The Role of Maternal Medication for Opioid Use Disorder In Child Health and Safety Outcomes

Background: Recent federal policy shifts have positioned medication for opioid use disorder (MOUD) as a key strategy for preventing family separation. The U.S. Administration for Children and Families (ACF) recently expanded the Title IV-E Prevention Services Clearinghouse to include three FDA-approved medications (methadone, buprenorphine, and naltrexone), authorizing states to utilize federal child welfare prevention funds for parental opioid use disorder (OUD) treatment. While the ACF encourages MOUD integration in prevention plans to reduce child maltreatment and foster care entry, the well-supported rating by the Clearinghouse is based primarily on studies focusing on adult or parental well-being outcomes. A critical knowledge gap remains regarding the direct impact of MOUD on longitudinal child health and safety outcomes in the child welfare context. This study bridges this gap by using linked CWS and Medicaid data to examine how MOUD engagement around the time of a CWS referral relates to child injuries, re-reporting, and length of foster care placement

Methods: We analyzed a population-based sample of 31,748 CWS referrals in Pennsylvania between 2015 and 2019 involving children with confirmed CWS cases and their Medicaid-insured mothers diagnosed with OUD within 180 days prior to or 90 days following the referral.

MOUD timing was categorized into four groups: (1) no MOUD, (2) before-referral only, (3) new initiation post-referral, and (4) ongoing. Child outcomes assessed 91 to 365 days post-referral included injuries, CWS re-reports, and total days in foster care. To address selection bias, we employed inverse probability weighting regression adjustment (IPWRA), using a multinomial logit model to estimate weights based on maternal history, demographics, and CWS case characteristics. We estimated the average treatment effect (ATE) for each MOUD timing relative to the non-MOUD group, reporting absolute differences for binary outcomes and mean differences for days in foster care.

Results: Mothers were distributed across MOUD groups: None (35.4%), before-only (18.4%), new (12.9%), and ongoing (33.2%). Compared to the non-MOUD group, the new MOUD was associated with a 3.2 percentage-point (PP) increase in the predicted probability of injury claims (95% CI: 2.1, 4.4). Ongoing MOUD was associated with a 4.1 PP increase in the probability of a new confirmed CWS case (95% CI: 2.6, 5.6). Despite the increase in re-reports, Ongoing MOUD was associated with a significant reduction in the mean number of days spent in out-of-home placement (ATE = -3.0 days; 95% CI: -4.3, -1.7).

Conclusions and Implications: This study demonstrates a nuanced relationship between MOUD timing and child outcomes, providing critical insights for the implementation of Title IV-E prevention strategies. The finding that ongoing MOUD significantly reduces the duration of out-of-home placement suggests that sustained maternal recovery may facilitate more efficient reunification and stabilize families, even when system contact remains frequent.