The use of substances such as cannabis and opioids in adults is on the rise in the United States.^{1,2,3,4,5,6,7,8,9,10,11,12} Children who reside in homes where adult drug use is occurring are at risk of accidentally ingesting those substances.^13,14,15 Recent research indicates that there has been a 26% increase in illicit drug ingestions in children since the onset of COVID-19 and pediatric hospitalizations for cannabis poisoning has doubled in areas with recreational legalization.^16,17,18 Young children often ingest these drugs through exploratory means as they are unaware of the dangers; caregivers who are using substances may be less able to monitor their children’s behavior.^19,20

When a young child tests positive for an illicit drug, a report to the child protection system (CPS) may occur, however reporting is variable depending on geographic location, institutional practice, state laws, and may be influenced by bias.^21,22,23,24 Prior research suggests that parental and/or caregiver drug use is a common concern on CPS reports, CPS investigator assessments, and out-of-home placements; since 2008, the number of entries into foster care due to parental substance use has risen and 23% of removals are directly attributed to parental drug use.^25,26 Prior research has primarily focused on CPS interactions that follow prenatal substance exposure, finding that around half of all infants diagnosed with substance exposure during pregnancy are reported to CPS, but that these interactions vary by substance type.^27,28,29 A previous study that examined drug exposure beyond the neonatal period using hospital data from 2006 to 2008 found that only 4% of cases were reported to CPS and reporting rates varied by substance type.³⁰ Given increases in child ingestion rates, and the legalization of cannabis in many states, understanding both reporting practices and CPS responses by drug type when a child tests positive is important.^{17,18,31,32,33,34}

In the present study, we use administrative data from a large free-standing children’s hospital linked to statewide CPS records to (1) document the characteristics of children who test positive for illicit drugs in emergency department (ED) and inpatient medical settings; and (2) examine associated CPS interactions (reports, substantiation, case opening, and out-of-home placement) by substance type.

There were 511 medical encounters with a positive drug screen during the study time frame; 262 (51.3%) were female, and 309 (60.5%) were aged 6 years or younger, with 59 (11.5%) under 1 year of age; fewer than 10 (<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, and 36 (7.0%) had other or unknown race and ethnicity. The Table presents the population characteristics stratified by whether a CPS report was made during the medical encounter. Cannabis (213 encounters [41.7%]) was the most frequent illicit substance identified in the urinalysis tests, followed by benzodiazepines (139 encounters [27.2%]), amphetamines (114 encounters [22.3%]), opiates (38 encounters [7.4%]), and fentanyl (36 encounters [7.0%]). More than half the medical encounters were inpatient admissions (288 encounters [56.4%]), two-thirds were paid for using public health insurance (342 encounters [66.9%]), and for 233 encounters (43.6%) the child had a previous report to CPS. Statistically significant differences in the distributions of encounters by CPS report status were observed by positive drug type. Compared with encounters not reported to CPS, encounters reported to CPS more commonly had a positive test for cannabis (CPS report: 130 encounters [53.3%] vs no CPS report: 83 encounters [31.1%]) and amphetamines (CPS report: 65 encounters [26.6%] vs no CPS report: 49 encounters [18.4%]) (P < .001). Encounters with children under age 1 (42 encounters [17.2%]) and aged 1 to 6 years (128 encounters [52.5%]) composed higher proportions of those reported to CPS (P < .001). Approximately three-quarters of encounters reported to CPS were paid for using public health insurance, which was higher than those not reported to CPS (182 of 244 encounters [74.6%] vs 160 of 267 encounters [59.9%]; P < .001). eTable 2 in Supplement 1 presents the study population characteristics by positive drug type.

Figure 2 presents the quarterly counts of encounters with positive drug tests overall and by substance type over time. Counts of positive drug tests overall and related to cannabis, fentanyl, and multiple positive drugs increased after the onset of the COVID-19 pandemic, with an overall peak observed in the third quarter of 2021. Mean (SD) quarterly counts of all positive tests were higher after the pandemic onset (32.9 [9.8]) than prior to the pandemic onset (16.5 [4.7]), which was also true for positive cannabis tests (after pandemic onset: 16.6 [4.7]; prior to pandemic: 5.7 [2.9]).

Figure 3 presents the percentage of encounters testing positive in each drug category who experienced the measured CPS interactions. Among all 511 children with a positive drug test, 244 (47.7%) were reported to CPS during the medical encounter, 113 (22.1%) had an allegation of maltreatment substantiated by CPS, 87 (17.0%) had a case opened for services by CPS, and 61 (11.9%) were placed out-of-home by CPS within 30 days. χ² tests documented statistically significant differences in the distributions for each of the CPS interactions by drug type (P < .001). The highest rates of CPS interactions were for encounters with positive tests for fentanyl: 19 of 36 (52.8%) had an allegation substantiated by CPS and 23 of 36 (63.9%) had a case opened for services and were placed out-of-home within 30 days. Cases were opened for services for 17 of 52 encounters with multiple positive drugs (32.7%), 39 of 114 amphetamine encounters (34.2%), and 22 of 213 cannabis encounters (10.3%). Similarly, out-of-home placements occurred less frequently for positive screens of amphetamines (30 of 114 [26.3%]), benzodiazepines (11 of 139 [8.0%]), and cannabis (<5% of 213).

Figure 4 presents encounter characteristics associated with the CPS outcomes of reports and case openings in the 2 regression models (adjusted with covariates). Child age had the highest risk of a CPS report as children under age 1 year (RR, 2.91 [95% CI, 2.21-3.83]) and aged 1 to 6 years (RR, 2.22 [95% CI, 1.75-2.83]) had higher risk of a report than children aged 7 to 12 years. For the outcome of a CPS case opened, children under age 1 year (RR, 1.71 [95% CI, 1.07-2.72]) had higher risk than children aged 7 to 12 years, but there was no difference for children aged 1 to 6 years.

The substance type also had statistically significant differences in risk for both CPS report and CPS case openings. Encounters with positive tests for cannabis had an increased risk of a CPS report (RR, 1.90 [95% CI, 1.13-3.21]) but lower risk of a case opened (RR, 0.21 [95% CI, 0.09-0.50]) than encounters not testing positive for cannabis. Encounters that included positive tests for multiple drugs had increased risk of a case opening (RR, 3.25 [95% CI, 1.53-6.92]), but not an increased risk of a CPS report compared with encounters that tested positive for a single drug type.

Encounters where the child had a prior CPS report had higher risk of a CPS report during the medical encounter (RR, 1.22 [95% CI, 1.04-1.44]) and a case opened for services (RR, 2.11 [95% CI, 1.35-3.31]) than those without a prior CPS report. Encounters paid for with public health insurance had higher risk of having a CPS case opened (RR, 1.86 [95% CI, 1.04-3.34]), but not to being reported to CPS. No statistically significant differences were observed by child race and ethnicity, child sex, or encounter type in the adjusted regression models.

Using linked hospital discharge and CPS administrative data, we documented that fewer than half (47.7%) of medical encounters for young children with a positive drug screen were reported to CPS at time of medical encounter, and 11.9% were placed out-of-home within 30 days. Importantly, the rates of CPS interactions differed by drug type, with deeper CPS penetration for children who tested positive for fentanyl. Our results align with previous studies regarding prenatal substance exposure, which found that those children who were reported to and placed by CPS differed by substance type.^27,28,29,42 These findings continue to suggest that both reporting parties and CPS workers take the type of substance into account when assessing the need for CPS intervention. Similar to previous studies using linked administrative data of prenatal substance exposure and medical encounters with diagnosed child maltreatment, immediate removals by CPS were uncommon.^28,29 This result is likely influenced by local policies, procedures, and laws regarding child maltreatment.^43,44

Mirroring national data, our study found a sustained increase in children through 12 years of age testing positive for drugs after March 2020, particularly for cannabis and fentanyl.^18,47 The increase of positive fentanyl tests may be associated with the increase of fentanyl use and availability in the US.^48,49,50 The increase in cannabis ingestions is likely multifactorial and may include legalization policies, the effect of the pandemic, and product packaging and marketing, but more research is needed to understand this trend.^{17,18,19,47,51,52}

This study reinforced that drug ingestions requiring medical attention are not limited to older children where intent (eg, accidental vs self-harm) may be in question. Almost two-thirds of the children in our study were 6 years of age or younger. Given the increased vulnerability of younger children, it was unsurprising that younger children were found to have higher risk of CPS reports and case openings. These findings highlight the need for public health campaigns that increase awareness and educate parents about the importance of safe storage of drugs and paraphernalia.¹⁸ Given that 54.0% of cannabis ingestions occurred for children between ages 1 and 6 years, this raises concerns about the attractive packaging of cannabis products and how these children are not able to discern the differences between what is safe to consume and what is not.^45,46

There is limited literature pertaining to CPS reporting practices when a young child tests positive for cannabis, and prior published opinions are mixed.^53,54 Our study found that encounters with positive cannabis tests had fewer CPS case openings and out-of-home placements than other drug types. Prior literature has shown an overlap of parental illicit drug use and child maltreatment; however, those studies do not isolate cannabis from other illicit drug ingestions and are limited in their ability to provide insight into the association between caregiver cannabis use and child maltreatment.^55,56,57 There remains a need to establish cannabis-specific recommendations for approaching CPS reporting decision-making. Our study results were mixed with regards to the association of race and ethnicity and insurance status with reporting practices. Prior literature raises concerns of CPS reporting bias related to race and ethnicity and socioeconomic status.^{58,59,60,61,62,63,64} Institutions should standardize their approach to reporting to reduce implicit bias and ensure all families are treated equally regardless of perceived race and socioeconomic status.⁶⁵

Notably in 43.6% of the total medical encounters with positive illicit drugs tests, the child had previously been reported to CPS. Research has demonstrated that prior maltreatment reports are a risk factor for a variety of poor outcomes including injury mortality before age 5, death due to medical causes prior to age 1, and youth suicide.^66,67,68 The results of our study highlight that there may be opportunities for identification and intervention of caregiver drug use prior to a child ingesting illicit drugs, while raising the question of what services are these children and families receiving.

In this cross-sectional study, fewer than half of children under age 12 who tested positive for illicit drugs during ED and inpatient medical encounters were reported to CPS, and less than 12% were placed in out-of-home care within 30 days. The frequency of children testing positive for drugs increased after the onset of the COVID-19 pandemic. These CPS interactions varied by substance type, suggesting that both reporting parties and CPS workers take the type of substance into account when assessing the need for CPS intervention.