A taxonomy of states' approaches to plans of safe care

1. Introduction

Perinatal substance use is a significant and growing public health concern. According to the National Survey of Drug Use and Health, in 2024, over 190,000 pregnancies in the U.S. (5.3%) were exposed to drugs (Center for Behavioral Health Statistics and Quality, 2025). Prenatal substance exposure (PSE) is a leading risk factor for child abuse and neglect (Austin et al., 2022; Goldstein & Font, 2025; Powell et al., 2025), sudden unexplained infant death (Lo et al., 2023; Piske et al., 2025), and maternal mortality (Han et al., 2024; Lisonkova et al., 2019). Up to 70% of children with PSE are referred to child protection systems by age 12 (Goldstein & Font, 2025; Powell et al., 2025), and 30 % of infants diagnosed with PSE at birth in California were placed into foster care before age 1 (Prindle et al., 2018). Infants with PSE who remain with their caregivers may be at increased risk of injury compared to peers placed into foster care (Austin et al., 2022; Palmer et al., 2025). These patterns reflect decades of federal and state policy efforts to address the needs of infants and families affected by substance use; efforts that have resulted in significant variation in how states respond to this population.

Federal child welfare law, the Child Abuse Prevention and Treatment Act (CAPTA), was amended in 2003 to improve the health and safety of infants with prenatal substance exposure (Lloyd et al., 2019). Since then, CAPTA has required states to have policies or procedures ensuring that healthcare providers involved in infant delivery “notify” Child Protective Services (CPS) of the birth and ensure the development of a “plan of safe care” (POSC) for infants “affected by” prenatal substance exposure. A POSC “generally entails an assessment of the family's situation and a plan for connecting families to appropriate services to stabilize the family and ensure the child's safety and well-being” (U.S. Government Accountability Office, 2018). For many years, little incentive or oversight existed for compliance with these elements of CAPTA and, as such, a minority of states developed POSC policies (Lloyd et al., 2019).

In 2016, in response to the opioid epidemic, the Comprehensive Addiction and Recovery Act (CARA) amended CAPTA, including adding a stated purpose of POSCs: to address the “health and substance use disorder treatment needs of the infant and affected family or caregiver.” This significant change shifted the focus beyond infant safety—the traditional role of CPS—to include the health and substance use treatment needs of both the infant and caregiver (Sieger et al., 2023).

The national child welfare system is guided by three concepts—safety, permanence, and well-being—meant to be held in tension with one another (Child Welfare Information Gateway, 2025; Holder, 2021). However, a traditional CPS response to prenatal substance exposure is often guided by a prioritization of safety, overriding the goals of permanence and well-being. This response typically includes four to five steps, based on the jurisdiction: (1) a referral to CPS from the community based on perceptions of risk, mandated reporting laws, or hospital policies, (2) a CPS decision to “screen-in” (or not) the referral based on statutory definitions of abuse or neglect or a risk assessment based on details included in the referral, (3) a CPS investigation into the veracity of the information included in the referral and other safety or risk factors, and (4) development of a safety plan that may include in-home child welfare services to address safety concerns or, if danger is perceived as great enough, (5) removal to foster care and court oversight (Child Welfare Information Gateway, 2025).

In prioritizing safety, this CPS-centric approach to prenatal substance exposure carries significant unintended consequences at odds with child health and well-being. Studies document that states relying on child welfare system involvement and foster placement for infants with PSE see reductions in women accessing prenatal care, substance use treatment during pregnancy, and medications for opioid use disorder, as well as increases in rates of neonatal abstinence syndrome (Atkins & Durrance, 2020; Austin et al., 2026; Bruzelius et al., 2024). Infants have higher rates of congenital syphilis in states with punitive PSE policies (Austin et al., 2025). One study documented greater developmental delays in infants with PSE placed into foster care compared to matched controls who remained at home (Novak et al., 2025). These punitive polices also fail to prevent substance use in pregnancy (Austin et al., 2026).

In contrast, a “public health approach” to child maltreatment prevention for this population would include early, universal screening, secondary prevention strategies for high-risk groups, and coordinated, multi-disciplinary care (Patrick et al., 2017). Many scholars and advocates believed CARA's changes to CAPTA offered an opportunity to expand this public health approach to infants with prenatal substance exposure (Lloyd Sieger et al., 2021). Aligning with CARA would mean state POSC policies should cover all infants affected by prenatal substance exposure and, at a minimum, ensure identification and referral to healthcare and treatment services for both caregiver and infant (Lloyd et al., 2019). Furthermore, federal CARA affords states leeway in deciding when a POSC is developed and by whom, including the opportunity to develop POSC before involving CPS, if CPS is involved at all (Child Welfare Information Gateway, 2020b).

Unfortunately, a 2018 policy scan found few states' POSC approaches aligned with the parent-child dyad language in CARA (Lloyd et al., 2019). In most cases, states responded to CARA's changes by implementing new CPS reporting mandates or retitling their traditional safety planning process a “plan of safe care” (Lloyd et al., 2019). Simply retitling traditional child protection activities has been viewed as a missed opportunity to institutionalize an upstream, public health approach to supporting families caring for an infant with prenatal substance exposure (Lloyd et al., 2019; Lloyd Sieger et al., 2021; Patrick et al., 2017; Patrick et al., 2019).

However, a few states did use CARA's passage as an opportunity to innovate in a public health direction. New Mexico, for example, codified in statute that prenatal substance exposure alone does not require a CPS report; instead, healthcare providers offer voluntary POSCs with care coordination through health insurers—not the child welfare system—connecting families to medical, substance use, and social services (NM Health; New Mexico Department of Health et al., 2022; Sharp et al., 2023). The implementation experience of these innovating states, while instructive, has not been systematically documented or compared across the broader national landscape.

The current state of POSC policies nationally is poorly understood. A recent policy surveillance study found that, while only 18 states had statutes or regulations about POSC, all but one state has implemented POSCs in some form (Lloyd Sieger et al., 2025). That study highlighted significant challenges in accessing states' POSC policies, in part because states use a variety of terms for their POSC policies and, despite a federal mandate, do not make current and historic state reports readily available for public inspection (Lloyd Sieger et al., 2025).

A lack of systematic, national accounting of POSC approaches has hindered evidence-based policymaking and comparative research. The literature also lacks a taxonomy of common POSC approaches; a precondition for empirically assessing the effects of alternative policy types. Such a taxonomy is urgently needed as CAPTA approaches federal reauthorization (Child Welfare Information Gateway, 2019), and policymakers need information to guide POSC changes. Therefore, the purposes of this paper are to: 1) review each state's stated approach to POSC, 2) develop a taxonomy of states' stated POSC approaches, and 3) assign each state to a category within this taxonomy.

2. Methods

3. Results

4. Discussion

For more than twenty years, federal policy has required states to use POSC in responding to infants with prenatal substance exposure; however, most states did not have a POSC approach in effect until after CARA's 2016 passage. Over time, states have adopted a variety of POSC approaches, but no previous research has articulated a taxonomy for categorizing states' POSC policies, a precondition for empirically assessing the effects of different types of policies. This has contributed to a paucity of empirical research examining whether and how POSC policies can improve outcomes for infants, parents, and families.

We previously documented the many barriers involved in inspecting states' POSC approaches (Lloyd Sieger et al., 2025). Employing a variety of tools to identify a description of each state's POSC approach, generate a taxonomy, and apply the taxonomy to states' policies, we extend that research, identifying state policies by reviewing 123,000 pages of text to identify only a few paragraphs total per state of relevant information. This is the proverbial “needle in a haystack.” To find these needles, we leveraged a commercial large language model, a tool that proved immensely helpful at reducing the size of the haystack but still required extensive expert review and critical analysis to interpret legal jargon in context and to categorize the legal data. Future research on POSCs may increase in rigor if primary data from state child welfare agencies is collected systematically to capture some of the granular details that were difficult to glean from the State Reports, or if states were to make these policies publicly available outside of state reports.

We extended past research by creating a POSC taxonomy. Existing literature on POSC has pointed to two approaches: a (rare) public health approach delivered outside the context of CPS, and a widespread traditional CPS-based approach (Lloyd et al., 2019; Lloyd Sieger et al., 2025; Sieger et al., 2022). We distilled five different types of approaches, differentiated by their relationship with the trajectory into and through the child welfare system, identifying nuance between the two extremes. Although states' approaches differ in countless other ways, such as which state partners are assigned/identified, training frequency, funding streams, modes of documentation, as well as a variety of ongoing pilot projects, our taxonomy reflects decision-points in CPS trajectories likely to have the largest impact on focal outcomes, including increasing healthcare access, preventing child maltreatment, and keeping parents and children together whenever possible.

Our taxonomy illustrates that most states have restricted POSC access to families who get reported to CPS and, in many of these states, only families whose maltreatment reports result in opening a child welfare case, frequently after substantiating a maltreatment allegation. Rates of substantiation vary considerably across states, often reflecting differences in legal and organizational contexts rather than the “facts” of maltreatment (Font & Maguire-Jack, 2021). Although many of these cases will involve court-ordered service plans and out-of-home placement, not all will (Font & Maguire-Jack, 2021). A new study from Pennsylvania examining linked CPS and Medicaid data for families with a CPS case between 2015 and 2018 found that the extent of CPS system penetration was significantly associated with whether the child's mother accessed SUD treatment (Goldstein & Font, 2025). Specifically, mothers whose children were placed into foster care were significantly more likely to enter treatment than mothers receiving in-home services. The Pennsylvania study did not focus on cases involving infants with prenatal substance exposure or families with a POSC; a subgroup analysis pointed to more tempered effects for cases involving children under one year old (Goldstein & Font, 2025). Notably, Pennsylvania uses an Alternative Response approach, suggesting that the differential response pathway for POSC may increase connection to treatment for mothers of infants compared to families with older children receiving traditional in-home services. Nonetheless, the Pennsylvania study suggests that traditional child welfare intervention may motivate (or force) parents to enter substance use treatment (Goldstein & Font, 2025). No research has specifically examined the effects of POSC policies in a state that uses traditional child welfare-based approaches (i.e., All CPS Referrals or Open Case Only).

We also found that eight states used a Hospital-initiated approach to POSC, an approach less traditional than approaches embedded in the child welfare system. Research on Connecticut and New Mexico, two states using such an approach, suggests that most but not all eligible families receive POSC (Sharp et al., 2023; Sieger et al., 2023). New Mexico, in particular, has faced considerable recent scrutiny (Riley, 2025), as it assigns the responsibility of POSC development to case managers embedded in health insurance systems. Although the New Mexico policy also integrates “CARA Navigators” in the CPS system (i.e., CPS case managers assigned to work with prenatal substance exposure cases), media and advocates have characterized the voluntary POSC as causing several high-profile infant deaths (New Mexico Legislative Finance Committee, 2023; Riley, 2025; Sharp et al., 2023). However, CPS systems that respond to such tragic events by increasing the foster care placement rates do not impact the rate of child fatalities (Heath, 2024), as such death are incredibly rare, difficult to predict, and often occur after the family is known to CPS. On the other hand, Connecticut, which also uses a Hospital-initiated approach and has also observed reduced rates of reports and foster care placement among infants with prenatal substance exposure (Sieger et al., 2025), has ostensibly increased the precision of the pre-referral process (i.e., the hospital workers' decision making), thus ensuring that high maltreatment risk cases are still connected to CPS (Sieger et al., 2022), while lower risk families are referred for supports elsewhere. Future research using causal inference approaches will aid in understanding the extent to which these POSC schemes impact the health and safety of infants.

The Dual Pathways approach, only in Vermont and Louisiana, was unique, warranting its own categorization. In these states, infants exposed only to certain substances receive a Hospital-initiated POSC with no CPS contact, while all other types of prenatal substance exposure result in a CPS referral for safety planning with the child welfare department. Although not explicitly stated, the forms of prenatal substance exposure are eligible for a POSC are considered low risk from a CPS standpoint. In Vermont, POSC-eligible infants are those exposed to cannabis, which appears not to increase risk for subsequent maltreatment, (Ryan et al., 2025) or appropriately used controlled medications (e.g., pain medications, psychotropics). Similarly, in Louisiana, infants are eligible for POSC only if the infant is born affected by controlled substances used in a lawfully prescribed manner. The Dual Pathways approach does three novel things: 1) it leverages the type of substance exposure as a proxy for safety, 2) it protects parents appropriately using medications from unnecessary CPS intrusion, and 3) it offers additional support to these low-risk families outside the context of the child welfare system. These elements address some criticisms of CAPTA, including concerns related to CPS involvement when parents are receiving medications to treat opioid use disorder (MOUD) (Lloyd et al., 2019). Leading professional organizations have made calls for exceptions to CPS reporting for certain medications (American Psychological Association, 2020; Guyer et al., 2024). To date, no studies exist on the effects of Vermont's or Louisiana's approach.

States implementing an Alternative Response approach have implemented a distinct, voluntary, in-home services pathway for infants with prenatal substance exposure. Historically, younger children have been less likely to receive these services (Damman et al., 2020). This likely reflects many factors including their increased physical vulnerability. Furthermore, parents receiving voluntary services may access less substance use treatment compared to parents whose children were placed into foster care (Goldstein & Font, 2025), and infants with substance-related allegations who remain at home may be at higher risk of subsequent injury compared to their peers in out-of-home placement (Palmer et al., 2025). Research from Delaware, a state using an Alternative Response approach, suggest that concerns for parental disengagement and lack of infant safety with in-home POSC may be unfounded (Deutsch et al., 2022). Ninety-four percent of the Delaware study sample (i.e., infants with prenatal substance exposure reported to CPS) received a POSC, suggesting high levels of implementation and engagement. The majority (88%) remained at home (Deutsch et al., 2022), suggesting high levels of safety and, if safety became a concern, appropriate increase in intensity of response (i.e., out-of-home placement). Seven infants in the study sample (0.51%) sustained serious injuries and four infants died (0.30%). This fatality rate is equivalent to 2.7 per 1000 births. For comparison, the national infant mortality rate in 2022 was 5.1 per 1000 births. (Ely & Driscoll, 2024).

Supplementary Material

Data availability

We have shared the data in our supplement.