABSTRACT. Objective. The purposes of this study ment of Child Protective Services, or previous removal of were to follow the judicial placement of newborns with a child because of substance abuse. positive toxicology screening results and to determine Conclusion. Identifying and reporting newborns ex- how long such infants remained in foster care, separated posed to maternal substance abuse during pregnancy can from their mothers or other relatives, and the length of be associated with beneficial changes in the environment court dependency. We also determined the mothers’ com- of the infants and successful rehabilitation of many pliance with court orders, the availability and use of mothers. The use of judicial supervision, rehabilitative rehabilitative services, factors used by the court to deter- and supportive services, and long-term involvement of mine the final disposition, and the eventual placement of social services without criminal prosecution are key to the infants. successful outcome. This study supports the policy and Methods. The cohort sample consisted of all infants recommendation of the American Academy of Pediatrics from San Mateo County (CA) born at Stanford University and should lessen health professionals’ concerns about Hospital during a 2-year period whose urine tests in the negative effects of reporting these patients to Child Pro- well-baby nursery were positive for illicit substances. tective Services. Pediatrics 1997;100(5). URL: http://www. Fifty-three newborns were identified, and their medical pediatrics.org/cgi/content/full/100/5/e1; substance abuse, records and court documents were matched and reviewed newborn, social services, foster care, protective services. from birth until termination of judicial review (or 5 years). Data were summarized and analyzed by logistic regressions to identify predictors of specific outcomes. ABBREVIATIONS. SIDS, sudden infant death syndrome; CPS, Results. All 53 infants had normal physical examina- Child Protective Services; CPR, cardiopulmonary resuscitation. tions and uneventful hospital courses. Their ethnic dis- tribution, with 68% being African-American and 7% be- ubstance abuse during pregnancy is not only a ing Hispanic, differed from the rest of the nurs- ery population, which was predominantly Hispanic. medical problem for the infant and mother, but Twenty-six (46%) of the 53 infants were returned to their also results in major social consequences for S 1,2 mothers within 1 week of birth; 39 (76%) of the infants other family members and the community. In the were reunited with some relative within the first month past decade, the medical literature has focused on of life. At 12 months of age, 10 infants (19%) remained in the potential impact of maternal substance abuse on foster care; however, none remained in foster care be- the fetus and subsequent child development.3–17 The yond 18 months. The length of time infants were depen- sequelae of intrauterine drug exposure include im- dents of the court ranged from 1 month to >5 years; 70% paired fetal growth,17–23 prematurity,24 neurologic of the cases were “closed” between 6 and 30 months of deficits,25–27 behavioral changes,28–33 developmental life. Nine (17%) were dependents of the court for >36 delays,34 sudden infant death syndrome (SIDS),35–40 months. Final placement of the infants was 35 (66%) 41–43 reunited with at least one parent, 9 (17%) in long-term and increased risk for child abuse. Because of the guardianship relationships with other relatives, and 9 perception that drug-using mothers are unable to (17%) adopted. All of the mothers were ordered to com- care for their infants adequately, or that drug- plete a drug rehabilitation program; 24 mothers (44%) affected environments are unsafe for infants, hospi- fully complied and had repeatedly drug-free urine tests; tals have taken measures to identify infants exposed 2 others (4%) had drug-free urine tests after incomplete to drugs during pregnancy, and child protective au- participation in drug rehabilitation. Twenty-two (42%) of thorities in many jurisdictions have acted to separate the mothers never complied with drug rehabilitation. the infants from their mothers at birth. The impact of Subsequent drug use was evident in less than half of the mothers during the period of study. Only one mother these interventions has not been studied. was reported for child abuse. Characteristics that most Public policies have been implemented in response strongly predicted failure in family reunification were a to the increased use of drugs and the reported risks history of failed drug rehabilitation, previous involve- for the infant. In some locales, public attitudes have encouraged criminal prosecution of the mother; other jurisdictions emphasize a more therapeutic ap-

From the Department of Pediatrics, Division of General Pediatrics, Stanford proach. It is not uncommon for a positive drug test to University School of Medicine, Palo Alto, California. be interpreted as prima facie evidence of child endan- Received for publication Feb 3, 1997; accepted Jun 9, 1997. germent, resulting in allegations of child neglect Reprint requests to (J.R.M.) Department of Pediatrics, Division of General against the mother and interruption of maternal cus- Pediatrics, Stanford University School of Medicine, 750 Welch Rd, Suite 325, 44–46 Palo Alto, CA 94304. tody. Indeed, positive newborn urine toxicology PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad- screening results have been used as evidence to pros- emy of Pediatrics. ecute mothers criminally as drug users or even as http://www.pediatrics.org/cgi/content/full/100/5/Downloaded from www.aappublications.org/newse1 by PEDIATRICS guest on September Vol. 28, 100 2021 No. 5 November 1997 1of9 drug traffickers.45 A more therapeutic model holds tody could be awarded to a mother, her infant might remain a that a diagnosis of child neglect is intended to lead to dependent of the court, ensuring that county agencies could mon- itor the infant’s health and safety and the mother’s activity and the provision of rehabilitative services to further the rehabilitative efforts. Provision of preventive and rehabilitative 45,47–49 best interests of the child. The American Acad- services was a policy requirement of the county; the current em- emy of Pediatrics considers unethical the practice of phasis of child welfare services is on keeping the family intact. performing drug screening for the primary purpose Cases could be closed and court involvement terminated at any of of detecting illegal use.50 the review hearings, but a final determination of custody and placement was required before 18 months of age. The length of The medical literature has not ignored the contro- time the infants were dependents of the court was determined by versial legal ramifications of criminal prosecution of the judicial review of each mother’s compliance with court orders new mothers.45,49–54 Studies conducted to examine and by reports from social service workers regarding her progress which infants are most likely to be placed in foster and stability and the safety of the infant’s environment. care show that the race and age of the mother are significant factors.1 However, to our knowledge, no Subjects study has been conducted to assess the long-term The subjects were drawn from the infants on the teaching consequences for the infants or their mothers result- service of the well-baby nursery at Stanford University Hospital. This service comprised all newborns who do not have a private ing from newborn drug screening results being re- pediatrician on the hospital medical staff. All newborns who had ported to judicial authorities. Many questions need positive urine toxicology screening results during a 2-year period answering: Are adequate resources to assist the fam- were identified. The medical records of those with addresses in ilies provided? Are effective rehabilitative services San Mateo County (CA) were reviewed and matched by name and date of birth with records in the county’s Department of Social available and are they used by the mothers? Do the Service. Data from the medical records included the mother’s age, infants return to their mothers or languish in foster race, marital status, and prenatal history, as well as the infant’s care for long periods of time? For how long do the physical examination, neonatal course, laboratory results, length courts retain legal custody and control of the infant? of hospitalization, and discharge plans. The county social service What are the factors that lead to termination of court records included the findings and results of the judicial hearings and all reports by case workers. These data included information involvement? In short, does the reporting of these about the mother (eg, previous social history, reasons for detain- children really benefit either the infant or the ing the infant, compliance with previous court orders, services mother? Answering these questions through large used, and housing and employment arrangements) and the infant studies will be difficult because of complex interac- (placement and custody status before and after each hearing, services received, and reasons for closing the case). Developmen- tions among the medical, legal, and social systems. tal status of the infant was not documented regularly and there- Moreover, because of the lifestyles accompanying fore was not included in data collection. This information from the illicit activity and substance abuse, the study popu- medical and social service records was coded and entered into lation is diverse and difficult to follow prospectively. computerized databases, identified by number codes only. Access The purpose of this study was to examine what to these data was granted after successfully petitioning the court for each case. Because the study consisted of data review and happened to mothers and infants in one county in because the court had legal custody of the children while their Northern California after the infants’ positive toxi- cases were active, consent for access to the records was not re- cology screening results were reported to county quested from individual parents or foster parents. The study authorities. This report presents descriptive informa- protocol was reviewed and approved by the Institutional Review Board at Stanford University. tion intended to begin the process of answering the The people using the teaching service of the well-baby nursery questions presented above. It is based on a retrospec- represented a diverse population: 75% were Hispanic, 15% were tive and concurrent review of medical and social non-Hispanic Caucasians, 8% were African-American, and 2% service agency records, following a group of drug- were Asian or South Pacific Islanders. Most were enrolled in or exposed newborns for 5 years. eligible for Medicaid. Statistical Analysis METHODS The JMP and SAS statistical programs were used to perform Policies and Drug Testing univariate and multivariate analyses. Exploratory data analysis was undertaken using ␹2 tests for categorical variables and logistic In the well-baby nursery of Stanford University Hospital, a regression to assess several independent variables as predictors of urine toxicology screen was performed on all newborns whose eventual placement of the infants and the duration of court cus- mothers met one or more of the following criteria: drug use in the tody. previous year, no prenatal care or a few prenatal visits with many missed appointments, unexpected delivery of an infant outside the hospital, or abruptio placenta. Urine was analyzed by gas RESULTS chromatography and mass spectrometry. Each infant whose urine There were 2420 infants on the teaching service of tested positive for an illegal substance was reported immediately to the county social services department and placed in protective the nursery during the 2-year period of subject en- custody of the court, which meant that the infant could not leave rollment. A total of 540 infants underwent urine the hospital without court approval. At the time of this study, such toxicology screening; 112 infants from three counties infants were discharged routinely from the hospital to foster care tested positive, with 65 from San Mateo County. The while assessment of their home and family was undertaken by medical and social service records were matched and social workers from the Child Protective Services (CPS). A court hearing (initial detention hearing) was required within 1 week of complete data retrieved for 53 infants from San hospital discharge to determine the longer-term placement and Mateo County. Considering the maternal age, parity, custody of the infant and to stipulate orders for the parents. Every indications for urine testing, clinical findings, and 3 months thereafter, follow-up hearings were scheduled to review the drugs identified, there were no characteristics the parents’ progress and compliance and to make additional determinations regarding custody of the infants. distinguishing the 12 incomplete or unmatched sets Physical custody and legal control of the infant are two distinct of records from this county. During the enrollment and somewhat independent parameters. Although physical cus- period, two other infants were discharged from the

2of9 PERINATAL SUBSTANCEDownloaded from ABUSE www.aappublications.org/news by guest on September 28, 2021 well-baby nursery to foster care. They had no docu- well enough to remain in the level 1 nursery; the mented drug exposure, and they were not part of this others were full-term and of normal weight. No be- study. havioral or physical characteristics specific to sub- Cocaine was the principal drug identified, being stance abuse were recorded. present in 47 infants. Opiates were identified in 5, amphetamines in 2, and other drugs in 4. Five infants Initial Disposition had more than one drug identified. All 53 infants were dependents of the court when During the period subjects were entered into this discharged from the hospital. A total of 50 (94%) of study, four other infants were also discharged from the infants went from the hospital directly to foster the well-baby nursery to foster homes. They were not homes, 2 (4%) were entrusted to relatives, and 1 included in this study because their needs for social infant went home with the mother. Less than 1 week services were not related to substance abuse. after her infant’s discharge from the hospital, each Subject Characteristics mother attended a detention/dispositional hearing (Table 2). Demographic and clinical characteristics of the subject population are shown in Table 1. The age of the mothers was distributed normally around a Duration of Foster Care and Subsequent Separation mean of ϳ26 years. This is similar to the age distri- From Parent bution of other mothers using this perinatal center. The length of time the infants were separated from However, their ethnic distribution did not reflect the their mothers and in foster care is illustrated in Fig 1. general population of the teaching service of this For a majority, foster care placement lasted Ͻ1 week; nursery (described previously): almost two thirds of 26 (46%) of the infants were returned to their moth- the subjects were African-American and a minority ers, and 5 (9%) were placed with relatives as a result were Hispanic, Caucasian, or Asian. A large majority of the initial disposition/detention hearing. Eight of the mothers had previous pregnancies and were others (15%) were returned to a parent later in the not married. Most had previous abortions. Social first month of life. One of those placed initially with service files frequently revealed previous incarcera- relatives also returned to a parent within the first tion (18 mothers), involvement of CPS before this month. Thus, within 1 month of birth, 74% (39/53) pregnancy (19 mothers), previous placement of chil- had been reunited with relatives or parents; 66% dren in foster care (16 mothers), and attempted drug (35/53) were with a parent, and 8% (4/53) were with rehabilitation (16 mothers). Several mothers had two relatives. or three of these characteristics. Of the 14 (26%) who remained in nonrelative foster All of the infants had normal physical examina- care for Ͼ1 month, 3 were united eventually with tions, with about one in three described as jittery. relatives (after 2 to 10 months of foster care) and 5 Five (9%) were slightly premature, but mature and were returned to a parent (2 in the second and third months, 2 as a result of the 6-month hearing, and 1 after 18 months). Thirteen infants in this study (25%) TABLE 1. Characteristics of the Mothers and Infants were never reunited with their parents; only 6 (11%) Mean Value or Range were never reunited with relatives. Percentage No infant was placed for adoption in the first 6 months of life. Yet no infant was in foster care Ͼ18 Mothers Age 25.75 17–38 months without being in the process of being White (%) 23 adopted. Of the 26 infants who were returned to Hispanic (%) 7 their parents in the first month of life, 7 (27%) even- African American (%) 68 tually reentered the foster care system because of Asian (%) 2 continued drug use by the mother. At 12 months of Medicaid (%) 94 Single (%) 75 age, 10 infants (19%) remained in foster care. All of Married (%) 13 the others had been returned to relatives or parents, Separated (%) 4 or they had been placed in long-term guardian rela- Divorced (%) 8 tionships or adopted. Most infants who were suc- Gravida 3.96 0–9 Parity (live births) 1.45 0–8 cessfully reunited with their mothers did so in the History early postpartum period. The median time spent in No abortion (%) 29 1 Abortion (%) 35 Ͼ1 Abortion (%) 39 1–9 Incarceration (%) 34 TABLE 2. Duration of Services Provided to Infants and Sep- CPS* (%) 36 aration From Relatives (Days) Previous removal of child (%) 30 Service Median Mean Range Drug rehabilitation attempt (%) 30 Infants Initial hospitalization 3 3 1–12 Weight, g 2956.4 2211–3856 Time to first hearing 5 3.5 1–28* Gestational age, weeks 39 36–41 Court dependence 411 633 30–2488 Fussy/jittery (%) 30 Separation from any relative 6 44 2–547 Respiratory symptoms (%) 2 Separation from any parent 6 43 2–547 * CPS indicates previous involvement with Child Protective Ser- * All hearings were initiated within 7 days of discharge from the vice. hospital. Four continued for as long as 28 days.

Downloaded from www.aappublications.org/newshttp://www.pediatrics.org/cgi/content/full/100/5/ by guest on September 28, 2021 e1 3of9 Fig 1. Duration of initial foster care. foster care for infants who returned to their parents review hearing, the most common time for termina- was only 6 days. tion of dependency status was at the 12-month re- view hearing (16 infants, 30%). Nine infants (17%) Duration of Dependent-of-the-Court Status were dependents of the court for Ͼ36 months; all 9 The duration of dependent-of-the-court status had been placed before 1 year of age into long-term ranged from 30 days to Ͼ6 years, but most (28 in- guardianship relationships that were reviewed peri- fants, 53%) were dependents of the court for 6 to 36 odically by the court. months (Fig 2). The median length of time for court dependency was slightly Ͼ13 months (Table 2). Al- Justification for Closing the Cases and Terminating though 4 infants (8%) had their cases closed and their Court Dependency dependency status terminated in the first 4 months The reasons for terminating dependency status and 9 cases (17%) were closed after the first 6-month were listed in court records. For infants who were

Fig 2. Duration of dependent-of-the-court status, shown as percent of infants remaining as dependents versus time elapsed in months.

4of9 PERINATAL SUBSTANCEDownloaded from ABUSE www.aappublications.org/news by guest on September 28, 2021 returned to their parents, the most common reasons TABLE 4. Requirements and Court-Ordered Services for the were “establishment of a stable home” (30 infants, Mothers 57%), “repeatedly negative drug tests” (26 infants, Requirement Mothers 49%), and “no need for further investigation” (24 Ordered to infants, 45%). Seventeen cases (32%) became “inac- Comply tive” when the infant was adopted or was placed in n% permanent guardianship. Seven cases (13%) were Drug rehabilitation program 53 100 closed when the infant moved to another jurisdiction Random urine drug testing 52 98 within the same state; 3 (6%) moved out of state; 2 Public health nurse visits 46 87 (4%) were lost to court follow-up. Cardiopulmonary resuscitation course 42 79 Cooperation with social services 6 43 Eventual Disposition Keeping infant’s medical 35 66 appointments* The eventual custody determination for the infants Psychological counseling 21 40 is shown in Table 3. When court involvement and Parenting education 13 25 active case management by social services were ter- * For parents who were granted custody of the child. minated, 35 infants in this study (66%) had been placed permanently in the custody of a biological parent (31 in the mother’s custody, 4 with the father). ing continued drug use; only 1 of these women re- Five (9%) had been placed permanently in the cus- gained full custody of her infant. Of all orders given tody of relatives other than parents; 9 (17%) had been to the mothers, complying with drug rehabilitation adopted, some by relatives. and having negative urine drug test results were the Table 3 also lists the place of residence of the orders linked most closely with regaining custody of person with legal custody of the child at the time the the infant. case was closed. A total of 16 (30%), including those adopted by nonrelatives, were residing in a two- Subsequent Maternal Problems parent home. Fourteen (26%) lived with one biolog- After the initial hearing, subsequent problems ical parent; 20 (38%), including some who were with were recorded for 23 (43%) of the mothers while the their mother, resided in the home of relatives. infant was still a dependent of the court. These prob- lems, which invariably interfered with reunification Services Rendered and Compliance With Orders efforts, included documented return to habitual drug The most frequent court orders stipulated at the use (17 mothers), being incarcerated (4 mothers), initial hearing are listed in Table 4. Virtually all of the giving birth to another infant with positive urine mothers were ordered to complete drug rehabilita- drug screening results (5 mothers), and being re- tion and education programs and to provide urine ported for child abuse (1 mother). for drug testing during random visits by public health nurses. The county provided rehabilitation Predicting Eventual Disposition programs; in 3 cases (6%), residential treatment was Exploratory data analysis was performed to inves- specified. Six months after leaving the hospital, 15 tigate whether family reunification success could be mothers (28%) had complied with the order for drug predicted by specific maternal characteristics sug- rehabilitation and 12 (22%) had produced drug-free gested by previous literature1,4 and comments in the urine on random tests. At the time of termination of judicial records. Initially, a series of ␹2 tests was court dependency, however, 24 mothers (44%) both performed to examine differences among three had complied fully with the rehabilitation program groups of infants: those whose reunion with a parent and had consistently “clean” urine test results. Two occurred in the first week after leaving the hospital; other mothers (4%) had repeatedly drug-free urine those who reunited Ͼ1 week after discharge; and test results despite not completing the rehabilitation those who never reunited with a parent. The results program. In these 26 cases, the child was eventually of this exploration are shown in Table 5. The 22 placed in custody and control of at least one biolog- mothers who were reunited with their infants within ical parent. Twenty-one other mothers (42%) never 7 days of leaving the hospital were slightly older but complied with drug rehabilitation; 17 (81%) of these had fewer pregnancies and fewer living children mothers never regained custody of their infants. Sev- than the others. However these characteristics did enteen mothers had random urine tests demonstrat- not differentiate this group statistically. However,

TABLE 3. Eventual Custody Arrangements for the Infants Place of Residence Person Awarded Permanent Custody Mother Father Other Adopted Guardian Relative Home with two parents 12 — — — — Home with one parent 12 2 — — — Home of relatives 6 2 5 5 2 Home of unrelated — — — 4 Other 1 — — — 2 Total 31 4 5 9 4

Downloaded from www.aappublications.org/newshttp://www.pediatrics.org/cgi/content/full/100/5/ by guest on September 28, 2021 e1 5of9 TABLE 5. Maternal Characteristics Grouped by Duration of Infant’s Separation From Mother Maternal Characteristic Early Return Late Return Never Returned (Յ7 days) (Ͼ7 days) n ϭ 13 n-18 n ϭ 22 Age (mean Ϯ SD) 25.9 Ϯ 5.1 27.1 Ϯ 7.2 24.6 Ϯ 4.2 Gravity (mean Ϯ SD) 3.7 Ϯ 1.4 4.3 Ϯ 1.2 4.0 Ϯ 1.9 No. of living children (mean Ϯ SD) 1.2 Ϯ .9 1.7 Ϯ 1.7 1.4 Ϯ .8 No. of abortions 1.5 Ϯ 1.3 1.6 Ϯ 1.5 1.4 Ϯ 1.5 Any prenatal care (%)* 72 61 38 Polydrug use (%)* 9 30 33 Lives with relatives or in own home (%)* 65 23 33 White (%)* 31 30 5 African-American (%)* 59 61 83 History of CPS (%)** 14 38 67 History of child removal (%)** 5 38 56 History of rehabilitational failure (%)** 5 54 44 History of incarceration (%)** 23 54 39 Father able to help (%)** 73 8 39 * Difference among groups significant at the P Ͻ .05 level. ** Difference among groups significant at the P Ͻ .01 level. the “early reunion” mothers were significantly less results led to identification of significant dysfunction likely to have had a child removed from the home or in the mother’s living situation. In the families in any previous contact with CPS, or to have had a which the infant was returned to the mother at the history of failed attempts at drug rehabilitation. They earliest hearing, these dysfunctions were not consid- were more likely to have had at least some prenatal ered physically dangerous to the welfare of the in- care and to live in their own homes or in the homes fant. Whether such identification can lead to produc- of relatives. Mothers who lived with the father of the tive intervention was one of the initial questions this infant also regained custody earlier. All of these char- study attempted to address. acteristics were noted in court assessments of the Twenty-four (45%) of the mothers completed a home environment. drug rehabilitation program and produced negative In contrast, mothers who never regained custody urine drug screening results for a prolonged period, of their infants were more likely to be African-Amer- as a consequence of court orders. Twenty-four moth- ican, to have had a history of previous involvement ers (45%) were unable to comply with the orders to with CPS, or to have had a child removed from the complete a rehabilitation program, some because home previously. They were also more likely to have they never got involved in a program, others because failed drug rehabilitation. they tried and failed, and a few because they moved. Logistic regressions were used to explore these Fourteen of the 22 mothers ordered to undergo psy- data further, using the maternal characteristics that chiatric treatment or counseling complied. Twenty- appeared significant by ␹2 tests. Although the model one (40%) of the mothers eventually established as a whole did not exhibit statistical significance, two housing considered by the courts to be stable. In 26 characteristics that were related strongly to infants cases (49%), services offered were used fully by the never returning to a parent were the mother’s previ- mothers. In 6 cases (11%), the mothers partially used ous involvement with CPS and the mother having services available, and in 9 additional cases (17%), previously lost custody of a child. The odds ratio for only the children received benefits of services. a mother with previous CPS involvement never hav- ing her infant returned to her was 3.4. Maternal failure at previous rehabilitative at- DISCUSSION tempts and the absence of a father capable of helping For the general pediatrician, reporting infants who were the two variables related strongly to not reunit- have experienced fetal drug exposure is not particu- ing in the first week after hospital discharge, but they larly controversial if the act of reporting leads to did not distinguish between late reunification and remedial and beneficial action, because the tradi- nonreunification. Five of the 16 mothers who had tional role of the physician is that of provider of failed rehabilitation previously eventually did suc- therapy. However, if there are no beneficial out- ceed this time and regained full custody of the infant comes of reporting these situations, the practice can- involved in this study. An additional characteristic, not be condoned. The findings of this study support the amount of prenatal care received, was related the idea that identifying and reporting maternal sub- linearly to the timing of the infant’s return to the stance abuse during pregnancy can be associated mother, with more prenatal care being associated with beneficial changes in the environment of the with early return of the infant. infants and successful rehabilitation of the mother when the reporting process is accompanied by judi- Impact of Policy on Living Situation of Infants and cial investigation, provision of rehabilitative and Mothers supportive services, and long-term involvement of In all but one case, the investigation initiated by the courts or social services without criminal prose- the reporting of the infant’s urine toxicology test cution. This is entirely consistent with and would

6of9 PERINATAL SUBSTANCEDownloaded from ABUSE www.aappublications.org/news by guest on September 28, 2021 support the recent recommendations of the Ameri- atory analysis of the data, not true hypothesis testing. can Academy of Pediatrics.55 Although 53 subjects were included in the logistic However, the sample size of this study was small, model, this was not a random sample of a large and the subjects were drawn from patients who were population, and this analysis served best simply to in the nursery reserved for “well babies.” The study describe the data. Firm conclusions about which ma- involved a subset of patients in that nursery who do ternal characteristics are most useful in determining not have a private pediatrician on the hospital’s med- policy must await additional investigation of larger ical staff. During the period of subject enrollment, no sample groups. The number of mothers who even- drug screenings were performed on the infants cared tually underwent rehabilitation and regained cus- for by private pediatricians in this nursery, suggest- tody of their children even after months of noncom- ing that no other drug-exposure referrals to CPS pliance and continued drug use suggests that early from the well-baby nursery occurred. The subjects decisions leading to permanent out-of-home place- were identified by selective screening based on iden- ment might be improper. Even a few mothers carry- tified risk factors. If universal screening had been ing all the predictors for failure succeeded in break- used or if other screening methods had been used ing out of their dysfunctional lifestyles. (eg, meconium or hair), it is possible that the sample The one infant who eventually experienced abuse size would have been larger or different. Such uni- was an atypical case throughout many months of versal screening is not endorsed by the American court dependency. The mother of this infant was the Academy of Pediatrics.55 only mother in this study who had her child returned Whether the results of this study are capable of to her despite failing to comply with drug rehabili- being generalized to other communities or larger tation and urine testing. Although she was moni- populations is unclear. This study was performed in tored by the courts for 18 months, it was felt she had a county offering progressive services. Although developed a stable relationship with her child, and dominated by suburban living, San Mateo County the caseworker argued for the return of her child has pockets of poverty, crowding, and drug use despite her lack of compliance with court orders. If more characteristic of inner cities. For example, the this case serves as an example, it suggests that the finding that only one of the infants was involved in close monitoring and strict demand for compliance reported child abuse is in marked contrast with other with court orders that the other mothers experienced reports.43,56 Whether such differences are related to were appropriate and beneficial to the children. the subjects or the policies was not addressed by this Other findings in this study show the impact of study. Nevertheless, the beneficial changes in the life court-ordered long-term monitoring of the mothers’ and environment observed in half of the mothers and progress and compliance. Seventeen of the mothers most of the infants can serve as an endorsement of who underwent random testing of their urine were the policies of reporting these patients, involving found to have a continuing problem with drugs. services, and maintaining legal custody as a tool for Only one of these mothers regained full custody of monitoring and coercing progress and reform. This her child. Clearly, a monitoring system was in place study did not address directly the question of and was truly being used in the disposition process. whether the assessments leading to the “initial” dis- However, some court orders, eg, keeping all medical position could occur before the mother or infant is appointments, appeared to be not as critical in the discharged from the hospital and thus obviate the 1 decision to return a child to the mother. In addition, week of foster care experienced by so many of the some orders appeared to be used more as a test of study subjects. Another issue worthy of mention is mother’s compliance rather than truly having a re- the use of court outcome as a predictor of staying off habilitative function. For example, all the mothers in of drugs in the long term. Because the data were this study were ordered to participate in a class to collected from social service files, no information learn cardiopulmonary resuscitation (CPR). This or- about the use of drugs after the cases were closed der was said to be based on literature suggesting that was available unless the mother reconnected with cocaine-exposed infants might be at increased risk social service agencies. for SIDS in the first few months of life.35–40 However, The mothers of this study did not have the same if a mother had not received CPR training by the time demographic characteristics as those of the nursery of the 6- and 12-month review hearing, long after the as a whole. As mentioned in the text, these women theoretic risk of SIDS, she would still be ordered to were predominantly African-American, often with undertake CPR training. This suggests a need for complicated obstetric histories. This finding is con- more communication between the court and health sistent with a study of the epidemiology of drug use care providers in establishing guidelines for inter- in pregnancy throughout the entire state of Califor- vention and therapy. In addition, the impact of place- nia,57 suggesting that this group of subjects may rep- ment decisions on the child’s development and be- resent larger populations. havior was never monitored or formally addressed. The finding that certain maternal characteristics Issues such as discontinuity of care and the impact of predicted failure of the mother to regain custody of kinship care versus foster care may have a significant the infant suggests that an individualized approach impact on the children, but data specific to these to the placement of children from the hospital is issues were not available. practical. However, the sample size in this study was One finding that does not appear in group data but small, and the description of certain maternal char- was apparent to those involved in reviewing each acteristics as being predictive resulted from explor- chart is that in a few cases, the threat of losing her

Downloaded from www.aappublications.org/newshttp://www.pediatrics.org/cgi/content/full/100/5/ by guest on September 28, 2021 e1 7of9 child through adoption and the finality of the deci- and body composition after in utero exposure to cocaine and marijuana. sions of the 18-month hearing were critical in moti- J Pediatr. 1990;117:622–626 20. Hadeed AJ, Siegel SR. Maternal cocaine use during pregnancy: effect on vating the mother to finally enter and complete drug the newborn infant. Pediatrics. 1989;84:205–210 rehabilitation. 21. Jacobsen JL, Jacobsen SW, Sokol RJ, et al. Effects of alcohol, smoking, This study did not address the question of what and illicit drugs on fetal growth in black infants. J Pediatr. 1994;124: happens to infants exposed to drugs in utero but 757–764 not detected or reported by the nursery. A number 22. Kliegman RM, Madura D, Kiwi R, et al. Relation of maternal cocaine use with risks of prematurity and low birth weight. 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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Perinatal Substance Abuse: The Impact of Reporting Infants to Child Protective Services James R. MacMahon Pediatrics 1997;100;e1 DOI: 10.1542/peds.100.5.e1

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