A Policy Scan on Plans of Safe Care for Infants With Prenatal Substance Exposure

Abstract

OBJECTIVE:

Since 2016, federal law has stipulated state child welfare agencies must maintain policies and procedures to address the needs of infants with prenatal substance exposure (PSE) and their caregivers through a plan of safe care (POSC) focused on health and substance use treatment. Research into the effects of POSC across states has been slow due to a lack of accounting of states’ POSC policies. The current study documents the status and contents of states’ POSC policies.

METHODS:

We used search terms related to POSC in Nexis Uni, a legal software, to identify state statutes and regulations in effect during spring or summer 2024. We used a mixed deductive-inductive content analysis approach to identify domains of interest of POSC policies. To overcome limits of the legal search, we additionally compiled states’ reports to Congress that describe their POSC policies. We calculated an accessibility rating to characterize the extent to which each state’s POSC policy was available for public inspection.

RESULTS:

Every state except Illinois maintains some type of POSC policy, primarily in the form of an administrative manual, while only 18 states had enacted POSC statutes or regulations. Administrative manuals are not easily accessible to the public or clinicians. While statutes and regulations are publicly accessible, they are inconsistent regarding parts of the POSC “process” are codified. Thirty-one states had very low levels of accessibility of POSC policies.

CONCLUSIONS:

Ensuring consistent and transparent intervention for families with PSE will require greater clarity in policies and additional policy implementation supports.

INTRODUCTION

Hospitalists work on the frontlines of identifying and responding to prenatal substance exposure (PSE), an increasingly common pathway into the child welfare system.¹ Rates of newborn referrals to child protective services (CPS) increased by over 55% between 2011 and 2019, driven by increased concerns about caregivers’ substance use.¹ In 2022, conservative estimates suggest over 45 000 infants with PSE from 50 states were referred to CPS,² equivalent to 1 infant every 12 minutes. The actual rate is likely much higher, as federal data systems tracking referrals rely on complex and notoriously inaccurate measurement methods.¹

Since 2003, the federal Child Abuse Prevention and Treatment Act (CAPTA) has required states to have laws (eg, statutes or regulations) or other policies (eg, administrative guidelines) ensuring “notification” to CPS and the development of a “plan of safe care” (POSC) for infants “affected by” PSE. Since the passage of the Comprehensive Addiction and Recovery Act (CARA) of 2016, the stated purpose of POSCs is to address the “health and substance use disorder treatment needs of the infant and affected family or caregiver.” In just 2 short paragraphs, CAPTA is the only federal child welfare law that addresses PSE, giving states significant flexibility and limited funding for defining, developing, and implementing POSCs.

There has been slow and staggered adoption by states of the federal policy’s key aspects.³ A 2019 policy scan found 30 states (59%) had no POSC policy, and only 9 states (17.6%) had POSC policies aligned with all CAPTA elements.⁴ A recent review documented 17 states with POSC statutes and regulations but did not analyze their content.⁵ Notably, POSC is not a term universally used among states, making searches for state policies challenging.

Despite slow initial adoption, much attention has recently been paid to state POSCs. Organizations such as the National Center on Substance Abuse and Child Welfare and Casey Family Programs have produced considerable resources educating states about POSCs.^6,7 New funding streams, including opioid abatement dollars and the 2021 American Rescue Plan Act (ARPA), aided states in further developing substance-related policies, including POSCs.⁸ To what extent these efforts translated into more sophisticated implementation of POSCs, including more transparent, actionable, and enforceable POSC policies, is unknown.⁴ To enhance the field’s understanding, this policy surveillance study seeks to better understand the status of POSC policies across the United States.

METHODS

Data Collection

State Statutes and Regulations

To document whether states maintained any type of POSC policy (yes/no) and, if yes, the local terminology used for their POSC, we iteratively developed a search string based on POSC-related terms in Nexis Uni legal software (see Supplemental Information 1 for search string). We used the finalized search string to download state statutes and regulations in effect as of November 2024. Two reviewers independently evaluated each law for inclusion based on defined inclusion/exclusion criteria. Laws were included if they described the state’s approach to “plans of safe care,” which we defined as a systematized, statewide process for referring infants with PSE and their caregivers for support services (either within or outside the child welfare system) with a goal of ensuring health, safety, or well-being. Laws were excluded if they only applied to licensed substance use disorder facilities, only applied to children older than infants, only applied to neonatal abstinence centers or residential infant care centers, only restated federal requirements, only discussed requirements related to the federal Individuals with Disabilities Education Act rather than CAPTA, only described requirements for policymakers to make future plans (eg, to assess the feasibility of a hypothetical future program), or used relevant terminology in the wrong context (eg, discussed plans to keep children safe from violence in residential facilities). Statutes and regulations that met inclusion criteria came from 18 states. The number of statutes and/or regulations per state ranged from 1 to 9, with an average of 3.8 concurrent laws per state.

Annual Progress and Services Reports

CAPTA does not require states to enact laws outlining their POSC processes, and our legal search resulted in relatively few states with relevant statutes or regulations. Therefore, to overcome the limitations of the legal search, we compiled states’ Annual Progress and Services Reports (APSRs), a mandated state report of programs and policies of CAPTA requirements, including POSCs. Although federal regulations require states to submit APSRs to Congress annually and to make APSRs publicly available (45 CFR §1355.21(c)), we faced considerable hurdles in locating these documents. Between January and June 2023, we searched for APSR copies online, locating 282 APSRs and 30 CAPTA State Plans (which are addenda to APSRs). Because no state had all documents from 2016 to 2024 available online, we emailed state administrators, using contact information found in other years’ APSRs or available on the state’s child welfare agency web page. Most states willingly provided documents via email but could not provide all requested documents. We received 42 documents from states, directly resulting in a total of 354 documents, with at least 1 document from every state. After excluding 4 unopenable documents, the number of documents received per state ranged from 1 to 13, with an average of 6.7 per state across years. We reviewed APSRs starting with the most recent available year, identifying states’ specific terminology for POSCs using searches for the terms “prenatal,” “plan,” “plan of safe care,” “safe care,” “newborn,” “infant,” and “expos.”

Analysis

Content Analysis of Statutes and Regulations

A mixed inductive-deductive content analysis approach was used to identify trends in the 18 states’ statutes and regulations describing POSCs. After a preliminary review of laws and a research team discussion, 2 POSC experts identified 3 POSC domains of interest: “eligibility, development, and monitoring.” These domains were selected as most germane because under federal law, states should outline a statewide process for identifying infants “affected by prenatal substance abuse” (ie, eligibility), have a process for developing a physical or electronic document(s) addressing service needs for infants with PSE and their caregivers, and monitoring the dyad’s receipt of services (42 USC §5106(b)(2)(B)). Within domains, the 2 experts created 12 binary questions about the presence or lack of a specific state policy component (Table 1, left column). For example, “Does the law indicate whether parents are involved in POSC development?” (yes or no) was asked under the “POSC development” domain. Next, the POSC experts independently answered the binary questions for a given state, using all relevant POSC statutes and/or regulations found for that state, subsequently discussing any discrepancies in their answers. We then calculated the percentage of components of interest present in each domain in each state. For example, if a state defined “infant” but did not define “affected by” or clarify which infants get a POSC, then the state statutes/regulations included 33% of the POSC eligibility components. We did not analyze APSRs for the content of the POSC policies, as the focus of the APSR analysis was to understand whether states maintained some type of POSC policy in the absence of a formal statute or regulation.

Table 1:

Coding Structure of Three Domains and 12 Specific Policy Components of Interest

Domain & Policy Component	Example Text	Citation
POSC Eligibility
Defines “infant”	“Newborn” means a child under the age of 30 days who is born or who receives care in the State.	Md. Family Law Code Ann. § 5-704.2
Defines “affected by”	“Infant with prenatal substance exposure” means a child not more than 1 year of age who is born with and identified as being affected by substance abuse or withdrawal symptoms or a fetal alcohol spectrum disorder. The health-care provider involved in the delivery or care of the infant shall determine whether the infant is affected by the substance exposure.	16 Del. C. § 902B
Clarifies which infants get a POSC	The Colorado plan of safe care shall be completed: A. Any time a referral is accepted for assessment and the child meets the definition of substance exposed newborn as described in 19-1-103(1)(a)(vii), C.RS and 19-3-102(1)(g), C.R.S.	12 CCR 2509’-’2 (2024)
POSC Development
Clarifies when a POSC is developed	A provider of health care who delivers or provides medical services to an infant in a medical facility and who, in his or her professional capacity, knows or has reasonable cause to believe that the infant was born with a fetal alcohol spectrum disorder, is affected by a prenatal substance use disorder or is experiencing symptoms of withdrawal from a substance as a result of exposure to the substance in utero shall ensure that a CARA Plan of Care is established for the infant before the infant is discharged from the medical facility.	NAC 449.947
Clarifies who POSC services are for	“Plan of care (POC)” as defined in Subsection T of Section 32A-1-4 NMSA 1978 means a plan… addressing the treatment needs of the child and any of the child’s parents, relatives, guardians, family members or caregivers to the extent those treatment needs are relevant to the safety of the child.	8.10.5.7 NMAC
Clarifies which agency/professional develops the POSC	In response to an alternative response assessment, the department … Shall develop a plan of safe care for the substance exposed infant.	N.D. Cent. Code, § 50-25.1-02
Indicates whether parents are involved in POSC development	Instructions to providers regarding such providers’ participation in the discharge planning process, including the creation of written plans of safe care, which shall be developed between such providers and mothers of such newborns as part of such process.	Conn. Gen. Stat. § 17a’-’102a (2024)
POSC Monitoring
Clarifies which agency/professional coordinates POSC services	When an infant is identified as an infant with prenatal substance exposure, the CPS worker must… Ensure the infant with prenatal substance exposure and family are referred to services identified in the plan of care.	OAR 413-015-0415
Clarifies which POSC recipients are monitored	Notify all participants involved in the plan of safe care of the final case decision. The final decision includes whether the case will be transferred for ongoing PCSA services, closed and referral made to community services, or closed.	OAC Ann. 5101:2-36-03
Clarifies who monitors/enforces POSC compliance	DCFS shall monitor plans of care via the regional child welfare teams with multidisciplinary professionals to address the availability and delivery of the appropriate services for the newborn, affected caregiver and family.	LAC 67:V.1135.
Clarifies which agencies/professionals receive a copy of the POSC	The patient care team shall obtain consent(s) or authorization(s) to share the Plan of Safe Care with identified service providers and family support network members and collect needed information for the implementation of the Plan of Safe Care and associated services.	WY Rules and Regulations 049.0035.2 § 2
Clarifies whether public health monitoring is required	Collection of data to meet Federal and State reporting requirements.	23 Pa.C.S. § 6386

Accessibility Rating of States’ POSC Policies

We developed a simple algorithm to rate the accessibility of states’ POSC policies based on (1) proportion of publicly available APSRs since 2016, (2) whether the POSC policy was codified in statutes and/or regulations, and (3) whether local terminology conformed to the federal law (ie, the POSC is called a “plan of safe care”). States were rated based on the proportion of requested APSRs publicly available or freely provided by the state (<33% = 0, 33%–66% = 1, >66% = 2). Because statutes and regulations are publicly available, while administrative manuals are often inaccessible to the public, states received 3 points if their POSC policy was codified in statutes or regulations (yes = 3, no = 0). States received an additional point for referring to their POSC as a “plan of safe care,” as opposed to another atypical term of art (yes = 1, no = 0). States could thus earn an accessibility rating between 0 and 6. The data informing these ratings are included in Supplemental Table 1.

RESULTS

Content of State Statutes and Regulations Describing POSC

Only 18 states described POSCs in their statutes or regulations (Arkansas, Colorado, Connecticut, Delaware, Louisiana, Maryland, Maine, North Dakota, Nebraska, New Hampshire, New Mexico, Nevada, Ohio, Oklahoma, Oregon, Pennsylvania, Virginia, and Wyoming), and varied substantially in POSC process components that were codified. Table 1 includes illustrative text and citations for each policy component (middle and right columns). Table 2 and Figure 1 summarize the components assessed in each domain in each state. Table 2 describes, specifically, which of the components each states’ policy describes. Figure 1 illustrates the scope of POSC content that each state’s statutes and regulations describe using a 3-point scale (0%–33%, 34%–66%, or 67%–100%). Figure 1 illuminates that states’ policies addressed significantly more elements of “POSC eligibility” and “POSC development” compared with “POSC monitoring.” Figure 1 further points to regional clustering in states that have POSC laws, reflecting the impact of regional proximity on POSC policymaking.³ Across the 18 states, we found indicators of 74% (3.0 out of 4) of “POSC eligibility” policy components, 81% (2.4 out of 3) of “POSC development” policy components, and 43% (2.2 out of 5) of “POSC monitoring” policy components. In other words, state statutes and regulations generally had more information about the beginning of the POSC process (ie, who gets a POSC and who develops it), with substantially less information about monitoring processes. Five of the 18 states did not address POSC monitoring at all. In contrast, 3 states (Delaware, Louisiana, and New Mexico) addressed all 5 aspects of POSC monitoring. Seven states addressed all aspects within the POSC eligibility domain (Arkansas, Delaware, Ohio, Oklahoma, Oregon, Pennsylvania, and Virginia), and 7 states addressed all 4 aspects within the POSC development domain (Colorado, Connecticut, New Mexico, Ohio, Oregon, Pennsylvania, and Wyoming). Delaware and Pennsylvania both addressed 11 of 12 policy components of interest. Nebraska addressed only 1 of 12 policy components.

Table 2:

Findings from Content Analysis of States’ POSC Statutes and Regulations Current (In Force) as of August 2024

	POSC Eligibility			POSC Development				POSC Monitoring
State	Defines “infant”	Defines “affected by”	Clarifies which infants get a POSC	Clarifies when a POSC is developed	Clarifies who POSC services are for	Clarifies which agency/ professional develops POSC	Indicates whether parents are involved in POSC development	Clarifies which agency/ professional coordinates POSC services	Clarifies which POSC recipients are monitored	Clarifies who monitors/ enforces POSC compliance	Clarifies which agencies/ professionals receive a copy of the POSC	Clarifies whether public health monitoring is required
AR	1	1	1	1	1	1	0	1	1	0	0	0
CO	0	1	1	1	1	1	1	0	0	0	0	0
CT	0	1	1	1	1	1	1	0	0	0	1	1
DE	1	1	1	1	1	1	0	1	1	1	1	1
LA	0	1	1	1	1	1	0	1	1	1	1	1
MD	1	0	1	1	1	1	0	1	1	1	0	0
ME	0	1	1	1	1	1	0	0	0	0	0	0
ND	1	1	0	1	1	1	0	1	1	1	0	0
NE	0	1	0	0	0	0	0	0	0	0	0	0
NH	0	0	1	0	1	1	1	0	0	0	1	0
NM	0	0	1	1	1	1	1	1	1	1	1	1
NV	0	1	1	1	1	1	0	0	0	0	1	0
OH	1	1	1	1	1	1	1	1	1	1	0	0
OK	1	1	1	1	1	1	0	0	0	0	0	0
OR	1	1	1	1	1	1	1	1	1	1	0	0
PA	1	1	1	1	1	1	1	1	1	1	0	1
VA	1	1	1	1	1	1	0	0	0	0	0	0
WY	0	1	1	1	1	1	1	0	0	0	1	1

Table Notes. This table summarizes the results from the legal scan of statues and regulations in force in 2024 per our search described in the manuscript. All relevant laws were coded for each state. The above presents results collapsed across all relevant laws for each state, which ranged from one law to nine laws, with an average of 3.8 per state. If a state’s law(s) included any text relevant to the given policy component (e.g., the law defined “infant” as under 30 days old), then the state was coded “1” for the given policy component. If a state’s law(s) did not include any relevant text, the state was coded “0” for the given policy component.

FIGURE 1.

Proportion of POSC policies of interest codified in statutes and regulations in 18 states, 2024. Each tonal band indicates the proportion (out of 1) of policies of interest that states’ statutes or regulations addressed within each of the 3 domains. If a state’s statutes or regulations addressed all policies of interest of all 3 domains, then each band would extend 1 full point on the y-axis. If the band is missing, it is because the state’s statutes or regulations omit all policies in the given domain. The darkest bands indicate the proportion of POSC eligibility policies addressed, light bands indicate the proportion of POSC development policies addressed, and medium bands indicate the proportion of POSC monitoring policies addressed.

Abbreviation: POSC, plan of safe care.

Accessibility Rating

Figure 2 illustrates the accessibility ratings (calculated according to the methods described above) across states. Darker colors indicate less accessibility, while lighter colors indicate greater accessibility. The average rating across states was 3.3 out of 6 (SD = 1.7), where 6 was the most accessible. Supplemental Table 1 outlines for which years APSRs for each state were collected. Supplemental Table 2, which indexes each state’s accessibility rating, includes the terminology for POSC used in that state and indicates whether the state maintains an enacted statute and/or regulation. Of note, 12 different terms for POSC are in use across states (see Supplemental Table 2). Eight states scored an accessibility rating of 6. Seven states scored a 5, 1 state scored a 4, 19 states scored a 3, 11 states scored a 2, 3 states scored a 1, and 2 states scored a 0 (least accessible). In sum, 35 states scored a 3 or below, indicating low levels of accessibility. Fifteen of the 16 states scoring a 5 or 6 have enacted POSC statutes and/or regulations (these states are included in Figure 1).

FIGURE 2.

Accessibility of POSC policies in 50 states and Washington, DC. Data for this figure come from the authors’ rating of each state’s POSC policy’s accessibility. Lighter shades (eg, Pennsylvania) indicate higher accessibility ratings, and darker shades (eg, Iowa) indicate lower accessibility ratings. The ratings considered 3 factors detailed in the supplemental table, including the extent of public availability of states’ reports to Congress that outline POSC processes, whether the state’s POSC process was codified in a statute or regulation, and whether the state used the term “plan of safe care” for their POSC.

Abbreviation: POSC, plan of safe care.

DISCUSSION

Five years ago, 30 states had no POSC policy, either in statute, regulation, or administrative manual.⁴ Despite a lack of dedicated funding from CAPTA to support POSC implementation, as of 2024, only Illinois lacks a POSC policy; however, it has 2 POSC-related bills under consideration (Illinois HB0003, Illinois HB1468) and a long history of leveraging its public health system to support infants with PSE.⁹ While considerable effort has gone into developing POSC policies, our research indicates that most processes are codified in administrative manuals, which may therefore lack the public and political input and support, legal enforcement, or targeted state funding necessary to ensure effective implementation.

Our results closely align with a legislative review that found POSC laws in a minority of states.⁵ Although CAPTA does not require states to enact POSC laws, every state maintains laws reflecting other CAPTA requirements, such as mandated reporting for child abuse or neglect. Therefore, it is notable that so few states have enacted laws on POSC. Policies in administrative manuals are less accessible to the public during the policy formation and implementation process, as input via public hearings or review boards is reserved for specific activities and typically at the discretion of the administrative agency.¹⁰ Administrative procedures are often revised unilaterally and behind closed doors, as public announcements on plans for changing agency rules or processes are not always required. Agency rulemaking without public input prevents “the opportunity to bring valuable evidence to the agency’s attention, to explain the effects of a proposed rule that the agency may not have appreciated, and simply to bring a perspective that the agency itself otherwise would not have.”¹¹ (p. 8) In the case of PSE, which impacts systems and providers across a variety of disciplines and settings, internally developed child welfare policies would be vulnerable to maintaining the “status quo” of child welfare practice rather than adopting upstream, interdisciplinary, and nonpunitive approaches.^4,12,13 For example, a pediatrician would have no means of enlightening child welfare system leaders on the importance of breastfeeding to reduce symptoms of neonatal abstinence syndrome,¹⁴ and the potentially adverse effect that automatic parent-child separation could have on achieving that outcome, without a period of public testimony during the consideration of a public law.

In terms of transparency in implementation, administrative manuals can be updated at any time with little public input, unlike statutes and regulations. Outdated versions of policy manuals often linger online, causing additional confusion. A pediatrician involved in developing a POSC would face difficulties understanding when and for whom a POSC is required. Relatedly, a hospitalist would have difficulty ascertaining whether the state is following its own POSC manuals—information necessary to argue in court that an administrative agency is applying policies in a capricious or discriminatory manner. Compounding this, we found that states use a dozen different terms for POSC, making it difficult for researchers to identify trends in POSC policies—information necessary for studying the effects of the policies on health or child welfare outcomes. Use of terminology consistent with federal law (ie, “plan of safe care” instead of “safe care plan”) could aid in systematic efforts to assess POSC policies nationally. Of note, policymakers and advocates have criticized the term “plan of safe care” as stigmatizing, which has likely contributed to states adopting other terms for these plans. Our point is not to support using the term “plan of safe care” but rather to argue for consistent terminology across states.

Of states with POSC laws, none addressed all policy components. Most of the 18 states indicated when, how, and by whom POSCs were developed. Most states also specified who should get a POSC, including by defining “infants affected by substance abuse.” Such definitions are important because related federal laws have been scrutinized for lack of clinical meaning and broad interpretability.¹³ However, even among states discussing development or applicability of POSCs, very few clarified what happens after the POSC is developed, including who coordinates POSC services, who monitors a POSC, which families are monitored, who receives a copy of the POSC, and whether aggregated public health monitoring is required. Federal CAPTA does not clarify these details but allows states to support locally relevant implementation.¹⁵ However, our findings suggest that, rather than planning context-appropriate approaches, many state POSC policies are ambiguous, potentially creating difficulties in implementation and enforcement. Increasing federal CAPTA specificity could help ensure that the goals of the federal policy are achieved at the state level.

We also found that the language in POSC laws was frequently difficult to understand, even by 2 POSC expert researchers and an attorney. Therefore, many child welfare agency leaders and staff tasked with overseeing the implementation of these laws may also experience difficulties in interpreting them. Concerned providers would likely face even steeper challenges, as most POSC policies exist in administrative manuals inconsistently available to the public. Notable exceptions were Delaware and Pennsylvania, where statutes and regulations describe POSC processes in detail, and could serve as potential models for other states drafting policies.

Pediatric hospitalists and neonatologists identify infants with PSE (or infants “affected by substance abuse”) and may aid in developing POSCs around the birth event,¹⁶ while outpatient pediatricians can play a key role in implementing POSCs.¹² Furthermore, some states permit health care providers to initiate POSC before child welfare agency involvement as best practice aims for prenatal POSC initiation.¹⁷ Equipping the pediatric workforce with knowledge about CPS reporting mandates, definitions of “affected by,” and POSCs is critical to ensuring integrated and appropriate care for this high-risk population. During both the newborn hospitalization and later well-visits, pediatricians can engage parents in nonstigmatizing psycho-education on potential consequences of PSE throughout childhood and conduct routine developmental and social determinants of health assessments with children. Understanding which infants get a POSC, which care providers or state agencies must be involved in developing the POSC, and the duration and monitoring of POSC is central to achieving these outcomes. Unfortunately, our findings suggest providers in most states may face barriers to accessing, and thus implementing, their states’ POSC policy.

Improving POSC implementation nationally may be aided by additional federal support. CAPTA, the policy requiring POSCs, enumerates dozens of other requirements for state child welfare agencies, yet relatively paltry state grants support compliance with all CAPTA tenets. In FY 2023, CAPTA state grants totaled $105 million, less than 1% of federal child welfare spending that fiscal year.¹⁸ The 2021 ARPA contributed additional dollars, likely facilitating 29 states adopting POSC policies subsequently, but that funding must be liquidated by December 30, 2025.⁸ Furthermore, the extreme state-to-state variation we observe suggests states and local partners are driving POSC policy and practice change. If Congress hopes to ensure that infants with PSE receive care and support regardless of where they are born, additional federal funding and implementation support is needed. Given the potential benefits of POSC and the important role hospital-based pediatricians play in supporting these dyads, national and state pediatric and hospital organizations may wish to advocate for changes.

Limitations

Study limitations include challenges associated with the nature of policy research, such that laws, regulations, and administrative manuals can and do frequently change. Relatedly, policies, although enacted, may not reflect actual practice. We used search terms known to us, but some states could have POSC-type policies not captured using our search process. Finally, 9 states operate county-run child welfare agencies. Each of these counties could have different policies or practices not apparent in the documents we reviewed.

CONCLUSION

POSC is the first federally legislated intervention for infants with PSE. Although states have made considerable progress in implementing POSC policies, more work is needed. We posit that a replicable and comprehensive POSC policy needs to address, at a minimum, the 12 policy components of interest in our analysis. Policies lacking these details leave unanswered questions as to when, for whom, by whom, and how a POSC is implemented. Pediatricians working with families with PSE may benefit from reviewing their state’s POSC approach and, for those in most states, advocating for clearer and more transparent POSC processes.

ABBREVIATIONS

APSR

Annual Progress and Services Report

ARPA

American Rescue Plan Act

CAPTA

Child Abuse Prevention and Treatment Act

CARA

Comprehensive Addiction and Recovery Act

CPS

child protective services

POSC

plan of safe care

PSE

prenatal substance exposure