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Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009

Prevention and Drug Treatment
Authors: Mark F. Testa Brenda Smith

Substance-Exposed Infants: The Case of Illinois

As noted, two decades ago Illinois became one of the first states to make the presence of illegal drugs in newborns prima facie evidence of abuse and neglect. It enacted legislation that expanded the definition of abused or neglected minor to include newborns whose blood, urine, or meconium contained any amount of a controlled substance or its metabolites. The mandate helped to fuel a rise in the number of SEI reports that peaked at 20 per thousand births in fiscal year 1994 (see figure 1). More than 90 percent of reported SEI cases were subsequently indicated for maltreatment because a positive toxicology report meets the credible evidence standard that abuse or neglect has occurred. The proportion of substance-exposed infants who were taken immediately into protective custody (PC) lagged behind the steep rise in reports and hit its highest point in 1999 with 41 percent of reports triggering the state’s removal of the infant at birth. Currently the proportion of protective custodies hovers around 33 percent of SEI reports. The risk of removal, however, does not end with the child’s birth. Substance-exposed infants run a high risk of being placed in foster care throughout their early childhood.

Figure 1 also charts the foster care rates as of March 30, 2008, among successive cohorts of children born substance-exposed from fiscal years 1985 to 2007. The rate of foster care was highest among the cohort of children born in fiscal year 1994. Of the 2 percent of infants reported as substance-exposed during that year, the proportion that was later taken into foster care for any reason reached 50 percent as of March 2008. Among all birth cohorts, the removal proportion hit a high of 56 percent among children born substance-exposed during fiscal year 1999. Since that time, the proportion has stabilized at around 50 percent for recent birth cohorts.

There was some debate in Illinois over whether the drop in SEI rates after fiscal year 1994 mirrored a decline in maternal drug abuse or instead simply reflected changes in hospital surveillance practices. In Illinois, children are not universally screened at birth for substance exposure. Each hospital differs in its protocols as to what risk factors—for example, no prenatal care, past drug use, low birth weight—warrant ordering a drug test. As a result, concerns arose that publicly funded, inner-city hospitals were using protocols that resulted in more drug testing than the protocols used by privately insured, suburban hospitals, thus bringing African American infants disproportionately to the attention of CPS. For example, approximately 59 percent of Illinois infants born in 1995 were non-Hispanic whites and 20 percent were African Americans. In that same year, approximately 12 percent of SEI reports involved non-Hispanic white infants while 83 percent involved African American infants. These figures translate into a disproportionality ratio of twenty SEI reports on black infants for every one report on a white infant. The disproportionality ratio was the same when black infants were compared with Hispanic infants.

By 2002, the disproportionality ratio in Illinois had fallen to seven SEI reports on black infants for every one report on a non-Hispanic white infant. The entire decline in racial disproportionality was explainable by the 64 percent drop in black SEI rates from 65.9 per thousand births in 1995 to 23.9 per thousand births in 2002. During the same period, Hispanic SEI rates also fell by 61 percent, from 3.2 per thousand births in 1995 to 1.2 per thousand births in 2002. In contrast, SEI rates rose slightly among non-Hispanic white infants, from 3.2 to 3.5 per thousand births. While it cannot be discounted that the large SEI decline among African Americans reflected an actual drop-off in the prevalence of parental drug abuse from its epidemic levels in the early 1990s, the concomitant decline among Hispanics but not among majority whites suggests that changes in drug surveillance practices, particularly in the inner city, may have also figured in the SEI decline.

During the years when SEI reports were climbing in Illinois, child welfare advocates and drug professionals were calling for the expansion of drug treatment programs for women and children. After the fall-off in report rates, attention turned to treatment retention and the completion of services. The shift in focus from program availability to service completion reflected both the aforementioned decline in SEI levels as well as new insights gained from the tighter collaboration between drug and child welfare professionals in the state.

In 1997, the independent evaluators of a joint initiative between the Illinois Department of Children and Family Services and the Illinois Department of Alcohol and Substance Abuse were forced to drop the intended “no treatment” comparison group from their quasi-experimental study because they unexpectedly discovered that nearly three-quarters of their intended control group had in reality received some kind of substance abuse treatment.55 In their peer-reviewed article,56 the authors instead focused on the differences between women who received regular treatment services and those who received enhanced treatment services that provided special outreach and case management services as well as transportation and child care services to lower the barriers that prevent mothers from succeeding in treatment. The results of the evaluation linked participation in the enhanced services program with lower self-reported drug use but, surprisingly, linked better access to transportation and child services with higher use. The authors concluded that clearly something else besides access to services made the enhanced service program more effective.57

Also in 1997, early results from the Illinois Performance-Based Contracting Initiative showed providers were far less successful in achieving permanence for children by reunification than they were by adoption or guardianship.58 Analysis of permanency outcomes showed that reunification rates were particularly low among children born substance-exposed. Of the 1,859 substance-exposed infants in fiscal year 1994 who were ever removed, less than one-fifth (18 percent) were reunified with birth parents, whereas two-thirds were adopted (65 percent) and one-tenth were taken into subsidized guardianship. Also of concern were the racial disparities in family preservation and reunification patterns. Of all SEI reports in fiscal year 1994, only 55 percent of black infants were retained in or ever returned to parental custody compared with 71 percent of non-Hispanic white infants and 73 percent of Hispanic infants.