Association Between State-Level Criminal Justice-Focused Prenatal Substance Use Policies in the US and Substance Use-Related Foster Care Admissions and Family Reunification

Importance States have enacted criminal justice-related substance use policies to address prenatal substance use and protect infants from adverse health effects of parental substance use. However, little is known about the consequences of these policies for permanency outcomes among infants in the foster care system in the United States. Objectives To evaluate the consequences of criminal justice-related prenatal substance use policies for family reunification and to examine differences in parental reunification by racial/ethnic group. Design, Setting, and Participants In this cohort study using data from the 2005 to 2017 Adoption and Foster Care Analysis and Reporting System, 13 cohorts of infants who entered the foster care system were followed up. States with criminal justice-related prenatal substance use policies were compared with states without such policies before and after their enactment using a discrete-time hazard model adjusted for individual covariates, state, and cohort fixed effects. The sample consisted of 350 604 infants 1 year or younger who had been removed from their home because of parental drug or alcohol use. Main Outcomes and Measures Length of time from entering the child welfare system to first reunification with a parent and hazard rates (HRs). Results Of the 350 604 infants 1 year or younger, 182 314 (52%) were boys, 251 572 (72%) were non-Hispanic white children, and 160 927 (46%) lived in US states with a criminal justice-focused prenatal substance use policy. Among those who were reunified, 36% of the reunifications occurred during the first year and 45% in the second year. Foster care infants who were removed from their homes because of parental substance use who live in states that have adopted criminal justice-oriented policies had a lower chance of reunification with a parent compared with states that have not adopted those policies (HR, 0.95; 95% CI, 0.94-0.96). Specifically, non-Hispanic black children who live in a state that has adopted criminal justice-oriented policies had a lower chance of reunification with a parent than non-Hispanic white children who live in a state that has not adopted those policies (HR, 0.87; 95% CI, 0.81-0.94). Conclusions and Relevance Given the child welfare system's legal mandate to make every effort toward parental reunification, a more comprehensive treatment and supportive policy approach toward parental substance use might be warranted.