The Application of a Social Justice Theory to the Well-being of Substance-Exposed Infants

  • Craig ClineEmail author
Original Paper


In utero exposure to drugs and alcohol threatens the well-being of infants. Federal law has established child well-being as one of the three main goals of the child welfare system, and recent changes to federal law require state child welfare programs to assess the needs of substance-exposed infants and plan for their safe care. CPS workers are often the first point of contact these infants have with the public child welfare system; yet, CPS workers have no framework for assessing the well-being of substance-exposed infants. In this article, the author applies the Theory of Justice as Well-being to substance-exposed infants as a way to assess the deficits to well-being these infants experience. Furthermore, Justice as Well-being is applied to substance-exposed infants and their families to serve as a conceptual framework for an interprofessional approach to planning for the treatment and safe care needs of this highly vulnerable child welfare population.


Substance-exposed infants Well-being Social justice Child welfare 


Each year approximately 15 percent of infants are identified as affected by in utero exposure to alcohol or illicit drugs (U.S. Department of Health and Human Services 2018). These infants, referred to as substance-exposed infants (SEI), may exhibit physical and developmental problems, and are often born into environments that threaten their safety and well-being. In recent decades, the responsibility for assessing the needs of SEI and ensuring their safe care has been vested in state child welfare agencies. Child protective service (CPS) workers play an important role in assessing the safety needs of SEI because ensuring a safe caretaker the infant is paramount; however, these infants also face threats beyond their immediate care. More specifically, SEI are in danger of experiencing deficits in well-being associated with the circumstances of their birth.

This article calls for a greater focus on well-being during the earliest stages of child welfare involvement with SEI. In this article, the Theory of Justice as Well-being, developed by Powers and Faden (2006), is applied to SEI to examine the extent to which these infants experience threats to their well-being. The Theory of Justice as Well-being contends that social justice is attained when an individual achieves a sufficient level of well-being. Powers and Faden (2006) conceptualize well-being as being composed of six domains – health, personal security, attachment, reasoning, respect, and self-determination. The application of the Theory of Justice as Well-being to SEI highlights the need for an interprofessional assessment of well-being for this vulnerable child welfare population. Furthermore, this article discusses how Justice as Well-being can be used to guide the assessment of SEI and how that information can be used to develop a care plan aimed at enhancing the well-being of SEI.

Child Welfare’s Mandate for SEI

Throughout the 1980s and 1990s, some health professionals began warning about the potential long-term effects of prenatal cocaine exposure (PCE) on infants (Martin 2010). Concerns for the health and safety of these infants led some states to enact laws directing child welfare agencies to respond to reports involving SEI. While not all of the concerns about long-term effects of PCE materialized, concerns for the health of SEI and the potential for on-going maternal substance use in the post-natal environment have remained. These concerns led federal lawmakers to consider SEI a population requiring special attention in the Child Abuse Prevention and Treatment Act (CAPTA). The Keeping Children and Families Safe Act (2003) amended CAPTA to require health care providers to report SEI to state child welfare agencies. Additionally, child welfare agencies are now mandated to have policies and procedures in place to address the needs of SEI and to develop plans for the safe care of these infants.

The current rise in opioid use during pregnancy mirrors the opioid epidemic among the general population (American College of Obstetricians and Gynecologist and American Society of Addiction Medicine 2017). This has sparked a renewed interest in SEI at the federal level through the passage of several recent laws including the Protecting Our Infants Act of 2015 (POIA), the Comprehensive Addiction and Recovery Act of 2016 (CARA), and the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018 (SUPPORT).

POIA mandated the Department of Health and Human Services (DHHS) to review its activities related to prenatal opioid exposure and neonatal abstinence syndrome. Through POIA, DHHS was also tasked with addressing gaps in research, and developing best practice guide lines for preventing prenatal opioid exposure, treating opioid use disorder in pregnant women, and preventing, identifying, and treating neonatal abstinence syndrome (U.S. Department of Health and Human Services 2017a).

CARA amended CAPTA to require that plans of safe care for SEI involve both infants and their families (U.S. Department of Health and Human Services 2017b). This is a significant update to CAPTA, which previously only required the plan of safe to care address the infant’s needs. Additionally, CARA requires states to develop and implement monitoring systems to determine compliance with state requirements for services for the infant and affected family or caregiver. Finally, CARA mandates states to report to the federal government information concerning SEI, including the number of infants identified as substance-exposed, the number of infants for whom a plan of safe care was developed, and the number of infants for whom referrals for services for the infant and affected caregiver were made (U.S. Department of Health and Human Services 2017b).

Among SUPPORT’s (2018) provisions related to pregnant women and infants are increases in funding for residential substance use treatment programs for pregnant and post-partum women and grants to states to assist child welfare agencies and other social, medical, and mental health service providers in making improvements to plans of safe care for SEI. Grant funding provided through SUPPORT emphasizes the development of plans of safe care that include caregiver engagement, and the development of multidisciplinary assessment and intervention strategies for infants and their families.

Policy Challenges for SEI

Before examining a social justice-informed approach to addressing the needs of SEI and their families, it is important to reflect on the unique position of infants with prenatal substance exposure and their families within child welfare. The civil child protection system, which has been slowly developing and evolving in the USA since 1875 (Myers 2006), was designed to respond to reports of child abuse and neglect and to prevent further harm. It was not originally designed to address potential harm to infants stemming from women’s behavior while the infants are in utero. Consequently, overlaying existing child welfare practices onto SEI and their families has proven challenging. These challenges are evident in the myriad approaches to SEI among different state child welfare systems. For example, twenty-five states and the District of Columbia require health care professionals to report to state child welfare agencies when substance use during pregnancy is diagnosed or suspected, and eight states require testing upon diagnosis or suspicion of substance use (Guttmacher Institute 2019). Currently, 23 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil statutes, and in two states (Minnesota and South Dakota), substance use during pregnancy is grounds for civil commitment (Guttmacher Institute 2019). In Missouri, a mother is considered unfit if she tests positive for substances within 8 hours after delivery and she has been convicted of child abuse or neglect before or if she failed to complete a drug treatment program previously recommended by CPS. Additionally, in Alabama, drug use during pregnancy is considered chemical endangerment of a child, and in South Carolina, substance use during pregnancy is considered a maternal act which may endanger a viable fetus – a person under South Carolina’s criminal child endangerment statute (Guttmacher Institute 2019).

The differences in state child welfare system responses to SEI stem from the complexity of issues surrounding reproductive privacy, the regulation of expectant parent behavior during pregnancy, and the risk-averse nature of the public child welfare system. Even now, many states are trying to come into compliance with CARA’s new requirement of reporting SEI to child welfare systems and developing a plan for their safe care even in situations where the mother is taking a legally prescribed substance or is actively engaged in treatment for a substance use disorder. Against this backdrop, this article accepts the federal mandate for the inclusion of SEI in state child welfare plans and assumes, as evidenced by the CARA provision highlighted above, that SEI and their families will continue to be a population of special concern for state child welfare systems. This article seeks to promote a social justice approach to meeting the needs of SEI and the needs of their families. The application of a social justice theory to work with SEI and their families can move the child welfare system toward recognizing child well-being as the primary goal of child welfare with safety and permanency as two important components of well-being.

Child Welfare and Well-being

The Adoption and Safe Families Act (ASFA) established safety, permanency, and well-being as the primary goals of state child welfare systems. While a focus on safety and permanency has been at the center of child welfare practice since the 1970s (Wilson 2014), the definition of well-being, as it relates to children in the child welfare system, has been unclear since ASFA’s passage in 1997. Initially, some child welfare professionals believed that achieving safety and permanency equated to well-being, while others felt that school attendance, medical and dental visits, and mental health services for foster children satisfied well-being (Wilson 2014). More recently, research related to brain development, effects of trauma, and protective factors have brought about a new focus on child well-being (Conradi et al. 2011; Pence 2011; State Policy Advocacy and Reform Center 2013).

The Administration for Children, Youth, and Families has called on child welfare professionals to emphasize well-being in all areas of practice and has adapted a well-being framework which includes four basic well-being outcome domains (cognitive functioning, physical health and development, behavioral and emotional functioning, and social functioning) and two intermediate outcome domains (environmental supports and personal characteristics) (U.S. Department of Health and Human Services 2012). Despite this renewed focus on well-being, child welfare agencies still struggle to conceptualize, let alone operationalize, well-being for children.

Substance-exposed infants are a particularly vulnerable child welfare population and, from birth, may experience significant threats to their well-being. Given ACYF’s call for a focus on well-being in all areas of child welfare practice, professionals working with SEI are in need of a guiding theoretical framework to explain the extent to which the well-being of SEI is threatened by the circumstances of their birth and to help these professionals identify risks to well-being for SEI.

Well-being and Social Justice

The principles of social justice “specify the basic rights and duties… assigned by the main political and social institutions, and… regulate the division of benefits arising from social cooperation and allot the burdens necessary to sustain it” (Rawls 2001, p. 7). The responsibility of public child welfare to ensure safety, secure permanency, and enhance well-being through the distribution of financial and material resources, plus social services and supports to at-risk children and families is a form of egalitarian distribution and lends itself to analysis through a social justice framework.

Understanding and assessing the well-being of SEI can be done using an egalitarian approach to social justice. Often, egalitarian theories of social justice are only considered in the context of how one group is fairing in comparison with other groups in terms of material equality; however, egalitarianism is not inherently limited to defining and creating a sufficient level of economic equality for all. Powers and Faden (2006) have advanced an egalitarian theory of social justice concerned with ensuring a sufficient level of well-being for everyone. This theory is known as Justice as Well-being.

The Theory of Justice as Well-being, advanced by Powers and Faden, is unique within egalitarianism. Unlike other egalitarian theories of social justice, it does not start with an ideal set of circumstances around which a just society should be formed; rather, it assumes the reality that life conditions and social structures are unjust and less than ideal and that “unjust inequalities will continue to provide the real world context in which questions of justice will arise” (Powers and Faden 2006, p. 5). The Theory of Justice as Well-being relies on a sufficiency approach in which the concept of well-being is reduced to six core dimensions – health, personal security, attachment, reasoning, respect, and self-determination (Powers and Faden 2006). In the estimation of Powers and Faden, it is the job of those who seek to advance social justice to attend to the barriers which stand in the way of people attaining a sufficient level of well-being in each of these dimensions.

As previously stated, child welfare agencies are mandated to address the needs of SEI and plan for their safe care. CARA expanded the mandate to include the needs of the infant’s caretaker(s) in the plan of safe care. The child welfare system alone is not equipped to assess the many needs of these infants and their families. The SUPPORT Act begins to recognize this by promoting grant opportunities that focus on the development of multidisciplinary assessment and intervention strategies for infants and their families. Justice as Well-being provides a unique theoretical framework which CPS workers, through interprofessional collaboration, can apply to assessing and planning for the safe care needs of SEI and the treatment needs of their caretaker(s).

Substance-Exposed Infants and the Six Dimensions of Well-being

The lives of SEI begin in circumstances which threaten their well-being. They are more prone to physical health problems and developmental delays. They are often born to mothers and fathers who are living in poverty, struggling with addiction, and have unaddressed mental health needs (National Abandoned Infants Assistance Resource Center 2012; Patrick et al. 2012). Using the Powers and Faden six dimensions of well-being as a conceptual framework, the following sections explore threats to well-being experienced by SEI.


Health is generally understood in terms of biological functioning. Powers and Faden (2006) accept this definition and expand it to include conditions which do not immediately impede physiological functioning. Health as a dimension of well-being includes stable mental health, pain reduction, premature mortality, and loss of mobility. Powers and Faden explain that individuals who have unmet mental health needs or experience acute or chronic pain are not considered to be in optimal health even if their biological functioning is not impaired. Deficits in these health-related areas contribute to an overall deficit in the well-being of individuals. By applying this definition of health, the conditions which threaten a sufficient level of well-being are illuminated for the SEI population.

Physical health problems attributed to in utero substance exposure are among the most immediate threats to a SEI’s well-being. Health outcomes for SEI can vary depending on drug type, frequency of drug use, duration of maternal substance use in pregnancy, and access to and utilization of prenatal care. Some of the medical conditions associated with in utero substance exposure include fetal death, high blood pressure, decreased head circumference, heart defects, gastroschisis, and low birth weight (Hjerkinn et al. 2009; Narkowicz et al. 2013). Additionally, in utero exposure to cocaine or opiates is believed to make infants more susceptible to premature birth (Quesada et al. 2012; Whiteman et al. 2014) which places infants at risk of medical complications due to underdeveloped neuromuscular, respiratory, gastrointestinal, and immune systems.

Another condition associated with in utero substance exposure is neonatal abstinence syndrome (NAS). NAS has received significant attention in research and media in the past several years due to increasing rates of opiate use. NAS is primarily attributed to maternal opiate use (Patrick et al. 2012) and occurs as a result of the discontinuation of exposure to substances that the mother was using during pregnancy (Hamden et al. 2014; Kocherlakota 2014). NAS is demonstrated in the infant through tremors, high-pitched crying, frequent yawning and sneezing, poor feeding, diarrhea, poor weight gain or weight loss, congestion, and fever (Hudak and Tan 2012). Infants who are diagnosed with NAS, attributable to their mothers’ use of methadone as a form of medication assisted treatment, have also been found to have smaller head circumferences than infants without NAS (Towers et al. 2018). Additionally, an increased risk of SIDS for SEI is correlated with maternal opiate use and may be attributed to respiratory control abnormalities (Ali et al. 2012).

Despite the attention given to opiates and their effect on infants through NAS, the effects of alcohol abuse during pregnancy should not be overlooked. Fetal Alcohol Syndrome, partial Fetal Alcohol Syndrome, and Alcohol-related Neurodevelopmental Disorder represent the range of fetal alcohol spectrum disorders (FASD) attributed to in utero alcohol exposure. Incidence of FASD ranges from two to five percent of all children born in the USA with a higher prevalence among low socio-economic populations (Muralidharan et al. 2013). While fetal alcohol spectrum disorders are currently not being given the same attention as NAS, those concerned with the well-being of infants should not be missing opportunities to intervene on behalf of infants with a FASD.

Personal Security

Personal Security involves threats to individual well-being which jeopardize physical and psychological safety. Personal security is an essential dimension of well-being because living in fear of abuse renders it “impossible to live a decent life” (Powers and Faden 2006, p. 19). Parental substance use in the caretaking environment jeopardizes the well-being of infants by threatening their immediate safety and placing them at risk of maltreatment.

Most states require child welfare workers to use assessment tools in their efforts to evaluate child safety and risk (University of California at Berkeley 2005). The purpose of a safety assessment is to evaluate the family for conditions which pose a threat to immediate child safety and the need for interventions to ensure safety. Parental substance use is identified as a safety threat on assessment instruments because of its likelihood to impair caretaker capacity and inhibit effective supervision. In cases involving a SEI, maternal substance use is manifest, even if the substance use is not actively occurring or the mother is not currently under the influence of drugs or alcohol. Consequently, it is often assumed that safety of a SEI is jeopardized. CPS workers are often quick to ensure the immediate safety (the personal security) of SEI, but assessing the potential for subsequent maltreatment of SEI is much more difficult.

The purpose of risk assessment in child welfare is to predict the likelihood of child maltreatment for a child in her current environment. Actuarial risk assessment tools, based on empirical relationships between predictive variables and outcomes, have been developed to aid child welfare workers in assessing risk (Shlonsky 2007). Most risk assessment instruments include parental substance use as a risk factor for child maltreatment. In 2016, 15.2% of child maltreatment victims less than one year of age had a caregiver with a drug abuse risk factor and 4.8% had a caregiver with an alcohol abuse risk factor (U.S. Department of Health and Human Services 2017c).

The extent to which SEI are at risk of subsequent maltreatment associated with caregiver substance use is difficult to assess. The findings from the limited data available on the recurrence of maltreatment among SEI are mixed. While one study found an increased risk of maltreatment for infants of substance using mothers compared with non-substance using mothers (McGlade et al. 2009), another study found that increased risk of maltreatment is not necessarily attributable to drug use status and that substance using mothers of infants have no greater potential for maltreatment than non-using or treatment involved mothers with similar backgrounds – low-income and other risk factors (Smarsh-Hogan et al. 2006). The removal of SEI from the custody of their parents or the removal of subsequent infants from a woman who previously gave birth to an SEI also makes it difficult to assess the likelihood of subsequent maltreatment (Mullins et al. 2005; Toplin and Mattick 2015). Finally, while CPS workers are tasked with assessing safety and predicting risk, their actions, at times, are more likely to trigger relapse than they are to aid parents in maintaining sobriety. In fact, the threat of losing custody of their child has the potential to contribute to relapse among mothers of SEI (The American College of Obstetricians and Gynecologist and American Society of Addiction Medicine 2017).


SEI are at risk for threats to their well-being in the dimension of reasoning. Powers and Faden (2006) define reasoning as theoretical and practical. Within psychology both types of reasoning are subsumed under the heading of cognitive reasoning. Powers and Faden (2006, p. 21) report that reasoning abilities are affected by physical well-being and the social environment in childhood, and they stress that “assaults on brain development” during the prenatal and early childhood periods can significantly impact cognitive reasoning.

Few areas of research related to SEI have received as much attention as the effect of prenatal cocaine exposure (PCE) on children’s behavioral and emotional regulation. It is believed that PCE is associated with structural deficits in areas of the brain involved in executive function and inhibitory control (Grewen et al. 2014). In school-age children, high PCE is related to more externalizing behavior problems (Bada et al. 2011) and has a significant negative association with self-regulation and attention based on reports from teachers and parents (Ackermann et al. 2010). Additionally, cocaine use during the first and second trimester is correlated with off task distractibility at nine months of age (Gaultney et al. 2005) and cocaine use during the third trimester predicts externalizing behavior problems, inattention, and impulsivity among school-age children (Richardson et al. 2011).

Other research findings suggest a more indirect pathway between PCE and emotional regulation, supporting evidence for the environmental impact on reasoning. For example, in studies involving PCE among infants and toddlers, the quality of the caregiving experience, maternal harshness, and maternal negative aspect were associated with children’s ability for self-regulation and externalizing behavior problems in early childhood (Eiden et al. 2011, 2015; Molner et al. 2014). Challenges with behavioral regulation place children at increased risk for problems with early learning (Conradt et al. 2013). Moreover, Bada and associates (Bada et al. 2012) found that children with higher levels of individual, family, and community protective factors had lower problem behavior scores regardless of drug exposure.

Other drugs of abuse have not been studied for their impact on cognition as thoroughly as cocaine; however, there is evidence of cognitive deficits among other-drug exposed infants. Opioid exposure has been attributed to delays in cognition, psychomotor development, and language skills (Beckwith and Burke 2015; Hunt et al. 2008). Additionally, Messinger et al. (2004) found that opiate-exposed infants are more likely to have lower scores for psychomotor development than non-exposed infants; however, the effect of opiates did not remain when controlling for birth weight and the caregiving environment. Finally, a team headed by Twomey et al. (2013) found that prenatal methamphetamine exposure was linked to child behavioral problems at five years of age; however, families that were able to meet the child’s developmental needs were associated with few behavioral problems in children at this age.

FASDs also contribute to deficits in reasoning. Toddlers with FASD may begin to exhibit poor self-regulation (Rasmussen 2005), which increases the challenges associated with parenting these children. As these children move into early childhood, they often become increasingly sociable and talkative with little regard for distinguishing between family members and strangers (Coons 2013). Challenges in the academic setting become more apparent for these children as they enter later childhood and are often unable to meet classroom expectations (Streissguth 1997).


Attachment refers to the bonds of affection that infants build with their caregivers (Bowlby 1969). Attachment bonds between children and parents are central to human well-being and are correlated with the ability of children to develop attachment with others (Powers and Faden 2006). Insecure attachments between children and parents contribute to a lack of social connection and are exhibited in conduct disorders, lack of self-restraint, and antisocial levels of aggression (Commission on Children at Risk 2003). According to Powers and Faden (2006), the formation of bonds of attachment is necessary for a just society because a failure to form attachments and society’s failure to aid others in the formation of attachments can result in unjust treatment.

Prenatal substance use can threaten the formation of healthy attachment bonds. Several studies on attachment and prenatal substance exposure found a correlation between in utero exposure to drugs and alcohol and attachment problems. Among SEI, rates of attachment insecurity exceed rates found among infants in poverty, infants born prematurely, and infants whose mothers have a diagnosed mental illness (Swanson et al. 2000). In a sample of prenatally exposed toddlers and their mothers who were using cocaine, there were significantly more disorganized and disoriented attachments found than in a middle class normative sample (Espinosa et al. 2001). The findings for both of these studies were similar to findings involving attachment and prenatal alcohol use (O’Connor et al. 1987).

Respect and Self-determination

Respect and self-determination are distinct dimensions of well-being and are separately defined by Powers and Faden. For the purposes of this discussion, respect and self-determination will be defined separately but examined together in the context of the threat that current child welfare interventions pose to these dimensions of well-being.

Respect is essential to well-being because it acknowledges the dignity of others and affirms that others are “moral beings deserving of equal moral concern” (Powers and Faden 2006, p. 22). Self-determination as a dimension of well-being is the practical recognition that humans should have some control over who they are and who they want to become (Powers and Faden 2006). Child welfare interventions are often perceived as a threat to parental self-determination, and feelings of respect can either be enhanced or diminished in the lives of the families of SEI based on parents’ interactions with child welfare workers and other professionals.

Child welfare system involvement in the lives of families of SEI is a form of unsolicited government intervention. As such, the parents of SEI are involuntary participants in social service systems. A key factor in helping involuntary service users is successful engagement (Munro 2011), and respect is a critical component of successful engagement. Several recent qualitative studies illustrate parents’ perceptions of their interactions with the public child welfare system as it relates to respect, and factors associated with engagement or disengagement have been identified.

Families involved with child welfare agencies feel entitled to respect from staff and they link respect to professionalism (Buckley et al. 2011). A recent qualitative study by Kuo et al. (2013) found that the overall perception of public child welfare staff among child welfare involved pregnant and post-partum substance abusing women was predominantly negative. The study participants reported feeling they were not treated like human beings and that the way child welfare staff spoke to them was threatening and disrespectful. Additionally, negative worker attitudes, poor communication, lack of staff member follow-up, lack of staff member knowledge, strong and coercive interventions, and distrust of parents have been found to contribute to disengagement (Harris 2012; Healy et al. 2011). Conversely, listening; providing practical help, confidence, and emotional support; showing warmth and friendliness; having a good sense of humor; offering reassurance; being non-judgmental and non-stigmatizing; showing sympathy and kindness; and providing confidence are characteristics of child welfare staff involvement that have been identified as promoting positive outcomes and supporting parent – worker partnerships (Buckley et al. 2011; Harris 2012; Healy et al. 2011).

These characteristics are illustrative of CPS worker feelings of respect or lack of respect for the dignity and worth of their clients. Showing respect and listening to the voices and desires of the parents of SEI is necessary not only because it is the ethical thing to do, but also because it has the ability to enhance the well-being of families on a more pragmatic level. Turney stated, “parents are… likely to be the source of much useful information about the child, the current family situation and the broader family history. They can also facilitate or obstruct access to the child” (2011, p. 149). As a result, CPS staff should be engaged in practices that promote respect and self-determination. While not a guarantee of an effective parent-staff partnership, such practices do increase the likelihood that the worker will be able to engage the family in a way that enhances the well-being of the infant.

Justice as Well-being and the Safe Care of Substance-Exposed Infants

Examining the well-being of SEI through the lens the Theory of Justice as Well-being provides shows that SEI experience significant deficits in well-being,, but child well-being is rarely the focus of CPS assessments and, unlike instruments associated with safety and risk, CPS workers have no uniform conceptual lens through which to examine the well-being of SEI. In the absence of such instruments, the Theory of Justice as Well-being should be used as a guiding theoretical framework to assess the well-being of SEI because it conceptualizes the interrelated dimensions of well-being, while also emphasizing safety (personal security) and permanency (attachment). The Theory of Justice as Well-being will help CPS workers identify the dimensions in which SEI are experiencing deficits to well-being, evaluate the extent of those deficits, and develop a plan to enhance the well-being of SEI and their families.

Safe Care Assessment and Planning

Multi-disciplinary approaches to a wide variety of child welfare related concerns are now common in child welfare practice. For example, it is not unusual for communities to have multi-disciplinary teams to address truancy, drug-endangered children, and physical or sexual abuse. The purpose of these meetings can vary greatly with some focused on investigation, while others seek to address child and family needs or develop service plans. In order to assess the needs of SEI and engage the families of SEI in the development of a plan to enhance infant well-being, an interprofessional approach which brings family members and community professionals together should be implemented. Given the child welfare system’s mandate for the safe care of SEI, it is necessary for child welfare agencies to take the lead in establishing interprofessional teams for these purposes. The following sections highlight the expertise and contributions members of an interprofessional team would bring to assessing and planning for the well-being of SEI.

Health Care Professionals

The potential for acute and chronic negative health outcomes for SEI is a threat to their well-being. When assessing an infant’s well-being, health must be considered. Health care professionals are often the first point of contact for SEI and their families. In many instances, health care professionals have had contact with the mother of an SEI during the prenatal period. These individuals are often familiar with the mother’s medical history, her efforts toward recovery, and any referrals for treatment and recovery services made during the prenatal period. Relationships between health care providers and the mother of the SEI, at times, have already been established. CPS workers will need to rely on health care professionals to obtain information about the infant’s immediate medical needs and changes to the infant’s medical care. Mothers and fathers of SEI should be supported in their relationship with their infant’s health care providers, and to the extent possible, any conversations CPS workers have about the SEI with health care professionals should take place in the presence of the mother and father of the SEI. The same should apply once a pediatrician has been established for the SEI.

Child Protective Service Workers

In most states, CPS workers receive training in the use of actuarial safety and risk assessment instruments. The uses of such instruments are designed to identify immediate safety concerns and guide workers in making decisions related to the need for case closure, in-home intervention, or out-of-home care. In addition to making these determinations, when placed in the context of the Theory of Justice as Well-being, an accurate assessment of child safety and risk can provide CPS workers with a consistent method for obtaining information about threats and deficits to the personal security of SEI.

Safety and risk factors indicated on actuarial assessment instruments focus on micro and meso-level factors like family violence, mental health, parent(s) childhood history of abuse, substance use, history of CPS reports or demographic factors like the number of children in the home and the ages of the children. While these are important points to assess when predicting the likelihood of future maltreatment, making decisions solely on the basis of micro and meso-level risk factors fails to take into consideration macro-level factors that may also threaten the well-being of SEI.

Historically, economic uncertainty, unemployment, and poverty have been linked to child maltreatment (e.g., Gil 1969, 1971; Krugman et al. 1986; Light 1973; Steinberg et al. 1981). More recent studies have supported these earlier findings, and underscore the importance of examining macro-economic conditions and their relationship to child maltreatment. Douglas and McCarthy (2011) found that for each additional 1% of the population living in poverty, the child maltreatment fatality rate increased by 0.09 per 100,000 children and that where poverty rates were higher child maltreatment fatality rates were also higher. Berger et al. (2011) reported that the rate of abusive head trauma in children under the age of five years increased during the 19 months of an economic recession compared with the 47 months prior to the recession. Similarly, abusive head trauma was examined in a study of 639 infant head traumas during the period from December 2001 to June 2010. In this study, Huang et al. (2011) found that monthly incidence of non-accidental head trauma doubled during the time period of the recession and there was an increase in fatalities and severe brain injury associated with non-accidental head trauma during the recession period. Finally, Wood et al. (2012) explored child physical abuse admissions to hospitals in connection with unemployment rates, 90 day delinquency rates, and foreclosure rates. This research did not reveal a clear relationship between unemployment rates and physical abuse, but it did find a strong correlation between child physical abuse hospital admissions and housing insecurity. More specifically, active mortgage foreclosures were associated with a diagnosis of physical abuse upon admission and traumatic brain injury admissions that are suspicious for child physical abuse (Wood et al. 2012).

These studies highlight the importance of considering macro-level risk factors, specifically macro-economic factors, which threaten the personal security domain of an SEI’s well-being. CPS workers, as social workers (and ideally, those assessing the needs of SEI will be social workers by education and licensure), are in a unique position, given their person-in-environment perspective, to explore these, and other, macro-economic risk factors with families while still assessing micro and meso-level risk factors.

Child Development Specialists

Assessing deficits to the reasoning abilities of SEI requires knowledge of the developmental milestones of infants. Many CPS workers do not receive training specific to developmental milestones in infancy and may be unable to make an informed assessment of the cognitive and behavioral delays of SEI. Consequently, state child welfare systems should develop training for child welfare professionals, foster or kinship parents, and birth parents that focuses on developmental milestones in infancy, with specific attention to threats to development resulting from in utero substance exposure. Child welfare staff and parents who are trained to recognize developmental delays will be more likely to identify delays early and seek assistance in an effort to correct delays.

Another approach to assessing the reasoning of SEI is available through state early intervention services under Part C (infants and toddlers with disabilities) of the Individuals with Disabilities Education Act (IDEA). Referrals for Part C early intervention services should be made when an infant is identified as substance-exposed in order to assess the impact that in utero substance exposure has had on the infant’s cognitive development. A referral for Part C services, followed by a complete developmental assessment, can provide CPS workers with information needed to adequately assess the threats to the dimension of reasoning for SEI and to execute plans to provide the services needed based on the assessment.

Mental Health and Substance Use Treatment Professionals

Threats to the domain of attachment for an SEI may be related to a number of factors including in utero substance exposure, parental substance use, parents unmet mental health needs, and/or parent-infant separation due to the infant being removed from the parent(s) custody. Deficits in attachment in infancy are difficult for CPS workers to assess. While some CPS workers may have a background in mental health which includes formal training in attachment theory and the phases of attachment, most CPS workers are not equipped with this knowledge or other areas of knowledge associated with infant mental health. In order to compensate for a lack of knowledge in this area, child welfare agencies must partner with maternal and infant mental health professionals trained in attachment theory. Mental health professionals with a background in infant mental health can assess attachment in SEI and consult with CPS workers to inform the overall assessment of infant well-being. Additionally, in cases where the SEI is in the custody of the state, CPS workers and other child welfare workers should consult with the mental health provider trained in infant mental health to develop a parent-infant visitation schedule that fosters bonds of healthy attachment.


Child welfare agencies should employ a trained facilitator for the purpose of bringing together the family members of the SEI, the CPS worker, other child welfare professionals, and the community professionals. Working collaboratively, and under the direction of a facilitator, these individuals can assess the well-being of the SEI and develop a care plan with the family of the infant. Special attention should be given to the family members of the SEI in order to ensure that their voices are not drowned out and that deference is given to their wishes and desires for their infant, except in instances where their desires pose an immediate safety concern for the SEI. Through this collaborative, caregiver-focused, interprofessional approach targeted interventions designed to strengthen the infant’s well-being and enhance family functioning can be implemented.

The Role of Respect and Self-determination

Throughout the assessment process, CPS workers and other members of the interprofessional team must engage the mother, father, and other family members of an SEI in ways that promote healthy worker – client relationships. The mother and father of SEI have the right to be treated in manner that recognizes their dignity and inherent worth. Respect and self-determination, as dimensions of well-being, may be enhanced or diminished for the family members of SEI based on the experiences they have with members of the interprofessional team. If the parents of the SEI feel respected by members of the interprofessional team, they are more likely to engage in the assessment process and provide more detailed information about their own needs and their current ability to care for their infant. Likewise, the parent(s) of SEI will be more likely to be active participants in services for themselves and their infants if they consider the team a source of non-judgmental support rather than a system of control which they must appease. The assessment, and subsequent planning process, must be undertaken in a respectful and supportive manner, recognizing that the actions of the interprofessional team have the potential to enhance maternal and paternal sobriety and success or contribute to relapse and additional threats to infant well-being.

Practical Considerations

Changes to child welfare agency approaches to reports involving SEI are unlikely to come without additional staff time and financial resources. CPS workers would need to be afforded sufficient time to obtain information related to each of the domains of well-being and work collaboratively with other professionals to thoroughly assess deficits that may be experienced by the infants in each domain. Given the time needed to thoroughly conduct such an assessment, it may be necessary for child welfare agencies receiving a high volume of SEI reports to have specialized CPS workers specifically assigned to working with SEI and their families. This is likely to create additional costs to agencies, but given the highly vulnerable nature of these infants, and the unique window of opportunity for successful substance use and mental health intervention presented by the birth of an infant, it is critical that all necessary resources be allocated for SEI and their families.

Additionally, costs to local and state child welfare agencies associated with training CPS workers and foster and kinship families in the developmental stages of infants could prove costly unless it could be incorporated into training schedules for newly hired CPS workers and kinship/foster care training curricula. Training in infant developmental milestones with biological families would also create additional costs to agencies; however, if child welfare staff or foster or kinship families are trained then it is possible that they could provide training to biological families.

Finally, because the Theory of Justice as Well-being is an egalitarian theory focusing on a sufficiency of well-being, rather than on material or economic equality, it does not specifically address some of the real economic challenges that families and individuals may experience. CPS workers, family members, and community professionals may be able to work together to enhance the well-being of SEI; however, families of SEI who are experiencing poverty may have difficulty maintaining well-being for these infants. Faced with housing instability, job insecurity or poor neighborhood conditions, it may be difficult for families of SEI to maintain gains made to well-being in dimensions like health and personal security unless sustained supportive services and economic benefits are provided to enhance the financial situation of some SEI and their families through the assessment and safe care planning process.


Applying the Theory of Justice as Well-being as a guiding theoretical framework for assessing the well-being of SEI provides a clear conceptualization of the dimensions in which well-being deficits may be present. Furthermore, it allows for an interprofessional approach to address the well-being needs of SEI by enabling those involved in planning for these infants to target interventions at the dimensions in which deficits are present.

The well-being of children has been an area of attention for state child welfare systems since the inception of ASFA in 1997; however, the role that CPS workers can play in attending to the well-being of children has been largely neglected. While the focus on child safety and risk in CPS casework is understandable, the lack of attention given to the well-being needs of some of child welfare’s most vulnerable children is concerning. The SEI provisions of CAPTA allow state CPS systems to intervene early in the lives of children who are identified as substance exposed at birth. These provisions provide public child welfare agencies with tremendous opportunities to enhance the well-being of SEI and promote social justice for these vulnerable infants.

Social justice is at the core of social work and should be reinstated as a guiding principle in public child welfare. Efforts to ensure safety and reduce maltreatment risk should not overlook the need to promote the well-being of SEI. SEI are born into circumstances that neither they nor their families would consider optimal, as a result, CPS workers must be prepared to promote justice for this population by working collaboratively with other community professionals and closely and respectfully with the parents of SEI. The Theory of Justice as Well-being provides CPS workers with a guiding theoretical framework to engage in this important work on behalf of SEI and their families.



Special thank you to Wendy Whiting Blome who supported my early efforts at developing the ideas presented in this paper.

Compliance with ethical standards

Conflict of interest

The author declares that there is no conflict of interest.


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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Social WorkShepherd UniversityShepherdstownUSA

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