How can the child welfare system support families affected by substance use disorder?

Parental substance use is a key factor associated with infants and children (particularly young children) coming into foster care.^1,2 The opioid epidemic and increases in substance-related deaths have resulted in increases in the number of families coming to the attention of child protective services and in the number of children entering out-of-home care. To learn more about prenatal substance exposure see: What are some evidence-based interventions to prevent and mitigate the effects of prenatal substance exposure? and What are some developmentally appropriate interventions for infants and children affected by prenatal substance exposure?

Raising children can be complicated for any parent, and substance use may pose challenges to meeting children’s physical, psychological, and emotional needs. However, several misconceptions exist, including the conflation of risk with substance use, which can often lead to policies and practices that disadvantage families coming to the attention of child welfare. This may include decision-making about child safety based solely on the presence of substance use and the results of a drug test rather than an assessment of how the substance use affects child safety.

Substance use disorders are a disease of the brain that can be effectively treated and managed. A prevention-based approach in which families affected by parental substance use are engaged in assessment and treatment services (when clinically necessary) as early as possible can reduce reactive, crisis-based responses, including child welfare investigation and family separation. Of course, a single system does not have all the resources necessary to mitigate the complex effects of substance use on families. Collaborative relationships among professionals in child welfare, community organizations, courts, healthcare, mental health, and substance use services and disorder treatment are necessary. Systems partnerships can implement a comprehensive approach that includes a clinical assessment to determine the presence and severity of a substance use disorder, and a comprehensive assessment of the family’s strengths and needs.

This brief offers an overview of how parental substance use and substance use disorders can affect children and families. It also discusses challenges facing the child welfare system, a framework to guide collaboration, and relevant examples, strategies, policies, and funding opportunities to improve outcomes for families affected by substance use disorders.³

Effects of substance use disorders on children and families

Substance use disorders can result in trauma and disruption in the lives of children and families. The stigma surrounding it can keep families from seeking the treatment they need before problems escalate to the point of involvement of the child protection agency. Structural inequities based on race/ethnicity and socioeconomic factors present additional roadblocks. It is critical to ensure equity in access to treatment for all communities.^4,5,6

Without efforts to eliminate stigma and inequities, we will continue to see disproportionality in which families are referred to child welfare, which families receive substantiated allegations of child maltreatment, and which families are separated and reunified.^7,8,9 (See: Disproportionalities and Disparities in Child Welfare, A Supplement to Understanding Substance Use Disorders, Treatment, and Family Recovery: A Guide for Child Welfare Professionals.)

Substance use disorder is costly both in terms of the financial costs of increased child welfare utilization and the ripple effect of its impacts on children, families, and society at large, including the trauma of children being removed from their parents. For families involved with the child welfare system, substance use disorders often result in challenges in making reasonable and active efforts to keep children in their home or achieve permanency quickly. Reasonable and active efforts for families affected by substance use and substance use disorders include timely access to assessment services to determine the appropriate evidence-based treatment plan for each family, including family-centered care and recovery support.¹⁰

Grandparents and other family members often face financial, social, physical, and mental health challenges, particularly when they become long-term or permanent caregivers.

Challenges facing the child welfare system

The child welfare system faces numerous challenges in effectively responding to cases affected by substance use and substance use disorders, including:

• Increased caseloads: Jurisdictions with higher rates of drug-related hospitalizations and deaths have higher child welfare caseload rates. In general, indicators of substance use disorders also correlate with higher rates of more complex child welfare cases. According to fiscal year 2020 Adoption and Foster Care Analysis and Reporting System (AFCARS) data, “drug abuse (parent)” was a circumstance associated with out-of-home placement for more than one-third (35%) of children entering foster care and “alcohol abuse (parent)” was a circumstance for 6% of children entering foster care. It is widely understood that these data are an undercount, with studies finding up to 90% of child welfare cases to involve families affected by substance use disorders.   
• Biases and disparities in reporting and surveillance: Various racial and socioeconomic factors impact the well-being of infants and families affected by prenatal substance exposure. Black and Native American women are more likely to be tested for substance use,¹¹ and Black women were reported to local health departments at approximately 10 times the rate of white women, despite similar rates of substance use.¹² Black women and women who give birth in communities with a high proportion of Medicaid beneficiaries also are more likely to be reported to child welfare for substance use during pregnancy.^13,14
• Need for coordination: Although a multi-system approach is needed to address substance use and substance use disorders among parents and other caregivers, collaboration between the child protection agency, the courts, and substance use disorder treatment programs is hindered by differences in agency approaches and priorities and challenges in sharing client information and program data.¹⁵ These challenges are further compounded when working across state lines.
• Inaccurate understanding or application of criteria: There is a lack of sufficient understanding of substance use versus substance use disorders, or conflating the two, as well as a lack of accurate assessment of the impact of either one on indicators of child safety.
• Overreliance on drug testing: Drug testing (particularly urine and toxicology testing, which often produce inaccurate results¹⁶) is overused as a diagnostic indicator or as a measure of safety. The overreliance on testing leads to decisions being made that can have serious, irreversible, and inequitable consequences for families, particularly for Black and Native American mothers who are more likely to be reported to child welfare and health departments at the time of giving birth.^16,17,18 (See Brief 1: Considerations for Developing a Child Welfare Drug Testing Policy and Protocol and Brief 2: Drug Testing for Parents Involved in Child Welfare: Three Key Practice Points.)
• Limited family-centered services: Jurisdictions report a lack of family-centered substance use disorder treatment services, which support parenting roles by providing a variety of services including child care, child developmental services, family therapy, and parenting classes. Resource availability is especially a challenge in rural areas, which tend to have higher rates of substance use disorder and fewer resources. Rural areas may benefit from specific strategies to address substance use disorders.
• Permanency policies at odds with timelines for recovery: The relatively short timelines for achieving permanency, as mandated in the 1997 Adoption and Safe Families Act, may be at odds with how long it actually can take for parents to recover from substance use disorders, and the provision of timely and available supports for families. The act requires states to file petitions to terminate parental rights after children have been in out-of-home care for 15 of 22 consecutive months. Case planning should include recovery support and management; procedures for dealing with relapse, which can be a regular part of recovery. (See: National Center on Substance Abuse and Child Welfare Child Welfare Training Toolkit and Tutorials for Child Welfare, Substance Use Disorder Treatment, and Legal Professionals.)

A comprehensive framework

Developed by Children and Family Futures, the Comprehensive Framework to Improve Outcomes for Families Affected by Substance Use Disorders and Child Welfare Involvement provides 10 elements that child protection agencies, substance use disorder treatment, mental health treatment, juvenile court dependency systems, and other agencies and providers can use to more effectively collaborate with one another. It provides examples of collaborative practice in each element and can be used as a guide for other jurisdictional efforts.

System-level policy efforts that support practice innovations

• Commitment to shared mission, vision, and goals
• Efficient cross-systems communication
• Ongoing cross-training and staff development
• Sustainability and institutionalization of practices
• Measuring and monitoring outcomes Practice strategies and innovations

Practice strategies and innovations

• Early identification of families in need of substance use disorder treatment
• Equitable and timely access to assessment and treatment services
• Recovery support services
• Family-centered treatment services
• Frequent monitoring and therapeutic responses to behavior

The Substance Abuse and Mental Health Services Administration’s report, A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders, applies many elements of the comprehensive framework for use when collaborating between child welfare, medical service providers, and other service providers.

Program examples incorporating aspects of the comprehensive framework

Various federal programs and jurisdictions have incorporated aspects of the comprehensive framework.

Regional Partnership Grants (RPGs) support interagency collaborations and the integration of programs, services, and activities designed to improve safety, permanency, and well-being outcomes among children who are in or at risk of out-of-home placements due to a parent or caregiver’s substance use disorder. From the program’s inception in 2007 to 2022, the Children’s Bureau has awarded seven rounds of RPG funding to 127 projects across 40 states, including tribal communities.

The Family Connections through Peer Recovery RPG is a collaborative initiative in Florida that includes the state Department of Children and Families Southeast Region, the Broward Behavioral Health Coalition, ChildNet, the Dependency Drug Court of Broward County, and the Broward County Sheriff’s Office. It provides services to families affected by substance use disorders that are involved with the child welfare system. Based on a family-focused and strengths-based care coordination approach, parents are provided with intense support from family care coordinators and peer specialists to promote engagement in treatment and other services. The initiative has resulted in an increase in the number of parents entering and completing substance use disorder treatment.

Safely Advocating for Families Engaged in Recovery (SAFER) is a statewide collaborative effort in Oklahoma to develop and implement a comprehensive and coordinated response to prenatal substance exposure. The goals of the initiative include improved identification of substance use during pregnancy to ensure access to treatment and provision of early intervention and home visiting services to affected infants and families. Services include peer supports for parents and early intervention for infants and children. A range of systemic innovations have been implemented, including stigma reduction initiatives and prenatal and postpartum family care plans, which include early access to treatment (both residential and outpatient), prenatal care, and ongoing engagement in services. Family care plans ensure timely access to substance use disorder treatment, prenatal care, and ongoing engagement in services after the birth of the infant. Various pilot programs have been implemented under the SAFER initiative, with the majority of infants with prenatal substance exposure discharging home from the hospital with their parents where ongoing supports and services have safely maintained them in the home.^20,21

Opportunities

The child welfare system can better serve families affected by substance use disorders by implementing evidence-based practice strategies and innovations, and by making use of available funding and policies. The Children’s Bureau’s primer for child welfare professionals working with parents who have substance use disorders provides a helpful overview of relevant state and federal laws and how child welfare professionals can assist families, including collaboration with treatment providers.

Practice strategies and innovations

Many programs and practices are available to help families with substance use disorders who are involved with or at risk of involvement with the child welfare system.

A family-centered approach to treatment recognizes that substance use disorders affect every member of the family. As such, family-centered approaches provide a comprehensive range of treatments and supports to meet the needs of each member in the family. The National Center on Substance Abuse and Child Welfare prepared a set of three modules on implementing a family-centered approach: 1) Overview of a Family-Centered Approach and Its Effectiveness; 2) On the Ground—Family-Centered Practice; and 3) Collaboration To Support Family-Centered Practices at the County and State Level.

Sobriety Treatment and Recovery Teams (START) serve families with young children who are involved in the child welfare system and have at least one parent with a substance use disorder. Families are deeply involved in case planning and treatment decision-making. Program activities include intensive case management, coaching, counseling, peer support, and recovery services, involving a broad range of providers. Several states have implemented START and Ohio is conducting an evaluation of its implementation and effectiveness.

The Parent-Child Assistance Program (PCAP), an intensive three-year home visitation program for pregnant and parenting mothers with substance use disorder, focuses on connecting mothers to supports and services and providing relationship-based coaching and role modeling. PCAP has been demonstrated to be a cost-effective way to help children stay safely with their parents.

In Oregon, the Families Actively Improving Relationships (FAIR) program provides evidence-based strategies to address needs of parents involved in the child welfare system who have substance use disorder. The strategies are offered in an intensive outpatient setting and include mental health and substance use disorder treatment, training in parent skills, and case management. A randomized study found that parents participating in FAIR demonstrated improvements in mental health symptoms, decreases in opioid and methamphetamine use, decreases in parenting stress, and increases in housing stability.

Family-Based Recovery (FBR) is another intensive, in-home substance use disorder treatment program, providing comprehensive case management, individual and group psychotherapy, parent-child support, and developmental guidance. In Connecticut, FBR has demonstrated a 93% parent engagement rate, decreased substance use, reductions in child maltreatment, and reductions in the number of children entering out-of-home care.

When outpatient services aren’t appropriate, family-based residential treatment programs allow children to live safely with their parents while their parents undergo substance use disorder treatment, avoiding the need for out-of-home placement and the trauma associated with separation. In Arizona, the Patina Wellness Center interweaves traditional Native American healing practices with evidence-based treatment approaches and has seen high rates of recovery for its clients. In Los Angeles County, SHIELDS for Families provides family-centered treatment and supportive housing services for families affected by substance use and mental health issues, allowing the entire family to live together in an individual apartment and stay for up to one year after treatment. Over 200 families benefit from services annually. (See: Family-Based Residential Treatment Directory of Residential Substance Use Disorder Treatment Programs for Parents with Children.)

Family treatment courts (FTCs) involve people from child protection, substance use disorder treatment, mental health agencies, dependency courts, and other community agencies in a collaborative approach to serve families affected by substance use disorder. FTCs can reduce the amount of time children spend in out-of-home care and hasten permanency. The Center for Children and Family Futures and the National Association of Drug Court Professionals created a comprehensive report detailing eight best practices for FTCs. Practices used in FTCs — including early identification and treatment, the use of peer recovery coaches, intensive case management and case coordination, supportive engagement, and time for families to connect — can help inform other efforts to assist families with substance use disorders and catalyze needed systems change.

Medication-assisted treatment (MAT) combines the use of medications with counseling and behavioral therapy to address alcohol use disorder and opioid dependency. A large study involving 25 states found that increased treatment capacity for opioid use disorder (through increased buprenorphine capacity) is associated with decreased rates of substantiated child maltreatment. The National Center on Substance Abuse and Child Welfare created a MAT resource for judicial professionals working with families affected by opioid dependency, and the federal Office of the Assistant Secretary for Planning and Evaluation created a brief about challenges and opportunities in using MAT in the context of child welfare.

Some successful strategies for reunification among families with substance use disorders include keeping families at the center of support and decision-making, early access to treatment, frequent encouragement and feedback, and the use of peers and recovery specialists. A sampling of substance use disorder treatment programs for families involved with or at risk of involvement with the child welfare system is described in the California Evidence-based Clearinghouse and the Title IV-E Prevention Service Clearinghouse.

Policies and funding

To receive Child Abuse Prevention and Treatment Act funds, states must develop plans of safe care for infants who have been affected by familial substance use or fetal alcohol spectrum disorder. The plans must include treatment needs for the affected parents and caregivers and are ideally developed with input from parents and caregivers. (For more information about the legislative and policy context, key implementation considerations, and jurisdictional examples of plans of safe care, see: What are infant plans of safe care and some examples of state responses to infants affected by substance abuse?)

The Family First Prevention Services Act expands how jurisdictions can use Title IV-E funds to help families access needed substance use disorder services and prevent entry into out-of-home care. The three primary ways Family First supports prevention include: 1) allowing jurisdictions to use Title IV-E foster care maintenance payments on behalf of children who are living with their parents in residential treatment facilities for substance use disorder; 2) providing new Title IV-E prevention services funds to support programs and services to prevent entry into out-of-home care; and 3) reauthorizing RPG funding for programs like the two described above. Children and Family Futures, ChildFocus, and the National Association of State Alcohol and Drug Abuse Directors developed a toolkit to guide jurisdictions in implementing substance use disorder-related provisions of Family First.

Opioid settlement funds from multidistrict litigation against pharmaceutical companies provide a large funding source for jurisdictions to prevent and address substance use disorders. The Bloomberg School of Public Health at Johns Hopkins University created a list of five principles that jurisdictions should consider to ensure that opioid settlement funds are used most effectively. These include: 1) spend money to save lives; 2) use evidence to guide spending; 3) invest in youth prevention; 4) focus on racial equity; and 5) develop a fair and transparent process for deciding where to spend the money. The RAND Corporation has also developed resources to help jurisdictions effectively use opioid settlement funds.

1 Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Crouse, G., Ghertner, R., Madden, E. & Radel, L. (2021). Foster Care Entry Rates Grew Faster for Infants than for Children of Other Ages, 2011–2018.
2 Sokol, R. L., Victor, B. G., Mariscal, E. S., Ryan, J. P. & Perron, B. E. (2021). Using administrative data to uncover how often and why supervisory neglect happens: Implications for child maltreatment prevention. Child Abuse & Neglect, 122.
3 Content of this brief was informed through consultation with members of the Knowledge Management Lived Experience Advisory Team on January 6, January 23, and January 27, 2023. This team includes youth, parents, kinship caregivers, and foster parents with lived experience of the child welfare system who serve as strategic partners with Family Voices United, a collaboration between FosterClub, Generations United, the Children’s Trust Fund Alliance, and Casey Family Programs. Members who contributed to this brief include Keith Lowhorne, Raul Enriquez, and Lisa Myles. Content of this brief also informed by an interview with Colleen Puckett, CEO, Parent and Owner, Families’ Anchor, on February 21, 2022.
4 Larochelle, M. R., Slavova, S., Root, E. D., Feaster, D. J., Ward, P. J., Selk, S. C., Knott, C., Villani, J., & Samet, J. H. (2021). Disparities in opioidoverdose death trends by race/ethnicity, 2018–2019, from the HEALing Communities Study. American Journal of Public Health, 111, 1851-1854.
5 Cummings, J. R., Wen, H., Ko, M., & Druss, B. G. (2014). Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States. JAMA Psychiatry, 71(2), 190-196.
6 Skewes, M. C., & Blume, A. W. (2019). Understanding the link between racial trauma and substance use among American Indians. American Psychologist, 74(1), 88–100.
7 Center for the Study of Social Policy & Annie E. Casey Foundation. (2011). Disparities and disproportionality in child welfare: Analysis of the research.
8 Child Welfare Information Gateway. (2021). Child welfare practice to address racial disproportionality and disparity. U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau.
9 National Conference of State Legislatures. (2021). Disproportionality and race equity in child welfare.
10National Quality Improvement Center for Collaborative Community Court Teams and American Bar Association Center on Children and the Law. (n.d.). Reasonable and Active Efforts, and Substance Use Disorders: A Toolkit for Professionals Working with Families in or At Risk of Entering the Child Welfare System.
11 Kunins, H. V., Bellin, E., Chazotte, C., Du, E., & Arnsten, J. H. (2007). The effect of race on provider decisions to test for illicit drug use in the peripartum setting. Journal of Women’s Health,16(2), 245– 255.
12 Chasnoff, I. J., Landress, H. J., & Barrett, M. E. (1990). The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. New England Journal of Medicine, 322(17), 1202–1206.
13 Chasnoff, I. J., Landress, H. J., & Barrett, M. E. (1990). The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. New England Journal of Medicine, 322(17), 1202–1206.
14 Rebbe, R., Mienko, J. A., Brown, E., & Rowhani-Rahbar, A. (2019a). Hospital variation in child protection reports of substance exposed infants. The Journal of Pediatrics, 208, 141–147.
15 Radel, L., Baldwin, M., Crouse, G., Ghertner, R., & Waters, A. (2018). Substance use, the opioid epidemic, and the child welfare system: Key findings from a mixed methods study. p. 8.
 16Farst, K. J., Valentine, J.L., & Hall, R.W. (2011). Drug Testing for Newborn Exposure to Illicit Substances in Pregnancy: Pitfalls and Pearls. International Journal of Pediatrics, Volume 2011. doi:10.1155/2011/951616
17 Chasnoff, I. J., Landress, H. J., & Barrett, M. E. (1990). The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. New England Journal of Medicine, 322(17), 1202–1206.
18 Rebbe, R., Mienko, J. A., Brown, E., & Rowhani-Rahbar, A. (2019a). Hospital variation in child protection reports of substance exposed infants. The Journal of Pediatrics, 208, 141–147.
19 Stone, R. (2015). Pregnant women and substance use: fear, stigma, and barriers to care. Health and Justice, 3, 2.
20 National Center on Substance Abuse and Child Welfare. (2022). Improving Systems Through Collaboration: Top Down or Bottom Up? Both! [Presentation]
21 Brien, B., Stephenson, T., & Shores, C. (2022). Safely Advocating for Families Engaged In Recovery (SAFER) Initiative [Presentation], Prevention and Recovery Conference, December 07, 2022.