Research on the outcomes of drug-exposed children evinces elevated developmental risks from the interaction of subtle biological vulnerabilities and compromised parenting. States, however, have generally not reviewed the procedures and policies they developed in the early 1990s when there was less research and experience with these children. At that time the gravest risks related to perinatal substance exposure seemed to be excessively punitive treatment of mothers by overzealous criminal justice prosecutors. This article clarifies policy options for reporting and serving children who are born testing positive for controlled substances and also calls for strengthening existing state policies regarding child abuse reporting and response.
Child welfare services touch the lives of at least three million children each year, with at least one million children receiving ongoing services at home or in out-of-home care.
About one in eight children (13%) were less than 12 months of age at the time they were reported to child welfare. [Barth et al. 2000]; of these children almost 82% (with known reasons for reporting) were reported for reasons of neglect. Young children continue to be the largest group entering out-of-home care-approximately one in five admissions into care is for infants and about half of those are for newborns [Wulczyn et al. 1999]. Infants' lengths of stay in out-of-home care are exceptionally long, in part due to the high proportion-about one-third [Wulczyn et al. 1999]-that will experience the lengthy process of adoption.
Although there is no certainty about the proportion of cases that are reported to child welfare services stemming from substance abuse, there is a consensus that it is so far the majority of cases [U.S. Department of Health and Human Services 1999]. More than three-quarters of state child protection administrators across the country report substance abuse as one of the top two problems presented by their caseloads [Weise & Daro 1995]. A decade ago, Besharov  concluded that over 73% of neglect-related child fatalities in 1987 were attributable to parental alcohol and drug abuse.
Child Welfare Policy Regarding Infants Born Exposed to Substances
In the late 1980s and early 1990s, states struggled with policy decisions about handling the many child abuse cases that were based on exposure to crack cocaine. Although the issue of children being born exposed to drugs was not new for child welfare [Fanshel 1975], the size of the population of concern in metropolitan hospitals was startling to the public. Coupled with early reports of the possibility of serious lifetime harms from prenatal crack cocaine exposure, some child welfare agencies became involved in massive increases in the placement of children into out-of-home care. In some communities, one-fifth of all newborns were placed into care [Wulczyn 1994]. New York state had consecutive annual foster care caseload increases of 28%, 29%, and 26% between 1986 and 1989-more than doubling its out-of-home care census in that time. Child welfare administrators, judges, and advocates for children and drug-involved parents began to call for clarification about the procedures by which children should be determined to need which child welfare intervention following what process. At that time, the empirical basis for making that determination was inadequate.
Policy decisions had to be made, nonetheless, and states chose approaches based, substantially, on political considerations of interest groups. A few states and counties opted to incarcerate pregnant mothers who used substances, but this option was not embraced by enough interested parties to be seriously considered. (Indeed such punitive proposals seemed to coalesce professionals opposed to all actions that appeared "punitive," including mandated reports.) The most common options that states adopted were: * a positive drug-test for a child at birth as grounds for an automatic child abuse and neglect report (as in Iowa);
* a positive infant drug test serving as the basis for a substantiated child abuse and neglect finding (as in South Carolina);
* a positive drug test as grounds for referral to a maternal and child health agency (MCHA) and nothing more (as in California); or
* silence about the appropriate responses (as in Maryland). …