Children prenatally exposed to alcohol and other drugs: what the literature tells us about child welfare information sources, policies, and practices to identify and care for children

Figures & data

Figure 1. Identification and screening of articles.

Table 1. Types of prenatal substance exposures and ages of children addressed in a structured review of articles, U.S., 2006–2018

Types of articles	Research/Evaluation studies^a N = 16 (%)	Policy/Practice^b N = 16 (%)	Total number of articles N = 32 (%)
Types of substances
Drugs-only	3 (19)	4 (25)	7 (22)
Alcohol-only	1 (6)	6 (38)	7 (22)
Both drugs and alcohol	12 (75)	6 (38)	18 (56)
Specific drugs addressed^c
Cannabis	4 (27)	0 (0)	4 (16)
Cocaine	8 (53)	1 (10)	9 (36)
Methamphetamines	4 (27)	0 (0)	4 (16)
Opioids	9 (60)	3 (30)	12 (48)
Drugs not specified	5 (33)	6 (60)	11 (44)
Ages of children^d
Newborns/< 1 year^e	11 (69)	5 (31)	16 (50)
Infants and toddlers	–	3 (19)	3 (9)
3–6 years	1 (6)	–	1 (3)
4–18 years	2 (13)	–	2 (6)
>15 years	1 (6)	–	1 (3)
0–18	1 (6)	8 (50)	9 (28)

^aOriginal research (n = 12) and program evaluations (n = 4)

^bStructured reviews (e.g., policies, validated instruments), program model descriptions without evaluation results, or informational summaries for practitioners/policy makers

^cSpecific drugs reported in 15 research and 10 policy/practice articles; articles could address more than one type of drug)

^dAge of population at beginning of study

^eMost often neonates, one study focused on infants less than 1 year of age

Table 2. Information sources used by studies to identify children with prenatal substance exposures by age, structured review of articles, U.S., 2006–2018

Ages of children	Information sources used to identify prenatal substance exposure^a	Number of studies
Newborns/< 1 year(N = 11)	Child welfare data: Allegations of newborns with prenatal substance exposure reported to child protective services	7
	Hospital administrative data: ICD-9 diagnostic codes reported at birth	3
	Positive newborn toxicology screen, review of medical charts	1
3–6 years (N = 1)	Review of child welfare case records	1
4–18 years (N = 2)	Review of child’s birth: medical, child welfare, court, and/or adoption records	2
> 15 years (N = 1)	Adoptive parent report	1
0–18 years (N = 1)	Adoptive parent report	1

^aInformation sources listed are those used to identify prenatally exposed children. Other data sources were used to investigate variables of interest, such as child welfare data to determine child outcomes.

Table 3. Manuscripts reporting data sources identifying prenatal exposure to alcohol, structured review of articles, U.S., 2006–2018

	Sample size	Data sources used to identify child’s prenatal exposure to alcohol	Percentage identified^a
Newborns reported to child protection for prenatal substance exposure (Sun et al., 2007)	457	Reports to child protection for prenatal exposure confirmed by positive toxicology	0.4
Children aged 3–6 transitioning to a new foster care placement (Smith et al., 2007)	117	Review of caseworker reports based on available information (e.g., report of family members, psychological evaluations, court reports)	15
Children currently or formerly in foster care referred to clinic for behavioral issues (Chasnoff et al., 2015b)	547	Review of child’s birth, medical, child welfare, and/or court records to determine prenatal alcohol exposure; pediatric, neurologic, and dysmorphology examination of child to diagnose FASD	28.5
Children aged newborn to 3 years in foster care whose mothers were suspected of using cocaine during pregnancy (Doris et al., 2006)	146	Review of maternal medical records documenting use of alcohol during pregnancy	32

^aRefers to percentage of children identified with prenatal exposure to alcohol and other drugs for each article.

Table 4. Child welfare system policies and practices addressed in manuscripts, structured review of articles, U.S., 2006–2018

Policy and practices	Article focus	Number of articles
Respond to reports of child abuse and neglect	Research on child and family factors associated with reports to child protection, investigations of maltreatment, and child placement in foster care	6
	Hospital and agency policies and practices in response to reports of prenatally exposed newborns	2
Assess child and family needs and refer to appropriate services	Studies of service needs and characteristics of children with co-occurring disorders	2
	Recommendations of standardized screens to collect information on maternal use of substances during pregnancy	1
Provide safe temporary care and permanent home for the child	Visitation practices with birth families who have children affected by prenatal substance exposure	1
	Recommendations of evidence-based practices that could be used to support foster families caring for children	1
	Studies of factors associated with child’s post-adoption outcomes: health, educational, and mental health	2
Efforts to improve service delivery	Descriptions of model court programs focused on identifying children and referring children and families to services	2
	Descriptions of model programs intended to enhance substance use treatment to parents and services for children	5
	Recommendations to improve speech and language therapist’s practice by considering the child’s history of maltreatment and prenatal substance exposure	3
System-wide policy and practices	Policy recommendations to effectively address prenatal substance exposure by reducing punitive responses and increasing resources	3
	Policy recommendations to support data collection and reporting across child welfare and substance abuse treatment systems	2
	Child welfare staff knowledge and training needs to respond to families and children affected by prenatal exposure to substances	2

Table A1. Key terms: structured peer-reviewed library database search for articles, U.S., 2006–2018

Child welfare system/Children served by child welfare system		Prenatal exposure to alcohol and/or substances
Child protection Child protective services Protective services Child abuse Child abuse/neglect Child neglect Child maltreatment Foster care Social work Maltreatment Out-of-home care Kinship care Kith and kin Relative placement Family reunification	MeSH terms Child welfare Foster home care		Prenatal exposure Prenatal alcohol exposure Prenatal substance exposure Substance exposed infants	MeSH terms Prenatal exposure delayed effects Fetal alcohol spectrum disorders Neonatal abstinence syndrome

Turchi, R. M., & Smith, V. C.; AAP Committee on Substance Use and Prevention, AAP Council on Children with Disabilities. (2018). The role of integrated care in a medical home for patients with a fetal alcohol spectrum disorder. Pediatrics, 142(4), e20182333. doi:https://doi.org/10.1542/peds.2018-2333

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Stratton, K., Howe, C., & Battaglia, F. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention and treatment. Washington, DC: The National Academies Press.

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Chasnoff, I. J., Wells, A. M., & King, L. (2015b). Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure. Pediatrics, 135(2), 264–270. doi:https://doi.org/10.1542/peds.2014-2171

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Doris, J., Meguid, V., Thomas, M., Blatt, S., & Eckenrode, J. (2006). Prenatal cocaine exposure and child welfare outcomes. Child Maltreatment, 11(4), 326–337. doi:https://doi.org/10.1177/1077559506293462

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