Overview
In 2024, almost 46,000 infants in the U.S. were referred to child protective services with prenatal substance exposure, and over a third of children who entered out-of-home care had parental alcohol or drug use as an identified reason for removal. Parental substance use and prenatal substance exposure often are cited as factors for children entering foster care. The presence of a substance use disorder alone should never be the determining factor on child removal. Instead, decisions on family separation must be based on an assessment of how substance use disorder within a family is affecting child safety.
A Plan of Safe Care is designed to ensure the safety and well-being of an infant affected by parental substance abuse by addressing the health and treatment needs of both the infant and the affected family or caregiver. Plans of Safe Care (POSC) can respond to child safety risks, help keep families safely together, and prevent the need for foster care.
For infants affected by substance abuse, POSC bring together affected families and various service providers — including maternal and infant healthcare, substance use disorder treatment, mental health treatment, early childhood, and child welfare. This collaborative approach(Opens link in new tab) ensures a comprehensive response that prevents crisis-based reactions, addresses infant safety, promotes healthy child development, and strengthens family protective factors. This brief describes key considerations, decision points, and jurisdictional examples for implementing POSC.
Evolving requirements
Since 2003, three significant changes have been made to requirements for implementing POSC. Variation is wide among states, both in the implementation of policy and procedures and the rate of infants placed in out-of-home care due to substance use disorder-related issues.
The Keeping Children and Families Safe Act of 2003(Opens link in new tab) created new conditions, including POSC, for states to receive grant allocations under the Child Abuse and Prevention Treatment Act (CAPTA)(Opens link in new tab). Requirements include policies and protocols for the following:
- Appropriate referrals to child protection services and other relevant systems to address the needs of infants born with and identified as affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.
- A requirement that health care providers involved in the delivery or care of such infants notify the child protective services agency of the occurrence of such condition “except that such notification shall not be construed to establish a definition under federal law of what constitutes child abuse or require prosecution for any illegal action.”
- The development of POSC for infants born with and identified as being affected by illegal substance abuse or withdrawal symptoms.
- Immediate screening, risk, and safety assessment, and prompt investigation of such reports.
The CAPTA Reauthorization Act of 2010(Opens link in new tab) amended the requirements by adding fetal alcohol spectrum disorder (FASD) to the definition of an infant affected by parental substance abuse. More recently, the Comprehensive Addiction and Recovery Act (CARA) of 2016(Opens link in new tab), which was passed in response to the nation’s opioid epidemic, included the following changes to the CAPTA provisions:
- Removed the term “illegal” when referring to substance abuse.
- Required that POSC meet the needs of both the infant and the family or caregiver affected by substance use disorder.
- Specified data reporting on infants and POSC, including the number of infants: a) identified as being affected by substance abuse, withdrawal symptoms resulting from prenatal drug exposure, or FASD; b) with a Plan of Safe Care; and c) receiving referrals for appropriate services including those for the affected family or caregivers.
- Required states to develop and implement monitoring systems for POSC to determine whether — and in what manner — local entities provide, in accordance with state requirements, referrals to and delivery of appropriate services for the infant and affected family or caregiver.
National implementation of Plans of Safe Care continues to evolve as jurisdictions incorporate lessons, adopt technological innovations, and respond to emerging federal and state priorities.