Letters
RESEARCH LETTER
Trends in Foster Care Entry Among Children
Removed From Their Homes Because of Parental
Drug Use, 2000 to 2017
After more than a decade of declines in the foster care case-
load in the United States, cases have risen steadily since
2012.1 Between 2012 and 2017, the number of children liv-
ing in foster care and entering care increased by 12% and
8%, respectively.1 One proposed explanation for this recent
growth is the opioid epidemic, but supporting evidence is
scarce.2,3 In this exploratory study, we examine trends in
the number of children entering foster care because of
parental drug use and describe changes in their characteris-
tics over time.
Methods | We analyzed data from the Adoption and Foster
Care Analysis and Reporting System, a federally mandated
data collection system that receives case-level information
on all children in foster care in the United States. The data-
base includes information on child demographic charac-
teristics, health status, geographic area, and home removal
reason (ie, physical/sexual abuse, neglect, child disability/
behavior problems, child alcohol/drug use, parental alcohol/
drug use, death, incarceration, inability to cope, abandon-
ment, relinquishment, or inadequate housing). Data were
deidentified, and this study did not meet Weill Cornell
Medicine institutional review board’s definition of human
subjects research.
We identified entries of children in foster care during
fiscal years 2000 to 2017 and stratified the sample based
on home removals attributable to parental drug use, defined
as the principal caretaker’s recurrent and lasting use of
Figure. National Trends in Foster Care Entries Attributable to Parental Drug Use, 2000 to 2017
60
Total entries
45
Entries owing to other reasons
Entries, %
30
15
0 Proportion of entries owing to parental drug use
2000 2004
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drugs. The number of entries is not synonymous with the
number of children because children may enter foster care
more than once. We calculated national trends of the
number and proportion of foster care entries because of
parental drug use and reported children characteristics at
different time intervals for this population. Characteristics of
children entering care for other reasons were reported for
comparison. Analyses were conducted using Stata version 15
(StataCorp).
Results | There were 4 972 911 foster care entries between fis-
cal years 2000 and 2017 (October 1, 1999, to September 30,
2017), 1 162 668 (23.38%) of which were home removals
attributable to parental drug use. The number and propor-
tion of entries attributable to parental drug use rose dra-
matically and steadily during this period, from 39 130 of
269 382 removals (14.53%) in 2000 to 96 672 of 266 583
removals (36.26%) in 2017 (Figure).
Compared with children entering care for other reasons,
children entering because of parental drug use were more
likely to be 5 years or younger (1 441 741 of 3 635 362 remov-
als [39.65%] vs 699 340 of 1 162 448 removals [60.16%]),
white (1 597 066 of 3 524 011 removals [45.32%] vs 616 153 of
1 131 294 removals [54.46%]), and from the southern region
of the United States (1 119 679 of 3 636 17 7 removals
[30.79%] vs 519 988 of 1 162 668 removals [44.72%]) (Table).
The characteristics of children entering care because of
parental drug use changed over time. Notably, between fis-
cal years 2000 to 2005 and 2012 to 2017, the proportion of
children who were white (2000-2005, 148 780 of 291 017
removals [51.12%] vs 2012-2017, 276 296 of 480 012 remov-
als [57.56%]), from the Midwest (2000-2005, 56 734 of
300 633 removals [18.87%] vs 2012-2017, 124 535 of 492 209
300
250
Thousands of Entries, No.
200 Adoption and Foster Care Analysis
and Reporting System data for fiscal
years 2000 to 2017. Fiscal years are
150 from October 1 to September 30.
Entries owing to parental drug use Parental drug use was missing for
3.5% of the sample. Total foster care
100 entries were stratified into removals
for parental drug use (n = 1 162 668)
and other reasons (n = 3 636 177).
50
Logistic regression was performed to
estimate a linear trend in the
2008 2012 2016 proportion of entries for parental
Year drug use during the study period
(coefficient, 1.07; P < .001).
(Reprinted) JAMA Pediatrics Published online July 15, 2019 E1
 Letters

Table. Characteristics of Children Entering Foster Care Because of Parental Drug Use Removal vs Other Reasons, 2000 to 2017a

Removals, No. (%)

Attributable to Parental Drug Usea Attributable to Other Reasonsb
Characteristic
of Removed Children 2000-2005 2006-2011 2012-2017 Total 2000-2005 2006-2011 2012-2017 Total
Sex
Male 150 488 187 050 250 908 588 446 702 088 621 955 553 571 1 877 614
(50.08) (50.59) (50.99) (50.63) (51.38) (51.80) (51.85) (51.66)
Female 149 991 182 695 241 192 573 878 664 494 578 635 514 111 1 757 240
(49.92) (49.41) (49.01) (49.37) (48.62) (48.20) (48.15) (48.34)
Age at entry
Neonatal 38 836 47 388 59 686 145 910 63 001 60 395 57 760 181 156
(≤1 mo) (12.92) (12.82) (12.13) (12.55) (4.61) (5.03) (5.41) (4.98)
Postneonatal 31 721 45 010 60 980 137 711 104 330 105 337 94 753 304 420
(>1 mo-<1 y) (10.56) (12.17) (12.39) (11.85) (7.63) (8.77) (8.87) (8.37)
1-5 y 100 054 134 750 180 915 415 719 336 296 321 605 298 264 956 165
(33.29) (36.44) (36.76) (35.76) (24.60) (26.78) (27.93) (26.3)
6-10 y 66 642 74 429 110 560 251 631 268 703 218 918 216 436 704 057
(22.18) (20.13) (22.46) (21.65) (19.66) (18.23) (20.27) (19.37)
≥11 y 63 267 68 195 80 015 211 477 594 535 494 458 400 571 1 489 564
(21.05) (18.44) (16.26) (18.19) (43.5) (41.18) (37.51) (40.97)
Race/ethnicityc
White, non-Hispanic 148 780 191 077 276 296 616 153 638 264 520 361 438 441 1 597 066
(51.12) (53.04) (57.56) (54.46) (48.63) (44.34) (42.24) (45.32)
Black, non-Hispanic 79 886 73 711 68 687 222 284 363 585 316 655 268 741 948 981
(27.45) (20.46) (14.31) (19.65) (27.7) (26.98) (25.89) (26.93)
Other, non-Hispanic 21 908 30 110 49 028 101 046 87 823 95 069 97 929 280 821
(7.53) (8.36) (10.21) (8.93) (6.69) (8.10) (9.43) (7.97)
Hispanic 40 443 65 367 86 001 191 811 222 732 241 451 232 960 697 143
(13.90) (18.14) (17.92) (16.96) (16.97) (20.57) (22.44) (19.78)
Geographic region
Northeast 42 004 49 981 60 402 152 387 156 069 156 321 140 964 453 354
(13.97) (13.51) (12.27) (13.11) (11.41) (13.02) (13.20) (12.47)
Midwest 56 734 70 260 124 535 251 529 381 035 308 709 253 988 943 732
(18.87) (19.00) (25.30) (21.63) (27.86) (25.71) (23.78) (25.95)
South 136 419 169 510 214 059 519 988 415 147 367 197 337 335 1 119 679
(45.38) (45.84) (43.49) (44.72) (30.36) (30.58) (31.59) (30.79)
West 65 476 80 075 93 213 238 764 415 187 368 629 335 596 1 119 412
(21.78) (21.65) (18.94) (20.54) (30.36) (30.70) (31.43) (30.79)
Geographic area
Metropolitan 138 161 296 535 371 211 80 5907 554 814 980 463 874 690 2 409 967
(81.69) (80.18) (75.42) (78.16) (81.47) (81.65) (81.91) (81.7)
Nonmetropolitan, 27 864 66 175 108 557 202 596 112 479 196 781 173 337 482 597
urban (16.47) (17.89) (22.06) (19.65) (16.52) (16.39) (16.23) (16.36)
Nonmetropolitan, 3107 7115 12 427 22 649 13 739 23 526 19 777 57 042
rural (1.84) (1.92) (2.52) (2.20) (2.02) (1.96) (1.85) (1.93)
Diagnosed physical/ 42 584 49 276 56 928 148 788 232 460 230 909 207 456 670 825
mental health condition (14.16) (13.32) (11.57) (12.80) (17.00) (19.23) (19.43) (18.45)
a
Adoption and Foster Care Analysis and Reporting System data for fiscal years experienced removal for other reasons during the study period and compare
2000 to 2017. Fiscal years are from October 1 to September 30. Parental drug the characteristics of children across time intervals separately among those
use was missing for 3.5% of the sample. Total foster care entries were who experienced parental drug use and other removal reasons. Given the
stratified into removals for parental drug use (n = 1 162 668) and other reasons large sample, P values were all <.001.
(n = 3 636 177). c
Race/ethnicity was self-identified. In the case of young children, parents
b
Pearson χ2 tests were used to compare the characteristics of children who identified the race/ethnicity of the child.
experienced parental drug use removals and those of children who

removals [25.30%]), and in nonmetropolitan areas (2000-
2005, 30 971 of 169 132 removals [18.31%] vs 2012-2017,
120 984 of 492 195 removals [24.58%]) increased. These pat-
terns were not observed among children entering care for
other reasons.
Discussion | The number of foster care entries attributable to
parental drug use increased substantially from 2000 to 2017
(from 39 130 to 96 672 removals, an increase of 57 542
removals [147.05%]), even when entries for other removal
reasons mostly declined. These findings suggest that greater
parental drug use has contributed to increases in foster care
caseloads and coincide with increasing trends in opioid use
and overdose deaths nationwide during this period.
Foster care placement generally implies that a child has
faced abuse or neglect. Adverse childhood experiences,
such as abuse, neglect, or having a parent who uses drugs,
increase the risk of chronic health conditions and other poor
outcomes across the lifespan.4 Additionally, when children
enter foster care because of parental drug use, episode dura-

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tion is longer and less likely to result in reunification with
the parent.5 This is of special concern because of the large
proportion of children experiencing entry before age 5
years, a critical period for forming stable attachments.
Limitations of this study include potential reporting
inconsistencies in parental drug use. Moreover, it is possible
that factors other than drug use influenced entries for
parental drug use.
Policy makers must ensure that the needs of this new wave
of children entering foster care because of parental drug use
are being met though high-quality foster care interventions.
These have been shown to mitigate some of the adverse ef-
fects of early childhood deprivation and disruptions in
attachment.6
Angélica Meinhofer, PhD
Yohanis Angleró-Díaz, MD
Author Affiliations: Department of Healthcare Policy & Research, Weill Cornell
Medical College, New York, New York (Meinhofer); Department of Psychiatry,
Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
(Angleró-Díaz).
Corresponding Author: Angélica Meinhofer, PhD, Department of Healthcare
Policy & Research, Weill Cornell Medical College, 425 E 61st St, Ste 301,
New York, NY 10065 (anm4001@med.cornell.edu).
Published Online: July 15, 2019. doi:10.1001/jamapediatrics.2019.1738
Author Contributions: Dr Meinhofer had full access to all of the data in the
study and takes responsibility for the integrity of the data and the accuracy of
the data analysis.
Concept and design: Meinhofer.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
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Letters
Critical revision of the manuscript for important intellectual content:
All authors.
Statistical analysis: Meinhofer.
Obtained funding: Meinhofer.
Administrative, technical, or material support: Meinhofer.
Supervision: Meinhofer.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by the National Institute of Mental
Health (grant T32MH073553).
Role of the Funder/Sponsor: The funder had no role in the design and conduct
of the study; collection, management, analysis, and interpretation of the data;
preparation, review, or approval of the manuscript; and decision to submit the
manuscript for publication.
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doi:10.1016/S0749-3797(98)00017-8
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