Child Protection System Interactions for Children With Positive Urine Screens for Illicit Drugs

Importance Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive. Objective To document the child protection system involvement and the characteristics of children who test positive for illicit substances. Design, Setting, and Participants This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children’s Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024. Exposure Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine. Main Measures and Outcomes CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements. Results A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 51.3% were female; 309 60.5% were age 6 years or younger; fewer than 10 lt;3.0% were American Indian or Alaska Native; 252 49.3% were Hispanic any race, 20 3.9% were non-Hispanic Asian, 56 11.0% were non-Hispanic Black, 143 28.0% were non-Hispanic White, 36 7.0% had other or unknown race and ethnicity; 233 43.6% had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 9.8) compared with prior to the pandemic onset (16.5 4.7); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 4.7 vs 5.7 2.9). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk RR, 2.91 95% CI, 2.21-3.83) and child protection case openings (RR, 1.71 95% CI, 1.07-2.72) than encounters involving older children. Conclusions and Relevance In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.