KU Medical Center researcher publishes study on system to improve referrals to child protective services

A novel notification system for infants exposed to substances while their mothers were pregnant has resulted in a decrease in babies referred at birth to child protective services, according to a study led by a University of Kansas Medical Center researcher and published in the July 2025 issue of Health Affairs. This study, conducted with the state of Connecticut, also led to fewer infants being placed in foster care.

Margaret Sieger, Ph.D., associate professor of population health at KU Medical Center and the lead author on the study, notes that this reduction “reflects a more precise and effective way of identifying infants who actually need a child welfare referral, rather than just casting an enormously wide net and not being able to respond to everyone effectively in a resource-constrained system.” 

Sieger’s research at the intersection child welfare services and substance use began when she was an assistant professor in the School of Social Work at the University of Connecticut, where she started researching the impact of the Child Abuse Prevention and Treatment Act (CAPTA), federal legislation first enacted in 1974 to protect children from abuse.

Connecticut’s system, instituted in 2019, was devised in response to updated provisions of CAPTA that require states to identify and intervene with infants affected by prenatal substance exposure and develop a “plan of safe care” for both the infant and the mother or caregiver that addresses unmet health needs and treatment for substance use. Substance use disorder in pregnancy is associated with a range of problems, including premature birth, low birth weight, birth defects, neonatal withdrawal symptoms and cognitive and behavioral issues.

But “the way the CAPTA policy defines infants with prenatal substance exposure is very broad,” said Sieger. “The way it’s written, people who are using medications appropriately could become subjected to child-welfare referral and potential intervention. These people could include a mom who is using methadone to treat her opioid use disorder, has been in recovery for 10 years and is stable, or a patient who is using pain medications to treat chronic back pain or sickle cell disease.”

While some states have interpreted the CAPTA mandate as requiring every prenatal exposure to be reported to the child welfare system or even revised their statutes to make any substance exposure de facto abuse or neglect, Connecticut took a different approach.

In 2019, the state’s Department of Children and Families implemented a de-identified notification system. Through an online portal, hospitals provide the state with public health-level information on the incidence of substance-exposed births and the resulting plans of safe care, but not any data that reveals the identities of the infants, mothers or caregivers. Instead, the family receives the plan of safe care from a hospital social worker or other community-based provider who also can connect them to services that address health and substance abuse and psychological needs. 

The online portal also contains a short questionnaire asking if the child has tested positive for substances resulting from substance misuse and if the provider has concerns about abuse or neglect or that the mother’s substance use will impact her functioning. If the provider answers yes to any of these questions, they are directed to make a report to child protective services the traditional way.

Sieger and her colleagues wanted to find out how Connecticut’s system has impacted rates of these reports to child protective services at birth due to prenatal substance exposure, as well as how it has affected the proportion of those reports that resulted in infants being placed in foster care.

The researchers analyzed data from the state’s Department of Children and Families and Department of Public Health from March 2017, two years before Connecticut’s new policy took effect, through July 2022. 

They found that after the new policy was implemented in 2019, the rate of CPS reports due to prenatal substance exposure fell by an average of 7% each month. Meanwhile, the proportion of those reports resulting in foster-care placement fell by an average of 4% per month.

“Infants are now the fastest-growing age group in the U.S. foster care system, largely driven by parental substance use,” said Stephen Patrick, M.D., MPH, a neonatologist, chair of the Department of Health Policy and Management at Rollins School of Public Health at Emory University and a co-author on the study. “Our study found that Connecticut’s unique approach to substance-exposed infants was associated with fewer foster care placements, offering a potential model for other states.”

“What this suggests to me is that this is a more targeted and precise approach to identifying which infants need a referral,” said Sieger. “This is good news, of course, but with caution. The one unanswered question is, are they under-responding? By not expanding the referral apparatus and the number of children in foster care, are they leaving any children at risk?”

Sieger plans to do a future study looking at whether there is an increase of referrals later in infancy or early childhood, suggesting that families who were diverted away from child protective services at birth are then referred later because of a high-risk situation.

The researchers are also working on a paper outlining how Connecticut devised and implemented its new system to enable other states to implement similar systems. Sieger also is part of a workgroup in the state of Kansas now evaluating the state’s CAPTA policies, with the goal of potential collaboration. “It boils down to really strong interdisciplinary collaboration between child welfare, mental health and hospital systems,” said Sieger.

“This is an example of what a public health approach to prenatal substance exposure looks like — universal surveillance at the population level to understand the incidence of the problem, hot spots, trends in substance use, and so forth,” she said. “And everyone gets a supportive plan of safe care, and then any really high-risk families get a traditional referral for child welfare.”