How can families affected by substance use disorder safely stay together?

Estimates on the prevalence of substance use disorder among families involved with the child welfare system vary widely, ranging from 5% to 90%.^1,2 The wide variation is attributed to a variety of factors, including the population studied (for example, families receiving in-home versus out-of-home child welfare services) and differences in state child protection protocols and data systems in collecting information about when substance use is a factor in cases. According to data collected and reported by all states, parental substance use is cited as a factor in about one-quarter (26%) of substantiated cases of child maltreatment and in over one-third (36%) of cases in which a child is removed from home.^3,4 (For more information see How to Use Data for Change: Improving Outcomes for Families Affected by Substance Use.) Families affected by parental substance use disorder have a lower likelihood of successful reunification with their children, and their children tend to stay in foster care longer than children of parents without substance use disorder.^5,6,7,8,9

Substance use disorder is a disease of the brain that can be effectively treated and managed and accurate and equitable screening and assessment is critical in identifying if families need support and what types of support they need. 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 protection investigation and family separation.

Fortunately, investing in healing interventions for these families can prevent family separation and result in successful recovery for parents, and in cases where separation has occurred, these strategies can lead to timely reunification. Child welfare leaders should rely on evidence about what works to meet the complex needs of families affected by substance use disorder and keep families together, including complying with reunification timelines when separation has occurred. This brief offers strategies for minimizing the time children are separated from parents as a result of substance use disorder.

Addressing stigma

Substance use disorders — and child abuse and neglect — are some of the most highly stigmatized conditions, much in the same way of mental health disorders.¹⁰ Stigma exists at various levels (structural, public, self-inflicted) and creates various challenges for parents with substance use disorder compared to families where substance use disorder is not a factor, including the challenge to access services. It also may influence whether parents feel comfortable reaching out for support, making it an important consideration for child welfare leaders and those working in substance use treatment services when determining how to make support available to families that may need it.

Structural stigma refers to laws, policies, or regulations that intentionally and unintentionally result in discrimination.

Public stigma stems from beliefs and behaviors of individuals and groups — based on stereotypes — that result in discrimination, such as the belief that individuals choose to overuse drugs and alcohol rather than the belief that individuals are affected by a substance use disorder which affects the person’s brain chemistry. Self-stigma is often the result of internalized stereotypes and negative beliefs and is often a barrier to individuals accessing treatment for substance use disorder and other services.

Parents with substance use disorder face many challenges associated with stigma and often must work through self-stigma to engage in treatment. This path involves understanding that their substance use may be affecting their children, and acknowledging that they need help. A family-centered approach is critical to eradicating stigma and ensuring the best outcomes for families affected by substance use disorder.

For more information, see: Disrupting Stigma: How Understanding, Empathy, and Connection Can Improve Outcomes for Families Affected by Substance Use and Mental Disorders.

Keeping families together

Family separation is a traumatic event for everyone involved, and has both short-term effects on children, such as developmental regression and difficulty sleeping, and long-term effects, including heart disease, hypertension, permanent neurological changes, mental health concerns, and substance use.^11,12 Keeping families together, whenever safe to do so, is critical to child and family well-being. The federal Family First Prevention Services Act provides two opportunities to prevent separation of families affected by substance use disorder.

Support to children placed with parents in residential treatment

States may claim Title IV-E foster care maintenance payments for a child in foster care who is placed with a parent in a licensed family-based residential treatment facility.¹³ This component of the Family First Act allows funds that otherwise would pay for the placement of a child in out-of-home care to cover the room and board costs of the child residing with a parent in a residential family-based substance use treatment program. States vary in their implementation approaches.

In California, a voluntary placement agreement is implemented for the placement of children with their parents in a licensed residential family-based treatment facility. Detailed guidance was released in 2021 that covered licensure and other requirements for these types of placements. Minnesota implemented state statutes governing licensure requirements for residential family-based treatment programs. Utah has put in place various strategies, such as child and family team case reviews and trial home placements, to overcome implementation challenges. The case reviews are held with the family, service providers, family allies, and others. The team meets regularly to discuss key decision points on a case, such as reunification. A court may authorize a trial home placement when a parent is ready to discharge from treatment and a decision has been made that the family is not yet ready for reunification. When a child already has been living with a parent in a residential family-based facility, the trial home placement period is used as a time for the family to transition living on its own and ensure there is enough support to minimize risk of relapse.

For more information, see: Implementing the Substance Use Disorder Provisions of the Family First Prevention Services Act.

Funding for additional supports

A new funding stream, Title IV-E prevention services, supports substance use disorder treatment, mental health services, and in-home parenting skill-based programs that are reviewed and rated by the Title IV-E Prevention Services Clearinghouse. As of November 2023, 16 substance use disorder interventions have been rated and approved, including Motivational Interviewing, Screening, Brief Intervention, and Referral to Treatment, and Sobriety Treatment and Recovery Teams (START).

For more information, see:

• Implementing the Substance Use Disorder Provisions of the Family First Prevention Services Act: A Toolkit for Child Welfare and Treatment Stakeholders
• Implementing the Substance Use Disorder Provisions of the Family First Prevention Services Act: Challenges and Strategies
• What are some evidence-based interventions to prevent and mitigate the effects of prenatal substance exposure?

Supporting timely reunification

Reuniting children with their families as soon as safely possible is essential for their healthy development and ability to thrive. But for families affected by substance use disorder, timely reunification can be a challenge. Recovery from substance use disorder is a lifelong and often cyclical process, and short-term relapse can be a part of that process — and is an important consideration when it results in impairment that affects children. However, the federal Adoption and Safe Families Act requires states to move to terminate parental rights for any child who has been in foster care for 15 months of the last 22 months. The tension between the urgency for children to reunite safely with their families and the time necessary for parents in recovery to engage in post-treatment services and prepare to safely care for their children is a challenge for child welfare, dependency court, substance use treatment, and other systems.

Ultimately, the single strongest predictor of safe reunification for families affected by substance use disorder is completion of treatment. Studies have shown that women who complete 90 or more days of substance use disorder treatment nearly double their likelihood of reunification.¹⁴ Specifically, women who enter early into treatment are more likely to reunify than women who don’t, and their children spend less time in foster care.¹⁵

Engagement strategies that help motivate parents to enter and remain in treatment are critical to enhancing outcomes. Research indicates that parents are more likely to enter treatment if they are supported by a recovery coach.¹⁶ Recovery coaches work with parents, child welfare caseworkers, and treatment agencies to remove barriers to treatment, engage parents in treatment, and provide ongoing support following family reunification. For more information, see: The Use of Peers and Recovery Specialists in Child Welfare Settings.

Applying a family-centered approach

Supporting and caring for the entire family — not just the affected parent or child — can be effective in addressing the complex issues underlying substance use. Parental recovery occurs in the context of family relationships, with attachment and parent-child bonding particularly important. The need for support is ongoing, with significant and meaningful change developing over time. In addition to substance use disorder treatment, child welfare leaders may want to consider a range of approaches to serve families, including attachment-based parent-child strengthening interventions, trauma-informed and trauma-responsive services, peer supports, child developmental interventions, and post-reunification supports. For more information, see: Implementing a Family-Centered Approach Series.

A practice and systems-level framework for support

Children and Family Futures has produced a Comprehensive Framework to Improve Outcomes for Families Affected by Substance Use Disorders and Child Welfare Involvement as a resource. It details 10 system- and practice-level elements that systems — child welfare, substance use treatment, mental health treatment, juvenile court dependency — and agencies can use in collaboration to improve outcomes for families. It offers examples of collaborative practice in each element and serves as a guide for other jurisdictional efforts.

Systems-level policy efforts that support practice innovations include:

• 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 include:

• Early identification of families in need of treatment for substance use disorders.
• Equitable and timely access to assessment and treatment services.
• Peer and other recovery support services.
• Family-centered treatment services.
• Frequent monitoring.

Family treatment courts

Family treatment courts (FTCs) align with this framework, as they involve child welfare, substance use disorder treatment, mental health treatment, dependency courts, and agencies in a collaborative approach to serve families. FTCs are shown to prevent family separation, reduce the amount of time children spend in out-of-home care, and accelerate permanency.^17,18,19,20 Practices used in FTCs — including early identification and treatment, peer recovery coaches, intensive case management and case coordination, supportive engagement, and time for families to connect — help inform other efforts to assist families with substance use disorders and catalyze needed systems change. They also offer a timely, therapeutic, and motivational approach to providing feedback and support to parents during their treatment and recovery. For more information, see: Family Treatment Court Best Practice Standards.

Sobriety Treatment and Recovery Teams

Sobriety Treatment and Recovery Teams (START) is a specialized child welfare service delivery model that has been shown, when implemented with fidelity, to improve outcomes for families with young children affected by parental substance use and child maltreatment. The model uses a variety of strategies to promote collaboration and systems-level change within and between child welfare agencies, substance use and mental health treatment providers, the judicial system, and other family-serving entities. Activities include shared decision-making meetings, peer support, intensive case management, rapid access to recovery services, and services for all family members, including older children and non-custodial parents. START teams focus on safely keeping children with their parents but continue to provide services to the family until permanency is achieved, whether children are in or out of the home. START has undergone rigorous evaluation described in at least a dozen peer-reviewed publications. Outcomes include decreased out-of-home placements and decreased parental substance use. Several states have implemented START, and Kentucky, Maryland, and Ohio are conducting impact studies of its implementation and effectiveness.

1 Seay, K. (2015). How Many Families in Child Welfare Services Are Affected by Parental Substance Use Disorders? A Common Question that Remains Unanswered. Child Welfare. 94(4):19-51.

2 Substance use is not always assessed accurately or equitably, which is part of why it is challenging to determine a reliable estimate. This is a critical topic for child welfare and medical professionals to explore.

3 U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2023). Child Maltreatment 2021.

4 U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (n.d.). The AFCARS Report, Preliminary FY 2021 Estimates as of June 28, 2022 – No. 29.

5 National Institute on Drug Abuse. (2023). Your Words Matter – Language Showing Compassion and Care for Women, Infants, Families, and Communities Impacted by Substance Use Disorder.

6 Hadland S.E., Park, T.W.,  & Bagley, S.M. (2018).  Stigma associated with medication treatment for young adults with opioid use disorder: a case series. Addict Sci Clin Pract. 13(1):15. doi:10.1186/s13722-018-0116-2

7 Stone, R. (2015). Pregnant women and substance use: fear, stigma, and barriers to care. Health Justice. doi:10.1186/s40352-015-0015-5

8 Faherty, L.J., Kranz, A.M., Russell-Fritch, J., Patrick, S.W., Cantor, J., & Stein, B.D. (2019). Association of punitive and reporting state policies related to substance use in pregnancy with rates of neonatal abstinence syndrome. JAMA Netw Open. 2(11):e1914078. doi:10.1001/jamanetworkopen.2019.14078

9 Syvertsen, J.L., Toneff, H., Howard, H., Spadola, C., Madden, D., & Clapp J. (2021). Conceptualizing stigma in contexts of pregnancy and opioid misuse: a qualitative study with women and healthcare providers in Ohio. Drug Alcohol Depend. doi:10.1016/j.drugalcdep.2021.108677

10 Kennedy, S. C., Miller, C., & Wilke, D. (2020). Development and validation of the Child Welfare Provider Stigma Inventory. Journal of Social Work, 20(6), 703–729..

11 Broadhurst, K., & Mason, C. (2020). Child removal as the gateway to further adversity: Birth mother accounts of the immediate and enduring collateral consequences of child removal. Qualitative Social Work, 19(1), 15-37.

12 American Bar Association Section of Litigation, Children’s Rights Litigation Committee. (2019). Trauma Caused by Separation of Children from Parents, A Tool to Help Lawyers.

13 Part of the reason why implementation has varied is that this provision requires the child to be placed in foster care. Many states have been using this approach with TANF or other funds in order to avoid placing a child in care that doesn’t otherwise need to be there.

14 Grella, C., Needell, B., Shi, Y. & Hser, Y. (2009). Do drug treatment services predict reunification outcomes of mothers and children in child welfare? Journal of Substance Abuse Treatment, 36, 279–293.

15 Green, B. L., Rockhill, A., Furrer, C. (2007). Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis. Children and Youth Services Review, 29, 460–473.

16 Ryan, J., Perron, B., Moore A., Victor, G., & Park, K. (2017). Timing matters: A randomized control trial of recovery coaches in foster care. Journal of Substance Abuse Treatment, 77, 178–184.

17 Green, B.L., Furrer, C., Worcel, S., Burrus,S., & Finigan, M.W. (2007). How effective are family treatment drug courts? Outcomes from a four-site national study. Child Maltreat. 12(1):43–59.

18 Bruns, E.J., Pullmann, M.D., Weathers, E.S., Wirschem, M.L., & Murphy, J.K. (2012). Effects of a multidisciplinary family treatment drug court on child and family outcomes: results of a quasi-experimental study. Child Maltreat. 17(3):218–30.

19 Lloyd, M.H. (2015). Family drug courts: conceptual frameworks, empirical evidence, and implications for social work. Fam Soc. 96(1):49–57

20 Zhang, S., Huang, H., Wu, Q., Li, Y., & Liu, M. (2019). The impacts of family treatment drug court on child welfare core outcomes: a meta-analysis. Child Abuse Negl. 88:1–14.