On Child Welfare, an Insufficient Federal Response to the Opioid Epidemic

In 2012, following more than a decade of significant decline, the number of American children in foster care began rising. Between 2012 and 2016, the number of children in foster care nationally has increased by more than 10 percent. There is broad agreement that the ongoing opioid epidemic has been a primary contributor to those increases.

Now, a recent research brief issued by the U.S Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) should sound alarm bells for child welfare advocates. The impact of the opioid crisis on children and families “has continued to intensify,” according to ASPE. We urgently need a comprehensive federal response.

This 2016 photo of a grandmother and her boyfriend, overdosed in the front seat with her grandchild in the back, became symbolic of the need for stronger government response to the child welfare side of the opioid epidemic

The brief notes that foster care caseloads are rising, and that the children being served through the child welfare system represent “more complex and severe … cases.” Many are coming from homes where substance abuse is not the only issue. These families “come with a range of interrelated issues and needs,” including “domestic violence, mental illness and long histories of traumatic experiences.”

The complex nexus of issues also makes reunification more difficult. Supportive services will need to address “co-occurring problems to support both the parent’s recovery and the child’s safety and well-being.”

The epidemic amplifies long-standing challenges facing child welfare. Social workers are “overwhelmed by the volume of cases, the lack of treatment resources, and the sheer magnitude of the problem,” leading to “high stress, burnout and turnover.” Meanwhile, the increase in the number of children entering foster care and their likely length of stay as their parents struggle to recover are compounding the country’s critical shortage of foster parents.

Unfortunately, despite growing awareness about the strain that the epidemic is placing on foster care, the federal government’s response has been woefully inadequate.

Congress has appropriated considerable sums to support law enforcement, drug treatment and prevention programs, but has failed to accompany this with any dedicated supplemental funding for foster care. Meanwhile, due to arcane income restrictions, only about half of children who come into foster care are supported by Title IV-E federal funds, meaning the other half are being cared for without federal resources.

Supporters of the recently-enacted Family First Prevention Services Act (Family First) framed it as a response to the opioid crisis, pointing to the provision allowing the use of Title IV-E funds to reimburse states for substance abuse treatment and mental health counseling. In fact, the shortcomings of Family First promise to inhibit our ability to respond to the opioid crisis.

Under Family First, substance abuse services are only authorized for up to 12 months. Given the severity of opioid addiction and the aforementioned co-occurring issues in many homes, those time limits may be too short to be effective. A 2010 study of 109 opiate-dependent patients released from residential treatment found that 91 percent of them relapsed.

Second, substance abuse treatment services under Family First are authorized only once conditions in a home have deteriorated to the point where a child is at imminent risk of removal. By delaying access to supportive services until that point, the law increases the likelihood that the children of addicted parents entering treatment will have to be moved, at least temporarily, to another home — often, and preferably, the home of a relative.

Family First creates impossible choices that ultimately set families up to fail, effectively forcing a choice between the well-being of a parent and the well-being of the child affected by the parent’s addiction. Under Family First, Title IV-E funds may only be used for treatment of the parent if the child is kept out of foster care. Children are often “kept out” of foster care by moving them out of a parent’s home and placing them with a relative without the support of foster care funding and services — a practice often called “diversion.”

To be sure, prioritizing placements with relatives is both preferable and mandated by law; children who are removed from their home and placed with a relative have greater placement stability, better health and education outcomes, and experience less trauma. But recent research suggests that children placed with relatives also have a higher risk of poverty, which is likely linked to the fact that relatives are less likely to receive foster care payments and other income supports.

Family First exacerbates this problem, creating a Hobbesian choice for families and child welfare systems: use federal IV-E funds to support services for the child’s parents or use federal IV-E funds to support the child’s care by a relative.

Family First actually requires states to adopt model licensing standards, which could and should enable more relatives to be licensed and receive foster care funding. But because Family First allows prevention services for the parent only if the child is not placed into foster care, states have little incentive to use the model standards in order to license kin and get them the financial aid they so desperately need.

The end result is that states that want to use IV-E prevention funding to support the parent are forced to deny relatives the funding they need to support the daily care of a child.

Furthermore, in requiring that the child be kept out of foster care, Family First limits temporary placement options for the child, relying heavily on relatives. This is particularly problematic in opioid addiction, because, even compared to methamphetamine and crack cocaine addiction, opioid addiction more often involves intergenerational substance abuse, according to the ASPE brief. In such cases, it is more likely that “other family members across multiple generations are … using substances themselves, making substitute caregivers within the family more difficult to find and causing the child welfare system to more frequently take and retain custody of children.”

If there are no safe and available relative homes, the child will need to be moved into foster care and the parent will not be eligible for substance abuse treatment through IV-E.

Due to the complex interrelated issues occurring in the homes described by ASPE, families require a broad range of services for both the children and the parents, including “family therapy, programs building parenting skills, child development services, and interventions addressing domestic violence.” Of these, only parenting skills programs are supported through Family First, and only those that meet evidence-based criteria yet to be developed by HHS.

There is no easy fix here. Foster care caseloads will continue to increase until the epidemic comes under control. In the meantime, we need increased federal resources to support state and local foster care systems and children in need of protection. These resources should allow children placed with relatives to receive foster care benefits concurrently with substance abuse treatment for the parent.

Federal resources are also needed to support additional foster parent recruitment and retention to address the shortage of foster family homes. Federal funds are needed to support workforce training and increased access to specialized services for the children coming into care with greater exposure to trauma and related challenges. We desperately need a coordinated federal advocacy campaign to address these broad system needs.


Would an Israeli Kibbutz style work?  Put the kids in group homes with stable parent figures, more kids  could be cared for at one time.  These kids would be addiction-prone genetically, so extra attention could be directed at education/motivation to avoid picking up the problem; “the ‘victims’ of this disease are often volunteers”.  Take a proactive approach, parents would get the kids back when certain milestones have been achieved, but ongoing monitoring would happen for the first 2 decades of the child’s life, maybe longer, by age 25 the prefrontal cortex is pretty well developed, the control source of impulsivity vs. judgement.

Dr. Raymond Oenbrink