FINAL PROJECT--Options
The Problem
The United States is experiencing unprecedented rates of drug overdose deaths and drug-related problems, driven primarily by opioids.
Five pathways by which opioid-related problems can spill over and affect child health and safety:
child or adolescent poisoning and overdose: this could happen because of intentional misuse or accidental ingestion of prescription drugs by young children;
opioid misuse in pregnancy: opioid misuse in pregnancy is associated with inadequate prenatal care, preterm birth, low birth weight, respiratory depression, and neonatal abstinence syndrome (NAS);
impaired parenting and attachment: parents’ opioid misuse may impair their ability to adequately supervise, bond with, and care for their children;
material deprivation: money spent on drugs may come out of family finances needed to care for children; and
extended separation from parents: children may be separated from a parent with an opioid-related problem because of a parent’s incarceration, residential psychiatric or drug treatment, or death or because of a child’s placement in foster care.
Indeed, quantitative and qualitative studies suggest that increases in parental opioid misuse and overdose death have resulted in concomitant increases in these adverse childhood experiences and that many children are ending up in foster care. This is supported by multiple sources and is a key reason for urgent action.
Three decades of evidence now make clear that this type of childhood adversity increases the risk of physical and mental health problems and many of the leading causes of adult death.
There is an urgent need to meet the needs of these children and their families to prevent and remediate the long-term developmental consequences of parental opioid misuse.
Citation snapshot: Feder KA, Letourneau EJ, Brook J. Children in the Opioid Epidemic: Addressing the Next Generation’s Public Health Crisis. Pediatrics. 2019;143(1):e20181656.
Authors and affiliations summarize collaborative efforts across mental health, social welfare, and related fields; funded in part by NIH and other sources.
Key Concepts and Terminology
Opioid epidemic: widespread misuse of opioids leading to overdose deaths and related harms.
MAT: medication-assisted treatment, using medications such as buprenorphine or methadone to treat opioid use disorder (OUD).
NAS: neonatal abstinence syndrome, withdrawal symptoms in newborns exposed to opioids in utero.
OUD: opioid use disorder.
Cross-systems collaboration: coordinated efforts across child welfare, behavioral health, and justice systems to provide comprehensive care.
Regional Partnership Grants (RPGs): federal initiative since 2007 to promote collaboration across systems; total grants awarded = .
Trauma-informed practices: care approaches that recognize and respond to the impact of trauma.
Evidence-based practices: interventions proven effective through systematic evaluation.
Family drug courts: specialized dockets to divert parents using drugs into treatment and support services.
Partial federal reimbursement (time-limited services): new mechanism to fund family services under the child welfare umbrella; standards of evidence apply.
Possible Solutions and Challenges
MAT as a foundational step:
MAT with buprenorphine or methadone improves outcomes for opioid use disorder compared with non-medication treatments.
Benefits extend to pregnant women and to parents involved with child welfare (improved birth outcomes and child safety).
MAT increases engagement in obstetric care, which can facilitate access to family planning and help prevent unwanted pregnancies.
Providers should review safe storage practices and consider the presence of children in the household when determining dosage and follow-up frequency to avoid accidental ingestion.
Access barriers:
Financial barriers and a shortage of specialty programs for pregnant women create access challenges.
Complexity beyond treatment:
Needs of affected families are intertwined with poverty, co-occurring mental health conditions, use of other substances, domestic violence, and homelessness.
Cross-systems collaboration:
Effective care requires a best-systems-practice approach that goes beyond isolated evidence-based practices.
Substance use treatment programs are often ill-equipped to meet family needs; child welfare systems may lack knowledge, guidance, and resources to adopt best practices for substance use treatment.
Promising approaches from RPGs:
Shared outcome measures, joint trainings for professionals, and formal data sharing agreements to improve cross-system coordination.
Expanding parenting programs for parents in substance use treatment and peer recovery programs for parents involved with child welfare has shown improvements in substance use and child welfare outcomes.
Family drug courts tend to increase treatment retention and reduce foster care time.
Adopting trauma-informed practices and addressing housing needs also improve outcomes.
Examples and hypothetical scenarios:
Hypothetical: A mother with OUD on MAT engages with a cross-system team (welfare, health, justice). Through RPG-guided collaboration and trauma-informed housing support, the family maintains stable housing, the child remains at home, and the mother achieves sustained recovery and parental rights protections.
The Changing Policy Landscape
Two key federal policy shifts affect state capacity to address pediatric impacts:
Medicaid policy changes:
expansion of Medicaid to more adults with low income sharply reduced the uninsured rate for adults with opioid use disorder, likely facilitating access to MAT. (Positive impact)
states were permitted for the first time to deny Medicaid coverage to parents who neither worked nor had a disability preventing working; this could be counterproductive for parents with OUD who cannot confer eligibility for disability. Without insurance, these parents may be unable to afford treatment.
Time-limited federal reimbursement for family services:
state child welfare agencies can receive partial federal reimbursement for time-limited substance use, mental health, and parental training services provided to families with a child at risk for entering foster care.
Services funded through this mechanism must meet standards of evidence; this creates incentives to increase the proportion of evidence-based practices in child welfare portfolios.
Implications for states:
Plan to leverage new federal reimbursement to fund preventive services for families affected by opioids.
Invest in combined MAT and evidence-based parenting interventions to address long-term child outcomes.
Use RPG findings to inform adoption and implementation across public and private agencies.
Cautions:
Work requirements for Medicaid could impede access to the services needed to protect children and keep families together.
What’s Next? (Actionable Directions)
Immediate planning for reimbursement opportunities:
States should plan to leverage new federal reimbursement to fund preventive, family-centered services that integrate MAT and parenting interventions.
Use RPG evidence to guide adoption and implementation of best practices across agencies.
Policy considerations:
Reconsider or limit Medicaid work requirements to avoid reducing access to essential treatment and services for OUD-affected families.
Research priorities:
There is an urgent need to consolidate evidence about: (a) the consequences of the opioid epidemic for children, (b) effective prevention/amelioration strategies.
Current gaps include accurate estimates of the number of children in households with a parent with OUD, the services these families are receiving, and gaps between need and capacity.
Opportunities to refine existing interventions and develop new ones tailored to families affected by opioid-related problems.
Professional advocacy:
Pediatricians and child-serving professionals should be vocal advocates for the needs of children whose families are affected by opioid-related problems.
Public officials must be made aware of the imperative to act on behalf of the next generation, whose long-term health depends on meeting these needs.
Abbreviations
MAT: \(medication-assisted treatment\)
NAS: Neonatal Abstinence Syndrome
OUD: Opioid Use Disorder
Additional Notes and Connections
Real-world relevance: Cross-system collaborations and policy changes can directly influence child welfare outcomes, family stability, and long-term health trajectories for children affected by parental opioid problems.
Ethical considerations: Balancing public health aims with parental autonomy and access to care; ensuring that Medicaid policy changes do not disproportionately penalize families with OUD.
Foundational links: The emphasis on trauma-informed care, housing stability, and integrated services connects to broader public health and social determinants of health frameworks.
References (selected)
Patrick SW, Schiff DM; Committee on Substance Use and Prevention. A public health response to opioid use in pregnancy. Pediatrics. 2017;139(3):e20164070
Radel L, Baldwin M, Crouse G, Ghertner R, Waters A. Substance use, the opioid epidemic, and the child welfare system: key findings from a mixed methods study. 2018. Available at: https://aspe.hhs.gov/system/files/pdf/258836/SubstanceUseChildWelfareOverview.pdf. Accessed March 23, 2018
Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893
Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174–186
Hall MT, Wilfong J, Huebner RA, Posze L, Willauer T. Medication-assisted treatment improves child permanency outcomes for opioid-using families in the child welfare system. J Subst Abuse Treat. 2016;71:63–67
Stedt EV, DeCerchio K. Regional partnership grants collaborative approaches: lessons learned from the RPG program. In: Child Welfare League of America National Conference; August 2, 2016; Orange County, CA. Available at: https://www.cwla.org/wp-content/uploads/2016/09/D3WorkshopRPG_Final.pdf. Accessed May 22, 2018
Feder KA, Mojtabai R, Krawczyk N, et al. Trends in insurance coverage and treatment among persons with opioid use disorders following the Affordable Care Act [published correction appears in Drug Alcohol Depend. 2018;182:122]. Drug Alcohol Depend. 2017;179:271–274
The Problem
The United States is experiencing unprecedented rates of drug overdose deaths and drug-related problems, driven primarily by opioids, including prescription painkillers, heroin, and synthetic opioids like fentanyl. This crisis has profound and multi-generational impacts.
Five pathways by which opioid-related problems can spill over and affect child health and safety:
Child or adolescent poisoning and overdose: This can occur due to accidental ingestion of prescribed or illicit opioids by curious young children, often left unsecured, or intentional misuse, experimentation, and self-harm among adolescents. Pediatric opioid exposure is a significant concern.
Opioid misuse in pregnancy: Opioid misuse during pregnancy is critically associated with inadequate prenatal care, increased risks of premature rupture of membranes, preterm birth, low birth weight, respiratory depression in the newborn, and neonatal abstinence syndrome (NAS). Long-term neurodevelopmental effects on the child are also a concern.
Impaired parenting and attachment: Parental opioid misuse can significantly impair a parent's ability to adequately supervise, bond with, and care for their children due to cognitive impairment, emotional unavailability, and prioritizing drug-seeking over child-rearing responsibilities. This can lead to neglect and, in severe cases, abuse.
Material deprivation: Money spent on illicit drugs or addiction treatment often diverts essential family finances needed to provide children with basic necessities such as food, shelter, clothing, medical care, and educational supplies, leading to significant economic strain and instability.
Extended separation from parents: Children may experience prolonged separation from a parent with an opioid-related problem due to the parent's incarceration, mandated residential psychiatric or drug treatment, or death. Additionally, children may be placed in foster care by child protective services when parental opioid misuse leads to neglect or abuse that compromises child safety.
Indeed, quantitative and qualitative studies suggest that increases in parental opioid misuse and overdose death have resulted in concomitant increases in these adverse childhood experiences (ACEs) and that many children are ending up in foster care. This is supported by multiple sources and reinforces the urgent need for intervention.
Three decades of evidence now make clear that this type of childhood adversity significantly increases the risk of a wide range of physical and mental health problems (e.g., cardiovascular disease, depression, anxiety) and many of the leading causes of adult death, as well as contributing to future substance use, lower educational attainment, and involvement with the criminal justice system.
There is an urgent need to meet the comprehensive needs of these children and their families to prevent and remediate the long-term developmental consequences of parental opioid misuse and to break intergenerational cycles of addiction and trauma.
Citation snapshot: Feder KA, Letourneau EJ, Brook J. Children in the Opioid Epidemic: Addressing the Next Generation
s Public Health Crisis. Pediatrics. 2019;143(1):e20181656. This publication in a highly respected pediatric journal underscores the significance of the issue for child health.
Authors and affiliations: Summarize collaborative efforts across mental health, social welfare, and related fields by experts from various institutions; funded in part by NIH and other sources. This multi-disciplinary collaboration highlights the complex nature of the problem and the need for integrated solutions.
Key Concepts and Terminology
Opioid epidemic: Refers to the widespread and rapidly increasing misuse of opioids, leading to a public health crisis characterized by escalating rates of opioid use disorder, overdose deaths, and related harms. The epidemic has evolved from prescription opioid misuse to heroin and increasingly, to potent synthetic opioids like fentanyl.
MAT (Medication-Assisted Treatment): An evidence-based treatment approach that combines behavioral therapies and medications such as buprenorphine or methadone to treat opioid use disorder (OUD). These medications work by acting on opioid receptors in the brain to reduce cravings and withdrawal symptoms, stabilizing brain chemistry and supporting long-term recovery.
NAS (Neonatal Abstinence Syndrome): A set of withdrawal symptoms experienced by newborns who were exposed to opioids in utero. Symptoms can include irritability, tremors, hypertonia, feeding difficulties, vomiting, diarrhea, and seizures, requiring specialized medical care.
OUD (Opioid Use Disorder): A chronic, relapsing brain disease characterized by compulsive opioid seeking and use despite harmful consequences, with diagnostic criteria including significant impairment, distress, tolerance, and withdrawal symptoms upon cessation.
Cross-systems collaboration: Coordinated and integrated efforts across various public service systems, including child welfare, behavioral health (mental health and substance use treatment), education, and justice systems, to provide comprehensive, family-centered care for families affected by opioid misuse. This approach aims to address the interconnected challenges faced by these families.
Regional Partnership Grants (RPGs): A federal initiative (since ), administered by the Administration for Children and Families (ACF), designed to promote comprehensive, coordinated, and family-centered services for families affected by parental substance abuse, particularly opioids. A total of grants have been awarded, fostering collaboration across child welfare, substance abuse treatment, and court systems to improve child safety, permanency, and well-being.
Trauma-informed practices: Care approaches that recognize the pervasive impact of trauma on individuals and families, understanding how trauma can manifest in behavior, and responding in ways that promote safety, trustworthiness, peer support, collaboration, empowerment, and cultural humility, rather than re-traumatizing individuals.
Evidence-based practices: Interventions, programs, or policies that have demonstrated effectiveness through rigorous scientific evaluation and systematic evaluation, such as randomized controlled trials, ensuring that care is based on the best available research evidence.
Family drug courts: Specialized judicial dockets designed to divert parents with substance use disorders, particularly OUD, into court-supervised treatment and support services rather than traditional punitive legal processes. They facilitate regular court appearances, drug testing, and individualized treatment plans to promote recovery and family reunification.
Partial federal reimbursement (time-limited services): A new mechanism established by the Family First Prevention Services Act (FFPSA) in that allows state child welfare agencies to receive partial federal funding for up to months of prevention services—including substance use disorder treatment, mental health services, and parental skills training—for families with children at risk of entering foster care. This aims to support families and prevent unnecessary child removals.
Possible Solutions and Challenges
MAT as a foundational step:
MAT with buprenorphine or methadone significantly improves outcomes for individuals with opioid use disorder compared with non-medication-assisted treatments. It works by reducing cravings and withdrawal symptoms, thus stabilizing individuals and preventing overdose deaths.
The benefits of MAT extend to pregnant women, leading to improved birth outcomes, and to parents involved with child welfare systems, enhancing child safety by supporting parental recovery and stability.
MAT increases engagement in obstetric care, which can further facilitate access to family planning services and help prevent unwanted pregnancies, a crucial aspect of comprehensive care.
Providers should meticulously review safe storage practices for prescribed medications (e.g., using locked cabinets, disposing of unused medication properly) and actively consider the presence of children in the household when determining dosage and follow-up frequency to prevent accidental ingestion or misuse by children.
Access barriers:
Significant financial barriers, including lack of adequate health insurance coverage or high co-pays, and a persistent shortage of specialty MAT programs, particularly those equipped to serve pregnant women, create profound access challenges. This is compounded in rural areas where providers are scarce.
Complexity beyond treatment:
The needs of affected families are deeply intertwined with complex co-occurring issues such as poverty, untreated mental health conditions (e.g., depression, anxiety, PTSD), polydrug use (use of other substances), domestic violence, and homelessness. These factors complicate treatment and recovery efforts, requiring a holistic approach.
Cross-systems collaboration:
Effective care necessitates a best-systems-practice approach that transcends isolated evidence-based practices, recognizing that no single system can address the multifaceted needs of these families alone.
Substance use treatment programs are often ill-equipped to meet the comprehensive family needs, frequently lacking child-focused services, family therapy expertise, or the ability to coordinate with other service providers. Conversely, child welfare systems may lack specialized knowledge, guidance, and resources to effectively assess and manage substance use disorders or adopt best practices for substance use treatment.
Promising approaches from RPGs:
Shared outcome measures, joint trainings for professionals (e.g., child welfare workers, substance use counselors, legal personnel), and formal data sharing agreements are integral to improving cross-system coordination and fostering a consistent, integrated approach to care.
Expanding parenting programs specifically designed for parents in substance use treatment (e.g., those addressing attachment, discipline, child development) and implementing peer recovery programs for parents involved with child welfare have demonstrated improvements in both substance use outcomes and child welfare metrics (e.g., reduced recurrence of maltreatment, increased reunification rates).
Family drug courts tend to increase treatment retention rates and significantly reduce the average time children spend in foster care by providing focused support and accountability for parents.
Adopting trauma-informed practices across all systems and directly addressing housing needs (e.g., through supportive housing initiatives) are also crucial strategies that demonstrably improve overall outcomes for both parents and children.
Examples and hypothetical scenarios:
Hypothetical: A mother with OUD on MAT engages collaboratively with a cross-system team including child welfare caseworkers, healthcare providers, and justice system representatives. Through effective RPG-guided collaboration, comprehensive case management, and trauma-informed housing support, the family maintains stable housing, the child remains safely at home, and the mother achieves sustained recovery and secures her parental rights protections.
The Changing Policy Landscape
Two key federal policy shifts significantly affect state capacity to address the pediatric impacts of the opioid epidemic:
Medicaid policy changes:
The expansion of Medicaid to more adults with low income under the Affordable Care Act (ACA) sharply reduced the uninsured rate for adults with opioid use disorder. This policy change likely facilitated unprecedented access to MAT and other crucial substance use disorder treatment services, having a profoundly positive impact on treatment engagement.
In , states were permitted for the first time by the federal government to deny Medicaid coverage to parents who neither worked nor had a disability preventing working. This policy could be counterproductive for parents with OUD who may be unable to secure employment due to their disorder or who cannot confer eligibility for disability. Without insurance, these parents may be unable to afford life-saving treatment, potentially undermining recovery efforts and increasing risks to children.
Time-limited federal reimbursement for family services:
Effective in , the Family First Prevention Services Act (FFPSA) allowed state child welfare agencies to receive partial federal reimbursement (up to ) for time-limited (up to months) substance use disorder treatment, mental health services, and parental training services. These services are provided to families with a child at imminent risk for entering foster care, with the explicit goal of preventing foster care placement.
Services funded through this mechanism must meet rigorous standards of evidence (e.g., well-supported, supported, or promising practices). This requirement creates strong incentives for states to increase the proportion of evidence-based practices in their child welfare portfolios, promoting higher quality and more effective interventions.
Implications for states:
States should proactively plan to leverage the new federal reimbursement opportunities to fund a comprehensive array of preventive services for families affected by opioids, focusing on early intervention and family preservation.
There is a critical need to invest in combined MAT and evidence-based parenting interventions to address both parental recovery and long-term child developmental outcomes, recognizing the interconnectedness of these challenges.
States should utilize the extensive findings and lessons learned from Regional Partnership Grants (RPGs) to inform the successful adoption and implementation of integrated best practices across public and private agencies, fostering a coordinated statewide response.
Cautions:
Strict work requirements for Medicaid eligibility could severely impede access to the essential treatment and support services needed to protect children, stabilize families, and keep them together, potentially exacerbating the opioid crisis's impact on vulnerable populations.
What’s Next? (Actionable Directions)
Immediate planning for reimbursement opportunities:
States must strategically plan to leverage the new federal reimbursement from the FFPSA to fund preventive, family-centered services that seamlessly integrate MAT for parents with evidence-based parenting interventions, aiming to address both substance use and child well-being comprehensively.
Utilize robust RPG evidence and implementation guidance to inform the systematic adoption and implementation of best practices across a broad spectrum of state and local agencies, ensuring consistency and quality of care.
Policy considerations:
Policymakers should critically reconsider or limit Medicaid work requirements, recognizing their potential to inadvertently reduce access to essential treatment and support services for OUD-affected families, which could have detrimental long-term consequences for both parents and children.
Research priorities:
There is an urgent and ongoing need to consolidate and expand the evidence base regarding: (a) the precise long-term consequences of the opioid epidemic for children across various developmental domains, and (b) the most effective prevention and amelioration strategies for these children and families.
Current gaps in research include accurate, real-time estimates of the number of children residing in households with a parent with OUD, detailed information on the specific services these families are currently receiving, and a clear understanding of the gaps between identified needs and existing service capacity.
Significant opportunities exist to refine existing interventions and to develop innovative, new ones specifically tailored to address the unique and complex challenges faced by families affected by opioid-related problems, ensuring interventions are culturally sensitive and trauma-informed.
Professional advocacy:
Pediatricians and all child-serving professionals (e.g., educators, social workers, mental health providers) should serve as vocal and persistent advocates for the comprehensive needs of children whose families are affected by opioid-related problems, raising awareness and promoting policy changes.
Public officials must be made acutely aware of the ethical and public health imperative to act decisively on behalf of the next generation, whose long-term health, development, and societal contributions profoundly depend on effectively meeting these complex needs during critical developmental periods.
Abbreviations
MAT: \
NAS: Neonatal Abstinence Syndrome
OUD: Opioid Use Disorder
RPGs: Regional Partnership Grants
FFPSA: Family First Prevention Services Act
ACA: Affordable Care Act
ACEs: Adverse Childhood Experiences
Additional Notes and Connections
Real-world relevance: The successful implementation of cross-system collaborations and adaptive policy changes can directly and positively influence critical child welfare outcomes, enhance family stability, and significantly improve the long-term health and developmental trajectories for children affected by parental opioid problems across the nation. This demonstrates a clear link between policy and public health.
Ethical considerations: Addressing the opioid crisis involves complex ethical considerations, including balancing public health aims (e.g., reducing overdose deaths, protecting children) with critical aspects of parental autonomy and equitable access to care. It also involves ensuring that Medicaid policy changes do not disproportionately penalize or exclude families with OUD, which could exacerbate existing disparities and harm vulnerable children.
Foundational links: The strong emphasis on trauma-informed care, ensuring housing stability, and integrating services connects directly to broader public health and social determinants of health frameworks. These frameworks recognize that health and well-being are influenced by a wide array of social, economic, and environmental factors beyond individual behaviors, highlighting the need for comprehensive and systemic solutions.
References (selected)
Patrick SW, Schiff DM; Committee on Substance Use and Prevention. A public health response to opioid use in pregnancy. Pediatrics. 2017;139(3):e20164070
Radel L, Baldwin M, Crouse G, Ghertner R, Waters A. Substance use, the opioid epidemic, and the child welfare system: key findings from a mixed methods study. 2018. Available at: https://aspe.hhs.gov/system/files/pdf/258836/SubstanceUseChildWelfareOverview.pdf. Accessed March 23, 2018
Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893
Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174–186
Hall MT, Wilfong J, Huebner RA, Posze L, Willauer T. Medication-assisted treatment improves child permanency outcomes for opioid-using families in the child welfare system. J Subst Abuse Treat. 2016;71:63–67
Stedt EV, DeCerchio K. Regional partnership grants collaborative approaches: lessons learned from the RPG program. In: Child Welfare League of America National Conference; August 2, 2016; Orange County, CA. Available at: https://www.cwla.org/wp-content/uploads/2016/09/D3WorkshopRPG_Final.pdf. Accessed May 22, 2018
Feder KA, Mojtabai R, Krawczyk N, et al. Trends in insurance coverage and treatment among persons with opioid use disorders following the Affordable Care Act [published correction appears in Drug Alcohol Depend. 2018;182:122]. Drug Alcohol Depend. 2017;179:271–274